Maternal, Infant, and Early Childhood Home Visiting Program Reauthorization Included in Final Appropriations Package with Tribal Set-Aside Increase

On December 29, 2022, the Jackie Walorski Maternal and Child Home Visiting Reauthorization Act of 2022 (H.R. 8876) was included in the final appropriations package, also known as the omnibus, for Fiscal Year (FY) 2023. Notably, the omnibus reauthorized the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and increased funding through FY 2027. The program supports home visit programs, including the Tribal Home Visiting Program (THVP), for expectant and new parents who live in communities that are at risk for poor maternal and child health outcomes. To continue improving the infant and maternal health of American Indian/Alaska Native (AI/AN) communities, the bill provides a notable improvement to the THVP program by (from 3% to 6%) starting in FY 2023. The National Council of Urban Indian Health (NCUIH) has advocated for the reauthorization of MIECHV and increasing funding for the Tribal set-aside and continues to advocate on behalf of AI/AN mothers and infants.

In addition, the bill makes several to the MIECHV program overall, such as:

• $500,000,000starting grant base in FY23, scheduled funding increases of $50,000,000 through FY 2027.
• Dedicates a 2% set-aside for workforce support, retention, and case management.
• Allows set-asides for research, evaluation, and administration (3%) and technical assistance (2%).
• Creates an “outcomes dashboard” to help Congress and the public track MIECHV’s success in improving family outcomes.
• Annual report to Congress to better oversee the program and make improvements in the future.

Background

The Tribal Home Visiting Program

Since 2010, a 3% set-aside has been allotted to the THVP, a program administered within MIECHV to specifically support and promote the health and well-being of AI/AN families.

From the MIECHV 2015 Congressional Report, THVP grantees, including urban Indian organizations (UIOs), served 870 families—5 times the number served in FY 2012. Nearly 20,000 home visits were provided to 3,197 adult participants and children between FY 2012 and FY 2014. After 3 years of implementation, 77% of grantees also demonstrated overall improvement in several benchmark areas. These include:

• 62% improvements in maternal and newborn health
• 85% increase in the prevention of child injuries, child abuse, neglect, or maltreatment, and reduction of emergency department visits
• 69% improvement in school readiness and achievement
• 77% reduction in crime or domestic violence
• 77% improvement in family economic self-sufficiency
• 69% improvements in the coordination and referrals for other community resources

Since its inception, the THVP has been an influential program to help improve the development of healthy AI/AN children and families through coordinated, culturally relevant, and evidence-based home-visiting strategies addressing critical maternal and child health needs.

NCUIH Advocacy

NCUIH has engaged in extensive advocacy on behalf of AI/AN mothers and infants for increased funding and support to the UIOs that provide maternal health, infant health, prenatal, and family planning services. On March 9, 2022, NCUIH signed on to a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing the MIECHV program and doubling the Tribal set-aside, which includes UIOs.

NCUIH also submitted comments on March 10, 2022, to the Health Resources and Services Administration (HRSA) Advisory Committee on Infant and Maternal Mortality (ACIMM), which advises the Secretary of Health and Human Services (HHS) on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and severe maternal morbidity, and improving the health status of infants and women before, during, and after pregnancy. On August 31, 2022, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program. In those comments, NCUIH continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations.

On September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, presented before the HRSA ACIMM on urban Indian disparities and policy changes to address these disparities. Raimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.”

Thanks to this NCUIH advocacy, H.R. 8876 included language to double the Tribal set-aside from 3% to 6% in FY 2023, which was ultimately included in the final appropriations package for FY 2023.

AI/AN Maternal Health Disparities

American Indian and Alaska Native (AI/AN) communities throughout the country, including urban AI/AN communities, experience significant maternal and infant health disparities compared to the general population. A report by the National Center for Health Statistics noted that between 2005 and 2014, AI/ANs were the group that did not experience a decline in infant mortality.

Over half of UIOs provide care for maternal health, infant health, prenatal, and/or family planning. A study of Natives in UIO service areas found that while birth rates, in general, were lower in the urban Native population (12.8 and 16.5 per 1,000 population, respectively), premature birth rates for both urban and non-urban AI/AN were higher than those of all other races and ethnicities combined (12.3% of live births among AI/AI in urban areas and 10.9% among the general population in the same area).

Through expanded research efforts, many factors have been directly identified as reasons for AI/AN infant and maternal health disparities. These include:

• 41% of AI/AN women cite cost as a barrier to receiving the recommended number of prenatal visits.
• AI/AN women are 3-4x more likely to begin prenatal care in the third trimester.
• 21% of AI/AN women ages 15-44 are uninsured, compared to 8% of white women.
• 23% of AI/ANs report they have faced discrimination in clinical settings due to being an AI/AN.
• 15% report avoiding medical care for themselves or family members due to fear of discrimination.
• Access to culturally appropriate care can be difficult for AI/ANs living in urban areas, as most IHS clinics and hospitals, as well as Tribal healthcare facilities, are located on reservations.