Bipartisan Bicameral Urban Indian Health Confer Act Reintroduced by Senator Smith, Senator Mullin, and Representative Grijalva

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On February 15, 2023, Senators Tina Smith (D-MN) and Markwayne Mullin (R-OK) re-introduced the Urban Indian Health Confer Act (S.460) This is part of an ongoing effort to rectify longstanding parity issues within the Indian health system. The legislation would require agencies and offices within the U.S. Department of Health and Human Services (HHS) to confer with Urban Indian Organizations (UIOs) on policies and initiatives related to healthcare for over 70% of American Indians and Alaska Natives (AI/ANs) that live off reservations. The National Council of Urban Indian Health (NCUIH) worked closely with the Senators on this bill which was originally introduced in May 2022 as S. 4323 by Sen. Smith, as well as with Representative Raúl Grijalva (D-AZ-7) on the House companion bill (H.R. 630), which was recently re-introduced on January, 30, 2023. The original House legislation, H.R. 5221, passed the House of Representatives by a vote of 406 to 17 on November 2, 2021.

NCUIH has long advocated for the importance of facilitating confer between UIOs and numerous federal branches within HHS to ensure access to high-quality health services for all AI/ANs. Currently, only the Indian Health Service (IHS) has a legal obligation to confer with UIOs.

“The Urban Indian Health Confer Act is a critically important step in addressing urban Indian health disparities. This bill will ensure that HHS, and HHS departments outside of the Indian Health Service, communicate directly with urban Indian organizations on matters relating to urban Native health. It will also ensure that our clinics are properly informed of policy changes and have a formal means of initiating discussion with HHS on policies and programs that affect the health of urban Indian communities. Open communication between HHS and UIOs will allow HHS to become more responsive to the needs of the over seventy percent of American Indians and Alaska Natives residing in urban areas and is necessary to improve urban Indian health.” -NCUIH CEO, Francys Crevier (Algonquin)

In a July 2022 Senate Committee on Indian Affairs (SCIA) hearing on the Urban Indian Confer Health Act, Representative Grijalva expressed the need for Urban Confer at HHS, stating that “HHS’ failure to communicate with UIOs about healthcare policies that impact urban Indian communities is inconsistent with the federal trust responsibility and contrary to sound public health policy. The Urban Indian Health Confer Act will establish direct communication for UIOs across the entire department and ensure that urban Indian communities are aware of healthcare policy changes.”

In the same SCIA hearing, this bill was shown support by urban Indian leader and CEO of the Indian Health Board of Minneapolis, Dr. Patrick Rock (Leech Lake Band of Ojibwe), who stated in his testimony that “…an urban confer policy across HHS agencies, including CMS, would be instrumental in ensuring that obstacles relating to programs and benefits that directly affect UIOs are addressed quickly so UIOs are better equipped to provide healthcare to their patients.”

Background

Urban Confer with HHS and UIOs

An Urban Confer is an established mechanism for dialogue between federal agencies and UIOs. Urban confer policies are a response to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that have resulted in 70% of AI/AN people living outside of Tribal jurisdictions, thus making Urban Confer integral to addressing the care needs of a majority of AI/ANs. An urban confer policy that includes all HHS agencies ensures that obstacles relating to programs and benefits that directly affect UIOs are addressed quickly so UIOs are better equipped to provide healthcare to their patients. NCUIH has long advocated for facilitating confer between numerous federal branches within HHS and UIO stakeholders. Currently, only IHS has a legal obligation to confer with UIOs. It is important to note that urban confer policies do not supplant or otherwise impact Tribal consultation and the government-to-government relationship between Tribes and federal agencies.

Such blatant disregard to communicate with UIOs is not only a failure to urban Indians and is inconsistent with the government’s responsibility, but it is contrary to sound public health policy. The bill would codify the intent of the Federal Trust Responsibility to ensure equitable health care access to AI/AN by amending legislative text in Section 514, Subsection (b) of the Indian Health Care Improvement Act (25 U.S.C. § 1660d) (IHCIA).

This bill would require the Secretary of HHS, to the maximum extent practicable, to confer with UIOs in carrying out the health services of the Department.

Next Steps

The Senate bill (S.460) was referred to the Senate Committee on Indian Affairs. The House companion bill (H.R.5221) was referred to the Committee on Natural Resources and the Committee on Energy and Commerce. It currently awaits consideration.

NCUIH continues to advocate for an established confer policy between all HHS agencies and UIOs to improve the delivery of health services to all AI/ANs living in urban settings.

Resources

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HHS Issues Notice of Funding Opportunity for Native Language Preservation and Native American Cultural Preservation

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The Administration for Children and Families (ACF) Administration for Native Americans (ANA) currently has three Notice of Funding Opportunities (NOFOs) open as grant applications related to Native language and cultural preservation. Urban Indian Organizations (UIOs) are eligible and encouraged to apply by March 31, 2023. The National Council of Urban Indian Health (NCUIH) has advocated for the sharing and use of Native languages in tribal communities as a method to strengthen community bonds and to support a sense of belonging.

The current grants accepting applications are:

Applications are due March 31, 2023.

Background on the Grants

The purpose of each grant below varies in objectives they serve related preservation of Native languages and cultures:

  • Native American Language Preservation and Maintenance (P&M)
    • The P&M program provides funding for projects designed to ensure continuing vitality of Native American languages. This program allows for a broad array of Native language related projects including establishing a language program, improvements to an existing program, and the development of language instruction and activities.
  • Native American Language Preservation and Maintenance – Esther Martinez Immersion (EMI)
    • The EMI program provides funding for community-based projects that ensure continuing vitality of Native languages through immersion-based instruction. Programs funded under the EMI NOFO must meet the requirements for either a Native American Language Nest, or a Native American Language Survival School, as defined by Esther Martinez Native American Languages Preservation Act
  • Social and Economic Development Strategies (SEDS)
    • This NOFO is focused on community-driven projects designed to grow local economies; strengthen Native American families, including the preservation of Native American cultures; and decrease the high rate of current challenges caused by the lack of community-based businesses and social and economic infrastructure in Native American communities.

How to Apply

Instructions for navigating the grant application process can be found here.  The search for locating each grant can be found here. Included below are details pertaining to each grant individually.

  • Native American Language Preservation and Maintenance (P&M)
    • Expected Number of Awards: 9
    • Estimated Total Program Funding: $2,000,000
    • Award Ceiling: $300,000
    • Award Floor: $100,000
  • Native American Language Preservation and Maintenance – Esther Martinez Immersion (EMI)
    • Expected Number of Awards: 5
    • Estimated Total Program Funding: $1,500,000
    • Award Ceiling: $300,000
    • Award Floor: $100,000
  • Social and Economic Development Strategies (SEDS)
    • Expected Number of Awards: 30
    • Estimated Total Program Funding: $9,500,000
    • Award Ceiling: $400,000
    • Award Floor: $100,000
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GAO Report Finds that Tribes and Native Organizations Faced Barriers to Accessing Federal COVID-19 Relief Funds Due to Administrative Burdens

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On December 15, 2022, the U.S. Government Accountability Office (GAO) issued a report that examined approaches federal agencies used to administer programs that provided COVID-19 funds under the Coronavirus Aid, Relief, and Economic Security (CARES) Act to tribal recipients and outlined lessons learned that could improve future federal relief to recipients. Tribal recipients included tribal entities, tribal members, urban Indian organizations (UIOs), and American Indian or Alaska Native individuals (AI/AN). Among the top lessons learned included prioritizing established mechanisms and structures to distribute relief funds to tribal recipients. The National Council of Urban Indian Health (NCUIH) has advocated extensively for emergency relief funding to UIOs in a manner consistent with GAO’s recommendations throughout the COVID-19 pandemic.

Background

GAO is an independent, non-partisan agency that works for Congress. GAO examines how taxpayer dollars are spent and provides Congress and federal agencies with objective, non-partisan, fact-based information to help the government save money and work more efficiently.

To do so, GAO conducts reviews of federal agencies and programs, including those that serve Tribes, their citizens, and descendants. (GAO generally does not audit Tribes’ activities). GAO reviews span a broad range of topics of concern to Tribes, including health care, education, economic development, environmental protection, justice, and infrastructure, among others including this report. GAO’s oversight of federal programs that serve Tribes and their citizens aims to help the Congress determine how best to meet the government’s longstanding commitments to federally recognized Tribes.

GAO conducted this report, in part, due to the disproportionate and devastating impact the COVID-19 pandemic has had on public health and economies of federally recognized Tribes and their members living both on and off reservation land including urban areas.  Additionally, the CARES Act includes a provision for GAO to conduct monitoring and oversight related to the COVID-19 pandemic. The report notes that Congress has appropriated at least $43.6 billion since March 2020 for federal programs serving Tribes, their members, and tribal organizations including UIOs. The report examined approaches select federal agencies, including the United States Department of Agriculture (USDA), Department of Health and Human Services (HHS), Interior, and the Treasury, used to administer programs that provided COVID-19 funds to tribal recipients and lessons learned that could improve future federal relief to these recipients. GAO reviewed federal agency documents and interviewed agency officials, tribal recipients, and representatives of tribal organizations selected amongst federal agencies.

Report Findings and Recommendations

GAO identified lessons learned from select federal agencies’ administration of COVID-19 relief funding that could improve future federal relief for tribal recipients. For example, using existing mechanisms, such as contracts and compacts, can enable agencies to quickly distribute funds to recipients and mitigate administrative burdens for agencies and Tribes. By enabling agencies to use existing mechanisms to distribute funds, Congress would better ensure that they distribute these funds more quickly and with minimal additional administrative burden on tribal recipients and agencies. This also allows agencies to maintain accountability in the use of the funds through existing reporting mechanisms. Additionally, GAO found that increasing federal capacity and expertise for working with tribal recipients could improve federal administration of future funding for tribal recipients. In accordance with a 2021 Presidential Memorandum, each selected agency is implementing an action plan that includes building capacity and expertise to better meet the unique needs of tribes and tribal communities. GAO recommends Congress should consider, when seeking to provide Tribes with emergency relief that it wants to be distributed as quickly as possible, providing this relief in a manner that enables agencies to distribute it through existing mechanisms and structures, such as self-determination contracts and self-governance compacts, as appropriate.

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NCUIH Advocacy Results in New Guidance from HHS on 100% FMAP for Urban Indian Organizations

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On December 27, 2022, the Center for Medicaid Services (CMS) released a State Medicaid Director Letter (SMDL) #22-006: “Additional Guidance on Section 9815 of the American Rescue Plan Act of 2021.” The SMDL provides additional guidance to states on Section 9815 of the America Rescue Plan Act of 2021 (ARPA), which amended Section 1905(b) of the Social Security Act to set the federal medical assistance percentage (FMAP) for Medicaid services provided at Urban Indian Organizations (UIOs) at 100% for eight fiscal quarters, starting on April 1, 2021. The National Council of Urban Indian Health (NCUIH) and UIO advocacy efforts helped secure the inclusion of Section 9815 in the ARPA, and NCUIH has called on the Administration to provide guidance to states to ensure this provision is implemented in the way intended by Congress. ARPA Section 9815’s 100% FMAP UIO extension ends on March 31, 2023, and UIOs have generally have not seen the benefit of the provision that was intended to increase resources for Indian healthcare providers.

Overview of Additional Guidance provided in SMD #22-006:

The guidance reiterates prior guidance issued by CMS, and invites individual State Medicaid Directors to reach out to CMS for additional information or guidance on implementing ARPA Section 9815. Below is a brief overview of the additional guidance relating to UIOs provided by SMD #22-006. The SMD:

  • Reiterates that CMS interprets ARPA’s 100% FMAP UIO extension to apply to Medicaid services received by all Medicaid beneficiaries through UIOs with a grant or contract with the Indian Health Service (IHS) under title V of the Indian Health Care Improvement Act
  • Provides that 100% FMAP is available for state expenditures on Medicaid services provided by a non-UIO provider but furnished under a qualifying care coordination agreement with UIOs for the ARPA period.
  • Reiterates that states have the discretion to set and adjust Medicaid provider payment rates if the state payment rates are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the state plan at least to the extent that such care and services are available to the general population in the geographic area. (42 U.S.C. 1396a(a)(30)(A))
  • Reiterates that states must comply with the provisions of section 1902(bb) of the Act when setting Medicaid payment rates for Federally Qualified Health Center (FQHC) services that are furnished by FQHCs.
  • Provides that CMS is available to provide technical assistance to states that believe adjusting their reimbursement rates to UIOs, Centers, or Systems is appropriate.
  • Encourages states needing technical assistance to contact their CMS state lead, and UIOs, Centers, and Systems needing technical assistance to contact their CMS Native American Contact.

ARPA Section 9815’s UIO 100% FMAP extension expires on March 31, which is less than two months away. NCUIH is continuing policy work to ensure that UIOs can benefit from this Section as was intended by Congress. NCUIH also is continuing efforts to secure permanent 100% FMAP for UIOs.

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NCUIH Bill Helps Urban Indian Organization Purchase New Building for Women’s Health and Pediatric Services

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In October 2022, the Oklahoma City Indian Clinic (OKCIC), one of the 41 Urban Indian Organizations (UIOs) serving the more than 70% of American Indian and Alaska Native (AI/AN) individuals living in urban areas, announced their purchase of a new clinic building in Oklahoma City, Oklahoma. “This building is larger than our other locations” says Oklahoma City Indian Clinic’s Chief Operating Officer Lysa Ross. “The extra space will give us more opportunities to expand services and continue providing excellent health care to American Indians.” In 2021, The National Council of Urban Indian Health (NCUIH) worked tirelessly to include the Padilla-Moran-Lankford Urban Indian Health amendment to the bipartisan infrastructure package which allows UIOs to use existing Indian Health Service (IHS) funding for facilities improvement and renovations.

The clinic plans to renovate the nearly 65,000 square foot structure, with six-stories, to hold primarily women’s health and pediatric services. Their pediatric department offers several specialty clinics, including an asthma and a foster care clinic. Well-child visits, same-day visits, physical examinations, immunizations, and vision and hearing checks will also be procedures provided in the new building. The women’s health department at Oklahoma City Indian Clinic offers birth control, preventative health and wellness services and prenatal care, including delivery options.

The new building is still undergoing renovations, but OKCIC plans to see patients at this new location in 2023.

Background

NCUIH has worked on a bipartisan basis for legislation that that would expand the use of existing IHS resources under Section 509 of the Indian Health Care Improvement Act (IHCIA) (25 U.S.C. § 1659) to increase the funding authority for renovating, constructing, and expanding UIOs. In August 2021, NCUIH successfully advocated for the Padilla-Moran-Lankford Urban Indian Health Amendment to be included in the bipartisan infrastructure package, which allows UIOs to use existing IHS funding for infrastructure projects.

Prior to the passage of the bipartisan infrastructure package with this amendment, IHS did not have funding allocated specifically for use toward UIO facilities, maintenance, sanitation or medical equipment, nor could UIOs use their contract funds to make such purchases or payments. At the height of the pandemic, while the whole IHS system transitioned to telehealth, negative pressurizing rooms and other facility renovations that were needed to safely continue to see patients, restrictions within the relevant statutory text would not allow UIOs to spend their funds to make similar such transition. Section 509 of the Indian Health Care Improvement Act (IHCIA), where the technical fix this amendment provided exists, only allowed IHS to provide UIOs with funding for minor renovations and to assist UIOs in meeting or maintaining compliance with The Joint Commission (TJC) accreditation standards.

Prior to the passage of the Padilla-Moran-Lankford amendment, in May, Congressmen Ruben Gallego (D-AZ) and Don Bacon (R-NE) introduced the Urban Indian health Facilities Provider Act (H.R. 3496) in the House of Representative, expanding the use of existing IHS resources under Section 509 to increase the funding authority for renovating, constructing, and expanding UIOs. An identical bill was introduced at the same time in the Senate (S. 1797) by Senators Alex Padilla (D-CA) and James Lankford (R-OK), with initial co-sponsors including Senators Moran (R-KS), Feinstein (D-CA) and Smith (D-MN) who is on the Senate Committee on Indian Affairs.

NCUIH also testified in support of the Urban Indian health Facilities Provider Act before both the House Natural Resources Subcommittee for Indigenous Peoples of the United States (SCIP) and the Senate Committee on Indian Affairs (SCIA) in May of 2021. Sonya Tetnowski (Makah Tribe), Chief Executive Officer of the Indian Health Center of Santa Clara Valley and the NCUIH President-Elect at the time of the hearing, testified before SCIP, and Robyn Sunday-Allen (Cherokee), Chief Executive Officer of the Oklahoma City Indian Clinic and NCUIH Vice President, testified before SCIA.

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Fall 2022 Semester Law and Policy Fellows Depart and Reflect on Time with NCUIH

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With the new semester of the school year well underway, the National Council of Urban Indian Health (NCUIH) bids farewell to the Law and Policy Fellows that worked with us throughout the semester. Both students were key collaborators within the work that NCUIH accomplished while they were with us. They attended hundreds of calls, wrote NCUIH communication materials such as blogs and newsletter posts, and were directly responsible for several discrete research projects. NCUIH wishes Adrianne and Palmer all the best as they continue their education and professional growth.

Headshot of Palmer Scott

 “NCUIH treated me like one of their own and I couldn’t imagine the cost of having missed an opportunity like this.” – Palmer Scott (Muscogee (Creek) Nation)

 Palmer Scott (Muscogee (Creek) Nation) leaves NCUIH to finish his 3L year at the University of Oklahoma College of Law, where he is the Vice President of the campus’ Native American Law Student Associate (NALSA) and is the Moot Court Administrator for the National Native American Law Student Association (NNALSA), among other extra curriculars. Here’s what he had to say about his fellowship with NCUIH:

“I am a citizen of the Muscogee Nation and an advocate for civil rights/social movements. As a third-year law student at the University of Oklahoma College of Law, I desired an externship at an organization that aligned with my morals and purpose. NCUIH was an easy contour to my passions for social justice. I attended a Native American Bar Association D.C. meeting with NCUIH where the CEO, Francys Crevier, asked for me to come work with them in the Fall. I applied to be a legal fellow while participating as a board member of the National Native American Law Students Association furthering my commitment to my communities.

I learned that around 70% of the Native American population lives in urban areas. The trust responsibility the federal government maintains with tribal nations extends into these urban areas. I am proud to witness Congress grant advance appropriations to the Indian Health Service, partly due to the advocacy and dedication of NCUIH team members. I also learned a lot of information regarding agency comment periods and the sweeping regulations involved in the healthcare industry.

The connections I made at NCUIH will last throughout my career. My supervisor Rori was always helpful, friendly, and supportive. The relations between a non-profit and the federal government were insightful. I witnessed many advocates from all over Indian Country speak about the issues their specific communities face. I plan to take the knowledge gained from the agency meetings and projects I completed with me for the rest of my career. NCUIH treated me like one of their own and I couldn’t imagine the cost of having missed an opportunity like this. Mvto!”

Headshot of Adrianne Elliott

“The mentorship I received from the policy team proved invaluable to my professional and personal growth. I am passionate about advancing self-determination and sovereignty for Native peoples across the country and look forward to bringing this new knowledge and skillset into the next steps in my Indian law career to ensure all Natives are included in laws and policies that impact them and their wellbeing.” – Adrianne Elliott (Cherokee Nation of Oklahoma)

Adrianne Elliot (Cherokee Nation) was able to extend her summer Law and Policy Fellowship throughout the fall semester. NCUIH is honored that she wished to continue working with us, and that she was able to continue her invaluable work on behalf of urban Native Americans across the nation. To read her reflection from the summer, click here.

About NCUIH Law and Policy Fellowship

Available to undergraduate, graduate and law students as remote work, this opportunity allows students to work part-time throughout the semester, accommodating for classes and availability, or full time during the summer. Internships and Fellowships are available for academic credit or for compensation, dependent on funding. If you, or someone you know, is interested in learning more about what it means to be a NCUIH Law and Policy Fellow, please visit the NCUIH Internship and Fellowship Program webpage to learn more about the opportunities NCUIH offers.

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Tribal Leaders Highlight Need for Increased Urban Indian Health Funding in Fiscal Year 2025 IHS Budget Requests

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On January 25-26, 2023, the Indian Health Service (IHS) held its annual Area Report Presentations Webinar for Fiscal Year (FY) 2025 where Tribal leaders from all 12 IHS Areas and leaders from Native organizations, including the National Council of Urban Indian Health (NCUIH), presented on their budget requests. Many Tribal leaders emphasized the need to increase funding and resources for urban Indian health in the FY2025 budget. Navajo Nation President Buu Nygren stated: “The [Navajo] nation is also supporting the push to support urban Indian healthcare facilities and many Navajos live off the reservation should still be able to receive equitable healthcare through the IHS network system.” Areas also highlighted the need for increased funding for mental and behavioral health, as social isolation during the height of the pandemic negatively affected physical and emotional well-being. Additionally, Area leaders mentioned the critical need for increased funding for Health Information Technology (IT) modernization, permanent authorization of the Special Diabetes Program for Indians (SDPI), and permanent exemption from sequestration.

Background on Budget Formulation

As part of the trust responsibility to provide health care to all American Indians and Alaska Natives (AI/ANs), Tribal leaders present their funding needs each year to the Secretary of HHS and the Director of the Office of Management and Budget. The recommendations are formed through the Tribal Budget Formulation Work Group (TBFWG) and serve as a framework for the Administration in setting budget amounts for their annual requests to Congress. This process ensures the federal government has the resources to provide health care to all AI/ANs in fulfillment of the trust responsibility.

Area Report Highlights

Several Areas featured the work of urban Indian organizations (UIOs) in their presentations and advocated for increased allocation of funding and resources for urban Indian health.

  • IHS Phoenix Area highlighted the program increase of $92.6 million identified in FY2024 remains a top priority for FY2025 for urban Indian health. The Area advocated that services must be aligned and enhanced across the Indian health care system.
  • IHS Bemidji Area stressed that UIOs are underfunded and rely heavily on restrictive grants which can be financially unstable and recommended an increase of $23 million for urban Indian health in FY 2025.
  • IHS Oklahoma City Area stressed that although 78% of AI/AN people reside in urban areas, the funding allocation for urban Indian health only reflects approximately 1% of the IHS annual budget. They recommend that urban Indian health is prioritized as a part of tribal health priorities to advocate that Congress increase the budget to appropriate funding levels.
  • IHS Tucson Area highlighted that the urban Indian line item needs to be fully funded to address critical health disparities faced by AI/ANs residing in urban areas. They also shared multiple success stories such as the completion of a new housing development to address the housing shortage and a completed recreation center that brings water and electricity to rural communities.
  • The IHS Billings Area Representatives emphasized that the current funding level for the urban Indian population is inadequate and that leaving the reservation does not forfeit the rights to health care.

NCUIH Supports Full Funding of Urban Indian Health and Other Key UIO Priorities for FY2025

Chandos Culleen, NCUIH’s Director of Federal Relations, presented the following UIO priorities for FY 2025 during the Area Report Webinar:

  1. Urban Indian health funding amount of $977.4 million, an increase of $3.8 million over FY 2024 recommendations.
      1. This amount reflects the average of the draft 12 IHS Area recommendations and is critically needed to address health priorities for Natives in urban areas including:
        1. Ensuring Urban Indian Health funding keeps pace with population growth.
        2. Providing funding for UIO facilities and infrastructure.
        3. Expanding service offerings to Native patients in urban areas.
  2. Establishing permanent 100% Federal Medical Assistance Percentage (FMAP) for UIOs.
  3. Increased behavioral health funding for UIOs.
  4. Maintaining advance appropriations for IHS.
  5. Special Diabetes Project for Indians (SDPI) reauthorization.

Top Priorities

Mr. Culleen emphasized that UIOs only receive funding from one line item in the IHS budget, urban Indian health, which is historically underfunded and does not keep up with rising medical inflation costs. UIOs do not have access to other distinct IHS funding sources such as facilities improvements and upgrades, funding from Hospitals and Health Clinics, Purchase & Referred Care, and Contract Support Costs. Only an increase to the Urban Health line item assures increased service capacity for UIOs.

Next Steps

IHS will hold their FY 2025 National Tribal Budget Formulation Work Group on February 14-15, 2023 where tribal representatives from each Area come together to review and consolidate all the Area’s budget recommendations into a comprehensive set of national health priorities and budget recommendations. NCUIH will continue to advocate for full funding for urban Indian health and increased resources for UIOs.

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