Urban Indian Organizations Encouraged to Apply to IHS Produce Prescription Pilot Program by June 8, 2023

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On April 24, 2023, the Indian Health Services (IHS) announced the availability of $2.5 million in funding to support the development of produce prescription programs for Native communities. The IHS produce prescription program is designed to assist American Indian and Alaska Native (AI/AN) individuals and families who are experiencing food insecurity and/or diet‑related health problems to more easily obtain fresh produce by receiving a prescription from a health care provider. Launching these programs in Native communities will support the efforts to reduce food insecurity, incorporate more traditional foods, and improve health outcomes among AI/AN people by increasing their access to healthy foods. Urban Indian Organizations (UIO) are eligible to apply. The application deadline is June 8, 2023, and the earliest anticipated start date is June 23, 2023. IHS anticipates issuing approximately six to eight awards for up to $500,000 for a performance period of five years.

Background

This pilot program is part of the IHS’s efforts to implement the Biden Administration’s National Strategy on Hunger, Nutrition, and Health (the Strategy). The program provides an opportunity to engage with UIOs by addressing food insecurity and decreasing the risk of diet-related illness among AI/ANs. By incorporating traditional foods, it also provides an opportunity to deliver culturally appropriate nutrition education for the more than 70% of AI/ANs living off-reservations. AI/AN people experience the highest rates of diabetes across all racial and ethnic groups compared to non-Hispanic whites. Moreover, diabetes and heart disease are among the top five leading causes of death for AI/AN people who live in urban areas and urban AI/AN people are more than three times more likely to die from diabetes than their white peers and have higher death rates attributable to heart disease than urban white people. Additionally, according to a report published in the Journal of Hunger & Environmental Nutrition, “[u]rban AI/ANs were more likely to experience food insecurity than rural AI/ANs.”

 NCUIH’s Role

NCUIH continuously advocates for health equity and advancement of urban AI/AN communities, including food security for AI/ANs living in urban areas. On July 15, 2022, NCUIH submitted comments to the Administration, the Department of Health and Human Services (HHS), and the US Department of Agriculture (USDA) and recommended that they support UIOs to promote food security, nutrition, and exercise; include urban AI/AN populations in future research efforts and government projects; and establish consistent Urban Confers regarding nutrition, hunger, and health. NCUIH also supports an increase in funding for maintaining Special Diabetes Program for Indians (SDPI) to enable the program to continued success in reducing diabetes and diabetes-related illnesses throughout Indian Country.

Further, in September 2022, Walter Murillo (Choctaw), CEO of NATIVE HEALTH and President-Elect of NCUIH, headlined a panel titled “Breaking Barriers: Bridging the Gap Between Nutrition and Health” at the White House Conference on Hunger, Nutrition, and Health, where they unveiled the Strategy. Mr. Murillo highlighted high rates of food insecurity in Indian Country, which intersects with other social determinants of health such as limited housing, employment, and lack of trust in health care systems in Native communities.

NCUIH will continue to advocate for the resources needed to reduce health disparities for AI/ANs, regardless of where they live.

Proposed Legislation to Lift US Debt Limit Threatens Native Health Care

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Happy May! In this month’s newsletter, we bring you important updates and information regarding our latest developments and initiatives within the Urban Indian Health Community.

  • May 10th – The Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies will hold a hearing on the FY24 budget request for Indian Country. Tune in at 10 a.m. EDT here.

1 Big Thing: Proposed Legislation to Lift US Debt Limit Threatens Native Health Care

graphic of a capitol building

On April 17, 2023, Speaker of the House Kevin McCarthy (R-CA-20) proposed legislation to lift the US debt limit for a year, which passed the house by a vote of 215-217 on April 19.

The bottom line: The proposal includes several measures, including reverting federal spending to Fiscal Year (FY) 2022 levels, limiting spending increases to 1% a year for the next 10 years, rescinding any unspent Covid-19 funds, and enacting stricter work requirements for social programs such as Medicaid.

“The federal government must continue to work towards its trust and treaty obligation to maintain and improve the health of American Indians and Alaska Natives. Unfortunately, this legislation proposes senseless cuts at a time when our providers are making strides to improve the health of our communities. The United States’ promises to Native people are non-negotiable and our families should not be victims of DC politics over the debt ceiling,”

— Francys Crevier (Algonquin), NCUIH CEO.

Why it matters: These proposals would significantly impact healthcare access for Native communities. The federal government’s trust responsibility includes a duty to provide “federal health services to maintain and improve the health of the Indians.” The federal government cannot fulfill this responsibility if it does not provide the Indian health system with adequate funding.

By the numbers: If federal spending is reverted to FY 2022 levels, the Indian Health Service (IHS) line item would see a 4.7% reduction to $6.63 billion, while the urban Indian line item would see an 18.8% reduction.

  • Funding cuts have historically forced Indian health providers to make difficult decisions about the scope of the healthcare services they can offer to Native patients.

  • The $220 million reduction in IHS’ budget authority for FY 2013 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for AI/ANs.

  • According to the Tribal Budget Formulation Workgroup, the amount for FY 2024 IHS should be at least $51.4 billion.

What’s next: The bill now awaits a vote in the Senate. President Biden has indicated that he would veto the legislation should it pass through Congress.

NCUIH Testifies before Congress on Tribal Healthcare Delivery

On March 29, 2023, NCUIH Board member Maureen Rosette testified before the House Natural Resources Subcommittee on Indian and Insular Affairs at a hearing titled “Challenges and Opportunities for Improving Healthcare Delivery in Tribal Communities.” Ms. Rosette’s testimony focused on the lack of funding, and uncertainty in funding, impacts oversight and UIO’s ability to provide for their patients.

What they’re saying:

  • In her opening remarks, Chairwoman Harriett Hageman (R-WY- AL) reaffirmed the trust and treaty obligation to Native health care, stating that “the federal government has taken upon itself to provide for the care of American Indians and Alaska Natives.”

  • Ms. Rosette emphasized that advance funding for IHS is needed to provide stable and predictable funding to ensure the continuity of care for American Indian and Alaska Native people.

“Advance Appropriations will now allow IHS to make long-term cost-saving purchases and minimize the administrative burdens for the agency and UIOs. It will also improve accountability and increase staff recruitment and retention at IHS. When IHS distributes its funding on time, our UIOs can pay their doctors and providers- giving Native people the access to care and services they need to be thriving communities,”

-Maureen Rosette, NCUIH Board Member and NATIVE Project COO.

Go deeper:

NCUIH and Congressional Leaders Request Full Stable Funding for IHS and Urban Indian Health

image of a capitol building with receipt

On April 8, 2023, NCUIH sent a letter to Chairman Jeff Merkley (D-OR) of the Senate Interior Appropriations Committee with funding requests for Indian health in FY 2024. On March 24, 2023, NCUIH also sent a letter to Chairman Kay Granger (R-TX-12) and Ranking Member Rosa DeLauro (D-CT-3) of the House Interior Appropriations Committee with the same requests.

In the letters, NCUIH requested the following:

  • Full funding at $51.42 billion for IHS and $973.59 million for Urban Indian Health for FY 2024, as requested by the Tribal Budget Formulation Workgroup (TBFWG).

  • Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration.

  • Appropriate $80 million for the Native Behavioral Health Resources Program.

NCUIH also worked with Members of Congress on leading letters to their colleagues to request full funding for urban Indian health in FY 2024 and advance appropriations for IHS.

  • On April 4, 2023, Sen. Tina Smith (D-MN) and 10 other Senators sent a letter to Chairman Jeff Merkley (D-OR) and Ranking Member Lisa Murkowski (R-AK) of the Senate Interior Appropriations Committee.

  • On March 24, 2023, a group of 38 Representatives sent a letter to the House Interior Appropriations Committee.

Go deeper:

IHS Policy & Guidance: Distribution Decision for IHS FY 2023 Funding Increase, Updated FTCA Guidance

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IHS Dear Urban Leader Letter on distribution decision for IHS FY 2023 Urban Indian Health funding increase:

  • IHS will distribute 90% of the funding equally to UIOs in the amount of $13.5 million. Funding will be transferred to UIOs via IHS contracts.

  • 10% will be distributed to the IHS Office of Urban Indian Health Programs in the amount of $1.5 million.​

IHS Updated Q&A on Federal Tort Claims Act (FTCA) Coverage​:

  • The FTCA is a federal law that allows parties claiming to have been injured by certain tortious actions of persons acting within the scope of their duties to present claims for property damage, personal injury, and/or wrongful death to the federal agency or agencies involved in the incident.

  • UIOs and their employees are covered by the FTCA. For a UIO employee’s actions to be covered by the FTCA, the tortious act or omission must be medical in nature (including the operation of an emergency vehicle) and have been committed by a covered employee within the scope of the employee’s official duties. ​

  • The main difference between the 2022 and 2023 FTCA guidance is that the 2023 guidance makes clear that non-medical malpractice tort claims are not eligible for FTCA coverage.​

NCUIH Priorities: 100% Federal Medical Assistance Percentage & Native Veterans

photo of Noelle Clough, Project Manager; and Robin Quiroz, Outreach and Engagement Specialist, Native American Connections

Noelle Clough, Project Manager; and Robin Quiroz, Outreach and Engagement Specialist, Native American Connections

100% FMAP for Medicaid Services at UIOs

  • On March 15-16, 2023, the Centers for Medicare & Medicaid Services (CMS) Tribal Technical Advisory Group (TTAG) held it’s Face-to-Face meeting with CMS leadership.

  • The TTAG approved 100% FMAP for Medicaid services at UIOs as a top Medicaid Legislative Policy Priority.

  • NCUIH staff attended as technical advisors to NCUIH President-Elect, Walter Murillo, who serves as the NCUIH representative on TTAG.

Native Veterans Homeless Initiative

  • On March 22, 2023, NCUIH met with the White House Council on Native American Affairs (WHCNAA) to discuss the Homeless Veteran Initiative for urban Native Veterans.

  • Department of Veterans Affairs (VA) is hosting stand down events in five areas: Phoenix, Seattle, Los Angeles, Albuquerque, and Alaska.

  • On April 28, 2023, Office of Urban Indian Health Programs Director Dr. Rose Weahkee attended the Maricopa County Stand Down event in Phoenix, AZ. Native American Connections set up a booth to offer a range of health care, behavioral health care, and housing services. The Stand Down event featured VA staff, community partners, and volunteers who provided food, clothing, and health screenings to homeless and at-risk Veterans. Veterans received referrals for health care, housing solutions, employment, substance use treatment, mental health counseling, and other essential services. Services were also offered to their pets.

NCUIH Leads Over 200 Organizations in Urging the Administration to Protect Healthcare Access for Families During Medicaid Unwinding

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On April 24, 2023, NCUIH, in collaboration with the Asian & Pacific Islander American Health Forum, the Coalition on Human Needs, The Leadership Conference on Civil and Human Rights, the National Association for the Advancement of Colored People, National Urban League, Protect Our Care, UnidosUS and 220 other organizations sent a letter to the Department of Health and Human Services (HHS) Secretary Xavier Becerra.

Did you know?: Since Medicaid unwinding may disproportionately harm vulnerable communities, the Consolidated Appropriations Act of 2023 included authorities to protect beneficiaries from losing Medicaid coverage for administrative reasons. For example, according to the Assistant Secretary for Planning and Evaluation, three-fourths of children losing Medicaid will remain eligible but be terminated because of state administrative requirements. The letter calls on the Administration to use the full extent of these authorities to safeguard Medicaid coverage and outlines specific steps the Administration can take to avoid wrongful terminations.

“The unwinding currently taking place will have devastating and disproportionate impacts on Native people. It is estimated that 12% of all Native American children and 6% of all Native adults will lose their Medicaid or CHIP coverage as state Medicaid programs unwind. There is no reason that our people should lose access to necessary healthcare services because of administrative barriers. The federal government must do everything in its power to honor the trust responsibility to Native people and ensure we are not left without coverage,”

— Francys Crevier (Algonquin), NCUIH CEO.

The letter requests the Administration take four key steps to protect families: 

  • CMS mitigation plans should prevent states from wrongfully terminating beneficiaries for purely procedural reasons.

  • CMS should hold state and local Medicaid agencies accountable for compliance with civil rights laws.

  • CMS should promote transparency and accountability by publishing state unwinding and performance indicator data as soon as possible.

  • CMS should hold states accountable for renewing coverage based on data matches “to the maximum extent practicable,” as required by Affordable Care Act.

Go deeper:

One last thing: NCUIH Visits Phoenix UIOs

photo of NCUIH staff at NATIVE HEALTH of Phoenix.

NCUIH staff visited NATIVE HEALTH of Phoenix.​

During NCUIH’s senior staff retreat in Phoenix, AZ, NCUIH staff visited NATIVE HEALTH and Native American Connections to see the important work they are doing for urban Indian health.

NATIVE HEALTH has grown over its forty-year history to offer a full array of health care and social services throughout the Phoenix metropolitan area by providing a wide range of programs, including primary medical, dental, behavioral health, WIC (available at four sites), and community health and wellness programs.

photo of NCUIH staff at Phoenix Indian School Visitor Center

NCUIH staff visited Phoenix Indian School Visitor Center

NCUIH staff also visited the Phoenix Indian School Visitor Center for a tour led by Patty Talahongva, a former student and former director of the center.​

photo of NCUIH staff at Native American Connections

NCUIH staff visited Native American Connections

Native American Connections owns and operates 22 sites throughout Phoenix offering a continuum of affordable housing, health, and community development services that touch and change the lives of over 10,000 individuals and families each year.

Upcoming Events and Important Dates​

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Upcoming Events:

  • May 8-9​ – California Consortium of Urban Indian Health Conference​
  • May 10 ​- Tribal Consultation and Urban Confer: IHS Health Information Technology Modernization Resources​
  • May 10 at 10am – Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies Hearing on the FY24 budget request for Indian Country. Tune here.
  • May 15-18 ​- NCUIH Annual Conference​
  • June 4-8 ​- NCAI 2023 Mid-Year Convention & Marketplace​
  • June 21 ​- Next NCUIH Monthly Policy Workgroup Meeting

Upcoming Comments and Submissions​:

  • May 19 – Comment deadline for HHS Budget Testimony​

ICYMI:

  • On March 3, NCUIH submitted comments to HHS Office of the Assistant Secretary of Health (OASH) on Strengthening Primary Care.
  • On April 7, NCUIH submitted comments to IHS on Health IT (HIT) Modernization: Preparing for Change.
  • On April 24, NCUIH submitted comments to IHS on Access to Federal Medical Supplies.

VA Approves Copay Exemption for American Indian and Alaska Native Veterans

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On April 3, 2023 the Department of Veterans Affairs (VA) announced that American Indian and Alaska Native (AI/AN) veterans are exempt from copay requirements for urgent care or healthcare provided by VA. Under this new policy, the VA will reimburse copays paid on or after January 5, 2022, and it will waive future copays for AI/AN veterans. VA Secretary Denis McDonough stated “American Indian and Alaska Native Veterans deserve access to world-class health care for their courageous service to our nation. By eliminating copays, we are making VA health care more affordable and accessible — which will lead to better health outcomes for these heroes.” For years, the National Council of Urban Indian Health (NCUIH) has worked to remove copayment barriers for AI/AN veterans at the VA and recently provided comments to the VA’s Proposed Rule on the Copayment Exemption for AI/AN Veterans and was successful in getting the agency to remove a proposed cap on the amount of urgent care visits which qualify for the exemption. This is a significant victory that will directly impact the level of access to health care for AI/AN veterans. Current eligibility for the copay exemption is available to AI/AN Veterans who met the definition of “Indian” or “urban Indian” under the Indian Health Care Improvement Act.

Background

The copay exemption is a significant step to upholding the federal government’s trust responsibility to “maintain and improve the health of the Indians.” AI/ANs serve in the military at one of the highest rates of any group in the United States and many Native veterans receive healthcare from the Veterans Health Administration, an agency within VA, in addition to utilizing IHS, Tribal, and UIO facilities. Unfortunately, AI/AN veterans generally have a higher prevalence of mental health disorders compared with White veterans, and among all veterans, the prevalence of suicidal ideation is highest for those reporting a diagnosis of depression, anxiety, or post-traumatic stress disorder. Further, an estimated 86.2 percent of AI/AN veterans that live in urban areas generally have higher unemployment, lower education attainment, lower income, higher VA-service connected disability, and generally live in poorer housing conditions than non-Native veterans also living in urban areas.

NCUIH’s Role

NCUIH continuously advocates for Native veterans living in urban areas to ensure that they have access to the high-quality, culturally competent care the country owes to them for their military service and as a result of federal trust responsibility. In February 2023 NCUIH submitted comments to the VA regarding the copay exemption proposed rule and expressed VA copayments have historically represented a significant barrier to AI/AN veterans’ ability to access the healthcare this Nation owes them through VA facilities. NCUIH further recommended VA utilize self-attestation in determining eligibility for copay exemptions, VA cover all urgent care visits needed by Indian or urban Indian veterans, VA make clear that the copay exemption exists because of the trust responsibility, and VA host an Urban Confer and Tribal Consultation on the copay exemption. NCUIH appreciates the VA’s commitment to ensuring quality health care is more accessible for Indian and urban Indian veterans.

Medicaid and CHIP Enrollment Surges Amid Pandemic, Native People at Risk as Federal Continuous Enrollment Provision Expires

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Preliminary data for December 2022 shows that total Medicaid and CHIP enrollment grew by 21.2 million to a total of 92.3 million since February 2020. KFF estimates that Medicaid/CHIP enrollment will reach 95 million by March 2023.  This increase in enrollment is due, in part, to the continuous enrollment provision created by the Families First Coronavirus Response Act (FFCRA), which generally barred states from disenrolling Medicaid enrollees in exchange for receiving a temporary increase in the federal match rate. The federal continuous enrollment provision expired on March 31, 2023, meaning that states can now resume disenrollments, which had been paused since Congress passed FFCRA in March 2020. The Affordable Care Act (ACA) Medicaid expansion adults, other adults, and children experienced the most growth due to the continuous enrollment provision and are expected to see the largest enrollment declines after disenrollments resume.  Studies estimate that between 5% and 17% of current enrollees may lose their Medicaid coverage.

Increase in enrollment is concentrated in a small number of states with large populations, and therefore large Medicaid programs. One-third of the increase is found in California, New York, Texas, Florida, and Illinois. States who have implemented Medicaid expansion after 2020 – Oklahoma, Missouri, Nebraska, Utah, and Idaho – also have high enrollment growth. According to KFF “[h]ow states manage the large numbers of redeterminations during the “unwinding” of the continuous enrollment provision as well as how states engage with enrollees and other stakeholders, will impact the continuity of coverage for millions of Medicaid enrollees.”

Estimated Enrollment Growth From February 2020 to March 2023, by Eligibility Group and State

State CHIP Enrollees Children Under 19 ACA Adults Other Adults Adults Eligible Based on Disability or Age (65+) All
Arizona 42,300 223,300 221,100 159,700 -8,800 637,600
California -39,100 606,200 1,486,000 789,500 -13,100 2,829,500
Colorado -25,500 116,800 252,900 136,200 -16,000 464,400
Illinois -25,700 257,800 641,000 121,900 32,500 1,027,500
Kansas 19,100 71,100 N/A 42,800 11,000 144,000
Maryland 19,800 96,300 166,600 125,400 -14,400 393,700
Massachusetts 2,000 93,600 161,800 135,700 51,300 444,400
Michigan 57,100 154,200 369,500 187,200 22,100 790,100
Minnesota 600 121,900 117,000 111,400 8,800 359,700
Montana 2,100 17,500 46,600 14,000 -4,000 76,200
Nebraska 5,000 35,600 78,000 15,000 10,500 144,100
Nevada 10,900 70,200 164,300 54,900 -9,600 290,700
New Mexico 10,000 49,600 93,400 39,300 -18,500 173,800
New York -59,500 320,400 895,800 452,200 -2,400 1,606,500
Oklahoma 7,000 148,100 293,100 74,700 59,600 582,500
Oregon 47,900 31,200 241,500 103,400 -27,000 397,000
South Dakota 2,500 21,100 N/A 9,900 3,700 37,200
Texas -97,000 1,090,300 N/A 323,600 242,500 1,559,400
Utah -6,700 65,200 49,900 44,700 22,100 175,200
Washington 3,200 103,900 347,500 60,500 -8,700 506,400
Wisconsin 12,300 132,200 N/A 208,900 47,500 400,900
Medicaid Unwinding and American Indians and Alaska Natives (AI/ANs)

Native people may be at an increased risk of disenrollment in Medicaid and CHIP programs during the Medicaid unwinding period. Once disenrollments are completed, estimates say 12% of AI/AN children and 6% of AI/AN adults will lose CHIP or Medicaid coverage. There are also administrative barriers that may lead to a higher risk of losing coverage, such as geographical remoteness, limited access to internet or phone service, and language barriers.

Patients at Urban Indian Organizations (UIOs) may lose their Medicaid coverage as a result of the unwinding, and inadequate health insurance coverage or gaps in coverage may cause UIO patients to delay or avoid medical care altogether.  The federal government has a trust responsibility to provide federal health services to maintain and improve the health of AI/AN people. Medicaid and CHIP are critical to fulfilling the United States’ trust responsibility to maintain and improve AI/AN health.  NCUIH recently led over 200 organizations in urging the Administration to take concrete steps to ensure that eligible individuals and families do not lose Medicaid/CHIP coverage for purely administrative reasons during the unwinding period. You can read more about this effort here.

NCUIH Urges Senate and House Appropriations Committees to Provide Full Stable Funding for IHS and Urban Indian Health in FY 2024

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On April 8, 2023, the National Council of Urban Indian Health (NCUIH) sent a letter to Chairman Jeff Merkley (D-OR) and Ranking Member Lisa Murkowski (R-AK) of the Senate Interior Appropriations Committee requesting full funding for the Indian Health Service (IHS) and urban Indian health, advance appropriations for IHS, and resources for Native behavioral health in Fiscal Year (FY) 2024. On March 24, 2023, NCUIH also sent a letter to Chairman Kay Granger (R-TX-12) and Ranking Member Rosa DeLauro (D-CT-3) of the House Interior Appropriations Committee with the same requests.

The letter emphasizes the critical role that urban Indian organizations (UIOs) play in health care delivery to American Indian and Alaska Native (AI/AN) patients and the importance of providing UIOs with the necessary funding to continue to provide quality, culturally competent care to their communities. The requests included in the letter are efforts to achieve parity and uphold the federal trust responsibility for urban Natives.

In the letters, NCUIH requested the following:

  • $51.42 billion for IHS and $973.59 million for Urban Indian Health for FY24, as requested by the Tribal Budget Formulation Workgroup (TBFWG)
  • Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
  • Appropriate $80 million for the Native Behavioral Health Resources Program

These requests come at an important time to protect funding for urban Indian health. Current debt ceiling negotiations by Congress include proposals to cut spending for domestic programs and return funding for federal agencies to FY 2022 levels. These proposals would be detrimental to the success of IHS, Tribal organizations, and UIOs and would roll back historic funding levels that contribute to better health outcomes for Native communities. It is important that members of the House and Senate work to protect the health of all American Indians and Alaska Natives.

Full Letter Text

On behalf of the National Council of Urban Indian Health (NCUIH), the national advocate for health care for the over 70% of American Indians and Alaska Natives (AI/ANs) living off-reservation and the 41 Urban Indian Organizations (UIOs) that help serve this population, we write to respectfully request that Congress honor the federal trust responsibility by ensuring the following asks for Indian Country in Fiscal Year (FY) 2024:

  • $51.42 billion for the Indian Health Service (IHS) and $973.59 million for Urban Indian Health for FY24, as requested by the Tribal Budget Formulation Workgroup (TBFWG)
  • Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
  • Appropriate $80 million for the Native Behavioral Health Resources Program

We applaud the Committee’s longstanding leadership to ensure the trust responsibility for health care is upheld and honored for all AI/AN, especially last year with achieving advance appropriations for IHS.

UIOs Play a Critical Role in Providing Health Care for AI/ANs

UIOs are on the front lines in providing for the health and well-being of AI/ANs living off-reservation, many whom lack access to care that would otherwise be provided through on-reservation health care facilities. UIOs play a critical role in fulfilling the federal government’s responsibility to provide healthcare for AI/ANs and are an integral part of the Indian health system, which is comprised of the IHS, Tribal organizations, and urban Indian organizations (collectively, the I/T/U system). UIOs are critical health care access points to help serve the over 70% of AI/ANs in urban areas. Congress must do more to fully fund the IHS to improve health outcomes for all Native populations.

Need for Full Funding of the Indian Health System including Urban Indian Health

It is the policy of the United States “to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.” This requires that funding for Indian health must be significantly increased if the federal government is to finally fulfill its trust responsibility. At a minimum, funding must be maintained and protected as budget-cutting measures are being considered. UIOs are reporting historic levels of patients, need funding to fulfill the needs of the majority of the AI/AN population. Full funding will empower UIOs to hire more staff, pay appropriate wages, as well as expand vital services, programs, and facilities. Congress must do more to increase funding as the current FY23 funding level of $90.49 million which is only 9.3% of the full FY24 amount requested by Tribes and UIOs to meet current need.

Retain Advance Appropriations for IHS until Mandatory Funding is Enacted and Protect IHS from Sequestration

We applaud this Committee for your work on the historic inclusion of advance appropriations in the FY23 Omnibus.  This is a crucial step towards ensuring long-term, stable funding for IHS. Previously, the I/T/U system was the only major federal health care provider funded through annual appropriations. It is imperative that this Committee retain advance appropriations and ensure that IHS is protected from sequestration.

The GAO cited a lack of consistent funding as a barrier for IHS. The Congressional Research Service stated that advance appropriations would lead to cost savings as continuing resolutions (CRs) “prohibits the agency from making longer-term, potentially cost-saving purchases.” Lapses in federal funding quite literally put lives at risk. During the shutdown at the start of FY 2019, the Indian health system was the only federal healthcare entity that shut down. UIOs are so chronically underfunded that several UIOS had to reduce services, lose staff, or close their doors entirely, forcing them to leave their patients without adequate care. It is imperative that advance appropriations provide certainty to the IHS system and ensure unrelated budget disagreements do not put lives at stake.

Advance appropriations will improve accountability and increase staff recruitment and retention at IHS. When IHS distributes their funding on time, our UIOs can pay their doctors and providers. During a pandemic that has ravaged Indian Country and devasted the workforce, being able to recruit doctors and pay them on time is a top priority.

While advance appropriations are a step in the right direction to avoid disruptions during government shutdowns and continuing resolutions (CRs), mandatory funding is the only way to assure fairness in funding and fulfillment of the trust responsibility. Until authorizers act to move IHS to mandatory funding, we request that Congress continue to provide advance appropriations to the Indian health system to improve certainty and stability.

Cuts from sequestration, the automatic spending cuts that occur through the withdrawal of funding for government programs, force I/T/U providers to make difficult decisions about the scope of healthcare services they can offer to Native patients. For example, the $220 million reduction in IHS’ budget authority for FY 2013 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for AI/ANs. Therefore, we request that you exempt IHS from sequestration and other budget cutting measures as is required by the trust responsibility.

Appropriate $80 Million for the Native Behavioral Health Resources Program

Native people continue to face high rates of behavioral health issues caused by generational trauma and federal policies. Native people experience serious mental illnesses at a rate 1.58 times higher than the national average, and high rates of alcohol and substance abuse. In fact, between 1999 and 2015, the drug overdose death rates for Native populations increased by more than 500%. Native youth also experience the highest rates of suicide and depression, with the Native youth suicide rate being 2.5 times that of the national average.

In response to these chronic health disparities, Congress authorized $80 million to be appropriated for the Native Behavioral Health Resources Program for fiscal years 2023 to 2027. Despite authorizing an appropriation of $80 million for the Program, Congress did not appropriate that sum for FY 23.

We request that the authorized $80 million be appropriated to the Native Behavioral Health Resources Program for FY 24 and each of the remaining authorized years. Until the committee appropriates funding for this program, critical healthcare programs and services cannot operate to their full capability, putting Native lives at-risk. We ask that this essential step is taken to ensure our communities have access to the care they need.

Conclusion

Among the most sacred of the duties encompassed within the federal trust responsibility is the duty to provide for Indian health care. The United State’s failure to fulfill its obligations to provide health care to urban Indians has real and devastating effects on our communities. We urge Congress to act swiftly to redress this problem by appropriating $51.42 billion for the Indian Health Service and $973.59 million for Urban Indian Health in the FY24 Interior, Environment, and Related Agencies Appropriations. NCUIH looks forward to working with you as you craft a budget that upholds the trust responsibility to urban Indians.

Resources