Urban American Indian Undercount in the 2020 Census Went Underreported

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Figure 1: Interactive National Map of Urban Indian Organization (UIO) Service Areas showing the Distribution of American Indian/Alaska Natives (AI/AN) and Self-Response Rate (SRR)

There have been concerns for growing inaccuracies in the U.S. Decennial Census in recent decades, particularly affecting marginalized communities.  The most recent Decennial Census seems to have continued these inaccuracies, undercounting Black, Hispanic and American Indian and Alaska Native (AI/AN) peoples.i,ii The undercount for the AI/AN population living on reservation in the 2020 Decennial Census was reported in several publications after Census results were first announced by the Census Bureau .iii,iv, v,vi However, the undercount of the off-reservation AI/AN population, which includes urban AI/AN people, did not receive similar coverage by  the mainstream media, despite similar effects. Failure to report on the undercount of the urban AI/AN population contributes to the existing research gap and may impact federal health policy relating to this population.

Background: Undercount on Reservations and in the U.S. Balance

 After the Decennial Census, the U.S. Census Bureau conducted a Post-Enumeration Survey, to estimate the accuracy of the census, and estimating over- or undercount by state and demographic groupvii. In a demographic analysis of the undercount, the U.S. Census separated the nation’s AI/AN population into three groups:viii

  1. “On Reservation”: “the AI/AN population living within a federally or state recognized Indian reservation”
  2. “American Indian Areas Off Reservation”: “populations of AI/AN on lands not considered a reservation” This includes trust lands, tribal jurisdiction statistical areas, tribal designated statistical areas, Alaska Native Regional Corporations, and Alaska Native village statistical areas.
  3. “Balance of the United States”: everything else, including the many large cities across the county.

The Census undercount report found that in 2020, there was a statistically significant undercount of AI/AN people in both “On Reservation” and “Balance of the United States” populations. This undercount is shown in Table 4 from the U.S. Census Demographic Analysis which is provided in Figure 2 below. We recognize that “Balance of the United States” is not precisely the same as urban areas, since it also includes many non-urban areas that are not part of Tribal lands.  This adds another layer of inaccuracy, since inaccuracies specific to the urban AI/AN population count is hidden within the “Balance of the United States” undercount.  The majority of AI/AN people (over 70%) live in the “Balance of the United States”, including in the 38 metropolitan areas where Urban Indian Organizations (UIOs) are present.ix, x

Figure 2: Net Coverage Error Rates for Household Populations in the United States by Race and Hispanic Origin from the U.S. Census Post-Enumeration Survey Demographic Analysis.

Source: U.S. Census Bureau: Decennial 2020 Census: Post-Enumeration Survey Demographic Analysis.

The undercount for the “Balance of the United States” AI/AN population, which includes urban AI/AN populations, was mostly unreported by mainstream media sources. These sources pointed to the large undercount in the African-American, Hispanic, and the AI/AN population living “On Reservation”, but they failed to mention the statistically significant undercount among the AI/AN population in the “Balance of the United States”. In fact, one institution published “the American Indian or Alaska Native population not living on reservations was not miscounted.” This statement is incorrect, since the U.S. Census Demographic Analysis showed a statistically significant undercount of 0.9% in the AI/AN population in the “Balance of the United States” in 2020.xi This dismissal continues the erasure of the urban AI/AN population in data, news, and the consciousness of the public.

Census Enumeration Process: Self-Response Rate

To understand better how undercounting can occur we must take a closer look at the process of collecting data for the Census.  The first stage of the Census is the self-response operations. This is when each household in the country is sent the US Census survey to fill out and return. The 2020 Decennial Census was the first-time respondents were allowed to return their census online instead of by phone or mail. Self-response is considered the “gold standard” of census taking because of its high accuracy.xii Some areas followed an Update/Enumerate (UE) method, where census enumerators were sent to interview households and update the address frame, or an Update/Leave (UL), where the enumerator goes to the location to update the address frame and then leaves census forms there. These areas included Remote Alaska areas and American Indian areas that requested for initial interviews to be done by an enumerator. After the period for self-response expires, the U.S. Census undergoes Non-Response Follow-Up (NRFU) operations which include sending enumerators to confirm vacancies, conduct in person interviews and using administrative records to impute demographic information about incomplete enumerations.xiii Despite efforts to improve accurate coverage during NRFU, enumerations from NRFU increase the chance of erroneous enumeration and omission compared to enumerations from the self-response phase.xiv

NCUIH Self-Response Rate Analysis

NCUIH analyzed the cumulative self-response rate (SRR) by census tract within the 38 cities served by UIOs and compared it against the AI/AN population in those tracts.xv,xvi We chose to limit our analysis to UIO service areas in order to focus on an urban AI/AN population with access to the culturally competent healthcare and community services provided by these UIOs. In this analysis, we combined those who identified as AI/AN alone as well as those that identified as AI/AN in combination with other races, henceforth referred to as “AI/AN alone or in combination”.  To protect identification of AI/AN people, census tracts with fewer than 20 AI/AN people were excluded. Additionally, census tracts where the population was less than 0.5% AI/AN were also excluded for the same reason. Finally, to respect the sovereignty and privacy of Tribes with land in UIO service areas, census tracts with American Indian land in them were also excluded. In all, 20,423 census tracts were included in our analysis, while 1,228 census tracts were excluded for any of the previously listed reasons.

In our analysis we used graphs and linear regression to determine the association of AI/AN population concentration and SRR, for all UIO service areas aggregated as well as for each service area separately.  We also used maps to show the distribution of AI/AN population within these UIO service areas, and the relationship with SRR.

SRR Results

Our regression analysis indicated a statistically significant negative association between AI/AN population and SRR. For every 1% increase in the AI/AN percentage of the tract population, the self-response rate decreases by 0.68 percentage points.

In the data tool below, Figure 3, a scatter plot with a line-of-best fit is plotted relating the percentage of AI/AN people and the SRR for each UIO service area. Each point in the scatter plot represents each census tract. You can change the UIO service areas by clicking on the arrow tabs at the top of the tool. Additionally, the data tool includes a drop-down menu to select a specific service area of interest.

Figure 3: Interactive Graph showing Association between AI/AN Population Concentration and SRR in UIO Service Areas

The map data tool at the top of the page, Figure 1, can be used to explore service areas in more detail.

  • To view one of the infocards about a particular UIO service area, click on one of the circles where a UIO is located, and the tool will zoom into a card showing information about self-response rates and the AI/AN population in the service area.
    • Each card includes the total AI/AN alone or in combination population in that area as of the 2020 Decennial Census as well as two maps, one showing the self-response rates by census tract and another showing the AI/AN population percentage by census tracts.
    • Census tracts that were excluded in the analysis were not shown in these maps.
    • The card also includes the average self-response rate for the tracts in the area in addition to the percentage of tracts with low SRR (<60%) and the percentage with high SRR (80%+).
    • Each card includes the percentage of the AI/AN population that lives in the low SRR tracts and the percentage that live in the high SRR tracts.
  • There are two hidden zoom areas for western Montana and northern California to select a UIO more precisely in those regions.
  • To return to the entire map, click on the “home” button on the right side of the data tool, or scroll out with the mouse wheel.
  • The data tool also includes a glossary of terms and data sources used to do this analysis at the bottom right of the “home” map.

In sixteen UIOs service areas, AI/AN population is more strongly associated with lower self-response rate, which you can see where the percentage of AI/AN population in low SRR tracts is higher than the tracts with an SRR less than 60%.

Discussion of NCUIH SRR Analysis Results

Others have demonstrated the relationship between low self-response rate and increased inaccuracy in the U.S. Census.xii,xvii,xviii Between the significant undercount of AI/AN people in cities and the underreporting of the undercount, the urban AI/AN community remains partially hidden from the general population’s and decision maker’s view. The implications of this undercount to the urban AI/AN community are many, including inaccurate reference data needed to inform survey design aiming to record urban AI/AN respondents.19xix This will only exacerbate the gap in research on this overlooked population. Additionally, this undercount could jeopardize health in the population, as federal spending calculations, including the budget for the Indian Health Service, are affected.xx,xxi,xxii

As the U.S. Bureau of the Census undergoes its planning of the 2030 Census procedures, we need to have voices and evidence showing the arbitrary inequities in enumeration. Research such as this shows the need for changes, as we cannot forget that urban AI/AN people exist and thrive, and issues and inequities that affect this community cannot be overlooked.

i US Census Bureau Newsroom Archive. (2012, May) Census Bureau Releases Estimates of Undercount and Overcount in the 2010 Census. U.S. Census Bureau. https://www.census.gov/newsroom/releases/archives/2010_census/cb12-95.html#:~:text=The%202010%20Census%20undercounted%202.1%20percent%20of%20the,0.7%20percent%20was%20not%20statistically%20different%20from%20zero.

ii Kreiger, N (2019, Aug). The US Census and the People’s Health: Public Health Engagement from Enslavement and “Indians not Taxed” to Census Tracts and Health Equity (1780-2018). American Journal of Public Health: 109(8):1092-1100. doi: 10.2105/AJPH.2019.305017.

iii Wines, M. and Cramer M. (2022) “2020 Census Undercounted Hispanics, Black and Native American Residents.” The New York Times. https://www.nytimes.com/2022/03/10/us/census-undercounted-population.html.

iv Schneider, M. (2022) “Some Minority Groups Missed at Higher Rates in 2020 US Census.” AP News. https://apnews.com/article/us-census-bureau-hispanics-census-2020-d284cdbe32fd9ad1a1ad3794cd4d0362.

v Wang, H.L. (2022) “The 2020 census had big undercounts of Black People, Latinos and Native Americans.” National Public Radio. https://www.npr.org/2022/03/10/1083732104/2020-census-accuracy-undercount-overcount-data-quality.

vi Ax, J. (2022) “U.S. Census Undercounted Latinos, Black People and Native Americans.” Reuters. https://www.reuters.com/world/us/us-census-undercounted-black-people-latinos-native-americans-officials-say-2022-03-10/.

vii Marra, E., and Kennel, T. (2022, Mar) Source and Accuracy of the 2020 Post-Enumeration Survey Person Estimates. U.S. Census Bureau. https://www2.census.gov/programs-surveys/decennial/coverage-measurement/pes/2020-source-and-accuracy-pes-estimates.pdf

viii Khubba, S., Heim, K., and Hong, J. (2022) “National Census Coverage Estimates for People in the United States by Demographic Characteristics; 2020 Post-Enumeration Survey Estimation Report.” U.S. Census Bureau. https://www2.census.gov/programs-surveys/decennial/coverage-measurement/pes/national-census-coverage-estimates-by-demographic-characteristics.pdf.

ix Urban Indian Health Institute (2023) Urban Indian Health. Urban Indian Health Institute. https://www.uihi.org/urban-indian-health/#:~:text=7%20out%20of%2010%20American%20Indians%20and%20Alaska,Indians%20and%20Alaska%20Natives%20live%20in%20urban%20areas.

x Whittle, J (2017, Sep) Most Native Americans Live In Cities, not Reservations. Here are their Stories. The Guardian. https://www.theguardian.com/us-news/2017/sep/04/native-americans-stories-california.

xi Benson, S. (2022) “Census undercounted Black people, Hispanics, and Native Americans in 2020”.Politico. https://www.politico.com/news/2022/03/10/2020-census-undercount-black-people-hispanics-native-americans-00016138.

xii Salvo, J.J., Jacoby, A., and Lobo, A.P. (2020) Census 2020: Why Increasing Self-Response is Key to a Good Count. Significance. https://academic.oup.com/jrssig/article/17/1/30/7029480.

xiii Fontenot, A.J. (2022, Feb) 2020 Census Operational Plan: A New Design for the 21st Century. U.S. Census Bureau. https://www2.census.gov/programs-surveys/decennial/2020/program-management/planning-docs/2020-oper-plan5-and-memo.pdf.

xiv O’Hare, W.P. (2020) Are Self-Participation Rates Predictive of Accuracy in the U.S. Census? International Journal of Social Science Studies: 8(6). https://doi.org/10.11114/ijsss.v8i64967.

xv CRVRDO. (2021) US Census PL 94-171 Redistricting Data. United States Census Bureau. https://www.census.gov/programs-surveys/decennial-census/about/rdo/summary-files.html.

xvi United States Census Bureau. (2021) Decennial Census Self-Response Rates (2020, 2010). United States Census Bureau. https://www.census.gov/data/developers/data-sets/decennial-response-rates.html.

xvii Center for Urban Research (2020). “Census Self-Response Rates Mapped: 2000, 2010, 2020.” The Graduate Center: City University of New York. https://www.gc.cuny.edu/center-urban-research/research-projects/census-maps.

xviii Center for Urban Research (2020). “HRC 2020: Hard-to-Count Maps.” The Graduate Center: City University of New York. https://www.censushardtocountmaps2020.us/?latlng=40.01079%2C-98.08594&z=4&promotedfeaturetype=states&baselayerstate=3&rtrYear=sR2020latest&infotab=info-rtrselfresponse&filterQuery=false.

xix Jacobson, L. (2020) “Could an Undercounted 2020 Census Affect a Range of Federal Statistics.” Politifact. https://www.politifact.com/article/2020/aug/26/could-undercounted-2020-census-afflict-range-feder/#:~:text=Problems%20with%20the%20basic%20population%20count%20could%20have,spending%2C%20education%2C%20income%2C%20inequality%2C%20and%20poverty%2C%20experts%20said.

xx Macagnone, M (2020, June) Census Trying to Fix History of Undercounting Minorities. Roll Coll: Policy. https://rollcall.com/2020/06/18/census-trying-to-fix-history-of-undercounting-minorities/.

xxi Hale, K (2020, Mar) Being Undercounted in the U.S. Census Costs Minority Communities Millions of Dollars. Forbes. https://www.forbes.com/sites/korihale/2020/03/24/being-undercounted-in-the-us-census-costs-minority-communities-millions-of-dollars/?sh=5f24d6ce3aa0.

xxii George Washington Institute of Public Policy (2020, Apr) Counting for Dollars 2020: The Role of the Decennial Census in the Geographic Distribution of Federal Funds. The George Washington University. https://gwipp.gwu.edu/counting-dollars-2020-role-decennial-census-geographic-distribution-federal-funds.

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August Policy Updates: Budget Updates, UIO Focus Groups, & Important RFIs

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Welcome to the August edition of our monthly policy newsletter, delivering the latest updates and insights on key developments.

Budget Update:

Budget #

House Status:

  • The House Appropriations Committee advanced the Interior Appropriations bill on July 18.

Go deeper: House IHS Funding Bill Passes out of Committee with Advance Appropriations and Modest Increase for the Indian Health Service

Senate Status:

  • On July 27, 2023, the Senate Appropriations Committee passed their bill out of committee with a vote of 28-0 and will advance to the Senate floor for initial passage.
  • Similar to the House Bill, the Senate IHS Funding Bill also included Advance Appropriations and a modest increase for the Indian Health Service.
  • Establishment of UIO Interagency Workgroup: The bill also includes direction for IHS to establish a UIO Interagency Workgroup with the IHS, Department of Health and Human Services, Department of Housing and Urban Development, Department of Agriculture, Department of Justice, Department of Education, Department of Veteran Affairs, Department of Labor, the Small Business Administration, the Economic Development Agency, FEMA, the U.S. Conference of Mayors, and others as identified by UIOs.​

Next Steps:

  • With the government funding deadline of September 30 rapidly approaching, Congressional leaders are negotiating a continuing resolution to fund the government at the current level until December.
  • A continuing resolution will give Senate and House leadership time to negotiate a final bill that can pass in both chambers.

Upcoming Events and Important Dates: UIO Listening Session, National Fentanyl and Opioid Summit

Calendar with events on it

Upcoming Comments and Submissions​:

  • September 1 – Comment deadline to the Indian Health Service on Health Information Technology Modernization​
  • September 15 – Comment deadline to the DOI, DOJ, and Department of Health and Human Services on Strengthening the Indian Child Welfare Act (ICWA) ​

Upcoming Events

  • August 22-24: IHS – Partnership Conference.​
  • August 22-24: National Indian Health Board/Northwest Portland Area Indian Health Board is hosting a National Fentanyl and Opioid Summit​
  • August 23: NCUIH UIO Listening Session on HIV/AIDS. Register here.
  • August 29: Substance Abuse Mental Health Services (SAMHSA) Tribal Technical Advisory Committee Meeting​
  • August 29: SAMHSA Tribal Listening Session and Virtual Tribal Consultation on Behavioral Health and Substance Use Disorder Resources for Native Americans​
  • August 29-30: DOI Self-Governance Advisory Committee Meeting​
  • August 30-31: IHS Tribal Self-Governance Advisory Committee Meeting​
  • September 6: IHS – Advance Appropriations Listening Session for Tribal and UIO to share information and solicit input on advance appropriations implementation.​ UIOs are encouraged to attend and ask any questions you have regarding advance appropriations and their impact on your contracts. Click here to join the listening session.

Important Requests for Information from UIO Leaders

RFI

We need input from Urban Indian leaders to help shape our advocacy and comments to federal agencies on policies affecting UIOs and American Indians/Alaska Natives living in urban areas.

Please email policy@ncuih.org with information on the following:

DOI – Strengthening ICWA

  • Does your UIO work with State courts or child welfare agencies on child welfare or if not, would you like to?​
  • Does your UIO work with Tribes on child welfare or if not, would you like to?​
  • How can we improve the implementation of ICWA for Native children in urban areas? ​

DOJ – Medical/Legal Partnership​s

NCUIH recently met with the DOJ Office for Access to Justice (ATJ). ATJ is looking to support increased access to legal assistance for urban Native communities.

  • Do any UIOs have successful medical-legal partnerships?

IHS – Medicaid fraud schemes targeting American Indians and Alaska Natives

IHS Director Tso wrote a letter to Tribal and UIO leaders regarding fraudulent billing activities of registered behavioral health providers, and it appears to now be affecting programs in the Billings Area.​

  • Have any of your organizations been impacted by fraudulent residential treatment practices exploiting vulnerable Native communities?​

Medicaid Unwinding

  • How is unwinding proceeding in your state?
  • Do you have any data regarding AI/AN disenrollment?​

NCUIH Requests Urban Indian Inclusion in MMIP and Human Tracking Initiatives

Not Invisible Commission

Secretary Deb Haaland and Deputy Attorney General Lisa Monaco hosted the first in-person plenary session of the Not Invisible Act Commission at the U.S. Department of the Interior in Washington, D.C. in February 2023.

On August 10, NCUIH submitted comments to the Department of Interior’s (DOI) Not Invisible Act Commission regarding the Missing and Murdered Indigenous People (MMIP) and human trafficking (HT) crises​ to ensure that urban Native communities are considered.

The bottom line: NCUIH recommended that the Commission ensure that resources are available to combat MMIP, HT, and violent crime against American Indians and Alaska Natives in urban areas.

Why it matters: The federal government must ensure that it properly tracks and reports data on instances of missing persons, murder, and human trafficking of American Indians and Alaska Natives in urban areas.​

Go deeper: Learn more about the Not Invisible Commission.

Legislative Updates: Native American Child Protection Act Advances in House, Advance Appropriations Legislation Introduced

ICWA

In June, the Native American Child Protection Act (H.R. 663/S.2273) was passed by unanimous consent out of Natural Resources.​ The bipartisan legislation amends the Child Protection and Family Violence Prevention Act to include UIOs in the Indian Child Abuse Treatment Grant Program and permits UIOs to sit on the National Indian Child Resource and Family Services Advisory Board.​

On July 24, the House and Senate introduced the Indian Program Advance Appropriations Act (H.R. 4832/ S. 2424)​ to provide advanced appropriations for the Bureau of Indian Affairs, the Bureau of Indian Education, and the Indian Health Service.

Upcoming: NCUIH UIO Focus Groups

NCUIH UIO Focus Groups

We are excited to announce our upcoming virtual web series, “NCUIH UIO Focus Groups: Setting Policy Priorities for 2024.”

Why it matters: The focus groups will also provide an invaluable opportunity to reflect on the achievements and challenges of 2023, fostering a deeper understanding of the progress made and the areas that require further attention.

The big picture: Participants will be encouraged to share their personal experiences, insights, and feedback, ensuring that the perspectives of our UIO partners play a pivotal role in shaping the path forward.

  • October 3: Full Ambulatory​ at 1:00-2:30 pm EDT [Register Here]
  • October 3: Outpatient and Residential​ at 3:00-4:30 p.m. EDT​ [Register Here]
  • October 4: Limited Ambulatory​ at 1:00-2:30 p.m. EDT​ [Register Here]
  • October 4: Outreach and Referral​ at 3:00-4:30 p.m. EDT​ [Register Here]
  • October 5: Makeup Session​ at 1:00-2:00 p.m. EDT [Register Here]

What if I can’t make it?: If you cannot attend your facility-type session or the makeup session, NCUIH will schedule a one-on-one session with you. Please email policy@ncuih.org to request a one-on-one session.

NCUIH In Action

ncuih

MR presenting NCUIH Vice President of Policy and Communications, Meredith Raimondi, presents at IHS Bemidji Area Meeting with Urban Indian Leaders

On July 20, NCUIH presented on urban Indian health updates at the IHS Bemidji Area Urban-face to-face meeting and gave an update on relevant federal policies, appropriations, Supreme Court cases, and legislation.​

Culleen Presents

NCUIH/NORC Report Briefing for CMS TTAG

On July 26, NCUIH staff (Chandos Culleen, JD, Director of Federal Relations, Isaiah O’Rear, M.A., M.Ed, Health Policy Statistician & Nahla Holland (Eastern Pequot Tribal Nation) Research Associate) presented to the Centers for Medicare & Medicaid Services Tribal Technical Advisory Group on our Traditional Healing and Primary Care Case Management/Indian Managed Care Entity Reports.​

Francys presents

NCUIH CEO, Francys Crevier, participates in a panel discussion on Native life expectancy

On August 9-10, the University of New Mexico Center for Native American Health hosted its “Native American Life Discrepancy in 2023: A Chronic Disease of Injustice” Symposium. ​NCUIH CEO, Francys Crevier explored the intersection of historical injustices, socio-economic challenges, and systemic barriers that continue to contribute to significant health issues facing Indian Country. She highlighted the critical importance of collaborative efforts, policy advocacy, and community-driven initiatives in addressing these inequalities and fostering sustainable positive change for urban Native American health and well-being.

Thank you for all your hard work and advocacy!

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IHS Hosts Listening Session on Advance Appropriations, Provides Updates to Tribes and UIOs on Goals, Implementation Timelines, and Payment Processes

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On August 17, 2023, the Indian Health Service (IHS) hosted a listening session for Tribal and urban Indian organization (UIO) leaders to share information and solicit input on advance appropriations implementation. During the listening session, IHS shared that they are currently on track in terms of advance appropriations implementation. In September, IHS plans to start apportionment review and processing and in October, IHS will start distributing funds across the Indian Health, Tribal, and UIO (I/T/U) system. During this process, IHS is seeking input from Tribal and UIO Leaders on advance appropriations implementation regarding the following questions:

  • What additional information would be helpful to you?
  • Are there any considerations you think IHS is missing?
  • What is the best way to collect information about the impact of advance appropriations and success stories?

The IHS will host an identical listening session on Wednesday, September 6, 2023, from 3:00-4:30 p.m., Eastern Time. Click here to join the listening session.

Payment Processes

HHS financial systems will re-open after October 1, 2023, for Fiscal Year (FY) 2024 activities. All of the timelines and requirements to receive a payment remain the same. For example, funds will be paid out according to performance periods. If your UIO contract performance period is October – September, the earliest you could receive a payment for FY2024 is October 2023. If your performance period is November – October, the earliest you could receive a payment for FY2024 is November. Additionally, UIOs must have a signed Federal Acquisition Regulation (FAR) contract in place to receive a FY2024 payment.

Activities that did not receive FY 2024 advance appropriations include the following:

  • Electronic Health Record Modernization
  • Indian Health Care Improvement Fund
  • Health Care Facilities Construction
  • Sanitation Facilities Construction
  • Contract Support Costs
  • Section 105(l) Leases (Payments for Tribal Leases)

Background on IHS Advance Appropriations

The FY 2023 Consolidated Appropriations Act (Public Law 117-328) included a total of $5.1 billion in FY 2024 advance appropriations for the Indian Health Service, including the urban Indian health line item. The full year funding level will be available for programs on Oct. 1, 2023, regardless of whether Congress enacts a continuing resolution or full year bill. Advance appropriations provide long overdue funding stability and predictability for the IHS. Congress will determine a final appropriations level for the IHS in the FY 2024 appropriations process and has the ability to significantly increase the IHS budget, in-line with the recommendations of the National Tribal Budget Formulation Workgroup, through additional discretionary appropriations.

NCUIH Advocacy

After tireless advocacy from the National Council of Urban Indian Health (NCUIH) and our partners across Indian Country, Congress included advance appropriations for IHS in the FY 2023 final spending bill to provide stable funding for FY 2024. The current advanced appropriation expires in FY 2025, and NCUIH is continuing its advocacy to secure advanced appropriations for IHS for future years. NCUIH endorsed the bipartisan, bicameral Indian Program Advance Appropriations Act (H.R.4832/S.2424) which was reintroduced by Sen. Lujan (D-NM), Sen. Mullin (R-OK), Rep. McCollum (D-MN-04), and Rep. Cole (R-OK-04) on July 24, 2023. This bill would authorize advance appropriations for several accounts under the Bureau of Indian Affairs and Bureau of Indian Education within the Department of Interior and IHS within the Department of Health and Human Services.

On March 9, 2023, NCUIH CEO Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding and requested that advance appropriations for IHS be maintained. NCUIH also worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations for FY 2024, urging to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. On April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests. Due to this advocacy, advance appropriations for IHS was maintained for FY 2025 in both the House and Senate Interior Appropriations proposed FY 2024 spending bills.

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IHS Provides Guidelines and Resources for IHS, Tribal, and Urban Indian Healthcare Facilities on Combating the Syphilis Epidemic

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On July 19, 2023, Indian Health Service (IHS) released a Dear Urban Leader Letter detailing the current syphilis epidemic impacting American Indian and Alaska Native (AI/AN) communities. AI/AN people have the highest rates of syphilis, which has serious consequences including congenital cases that are linked to stillbirths or infant death occurring shortly after birth. To combat this epidemic, IHS has introduced several guidelines and resources recommended for all IHS, Tribal, and urban Indian organizations (UIOs) healthcare facilities system including:

  • Annual syphilis testing
  • Three-point syphilis testing for all pregnant people
  • Enhance screening rates by screening outside of hospitals and clinics
  • Presumptive treatment of syphilis
  • Create and build awareness and encourage people to get tested and treated

Background

A recent surge in syphilis cases has significantly impacted and affected Indian Country. Given that American Indian and Alaska Native people have highest primary and secondary syphilis rates in the country, it is vital that health care providers and educational campaigns work together to reduce the prevalence of syphilis and other sexually transmitted infections (STIs). Prevention education and outreach can significantly reduce the health disparities caused by syphilis. For more information regarding syphilis prevention and education, Syphilis Resource Hub offers up to date and in-depth trainings and strategies regarding disease control and prevention.

NCUIH’s Role

The National Council of Urban Indian Health (NCUIH) proactively monitors the impact of diseases effecting Indian Country. As part of this effort, NCUIH regularly hosts panels and webinars to keep UIOs and other stakeholders informed about current trends or best practices pertaining to disease control and prevention education. For example, on June 21, 2023, NCUIH hosted an online webinar Strengthening Syphilis Care in Indian Country aimed to tackle challenges, share innovative solutions, and pave the way for enhanced syphilis and other STI services and capacities for UIOs and Americans Indians and Alaska Native people. NCUIH will continue to advocate and monitor for the resources needed to reduce health disparities for American Indian and Alaska Native people regardless of where they live.

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IHS Initiates Listening Sessions for Tribal and Urban Indian Organization Leaders on Advance Appropriations Implementation

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On August 8, 2023, the Indian Health Service (IHS) sent a Dear Tribal Leader and Urban Indian Organization (UIO) Leader letter inviting Tribal and UIO leaders to participate in Agency-sponsored Listening Sessions to share information and solicit input on advance appropriations implementation. IHS will host two (2) identical Listening Sessions for Tribes and UIOs on August 17, 2023, and September 6, 2023. During the Listening Sessions, IHS will share additional information on implementation plans and strategies for advance appropriations, and seek Tribal and UIO input. The information discussed in these sessions will be used to prepare public-facing Frequently Asked Questions and other helpful materials.

Since advance appropriations was included in the final FY 2023 spending bill, the National Council of Urban Indian Health (NCUIH) has consistently requested that IHS host a Tribal Consultation and Urban Confer to ensure Tribes and UIOs are briefed on the implementation process and prepared for fund distribution. NCUIH recently met with IHS Director Roselyn Tso and emphasized the importance of hosting an Urban Confer before October 1, 2023. We look forward to continuing to engage with IHS to ensure successful implementation of advance appropriations for the whole IHS, Tribal, and UIO system.

The Advance Appropriations Implementation Listening Sessions will be on Thursday, August 17, 2023, 12:00-1:30 p.m., ET and Wednesday, September 6, 2023, 3:00-4:30 p.m., ET.

    • Click here to join the Thursday, August 17 Listening Session
    • Click here to join the Wednesday, September 6 Listening Session

Background on IHS Advance Appropriations

The FY 2023 Consolidated Appropriations Act (Public Law 117-328) included a total of $5.1 billion in FY 2024 advance appropriations for the Indian Health Service, including the urban Indian health line item. The full year funding level will be available for programs on Oct. 1, 2023, regardless of whether Congress enacts a continuing resolution or full year bill. Advance appropriations provide long overdue funding stability and predictability for the IHS. Congress will determine a final appropriations level for the IHS in the FY 2024 appropriations process and has the ability to significantly increase the IHS budget, in-line with the recommendations of the National Tribal Budget Formulation Workgroup, through additional discretionary appropriations.

NCUIH Advocacy

After tireless advocacy from the National Council of Urban Indian Health (NCUIH) and our partners across Indian Country, Congress included advance appropriations for IHS in the FY 2023 final spending bill to provide stable funding for FY 2024. The current advanced appropriation expires in FY 2025, and NCUIH is continuing its advocacy to secure advanced appropriations for IHS for future years. NCUIH endorsed the bipartisan, bicameral Indian Program Advance Appropriations Act (H.R.4832/S.2424) which was reintroduced by Sen. Lujan (D-NM), Sen. Mullin (R-OK), Rep. McCollum (D-MN-04), and Rep. Cole (R-OK-04) on July 24, 2023. This bill would authorize advance appropriations for several accounts under the Bureau of Indian Affairs and Bureau of Indian Education within the Department of Interior and IHS within the Department of Health and Human Services.

NCUIH has been advocating that advance appropriations be maintained for IHS until mandatory funding is achieved. On March 9, 2023, NCUIH CEO Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding and requested that advance appropriations for IHS be maintained. NCUIH also worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations for FY 2024, urging to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. On April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests. Due to this advocacy, advance appropriations for IHS was maintained for FY 2025 in both the House and Senate Interior Appropriations proposed FY 2024 spending bills.

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NCUIH Requests IHS Support Interoperability, Reimbursement for Health IT Modernization

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On June 9, 2023, the National Council of Urban Indian Health (NCUIH) submitted comments to the Indian Health Service (IHS) on Health Information Technology (HIT) Modernization in response to the February 6, 2023 joint Dear Tribal Leader and Urban Indian Organization Leader letter and the May 5, 2023 Tribal Consultation and Urban Confer on IHS HIT Modernization Resources. In its comments, NCUIH incorporates previous comments to IHS regarding the HIT modernization and Resource and Patient Management System (RPMS) replacement and again notes that the inclusion of urban Indian Organizations (UIOs) in the HIT Modernization process is consistent with, and required by, the federal government’s trust responsibility and the Indian Health Care Improvement Act and is also sound public health policy. 

Recommendations 

In its comments, NCUIH made the following specific requests, and recommendations to IHS: 

  • Incorporate necessary new capabilities in the modernized Electronic Health Record (EHR) solution. 
    • Ensure that the new EHR contains the full suite of EHR Capabilities. 
    • Supports the unique interoperability needs of UIOs by ensuring that the modernized EHR is either a complete EHR or a modular EHR that a UIO will be able to upgrade as it creates demand for new capabilities. 
  • Develop a timeline for IHS, Tribal, and UIO (I/T/U) facilities to use as a planning base to prepare for the transition to a new system and develop uniform training packages to assist I/T/U facilities in training their staff members on the new EHR. 
  • Take all necessary and practicable steps to secure funding for direct reimbursement of Tribal and UIO facilities for the cost of commercial off-the-shelf (COTS) EHR systems.

Background on NCUIH Work on IHS Health IT Modernization 

NCUIH has submitted several written comments to IHS on HIT Modernization. NCUIH also submitted written testimony to the House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies regarding the Fiscal year (FY) 2024 funding for UIOs in which NCUIH requested increased funding for EHR Modernization. Specifically, NCUIH requested support for the IHS’ transition to a new EHR system for IHS and UIOs by supporting the President’s budget request of $913 million in FY 2024 appropriations. 

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IHS Outlines Strategic Goals including Rapid Disbursement of Funds, for FY 2024 Advance Appropriations Implementation

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On July 19, 2023, the Indian Health Service (IHS) sent a Dear Tribal Leader and Urban Indian Organization Leader letter providing an update on the status of implementing the Fiscal Year (FY) 2024 advance appropriations provided to the IHS. To ensure the successful implementation of advance appropriations, the IHS has identified three strategic goals. Goal 1 aims to distribute FY 2024 advance appropriations for IHS, Tribal, and Urban Indian health programs as close as possible on or after October 1, 2023. Goal 2 aims to ensure regular engagement with Tribal Leaders, Urban Indian Organization (UIO) Leaders, and Congress so that all relevant stakeholders have a clear understanding of the Agency’s progress. Goal 3 aims to demonstrate the impact of advance appropriations to demonstrate the positive impacts.

IHS Strategic Goals for Advance Appropriations

The IHS’s first goal in implementing advance appropriations is to distribute the funds as soon as possible after October 1, 2023. To date, to achieve this goal, the IHS has taken the following steps:

  • Updating existing budget execution systems and internal timelines to allow funds to be distributed as quickly as possible. The IHS has confirmed that all financial systems will support the rapid distribution of funds.
  • Ensuring apportionments, which authorize the expenditure of funds, are prepared and approved timely by the IHS for submission to the Department of Health and Human Services (HHS) and Office of Management and Budget (OMB);
  • Partnering with all IHS Headquarters and Area Office staff involved in payments to Tribal Organizations and UIOs to ensure an effective process; and
  • Upon the enactment of a full year bill, the IHS will distribute any additional funds enacted by Congress as soon as possible after the passage of the bill.

The IHS’s second goal in implementing advance appropriations is to ensure regular outreach and engagement with Tribal Leaders, UIO Leaders, and Congress, so that all relevant stakeholders have a clear understanding of the Agency’s progress. To achieve this goal, the IHS is:

  • Making useful information about advance appropriations implementation available on the IHS Web site; 􀁸 Briefing Tribal Leaders and Urban Indian Organization Leaders on implementation progress during scheduled meetings and/or engagements. Conducting listening sessions, or Tribal Consultation and Urban Confer; and
  • Providing updates to Congress on the IHS’s progress toward implementation.

The IHS’s third goal in implementing advance appropriations is to demonstrate the positive impacts of advance appropriations, including:

  • Partnering with health programs operated by the IHS, Tribes, and UIOs to identify metrics for success, including success stories. The IHS is developing a plan to engage IHS, Tribal, and Urban Indian health programs on an ongoing basis to seek your input on how advance appropriations have improved your ability to provide high-quality health care services.
  • The IHS will complete an evaluation to assess the implementation, impact, and customer service satisfaction regarding the execution of advance appropriations.

Background on IHS Advance Appropriations

In FY 2023, the IHS received the first ever advance appropriation for the FY 2024 Budget. The FY 2023 Consolidated Appropriations Act (Public Law 117-328) included a total of $5.1 billion in FY 2024 advance appropriations for the Indian Health Service, which includes funding at the same level as FY 2023 enacted for nearly all IHS programs. The full year funding level will be available for these programs on Oct. 1, 2023, regardless of whether Congress enacts a continuing resolution or full year bill. Advance appropriations provide long overdue funding stability and predictability for the IHS.

NCUIH Advocacy

After tireless advocacy from the National Council of Urban Indian Health (NCUIH) and across Indian Country, advance appropriations for IHS was included in the FY 2023 final spending bill to provide stable funding for FY 2024. The current advanced appropriation expires in FY 2025, and NCUIH is continuing its advocacy to secure funding for IHS for future years. NCUIH endorsed the bipartisan, bicameral Indian Program Advance Appropriations Act (H.R.4832/S.2424) which was reintroduced by Sen. Lujan (D-NM), Sen. Mullin (R-OK), Rep. McCollum (D-MN-04), and Rep. Cole (R-OK-04) on July 24, 2023. This bill would authorize advance appropriations for several accounts under the Bureau of Indian Affairs and Bureau of Indian Education within the Department of Interior and IHS within the Department of Health and Human Services.

For FY 2024, NCUIH has been advocating that advance appropriations be maintained for IHS until mandatory funding is achieved. On March 9, 2023, NCUIH CEO Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding and requested that advance appropriations for IHS be maintained. NCUIH also worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations for FY 2024, urging to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. On April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests. Due to this advocacy, advance appropriations for IHS was maintained for FY 2025 in both the House and Senate Interior Appropriations proposed FY 2024 spending bills.

Next Steps

NCUIH continues to engage with IHS to ensure the successful implementation of advance appropriations for the whole IHS, Tribal organization, and UIO system. NCUIH encourages IHS to host an Urban Confer before October 1, 2023, to ensure UIOs are briefed on the implementation process and are prepared for fund distribution.

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NCUIH Submits Comments to CMS with Recommendations on Native American Access to Medicaid Services

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On July 3, 2023, the National Council of Urban Indian Health (NCUIH) submitted written comments and recommendations to the Centers for Medicare and Medicaid Services (CMS) Administrator, Chiquita Brooks-LaSure, in response to the May 2, 2023, request for comment on the CMS proposed rule regarding ensuring access to Medicaid services (CMS–2442–P).  NCUIH urged CMS to specifically consider how the proposed sections will advance the Nation’s efforts to fulfill its trust responsibility to provide services to maintain and improve the health of American Indians and Alaska Natives (AI/ANs).

NCUIH recommended that CMS take the following actions:

In its comments, NCUIH recommended that CMS ensure AI/AN representation on each state Medicaid Advisory Committee (MAC) and Beneficiary Advisory Group (BAG), ensure the rule does not impose additional burdensome reporting requirements on providers, engage with the Tribal Technical Advisory Committee (TTAG) to consider regulations or guidance to enforce the state consultation and confer requirements, and support 100% Federal Medical Assistance Percentage (FMAP) for Medicaid services provided at urban Indian organizations (UIOs) to ensure AI/AN Medicaid beneficiaries receive appropriate, quality culturally competent care. By extending this funding mechanism to cover all Medicaid services provided at UIOs, CMS can make substantial progress in reducing the existing barriers to healthcare access faced by urban Native populations.

Background on the Proposed Rule Ensuring Access to Medicaid Services (CMS–2442–P):

The proposed rule, Ensuring Access to Medicaid Services, includes both proposed changes to current requirements and newly proposed requirements that would advance CMS’s efforts to improve access to care, quality, and health outcomes, and better promote health equity for Medicaid beneficiaries across fee-for-service (FFS) and managed care delivery systems, including for home and community-based services provided through those delivery systems. These proposed requirements are intended to increase transparency and accountability, standardize data and monitoring, and create opportunities for states to promote active beneficiary engagement in their Medicaid programs.

Background on Medicaid and AI/ANs:

AI/AN people depend upon Medicaid to receive their healthcare coverage and services. In 2020, over 1.8 million AI/ANs were enrolled in Medicaid. According to a NCUIH analysis of American Community Survey (ACS) data, in 2019 Medicaid covered 1.3 million urban AI/ANs, including 30% of urban AI/AN adults under the age of 65. Medicaid and CHIP are important programs for addressing the significant disparities in insurance coverage which exist for AI/AN people.  For example, according to the Urban Institute, AI/AN children were uninsured at a rate of 8.9% in 2019, the highest rate for any ethnic group in the country.  AI/AN parents were uninsured at a rate of 18.7% in 2019, the second highest rate in the country. The Urban Institute reported that in 2019, AI/AN children remained more than twice as likely as white children to be uninsured and AI/AN were more than 2.5 times more likely to be uninsured than with white parents.

Medicaid is also an important source of funding for to support the operation of the Indian Health system, including UIOs who help serve the approximately 70% of AI/AN people who live in urban areas.  Medicaid remains the largest secondary source of funding for UIO clinics. In 2020, 33% of the total population served at UIOs were Medicaid beneficiaries, and 35% of the AI/AN population served at UIOs were Medicaid beneficiaries. As the Kaiser Family Foundation noted in 2017, “Medicaid funds are not subject to annual appropriation limits . . . since Medicaid claims are processed throughout the year, facilities receive Medicaid funding on an ongoing basis for covered services provided to AIANs.”  Because the Medicaid program receives Mandatory appropriations, Medicaid revenue is particularly essential for Indian health providers when IHS funding is reduced or interrupted by budgetary disagreements.

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NCUIH Endorses Bipartisan, Bicameral Bill To Secure Advance Appropriations For Critical Indian Country Programs

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On July 24, 2023, Senators Lujan (D-NM) and Mullin (R-OK) and Representatives McCollum (D-MN-04) and Cole (R-OK-04) reintroduced the bipartisan, bicameral Indian Program Advance Appropriations Act (H.R.4832/S.2424). The bill would authorize advance appropriations for several accounts under the Bureau of Indian Affairs and Bureau of Indian Education within the Department of Interior and the Indian Health Service (IHS) within the Department of Health and Human Services. The bill would specifically provide advance appropriations for IHS, Contract Support Costs, Payments for Tribal Leases, Indian Health Facilities, Operation of Indian Programs, Operation of Indian Education, and several other critical Indian Services accounts.  The bill is sponsored by twenty-three Democrats and four Republicans. The bill has been endorsed by the National Congress of American Indians, the National Indian Health Board, and the National Council of Urban Indian Health (NCUIH).

“The National Council of Urban Indian Health is pleased to endorse the Indian Programs Advance Appropriations Act from Senators Lujan, Mullin and Congresswoman McCollum and Congressman Cole. This legislation is simple and essential. It would enable Congress to appropriate funding for the Indian Health Service, the Bureau of Indian Affairs, and the Bureau of Indian Education one year in advance- ensuring timely and sustained funding for essential programs and services that are vital to the well-being and prosperity of Native communities. The Act demonstrates a commitment to transparency and accountability, ultimately empowering our communities to thrive. I urge Congress to swiftly pass this bill, a significant step forward in supporting Native American health and education initiatives.” – Francys Crevier (Algonquin), CEO, NCUIH.

Next Steps

The bill was referred to the Senate Committee on Indian Affairs and the House Natural Resources Committee. The bill has been added to the NCUIH bill tracker and can be found here.

Background

After tireless advocacy across Indian Country, advance appropriations for IHS were included in the fiscal year (FY) 2023 final spending bill to provide stable funding for FY 2024. On July 19, 2023, the House Appropriations Committee released their FY 2024 Interior, Environment, and Related Agencies Appropriations Bill – maintaining advance appropriations for FY 2023 at $5.878 billion. Despite the victory in the final FY23 spending bill for IHS, other critical Indian country programs were not included in advance appropriations. It is paramount that all critical programs receive advance appropriations to ensure all American Indians and Alaska Natives have continuous access to the essential services many rely on.

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Senate Interior Appropriations Bill Passes out of Committee with Advance Appropriations and a Modest Increase for the Indian Health Service

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The bill includes $7.27 billion for IHS, $2.6 billion less than the amount requested by the President.

On July 27, 2023, the Senate Appropriations Committee completed the markup of the Fiscal Year (FY) 24 Interior, Environment, and Related Agencies bill. The bill passed out of committee with a vote of 28-0 and will advance to the Senate floor for initial passage. The bill authorizes $7.27 billion for IHS— an increase of $218.6 million from FY23 but $2.68 billion below the President’s request. The FY24 budget also includes $92.4 million for Urban Indian health, which is $2 million above the FY23 enacted levels but $22.7 million under the House recommended amount and President Biden’s Request. Advance appropriations for IHS was maintained for FY25 and received an increase to $5.22 billion from $5.12 billion for FY24. Other key provisions include: $8 million to improve maternal health and $2.5 million for the Produce Prescription Pilot Program for Tribes and urban Indian organizations (UIOs) to increase access to produce and other traditional foods. A more detailed analysis follows below.

During the Full Appropriations Committee hearing, Chair of the Committee, Senator Patty Murray (D-WA) expressed the importance of protecting the Indian Health Service, “This bill plays a critical role in making sure we keep our promises to Tribes and deliver on key federal investments by sustaining funding for the Indian Health Service and providing new resources to support Tribal families, protect Tribal treaty rights, and more.” 


Line Item		 FY23 Enacted FY24 TBFWG Request FY24
President’s
Budget		 FY24 House Proposed FY24 Senate Proposed
Urban Indian Health $90,419,000 $973,590,000 $115,150,000 $115,150,000 $92,419,000
Indian Health Service $6,958,223,000 $50,996,276,000 $9,700,000,000 $7,078,223,000 $7,275,531,000
Advance Appropriations $5,129,458,00 Request is to expand advance appropriations to include all IHS accounts $5,129,458,00 $5,878,223,000 $5,228,112,000

Establishment of a UIO Interagency Workgroup

The bill also includes direction for IHS to establish a UIO Interagency Workgroup. The bill report reads, “Despite the excellent efforts of Urban Indian Organizations, AI/AN populations continue to be left out of many Federal initiatives. Therefore, the Committee directs the Indian Health Service to continue to explore the formation of an interagency working group to identify existing Federal funding supporting Urban Indian Organizations [UIOs] and determine where increases are needed, where funding is lacking, or what programs should be amended to allow for greater access by UIOs; to develop a Federal funding strategy to build out and coordinate the infrastructure necessary to pilot and scale innovative programs that address the needs and aspirations of urban AI/ANs in a holistic manner; develop a wellness centered framework to inform health services; and meet quarterly with UIOs to address other relevant issues. In addition to the Indian Health Service, the working group should consist of the U.S. Department of Health and Human Services, U.S. Department of Housing and Urban Development, U.S. Department of Agriculture, U.S. Department of Justice, U.S. Department of Education, U.S. Department of Veteran Affairs, U.S. Department of Labor, the Small Business Administration, the Economic Development Agency, FEMA, the U.S. Conference of Mayors, and others as identified by UIOs.”

The National Council of Urban Indian Health (NCUIH) has advocated for the creation of the UIO Interagency Workgroup as a key step to increasing support and resources to American Indians and Alaska Natives (AI/ANs) living in urban areas. On September 12, 2022, NCUIH submitted comments and recommendations to IHS regarding the formation of an Urban Interagency Workgroup with other federal agencies. The agency held an Urban Confer on July 13, 2022, in response to a letter sent to President Biden and Vice President Harris from several Senators, requesting the formation of such a workgroup. NCUIH will continue to work with House and Senate appropriators to ensure this language is included in the final appropriations bill.

Background and Advocacy

On March 9, 2023, President Biden released his budget request for FY24 which included $9.7 billion for IHS and proposed mandatory funding for IHS from FY 2025 to FY 2033 to the amount of $288 billion over-ten years as well as exempting IHS from sequestration. This mandatory formula would culminate in $44 billion for IHS in FY 2033, to account for inflation, staffing increases, long-COVID treatment, and construction costs. This move from discretionary to mandatory funding is essential as noted in the IHS Congressional Justification, “While the progress achieved through the enactment of advance appropriations will have a lasting impact on Indian Country, funding growth beyond what can be accomplished through discretionary spending is needed to fulfill the federal government’s commitments to Indian Country.” On March 17, 2023, IHS published their Fiscal Year (FY) 2024 Congressional Justification with the full details of the President’s Budget, which includes $115 million for urban Indian health – a 27% increase above the FY 2023 enacted amount of $90.42 million.

On July 18, 2023, the House of Representatives Appropriations Committee advanced the FY24 Interior Appropriations bill with $7.079 billion for IHS, an increase in FY25 advance appropriations for IHS to $5.8 billion, and $115.15 million for urban Indian health.

Full Funding, Maintain Advance Appropriations, and Mandatory Funding as Priorities

NCUIH requested full funding for urban Indian health for FY 2024 at $973.59 million for urban Indian Health in FY24 in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. NCUIH also requested that advance appropriations be maintained for the Indian Health Service (IHS) until mandatory funding is achieved. The marked increase for FY24 is a result of Tribal leaders, over several decades, providing budget recommendations to phase in funding increases over 10-12 years to address growing health disparities that have largely been ignored.

On April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee. The letter has bipartisan support and calls for support for Urban Indian Health based on the TBFWG’s recommendation and to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. Representatives Gallego and Grijalva also led a Congressional letter to the House Committee on Appropriations for FY 2024 with the same requests.

On March 9, 2023, NCUIH CEO Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding. NCUIH requested full funding for IHS at $51.41 billion and Urban Indian Health for FY 2024 as requested by the TBFWG, maintain advance appropriations for IHS, and support of mandatory funding for IHS.

Bill Highlights

Indian Health Service: $7.27 billion

  • Bill Report, Pg. 119, “The Committee recommendation provides $7,275,531,000 for IHS for fiscal year 2024 discretionary funding, an increase of $248,042,000 to the enacted level and a decrease of $2,194,123,000 to the requested level.”

Urban Indian Health: $92.4 million

  • Bill Report, pg. 123, “The recommendation includes $92,419,000 for the Urban Indian Health program, $2,000,000 above the enacted level.”

Contract Support Costs $1 billion and Tribal 105(l) leases $149 million

  • Bill Report, pg. 124, “The Committee has continued language from fiscal year 2021 establishing an indefinite appropriation for contract support costs estimated to be $1,051,000,000 in fiscal year 2024.
  • Bill Report, pg. 124, “The recommendation includes an indefinite appropriation of an estimated $149,000,000 for the compensation of operating costs associated with facilities leased or owned by Tribes and Tribal organizations for carrying out health programs under ISDEAA contracts and compacts as required by 25 U.S.C. 5324(l).”
  • The Biden Administration included Contract Support Costs and Tribal 105(l) leases as mandatory costs. The Committee did not recommend the line items to be mandatory costs.
    • NCUIH along with 22 other Tribes and Native organizations advocated for these tribal sovereignty payments as mandatory in a letter to Congressional appropriators.

Dental Health: $254.7 million

  • Bill Report pg. 122, “The recommendation includes $254,729,000 for dental health, an increase of $6,631,000 above the enacted level. The Service is encouraged to coordinate with the Bureau of Indian Education [BIE] to integrate preventive dental care at schools within the BIE system.”

Equipment: $32.59 million

  • Bill Report, pg. 125, “The recommendation includes $32,598,000 for medical equipment upgrades and replacement, equal to the enacted level.”

Electronic Health Records: $217.6 million

  • Bill Report, pg. 88, “The Committee is aware there is a need for a new electronic health record system to improve the overall interoperability, efficiency, and security of the Service’s information technology system and provides $217,564,000 for this effort, equal to the enacted level”

Mental Health: $130.2 million

  • Bill Report, pg. 122, “The recommendation includes $130,155,000 for mental health programs, an increase of $2,984,000 above the enacted level.”

Alcohol and Substance Abuse: $266.8 million

  • Bill Report, pg. 122, “The recommendation includes $266,843,000 for alcohol and substance abuse programs, an increase of $403,000 above the enacted level. The bill also provides $11,000,000 for opioid abuse, described below.”

Produce Prescription Pilot Program: $2.5 million

  • Bill Report, pg. 120, “The bill maintains funding at fiscal year 2023 enacted levels for the Alzheimer’s program and Produce Prescription Pilot program.”

Maternal Health: $8 million

  • Bill Report, pg. 120, “The Committee recommendation supports funding for maternal health initiatives and provides an additional $1,000,000 for these efforts as noted above.”

Alzheimer’s Disease: $5.5 million

  • Bill Report pg. 120, “The bill maintains funding at fiscal year 2023 enacted levels for the Alzheimer’s program and Produce Prescription Pilot program.”

Purchased and Referred Care: $997.8 million

  • Bill Report pg. 123, “—The recommendation includes $997,755,000 for purchased/referred care, an increase of $1,000,000 above the enacted level.”
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