November 2023

American Medical Association Adopts NCUIH-Supported Resolution on IHS Improvements, Includes Key Medicaid Parity Provision for UIOs

November 30, 2023/in Policy Blog/by Chelsea Gutierrez

On November 3, 2023, the National Council of Urban Indian Health (NCUIH) submitted written testimony to the 2023 Interim Meeting of the American Medical Association (AMA) House of Delegates (HOD), held on November 10-14, 2023, regarding the proposed resolution “Federal Medical Assistance Percentage Extension for Urban Indian Organizations” as part of a larger resolution, Resolution 812 (I-23), “Indian Health Service Improvements.” This testimony was read in support of the resolution and resulted in the adoption of the entire resolution by the AMA, with amendments, including the language in support of 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs).

In its testimony, NCUIH emphasized that “Congress must enact legislation to provide permanent 100% FMAP for Medicaid services provided at UIOs to ensure parity across the IHS healthcare system and further fulfill the federal trust obligation to provide healthcare to Native people.” NCUIH also shared examples of how the temporary extension of 100% FMAP in 2021 benefited UIOs in Washington and Montana and emphasized permanent 100% FMAP as a vehicle to provide UIOs with a much-needed source of supplemental income to support the continued provision of comprehensive and culturally competent health care.

The Reference Committee noted that 100% FMAP would “lead to enhanced and directed advocacy of priorities as identified by American Indian/Alaska Native-serving health organizations and other important stakeholders.” After discussion, the Committee recommended the entire resolution be adopted as amended. The House of Delegates adopted the resolution and its new language, which reads as follows:

“RESOLVED, that our American Medical Association supports an increase to the Federal Medical Assistance Percentage (FMAP) to 100% for medical services which are received at or through an Urban Indian Organization that has a grant or contract with the Indian Health Service (IHS) and encourage state and federal governments to reinvest Medicaid savings from 100% FMAP into tribally-driven health improvement programs.”

Adoption of this resolution means that 100% FMAP will now be a priority of the AMA moving forward. Having the support of the largest physician advocacy organization is an additional advocacy tool NCUIH and other organizations can utilize, and it shows Congress the necessity of passing 100% FMAP legislation.

Background on 100% FMAP for UIOs

Federal Medical Assistance Percentage (FMAP) refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. Congress first authorized 100% FMAP for the Indian healthcare system in 1976 because it recognized that “Medicaid payments are . . . a much-needed supplement to a health care program which has for too long been insufficient to provide quality health care to” Native people and because “the Federal government has treaty obligations to provide services to Indians, it has not been a State responsibility.” Unfortunately, UIOs were not included in this initial authorization and therefore, services provided at UIOs were not eligible for 100% FMAP.

In 2021, Congress amended the Social Security Act (SSA) to provide for eight fiscal quarters of 100% FMAP for UIOs. This amendment temporarily eased the financial burden on states by allowing states to be reimbursed by the federal government for the full cost of providing care to Medicaid beneficiaries at UIOs. As a result, some states were able to utilize the provision to increase funding to UIOs. Unfortunately, this provision expired on March 31, 2023, meaning that states once again are responsible for covering a portion of the cost of Medicaid services provided at UIOs.

About the AMA House of Delegates (HOD)

The House of Delegates (HOD) is the legislative and policy-making body of the American Medical Association. State medical associations and national medical specialty societies are represented in the HOD along with AMA sections, national societies such as American Medical Writers Association (AMWA), American Osteopathic Association (AOA) and the National Medical Association (NMA), professional interest medical associations, and the federal services, including the Public Health Service. At HOD Meetings, resolutions are referred to the Reference Committee for open discussion and to allow recommendations for HOD action. If adopted by the HOD, the resolution can become the foundation of a new AMA program, establish or modify policy on an issue, or become a new directive for action. Policies of the AMA House of Delegates are policy statements on health topics and are one of the cornerstones of the AMA as they define what the Association stands for as an organization. They provide the information and guidance that physicians and others seek from the AMA about health care issues.

The AMA Interim Meeting of the House of Delegates takes place in November every year. Materials presented at the 2023 Interim Meeting are generated by AMA delegates/delegations, the AMA Board of Trustees, AMA Councils and AMA Sections. The delegates will next meet in June for the 2024 AMA Annual Meeting in Chicago.

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NCUIH Joins Tribal Partner Organizations in a Letter to Congress Expressing Support for $250 Million in Opioid Response Funding for the Indian Health Service

November 29, 2023/in Policy Blog/by Jeremy Grabiner

On November 6, 2023, the National Council of Urban Indian Health (NCUIH) joined the National Indian Health Board (NIHB), the National Congress of American Indians (NCAI), and the Self-Governance Communication and Education Tribal Consortium in sending a letter to House and Senate leadership expressing support for the President’s supplemental funding request of $250 million for the Indian Health Service (IHS), as part of a $1.55 billion total investment in the fight against opioid addiction in America. This investment is in the form of Opioid Response grants through the Substance Abuse and Mental Health Services Administration (SAMHSA), and includes a 16% set-aside of emergency opioid response funding for Tribes and Tribal organizations.

This funding request has no guarantees that Congress will include the supplemental spending for FY 2024, especially given that partisan disputes will continue with the impending 2024 election. Also, with the Fiscal Responsibility Act spending caps lasting through 2025, it is essential that this funding is determined as “emergency” supplemental spending in order to see any increases in FY24.

In order to save lives in all Native communities, a meaningful investment in opioid crisis is essential. It is the federal government’s trust responsibility to provide “[f]ederal health services to maintain and improve the health of the Indians,” and this is a vital step in protecting Native lives.

Full Text of the Letter

Dear Speaker Johnson, Minority Leader Jeffries, Majority Leader Schumer, and Minority Leader McConnell:

On behalf of the undersigned organizations and the 574 sovereign Tribal nations we serve, we write in support of the President’s supplemental funding request of $250 million for the Indian Health Service (IHS), as part of a $1.55 billion total investment in the fight against opioids and addiction in America. This funding is urgently needed to help Tribal communities address the severe impacts of the opioid and fentanyl crisis.

Opioids are the latest face of a mental health and addiction crisis in America that is disproportionately impacting our Tribal communities. The Centers for Disease Control (CDC) data show that American Indians and Alaska Natives have experienced the highest age-adjusted overdose death rates of any group for the past decade. Most of these deaths are due to opioid use, including fentanyl and fentanyl-laced substances.

In August 2023, The Northwest Portland Area Indian Health Board, in partnership with NIHB, hosted the National Tribal Opioid Summit in Tulalip, Washington. This convening of Tribal leaders; federal, regional, and state decision-makers; and policy experts discussed the ongoing and increasing harm opioids have on Tribal communities, and the solutions for empowerment and healing throughout Indian Country. This investment will go a long way to making a meaningful investment in these solutions.

The mental health and addiction epidemic plagues all our communities and touches all our families, regardless of status, wealth, or beliefs. Tribes seek a formal commitment from Congressional leadership that Tribal governments are federally-recognized governments, Tribal jurisdiction is American jurisdiction, and Tribes must be provided funds and empowered, as sovereigns, in the fight against hate, sadness, and hopelessness.

The President’s proposal to address the Opioid Crisis is for the elected body of the People to provide $1.55 billion in additional funding to the Substance Abuse and Mental Health Services Administration (SAMHSA), including $250 million that would be transferred to the IHS and made available for two years.

Despite the clear need in Indian Country, few federal dollars have been solely dedicated for this purpose to Tribal nations. For example, in FY 2023, State Opioid Response (SOR) funding was $1.575 billion, and the Tribal Opioid Response Grants (TOR) were $55 million, which is roughly 3 percent of the total. Given the impact of the opioid crisis in Indian Country, $250 million will be a long overdue investment that will save lives for generations to come.

Despite these serious challenges, Tribal nations and Tribal health systems are innovating when it comes to behavioral health. By focusing on holistic care, traditional healing practices, and indigenous ways of knowing, we have seen remarkable results in Tribal communities for treatment of opioid use. Tribes have combined culturally centered prevention, treatment and recovery services with implementation of key evidenced-based practices, including Medication Assisted Treatment (MAT) clinics for opioid use disorder; syringe service programs; training, administration, and distribution of the life-saving overdose reversal medication naloxone; peer recovery support services; outpatient therapy and behavioral health integration.

Nearly 50 years of self-determination and self-governance policy have clearly demonstrated that empowering Tribes works and results in better outcomes at the same dollar-for-dollar investment. In simple terms, good governance. Additional funding will allow Tribes to improve and expand this programming that we know is effective.

Again, we reiterate our strong support for the inclusion of $250 million to IHS for opioid and fentanyl response. This funding could not be needed more urgently. If you have any questions, please do not hesitate to contact NIHB’s Director of Government Relations, Caitrin Shuy, at cshuy@NIHB.org.

Sincerely,

National Indian Health Board
National Congress of American Indians
Self-Governance Communication and Education Tribal Consortium
National Council of Urban Indian Health

Senate Hearing Emphasized the Need to Address Fentanyl Crisis in Tribal and Urban Native Communities

On November 8, 2023, the Senate Committee on Indian Affairs (SCIA) held an oversight hearing on examining fentanyl in Native communities, focusing on Native perspectives on addressing the growing crisis. During the hearing, recommendations to address both Tribal and urban Native communities were expressed to the committee.

“Fentanyl related deaths is on the rise in this country, and Native communities are being hit extra hard. From 2020-2021, American Indians and Alaska Natives are experiencing an alarming 3% rise in drug overdose deaths, the second biggest rise of all groups in the United States… These overdose death rates are nothing short of staggering… This growing crisis is rooted in long-standing structural inequities in Native communities such as lack of affordable housing, limited access to high-quality healthcare, and underfunded public safety programs compound fentanyl’s impact on Native communities.” – Chairman of the Senate Committee on Indian Affairs, Senator Brian Schatz (D-HI)

Dr. A. Aukai Austin Seabury, Ph.D., Executive Director & Licensed Clinical Psychologist at I Ola Lāhui, Inc., shared the importance of incorporating traditional healing and the uptake of reimbursement by third-party funders, “Something that seems to be of real promise is in the use of cultural practice as part of healing and recovery. Those programs that have emphasized those things seem to have wonderful outcomes, and we have even seen third-party insurers inspire mentoring and experimenting with models on how to fund and find mechanisms for funding cultural practices as a vital aspect of healing our communities.”

It was pointed out that the crisis is especially troubling in urban Indian youth, and Dr. Claradina Soto, Ph.D. recommended to the committee that investments need to be made in harm reduction education, access to naloxone, mental health services, youth rehab programs, and a focus on family cohesion and culturally based treatment to improve the lives of Native youth.

Watch the full hearing

Background

American Indians and Alaksa Natives experience high rates of behavioral health issues and SUD, and have the highest rates of suicide of any minority group in the United States and high rates of SUD. In fact, Native people experience serious mental illnesses at a rate 1.58 times higher than the national average. American Indians and Alaska Natives have some of the highest rates of behavioral health issues caused by several factors, including centuries of generational trauma, colonization, and forced assimilation policies from the United States government. According to a 2020 report from the Centers for Disease Control and Prevention, non-Hispanic American Indian and Alaska Native people had the highest rates of drug overdose deaths in both urban and rural counties, at 44.3 per 100,000 and 39.8, respectively.

In response to these chronic health disparities and the dire need for behavioral health resources for Indian health care providers, the House Energy and Commerce Committee drafted bipartisan legislation creating the Native Behavioral Health Resources Program. This legislation was included in the House-passed Restoring Hope for Mental Health and Well-Being Act (H.R.7666), and ultimately included in the Consolidated Appropriations Act, 2023. This provision authorized to be appropriated $80 million for the Native Behavioral Health Resources Program.

NCUIH supports increased resources to IHS to address this growing health disparity. On February 17, 2023, NCUIH signed onto a letter sent to the Director of the Office of Management and Budget, Shalanda Young, requesting that the Native Behavioral Health Resources Program be appropriated to combat the opioid epidemic and behavioral health crisis in Indian Country.

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November Policy Updates: Area Budget Formulation Underway, Medicaid Unwinding Webinar

November 27, 2023/in Policy Blog/by NCUIH

Happy Native American Heritage Month!

NCUIH

In This Edition: Congress has passed its short-term funding bill, conference season is underway, and many more developments in urban Native health policy.

📰 November marks the observance of Native American Heritage Month, a time to honor and celebrate the rich cultures, histories, and contributions of Native American and Indigenous communities.

Why it matters: Native American Heritage Month serves as a reminder of the resilience and strength of Indigenous communities throughout history. The National Council of Urban Indian Health (NCUIH) channels this spirit into advocacy efforts aimed at influencing policies that impact the health and wellness of urban Indians. By actively engaging with policymakers, stakeholders, and partners, we strive to create an environment where health policies are inclusive and considerate of the unique challenges urban populations face. Read more about our policy priorities here.

Our thought bubble: Together, let us honor the resilience and contributions of Native American communities by continuing to advocate for their health and well-being.

Crisis Averted: President Biden to Sign Temporary Spending Bill to Fund U.S. Government Into the New Year

Biden

On November 15, 2023, a full government shutdown was averted when Congress passed a two-tiered Continuing Resolution (CR) serving as a stopgap spending measure. The CR was signed into law by President Biden on November 16, 2023.

What is included: The CR includes two funding deadlines for the twelve appropriations accounts, January 19 and February 2.

The bottom line: Last year, Congress authorized $5.13 billion in advanced appropriations for IHS, insulating the majority of IHS programs from the worst effects of a government shutdown.

Go deeper: The CR re-authorized the Special Diabetes Program for Indians (SDPI) until January 19th at $25.89 million, and funds IHS accounts not receiving advanced appropriations at FY23 levels through February 2nd.

Did you know?: President Biden requested $250 million for IHS in emergency supplemental funding in response to the current opioid epidemic. Congress has not included this funding in this CR.

Moving Forward: Congress will continue negotiating a final spending bill during this time and NCUIH will monitor for updates.

Policy Webinar: Medicaid Unwinding for Urban Indian Organizations

NCUIH

Join NCUIH for a webinar on Medicaid Unwinding for UIOs where we will provide an overview on Medicaid unwinding, updates on our partnership efforts and the effect this work has the urban Native community. We will also discuss best practices and share updates on changes around the unwinding.

Register Here

Federal Updates: Prep Session for Budget Formulation, CMS Application

Illustration of Congress with empty speech bubbles

ICYMI: On November 7, NCUIH held a Prep Session for IHS Budget Formulation. NCUIH provided a PowerPoint template and suggested Talking Points for UIO leaders to use during their IHS Area Budget Formulation meetings.

UIOs may email policy@ncuih.org to request a copy of the template and talking points, and to set up a 1:1 session to discuss directly.

CMS Releases New Resources for ‘Making Care Primary Model’ Application – Available in 6 States with UIOs

CMS has released a user-friendly Application Manual for the Making Care Primary (MCP) Model, supporting user registration, portal navigation, and application submission.
The 10.5-year model, launching on July 1, 2024, aims to enhance care management and coordination, empower primary care clinicians, and address health-related social needs.
CMS, collaborating with State Medicaid Agencies in CO, NC, NJ, NM, NY, MN, MA, and WA, invites organizations to apply for the model, fostering full care transformation across payers.
Applications, due by November 30, 11:59 PM, can be initiated early for tailored support.
For details, visit the Request for Applications (RFA) or contact MCP@cms.hhs.gov.”

Upcoming Events and Important Dates including Area Budget Formulation Meetings

Calendar with events on it

Upcoming events and important dates:

Nov 28– IHS Portland Area Budget Formulation Meeting
Nov 28-29 – HHS Secretary’s Tribal Advisory Committee (STAC) in Washington, DC
Nov 30 – IHS National Tribal Advisory Committee (NTAC) Quarterly Meeting
Der 5– IHS Phoenix Area Budget Formulation Meeting
Dec 5-6 – Tribal Leaders Diabetes Committee Quarterly Meeting in-person in Portland, Oregon and virtual
Dec 6-7 – White House Tribal Nations Summit
Dec 11-12 – Department of Interior Self-Governance Advisory Committee Meeting
Dec 12– IHS Alaska Area Budget Formulation Meeting
Dec 13– IHS California Area Budget Formulation Meeting
Dec 13, 11:00 am – 5:30 pm EST- IHS Virtual Health Information Technology Modernization Summit (Register)

Go deeper: The Indian Health Service Virtual Health Information Technology Modernization Summit on December 13, 2023 is an opportunity for Tribal and UIO leaders to learn more about the new Electronic Health Record (EHR) and engage in robust and meaningful conversations with the IHS on important issues impacting Tribal and urban Indian communities as a result of the HIT Modernization program. During the Virtual Summit, IHS will host a caucus allowing Tribal and UIO leaders the opportunity to independently exchange viewpoints and share information. View the Virtual Summit Agenda here.

Dec 13– Great Plains Area Budget Formulation Meeting
Dec 14– Nashville Area Budget Formulation Meeting

NCUIH in Action: NCAI 80th Annual Convention & Marketplace, FedBar Presentation

Pictured: Francys Crevier, JD (Algonquin) NCUIH CEO and Walter Murillo (Choctaw) NCUIH Board President-Elect

NCUIH leadership participated in the 80th Annual Convention & Marketplace in New Orleans, Lousiana, emphasizing our commitment to advancing Indigenous health initiatives.

The big picture: NCAI elections were held for the new 2023-2025 Executive Committee: Mark Macarro, Chairman of Pechanga Band of Luiseño Indians – President; Brian Weeden, Chairman of the Mashpee Wampanoag Tribe – Vice President; Nickolaus D. Lewis, Lummi Nation Council Member – Recording Secretary; David Woerz, Chickasaw Nation Legislator – Treasurer.

One big thing: On November 3rd, NCUIH CEO Francys Crevier (Algonquin), JD, presented at the Federal Bar DC Indian Law Conference on “The Fight for Equity in Indian Country.” In her speech, she highlighted how important full, stable funding is for Indian health.

NCUIH CEO Francys Crevier (Algonquin), JD presents at Federal Bar DC Indian Law Conference.

Honoring Native Veterans: Bakersfield American Indian Health Project Organizes California’s First-Ever All Native American Honor Flight to Washington, DC

Pictured: Individuals wearing blue coats signify Native veterans who have served in the military.

On November 3, 2023, Native Veterans gathered at the National Native American Veterans Memorial in Washington as part of Kern County Honor Flight #48, California’s first Honor Flight made up of all Native American Veterans.

Go deeper: NCUIH member organization, Bakersfield American Indian Health Project, helped to organize this important trip. CEO, Angel Galvez (Tarasco and Purepecha), and BAIHP Board Secretary, Laura Juarez (Comanche) chaperoned Native Veterans from Kern County Honor Flight and participated in the Kern Country Honor Flight to honor their relatives who served in the Korean War.

L to R: Bakersfield American Indian Health Project (BAIHP) CEO, Angel Galvez (Tarasco and Purepecha), and BAIHP Board Laura Juarez (Comanche)

Army Veteran Sonya Tetnowski (Makah), NCUIH Board President and CEO of Indian Health Center of Santa Clara Valley

NCUIH would like to acknowledge the service of Sonya Tetnowski, NCUIH Board President and CEO of the Indian Health Center of Santa Clara Valley who served as an Army Paratrooper. Ms. Tetnowski also currently serves as a member of the Department of Veterans Affairs Advisory Committee on Tribal and Indian Affairs.

The bottom line: NCUIH honors all those who have served, especially the invaluable contributions of Native Veterans who have historically served at the highest rates among all Americans. We extend our deepest gratitude to Native Veterans and all Veterans for their selfless service and dedication to preserving the freedoms we hold dear.

Vice President Harris Applauds Urban Indian Organization, NATIVE HEALTH, as First Pilot Site for Indian Health Service Voter Registration Program

On March 5, 2023, President Biden announced agency actions to make the voting process more accessible in alignment with recommendations made by the Native American Rights Fund (NARF). This included a new initiative at the Indian Health Service (IHS) piloting “high-quality voter registration services across five different IHS facilities before the end of 2023”.

On October 23, 2023, Vice President Kamala Harris announced that the first facility under this pilot program will be NATIVE HEALTH, located in Phoenix, Arizona.

Did you know? Voting as a Social Determinant of Health has been acknowledged by the American Medical Association (AMA), and was included in their resolution from 2022, “Support for Safe and Equitable Access to Voting.”

NCUIH

NCUIH Welcomes Not Invisible Act Commission Report to Congress and Administration

Sonya Quote

At the start of National Native American Heritage Month, the Not Invisible Act Commission released its report entitled “Not One More” urging Congress and the Biden Administration to take immediate action to address the related crises of Missing and Murdered Indigenous Persons (MMIP) and human trafficking of Indigenous persons (HT).

Did you know?: NCUIH endorsed and advocated for the passage of the legislation that created the Commission and NCUIH’s Board President, Sonya Tetnowski (Makah), served on the Commission.

What they’re saying: “It was an honor to serve on this commission with so many tribal leaders from across Indian Country. We as a commission heard from over 260 survivors, families, advocates, government agencies, and law enforcement to understand the impact from as many perspectives as possible. This 200-plus page report should be the beginning of this process as we know that each recommendation will require specific work to accomplish,” said Ms. Tetnowski.

Why it matters: The Commission’s report is a resounding call to the United States to fulfill its trust responsibility to American Indians and Alaska Natives and address the public health and public safety in Native communities caused by centuries of policies designed to attack Tribal Nations and Native ways of living.

What else: The Commission specifically recognized the impact of federal policies on Native people living in urban areas, highlighting the testimony of one witness who told the Commission “We can’t forget the urban relocation programs in the 50s; I hope this Commission doesn’t forget those relatives that are living off rez.”

What’s next: The Not Invisible Act requires the Secretary of the Interior and the Attorney General to make publicly available and submit a written response to the recommendations within 90 days to the Commission and Congress.

New Report Estimates 400,000 Native Americans Terminated from Medicaid During Unwinding

The report is co-authored by the Asian and Pacific Islander American Health Forum, the Leadership Conference on Civil and Human Rights, NAACP, the National Council of Negro Women, the National Council of Urban Indian Health, the National Urban League, the Southern Poverty Law Center Action Fund, UnidosUS, the Coalition on Human Needs, and Protect Our Care.

NCUIH Joined 8 Organizations in Issuing Report on Impacts of Medicaid Terminations

Five Key Findings from the Report:

Medicaid losses during six months of unwinding already exceed history’s greatest two-year drop in Medicaid enrollment.
States have terminated Medicaid for 10 million people, causing grave harm, especially in communities of color. This includes an estimate of more than 400,000 Native Americans.
More than 70% of the people terminated from Medicaid may have been eligible.
The depth of Medicaid loss varies by state, to an extraordinary degree.
The states with the highest termination rates have not made the investments needed to operate functional Medicaid systems.

Our thought bubble: “The report highlights the disproportionate impact Medicaid unwinding is having on Native communities,” said Francys Crevier (Algonquin), NCUIH CEO. “Medicaid and CHIP coverage are critical to fulfilling the United States’ trust responsibility to maintain and improve Native health, as inadequate insurance coverage is a significant barrier to healthcare access for Native people. Eligible Native children and families are losing coverage for administrative reasons and the federal government has a trust obligation and must do more to protect them.”

Read the Report Here

One last thing, check out these upcoming funding opportunities:

Healthy Start Initiative – Eliminating Disparities in Perinatal Health (Health Resources & Services Administration)

– Deadline: December 15, 2023 (Apply)
Maternal and Child Health – Improving Oral Health Integration Demonstration Projects (Health Resources & Services Administration)

– Deadline: January 22, 2024 (Apply)
Youth Homelessness System Improvement (Department of Housing and Urban Development)

– Deadline: February 15, 2024 (Apply)

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House Passes Interior Appropriations Bill, Includes $7.078 Billion for the Indian Health Service and Maintains Advance Appropriations

November 22, 2023/in Policy Blog/by Emily Larsen

On November 3, 2023, the House of Representatives voted to approve the Fiscal Year (FY) 2024 Department of Interior, Environment, and Related Agencies Appropriations Act with a vote of 213 to 203. The bill provides a discretionary spending total of $25.417 billion, which is $13.433 billion below the FY23 enacted level and $21.37 billion below the President’s Budget Request. Despite the sizeable cut to the Interior, Environment, and Related Agencies bill, the Indian Health Service (IHS) received a 2.2% increase.

The bill authorizes $7.078 billion for IHS— an increase of $149 million from FY23 but $2.6 billion below the President’s request. Advance appropriations for IHS were maintained for FY25 and increased from $4.9 billion in FY24 to $5.8 billion for FY25. The bill also authorizes $115 million for the Urban Indian Health line item, a $15 million increase from the FY23 enacted level. Other key provisions include: $3 million for generators at IHS/Tribal Health Programs/Urban Indian Organizations (UIOs), $6 million for the Produce Prescription Pilot Program for Tribes and UIOs to increase access to produce and other traditional foods, as well as $35 million for Tribal Epidemiology Centers (TECs).

Line Item	FY23 Enacted	FY24 TBFWG Request	FY24 President’s Budget	FY24 House Passed
Urban Indian Health	$90,419,000	$973,590,000	$115,150,000	$115,150,000
Indian Health Service	$6,958,223,000	$50,996,276	$9,700,000,000	$7,078,223,000
Advance Appropriations	$5,129,458,000	$9,100,000,000	$5,129,458,000	$5,878,223,000

Next Steps

On November 15, 2023, Congress passed a Continuing Resolution (CR) that will keep the government funded through the beginning of 2024. Until the CR expires, the House and Senate will remain in negotiations to pass a bill that will fund the government through the rest of the fiscal year. Although the House of Representatives passed their version of the bill, it is unlikely to pass through the Senate. NCUIH will continue to monitor the state of appropriations and advocate for House-level funding in any funding negotiations or Omnibus legislation. The Senate introduced a separate Interior Appropriations bill on July 27, 2023. This bill has passed out of the Senate Appropriations Committee and is awaiting a full Senate vote. A date for this vote has not been set.

Background

On July 18, 2023, the House Appropriations Subcommittee on Interior, Environment, and Related Agencies released the Committee Bill Report for the FY24 budget with $115,156,000 for Urban Indian health. The bill appropriates $25.4 billion for Interior, Environment, and Related Agencies, which is $13.4 billion below the fiscal 2023 levels and $21.3 billion below the Biden Administration’s request. Despite the sizeable cut to the Interior, Environment, and Related Agencies bill and reducing funding for nearly every account to below FY23 enacted levels, the Indian Health Service (IHS) received a 2.2% increase.

The report and bill were approved by the House Subcommittee on Interior on July 13, 2023 and approved with amendments by the full House Appropriations Committee on July 19, 2023. The bill authorizes $7.078 billion for IHS— an increase of $149 million from FY23 but $2.6 billion below the President’s request. Advance appropriations for IHS was maintained for FY25 and received an increase to $5.8 billion from $4.9 billion in FY24.

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.

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Opportunity for Native Representation on the Census National Advisory Committee

November 20, 2023/in Policy Blog/by Alex Sampson

The Census Bureau is seeking nominiations for the National Advisory Committee on Racial, Ethnic and Other Populations (“NAC”). The purpose of the NAC is to provide advice to the Census Director on the full range of economic, housing, demographic, socioeconomic, linguistic, technological, methodological, geographic, behavioral, and operational variables affecting the cost, accuracy and implementation of Census Bureau programs and surveys, including the decennial census. Nominations must be received on or before Wednesday, January 10, 2024, and should be emailed to census.national.advisory.committee@census.gov with the subject line “2024 NAC Nominations.” This is an opportunity for American Indians and Alaska Natives (AI/AN), to examine areas such as students and youth, aging populations, race/ethnic distribution, and AI/AN tribal considerations.

Nominations

Individuals, groups, and/or organizations may submit nominations on behalf of candidates. A summary of the candidate’s qualifications (resumé or curriculum vitae) must be included along with the nomination letter. Nominees must be able to actively participate in the tasks of the committee, including, but not limited to, regular meeting attendance, committee meeting discussant responsibilities, review of materials, as well as participation in conference calls, webinars, working groups, and/or special committee activities.

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Policy Alert: FY23 Funding Extended, Averting a Government Shutdown

November 20, 2023/in Policy Blog/by NCUIH

What is included:

The CR includes two funding deadlines for the twelve appropriations accounts, January 19 and February 2. Last year, Congress authorized $5.13 billion in advanced appropriations for IHS, insulating the majority of IHS programs from the worst effects of a government shutdown. The CR re-authorized the Special Diabetes Program for Indians (SDPI) until January 19th at $25.89 million, and funds IHS accounts not receiving advanced appropriations at FY23 levels through February 2nd. President Biden requested $250 million for IHS in emergency supplemental funding in response to the current opioid epidemic. Congress has not included this funding in this CR.

Moving Forward:

Congress will continue to negotiate a final spending bill during this time and NCUIH will monitor for updates.

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PRESS RELEASE: NCUIH Welcomes Not Invisible Act Commission Report to Congress and Administration

November 17, 2023/in Policy Blog, Press Release/by NCUIH

Commission Urges Immediate Action to Address Missing and Murdered Indigenous Persons and Human Trafficking Crises

FOR IMMEDIATE RELEASE

WASHINGTON, D.C. (November 17, 2023) – At the start of National Native American Heritage Month, the Not Invisible Act Commission released its report entitled “Not One More” urging Congress and the Biden Administration to take immediate action to address the related crises of Missing and Murdered Indigenous Persons (MMIP) and human trafficking of Indigenous persons (HT). The National Council of Urban Indian Health (NCUIH) endorsed and advocated for the passage of the legislation which created the Commission and NCUIH’s Board President, Sonya Tetnowski (Makah), served on the Commission.

“It was an honor to serve on this commission with so many tribal leaders from across Indian Country. We as a commission heard from over 260 survivors, families, advocates, government agencies, and law enforcement to understand the impact from as many perspectives as possible. This 200-plus page report should be the beginning of this process as we know that each recommendation will require specific work to accomplish,” said Ms. Tetnowski.

The Commission’s report is a resounding call to the United States to fulfill its trust responsibility to American Indians and Alaska Natives and address the public health and public safety in Native communities caused by centuries of policies designed to attack Tribal Nations and Native ways of living. The Commission specifically recognized the impact of federal policies on Native people living in urban areas, highlighting the testimony of one witness who told the Commission “We can’t forget the urban relocation programs in the 50s; I hope this Commission doesn’t forget those relatives that are living off rez.”

Background

NCUIH along with other National Native Organizations worked in support of the Not Invisible Act legislation, which was enacted in October 2020. The Act required the Secretary of the Interior, in coordination with the Attorney General to establish and appoint a joint commission on violent crime against American Indians and Alaska Natives. Secretary of the Interior Haaland was the lead sponsor of the Not Invisible Act when she served in Congress. The bill was passed unanimously by voice vote in both chambers of Congress.

Commissioner Sonya Tetnowski is a citizen of the Makah Tribe and CEO of the Indian Health Center of Santa Clara Valley. She currently serves as the president of both NCUIH and the California Consortium of Urban Indian Health (CCUIH). Ms. Tetnowski works daily in support of the health and wellness services to American Indians and Alaska Natives living in urban areas. Violence against American Indians and Alaska Natives is a public health crisis and is considered a social determinant of health (SDOH). Both NCUIH and CCUIH are committed to the reduction of violence impacting Native communities.

Next Steps

The Not Invisible Act requires the Secretary of the Interior and the Attorney General to make publicly available and submit a written response to the recommendations within 90 days to the Commission and Congress. NCUIH will continue to uplift the work of the Commission and analyze the federal government’s response for further action once released.

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IHS to Host Health Information Technology Modernization Program Virtual Summit for Tribal and Urban Indian Leaders on December 13

November 17, 2023/in Policy Blog/by Alexandra Payan

On November 13, 2023, the Indian Health Service (IHS) released a Dear Tribal Leader Letter (DTLL) and Dear Urban Indian Organization (UIO) Leader (DULL) letter announcing that they will be hosting a Health Information Technology (HIT) Modernization Program Virtual Summit (Virtual Summit) on Wednesday, December 13, 2023 from 11:00 am – 5:30 pm EST. This one-day Virtual Summit is an opportunity for Tribal and UIO leaders to learn more about the new Electronic Health Record (EHR) and engage in robust and meaningful conversations with the IHS on important issues impacting Tribal and urban Indian communities as a result of the HIT Modernization program. During the Virtual Summit, IHS will host a caucus allowing Tribal and UIO leaders the opportunity to independently exchange viewpoints and share information.

Please register for the Virtual Summit here.

View the Virtual Summit Agenda here.

Background

HIT “is a broad concept that encompasses an array of technologies to store, share, and analyze health information.” This includes, but is not limited to, “the use of computer hardware and software to privately and securely store, retrieve, and share patient health and medical information.” HIT Modernization for the IHS, Tribal organization, and urban Indian organization (I/T/U) system is long overdue. Although HIT is necessary to provide critical services and benefits to American Indian and Alaska Native patients, the IHS has historically faced challenges in managing clinical patient and administrative data through the Resource Management System (RPMS). Initially developed specifically for the IHS, years of underfunding and a resulting failure to keep pace with technological innovation have left the RPMS impractical by current HIT standards. RPMS has been in use for nearly 40 years and has developed significant issues and deficiencies during this time, especially in recent years as HIT systems have rapidly advanced in sophistication and usefulness. As the Department of Health and Human Services (HHS) Office of the Chief Technology Officer (OCTO) and IHS found in the 2019 Legacy Assessment, systemic challenges with RPMS “across all of the IHS ecosystem currently prevent providers, facilities and the organization from leveraging technology effectively.”

During the November 8, 2023 Tribal Consultation and Urban Confer on HIT Modernization, IHS announced that they have selected General Dynamics Information Technology, Inc. to build, configure, and maintain an new IHS enterprise EHR system utilizing Oracle Cerner technology. The new EHR will replace the RPMS.

NCUIH Action

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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USDA New Four-Year Tuition Coverage for Tribal Scholars Program Accepting Applications until December 1

November 17, 2023/in Policy Blog/by Alex Sampson

The United States Department of Agriculture (USDA) recently announced that it is now accepting applications for the 1994 Tribal Scholars Program (the Program) to train the next generation of agricultural professionals and strengthen ties with tribal higher education institutions. This Program seeks to increase the number of American Indian and Alaska Native students studying agriculture, food, natural resource sciences, and related disciplines. The Program provides full tuition, fees, books, a housing stipend, and paid workforce training to any interested and eligible students pursuing degrees in agriculture, food, natural resource sciences, or related academic disciplines at a tribal college or university (TCU). Eligible applicants include graduating high school seniors, full-time students currently enrolled at a 1994 land-grant tribal college or university, or recent tribal college or university (TCU) associate degree graduates.

For FY 2024, 27 scholarship slots are available at:

Agriculture Research Service
Farm Service Agency
Farm Production and Conservation
Forest Service
National Institute of Food and Agriculture
Natural Resources Conservation Service

Application packages include an essay, resume, two letters of recommendation, and transcripts. The application deadline is December 1, 2023.

For more information on applying and submitting applications, click here.

Background on USDA’s Tribal College Program

The Tribal College Program was established to ensure USDA fulfills the requirements of the Equity in Educational Land-Grant Status Act of 1994 and Section 882 of the Federal Agricultural Improvement and Reform Act of 1996. These Acts established tribally controlled colleges and universities as land-grant institutions. Congress required that USDA develop a Memorandum of Agreement (MOA) with 1994 Institutions and establish programs to ensure these schools and the Native American communities they serve have equitable access to USDA’s employment, programs, services, and resources. There are currently 36 land-grant institutions (also known as “1994 Institutions”, “1994s”, and “tribal land-grants”).

The Tribal College Program does this by equipping tribal schools’ capacities to benefit Native American agriculture, rural Tribal economies, and to strengthen the United States’ food security. To help USDA fulfill its mandated responsibilities, the Tribal College Program staff provide critical assistance to the Secretary of Agriculture with the following:

Establishment and maintenance of formal MOAs with 1994 Institutions to ensure these schools and the rural, tribal communities they serve have equitable access to the Department’s employment, programs, services, and resources; and
Development of Departmental Regulations, policy, guidance and procedures;
Engage in outreach with these schools, the communities they serve, and the tribal governments that established them.

The Tribal College Program does its work through three programs, the USDA and American Indian Higher Education Consortium Leadership Group, the Tribal Scholars Program for students, and the Terra Preta do Indio Tribal Fellowship for staff and faculty members.

USDA 1994 Tribal Scholars Program

The USDA 1994 Tribal Scholars Program provides full tuition, fees, books, a housing stipend, and paid workforce training to any interested and eligible student pursuing degrees in agriculture, food, natural resource sciences, or related academic disciplines at a TCU. New for 2024, the tuition coverage can follow the student from a two-year associate program at a TCU to a four-year bachelor’s degree program (at a TCU or another land-grant institution). When the student has completed the scholarship requirements, including a paid internship, USDA may convert the student to a permanent USDA employee without further competition. Scholars accepted into the program will be eligible for noncompetitive conversion to a permanent appointment with USDA upon successful completion of their degree requirements by the end of the agreement period. (5 CFR 213.3202) (Agricultural Improvement Act of 2018 – Section 12519)

If selected, scholars must commit to at least one year of service to USDA for each year of financial assistance provided. The details of this requirement will be outlined in the service agreement for the scholar, their university, and the USDA sponsoring agency.

To learn more, please visit the USDA 1994 Tribal Scholars Program page.

USDA 1994 Tribal Scholars Program Application

Applicants may apply for more than one position. An application package includes:

Current Resume
Essay: Submit an essay answering these questions below with a word count of 500 – 800 words. (Note the position for which you are applying.)
- What motivates you to consider a career in public service working for the U.S. Department of Agriculture? Include information about your educational and career goals and how this scholarship may assist you.
- How did you become interested in studying food, agriculture, and natural resource sciences or another related discipline in college?
Two Letters of Recommendation: One letter of recommendation must be from the applicant’s academic counselor, advisor, or faculty member. Each letter must address the applicant’s:
- Personal strengths
- Leadership qualities and potential
- Academic and extracurricular achievements
- Future academic and career aspirations
Transcript indicating the applicant’s most recent academic work

For questions, please text or call 202-845-5646, 202-870-8035 or email 1994@usda.gov.

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The Importance of EHR Interoperability for Urban AIAN Veterans

November 14, 2023/in Research/by Isaiah O'Rear

In a recent ranking of the health care systems of high-income countries, the Commonwealth fund ranked the United States the worst out of the 11 analyzed. Along with the well-documented problems of high cost and poor access, the ranking also focused on the administrative inefficiencies in the American System. Unlike other countries, the United States has failed to implement a functioning system of portable Electronic Health Records (EHRs).ⁱ This failure leads to the “blocking” of crucial health information and the impairment of the “safety, quality, and effectiveness of care provided to patients.”ⁱⁱ The ability for patients to access their EHRs across multiple providers is important for better care coordination.

In an attempt to address this failure, in 2009 President Obama signed the Health Information Technology for Economic and Clinical Health (HITECH) Act to promote the adoption of EHRs by Medical Providers. Unfortunately, the HITECH Act did not provide adequate incentives to encourage the use of EHRs. By 2015, only 6% of physicians had the ability to share patient data across EHR systems.ⁱⁱⁱ This failure effects the quality of care of every American, but the challenges are greatest for patients who must regularly interact with multiple disconnected healthcare providers, such as American Indians and Alaska Natives.

All federally-recognized American Indians and Alaska Natives (AIANs) are entitled to receive care through the Indian health system managed by the Indian Health Service (IHS). AIANs have historically served in the U.S. military at a higher rate than any other population^iv, and these veterans are also entitled to receive healthcare through the veterans’ healthcare system managed by the Veterans Health Administration (VHA). However, AIAN veterans report significant challenges because IHS systems and VHA systems are not currently interoperable to connect and share patient information with each other.

The 144,844 AIAN Veterans who live in Urban Areas^v face an even more complex challenge. Many cities with large populations of AIAN Veterans contain no IHS facilities. IHS-funded Urban Indian Organizations (UIOs) serve 39 cities. Still, UIOs do not provide inpatient healthcare services, so Urban AIAN Veterans must interact with local healthcare systems to fully meet healthcare needs, which do not currently speak to each other.

In the most recent American Community Survey Five-Year Dataset (ACS 2017-21), 9.4% of Urban AIAN Veterans (under age 65) report being “currently covered” by the “Indian Health Service” and 39.4% report being “enrolled for VA health care.” Interestingly, 4.5% report overlapping coverage from IHS and VA.^vi

Table 1 lists the percentage of Urban AIAN covered by IHS and VA for the 20 cities with the largest Urban AIAN Veteran Populations from ACS. Unsurprisingly, IHS coverage is lowest in cities which contain no IHS facilities and no Urban Indian facilities (Washington-DC, Houston, Atlanta). The exception are Veterans in Denver and Dallas which report an approximately 5% IHS coverage rate even though those cities do not contain IHS facilities.^vii It is possible that some veterans are categorizing their use of services by UIOs as “IHS Coverage” when responding to the American Community Survey. IHS is highest in cities with multiple IHS facilities (Phoenix, Oklahoma City).^viii In general, in cities where IHS coverage is high, overlap with VA coverage is also high.

Table 1: IHS and VA Coverage in Twenty Metro Areas with Largest Urban AIAN Veteran Population.

Metro Area	% Covered by IHS	% Covered by VA	% Covered by IHS and VA	2021 Urban AIAN Veterans
Phoenix, AZ	26.6	36.3	13.0	5015
Los Angeles, CA	1.6	38.4	0.4	4780
New York, NY	7.9	28.5	4.9	4149
Washington, DC	0.2	27.4	0.2	4033
Seattle, WA	6.2	38.5	5.1	3947
Dallas, TX	4.6	42.3	1.7	3843
Houston, TX	1.8	42.1	0.7	3633
San Diego, CA	7.6	50.2	3.8	2890
Riverside, CA	11.9	41.5	7.5	2738
Chicago, IL	2.9	39.2	1.1	2667
Denver, CO	5.4	37.5	1.9	2596
Portland, OR	7.5	33.6	2.5	2559
Oklahoma City, OK	42.3	37.8	22.4	2389
San Antonio, TX	2.8	53.0	0.8	2349
Albuquerque, NM	47.5	35.4	21.0	2097
Atlanta, GA	2.2	35.4	0.8	2059
Las Vegas, NV	6.6	38.7	3.2	2034
Jacksonville, FL	0.9	37.3	0.9	2022
Austin, TX	3.1	49.2	2.6	1895
San Francisco, CA	0.3	27.8	0.0	1873

There are multiple issues with interpreting these results. The ACA asks about IHS “coverage plans” in the context of a question about health insurance, so it is unclear how a respondent should answer if they receive some healthcare through IHS, but also some from other providers outside the IHS health system. It is also unclear if patients receiving care from IHS-funded Urban Indian Organizations would include themselves as part of “Indian Health Service” coverage.

Adding another layer of complexity, Urban AIAN Veterans must also manage the overlap between the IHS and VA healthcare systems and their insurers (Figure 1).

Figure 1: Urban AIAN Veterans Overlapping Coverage

Only 1.3% of Urban AIAN Veterans receive coverage solely through IHS. Overlap with other healthcare systems and insurers is more common. 1.8% of Urban AIAN Veterans receive services from IHS while enrolled as a beneficiary of Medicaid. 1.2% of Urban AIAN Veterans receive services from both IHS and VA without any insurance coverage. 2.8% of Urban AIAN Veterans receive services from both IHS and VA while enrolled in private insurance. 10.1% of Urban AIAN Veterans receive coverage solely through IHS. 21.2% of Urban AIAN veterans receive services from the VA, while also enrolled in private health insurance.

The need for interoperability is clear, especially for Urban AIAN Veterans who may navigate multiple systems of care, that would benefit from coordination. In 2016, the 21st Century Cures Act passed and is currently being implemented with increasing requirements for interoperability^ix. In response to these requirements, IHS is piloting a “Four Directions Hubs” which connects IHS to the Joint Higher Information Exchange of the VA through the national Ehealth exchange as a positive reinforcement of the required effort. The pilot was implemented at 4 IHS sites with preliminary success. It is important that this effort can be scaled up to improve the multiple healthcare systems accessed by Urban AIAN Veterans to support the full I/T/U system.

ⁱ “Mirror, Mirror 2021: Reflecting Poorly,” August 4, 2021. https://doi.org/10.26099/01dv-h208.

ⁱⁱ Office of the National Coordinator for Health IT (ONC). 2015. Report to Congress on Health Information Blocking. April 2015. Available at: https://www.healthit.gov/sites/default/files/reports/info_blocking_040915.pdf

ⁱⁱⁱ Reisman, Miriam. “EHRs: The Challenge of Making Electronic Data Usable and Interoperable.” Pharmacy and Therapeutics 42, no. 9 (September 2017): 572–75. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5565131/.

^iv Proclamation on National Native American Heritage Month, 86 C.F.R. § 60545 (2021), available at https://www.whitehouse.gov/briefing-room/presidential-actions/2021/10/29/a-proclamation-on-national-native-american-heritage-month-2021/.

^v U.S. Census Bureau, 2017-2021 American Community Survey 5-year Public Use Microdata Samples (2022), retrieved from https://usa.ipums.org/usa/sda/. Urban Veterans are defined as respondents who 1. Reside in a Public Use Microdata Areas (PUMA) which lies fully or partially within a Metropolitan Area with a population of 50,000 or more; 2. Were formerly in the armed forces or armed forces. CODEBOOK for Variable Descriptions: https://sda.usa.ipums.org/sdaweb/docs/us2019c/DOC/nes.htm

^vi Ibid.

^vii Locations. “Locations | Indian Health Service (IHS).” Accessed June 6, 2023. https://www.ihs.gov/locations/.

^viii Ibid.

^ix AAMC. “Electronic Health Records: What Will It Take to Make Them Work?” Accessed June 6, 2023. https://www.aamc.org/news/electronic-health-records-what-will-it-take-make-them-work.

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