NCUIH Urges Congress to Protect the Indian Health Service from Automatic Budget Cuts in FY 2024

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On January 29, 2024, the National Council of Urban Indian Health (NCUIH) sent a letter to Congressional Leadership to request that Congress protect the Indian Health Service (IHS) from sequestration in the fiscal year (FY) 2024 funding bill. Sequestration of funding for IHS would jeopardize the capacity of Urban Indian Organizations (UIOs) to provide culturally appropriate essential services and impact access to care. Any reduction in funding for IHS and UIOs does not uphold the federal trust responsibility to provide health care services to American Indian and Alaska Native people.

Background

On June 3, 2023, the Fiscal Responsibility Act (FRA) passed with the purpose to suspend the debt limit and reinstitute discretionary spending limits in FY 2024 and FY 2025 for both defense and nondefense discretionary spending. To ensure Congress passes appropriations in a timely manner, the FRA includes a provision mandating sequestration if Congress does not meet certain deadlines. Sequestration refers to automatic spending cuts that occur through the withdrawal of funding for certain government programs.

On January 4, 2024, the Congressional Budget Office sent a letter to the House Budget Committee outlining that a Congressional approval of a full-year appropriations deal could result in a potential 9 percent sequestration, if the full-year funding is set at the amounts in the current continuing resolution. If the sequestering of funds occurred, it would significantly impact already underfunded UIOs. Current funding levels pose challenges for UIOs in offering competitive salaries to attract and retain qualified staff who are essential for delivering quality care to their communities. Additionally, UIOs need resources to expand their services and programs, including addressing pressing issues such as food insecurity, behavioral health challenges, and rising facilities costs.

Next Steps

NCUIH will continue to advocate to Congress to protect funding for IHS and UIOs in any FY24 spending bills. Congress must ensure that UIOs have the necessary resources to guarantee that American Indians and Alaska Natives receive the comprehensive and culturally competent healthcare services they deserve.

Full Text of the Letter

RE: Protect the Indian Health Service from Sequestration in the 2024 Funding Bill

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

On behalf of the National Council of Urban Indian Health (NCUIH) and the 41 urban Indian organizations (UIOs) that we represent, we write to respectfully request that the final Fiscal Year (FY) 2024 funding bill include a sequestration exemption for the Indian Health Service (IHS). Per the January 4, 2024 letter from the Congressional Budget Office to the House Budget Committee, approval of a full-year appropriations deal by Congress could result in an estimated 9 percent sequestration, if full-year funding is set at the amounts in the current continuing resolution. Such a reduction in funding would severely impact Indian Health Care Providers, including UIOs, who are on the front lines in working to provide for the health and well-being of American Indians and Alaska Natives in urban areas, many of whom lack access to the health care services that it is the United States trust responsibility to provide.

Sequestration forces Indian health-providers to make difficult decisions about the scope of healthcare services they can offer to Native patients. For example, the sequestration of $220 million in IHS’ budget authority for FY 2013 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for AI/AN patients. UIOs provide essential healthcare services to their patients, including primary care, urgent care, and behavioral health services, and are on the front lines in working to provide for the health and well-being of American Indian and Alaska Natives living in urban areas, many of whom lack access to the health care services that it is the federal government’s trust responsibility to provide. Sequestering funds would reduce UIOs’ ability to provide these essential services to their patients and communities, delaying care and reducing UIO capacity to take on additional patients. Therefore, we request that you exempt IHS from sequestration in an amendment to Sec. 255 of the Balanced Budget and Emergency Deficit Control Act.

Indian Country is united in its stance that the Indian healthcare system cannot support any reduction in funding. On September 22, 2023, NCUIH joined the National Congress of American Indians (NCAI), National Indian Health Board (NIHB), and five other national Native organizations in a joint press statement opposing any reductions in funding for vital Indian Country programs and reminding Congress that Native lives should never be used as political pawns.

Protecting IHS from sequestration is essential to upholding the federal trust responsibility to American Indian and Alaska Native people, and therefore we urge you to exempt IHS from sequestration in the final funding bill for FY24. As Chair Mike Simpson (R-ID-2) stated at a recent Full Appropriations Committee markup, “We have a moral and a trust responsibility to the Indians of this country, and we need to make sure that we are trying to address that. We still have a long way to go, but we are moving in the right direction.”

For additional information, please contact Meredith Raimondi, Vice President of Public Policy and Communications at the National Council of Urban Indian Health at mraimondi@ncuih.org. Thank you for your time and consideration.

Sincerely,
Francys Crevier, J.D.
Chief Executive Officer

March Policy Updates: Advocacy Updates, Event Reminders, and Engaging Opportunities Ahead!

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In this Edition:

🌟 Join us for Hill Day visits on Thursday, May 2, during our Annual Conference.

📊 Discover FY 2024 spending details and President Biden’s proposals for FY 2025. We’re actively advocating for critical funding to support IHS programs.

⚖ Learn about our efforts supporting opioid use treatment programs and UIO representation in health IT modernization planning.

🗓 Stay informed about key legal cases impacting federal responsibilities and administrative law.

🌍 Mark your calendars for upcoming virtual meetings, consultations, and federal comment opportunities.

🚀 Explore our recent engagements, from policy webinars to advocacy efforts on Capitol Hill and beyond.

NCUIH Annual Conference Hill Day

NCUIH

We invite you to join us for Hill Day visits on Thursday, May 2, during the annual conference. This opportunity allows you to engage with your representatives’ offices, advocating for urban Indian health issues and priorities.

Express your interest in participating by completing this form by Thursday, April 11.

NCUIH MEMBERS: As a member benefit, NCUIH will facilitate meetings with your Members of Congress, offer comprehensive background materials and training, and provide NCUIH staff to accompany you during your engagements. (Please note that the availability of NCUIH staff for meetings will be contingent upon scheduling constraints).

NCUIH

Registration for our 2024 Annual Conference closes on April 22.

Register Today

Budget Update: FY 2024 Spending Bill Signed Into Law, President Biden Proposes a 15% Increase for Indian Health Service in FY 2025 Budget

Illustration of a dollar bill in the shape of a staircase.

On March 8, 2024, President Biden signed the Consolidated Appropriations Act, 2024 into law, setting the spending for six of the twelve appropriations accounts in Fiscal Year (FY) 2024, including the Interior bill.

By the numbers:

  • $90.4 million appropriated for Urban Indian Health (flat funding)
  • $6.96 billion appropriated for the Indian Health Service (IHS) (+$3.6 million).
  • $5.19 billion appropriated for advance appropriations for IHS in FY 2025.
  • The Special Diabetes Program for Indians (SDPI) was authorized for $130 million from March 9 through December 31, 2024. This brings the total funding to $158 million for Calendar Year (CY) 2024. See chart below on funding breakdown:
NCUIH

On March 11, 2024, President Biden released his FY 2025 budget request, proposing a 15% increase for IHS & a 5% increase for Urban Indian Health.

By the numbers:

  • $8.2 billion proposed for IHS for FY 2025
  • $95 million proposed for urban Indian health for FY 2025
  • $979 billion in indefinite discretionary appropriations proposed for Contract Support Costs
  • $349 million in indefinite discretionary appropriations proposed for Section 105(l) Leases
  • $260 million in mandatory funding proposed for SDPI
  • Go deeper: Read more on NCUIH’s blog.

What’s next: NCUIH is actively submitting appropriations requests to Representatives and Senators from UIO districts/states.

NCUIH Advocates for Critical Funding for IHS to Support Opioid Use Treatment Programs & UIO Representation in Health IT Modernization Planning

Illustration of a man in a wheelchair

On March 22, NCUIH submitted comments to the Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) regarding the American Indian and Alaska Native CMS Quality Improvement Program 13th Scope of Work, and the proposed expansion of CMS Quality Improvement Program to include all Tribal and UIO facilities.

  • The bottom line: NCUIH recommended that CMS host Urban Confers or UIO Listening Sessions to engage directly with UIOs, and ensure CMS Contractor has expertise in working with UIOs.

On March 8, NCUIH submitted comments to IHS regarding the Health IT Modernization Enterprise Collaboration Group (ECG).

  • The bottom line: NCUIH recommended that IHS ensure all UIO facility types are represented in the ECG Domain Groups, encourage consideration of interoperability by the ECG either through existing Domain Groups or a new Domain Group focused exclusively on interoperability, ensure Tribal and UIO representation on the ECG Executive Committee, and clarify expectations for subject matter experts that participate in the ECG Domain Groups.

On March 4, NCUIH submitted comments to IHS regarding $250 million Fentanyl and Opioid Programs.

  • The bottom line: NCUIH requested that IHS ensure noncompetitive funding awards across the I/T/U system, account for administrative duties and reporting requirements in the funding methodology, continue to engage with UIOs, consider partnering with the Substance Abuse and Mental Health Services Administration (SAMHSA) to create a whole family treatment approach, request full funding for the I/T/U system, including mental health, alcohol and substance abuse, and urban health line items.

Upcoming Federal Comment Opportunities:

April 24– CMS Traditional Healing Framework

  • CMS is hosting an All Tribes Consultation on the Traditional Healing Framework on April 3, 2024, from 3:00-4:00 PM EDT. Register here.
  • CMS is also seeking feedback on a proposed Traditional Healing Framework for section 1115 demonstrations following the All Tribes consultation.
  • Comments are due to by April 24, 2024, and can be emailed to tribalaffairs@cms.hhs.gov.

March 28– National Institute of Health (NIH) Request for Information for FY 2026-2030 Strategic Plan for HIV and HIV Related Research

  • NIH is seeking feedback from researchers, health care professionals, advocates and health advocacy organizations, scientific or professional organizations, federal/state/local government agencies, community, and other interested constituents on the development of the FY 2026–2030 NIH Strategic Plan for HIV and HIV-Related Research.
  • Responses are due by March 28, 2024, and must be submitted electronically via this website.
  • More information can be found here.

April 12 – Department of Health and Human Services (HHS) 26th Annual Tribal Budget Consultation

  • On April 9-10, HHS is hosting their Annual Tribal Budget Consultation on the Agency’s FY 2026 budget request in Washington, D.C. Register here.
  • HHS is seeking feedback on the HHS FY2026 Tribal budget request, and Written comments will be accepted through April 12 at 5:00pm EST and must be emailed to consultation@hhs.gov with the subject line “HHS Annual Tribal Budget Consultation.”
  • More information can be found here.

October 1– HHS/United States Department of Agriculture (USDA) 2025 Dietary Guidelines Advisory Committee

  • The 2025 Dietary Guidelines Advisory Committee is tasked with reviewing the current body of nutrition science on specific topics and questions and developing a scientific report that includes its independent, science-based advice for HHS and USDA to consider. The Committee’s review, along with public comments on its scientific report and agency input, will help inform HHS and USDA as they develop the Dietary Guidelines for Americans, 2025-2030.
  • Comments are due to by October 01, 2024, and can be submitted electronically at www.regulations.gov.

Monitoring the Bench: Supreme Court Updates from NCUIH

Illustration of two gavels forming an x in front of the Supreme Court building

Becerra v. San Carlos Apache/Becerra v. Northern Arapaho Tribe (Consolidated)

  • Issue: Issue relates to federal responsibility to pay “contract support costs” to Tribes not only to support IHS-funded activities, but also to support the Tribe’s expenditure of third-party income.
  • Relation to UIOs: No strong relation to UIOs because it relates to CSCs, but will affect Tribal healthcare facilities, and potentially restrict the scope of CSCs to cover services at Tribal facilities.
  • Case Status: Oral Argument occurred on March 25. Decision to be released by June 30, 2024. Learn More here.
  • NCUIH Action: NCUIH joined the IHCIA Amicus Brief filed by the National Indian Health Board in support of Respondent Tribes on February 19.

Relentless, Inc. v. Department of Commerce and Loper Bright Enterprises v. Raimondo   

  • Issue: Issue surrounds clarifying level of deference given to federal agencies when a statute is ambiguous or silent on an issue.
  • Relation to UIOs: Has the potential to fundamentally change administrative law. Both cases have the potential to overturn Chevron deference, which would open up administrative agencies to more litigation and create discrepancies in how regulations are enforced.
  • Case Status: Decision to be released by June 30, 2024.
  • NCUIH Action: Monitoring.

Corner Post, Inc. v. Board of Governors of the Federal Reserve System

  • Issue: Issue surrounds when an injury accrues under the APA.
  • Relation to UIOs: Case could reduce the amount of time a claimant has to challenge the agency action.
  • Case Status: Decision to be released by June 30, 2024.
  • NCUIH Action: Monitoring.

Upcoming Events and Important Dates

Calendar with events on it

Upcoming Events:

  • March 28: Medicare, Medicaid and Health Reform Policy Committee (MMPC) Regulations Workgroup Meeting (virtual)
  • April 3: CMS All Tribes Consultation Webinar on Medicaid Coverage of Traditional Health Care Practices Provided at Indian Health Service and Tribal Facilities (virtual). Register here.
  • April 9: MMPC Monthly Meeting (virtual).
  • April 9-10: HHS Tribal Budget Consultation on FY 2026 Budget in Washington D.C. (in-person). Register here.
  • April 16-18: Tribal Self-Governance Conference in Chandler, Arizona. Register here.

ICYMI:

  • On January 18, IHS hosted a Tribal Consultation on the Definition of Indian Tribe. Consulting on what definition of Indian Tribe should be included in the updated IHS Tribal Consultation Polic9 (List Act Definition (25 U.S.C. § 5130); or ISDEAA Definition (25 U.S.C. § 5304(e))).

  • On February 29, SAMHSA hosted a Tribal Listening Session on Reducing Burden When Measuring Performance of SAMHSA Client-Level Grants:

    – SAMHSA is working to significantly redesign client-level performance management tools in use. SAMHSA specifically plans to develop a single, brief, client-level tool for use in all client-level grant programs.

  • On March 5-6, the IHS Tribal Leaders Diabetes Committee (TLDC) held a meeting in Reno, NV:

    – Adrianne Maddux, Denver Indian Health and Family Services Executive Director, represented UIOs.

    – All SDPI grant recipients (302) have been funded for 6 months of the 2024 grant year. All SDPI-2 grant recipients (8) have been fully funded for the entire 2024 grant year (until Dec. 21, 2024). SDPI-2 grants are funded only using unobligated funds.

    – SDPI Grantee Conference is in Albuquerque, NM from August 14-16, 2024.

  • On March 11, SAMHSA hosted an Expert Panel Reconvening: American Indian and Alaska Native Veteran Suicide Prevention

    -NCUIH staff participated in and represented UIOs on the Expert Panel and discussed plans for the gathering in August.

    -The Expert Panel updated participants with Department of Veterans Affairs (VA)/SAMHSA’s collaborative suicide prevention efforts and reviewed opportunities for culturally centered technical assistance for those who serve American Indian and Alaska Native service members, veterans, and their families.

  • On March 28, Novitas Solutions hosted two IHS webinars on Provider Enrollment & 2024 Medicare Updates.

    – The Provider Enrollment course focused on specific Part A and Part B CMS required enrollment applications for Indian Health Service, Tribal or Urban Indian providers and facilities and Cycle 2 revalidation requirements.

    – The 2024 Medicare Updates course was a review of the most recent Medicare Part A and Part B updates, including the Intensive Outpatient Program (IOP), requirements and enrolling Rural Emergency Hospitals (REH), Marriage and Family Therapists and Mental Health Counselors.

Recent Dear Tribal Leader Letters (DTLLs) and Dear Urban Leader Letters (DULLs)

  • March 4: HHS DTLL – IHS Consolidating Human Resources (HR) Offices

    – IHS Agency-wide consolidation of human resources offices, an initiative IHS has dubbed One HR.

    – IHS’ transition activities towards One HR: created an internal One HR; organizational changes that became effective February 26, 2024, including the designation of the Deputy Director of the Office of Human Resources- as the supervisor of all Regional Human Resource Directors. All HR staff will remain in their current positions at field locations.

    – Each Service Unit will have one or more assigned HR personnel which will enable IHS to provide direct services in IHS’ field locations.

  • March 5: HHS DULL – FY2024 IHS Urban Emergency Fund (UEF)

    – The UEF is a limited, discretionary allocation fund managed by the OUIHP to address some of the costs incurred during one-time, non-recurring emergencies and disaster relief efforts involving UIOs.

    – Each fiscal year, the OUIHP allocates up to $200,000 to the UEF.

    – Funding is not guaranteed and is subject to the availability of appropriations.

    – To be eligible for the UEF, a UIO must have a contract with the IHS.

  • March 20: IHS DTLL/DULL – Indian Health Service Announces Change in Publishing of Funding Opportunities Starting July 1, 2024

    – The IHS’ current process is to publish all NOFOs in the Federal Register (FR), post them on Grants.gov, and post links to both of those locations on the IHS Division of Grants Management (DGM) website.

    – The IHS will cease publishing NOFOs to the FR and continue to post to Grants.gov and the DGM website starting July 1, 2024.

NCUIH in Action: Native Voting Engagement, Meetings on the Hill, Advocating for Urban Indian Health, & More

NCUIH

On Feb. 28, NCUIH hosted a policy webinar with UIO partners about voter engagement and mobilizing Native votes.

  • UIO representatives presented: Ralyn Montoya (Navajo), Public Relations and Marketing Specialist at the Urban Indian Center of Salt Lake; Susan Levy, Communications and Community Relations Director at Native Health of Phoenix; and Rio Fernandes (Lower Elwha Klallam Tribe), Director of Civic Engagement at the National Urban Indian Family Coalition
  • Watch the webinar here. Access NCUIH voting materials here.

Walter Murillo attending TTAG Meeting

NCUIH President Elect, Walter Murillo (Choctaw), at CMS Tribal Technical Advisory Group (TTAG) Face-to-Face Meeting.

On March 6-7, CMS TTAG held a Face-to-Face Meeting

  • NCUIH President-Elect, Walter Murillo, represented UIOs and spoke about urban Indian health issues, including 100% FMAP for Medicaid services at UIOs & traditional healing reimbursement.
  • NCUIH & the National Indian Health Board accompanied Tribal Leaders during the MMPC/TTAG Hill Day on March 5.

NCUIH

NCUIH VP of Policy and Communications, Meredith Raimondi, and HRSA Administrator Carole Johnson.

On March 13, NCUIH represented UIOs by attending a Health Resource and Services Administration (HRSA) Panel Discussion on the FY 2025 President’s Budget.

  • NCUIH was able to talk to HRSA leaders about key UIO priorities such as Health Professional Shortage Areas (HPSA) scoring.
Logos of organizations at the HRSA NHSC meeting

On March 14, NCUIH co-hosted the HRSA National Health Service Corps (NHSC) Webinar for Tribal Communities

  • Chandos Culleen, NCUIH’s Senior Director of Federal Relations, shared that UIOs are important sites to consider when applying for the NHSC scholarship.

  • Eligible Auto-approved sites for the NHSC include: Indian Health Service Facilities, Tribally Operated 638 Health Programs, and Urban Indian Health Programs. Eligible auto-approved NHSC sites must apply to the NHSC by taking the following steps:

    – Log into the BHW Customer Service Portal.

    – If the site is already listed under My Sites, select the site name and then select Start a NHSC Site App.

    – If the site is not already listed under My Sites, select Create New Site in the left sidebar. After you create the site, select Start a NHSC Site App.

    – Complete the application. Under the Confirm Site Details section, FQHCs/LALs must include their BHCMIS IDs, and ITU sites must include their ASUFAC numbers. Auto-approved sites are exempt from uploading documentation into their NHSC applications. However, they must submit documentation during site visits or upon request.

NCUIH presentation at AAP CONACH meeting

On March 18, NCUIH represented UIOs and presented policy updates at the American Academy of Pediatrics (AAP) Committee on Native American Child Health (CONACH) Meeting in Washington D.C.

Francys at USET Panel

Francys Crevier (Algonquin), CEO of NCUIH, with the youth group and panelists at the Close Up Foundation/United South and Eastern Tribes, Inc. (USET) action expert panel.

On March 26, NCUIH CEO Francys Crevier joined an action expert panel organized by the Close Up Foundation and USET, emphasizing the importance of involving youth in policy advocacy to address pressing community issues.

One last thing, check out these upcoming funding opportunities:

  • IHS is accepting applications for grants for Native Public Health Resilience. This grant supports core Public Health functions, services, and activities to develop further and improve their Public Health management capabilities.

    Application Deadline Date: May 14, 2024. (Apply)

  • IHS is accepting applications for grants for Native Public Health Resilience Planning. The purpose of this program is to assist applicants to establish goals and performance measures, assess their current management capacity, and determine if developing a Public Health program is practicable.

    Application Deadline Date: May 14, 2024. (Apply)

President Biden Proposes a 15% Increase for Indian Health Service, 5% Increase for Urban Indian Health for FY 2025

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The FY 2025 budget request includes $95 million for urban Indian health, a 5% increase over the FY 2024 enacted amount, mandatory funding through FY 2033, and an IHS exemption from sequestration.

On March 11, 2024, the Indian Health Service (IHS) published their Fiscal Year (FY) 2025 Congressional Justification with the full details of the President’s Budget, which includes $95 million for Urban Indian Health – a 5% increase above the FY 2024 enacted amount of $90.4 million. The President’s proposal included a total $130.7 billion in discretionary funding for the Department of Health and Human Services (HHS) and $8 billion in funding for IHS, a 15% increase above the FY 2024 enacted amount of $6.96 billion. The budget request also includes $260 million in proposed mandatory funding for the Special Diabetes Program for Indians (SDPI), bringing the total IHS funding to 8.2 billion. The proposal maintains the IHS budget should be moved to mandatory funding and includes $979 million in indefinite discretionary appropriation for Contract Support Costs and $349 million for Section 105(l) Leases.

Budget Caps and Debt Limit Impacts

The President’s budget reflected a discretionary spending request that was in line with caps set under the 2023 debt limit deal. This means that while there was a decrease in the President’s overall budget request in comparison to FY 2024 request, the Indian Health Service and the Urban Indian Line Item still received an increase over the FY2024 enacted amount.

Mandatory Funding and Advance Appropriations

The budget transitions IHS funding from advance appropriations to full mandatory funding for IHS from FY 2026 to FY 2034 to the amount of $288.9 billion over ten-years, as well as exempting IHS from sequestration. On January 29, 2024, the National Council of Urban Indian Health (NCUIH) sent a letter to Congressional Leadership to request that Congress protect the Indian Health Service (IHS) from sequestration in the fiscal year 2024 funding bill. This mandatory formula would culminate in $42 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, “Mandatory funding is the most appropriate, long-term solution for adequate, stable, and predictable funding for the Indian health system.”

NCUIH Efforts to Support Tribal Request for FY 2025

The National Council of Urban Indian Health (NCUIH) requested full funding for urban Indian health for FY 2025 at $965.3 million and at least $53.85 billion for IHS in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. The marked increase for FY 2025 is due to Tribal leaders’ budget recommendations to address health disparities that have historically been ignored.

NCUIH Supports President’s Legislative Proposals

The President’s Budget includes potential legislative solutions to address workforce challenges in Indian Country. These proposals include meeting the IHS loan repayment/scholarship service obligation on a half-time basis and providing tax exemptions for IHS professions scholarship and repayment programs. NCUIH has endorsed the IHS Workforce Parity Act (S. 3022) which expands healthcare provider access to IHS scholarship and loan repayment programs, including scholarships for half-time clinical practice. The President’s budget also proposes that U.S. Public Health Service Commissioned Officers be permitted to be detailed directly with UIOs. On May 24, 2022, the National Council of Urban Indian Health (NCUIH) sent a letter to the Chairs of the House and Senate Appropriations Committees, expressing NCUIH’s support for detailing Public Health Service Commission Officers (PHSCOs) to Urban Indian Organizations (UIOs).

Next Steps

The Appropriations Committees will review the President’s Budget for consideration as they craft their bills for FY 2025. NCUIH will submit testimony and send letters to House and Senate Appropriators to request full funding for FY2025.  NCUIH will continue to work with the Biden Administration and Congress to push for full funding of urban Indian health in FY 2025.

Line Item   FY23 Enacted   FY24 Enacted  FY25 Tribal Request  FY25 President’s  Budget 
Urban Indian Health $90.42 million $90.4 million $973.6 million $94.99 million
Indian Health Service $6.96 billion $ 6.96 billion $51.4 billion $8.2 billion
Advance Appropriations $5.13 billion $5.19 billion ——————— ———————
Hospitals and Clinics $2.5 billion  $2.55 billion  $12.2 billion $2.93 Billion
Tribal Epidemiology Centers $34.4 million  $34.4

 million

  ——————– $34.4 million
Electronic Health Record System $218 million  $190.57 million  $491.9 million $435.1 million
Community Health Representatives $65.21 million  $65.2

million

 $1.2 billion $69.63 million
Mental Health $127.1 million  $129.77 million  $3.4 billion $138.75 million
IHS Cancer Moonshot Initiative —————- —————- ——————— 108 million
HIV & Hepatitis $5 million $5 Million ——————— $15 million

Overview of Budget

Key Provisions for IHS, Tribal Organizations, and Urban Indian Organizations (UIOs)

  • $8.1 billion for IHS for FY 2025
  • $95 million for urban Indian health for FY 2025
  • $979 million in indefinite discretionary funding for Contract Support Costs
  • $349 million in indefinite discretionary funding for Section 105(l) Leases
  • $260 million in mandatory funding up to 2026 for SDPI

Other Budget Highlights

  • Addressing Targeted Public Health Challenges
    • $15 million for HIV and Hepatitis C.
      • UIOs eligible
    • $21 million for addressing opioid use.
      • UIOs eligible
    • Urban Indian Health Program – Alcohol and Substance Abuse Title V Grants
      • $3.4 million
        • Allocates funds to the Office of National Drug Control Policy (ONDCP) budget to give resources to UIOs to provide high quality, culturally relevant prevention, early intervention, outpatient and residential substance abuse treatment services, and recovery support to address the unmet needs of the Urban Indian communities they serve.
  • IHS Cancer Moonshot Initiative
    • $108 billion
      • Develops a coordinated public health and clinical cancer initiative to implement best practices and prevention strategies to address the incidence of cancer and mortality among AI/ANs.
        • UIOs eligible
  • Indian Health Professions
    • $81.25 million
      • Offers additional IHS Scholarship and Loan Repayment awards, bolstering recruitment and retention efforts through these two high demand programs.
        • UIOs eligible

Legislative Proposals

  • U.S. Public Health Service Commissioned Officers to be Detailed to Urban Indian Organizations to Cooperate in or Conduct Work Related Functions of the Department of Health and Human Services

  • Sequestration Exemption for Indian Health Program
    • Proposal Description
      • Amends current law to exempt IHS from future sequestration cuts.
      • The services provided by the IHS are no less critical. Budget reductions of any kind have implications for the services IHS, Tribes, and Urban Indian organizations provide to American Indian and Alaska Native patients and communities.
    • NCUIH Action
      • January 29, 2024 Letter Requesting Exemption
  • Meet Loan Repayment/Scholarship Service Obligations on a Half-Time Basis
    • Proposal Description
      • Permit both Indian Health Service (IHS) scholarship and loan repayment recipients to fulfill service obligations through half-time clinical practice, under authority similar to that now available to the National Health Service Corps (NHSC) Loan Repayment Program (LRP) and Scholarship Program.
      • Permitting IHS scholarship and loan repayment health professional employees to fulfill their service obligations through half-time clinical practice for double the amount of time and to offer half the loan repayment award amount in exchange for a two-year service obligation could increase the number of providers interested in serving in the Indian health system.
    • NCUIH Action
      • NCUIH has endorsed the IHS Workforce Parity Act ( S. 3022) which expands healthcare provider access to IHS scholarship and loan repayment programs, including scholarships for half-time clinical practice.
  • Provide Tax Exemption for Indian Health Service Health Professions Scholarship and Loan Repayment Programs
    • The Indian Health Service (IHS) seeks tax treatment similar to that provided to recipients of scholarships and loan repayment from the National Health Service Corps (NHSC). The IHS seeks to allow scholarship funds for qualified tuition and related expenses received under the Indian Health Service Health Professions Scholarships to be excluded from gross income under section 117(c)(2) of the Internal Revenue Code of 1986 (IRC) and to allow participants in the IHS Loan Repayment Program to exclude from gross income, payments made by the IHS Loan Repayment Program under section 108(f)(4) of the IRC. With the above exemptions, the IHS programs would also be exempt from any Federal Employment Tax (FICA), making the IHS programs comparable to the current NHSC status.
    • NCUIH Action:
      • NCUIH has endorsed the IHS Workforce Parity Act (S. 3022) which expands healthcare provider access to IHS scholarship and loan repayment programs, including scholarships for half-time clinical practice.

Nine Urban Indian Health Centers Achieve HRSA Community Health Quality Recognition Badges in 2023

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In 2023, nine urban Indian organizations (UIOs) have received a Health Resources and Services Administration (HRSA) Community Health Quality Recognition (CHQR) Badge. The nine urban Indian organizations include: American Indian Health & Services, Inc., First Nations Community HealthSource, Gerald L. Ignace Indian Health Center, Helena Indian Alliance, Indian Health Board of Minneapolis, Indian Health Center of Santa Clara Valley, San Diego American Indian Health Center, Seattle Indian Health Board, and Hunter Health Clinic, Inc. In order to achieve a CHQR badge, a UIO must be a Health Center Program awardee or look-alike (LAL) and show quality improvements in one of these areas: access, quality, equity, health information technology, and COVID-19 public health emergency response. These badges are awarded annually, based on data from the latest Uniform Data System (UDS) reporting period. This shows how urban Indian organizations lead in high-quality patient care.

Background on HRSA and CHQRs

HRSA Health Center Program

HRSA funds and implements the Health Center Program to serve uninsured and Medicaid enrolled individuals and families, those who are uninsured and struggle to afford co-pays, experiencing homelessness, living in public housing, and those who have physical lack of access to care. There are approximately 1,400 HRSA-supported health centers and that provide healthcare services to 30 million patients. These health centers serve as cornerstones of essential preventive and primary care services. There are currently 10 dually-funded urban Indian organizations, meaning that they receive funding from both the HRSA Health Center Program and the Indian Health Service.

HRSA CHQR Badges

Each year, HRSA announces the top 10 percent of health centers receiving a Gold Health Center Quality Leader (HCQL) badge. These digital badges are awarded based on achievements in improving health outcomes and providing high-quality care for patients in rural and underserved communities. The CHQR badge program recognizes excellence by awarding both National Quality Leader Badges (NQLS) that acknowledge outstanding performance in many areas including behavioral health, maternal health, diabetes health, heart health, cancer screening, HIV prevention and care, and overall quality, as well as HCQL badges that acknowledge health centers for being access enhancers, reducing health disparities,  advancing health information technology (HIT), addressing social risk factors, and for being COVID-19 Public Health Champions.

FY 2024 Spending Bill Signed into Law, Includes Modest Increase for the Indian Health Service and Maintains Advance Appropriations

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The bill includes $6.96 billion for IHS and flat funding for Urban Indian Health.

On March 09, 2024, the Consolidated Appropriations Act, 2024 (H.R. 4366), also known as a ‘minibus,’ was signed into law by President Biden, finalizing appropriations for six spending accounts for fiscal year (FY) 2024. This follows a fourth continuing resolution (CR) for FY 2024 that extended partial government funding through March 8 and March 22. The bill, which passed in the House with a 339-85 vote, followed by final passage in the Senate with a 75-22 vote, is the first package of final Appropriations bills for FY 2024 and included Interior appropriations.

  • The minibus authorizes $6.96 billion for the Indian Health Service (IHS) for FY 2024, which is $3.6 million above the comparable FY 2023 level; $90.42 million for urban Indian health for FY 2024, which is equal to the FY 2023 enacted level; and advance appropriations for IHS totaling $5.19 billion for FY 2025.
  • In addition, the final package includes an authorization of $130 million for the Special Diabetes Program for Indians (SDPI) for the period of March 9 through December 31, 2024, bringing the total funding to $158 million for Calendar Year (CY) 2024 (includes SDPI funding allocated in FY 2024 CRs).

Despite cuts in funding for other programs in the Interior appropriations bill, such as a 10% cut to the Environmental Protection Agency (EPA), the Indian Health Service was thankfully able at a minimum maintain current funding levels. In addition, advance appropriations for FY 2025 were protected with a modest increase of $61.43 million, which will ensure that all AI/AN people will have continuous access to care, even in the event of a government shutdown. Finally, the reauthorization of the extremely successful SDPI will allow UIOs and other grantees to continue to use grant funding to offer a wide range of diabetes treatment and prevention services.

The National Council of Urban Indian Health (NCUIH) has long advocated for larger investments in American Indian and Alaska Native (AI/AN) health care and has called on Congress to strengthen its commitment to Indian Country with increased funding in the FY 2024 appropriations. The Tribal Budget Formulation Workgroup, a national workgroup that identifies annual Tribal funding priorities, requested full funding for IHS at $51.42 billion and $973.59 million for Urban Indian Health. Unfortunately, the final legislative text falls short of fully funding IHS so that the agency can properly provide health care services for all AI/AN people.

Bill Text:
Overview of IHS and Urban Indian Health Requests:

Table

Line Item FY 2023 Enacted FY 2024 TBFWG Request FY 2024 President’s Budget Request FY 2024 House Passed FY 2024 Senate Passed FY 2024 Enacted
Urban Indian Health $90.4 million $973.59 million $115.15 million $115.15 million $92.42 million $90.4 million
Indian Health Service $6.9 billion $50.9 billion $9.7 billion $7.078 billion $7.26 billion $6.96 billion
Advance Appropriations $5.1 billion $9.1 billion $5.13 billion $5.88 billion $5.23 billion $5.19 billion
Hospitals and Clinics $2.5 billion $12.338 billion $3.553 billion $2.66 billion $2.58 billion $2.551 billion
TECs $34.4 million _______ $34.4 million $35 million _______ $34.4 million
CHRs $65.2 million $1.247 billion $74.56 million ___________ _________ $65.2 million
Direct Operations $103.8 million $101.9 million $118.5 million $101.73 million $103.8 million $103.8 million
Mental Health $127.1 million $3.46 billion $163.99 million $130.86 million $130.16 million $129.77 million
BIA MMIW $25.1 million _________ __________ $15.56 million $26.09 million $25.1 million
EHRs $217.5 million $491.97 million $319.03 million  ________ $217.56 million $190.57 million
Produce Prescription Program $3 million _______ _________ $6 million $3 million $3 million
Key Provisions for IHS, Tribal Organizations, and UIOs:
  • $6.96 billion for IHS for FY 2024, $3.6 million above the FY 2023 level.
  • $90.419 million for Urban Indian Health for FY 2024, the same amount as the FY 2023 level.
  • $5.19 billion for advance appropriations for FY 2025, $61.43 million above the FY 2024 advance.
  • Fully funds Contract Support Costs and Payments for Tribal Leases
  • Total SDPI funding for CY 2024: $158 million
Funding Mechanism Dates Authorization Total Daily Rate 2024 Calendar Year

(Daily rate x funding period)*
CR 1 10/1/2023 – 11/17/2023 $19,726,027 $419,702 _______
CR 2 11/18/2023 – 1/19/2024 $25,890,411 $410,958 $8,219,178
CR 3 1/20/2024-3/8/2024 $20,136,986 $428,447 $20,136,986
Minibus 3/9/2024 – 12/31/2024 $130,000,000 $437,710 $130,000,000
Total 10/1/2023 – 12/31/2024 $195,753,424 ________ $158,356,164

*Calendar year funding calculated by multiplying the daily rate with the number of days in 2024 for that funding period.

Analysis:

Urban Indian Health

  • $90,419,000 for Urban Indian Health for FY 2024

Indian Health Service

  • $5,190,883,000 in advance appropriations for IHS for FY 2025
  • $6.962 billion in agency funding for IHS for FY 2024
    • Indian Health Services Account – $4,948,731,000
  • Hospitals and Health Clinics – $2,550,514,000
  • Tribal Epidemiology Centers (TECs) – $34,400,000
  • Electronic Health Records (EHRs) – $190,564,000, a $27 million decrease from FY 2023 enacted levels
  • Community Health Representative (CHRs) – $65,212,000
  • Mental health – $129,756,000
  • Produce Prescription Pilot Program – $3,000,000
  • Direct Operations – $103,805,000
  • Indian Health Care Improvement Fund – $74,138,000
  • Funds Indian Health Facilities at $813,183,000
  • Indefinite appropriation to fully fund contract support costs, which are estimated to be $1,051,000,000 in FY 2024
  • Indefinite appropriation to fully fund payments for Tribal leases, which are estimated to be $149,000,000 in FY 2024

Bureau of Indian Affairs (BIA)

  • $1,898,550,000 for Operation of Indian Programs
  • Missing and Murdered Indigenous Women (MMIW)
    • $24,898,000 for Law Enforcement Special Initiatives, of which an additional $5,000,000 is to continue addressing the MMIW effort.
  • Native Boarding School Initiative
    • $260,634,000 for Executive Direction and Administrative Services, including maintaining FY 2023 levels for the Native Boarding School Initiative.
  • Violence Against Women Act (VAWA)
    • $3,000,000 is for an initiative to support cross-designation of Tribal prosecutors as Tribal Special Assistant United States Attorneys
Topic Section Funding Language
Urban Indian Health Urban Indian Health $90,419,000 Pg. 52

“The agreement provides $90,419,000 for the Urban Indian health Program.”
Indian Health Service Advance Appropriations $5,190,883,000 Pg. 51

“The agreement provides advance appropriations for the Indian Health

Services and Indian Health Facilities accounts totaling $5,190,883,000 for fiscal year 2025. Advanced

appropriations are not provided for the Electronic Health Record System, Indian Health Care

Improvement Fund, Contract Support Costs, Payments for Tribal Leases, Sanitation Facilities

Construction, and Health Care Facilities Construction. Additional details, instructions, and requirements

follow in the table at the end of this division”
Staffing for New Facilities $56,061,000 Pg. 51

“The agreement includes $56,061,000 for staffing newly opened health facilities, which is the full amount required in fiscal year 2024 based upon updated estimates provided to the Committees. Funds for staffing of new facilities are limited to facilities funded through the Health Care Facilities Construction Priority System or the Joint Venture Construction Program that have opened in fiscal year 2023 or will open in fiscal year 2024. None of these funds may be allocated to a facility until such facility has achieved beneficial occupancy status. As initial estimates included as part of the annual budget request are refined, IHS is expected to communicate updated cost estimates to the Committees.”

New Report Shows Increase in Homelessness Disproportionately Affects American Indian and Alaska Native People

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In December 2023, the Department of Housing and Urban Development (HUD) published the 2023 Annual Homelessness Assessment Report (AHAR) to Congress, Part 1: Point-in-Time Estimates of Homelessness.  This report outlines the key findings of the Point-In-Time (PIT) count and Housing Inventory Count (HIC) conducted in January 2023. Specifically, this report provides 2023 national, state, and Continuums of Care (CoCs)-level PIT and HIC estimates of homelessness, as well as estimates of chronically homeless persons, homeless veterans, and homeless children and youth.

  • Overall, the report shows that there is an increase in homelessness across all genders, ages, ethnicities, and races, among individuals and families with children and in sheltered and unsheltered locations.
  • The report also showed that this increase disproportionately affected American Indian and Alaska Native (AI/AN) people, and more specifically AI/AN veterans.

Background on the HUD Annual Homelessness Report

Each year HUD reports to Congress an AHAR that provides, “nationwide estimates of homelessness, including information about the demographic characteristics of homeless persons, service use patterns, and the capacity to house homeless persons. The report is based on Homeless Management Information Systems (HMIS) data about persons who experience homelessness during a 12-month period, point-in-time counts of people experiencing homelessness on one day in January, and data about the inventory of shelter and housing available in a community.”

Key Findings on AI/AN Homelessness

In order to be included in the PIT count, “a person needs to meet the definition of experiencing homelessness used by HUD… defined as lacking a fixed, regular, and adequate nighttime residence.” The data was collected during January 2023 in an effort to meaningfully collect data on all people experiencing homelessness to identify trends and inform policy makers about the current state of U.S. homelessness. Key findings on AI/AN homelessness include the following:

  • Among all people experiencing homelessness, 4% identified as American Indian, Alaska Native, or Indigenous and were nearly twice as likely to be experiencing unsheltered homelessness than sheltered homelessness.
  • The largest percentage increase of people experiencing homelessness between 2022 and 2023 was among people who identified as American Indian, Alaska Native, or Indigenous, which increased by 18% (1,631 more people).
  • American Indian, Alaska Native, or Indigenous populations also showed a large percentage increase in both sheltered and unsheltered experiences of individual homelessness between 2022 and 2023, both of which rose by 18-19 % (or 2,860 people total).
  • 3% of all families with children experiencing homelessness in 2023 were American Indians, Alaska Natives, and Indigenous people.
  • Unaccompanied youth who identified as American Indian, Alaska Native, or Indigenous made up nearly twice as large of the share of youth located in unsheltered locations than sheltered locations (7% vs 4%).
    • The share of unaccompanied youth who identified as American Indian, Alaska Native, or Indigenous was highest in other largely urban CoCs (8%) and largely rural CoCs (7%) and lowest within largely suburban CoCs (2%).
  • Veterans who identify as American Indian, Alaska Native, or Indigenous made up a higher share of the unsheltered veteran population than the sheltered (5% vs 2%).

Background on AI/AN Homelessness

Housing Challenges for Urban AI/AN Households

AI/AN people in urban areas are “disproportionately disadvantaged economically and face cultural and experiential barriers to accessing services and achieving a measure of housing security and stability,” and when compared to all households, “have a higher median rate of cost burden and severe cost burden . . . are more likely to live in housing that lacks complete plumbing and kitchen facilities . . . [and] are more likely to live in overcrowded housing situations.” Many experts link the high rate of homelessness in AI/AN communities to the high level of poverty in AI/AN communities. Among the challenges that AI/AN people face in accessing housing and housing related services in urban areas are the lack of service organizations which assist AI/AN people, a shortage of funding sources designed to support AI/AN housing services in urban areas, and little cultural competency among mainstream providers. AI/AN people in urban areas also report an urgent need for temporary or transitional housing, especially for those seeking medical treatment, as well as a need for housing that reflects and accommodates AI/AN culture.

UIOs’ Unique Position to Address Homelessness and Social Determinants of Health

Congress has specifically declared that it is the policy of the United States, in fulfillment of its trust responsibility, to “ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.” UIOs are uniquely positioned to assist HUD in supporting underserved communities, ensuring access to and increasing the production of affordable housing, promoting homeownership, and advancing sustainable communities among AI/AN people.  In fact, some UIOs already provide housing services. Further, all UIOs provide numerous other social and community services to urban AI/AN people. Providing housing services aligns with UIOs’ mission to provide quality, accessible, and culturally competent health and public health services for AI/AN people living in urban settings because housing is a key social determinant of health (SDOH). HUD has also previously acknowledged the need to coordinate health, housing, and social welfare services. UIOs have the cultural competency and community connections necessary to further support HUD’s mission and assist HUD in fulfilling its trust responsibility to all AI/AN people.

NCUIH Action

On January 26, 2022, NCUIH submitted comments to HUD, encouraging the agency to incorporate urban Natives in its FY22-26 Strategic Plan and focus areas. HUD provides housing resources and funding for Tribes, but these resources are very limited when it comes to urban AI/AN people, or not applicable at all.

NCUIH is also working to address homelessness among urban Native veterans and works closely with the Department of Veterans Affairs (VA), Department of Health and Human Services (HHS), HUD, and the White House Council on Native American Affairs (WHCNAA) on the implementation of the interagency Native American Veteran Homelessness Initiative (the Initiative). This Initiative’s overall goal is to develop relationships between VA, IHS, and other organizations serving Natives. It aims to educate Native veterans about the resources offered by the VA and IHS, particularly focusing on those at risk of homelessness or currently experiencing homelessness. These resources include emergency and transitional housing services, permanent housing solutions, case management support, employment programs, and additional assistance.

IHS Progress Report Highlights Accomplishments Regarding FMAP and Native Veteran Homelessness, Among Other Urban Indian Health Priorities

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On September 30, 2023, the Indian Health Service’s (IHS) Office of Urban Indian Health Programs (OUIHP) posted a second quarter update outlining progress on the agency’s 2023 Work Plan to implement the goals from the 2023-2027 OUIHP Strategic Plan for urban Indian organizations (UIOs).

The quarterly report highlights the OUIHP accomplishments since June 2023 on the five pillars outlined in the strategic plan: provide effective, timely and transparent communication; improve OUIHP’s operational oversight and management; leverage partnerships to expand UIO resources; improve data quality; and expand the infrastructure and capacity of UIOs. Some of these accomplishments include providing technical assistance to Congressional staff regarding the extension of 100% Federal Medical Assistance Percentage (FMAP), completing revisions to the IHS Urban Confer Policy, and in collaboration with the White House Council on Native American Affairs Health Committee (WHCNAA), a brochure was developed to share information on VA services to help Native veterans who are at-risk of experiencing homelessness.

View the full list of accomplishments in the quarterly report here.

Background

In June 2023, IHS released their 2023-2027 OUIHP Strategic Plan which describes how OUIHP will achieve its mission and vision through five strategic pillars to support urban Indian organizations:

  • Provide effective, timely, and transparent communication;
  • Improve OUIHP’s operational oversight and management;
  • Leverage partnerships to expand UIO resources;
  • Improve data quality; and
  • Expand the infrastructure and capacity of UIOs.

IHS also released its corresponding work plan that outlines critical actions and activities to implement these strategic goals, and includes communications on progress, barriers encountered, and accomplishments. The OUIHP tracks progress for each activity and evaluates progress over time. According to the work plan, progress will be shared with UIOs, partners, and stakeholders quarterly.

NCUIH’s Role

NCUIH played a critical role in the drafting of the 2023-2027 OUIHP Strategic Plan and Implementation Plan. NCUIH has submitted a total of four comments to OUIHP with recommendations to strengthen the plans, specifically requesting that the agency develop quarterly reports to provide information on OUIHP’s progress towards achieving the goals and objectives described in the Strategic Plan, and making those reports publicly available.

NCUIH Joins Amicus Brief Filed by the National Indian Health Board in Support of Respondent Tribes in Becerra v. San Carlos Apache Case

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On February 19, 2024, the National Council of Urban Indian Health (NCUIH) joined attorneys for the National Indian Health Board (NIHB) in filing an amicus brief in support of Respondent Tribes for Case No. 23-250, Becerra v. San Carlos Apache Tribe (consolidated with Case No. 23-235, Becerra v. Northern Arapaho Tribe). The issue at question is whether IHS is required under the Indian Self Determination and Education Assistance Act (ISDA), 25 U.S.C. §5301 et seq, to pay contract support costs for the increased overhead expenses a Tribe incurs in connection with services funded by the exact same program income from third parties that IHS uses when operating the same program. Respondent Tribes argue that “ISDA broadly requires reimbursement for ‘any overhead expense incurred by the tribal contractor in connection with the operation of the Federal program … pursuant to the contract.’ The overhead expenses Tribes incur when using program income to provide more healthcare services fall squarely within this definition.”

While the issue at hand in this matter has no strong relation to Urban Indian Organizations, how the court decides this case will affect Tribal healthcare facilities, and potentially restrict the scope of contract support costs to cover overhead costs. Failure by the federal government to cover these overhead expenses would require Tribes to divert program income away from healthcare services. NCUIH supports Tribal sovereignty and the efforts by Respondent Tribes to ensure that IHS carries out the federal trust responsibility in the manner required by IHCIA.

Summary of the Brief’s Argument

Attorneys for NIHB focused their argument on the text and history of the Indian Health Care Improvement Act (IHCIA). Congress first authorized IHS to bill and collect from Medicare and Medicaid in 1976 when Congress first passed IHCIA. The evolution of IHCIA and amendments to it reflect Congressional intent to address specific programs surrounding funding, operation, and IHS oversight of federal Indian healthcare programs. Through this, it confirms that Congress has always regarded third-party program income as essential and integral to “the Federal Program” whether operated by IHS, Indian Tribe, or tribal organization under ISDA. The main points argued within the brief are:

  • Congress enacted IHCIA to redress critical funding shortfalls in federal Indian healthcare programs;
  • IHCIA and ISDA amendments demonstrate that third-party revenues are an essential element of “the Federal program” for which IHS must pay contract support costs; and
  • While Petitioners insist program income is not part of “the Federal program,” IHS continues to treat program income as a critical part of tribally operated programs, including by transferring program income, and personnel funded by program income, to tribes that assume control of IHS healthcare programs under ISDA.

Next Steps

Oral argument for this case is scheduled for March 25th with audio available for public access during and after the oral argument. After oral argument, the Supreme Court will issue a decision on the case by June 30th, 2024.

NCUIH Urges Protection of Indian Health Care Providers’ Ability to Serve Native People Amid HHS Grant Rule Revisions

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On January 18, 2024, the National Council of Urban Indian Health (NCUIH) submitted written comments to the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) Director, Melanie Fontes Rainer, regarding the notice of proposed rulemaking (NPRM) to repromulgate and revise certain regulatory provisions of HHS’ Uniform Administrative Rule Requirements, Cost Principles, and Audit Requirements for HHS Awards (the rule). NCUIH’s comments urge HHS to ensure that the proposed revisions to not inadvertently impact Indian health care providers’ aility to serve Tribal citizens.

Background

The NPRM pertains to the portions of the rule addressing applicability, and statutory and national policy requirements. Among the changes, HHS is proposing to repromulgate a section addressing discrimination and is including a section stating that HHS will follow all applicable Supreme Court decisions in administering its award programs. HHS is also proposing language providing for religious exemptions for certain provisions.

One of the ways in which the United States meets its trust obligation to provide services and resources to improve the health of American Indian and Alaska Native people is through awarding funding to Tribes, Tribal Organizations and urban Indian organizations (UIOs). HHS funding is critical to the success of the Indian Health Service, Tribes, and UIO (I/T/U) system and ensuring the federal government upholds the federal trust responsibility owed to American Indian and Alaska Native people.

NCUIH’s Recommendations

In its comments, NCUIH recommended that OCR:

  • Include language in the proposed rule that clearly states that nothing in the rule will limit ability of Tribes or UIOs to serve American Indian and Alaska Native people exclusively using HHS awards.
  • Ensure OCR and HHS grant staff are properly trained on the unique political status of American Indian and Alaska Native people.

NCUIH will continue to monitor the rulemaking process for HHS’ Uniform Administrative Requirements.

NCUIH Provides Recommendations to Federal Government Regarding Important Native Behavioral Health and Substance Use Disorder Program

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On January 30, 2024, the National Council of Urban Indian Health (NCUIH) submitted written comments to the Substance Abuse and Mental Health Services Administration (SAMHSA) Office of Tribal Affairs in response to SAMHSA’s July 2023 framing paper and October 2023 urban Indian organization (UIO) listening session concerning the development of the funding formula for the Behavioral Health and Substance Use Disorder Resources for Native Americans (BHSUDRNA) Program. NCUIH’s comments make seven key recommendations to SAMSHA when developing the funding methodology for the BHSUDRNA program.

Background

NCUIH, UIOs, Tribes, and Tribal Organizations worked closely with Congress to create a new Behavioral Health program modeled in part after the Special Diabetes Program for Indians (SDPI) to expand access to behavioral health funding for Native communities. Congress authorized this program via the Consolidated Appropriations Act, 2023 (CAA 2023).  The purpose of the Program is to provide services for the prevention of, treatment of, and recovery from mental health and substance use disorders among American Indians, Alaska Natives, and Native Hawaiians. The BHSUDRNA Program will be operated by SAMHSA in consultation with the Indian Health Service. Eligible entities include Urban Indian organizations.

NCUIH’s Recommendations

In its comments, NCUIH recommended that SAMHSA:

  • Ensure noncompetitive Program awards across the IHS/Tribal Organization/UIO (I/T/U) system.
  • Account for administrative duties in the funding formula.
  • Respect Traditional Healing and Indigenous Knowledge in the funding formula.
  • Ensure program measures do not impose additional burdensome reporting requirements.
  • Ensure that all information related to program application is widely available.
  • Seek additional expert feedback from Tribal Advisory Committees and Federal Agencies
  • Continue to engage with and incorporate UIO feedback in the development of the Program.

While Congress authorized $80 million in appropriations for this Program in each of Fiscal Years (FY) 2023-2027, Congress has not yet appropriated the necessary funding for the Program since its authorization. As part of its comments, NCUIH called on the Biden Administration to request that Congress fully fund the Program at the authorized levels.

NCUIH will continue to monitor the development of the funding formula for the BHSUDRNA Program and continue to advocate for Congress to fully fund the Program.