FAQ on the June 6, 2024, San Carlos Apache v. Becerra Supreme Court Decision

1. What was the case about?

  • The issue in this case was whether the Indian Self-Determination Act (ISDA) requires the Indian Health Service (IHS) to pay the contract support costs (CSCs) a tribe incurs when collecting and spending program income to further the services and programs transferred to tribes from IHS in a self-determination contract.
  • The program income at issue is revenue collected from third-party payers such as Medicare, Medicaid, and private insurers.

2. What did the Court decide?

  • The Supreme Court ruled 5-4, finding that the Indian Self Determination Act requires the Indian Health Service to reimburse Tribes for CSCs incurred when collecting and spending program income from third-party payers.
  • To summarize, the court found that self-determination contracts between Tribes and IHS require spending and collection of third-party revenue. By doing this and incurring administrative costs, IHS is required by ISDA to reimburse those CSCs.
  • The court also acknowledged and recognized that finding differently would go against the purpose and intent of ISDA, as it would penalize Tribes for pursuing self-determination.

3. Why is the Court’s decision correct from an Indian Law perspective?

  • Congress passed ISDA in 1975, in part, to support Tribal self-determination by promoting the “effective and meaningful participation by the Indian people in the planning, conduct, and administration” of federal healthcare programs.
  • Under ISDA, Tribes enter into contracts with the Indian Health Service (IHS) to assume responsibility for administering the healthcare programs that IHS would otherwise operate for the Tribe.
  • ISDA requires that health programs operated by Tribes under a self-determination agreement receive the same amount of funds that the program would have received had IHS maintained control of the program. This includes funding to cover administration and overhead costs that the government does not incur, and thus does not pay, when it runs the program, otherwise known as “contract support costs.”
  • In their decision, the court focused on the purpose of ISDA in the context of the plain language of the statute.
  • Using this approach, the court found that the expenses at issue fall squarely within ISDA’s definition of contract support costs, and reimbursement of these expenses align with statutory requirements.
  • By basing their decision on ISDA, the court has acknowledged the federal trust responsibility and obligation to Tribes.
  • Notably, the Court did not address the budgetary implications associated with including these costs in contract support costs payments, because ISDA clearly does not place any cost limitations on CSCs.
  • Cost analysis is within the domain of Congress, and it is outside of Court’s power to account for cost concerns when the statutory text does not require it.

4. What does this mean for CSCs?

  • CSCs must now include the expenses incurred by Tribes when spending third-party revenue to operate their healthcare program.
  • This means that IHS is now responsible for reimbursing those costs, on top of the CSCs already being reimbursed.

5. What does this generally mean for the IHS budget?

  • To account for the increased CSCs for collecting and spending third-party revenue, the overall CSCs line item will have to be increased.
  • This will be done during the appropriations process and could result in the IHS budget increasing overall, or for other areas to receive decreased funding to meet the increased requirement for CSCs.
  • It is not yet clear when and how the increased CSCs will affect the IHS budget, and NCUIH is monitoring budget discussions relating to this topic.
  • The federal government estimated the financial impact of the decision to be between $800 million and $2 billion annually but could not provide support for this estimation when pressed to do so by the Court in oral argument. It is not clear where the government got this number from, and it is too early to tell what the actual cost will be.

6. What are the expected effects on the FY2024 and FY2025 Budget?

  • The CSCs are not expected to affect the FY2024 appropriations, as they have already been set and dispersed, but the effect on FY2025 and beyond is unclear.
  • The Congressional Budget Office (CBO) is currently updating the FY2025 score for the Interior bill based off the decision, but how the score affects the actual budget will depend on the appropriated amount for FY25.

7. Is there a long-term budgetary solution for increasing CSC costs?

  • IHS and partner organizations such as NIHB have emphasized that the best option moving forward is for CSCs to be classified as mandatory funding starting in 2026.
  • This will be achieved in a similar process as advance appropriations were, through the appropriations process by including specific language in the appropriations bill.
  • The shift to mandatory has been a priority of the National Tribal Budget Formulation Workgroup for several years.
  • Last year, NCUIH also signed on to a letter with the National Indian Health Board and 21 Tribal Nations in support of shifting CSCs to mandatory for FY2024.
  • There is hope that the decision will place increased pressure on Congress to classify CSCs as mandatory.

8. How is IHS implementing the decision?

  • Director Tso and IHS are taking steps to create and implement a plan of action for updating the CSC reimbursement process to account for the decision.
  • On June 13, Director Tso released a Dear Tribal Leader Letter outlining the Agency’s plan moving forward, which includes convening the CSC Advisory Group in July 2024 and a full Tribal consultation by August 2024.
  • IHS also released an interim guidance document on the process for claiming CSCs for third party expenses.

9. Will UIOs be affected?

  • Again, it is not clear whether UIOs will be affected or not.
  • How the increase in CSCs will affect the budget will not be clear until the actual cost of the increase is known
  • NCUIH will keep a close eye on how the budget discussions are developing.

10. If UIOs are affected, how would this play out?

  • Once the costs are determined, it is possible that the urban Indian health line item will be reduced to make up for the additional CSCs.
  • This is because UIO funds are discretionary appropriations and the IHS budget is in the Interior appropriations bill.
  • There is only a certain amount of money the committee can allocate amongst all agencies within the Interior.
  • Another aspect to consider is that due to being an indefinite appropriation and being provided an unlimited amount of funds, CSCs are paid first before any other areas of the IHS budget can be paid, affecting the total amount available. It may not be just the urban Indian health line item impacted, but other areas of the IHS budget also seeing decreases as well.
  • However, because the urban Indian health line item has historically been close to 1% of the IHS budget, it is possible that the urban Indian health line item remains unaffected, and the funds are allocated from a different line item within the IHS budget.
  • Urban Indian Health is funded under the Indian Health Service through the Services Account. CSCs are funded through the Indian Health Service under the CSC Account. However, IHS has one overall budget.
  • Which line item is affected will be decided during the appropriations process.
  • NCUIH plans to monitor this situation moving forward and will provide updates, once there is more certainty in how the budget will be affected by the decision.
  • It’s important to note that this decision is not expected to impact funding for FY2024 as those funds have already been appropriated. Any impacts to UIOs or the IHS budget overall are expected to begin in FY2025.

House FY 2025 Bill Proposes 23% Increase for the Indian Health Service, Maintains Advance Appropriations

On June 27, 2024, the House Appropriations Subcommittee on Interior, Environment, and Related Agencies released the draft bill text for the fiscal year (FY) 2025 budget. The bill provides $38.478 billion for Interior, Environment, and Related Agencies, which is $72 million below the FY24 levels and $4.407 billion below the Biden Administration’s request. Despite the overall reduction, the bill proposes $8.56 billion for the Indian Health Service (IHS) which is $1.6 billion (+23%) above the FY24 enacted levels and $360 million (+4.4%) above the Biden Administration’s request. Additionally, the bill provides $5.98 billion in advance appropriations for FY26. Appropriations Committee Chairman Cole (R-OK) emphasized that this bill “safeguards the sacred oath this nation made to protect Native American communities.” 

Next Steps 

The House Appropriations Subcommittee on Interior, Environment, and Related Agencies will hold a markup meeting on June 28, 2024. Once the Subcommittee approves the bill, it will proceed to the full Appropriations Committee for markup on July 9, 2024. During this full Committee markup, a detailed bill report will be provided, outlining the specific amounts for line items within the IHS budget, including the urban Indian health line item. NCUIH will offer a detailed analysis of the budget once the bill report is released. 

NCUIH Calls for Full, Protected Funding of Indian Health Service & Funding for Key Indian Health Programs in Written Testimony to House and Senate Appropriators

In May 2024, The National Council of Urban Indian Health (NCUIH) submitted written testimony to the House and Senate Appropriations Subcommittees on Labor, Health and Human Services, Education, and Related Agencies (LHHS), as well as to the  House and Senate Appropriations Subcommittees on Interior, Environment, and Related Agencies regarding Fiscal Year (FY) 2025 funding. NCUIH advocated in its testimony for full funding for the Indian Health Service (IHS) and Urban Indian Health and increased resources for key health programs.

In the testimonies, NCUIH requested the following:

  • Full funding at $53.85 billion for the Indian Health Service (IHS) and $965.3 million for Urban Indian Health for Fiscal Year (FY) 2025 (as requested by the Tribal Budget Formulation Workgroup).
  • Maintain Advance Appropriations for the Indian Health Service, until mandatory funding is authorized and protect IHS from sequestration.
  • Fund the Initiative for Improving Native American Cancer Outcomes at $10 million for FY25.
  • Fund the Good Health and Wellness in Indian Country (GHWIC) Program at $30 Million for FY25.
  • Protect Funding for HIV/AIDS Prevention and Treatment.
  • Reclassify Contract Support Costs and 105 (l) Tribal Lease Payments as Mandatory Appropriations.

Next Steps:

These testimonies will be considered by the House and Senate Appropriations Committee and used in the development of FY25 spending bills. NCUIH will continue to advocate for these requests in FY 2025 and work closely with Appropriators throughout the remainder of the Appropriations process.

Full Text:

My name is Francys Crevier, I am Algonquin and the Chief Executive Officer of the National Council of Urban Indian Health (NCUIH), a national representative of the 41 UIOs contracting with the Indian Health Service under the Indian Health Care Improvement Act (IHCIA) and the American Indians and Alaska Native patients they serve. On behalf of NCUIH and the UIOs we serve, I would like to thank Chair Baldwin, Ranking Member Moore Capito, and Members of the Subcommittee for your leadership to improve health outcomes for urban Indians.

We respectfully request the following:

  • $53.85 billion for the Indian Health Service (IHS) and $965.3 million for Urban Indian Health for Fiscal Year (FY) 2025 (as requested by the Tribal Budget Formulation Workgroup).
  • Maintain Advance Appropriations for the Indian Health Service, until mandatory funding is authorized and protect IHS from sequestration.
  • Fund the Initiative for Improving Native American Cancer Outcomes at $10 million for FY25.
  • Fund the Good Health and Wellness in Indian Country (GHWIC) Program at $30 Million for FY25.
  • Protect Funding for HIV/AIDS Prevention and Treatment.

NCUIH Supports Tribal Sovereignty

First, I would like to emphasize that NCUIH respects and supports Tribal sovereignty and the unique government-to-government relationship between our Tribal Nations and the United States. NCUIH works to support those federal laws, policies, and procedures that respect and uplift Tribal sovereignty and the government-to-government relationship. NCUIH does not support any federal law, policy, or procedure that infringes upon, or in any way diminishes, Tribal sovereignty or the government-to-government relationship.

Urban Indian Organizations Play a Critical Role in Providing Health Care for American Indian and Alaska Native People

UIOs were created by urban American Indian and Alaska Native people, with the support of Tribal leaders, starting in the 1950s in response to severe problems with health, education, employment, and housing caused by the federal government’s forced relocation policies[1]. Congress formally incorporated UIOs into the Indian Health System in 1976 with the passage of IHCIA. Today, over 70% of American Indian and Alaska Native people live in urban areas. UIOs are an integral part of the Indian health system, comprised of the Indian Health Service, Tribes, and UIOs (collectively I/T/U), and provide essential healthcare services, including primary care, behavioral health, and social and community services, to patients from over 500 Tribes[2] in 38 urban areas across the United States. There are four different UIO facility types, including full ambulatory, limited ambulatory, outreach and referral, and outpatient and residential alcohol and substance abuse treatment, that offer a wide range of healthcare services.

UIOs are on the front lines in providing for the health and well-being of American Indian and Alaska Native people living in urban areas, many of whom lack access to care that would otherwise be provided through IHS and Tribal facilities. American Indians and Alaska Native people experience major health disparities compared to the general U.S. populations, including, lower life expectancy,[3] and higher rates of infant and maternal mortality. A lack of sufficient federal funding plays a significant role in these continuing devastating health disparities,[4] and Congress must do more to fully fund the Indian health system to improve health outcomes for all American Indian and Alaska Native people.

Request: Fully fund the Indian Health Service at $53.85 billion and Urban Indian Health at $965.3 million for FY25

The United States has a trust responsibility to provide “federal health services to maintain and improve the health” of American Indian and Alaska Native people. This responsibility is codified in IHCIA.[5] Additionally, it is the policy of the United States “to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.”[6] To finally fulfill its trust responsibility, we request that Congress fully fund Indian Health at $53.85 billion for the Indian Health Service and $965.3 million for Urban Indian Health. These amounts reflect the recommendations made by the Tribal Budget Formulation Work Group (TBFWG), a workgroup comprised of Tribal leaders representing all twelve IHS service areas and serving all 574 federally recognized Tribes.

According to the TBFWG, fulfillment of the trust responsibility “remain[s] illusory due to chronically underfunded and woefully inadequate annual spending by Congress.”[7] Congress must prioritize increasing funding, as the current FY24 allocation of $6.96 billion for IHS and $90.49 million for Urban Indian Health represents only 12.9% and 9.4% respectively of the total FY24 funding requested by Tribes and UIOs to adequately address current needs.

UIOs are primarily funded through a single line item in the IHS budget, the Urban Indian Health line item, and without a significant increase to this line item, UIOs will continue to be forced to operate on limited and inflexible budgets, that limit their ability to fully address the needs of their patients. As one UIO leader highlighted, “funding to the Urban Indian Health line item is critical in ensuring that our funding better meets the needs of urban tribal citizens who come to us seeking medical, dental, and behavioral health care. Increased funding means that we can worry less about having to deny or delay care because of budget constraints.” For example, current funding levels pose challenges for UIOs in offering competitive salaries to hire and retain qualified staff who are essential for UIOs to continue to deliver quality care to their patients. Additionally, UIOs need resources to expand their services and programs to address the needs of their communities, including addressing pressing issues such as food insecurity, behavioral health challenges, and rising facilities costs. One UIO reported, “increased funding will allow our UIO to sustain our program capacity, maintain our workforce, address infrastructure needs, and expand health services that are greatly needed within our community.” Increased investments in Urban Indian Health will continue to result in the expansion of health care services, increased jobs, and improvement of the overall health in urban Native communities.

Request: Retain Advance Appropriations for IHS until Mandatory Funding is Authorized and Protect IHS from Sequestration

Advanced appropriations allowed the I/T/U system to operate normally and without fear of funding lapses during the entire FY24 budget negotiation process. Among other benefits, when IHS distributes their funding on time, our UIOs can pay their doctors and providers without disruption, ensuring continuity of care for UIO patients. Additionally, advanced appropriations allow our UIOs to ensure they can stay open and provide patients with critically needed care, even in the event of a government shut down. We emphasize that advanced appropriations are a crucial step towards ensuring long-term, stable funding for the I/T/U system and, therefore, it is imperative that you include advance appropriations for IHS FY26 in the final FY25 Interior, Environment, and Related Agencies Appropriations Act.

While advance appropriations are a step in the right direction to avoid disruptions during government shutdowns and continuing resolutions, mandatory funding is the only way to assure fairness in funding and fulfillment of the trust responsibility. As the President’s FY25 budget notes, “Mandatory funding is the most appropriate, long-term solution for adequate, stable, and predictable funding for the Indian health system.”[8] We request your support for mandatory funding, and until authorizers act to move IHS to mandatory funding, we request you continue to provide advance appropriations to the Indian health system to improve certainty and stability.

We also request that this Committee protect IHS from sequestration through an amendment to Section 255 of the Balanced Budget and Emergency Deficit Control Act[9]. Sequestration forces Indian Health Care Providers to make difficult decisions about the scope of healthcare services they can offer to American Indian and Alaska Native patients. For example, the sequestration of $220 million in IHS’ budget authority for FY13 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for American Indian and Alaska Native patients[10].

Sequestering funds reduces UIOs’ ability to provide essential services to their patients and communities, delaying care and reducing UIO capacity to take on additional patients. One UIO leader emphasized that loss of funding “translates into Tribal citizens lacking access to care that is guaranteed to them through the trust and treaty obligations held by the United States. Cuts mean UIOs can’t provide things like insulin for diabetics, counseling services for survivors of domestic violence, and oral surgery for our relatives.”

Request: Fund the Initiative for Improving Native American Cancer Outcomes at $10 million for FY25

The FY24 LHHS spending bill appropriated $6 million in new funding to address Native American cancer outcomes, by creating the Initiative for Improving Native American Cancer Outcomes.[11] The Initiative will support efforts including research, education, outreach, and clinical access to improve the screening, diagnosis, and treatment of cancers among American Indian and Alaska Native people. The purpose of the Initiative is to ultimately improve the screenings, diagnosis, and treatment of cancer for American Indian and Alaska Native patients.

This Initiative will be critical to addressing cancer-related health disparities in Indian Country. According to the American Cancer Society, the mortality rates for liver, stomach, and kidney cancers in Native American people are twice as high as mortality rates for White people.[12]  We request that the Committee support the Initiative by continuing to appropriate funds for the Initiative in FY25 and increasing funding to $10 million.

Request: Fund the Good Health and Wellness in Indian Country (GHWIC) program at $30 Million for FY25

The GHWIC program provides essential funding support to Tribes, Tribal organizations, and UIOs to improve chronic disease prevention efforts, expand physical activity, and reduce commercial tobacco use. The program is currently funded at $24 million, but additional funding is needed to maintain programmatic success and account for rising costs. NCUIH requests the Committee support the GHWIC program by increasing funding to $30 million for FY25.

Request: Protect Funding for HIV/AIDS Prevention and Treatment

American Indian and Alaska Native people have the highest rate of undiagnosed HIV cases compared to other racial/ethnic groups in the U.S.[13], and according to IHS, as many as 34% of the American Indian and Alaska Native people living with HIV infection do not know it.[14] UIOs are an important resource for urban American Indian and Alaska Native people for HIV/AIDS testing and referral to appropriate care Maintaining UIO programmatic support for HIV/AIDS is critical to safeguarding the health of urban American Indian and Alaska Native populations. Therefore, we request that the Committee protect funding for HIV/AIDS treatment and prevention programs, such as the Minority HIV/AIDS Fund, by maintaining funding for these programs at current levels.

Request: Reclassify Contract Support Costs and 105 (l) Tribal Lease Payments as Mandatory Appropriations

We are also in strong support of the TBFWG’s proposal to reclassify Contract Support Costs (CSC) and Section 105(l) Tribal Lease Payments as mandatory appropriations.  These accounts are already mandatory in nature, and their inclusion in the discretionary budget makes it difficult for other programs to expand under discretionary funding caps.  In 2014, the Appropriations Committees highlighted the challenging nature of these payments, stating, “Typically obligations of this name are addressed through mandatory spending, but in this case since they fall under discretionary spending, they have the potential to impact all other programs funded under the Interior and Environment Appropriations bill, including other equally important tribal programs.”[15]  This proposal will make sure that other IHS programs are not impacted by these costs and can receive true increases to their line items. Reclassifying as mandatory appropriations will have no direct impact on the federal budget and does not conflict with restrictions set forth by the Fiscal Responsibility Act. On July 12, 2023, NCUIH joined the National Indian Health Board and 21 Tribal Nations and Native Partner Organizations in sending a letter to House and Senate leadership in support of this proposal.

Conclusion

The federal government must continue to work to fulfill its trust obligation to maintain and improve the health of American Indians and Alaska Natives. We urge Congress to take this obligation seriously and provide the I/T/U system with the resources necessary to protect the lives of the entirety of the American Indian and Alaska Native population, regardless of where they live. The requests outlined herein are an important step towards fulfilling this obligation, and we respectfully request your consideration of each request.

[1] Relocation, National Council for Urban Indian Health, 2018. 2018_0519_Relocation.pdf(Shared)- Adobe cloud storage

[2] Indian Health Service, IHS National Budget Formulation Data Reports for Urban Indian Organizations (2023), https://www.ihs.gov/sites/urban/themes/responsive2017/display_objects/documents/IHS_National_Budget_Formulation_Reports_Calendar_Year_2021.pdf

[3] Elizabeth Arias, et. al., Provisional life expectancy estimates for 2021, Vital Statistics Rapid Release; no 23, National Center for Health Statistics, Centers for Disease Control and Prevention, National Vital Statistics System (Aug. 2022), available at DOI: https://dx.doi.org/10.15620/cdc:118999.

[4] U.S. Comm’n on Civil Rights, Broken Promises: Continuing Federal Funding Shortfall for Native Americans (Dec. 2018), available at: https://www.usccr.gov/files/pubs/2018/12-20-Broken-Promises.pdf; The National Tribal Budget Formulation Workgroup, Advancing Health Equity Through the Federal Trust Responsibility: Full Mandatory Funding for the Indian Health Service and Strengthening Nation-to-Nation Relationships, The National Tribal Budget Formulation Workgroup’s Recommendations on the Indian Health Service Fiscal Year 2024 Budget 17 (May 2022), available at: https://www.nihb.org/docs/09072022/FY%202024%20Tribal%20Budget%20Formulation%20Workgroup%20Recommendations.pdf.

[5] 25 U.S.C. § 1601(1)

[6] 25 USC § 1602.

[7] The National Tribal Budget Formulation Workgroup, Honor Trust and Treaty Obligations: A Tribal Budget Request to Address the Tribal Health

Inequity Crisis, The National Tribal Budget Formulation Workgroup’s Recommendations on the Indian Health Service Fiscal Year 2025 Budget (April 2023), available at: https://www.nihb.org/resources/FY2025%20IHS%20National%20Tribal%20Budget%20Formulation%20Workgroup%20Requests.pdf.

[8] IHS FY25Congressional Justification, https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY-2025-IHS-CJ030824.pdf

[9] P.L. 118–31

[10] Contract Support Costs and Sequestration: Fiscal Crisis in Indian Country: Hearings before the Senate Committee on Indian Affairs.(2013) (Testimony of The Honorable Yvette  Roubideaux)

[11] H.R.2882 – 118th Congress (2023-2024): Further Consolidated Appropriations Act, 2024, H.R.2882, 118th Cong. (2024), https://www.congress.gov/bill/118th-congress/house-bill/2882/text.

[12] Siegel RL , Giaquinto AN , Jemal A . Cancer statistics, 2024. CA Cancer J Clin. 2024; 74(1): 12-49. doi:10.3322/caac.21820.

[13] IHS Awards New Cooperative Agreements for Ending the HIV and HCV Epidemics in Indian Country. (2022, September 27). Retrieved January 5, 2023, from https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/HIV-Funding-PressRelease09272022.pdf

[14] Indian Health Service, HIV/AIDS in American Indian and Alaska Native Communities. Retrieved August 8, 2023, from: https://www.ihs.gov/hivaids/hivaian/#:~:text=The%20IHS%20National%20HIV%2FAIDS,Get%20tested%20for%20HIV.

[15] Explanatory statement, DIVISION G- DEPARTMENT OF THE INTERIOR, ENVIRONMENT, AND RELATED AGENCIES APPROPRIATIONS ACT, 2014. https://docs.house.gov/billsthisweek/20140113/113-HR3547-JSOM-G-I.pdf

Coalition of Health Organizations Request Congress Increase Funding for Key IHS Resources to Address Native American Health Needs

On May 20, 2024, the American Indian/Alaska Native (AI/AN) Health Partners, a coalition of health organizations dedicated to improving health care for American Indians and Alaska Natives, sent letters to House and Senate Interior, Environment, and Related Agencies Subcommittee leadership regarding the fiscal year (FY) 2025 appropriations. In these letters, AI/AN Health Partners urged that House and Senate appropriators address workforce, housing, and equipment needs.

Letter Highlights:

  • $18,000,000 requested for increases in funding for the Indian Health Professions account for FY 2025 to make a meaningful dent in high vacancy rate across the Indian Health System.
  • Requests the Appropriations Committee make Indian Health Service loan repayments and scholarships tax free. This is in line with the National Health Service Corps and other federal loan repayment programs and would enable the Service to fund 218 more providers without increasing the Indian Health Professional account.
  • $11 million requested for new and replacement staff quarters, which is key for the Indian Health Service and Tribes to recruit and retain health care personnel.
  • $42,862,000 requested for medical and diagnostic equipment. The Indian health system manages approximately 90,000 devices consisting of laboratory, medical imaging, patient monitoring, pharmacy, and other biomedical, diagnostic, and patient equipment.
  • $435 million requested to modernize the electronic health records system and ultimately replace IHS’s current medical, health, and billing records systems.

Full Text:

Dear Chairman Simpson and Ranking Member Pingree:

The AI/AN Health Partners is a coalition of health organizations dedicated to improving health care for American Indians and Alaska Natives (AI/ANs). AI/ANs face substantial health disparities, and higher mortality and morbidity rates than the general population. The Indian Health Service (IHS) is critical to how they access health care. However, the IHS must have sufficient resources to meet its mission to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.

Maintaining a consistent and constant level of health care funding for Native Americans is vital to ensuring that the Indian Health Service, tribal, and urban Indian health care (I/T/U) programs can provide uninterrupted care. We thank you for recognizing the importance of the health care needs of Native Americans with your support of advanced appropriations for the IHS for FY 2025.

However, while the advanced appropriations provide stability for services, they do not allow for program growth which is especially important since the IHS estimates the nation’s Native American population will grow by 1.8 percent in 2026.

A long-standing priority for our organizations has been to ensure that the services provided by the I/T/U health care programs be maintained to meet the current and future AI/AN population needs. As you work to finalize FY 2025 appropriations for the IHS, we urge you to include several significant budget increases that we believe will dramatically improve the delivery of health care to AI/ANs.

Health Professions Workforce needs

The Indian Health Professions account provides loan repayment, the Service’s best recruitment tool, for providers who work in Indian Country. It also funds scholarships for Native American health care students. Currently, the IHS lacks sufficient funding to meet its needs. There are over 1,330 vacancies for health care professionals within IHS including: physicians, dentists, nurses, pharmacists, physician assistants, and nurse practitioners. Additionally, the IHS reported in its FY 2025 budget justification that it had 455 loan repayment applications from 85 behavioral health providers, 29 dentists, 52 NPs/PAs and 166 nurses that it could not fund. The inability to fund these applicants is a significant challenge for the recruitment efforts of the Service. For FY 2025, the Administration is requesting $81,252,000 for the Indian Health Professions account. This is a $684,000 increase that will fail to make any meaningful dent in the backlog of loan repayment applicants or the high vacancy rate across the system. It has been estimated that it would take approximately $18,000,000 to close this gap. We therefore request $18,000,000 for the Indian Health Professions account for FY 2025.

Making IHS loan repayment and scholarships tax free

We appreciate that the Committee is under pressure to cut back federal funding for all programs. Therefore, we urge the Committee to authorize, in its FY 2025 Interior Appropriations bill, legislation to provide a tax exemption for the Indian Health Service Health Professions Scholarship and Loan Repayment Programs. The IHS is currently paying more than $9 million in taxes for these programs. If the loan repayment and scholarship programs were made tax-free, it would enable the Service to fund 218 more providers without increasing the Indian Health Professions account. This is in line with the National Health Service Corps and other federal loan repayment programs that all enjoy tax-free status.

Staff quarters                                                                                                  

Decent staff housing is also key for the IHS and tribes to be able to recruit health care personnel. Many of the 2,700 staff quarters in the IHS health delivery system are more than 40 years old and in need of major renovation or total replacement. Additionally, in several locations, the amount of housing units is insufficient. Staff quarters, especially in remote areas, is necessary for attracting and keeping health care providers in Indian Country.

We were pleased to see that, for FY 2025, the Administration has requested $11 million for new and replacement staff quarters. We urge the Committee to fund this request and if possible, to increase it.

Medical and diagnostic equipment

Health care professionals need modern equipment to make accurate clinical diagnoses and prescribe effective medical treatments. The I/T/U health programs manage approximately 90,000 devices consisting of laboratory, medical imaging, patient monitoring, pharmacy, and other biomedical, diagnostic, and patient equipment. However, many of these facilities are using outdated equipment like analog mammography machines. In some cases, they are using equipment that is no longer manufactured. Today’s medical devices/systems have an average life expectancy of approximately six to eight years. The IHS has calculated for several years that to replace the equipment at the end of its six to eight-year life would require approximately $100 million per year. For FY 2025, the Administration has requested $33,874,000. This is an increase of only $1,276,000 over the current funding of $32,598,000 which was the same amount appropriated in FY 2023 and FY 2024. We urge the Committee for FY 2025 to fund the Indian Health Facilities equipment account at the House-approved FY 2024 amount of at least $42,862,000.

Electronic Health Records

Being able to have a modern electronic health record (EHR) system is necessary to enable the IHS and tribal health professionals to provide accurate and vital health care for patients. The IHS uses its EHR for all aspects of patient care, including maintaining patient records, prescriptions, care referrals, and billing insurance providers that reimburse the Service for over $1 billion annually. We urge the Committee to support the Administration’s request of $435 million that provides an additional $213 million to modernize its system and ultimately replace IHS’s current medical, health, and billing records systems.

Thank you for considering our requests. We look forward to working with you to improve health care for American Indians and Alaska Natives.

Sincerely yours,

American Academy of Pediatrics
American Association of Colleges of Nursing
American Association of Colleges of Osteopathic Medicine
American Dental Association
American Dental Education Association
American Medical Association
Association of Diabetes Care & Education Specialists
Commissioned Officers Association of the USPHS
International Certification & Reciprocity Consortium

NCUIH Requests Enhanced VA Support and Improved Reimbursement Rates for Urban Indian Organizations in Reimbursement Agreement Program

On May 15, 2024, that National Council of Urban Indian Health (NCUIH) submitted comments to the Department of Veterans Affairs’ (VA), in response to a May 1, 2024, Urban Confer regarding the revised template for the urban Indian organization (UIO)-VA Reimbursement Agreement Program (RAP) (“revised agreement”). In its comments, NCUIH requested that VA support UIO participation in the Program by providing technical assistance to UIOs and improving UIO reimbursement rates under the revised agreement.

Background

The VA Indian Health Service (IHS)/Tribal Health Program (THP)/UIO RAP provides VA reimbursement to IHS, THP, and UIO health facilities for services provided to eligible American Indian and Alaska Native Veterans. The agreements program was first initiated in 2012 for IHS and Tribal health facilities. It was expanded in 2022 to include UIOs. The RAP is part of a larger effort to improve access to care and coordination for American Indian and Alaska Native Veterans under a broader VA-IHS Memorandum of Understanding managed by Veterans Health Administration (VHA).

NCUIH previously submitted comments to VA in February 2022, requesting VA improve VA’s urban confer process and continue to improve VA’s relationship with UIOs.

NCUIH’s Recommendations

In its May 15, 2024, comments, NCUIH recommended that VA:

  • Continue to engage with and provide updates to UIO on the revised agreement through its development.
  • Improve the UIO reimbursement rates under the revised agreement.
  • Ensure changes to the scope of services include services provided at UIOs.
  • Provide technical assistance to UIOs to support UIO participation.

NCUIH will continue to monitor the development of the revised UIO-VA RAP template.

Utah and Nebraska State Medicaid Expansions in 2020 and AI/AN Health Insurance Access

Introduction

The Affordable Care Act (ACA), enacted in 2010 and implemented in 2014, included two provisions to expand health insurance coverage, the creation of health insurance marketplaces, and giving states the option to expand Medicaid coverage to families with incomes to 138% of the federal poverty level.[1]

One goal of the ACA was to expand health insurance coverage of the American Indian and Alaska Native (AI/AN) population. In 2013, prior to ACA implementation, 24% of AI/ANs reported having no health insurance coverage, as measured by the 2013 American Community Survey 1-Year Estimate. In 2015, after the implementation of ACA, 17% of AI/ANs were uninsured. There were 25 states who adopted Medicaid Expansion during the first year of eligibility in 2014. In expansion states, the percentage of the AI/AN population without insurance dropped from 23% pre-expansion to 15% post-expansion.[2] Similarly, the National Indian Health Board compared the AI/AN uninsured rate between the 2008-2012 Five-Year ACS and the 2017-21 Five Year ACS, and estimated that the national AI/AN uninsured rate fell from 24.2% to 14.8%[3]

As of April 2024, 41 states have adopted the ACA’s Medicaid Expansion program[4]. The most recent states to adopt the program are:

  • North Carolina, which implemented expansion in December 2023.
  • South Dakota, which implemented expansion in July 2023.
  • Oklahoma, which implemented expansion in June 2021.
  • Missouri, which implemented expansion in October 2021.
  • Utah, which implemented expansion in January 2020.
  • Nebraska, which implemented expansion in October 2020.

At the time of the drafting of this report, the most recent year of American Community Survey 1-Year Public Use Microdata Sample (PUMS) is from 2021. Therefore, Utah and Nebraska are the most recent expansion states with available post-expansion ACS data. In both Utah and Nebraska, Medicaid Expansion was adopted by ballot initiative in November 2018. In both states, there were efforts by the state legislature to limit and delay implementation.[5][6]

Despite similar origin stories, the two expansions led to different outcomes for AI/AN residents in each state. In Utah, the AI/AN uninsured rate dropped from 32.1% in 2019 to 19.5% in 2021. The rate of Medicaid coverage increased from 12.8% to 14.8%. In Nebraska the AI/AN uninsured remained almost unchanged (from 30.8% to 29.9%). The AI/AN Medicaid coverage rate decreased by 3%, while the non-AI/AN Medicaid coverage rate increased by 3% (Table 1).[7]

Table 1: Uninsured and Medicaid Coverage Rates for AI/AN and non-AI/AN respondents (Ages 19-64)

Uninsured 2019 Uninsured 2021 Medicaid 2019 Medicaid 2021
Utah AI/AN 32.1% 19.5% 12.8% 14.8%
Utah non-AI/AN 12.1% 11.4% 6.3% 8.3%
Nebraska AI/AN 30.8% 29.9% 15.5% 12.9%
Nebraska non-AI/AN 11.4% 9.4% 6.8% 10.3%

Data and Methods

In interpreting changes over time, it is difficult to disentangle the effect of state Medicaid expansion from national conditions such as the Covid-19 pandemic, national economic conditions, and Federal health policy. To better understand specific factors, I employed two logistic regression[8] models on insurance coverage, one model using the ACS 2019 1-year data and a second model using the ACS 2021 1-year data. This model excludes respondents under 19 and over 64 to avoid complications from CHIP and Medicare policies.

To isolate state-specific factors from national effects, I created two ‘dummy’ variables. The variable “Utah” is coded as 1 if the respondent resides in Utah and 0 if the respondent resides in any of the other 49 states or the District of Columbia. The variable “Nebraska” is coded as 1 if the respondent resides in Nebraska and 0 if the respondent resides in any of the other 49 states.

The model includes the “AI/AN” variable, this variable is coded as 1 if the respondent self-identifies as American Indian or Alaska Native, and 0 if the respondent does not. The variable is coded as 1 even if the respondent identifies with multiple other racial categories. According to the Medicaid and CHIP Access Commission, “There are several challenges to enrolling eligible AI/AN people in Medicaid, including geographical remoteness, limited access to Internet or phone service, language barriers, cultural factors, distrust of government programs, or lack of knowledge of the benefits of coverage.”[9]

To isolate the State-level Indian health policy context, the model includes interaction effects between the state dummy variables and the AI/AN variable.

The ACS health insurance question administered to respondents includes IHS usage listed as a type of “coverage” but IHS is not coded as “coverage” when Census derives an “Any Insurance Coverage” variable from the response option. Depending on the availability of services, IHS users may not perceive a need for additional coverage, so it is important to include this variable in the model.

In the research literature on the uninsured, age and income are consistent determinants of coverage, so the model includes age and family income as a percentage of the federal poverty line.[10]

Results

In 2019, non-AI/AN residents of Utah had 7.9% higher odds of coverage as compared to the rest of the United States. The logistic regression model also produces an estimate of the marginal effect of each variable, when all other variables are set to their means. In 2019, Utah residents had a 0.7% higher marginal probability of coverage. The “Utah Effect” in 2021 is not substantially different for non-AI/AN residents (Table 2).

In 2019 non-AI/AN Nebraska residents had a 1.6% higher marginal probability of coverage as compared to the rest of the U.S. In 2021, non-AI/AN residents had 2.6% higher marginal probability of coverage, as compared to the rest of the U.S. It is possible that this difference reflects increased access to health insurance from the Medicaid expansion.

In 2019, the national AI/AN population (excluding Utah and Nebraska) had a 0.9% lower marginal probability of coverage as compared to the national non-AI/AN population. It is interesting to note that this AI/AN coverage ‘disadvantage’ is independent of family income and may reflect aforementioned coverage barriers. The magnitude of the disadvantage doubles between 2019 and 2021, despite policy efforts to preserve coverage.

The interaction term between Utah residency and AI/AN status can be interpreted as either:

  • The coverage disadvantage of Utah residency among AI/AN respondents, OR
  • The coverage disadvantage of AI/AN status among Utah residents.

Among AI/ANs in 2019, AI/AN Utahans have a 6.4% lower marginal probability of coverage than AI/ANs elsewhere. Among Utahans in 2019, AI/AN Utahans have a 6.4% lower probability of coverage than non-AI/AN Utahans. In 2021, the Utah X AI/AN interaction term coefficient is not significantly different from zero, suggesting that Utah’s Medicaid expansion possibly ameliorated disadvantageous coverage barriers specific to AI/ANs in Utah.

Table 2: Odds Ratio on Insurance Coverage ACS 2019 and ACS 2021

2019 Odds Ratio 2019 Marginal Effect at Means 2021 Odds Ratio 2021 Marginal Effect at Means
Utah 1.079** 0.7% 1.061* 0.5%
Nebraska 1.185** 1.6% 1.358** 2.6%
AI/AN 0.917** -0.9% 0.770** -2.7%
Utah X AI/AN 0.593** -6.4% 0.984 -1.1%
Nebraska X AI/AN 0.638* -5.3% 0.376** -13.3%
IHS User 0.405** -12.6% .532** -7.6%
Age In Years 1.009** 0.1% 1.008** 0.1%
Family income as % of fed poverty line 1.004** 0.4% 1.004** 0.0%

** 99% Statistical Significance
*95% Statistical Significance

While non-AI/AN Nebraskans saw an improvement in probability of coverage between 2019 and 2021, the opposite effect is observed for Nebraska AI/AN’s. The coverage disadvantage of Nebraska residency among AI/AN respondents increased from 5.3% to 13.3%. More research is required to determine how this occurred in the context of Medicaid expansion.

[1] HealthCare.gov. “Medicaid Expansion & What It Means for You.” Accessed November 7, 2023. https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/.

[2] Samantha Artiga, Petry Ubri, and Julia Foutz. “Medicaid and American Indians and Alaska Natives.” Issue Brief. Henry J. Kaiser Family Foundation, September 2017. https://files.kff.org/attachment/issue-brief-medicaid-and-american-indians-and-alaska-natives.

[3] Rochelle Ruffer. “State Health Insurance Status Report.” National Indian Health Board, July 2023. https://www.nihb.org/resources/NIHB%20State%20Health%20Insurance%20Status%20Report_July%202023.pdf.

[4] Published: “Status of State Medicaid Expansion Decisions: Interactive Map.” KFF (blog), October 4, 2023. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/.

[5] Maresh, Sarah. “Expanding Medicaid in Nebraska and the Fight to Stop Harmful Waivers, Tiered Benefits.” National Health Law Program, November 2, 2022. https://healthlaw.org/expanding-medicaid-in-nebraska-and-the-fight-to-stop-harmful-waivers-tiered-benefits/.

[6] Musumeci, MaryBeth, Madeline Guth, Robin Rudowitz, and Cornelia Hall Published. “From Ballot Initiative to Waivers: What Is the Status of Medicaid Expansion in Utah?” KFF (blog), November 15, 2019. https://www.kff.org/medicaid/issue-brief/from-ballot-initiative-to-waivers-what-is-the-status-of-medicaid-expansion-in-utah/.

[7] Steven Ruggles, Sarah Flood, Matthew Sobek, Danika Brockman, Grace Cooper, Stephanie Richards, and Megan Schouweiler. IPUMS USA: Version 13.0 [ACS 2019 & ACS 2021]. Minneapolis, MN: IPUMS, 2023. https://doi.org/10.18128/D010.V13.0

[8] J. Scott Long. Regression Models for Categorical and Limited Dependent Variables. Vol. 7. Advanced Quantitative Techniques in the Social Sciences Series. Sage Publications, 1997.

[9] “Medicaid’s Role in Health Care for American and Alaska Natives.” Issue Brief. Medicaid and CHIP Access Commission, February 2021. https://www.macpac.gov/wp-content/uploads/2021/02/Medicaids-Role-in-Health-Care-for-American-Indians-and-Alaska-Natives.pdf.

[10] “Who Went Without Health in 2019, and Why?” Congressional Budget Office, September 2020. https://www.cbo.gov/system/files/2020-09/56504-Health-Insurance.pdf.

Supreme Court Agrees with Tribes that Indian Self Determination Act Requires Reimbursement of Contract Support Costs for Third-Party Expenses

On June 6, 2024, the Supreme Court released their opinion in Case No. 23-250, Becerra v. San Carlos Apache (consolidated with Case No. 23-235, Becerra v. Northern Arapaho Tribe). The Justices ruled 5-4 in favor of the Tribes and the majority opinion was authored by Chief Justice Roberts. The National Council of Urban Indian Health (NCUIH) applauds this decision, and has been in support of Tribes in this case, signing on to the amicus brief filed by the National Indian Health Board (NIHB). NCUIH appreciates that the court supports self-determination and its importance in furthering the health and well-being of American Indian and Alaska Native people.

Read the Court’s Opinion here.

The question presented in this case was whether under the Indian Self Determination Act (ISDA), a Tribe is entitled to recover contract support costs for expenses it incurs when spending third-party revenue to operate its healthcare program. During Oral Argument, on March 25, 2024, the Justices aimed their questions at how ISDA should be interpreted, and whether the spending of third-party revenue collected by Tribes is governed by ISDA contracts. At that time, concerns were raised over impacts the court’s decision would have if found in favor of the opposing party. For the Tribal respondents, they argued that Tribes would then be fully responsible for costs associated with third-party expenditures. For the federal government, they argued that there would be unavoidable impacts on IHS funding.  

Summary of the Court’s Holding 

The court found that self-determination contracts between Tribes and IHS require spending and collection of third-party revenue, therefore, by doing so and incurring administrative costs, IHS is then required to reimburse for those contract support costs. Statutory language provided in ISDA, specifically Section 5325(a), identifies that contract supports costs are requirements of a self-determination contract. The court then infers that this extends to third-party revenue because Tribes incur these costs to be in compliance with the terms of their contract with IHS. The court also addresses the limitations of ISDA found in Section 5326 but does not find that they would preclude payment of contract support costs incurred by spending of third-party revenue under a self-determination contract.  

 In response to arguments raised by the federal government, the court does not find any support within the language of ISDA. There is no language that suggests contract support costs are limited to programs funded by the Secretarial amount. Additionally, the court disagrees with the federal government stating that tribes should not be able to spend third-party revenue on a broader range of activities than IHS can. The differences raised by the federal government do not survive scrutiny, as the court does not see substantial differences between Tribes and IHS in proving services to non-Indians or requirements to “first” use Medicare and Medicaid proceeds to be in compliance with the programs. The court also finds no merit in the argument that Tribes are able to use third-party revenue to construct facilities, since IHS would not be required to pay contract support costs for new programs.   

 An impactful and meaningful aspect of the court’s opinion comes from the recognition that reading ISDA differently would be a harsh penalty on Tribes who pursue self-determination. The court recognizes the detrimental impacts to Tribes and the financing of their healthcare programs and services. If IHS was not required to cover contract support costs for third-party revenue, Tribes would be responsible and would have to divert income from other areas or pay out of pocket. This is contrary to the purpose of contract support costs, which are designated by Congress to fill the funding gap between Tribes and IHS. 

Impact on Urban Indian Organizations 

While this case has no strong relation to Urban Indian Organizations, there will be impacts to the IHS budget and how funds are allocated. UIOs receive funds through the urban health line item, but as they are only 1% of the entire IHS budget,  it is not likely that these funds will be affected by budget allocation changes.  NCUIH included the Tribal request to reclassify Contract Support Costs in its written testimony to Congress and will continue to advocate for Congress to honor this request. In discussing the financial impact, it is important to note that the amount suggested by the federal government of an additional $2 billion per year was not supported by any evidence. The appropriations process will be where the increased obligation for contract support costs will be addressed, which could take Congress several years, potentially not until FY2026. Even though contract support costs are an indefinite appropriation, there is still a limit to the amount of funds that can be provided. Avoiding decreases to line items outside of contract support costs would be most effective through shifting contract support costs from discretionary to mandatory funding. This is supported by the Biden Administration and was included in the President’s FY2025 Budget Proposal, classifying contract support costs as mandatory beginning in 2026. 

Driving Success: Best Practices for GPRA Compliance and Performance

GPRA/GPRAMA OVERVIEW:

The Government Performance and Results Act (GPRA) of 1993 is a federal law that mandates agencies to demonstrate effective and efficient use of congressional funds.1 The Indian Health Service (IHS) has been reporting GPRA data for over a decade.1 This data helps the IHS to evaluate its progress towards achieving its goals and objectives, which ultimately benefits the health of Native Americans.

To ensure that federal agencies make informed decisions, the Government Performance and Results Modernization Act (GPRAMA) was introduced in 2010 as an update to GPRA. This act requires federal agencies to leverage performance data in their decision-making processes. The GPRA and its modernization counterpart, the GPRAMA, play crucial roles in shaping how federal agencies are held accountable for their performance and results. For instance, in the context of healthcare services, GPRAMA shows Congress how well the IHS is providing care to American Indians and Alaska Natives who use IHS federal, tribal, and urban Indian health facilities.2

The IHS started reporting under GPRAMA in FY 2013, which involves a smaller set of measures compared to GPRA. 1 The 26 clinical GPRA/GPRAMA measures are collected throughout the GPRA year (October 1 to September 30) using the Integrated Data Collection System (IDCS) and exported to the National Data Warehouse (NDW).1 This data is cumulative and aggregates results from all reporting clinics, including federal, tribal, and urban Indian health programs, into national outcomes.1

Regardless of the electronic health record (EHR) system they use, urban Indian health programs can report GPRA data.1 This makes it easier for them to contribute to a comprehensive national database and ensures that the IHS has access to the information it needs to make informed decisions. By leveraging this data, the IHS can continue to provide effective and efficient healthcare services to Native Americans across the country.

COMPARATIVE UIO PERFORMANCE OF GPRA/GPRAMA MEASURES:3-5

GPRA/GPRAMA measures are indicators of how well the agency has provided clinical care to its patients. Overall, they measure how well the IHS has done in the prevention and treatment of certain diseases, and the improvement of overall health. The table below outlines the measures of performance of Urban Indian Organizations (UIOs) over three years (2018, 2019, 2020), comparing actual results against set goals. The measures are categorized into the “Top 3” and “Bottom 3” based on performance. In the “Top 3” category, Statin Therapy consistently exceeded its goals, demonstrating a significant improvement. Nephropathy and CVD Statin Therapy measures also performed well, with Nephropathy showing yearly increases in actual achievements. However, the “Bottom 3” measures faced challenges, with Exclusive/Mostly Breastfeeding meeting its goal in 2019, while IPV/DV Screening and Adult Immunizations fell short of their goals every year reviewed.  In 2020, two new measures, Topical Fluoride and Retinopathy Exam, were introduced as part of the GPRA tracking. However, in their first year, they did not meet their targets. This data underscores the substantial progress in some areas and the need for enhanced focus and improvement in others, particularly in preventative screenings and healthcare interventions.

TOP ACHIEVERS AND AREAS OF IMPROVEMENT (2018-2020) 3-5

   Top 3 Actual Goal Bottom 3 Actual Goal
2
0
1
8
1 Statin Therapy 61.6% 37.5% Exclusive/Mostly Breastfeeding (Age of 2 Mos) 25.0% 39.0%
2 Nephropathy 50.2% 34.0% IPV/DV Screening 30.1% 41.6%
3 CVD Statin Therapy 41.9% 26.6% Mammography Screening 33.6% 42.0%
2
0
1
9
1 Statin Therapy 61.4% 37.5% Adult Immunizations 33.5% 54.9%
2 Nephropathy 51.6% 34.0% Exclusive/Mostly Breastfeeding (Age of 2 Mos) 28.6% 28.6%
3 CVD Statin Therapy 40.3% 26.6% IPV/DV Screening 32.6% 41.6%
2
0
2
0
1 Statin Therapy 62.6% 51.6% Adult Immunizations 25.9% 59.7%
2 CVD Statin Therapy 42.8% 35.7% Topical Fluoride 14.1% 34.5%
3 HIV Screening Ever 31.5% 28.4% Retinopathy Exam 36.0% 53.5%

Definitions of Performance Metrics See Appendix*

BEST PRACTICES TO ADDRESS PROBLEMS AND CHALLENGES IN GPRA DATA:7

UIOs face several challenges in their efforts to collect data and achieve GPRA metrics. These challenges include the need to troubleshoot issues, secure healthcare center buy-in, provide adequate training, lack of employee capacity, and implement technology updates and requirements.

To begin to address these challenges, it is essential to prioritize Electronic Medical Record (EMR) reminders or alerts for clinicians, and updated medical coding, taxonomies, and ICD-10 codes. These updates will allow for more efficient and streamlined healthcare services and reporting.

Another critical challenge is the lack of healthcare center buy-in. The prioritization of GPRA within Urban Indian Organizations is an essential aspect of enhancing the quality of care. By visualizing benchmarks as indicators of care quality, as opposed to solely numerical targets, UIOs can integrate these standards into their daily operations. It is recommended that sites hold themselves accountable for adhering to these standards for both internal assessment and external reporting purposes. In instances where metrics are not met, it is advisable that they are considered as opportunities for Quality Assurance Projects.

Establishing a dedicated GPRA team comprising of both medical and non-medical staff can ensure that responsibilities are clearly defined, thereby making the targets more attainable and allowing providers to focus more on patient interactions.7 Effective coordination and communication are crucial to overcoming these challenges. Therefore, establishing a GPRA Coordination Committee and holding regular structured interactions, such as morning huddles or weekly medical meetings, provide ample opportunities to discuss GPRA metrics. These interactions facilitate the sharing of insights and strategizing on how best to further improve metrics, fostering a collaborative environment for continuous improvement. Furthermore, ensuring the availability, improvement, and sharing of GPRA data is fundamental. Data should be readily accessible, regularly updated, and shared with all stakeholders, including medical and quality improvement staff, to allow for early identification of issues and collaborative problem-solving.7

Encouraging internal development and the use of technology can further enhance the effectiveness of GPRA measures.7 UIOs should foster local solutions and employ information technology to track care delays and community health statuses. Innovations such as electronic clinical reminders and specialized clinics that provide comprehensive care and use incentives can significantly improve patient outcomes.  Additionally, learning from peers or other UIOs by visiting sites that exhibit best practices can provide invaluable insights into effective strategies and areas requiring improvement. This peer learning helps in directly understanding what works and what doesn’t from those who have experienced it first-hand.

It is important to focus on the actual health outcomes achieved through the implementation of GPRA measures, rather than merely the activities performed. Adhering to an outcomes-focused approach ensures that the efforts are not solely geared towards meeting metrics but genuinely improving patient health, which is the ultimate goal of these measures. In conclusion, addressing the challenges faced by Urban Indian Organizations is essential to improving healthcare services for communities. By prioritizing the necessary updates and providing adequate training, we can ensure that healthcare centers are fully invested in delivering high-quality care to all patients, and by promoting effective communication, we can continuously improve our services.

For more information on best practices visit: https://www.ihs.gov/crs/toolbox/.

For more information on GPRA Performance Measures visit: https://ihs.gov/sites/crs/themes/responsive2017/display_objects/documents/crsv24/GPRA-FY-2022-2023-2024.pdf

APPENDIX

References:

  1. Claymore, V., & Boney, M. (2024, March). UIO GPRA/GPRAMA UPDATES. Indian Health Services. Online; Online.
  2. Indian Health Services. (n.d.). Understanding the Government Performance and Results Act (GPRA)/ GPRA Modernization Act (GPRAMA). https://www.ihs.gov/crs/includes/themes/responsive2017/display_objects/documents/toolbox/GPRAHandoutforPatients.pdf
  3. Weahkee, R., & Mueller, R. (2018). 2018 Indian Health Service Urban Indian Health Organizations GPRA/GPRAMA Results. Rockville, MD; Indian Health Service.
  4. Weahkee, R., & Mueller, R. (2019). 2019 Indian Health Service Urban Indian Health Organizations GPRA/GPRAMA Results. Rockville, MD; Indian Health Service.
  5. Weahkee, R., & Mueller, R. (2020). 2020 Indian Health Service Urban Indian Health Organizations GPRA/GPRAMA Results. Rockville, MD; Indian Health Service.
  6. Indian Health Services. (n.d.). 2011 GPRA Best Practices. 2011 GPRA Meeting. https://www.ihs.gov/california/tasks/sites/default/assets/File/GPRA/2011GPRAMtg-GPRABestPractices.pdf

Definitions:

  • Adult Composite Immunizations: Percentage of adults age 19 and older who receive recommended age-appropriate vaccinations.
  • Breastfeeding Rates: Percentage of patients who, at the age of 2 months, were either exclusively or mostly breastfed.
  • Cancer Screening: Mammogram Rates: Percentage of women ages 52 to 74 years of age, who have had mammography screening within the previous two years.
  • Diabetes: Statin Therapy to Reduce CVD Risk in Patients with Diabetes: Percentage of patients with diagnosed diabetes who received a prescription for statin therapy.
  • Diabetes: Nephropathy Assessment: Percentage of patients with diagnosed diabetes assessed for nephropathy.
  • Diabetes: Retinopathy: Percentage of patients with diagnosed diabetes who received an annual retinal exam
  • Domestic (Intimate Partner) Violence Screening: Percentage of women who are screened for domestic violence at health care facilities.
  • HIV Screening Ever: Percentage of patients who were ever screened for HIV.
  • Statin Therapy for the Prevention and Treatment of Cardiovascular Disease: Percentage of patients with CVD or at high risk for CVD who receive a statin therapy prescription
  • Topical Fluorides: Percentage of patients ages 1-15 who received one or more topical fluoride applications.

Senator Warren and Representative Raskin Re-Introduce NCUIH-Endorsed CARE ACT, Invests $1 Billion a Year to Address Substance Use Crisis in Native Communities

On May 9, 2024, Senators Elizabeth Warren (D-MA) and Tammy Baldwin (D-WI) as well as Representatives Jamie Rasin (D-MD), Ann Kuster (D-NH), David Trone (D-MD) and Brittany Pettersen (D-CO) re-introduced the Comprehensive Addiction Resources Emergency (CARE) Act (S.4286 / H.R. 8323) to provide resources that combat the substance use epidemic, including in American Indian and Alaska Native communities. It is currently co-sponsored by 16 other Democratic senators and 73 Democratic representatives and supported by over 100 organizations. The bill is modeled after the Ryan White Comprehensive AIDS Resources Emergency Act, that supports federal research and programming that prevents substance use disorder and expands access to evidence-based treatments and recovery support services.

This legislation provides $125 billion in federal funding for Fiscal Years 2025-2035 and specifically nearly $1 billion a year for Tribal governments and organizations. The funding awards grants to fund core medical services, recovery and support services, early intervention and engagement services, harm reduction services, and administrative expenses.

The $1 billion is allocated to:

  • $790 million in grants to Tribal governments for substance use prevention and treatment.
  • $7.5 million for Tribal nations and regional Tribal epidemiology centers.
  • $50 million to Tribal Colleges and Universities as well as Indian-Health Service funded organizations that train Native health professionals.
  • $150 million to Native non-profits and clinics, including urban Indian organizations and Native Hawaiian organizations, specifically to test culturally informed care models.

Resources

Background on Substance Use in Urban Native Communities

NCUIH has long advocated for resources to address the ongoing substance use crisis that disproportionately affects Native people. Between 1999 and 2015, the drug overdose death rates for Native populations increased by more than 500 percent. In 2022, the CDC reported that the American Indian and Alaska Native populations had the highest rate of overdose deaths in the United States. They reported 56.6 deaths per 100,000 persons in 2021. Additionally, a 2020 report from the CDC highlighted that American Indian and Alaska Native people living in rural and urban areas need substance use disorder (SUD) treatment at virtually the same rate.

Next Steps

The bill has been referred to the Senate subcommittee on Health, Education, Labor, and Pensions and awaits consideration.  NCUIH will continue to monitor the bill’s progress

Life Expectancy Rates for American Indian and Alaska Native People Dropped Drastically During the COVID-19 Pandemic

Overview:

COVID-19 has impacted life expectancy across the globe, reversing trends of life expectancy gains.1,2 American Indian and Alaska Native (AI/AN) people have lower life expectancies than the non-Hispanic White (NHW) population. While the gap between life expectancies for the AI/AN and White populations decreased in the late 20th century and early 21st century, during the COVID-19 Pandemic, the difference in AI/AN and NHW life expectancies grew by over ten years. When looking at the top-of-the-decade life expectancies for each population, a 10+ year difference in life expectancy was last seen between the two populations in 1940.

Life Expectancy Definition:

Life expectancy at birth is the calculated estimate of years a given population (i.e., sex, race/ethnicity, place of residence, etc.) is expected to live if born in the given year, based on current mortality and life trends.3

Life expectancy for the AI/AN population from 1940-1990 was calculated using Indian Health Service (IHS) patient records to calculate life expectancy, so those decades would include single-race or combination-race IHS patients in the given timeframe. From 2000-2021, life expectancy for the AI/AN population was measured using National Vital Statistics System (NVSS) Centers for Disease Control and Prevention (CDC) data, which only included the single-race-identified AI/AN population.

Explanation of Data:

Historically, AI/AN people experienced significantly lower life expectancies than NHW people in the United States. Currently, the life expectancy for an AI/AN person born in 2021 is 65.2 years, 11.2 years less than an NHW person’s life expectancy born in the same year (76.4 years).4 The life expectancy for AI/AN people in 2021 was comparable to the overall life expectancy for Americans during the first two years of US military involvement in World War II (1942 and 1943).5,6

  • 2021 -> AI/AN pop. 65.2 years4
  • 1942 -> All Races/All Sexes US 66.2 years5
  • 1943 -> All Races/All Sexes US 63.3 years5

In addition, within the inaugural year of the COVID-19 pandemic, a universal decline in life expectancies was observed across the US. However, the decrease was particularly larger within the AI/AN community, where life expectancy decreased by nearly five years between 2019 and 2020. In contrast, the life expectancy for NHW populations diminished by approximately 1.5 years during the same period. This stark contrast underscores the profound inequities experienced among AI/AN people in the United States, highlighting the catastrophic repercussions of the COVID-19 pandemic on Native communities. Table 1 showcases the historic gap in life expectancies for AI/AN people compared to NHW people in the United States.

Table 1.

Historic Life Expectancy (at Birth) for AI/AN Population Compared to NHW Population

Year Life Expectancy for AI/AN Life Expectancy for NHW
1940 51.6 y/o7 62.1 y/o7
1950 60.0 y/o7 69.1 y/o7
1960 61.7 y/o7 70.6 y/o7
1970 65.1 y/o7 71.1 y/o7
1980 71.1 y/o7 74.4 y/o7
1990 73.2 y/o 76.1 y/o8
2000 73.1 y/o9 77.3 y/o10
2010 73.5 y/o9 78.9 y/o10
2019 71.8 y/o9 78.8 y/o4
2020 67.1 y/o4 77.4 y/o4
2021 65.2 y/o4 76.4 y/o4

Note: The table includes a summary of AI/AN and NHW populations’ life expectancy (at birth) for all sexes data by the decade in the same table. See Limitations of Data for more information on population.

Figure 1.

Historic Life Expectancy (at Birth) for AI/AN and White Populations in the United States

Note: See Table 1 for more information on population data for data sources for each decade.

Chart: Historic Life Expectancy (at Birth) for AI/AN and White Populations* in the United States by Decade

Limitations of the Data:

Life data tables for the AI/AN population were not produced by the CDC/US Census Bureau until 2019.8 Much of the life expectancy data comes from IHS and then is linked by researchers with data from NVSS, the US Census Bureau, or other government agencies, to collect an estimate on the AI/AN population’s life expectancy for a given year. For example, NVSS grouped different races/ethnicities into “White” and “Nonwhite” until 1969.11 Historic life expectancies for the Black population had to use “Nonwhite” data until additions were made to the racial categories for vital statistics data in 1970.12 Despite the addition of “Black” as a racial category in the ‘70s, the non-Hispanic AI/AN demographic was not included as a racial category for the NVSS United States Life Tables until the publication of the United States Life Tables, 2019 in 2022.13 However, the United States Life Tables, 2019 only include single-race-identified AI/AN people due to the 1997 Office of Management and Budget’s (OMB) standards on classifications for race and ethnicity.13–15 It is important to note that in 2019, the National Center for Health Statistics published a study  in the  Mortality and Morbidity Weekly Report  that sounded the alarm of a Public Health Emergency for the existing health disparities within the  AI/AN population, stating,

“My hope is that policymakers and health care providers recognize the very large disparity between this population and all other populations in this country… they have the worst health profile and mortality risk in this country. So, I would call it an emergency. It is something that should be taken very seriously.” 16

The study also showed that AI/AN people have higher mortality rates for most of the top leading causes of death and in most age groups compared with White, Black, and Hispanic people.

Specifically, the data in Table 1 for the life expectancy for AI/AN people from 1940-1990 used IHS records to calculate AI/AN life expectancy, while the NHW life expectancy used census data. The IHS data only uses a sample of AI/AN people who received services or care from an IHS facility. The IHS user population is not representative of all AI/AN people within the United States in that timeframe or in another timeframe.7,17

2000-2021 data for the AI/AN population use a more inclusive population from NVSS that encompasses more AI/AN people compared to IHS datasets, which are inclusive of AI/AN-identified people who do not receive care from IHS. However, due to NVSS following OMB standards for reporting, only single-race-identified AI/AN people were included in the AI/AN population.4,18

Additionally, death records for AI/AN people are frequently misclassified for race. There is continuous documentation of racial misclassification of AI/AN people in death certificates. This racial misclassification would undercount the mortality rate of AI/AN people due to their deaths being labeled as another race/ethnicity and counted towards that indicated race. Given the limited data publicly available on the AI/AN population, the NCUIH Research and Data Team could not account for the misclassification of the death rate. NVSS life tables did try to account for racial misclassification by linking death records to the 2010 decennial census.14 However, the census underreports AI/AN people, and thus, misclassification could still persist in NVSS life expectancy calculations.19

Works Referenced:

  1. Soucheray, S. WHO: COVID-19 pandemic reversed decade of life expectancy gains | CIDRAP. Center for Infectious Disease Research and Policy, University of Minnesota https://www.cidrap.umn.edu/covid-19/who-covid-19-pandemic-reversed-decade-life-expectancy-gains (2024).
  2. World Health Organization. COVID-19 eliminated a decade of progress in global level of life expectancy. World Health Organization https://www.who.int/news/item/24-05-2024-covid-19-eliminated-a-decade-of-progress-in-global-level-of-life-expectancy (2024).
  3. Centers for Disease Control and Prevention National Center for Health Statistics. NVSS – Life Expectancy. National Center for Health Statistics https://www.cdc.gov/nchs/nvss/life-expectancy.htm (2023).
  4. Arias, E., Tejada-Vera, B., Kochanek, K. & Ahmad, F. Provisional Life Expectancy Estimates for 2021. https://www.cdc.gov/nchs/data/vsrr/vsrr023.pdf (2022) doi:10.15620/cdc:118999.
  5. Bastian, B., Tejada-Vera, B. & Arias, E. Mortality Trends in the United States, 1900-2018. National Center for Health Statistics https://www.cdc.gov/nchs/data-visualization/mortality-trends/index.htm (2020).
  6. Library of Congress. World War II | Great Depression and World War II, 1929-1945 | U.S. History Primary Source Timeline | Classroom Materials at the Library of Congress | Library of Congress. Library of Congress, Washington, D.C. 20540 USA https://www.loc.gov/classroom-materials/united-states-history-primary-source-timeline/great-depression-and-world-war-ii-1929-1945/world-war-ii/.
  7. Snipp, C. M. American Indians: The First of This Land. (Russell Sage Foundation, 1989).
  8. Products – Life Tables – Decennial Tables – 1989-1991. https://www.cdc.gov/nchs/products/life_tables/89liftbl.htm (2019).
  9. Dwyer-Lindgren, L. et al. Life expectancy by county, race, and ethnicity in the USA, 2000–19: a systematic analysis of health disparities. The Lancet 400, 25–38 (2022).
  10. Arias, E. United States Life Tables, 2010. https://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_07.pdf (2014).
  11. Grove, R. & Hetzel, A. Vital Statistics Rates in the United States 1940-1960. https://www.cdc.gov/nchs/data/vsus/vsrates1940_60.pdf (1968).
  12. Sanghi, S. & Smaldone, A. The Evolution of the Racial Gap in U.S. Life Expectancy. https://www.stlouisfed.org/on-the-economy/2022/january/evolution-racial-gap-us-life-expectancy (2022).
  13. Arias, E. & Xu, J. United States Life Tables, 2019. National Vital Statistics Reports 70, (2022).
  14. Arias, E., Xu, J. & Kochanek, K. United States Life Tables, 2021. National Vital Statistics Reports: From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 72, (2023).
  15. Arias, E. & Xu, J. United States Life Tables, 2020. National Vital Statistics Reports 71, (2022).
  16. Arias, E., Xu, J., Curtin, S., Bastian, B. & Tejada-Vera, B. Mortality Profile of the Non-Hispanic American Indian or Alaska Native Population, 2019. Natl Vital Stat Rep 70, 1–27 (2021).
  17. YOUNG, T. K. Recent health trends in the Native American population. Population Research and Policy Review 16, 147–167 (1997).
  18. Life expectancy by county, race, and ethnicity in the USA, 2000–2019: a systematic analysis of health disparities. Lancet 400, 25–38 (2022).
  19. Zeymo, A. Urban American Indian Undercount in the 2020 Census Went Underreported. National Council of Urban Indian Health Research Blog https://ncuih.org/2023/08/28/urban-american-indian-undercount-in-the-2020-census-went-underreported/ (2023).