June Policy Updates: Supreme Court, Budget News and Upcoming Events

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In this Edition:

📸 Monitoring the Bench: Supreme Court Rules 5-4 in Favor of Tribes on Reimbursement of Contract Support Costs for Third-Party Expenses

🏢 FY 2025 Appropriations Update: House FY 2025 Bill Proposes 23% Increase for the Indian Health Service.

🏛 NCUIH in Action: Highlights from June events and conferences.

💬 Advocacy Highlights: Support for Tribal Border Crossing Bill & Addiction Resources.

📝 Federal Agency Comments: NCUIH Advocates for Tribal and Urban Input on IHS Health IT and Strategic Planning Initiatives

🔜 Consultations & Comment Opportunities: Behavioral Health Funding, VHA-IHS Operational Plan

📅 Upcoming Events: Important dates for July meetings and conferences.

📋 Funding Opportunities: HRSA and SAMHSA grants are available.

Monitoring the Bench: Supreme Court Rules 5-4 in Favor of Tribes on Reimbursement of Contract Support Costs for Third-Party Expenses

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

Becerra v. San Carlos Apache (consolidated with Becerra v. Northern Arapaho Tribe)

On June 6, the Supreme Court issued a 5-4 opinion in favor of Tribes.

The bottom line: The court held that when interpreting the Indian Self Determination Act (ISDA), Tribes are entitled to recover contract support costs (CSCs) for expenses incurred when spending third-party revenue to operate their healthcare programs.

Why it matters:

  • While there will be impacts on the IHS budget and how funds are allocated, it is not currently clear what budgetary impacts will be moving forward because the cost of covering these expenses is not yet known.

The big picture: House Appropriations Chairman Tom Cole (R-OK-4), House Appropriations Ranking Member Rosa DeLauro (D-CT-3), and Interior-Environment Appropriations Subcommittee Chairman Mike Simpson (R-ID-2) indicated support for the shift of CSC to mandatory funding.

  • Given the caps on funding under the Fiscal Responsibility Act, a shift to mandatory funding is not expected in FY2025.

What We’re Doing: On June 21, 2024, NCUIH joined a letter led by the National Indian Health Board and signed by the National Congress of American Indians (NCAI), and 25 other organizations, urging Congressional Appropriations leaders to transition CSCs and 105(l) leases to mandatory appropriations.

What else?: Cole said appropriators should consider moving IHS to the much larger Labor-HHS-Education measure, the largest nondefense bill.

Our thought bubble:

FC on SC

Go deeper: Read NCUIH’s Press Release and FAQ on the Supreme Court Decision.

What’s next: NCUIH will monitor budget conversations and potential impacts on the Urban Indian health line item.

Appropriations Updates: House FY 2025 Bill Proposes 23% Increase for the Indian Health Service

Illustration of the U.S. Capitol

House Updates:

On June 27, the House Appropriations Subcommittee on Interior, Environment, and Related Agencies released the draft FY 2025 budget bill.

By the numbers: 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.

Yes, but: Despite the overall reduction, the bill proposes $8.56 billion for 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.

Read the draft House Interior Bill.

Read NCUIH’s blog.

What else?: On June 27, the House Subcommittee held a markup for the Labor, Health and Human Services, Education and Related Agencies (LHHS) bill, which includes funding for vital programs such as Good Health and Wellness in Indian Country, Native Connections, and the AI/AN Suicide Prevention Initiative.

On June 28, the Subcommittee held a markup for the Interior, Environment, and Related Agencies bill.

Why it matters: This markup and bill show that Congress continues to prioritize the responsibility in spite of the spending caps imposed by the Fiscal Responsibility Act.

Senate Updates

On May 23, the Senate Interior Appropriations Committee held a hearing on the President’s FY 2025 budget for IHS.

What they’re saying: Sen. Van Hollen asked a question that NCUIH drafted about what can be done to address the underfunding of UIOs.

  • Director Tso responded that ensuring that reimbursement is similar to the rest of the I/T/U system is critical and that initiatives such as granting UIOs a 100% FMAP, would be instrumental in addressing UIO underfunding.

The Senate has not yet scheduled their subcommittee markups.

NCUIH Action

NCUIH submitted written testimony to the House and Senate Appropriations Committees regarding the FY25 budgets for IHS and HHS. In the testimonies, NCUIH requested the following:

  • Full funding for IHS and Urban Indian Health as requested by the Tribal Budget Formulation Workgroup

  • Maintain Advance Appropriations for IHS, until mandatory funding is authorized and protect IHS from sequestration.

  • Fund the Initiative for Improving Native American Cancer Outcomes

  • Fund the Good Health and Wellness in Indian Country Program

  • Protect Funding for HIV/AIDS Prevention and Treatment.

  • Reclassify Contract Support Costs and 105 (l) Tribal Lease Payments as Mandatory Appropriations.

Read NCUIH’s blog.

What’s Next?: After the subcommittees complete their markups, the full Appropriations Committee will hold markups to pass the subcommittee appropriations bills. The dates for the full committee markups are as follows:

  • July 9: Interior, Environment, and Related Agencies bill.

  • July 10: Labor, Health and Human Services, Education and Related Agencies bill.

  • With no Senate markups scheduled, the chances of passing a budget by September 30 decrease considerably.

Advocacy Highlights: Support for Tribal Border Crossing Bill & Addiction Resources

NCUIH

NCUIH has endorsed the bipartisan Tribal Border Crossing Parity Act (H.R. 7805), which would simplify the process for American Indian and Alaska Native people crossing the United States-Canada border and uphold Tribal sovereignty.

Why it matters: This bill would allow Tribal members to use their Tribe-issued IDs as proof of citizenship in a federally recognized Tribe to cross the border, rather than having to provide proof of 50% blood quantum.

Go deeper: Read NCUIH’s blog.

What else?: NCUIH has also endorsed the Comprehensive Addiction Resources Emergency Act of 2024 (CARE Act) (S.4286/H.R. 8323), which would provide $125 billion in federal funding with over $1 billion year for tribal governments and organizations.

Why it matters: The bill proposes $150 million to Native non-profits and clinics, including urban Indian organizations and Native Hawaiian organizations, specifically to test culturally informed care models.

Go deeper: Read NCUIH’s blog.

NCUIH Advocates for Tribal and Urban Input on IHS Health IT and Strategic Planning Initiatives

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On June 7, NCUIH submitted comments to IHS on Health Information Technology (HIT) Modernization Program: Deployment and Cohort Planning, which included a recommendation to ensure IHS accounts for challenges related to operational and financial costs.  

Background: IHS held a Tribal Consultation and Urban Confer on May 9 providing information and updates on the EHR implementation process. This is the second TC/UC and comment opportunity on HIT Modernization in 2024.

What’s next:

  • August 8, 2024 – Virtual Tribal Consultation/Urban Confer (HIT Modernization Program: Multi-Tenant Domain Considerations)

  • November 7, 2024 – Hybrid Tribal Consultation/Urban Confer (HIT Modernization Program: Site Readiness and Training)

What else?: On June 28, NCUIH submitted comments to IHS regarding IHS’ Strategic Plan for FY 2024-2028.

Background: IHS hosted an Urban Confer on May 30. The draft IHS Strategic Plan for FYs 2024-2028 will establish the Agency direction for the next 5 years.

Go deeper: NCUIH recommended that IHS incorporate urban Indian health into the plan, improve data accuracy, and engage UIOs throughout the plan’s development.

Upcoming Federal Comment Opportunities: Behavioral Health Funding, VHA-IHS Operational Plan

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Up First: July 22 – IHS Urban Confer regarding Division of Behavioral Health (DBH) Funding Initiatives.

Background: IHS held an urban confer on June 20, 2024. In fiscal year (FY) 2024, the IHS administered more than $59 million in behavioral health initiatives funding.

  • DBH is evaluating Agency-wide processes for distributing appropriated funding for 7 behavioral health initiatives: Substance Abuse Prevention, Treatment and Aftercare (SASP); Suicide Prevention, Intervention and Postvention (SPIP); Domestic Violence Prevention; Forensic Healthcare Services; Behavioral Health Integration Initiative (BH2I); Zero Suicide Initiative (ZSI); and Youth Regional Treatment Centers Aftercare (YRTC).

What’s next: The comment submission deadline for both the Tribal Consultation and Urban Confer is on Monday, July 22, 2024. Consultation comments should be directed to consultation@ihs.gov.

TBD– VHA-IHS MOU Operational Plan for FY24 and Joint Tribal Consultation and Urban Confer

  • Background: The VA and IHS sent a Dear Tribal and Urban Leader Letter seeking feedback on the VHA-IHS MOU Operational Plan for FY 2024. The date for the VA/IHS Urban Confer is TBD. Learn more here.

NCUIH in Action: UIO Site Visit, June Engagements & Representations at Key Conferences

FC at NARA

On June 4th, NCUIH CEO Francys Crevier represented UIOs at the 2024 Grantmakers in Health Annual Conference, and hosted a site visit for funders to NARA NW.

MR presenting

On June 11, NCUIH represented UIOs during a panel discussion at the Morehouse School of Medicine’s National COVID-19 Resiliency Network Partner Celebration.

Sam Moose (Mille Lacs Band of Ojibwe), Vice Chair, National Indian Health Board, Walter Murillo (Choctaw), NCUIH Board President

Sam Moose (Mille Lacs Band of Ojibwe), Vice Chair, National Indian Health Board, Walter Murillo (Choctaw), NCUIH Board President

On June 3-6, NCUIH represented UIOs at the NCAI Mid-Year Convention & Marketplace. NCUIH presented policy updates to the Health Subcommittee, which is co-chaired by NCUIH President Walter Murillo and NIHB. NCUIH President, Walter Murillo, also gave remarks at the General Assembly.

NCUIH Board President, Walter Murillo (Choctaw), presents before NCAI Mid-Year 2024 General Assembly.

NCUIH Board President, Walter Murillo (Choctaw), presents before NCAI Mid-Year 2024 General Assembly.

PhRMA Symposium

On June 24, NCUIH participated in the PhRMA Health Equity Symposium and engaged in meaningful discussions about assessing public policy solutions to advance health equity.

Recent Highlights: Tribal Leaders Diabetes Committee, OUIHP Strategic Plan Update

ICYMI:

June 11-12: IHS Tribal Leaders Diabetes Committee (TLDC) Meeting in Scottsdale, AZ:

  • Adrianne Maddux, Executive Director at Denver Indian Health and Family Services and NCUIH Board Treasurer, represented UIOs at the meeting.

  • All 310 SDPI and SDPI-2 grant recipients have received full funding for the 2024 grant year, ending December 31, 2024. SDPI recipients (302) are funded until March 31, 2025. Sufficient funds are allocated to support SDPI-2 until December 31, 2027.

  • TLDC discussed $70 million in unobligated grant funding, proposing $10 million for Calendar Year 2024 supplements and $60 million for a 1-year physical activity grant, or $70 million for multi-year supplemental funding for SDPI grantees. Plans for a Tribal Consultation and Urban Confer are in progress.

June 11: Medicaid, Medicare, and Health Reform Policy Committee (MMPC) Monthly Meeting 

  • Twenty Senate Democrats have signed a letter requesting that the syphilis outbreak in Indian Country be declared a public health emergency.

May 21: IHS OUIHP posted the 2023 OUIHP 4th Quarter Work Plan Update outlining progress on the agency’s 2023 Work Plan to carry out the goals from the 2023-2027 OUIHP Strategic Plan for UIOs. 

Go deeper: The accomplishments, as of December 31, 2023, highlighted included:

  • Collaborations with the Veterans Health Administration and the White House Council on Native American Affairs Health Committee

  • Providing technical assistance on 100% Federal Medical Assistance Percentage (100% FMAP) and the assignment of United States Public Health Service Commissioned Officers to UIOs.

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

June 5: The IHS Director writes to Tribal Leaders and Urban Indian Organization Leaders to announce Agency funding decisions on the Alzheimer’s Grant Program to Address Dementia in Tribal and Urban Indian Communities for fiscal years 2024 and 2025.

  • On May 20, 2024, the IHS released “Addressing Dementia in Indian Country: Enhancing Sustainable Models of Care,” a new 3-year funding opportunity that will fund six new Alzheimer’s programs totaling $1.2 million per year.

  • The grants will focus on expansion and sustainability planning as well as designing and testing approaches to incorporate current, new, and future billing opportunities through the Centers for Medicare & Medicaid Service (CMS).

Upcoming Events

Calendar with events on it

July 16: MMPC Face-to-Face Meeting

July 17-18: CMS TTAG Face-to-Face Meeting

One last thing, check out these upcoming funding opportunities:

Health Resources and Services Administration (HRSA) Nurse Education, Practice, Quality and Retention (NEPQR) – Workforce Expansion Program (WEP)

  • Application Deadline Date: July 26, 2024 (Apply)

Substance Abuse and Mental Health Services Administration (SAMHSA) Women’s Behavioral Health Technical Assistance Center

  • Application Deadline Date: August 20, 2024 (Apply)

American Medical Association Adopts Several American Indian and Alaska Native Health Focused Resolutions, Priorities Include Traditional Healing, Health Care Access, and Nutrition

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The American Medical Association (AMA) held their Annual Meeting of the House of Delegates (HOD), on June 7-12, 2024. During this, various resolutions were presented that focused on American Indian and Alaska Native Communities and Indian Health Service, Tribal, and urban Indian Organization (I/T/U) Facilities. The resolutions covered key issues such as Traditional Healing, Nutrition, Healthcare Access, and Missing and Murdered Indigenous People (MMIP). The AMA has previously shown support for UIOs, during their 2023 HOD meeting, when they passed Resolution 812 (I-23), which included language on 100% FMAP for UIOs. Resolutions, once adopted, become AMA policy and are used to guide how the AMA will advocate with federal and state governments or other entities.  As the largest medical association, adoption of these resolutions by the AMA shows Congress and various agencies the importance of specific issues and initiatives to address them.

Below are the resolutions that passed, as well as the adopted language:

CMS Report 3 – Review of Payment Options for Traditional Healing Services

  • “Our AMA support monitoring of Medicaid Section 1115 waivers that recognize the value of traditional American Indian and Alaska Native healing services as a mechanism for improving patient-centered care and health equity among American Indian and Alaska Native populations when coordinated with physician-led care”
  • “Our AMA support consultation with Tribes to facilitate the development of best practices, including but not limited to culturally sensitive data collection, safety monitoring, the development of payment methodologies, healer credentialing, and tracking of traditional healing services utilization at Indian Health Service, Tribal, and Urban Indian Health Programs”

Resolution 101 – Infertility Coverage

  • “Our AMA will work with interested organizations to encourage the Indian Health Service to cover infertility diagnostics and treatment for patients seen by or referred through an Indian Health Service, Tribal, or Urban Indian Health Program”
  • “Our AMA support the review of services defined to be experimental or 49 excluded for payment by the Indian Health Service and for the appropriate bodies to make 50 evidence-based recommendations for updated health services coverage”

Resolution 206 – Indian Health Service Youth Regional Treatment Centers

  • “Our AMA support the expansion of Indian Health Service Youth Regional Treatment Centers, recognizing them as a model for culturally-rooted, evidence-based behavioral health treatment, and prompt referral of eligible AI/AN youth to Youth Regional Treatment Centers (YRTCs) for community-directed care”

Resolution 208 – Improving Supplemental Nutrition Programs

  • “Our AMA support regulatory and legal reforms to extend eligibility for USDA Food Assistance to enrolled members of federally-recognized American Indian and Alaska Native Tribes and Villages to all federal feeding programs, such as, but not limited to, Supplemental Nutrition Assistance Program (SNAP) and Food Distribution Program on Indian Reservations (FDPIR)”

Resolution 209 – Native American Voting Rights

  • “Our AMA support Indian Health Service, Tribal, and Urban Indian Health Programs becoming designated voter registration sites to promote nonpartisan civic engagement among the American Indian and Alaska Native population”

Resolution 215 – American Indian and Alaska Native Language Revitalization and Elder Care

  • “Our AMA recognize that access to language concordant services for AI/AN patients will require targeted investment as Indigenous languages in North America are threatened due to a complex history of removal and assimilation by state and federal actors”
  • “Our AMA support federal-tribal funding opportunities for American Indian and Alaska Native language revitalization efforts, especially those that increase health information resources and access to language-concordant health care services for American Indian and Alaska Native elders living on or near tribal lands”
  • “Our AMA collaborate with stakeholders, including but not limited to the National Indian Council on Aging and Association of American Indian Physicians, to identify best practices for AI/AN elder care to ensure this group is provided culturally-competent healthcare outside of the umbrella of the Indian Health Service”

Resolution 242 – Health Care Access for American Indians and Alaska Natives

  • “Our AMA actively advocate for the federal government to continue enhancing and developing alternative pathways for American Indian and Alaska Native patients to access the full spectrum of cancer care and cancer-directed therapies outside of the established Indian Health Service system”
  • “Our AMA (a) support collaborative research efforts to better understand the limitations of IHS cancer care, including barriers to access, disparities in treatment outcomes, and areas for improvement and (b) encourage cancer linkage studies between the IHS and the CDC to better evaluate regional cancer rates, outcomes, and potential treatment deficiencies among American Indian and Alaska Native populations”

Resolution 305 – Public Service Loan Forgiveness Reform

  • “Our AMA also support the removal of any requirement for competitive bidding in the Indian Health Service that compromises proper care for the American Indian population”
  • “Our AMA will advocate that the Indian Health Service (IHS) establish an Office of Academic Affiliations responsible for coordinating partnerships with LCME- and COCA-accredited medical schools and ACGME-accredited residency programs”
  • “Our AMA will encourage the development of funding streams to promote rotations and learning opportunities at Indian Health Service, Tribal, and Urban Indian Health Programs”
  • “Our AMA will call for an immediate change in the Public Service Loan Forgiveness Program to allow physicians to receive immediate loan forgiveness when they practice in an Indian Health Service, Tribal, or Urban Indian Health Program”

Resolution 407 – Racial Misclassification

  • “Our AMA supports HIPAA-compliant data linkages between Native Hawaiian and Tribal Registries, population-based and hospital-based clinical trial and disease registries, and local, state, tribal, and federal vital statistics databases aimed at minimizing racial misclassification”

Resolution 408 – Indian Water Rights

  • “Our AMA raise awareness about ongoing water rights issues for federally-recognized American Indian and Alaska Native Tribes and Villages in appropriate forums”
  • “Our AMA support improving access to water and adequate sanitation, water treatment, and environmental support and health services on American Indian and Alaska Native trust lands”

Resolution 411 – Missing and Murdered Indigenous Persons

  • “Our AMA supports emergency alert systems for American Indian and Alaska Native tribal members reported missing on reservations and in urban areas”

Resolution 420 – Equity in Dialysis Care

  • “Our American Medical Association declare kidney failure as a significant public 36 health problem with disproportionate affects and harm to under-represented communities”
  • “Our AMA vigorously pursue potential solutions and partnerships to identify economic, cultural, clinical and technological solutions that increase equitable access to all modalities of care including home dialysis”

Resolution 502 – Tribally-Directed Precision Medicine Research

  • “Our AMA support clinical funding supplements to the National Institutes of Health, the U.S. Food and Drug Administration, and the Indian Health Service to promote greater participation of the Indian Health Service, Tribal, and Urban Indian Health Programs in clinical research”

Board of Trustees Report 31 – The Morrill Act and Its Impact on the Diversity of the Physician Workforce

  • “Our AMA acknowledges the significance of the Morrill Act of 1862, the resulting land-grant university system, and the federal trust responsibility related to tribal nations”
  • “Our AMA will convene key parties, including but not limited to the Association of American Indian Physicians (AAIP) and American Indian/Alaska Native (AI/AN) tribes/entities such as Indian Health Service and National Indian Health Board, to discuss the representation of AI/AN physicians in medicine and promotion of effective practices in recruitment, matriculation, retention, and graduation of medical students”

About the AMA House of Delegates (HOD)

NCUIH has worked with the AMA previously, as they have shown support for the needs of UIOs. Last year, NCUIH submitted written testimony to the 2023 Interim Meeting in support of a proposed resolution that included language on 100% FMAP for UIOs. This resulted in adoption of the resolution and acknowledgment by the AMA of FMAP for UIOs as a priority. Having the support of the AMA is impactful and shows Congress the need to pass 100% FMAP for UIOs. By adding resolutions during their recent HOD meeting that reflect additional needs and priorities of UIOs, the AMA is continuing this support and providing another advocacy tool for UIOs to utilize.

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

Senators Underscore the Importance of Urban Indian Health Funding and Safeguarding IHS Funding in FY 2025

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On May 23, 2024, the Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies held a hearing with the Indian Health Service (IHS) entitled “To examine proposed budget estimates and justification for fiscal year (FY) 2025 for Indian Country.” At the hearing Chairman Jeff Merkley (D-OR) and Ranking Member Lisa Murkowski (R-AK) welcomed testimony from Roslyn Tso, Director of the Indian Health Service, Jillian E. Curtis, CFO of the Indian Health Service, and Bryan Newland, Assistant Secretary for Indian Affairs at the Department of the Interior. The hearing focused on the President’s FY25 budget and legislative proposals and their potential impact on Indian Country.

Congress Underscores Importance of UIO Funding to Provide Health Care

Many committee members expressed the importance of a budget that fulfills the trust responsibility to provide healthcare to American Indian and Alaska Native people. Sen. Van Hollen, Chris (D-MD) focused his questioning to IHS about the needs of urban Indian organizations (UIOs). Senator Van Hollen expressed concerns that it is critical to mention UIOs, given that UIOs “ensure access to comprehensive, culturally relevant healthcare.” He noted that, “The Indian Health Service spends about 1% on the urban Indian health programs.” Going further Sen. Van Hollen posed the question to Director Tso asking, “What are the limitations today to urban Indian health organizations being able to provide care they need to, and what are some specific proposals to the administration budget that might address that issue?” In response, Director Tso explained that ensuring that reimbursement is similar to the rest of the IHS/Tribal/UIO (I/T/U) system is necessary. She suggested that initiatives such as granting UIOs a 100% Federal Medical Assistance Percentage would be instrumental.

Senator Merkley Emphasizes the Need to Safeguard IHS Funding from Sequestration

Chairman Merkley also noted that IHS needs the same funding protections as the Veterans Health Administration (VHA), “It [the President’s budget] also proposes to make IHS funding exempt from sequestration, which the VA has already gained under the Fiscal Responsibility Act. Well, IHS was forgotten, … we should adopt a number of the VA reforms to afford the same dignity to Native Americans and Alaska Natives.” He also expressed his frustration with the proposed cuts to the Electronic Health Records (EHR) line item, given that the IHS’ EHR is over 40 years old.

Senator Tester (D-MT) noted his concerns regarding the President’s IHS budget proposal being $53 billion short of the estimation determined by Tribes and the current 30% vacancy rate at IHS, “How do you fulfill trust responsibilities with those kinds of numbers?… We put you guys [IHS] in a lose-lose position – we need more doctors, we need more nurses, the works.”

NCUIH is thankful for advocates within Senate who recognize that funding is critical to provide safe, quality, and equitable healthcare for all American Indian and Alaska Native people. NCUIH will continue to advocate for full, mandatory funding for IHS and Urban Indian Health.