Senate Confirms Roselyn Tso as Director of the Indian Health Service

Tso’s confirmation comes after almost two years without a permanent IHS Director.

Today, September 21, 2022, Roselyn Tso (Navajo) was confirmed as the Director of the Indian Health Service (IHS) by voice vote in the Senate. Her confirmation comes after 21 months without a permanent IHS Director. Elizabeth Fowler (Comanche) has been serving as the Acting Director of IHS since the resignation of the previous Director, Rear Admiral Michael Weahkee (Zuni), in January 2021. The National Council of Urban Indian Health (NCUIH) welcomes Ms. Tso’s confirmation and continues to urge for the elevation of the role to Assistant Secretary within the Department of Health and Human Services (HHS) to bring better representation for the health needs of American Indians/Alaska Natives (AI/ANs).

“We are thrilled to have a confirmed leader for the Indian Health Service, and we graciously thank Liz Fowler for her tireless service during a pandemic that has been devastating our people. We look forward to working with Roselyn Tso to carry out the mission of IHS in fulfilling the trust responsibility to provide health care equity for all American Indians and Alaska Natives. We continue to work with Congress and this Administration to elevate this position within HHS where it belongs to lift Native voices and improve health outcomes,” – Francys Crevier (Algonquin), CEO, NCUIH.

Background

Roselyn Tso

Ms. Tso is a citizen of the Navajo Nation. She began working for IHS in 1984 and most recently served as the Director of the Navajo Area and Director of the Office of Direct Services and Contracting Tribes until her confirmation. Prior to her work in IHS, much of her professional career was spent in Portland, where she served in several capacities, including working with the three urban programs in the Portland Area that provide services ranging from community health to comprehensive primary health care services. Ms. Tso holds a Bachelor of Arts in interdisciplinary studies and a master’s degree in organizational management from Marylhurst University in Portland, Oregon. As the IHS Director, Ms. Tso is responsible for administering a nationwide health care delivery program that is responsible for providing comprehensive health care services to AI/ANs through IHS, Tribes, Tribal organizations, and urban Indian organizations (UIOs).

On March 9, 2022, President Biden announced the nomination of Ms. Tso as Director of IHS. On July 13, 2022, the Senate Committee on Indian Affairs (SCIA) voted to advance her nomination in a business meeting after she appeared before the Committee for her nomination hearing on May 25, 2022.

SCIA Hearing: Confirmation Needed to Address Health Disparities & Tribal Needs

The absence of a confirmed IHS Director has prevented Tribes, Tribal organizations, and UIOs from addressing the health care needs of their Native American populations, which directly falls under the responsibility of IHS. Since the resignation of Rear Admiral Weahkee, there have been countless requests from Indian Country calling on Congress and the Administration to nominate a new IHS director to address the growing health disparities experienced by AI/ANs. NCUIH has previously stressed the importance of appointing a permanent IHS Director and called for the elevation of the role to Assistant Secretary.

During the SCIA hearing to consider her nomination as Director of IHS, Ms. Tso highlighted how Native communities have been disproportionately impacted by COVID-19, which has been made worse given the absence of a confirmed Director. She stated, “I am reminded of the many health disparities facing American Indians and Alaskan Natives – health disparities that in many cases were made worse by COVID-19. For example, sadly, today, too many Navajo families still do not have access to running water in their homes. Access to clean, safe drinking water is essential to the health and well-being of our people.”

In addition, Ms. Tso stated during the hearing that she intends to utilize IHS resources to not only address the disparities caused by COVID-19, but to also “improve the physical, mental, social, and spiritual health and well-being of all American Indians and Alaskan Natives served by the Agency.” To achieve this goal, Ms. Tso said she would prioritize strengthening and streamlining business operations to create a more unified health care system, develop centralized systems to improve patient outcomes, accountability, and transparency, and finally address the needs and challenges experienced by the workforce. To conclude her testimony, Ms. Tso said that if confirmed as the Director of IHS, she would update agency policies and programs, as well as utilize the oversight authority of IHS to best serve each Tribal community.

Today’s full Senate consideration for the nomination of Ms. Tso as Director of IHS is the last step in her confirmation process.

Department of Veterans Affairs Seeking Nominations for IHS Billings Area Committee Member for the Advisory Committee on Tribal and Indian Affairs

On September 16, 2022, the Department of Veterans Affairs (VA) issued a notice seeking nominations of qualified candidates to be considered for appointment as a member of the Advisory Committee on Tribal and Indian Affairs (“the Committee”) to represent the Indian Health Service, Billings Area. The Committee is composed of 15 members with at least one member of the Committee representing urban Indian organizations (UIOs) nominated by a national urban Indian organization.  Appointed members of the Committee are invited to serve a two-year term. Nominations for membership on the Committee must be received no later than 5:00 p.m. EST on October 7, 2022, and should be mailed to the Office of Tribal Government Relations, 810 Vermont Ave. NW, Suite 915H (075), Washington, DC 20420 or emailed to tribalgovernmentconsultation@va.gov.

NCUIH and the VA

The National Council of Urban Indian Health (NCUIH) has continued to strengthen its partnership with the VA and has ensured UIO input is included in VA efforts. In October 2021, Sonya Tetnowski, President of NCUIH and CEO of the Indian Health Center of Satna Clara Valley, Army Veteran, and member of the Makah Tribe was appointed to the VA’s first-ever Advisory Committee on Indian Affairs. On January 25, 2022, during the first meeting of the Committee,  Ms. Tetnowski highlighted that American Indian/Alaksa Native (AI/AN) Veterans face significant barriers in accessing health care and other benefits. In an effort to ensure the Committee can represent the needs of all AI/AN Veterans, NCUIH recommends that UIOs consider working with Tribes and Tribal Organizations to nominate a Committee member.

Committee Objectives and Scope

In accordance with Public Law 116-315, the Committee provides advice and guidance to the Secretary of Veterans Affairs on all matters relating to Indian Tribes, tribal organizations, Native Hawaiian organizations and Native American Veterans.  According to the Office of Tribal Government Relations Director, Stephanie Birdwell, the Committee “…gives tribal leaders as well as American Indian, Native Hawaiians and Alaska Native Veterans a place at the table with the highest levels of leadership within the VA…” and “[i]t offers an unprecedented voice in how programs, policies, and services may be delivered and provided.”

Committee responsibilities include, but are not limited to:

  • Identifying evolving issues of relevance to Indian tribes, tribal organizations and Native American Veterans relating to programs and services of the Department;
  • Proposing clarifications, recommendations and solutions to address issues raised at tribal, regional and national levels, especially regarding any tribal consultation reports;
  • Providing a forum for Indian tribes, tribal organizations, UIOs, Native Hawaiian organizations and the Department to discuss issues and proposals for changes to Department regulations, policies and procedures;
  • Identifying priorities and providing advice on appropriate strategies for tribal consultation and UIOs conferring on issues at the tribal, regional, or national levels;
  • Ensuring that pertinent issues are brought to the attention of Indian tribes, tribal organizations, UIOs and Native Hawaiian organizations in a timely manner, so that feedback can be obtained;
  • Encouraging the Secretary to work with other Federal agencies and Congress so that Native American Veterans are not denied the full benefit of their status as both Native Americans and Veterans;
  • Highlighting contributions of Native American Veterans in the Armed Forces;
  • Making recommendations on the consultation policy of the Department on tribal matters;
  • Supporting a process to develop an UIO confer policy to ensure the Secretary confers, to the maximum extent practicable, with urban Indian organizations; and
  • With the Secretary’s written approval, conducting other duties as recommended by the Committee.

NCUIH Comments on the IHS Urban Indian Infrastructure Study

On August 23, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments regarding additional funding for the Urban Indian Infrastructure Study (Infrastructure Study) provided by the Consolidated Appropriations Act, 2022. The additional fiscal year (FY22) funding for the Infrastructure Study is approximately $800,696. NCUIH supports the appropriation of the additional funding and it recommended that IHS disseminate the findings of the FY21 Infrastructure Study, already in progress, to UIOs prior to making any decisions regarding the use of the additional funding. NCUIH also requested that the Office of Urban Indian Health Programs (OUIHP) create a timeline of when the Infrastructure Study will be released to UIOs, the contracting process necessary to use additional funding, and the deadline for obligation of the additional funding. Lastly, NCUIH requested that IHS host an additional Urban Confer after the release of updates about the scope and results of the FY21 Infrastructure Study.

Background

In 2021, Congress allocated $1 million in funds for IHS to conduct an Urban Indian Infrastructure study through the Consolidated Appropriations Act, 2021. The purpose of the Infrastructure Study is to further understand the most critical deficiencies facing UIOs. IHS contracted with The Innova Group, a healthcare consultancy entity, to conduct the Infrastructure Study.

On March 15, 2022, Congress provided $800,969 in additional funding to IHS for the Infrastructure Study through the Consolidated Appropriations Act, 2022. As of September 2022, the results from the Infrastructure Study have not been released by IHS and The Innova Group. On June 16, 2022, IHS requested input regarding the additional funding from 2022 and how these funds can be utilized by IHS. On June 23, 2022, UIO Leaders and NCUIH attended an Urban Confer where IHS explained that the Infrastructure Study will be completed by December 31, 2022, with results to be released in January 2023.

NCUIH’s Recommendations to IHS

NCUIH made the following recommendations regarding the Infrastructure Study:

  • Provide UIOs with the findings from the first Infrastructure Study prior to making any decisions regarding use of the additional funds
    • It is crucial that UIOs are aware of the scope, results, and usefulness of the Infrastructure Study before they make any recommendations regarding the use of the further funding.
    • Given the timeline presented during the Urban Confer, there should be an 8-month window in which UIOs and IHS will be able to review the Infrastructure Study results following their release in January 2023 and decide as to the best use of the additional funding
  • OUIHP should provide a timeline of the Planning Process to UIOs
    • NCUIH requested a timeline be released to UIOs delineating when the initial Infrastructure Study will be released, the contracting process necessary to use the additional funding, and the deadline for the obligation of the additional funding.
    • The requested timeline will provide clarity to UIOs. With a clearer picture in mind, the planning process and use of the additional FY22 funds for the Infrastructure Study becomes more cooperative between UIOs and IHS.
  • IHS should host an additional Urban Confer after releasing the results of the Infrastructure Study.
    • NCUIH notes that informed feedback from UIOs creates a scenario where the additional funding can be best used to support the needs of UIOs.

NCUIH continues to advocate for transparency in the process of the Infrastructure Study and greater support to address the critical infrastructure needs at UIOs. NCUIH will continue to keep UIOs informed as more information is made available from IHS.

 

 

NCUIH Board Approves Resolution on Advance Appropriations

On August 22, 2022, the National Council of Urban Indian Health (NCUIH) Board of Directors approved a resolution in support of advance appropriations for the Indian Health Service (IHS). Attaining advance appropriations has been a long-standing priority for NCUIH and Indian Country to ensure stable and predictable funding for IHS and American Indian/Alaska Native (AI/AN) healthcare.

Full Text of Resolution:

WHEREAS the National Council of Urban Indian Health (NCUIH) is the national representative of forty-one (41) urban Indian organizations (UIOs) receiving grants under Title V of the Indian Health Care Improvement Act (IHCIA) and the American Indians and Alaska Natives (AI/ANs) they serve;

WHEREAS NCUIH was established in 1998 to support the development of quality, accessible, and culturally sensitive health care programs for AI/ANs living in urban communities;

WHEREAS the United States has a unique and special relationship with AI/ANs as established through the U.S. Constitution, Treaties with Indian Tribes, U.S. Supreme Court decisions and Federal legislation;

WHEREAS this special relationship includes a trust responsibility to AI/AN citizens as established through Treaties with Indian Tribes, U.S. Supreme Court decisions, and Federal legislation;

WHEREAS the trust relationship requires the United States to provide federal health services to maintain and improve the health of AI/ANs, no matter where they live;

WHEREAS it is the declared policy of the United States, as provided in the ICHIA, “to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy;”

WHEREAS the Indian Health Service (IHS) is chronically underfunded by the federal government, and UIOs historically receive only one percent of appropriated funds for IHS;

WHEREAS the Indian health system, including IHS, Tribal, and UIO (I/T/U) facilities, is the only major federal provider of health care that is funded through annual appropriations;

WHEREAS according to the Congressional Research Service, since FY1997, IHS has only once, in FY2006, received full-year appropriations by the start of the fiscal year;

WHEREAS if IHS were to receive advance appropriations, it would not be subject to government shutdowns, automatic sequestration cuts, and continuing resolutions (CRs) as its funding for the next year would already be in place;

WHEREAS during the thirty-five (35) day government shutdown at the start of FY 2019, the Indian healthcare system was the only federal healthcare entity that was required to continue operations without appropriated funds;

WHEREAS during the FY 2019 shutdown, several UIOs did not have adequate funding to maintain normal operations, and were required to reduce services, lose staff, or close their doors entirely, putting the health and wellbeing of their patients at risk;

WHEREAS in a UIO shutdown survey, five (5) out of thirteen (13) UIOs indicated that they could only maintain normal operations for 30 days without federal funding;

WHEREAS advanced appropriations would uphold the trust responsibility by protecting the Indian healthcare system from future government shutdowns and not counting against spending caps; and

WHEREAS advanced appropriations are imperative to provide certainty to the Indian health system and ensure unrelated budget disagreements do not put AI/AN lives at stake.

NOW THEREFORE BE IT RESOLVED, that NCUIH requests that Congress amend the Indian Health Care Improvement Act to authorize Advanced Appropriation for IHS, including Tribal facilities and UIOs; and

BE IT FURTHER RESOLVED, that this resolution shall be the policy of NCUIH until it is withdrawn or modified by subsequent resolution.

CERTIFICATION

The foregoing resolution was adopted by NCUIH on August 22nd, 2022 with a quorum present.

 

Background on Advance Appropriations for IHS

Advance appropriations are appropriations that become available one year or more after the year for which the appropriations act is passed. The Indian healthcare system, which includes IHS facilities, Tribal facilities, and urban Indian organizations (UIOs), is the only major federal healthcare provider funded through annual appropriations. Funding through annual appropriations leads to funding uncertainty because the availability and amount of the appropriation is subject to the annual budget negotiation process. If IHS were to receive advance appropriations, it would not be subject to government shutdowns, automatic sequestration cuts, and continuing resolutions (CRs) as its funding for the next year would already be in place.

Lapses in federal funding risk American Indian and Alaska Native lives. Every year, on average, Congress passes five continuing resolutions to keep the government open while Congress reaches a budget agreement, and there were long government shutdowns in 1996, 2013, and 2019. During the Fiscal Year (FY) 2019 shutdown, several UIOs did not have adequate funding to maintain normal operations and were required to reduce services, lose staff, or close their doors entirely, putting the health and well-being of their patients at risk. In a UIO shutdown survey, five out of thirteen UIOs indicated that they could only maintain normal operations for 30 days without federal funding. One UIO suffered seven opioid overdoses, five of which were fatal. Presently, it is unlikely that Congress will reach a budget agreement before the September 30 deadline. If Congress does not reach a budget agreement, Congress will need to pass a continuing resolution to avoid a government shutdown.

NCUIH Resources on Advance Appropriations for IHS:

NCUIH and Indian Country Advocacy

NCUIH, along with three other national Native organizations the National Indian Health Board (NIHB), National Congress of American Indians (NCAI), United South and Easter Tribes (USET), have been advocating on behalf of advance appropriations for almost a decade. NIHB, NCAI, and USET have all passed resolutions in support of advance appropriations. However, these resolutions don’t explicitly mention UIOs or urban Indians. NCUIH’s resolution provides context for why advance appropriations are essential for UIOs and urban Indian populations and explicitly includes UIOs in the request for advance appropriations.

On January 17, 2019, NCUIH sent a letter to the Vice Chairman of the Senate Committee on Indian Affairs (SCIA), Tom Udall, in support of IHS advance appropriations legislation. On March 9, 2022, NCUIH joined NIHB and over seventy Tribal nations and national Indian organizations in sending a series of joint letters to Congress requesting advance appropriations for IHS in the FY 2022 omnibus. On June 16, 2022, NIHB and NCAI published a legislative action alert requesting that SCIA support and include IHS advance appropriations in the current FY 2023 appropriations bill. Most recently, NCUIH sent letters to Speaker Pelosi, House Minority Leader McCarthy , Senate Majority Leader Schumer, Senate Minority Leader McConnell, Senate Interior Appropriations Committee,  and SCIA to support advance appropriations for IHS.

Federal and Congressional Support

There has also been strong long-standing support from Congress on this issue. On January 12, 2022, the Native American Caucus sent a letter to House Appropriations Committee Chair DeLauro and Ranking Member Granger requesting that advance appropriations for IHS for FY 2023 be included in the final FY 2022 appropriations bill. On June 3 the Native American Caucus sent another letter encouraging the Committee to work towards shifting IHS from discretionary to mandatory funding and requesting that, while this shift is underway, the Committee include advanced appropriations for IHS  in the final FY 2023 Appropriations bill.

On April 25, 2022, a bipartisan group of 28 Representatives requested up to $949.9 million for urban Indian health in FY 2023 and advance appropriations for IHS until such time that authorizers move IHS to mandatory spending, and 12 Senators sent a letter with the same requests. Last year, for the first time ever, the Senate Appropriations Committee included an additional $6.58 billion in advance appropriations to IHS for FY 2023 in its FY 2022 Interior, Environment, and Related Agencies bill.

Back in 2014, SCIA held its first hearing on advance appropriation bill Indian Health Service Advance Appropriations Act of 2013 (S. 1570). In a 2019 House Natural Resources Subcommittee for Indigenous Peoples (SCIP) hearing on advance appropriations bills H.R. 1128 and H.R. 1135, former IHS Principal Deputy Director, Rear Admiral Michael Weahkee, reaffirmed Indian Country’s repeated request for advance appropriations stating that  “[t]hrough the IHS’s robust annual Tribal Budget Consultation process, Tribal and Urban Indian Organization leaders have repeatedly and strongly recommended advance appropriations for the IHS as an essential means for ensuring continued access to critical health care services. The Department continues to hear directly from tribes advocating support for legislative language that would provide the authority of advance appropriations for the IHS. The issues that Tribes have identified present real challenges in Indian Country and we are eager to work with Congress on a variety of solutions.” More recently on July 28, 2022  IHS Acting Deputy Director Elizabeth Fowler reaffirmed IHS’s support for advance appropriations during a SCIP hearing on the Indian Health Service Advance Appropriations Act (H.R. 5549) stating that  “[IHS] remain[s] firmly committed to improving quality, safety, and access to health care for American Indians and Alaskan Natives. Mandatory funding and advanced appropriations are necessary and critical steps toward that goal… [I] urge the House to act on advanced appropriations through the appropriations process with or without the authorizing legislation that is the subject of this hearing.”
The U.S. Commission on Civil Rights report from 2018, “Broken Promises: Continuing Federal Funding Shortfall for Native Americans” serves as another benchmark of support by including advance appropriations for IHS as a key recommendation to the federal government to ensure greater funding stability for IHS.

History of Advance Appropriations Bills

Legislation on this effort has been introduced in 11 bills since 2013:​

  •  10/2013 – Indian Health Service Advance Appropriations Act of 2013 (R. 3229/S. 1570) ​
  • Sponsor: Rep. Don Young/Sen. Lisa Murkowski ​
  •  1/2015 – Indian Health Service Advance Appropriations Act of 2015 (R. 395)    ​
  • Sponsor: Rep. Don Young ​
  • 1/2017 – Indian Health Service Advance Appropriations Act of 2017 (R. 235) ​
  •  Sponsor: Rep. Don Young ​
  •  2/2019 – Indian Programs Advance Appropriations Act (R. 1128/S. 229) ​
  • Sponsor: Rep. Betty McCollum/Sen. Tom Udall ​
  • 2/2019 – Indian Health Service Advance Appropriations Act of 2019 (R. 1135/S. 2541) ​
  • Sponsor: Rep. Don Young/Sen. Lisa Murkowski​
  •  10/2021 – Indian Health Service Advance Appropriations Act (R. 5549) ​
  •  Sponsor: Rep. Don Young ​
  • 10/2021 – Indian Programs Advance Appropriations Act of 2021 (R. 5567/S. 2985) ​
  • Sponsor: Rep. Betty McCollum/Sen. Ben Ray Lujan​
    • 7/28/2022- Subcommittee for Indigenous Peoples (SCIP) held a hearing on the Indian Health Service Advance Appropriations Act (R.5549)​
  • Sponsor: Rep. Don Young
Next Steps

NCUIH will continue to advocate for Advance Appropriations for the 2022-23 Fiscal Year.

New Omicron Targeting Vaccine Formula Approved as Booster Dose for Individuals 12 years and Older

On August 31, 2022, the US Food and Drug Administration (FDA) amended the previously issued emergency use authorizations (EUAs) for both the Moderna and the Pfizer-BioNTech (Pfizer) COVID-19 vaccines to authorize the use of bivalent formulations for boosters. The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) voted to recommend both the Moderna and Pfizer bivalent formulation boosters on September 1, 2022. This new formulation, which can be administered at least two months following the completion of a primary series or a previous booster dose, targets both the original virus and the current Omicron variants.  During a monthly call with Tribal and urban Indian organization (UIO) leaders, the Indian Health Service (IHS) stated that it started shipping the bivalent formulation the week of Labor Day and that these boosters will replace all booster formulations once rolled out. Currently, Omicron variants make up more than 99% of COVID-19 cases within the US.

As it stands, the monovalent (original) COVID vaccine is no longer the recommended booster for people ages 12 and up. In order for an individual to be considered ‘up to date’ on their COVID vaccination, they must have received the bivalent booster, regardless of previous booster status. Individuals who have previously caught COVID-19 can be vaccinated up to three months after the infection.

Background

American Indians and Alaska Natives (AI/ANs) have been disproportionately affected by the COVID-19 pandemic. At the height of the pandemic, AI/ANs were 3.5 times more likely to test positive, 3.2 times more likely to be hospitalized, and 2.2 times more likely to die to due COIVD-19.

Indian Country has had highly successful vaccine rollouts and UIOs have been instrumental in the success of vaccinating AI/AN populations in urban Areas. As of August 2022, AI/ANs have the highest vaccination administration rates in the US with 74.5% of AI/ANs having received at least one dose of one of the three previously available COVID-19 vaccines, per CDC data.

NCUIH Signs on to Amicus Brief in Support of the Indian Child Welfare Act

On August 19, 2022, the National Council of Urban Indian Health (NCUIH) and five urban Indian organizations (UIOs) (Nebraska Urban Indian Health Coalition, Inc., Sacramento Native American Health Center, Fresno American Indian Health Project, All Nations Health Center, and Oklahoma City Indian Clinic) signed on to the National Indigenous Women’s Resource Center’s (NIWRC) amicus brief to the Supreme Court in support of the constitutionality of the Indian Child Welfare Act (ICWA) in the Brackeen v. Haaland case. NCUIH worked directly with NIWRC to engage with UIOs to ensure that the submitted brief was inclusive of urban American Indians/Alaska Natives (AI/ANs).

The Amicus Brief Argues:

  • ICWA constitutes a critical safeguard that protects Indian women and children from abuse.
    • Indian children are especially susceptible to abuse and trafficking when placed in state-run adoptive and foster homes.
  • Declaring Indian to be a racial classification subject to strict scrutiny would impede Congress’ Trust duty and responsibility to address violence against Native women and children.
    • The Supreme Court used a political, not a racial, classification to eliminate tribal criminal jurisdiction over non-Indians in its 1981 decision in Oliphant v. Suquamish Indian Tribe (Oliphant).
    • Following Oliphant, Indian women and children face high rates of non-Indian violence in the United States.
    • The Violence Against Women Act (VAWA) 2013 utilized the same political classification as ICWA and
    • VAWA 2022 utilized the same political classifications as ICWA and Oliphant.
  • The transformation of Indian into a racial classification would significantly impede Congress’s ability to effectuate its Trust duty and responsibility to protect and safeguard the lives of Native Women and Children

Background and Advocacy

Legal Proceedings and Opposition to ICWA

In Brackeen, Texas, Indiana, Louisiana, and individual plaintiffs sued the federal government, arguing that ICWA and its implanting regulations are unconstitutional because they violate the equal protection and substantive due processes provisions of the Fifth Amendment and violate the anticommandeering doctrine of the Tenth Amendment.  The plaintiffs also argued that ICWA and the implementing regulations violate the nondelegation doctrine and the APA.

The initial 2018 ruling by Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas, held that ICWA (including its implementing regulations) is unconstitutional, and the regulations violate the APA.  Specifically, Judge O’Connor held that ICWA violates the Constitution’s guarantee of equal protection because it applies to all children eligible for membership in a Tribe, not just enrolled tribal members, and therefore operates as a race-based statute.  Judge O’Connor further held that ICWA violates the Tenth Amendment’s prohibition on the federal government issuing direct orders to states and unconstitutionally delegates Congress’s power by giving tribes the authority to change adoption placement preferences and make states abide by them.

The Fifth Circuit Court of Appeals overturned the District Court’s decision in most respects. The Court found that Congress had the authority to enact the law. The majority opinion also held that ICWA’s application to all children eligible for tribal citizenship is not a race-based classification and therefore ICWA does not violate equal protection. This reaffirms that the status of “Indian child” is not an unconstitutional racial classification. However, the court was equally divided as to whether references to “other Indian families” and “Indian foster home” are an unconstitutional racial classification. Because the Court was equally divided on this holding the District Court’s ruling was upheld, but it was without precedential authority.  Further, the Court affirmed the District Court’s conclusion that several of the “active efforts” required under ICWA violated the Tenth Amendment, which prohibits the federal government from imposing duties on state officials. The Court was again equally divided on whether ICWA’s placement preferences violate the Tenth Amendment.  This narrow but lengthy decision, which was over 300 pages and decided by a divided 16-judge court, creates a confusing precedent for those trying to navigate the law and makes the case ripe for review by the Supreme Court.   The Fifth Circuit also addressed APA challenges to the Bureau of Indian Affairs rules implementing ICWA.

On February 28, 2022 the U.S. Supreme Court agreed to review the Fifth Circuit’s decision in Brackeen v. Haaland. The challengers and their amici argue that American Indian/Alaska Native is a racial classification rather than a political classification, making ICWA constitutionally suspect under the Equal Protection Clause. The challengers and their amici further argue that ICWA violates several constitutional provisions including anti-commandeering and nondelegation.

  • On May 26, 2022, the Court received amicus briefsfrom supporters of the ICWA challengers highlighting their arguments.
  • On August 19, 2022, the next round of amicus briefs in support of ICWA and Tribal intervenors were due.
  • Oral argument is scheduled for November 9, 2023.
  • The Supreme Court will release its decision by June 30, 2023.

ICWA and its Importance to AI/ANs

It was critical that NCUIH signed onto NIWRC’s brief because of the threat posed by the overturning of ICWA. ICWA represents the gold standard in child welfare proceedings, strengthening and preserving AI/AN family structure and culture. When it was established in 1978, studies showed that between 25% and 35% of all Native children were removed from their homes by state child welfare and private adoption agencies. Of those, 85% were placed with non-Native families, even when fit and willing relatives were available. ICWA ensures that the previously forced removal of AI/AN children from their homes and their placement into white families will not be repeated.

Today, Native children continue to be overrepresented in state foster care systems at a rate 2.7 times higher than their non-Native peers. This means that while AI/AN children represent 0.9% of all children in the United States, they are 2.1% of all children who are placed in foster care. Because more than 70% of AI/AN people live in urban settings, this overrepresentation undoubtedly includes AI/AN children living in urban areas. According to the Indian Health Service (IHS), Native youth living off-reservation often face a higher risk of health problems, including mental health and substance abuse, suicide, gang activity, teen pregnancy, abuse, and neglect. Additionally, IHS found that urban Indian populations experience the same health problems as the general Indian population, but these problems are exacerbated by a lack of access to family and traditional cultural environments.  Challenges to ICWA threaten to place urban Native youth at even greater risk if they enter foster or adoption systems that do not offer protections to keep them from being further removed from their communities and culture.

NCUIH previously provided an in-depth analysis on the impact of ICWA. We will continue to monitor ongoing developments as Brackeen v. Haaland proceeds to oral argument and provide updates on how the case impacts urban Indians.

ICWA as a Vehicle to Challenge Federal Indian Law

It is also important to recognize that this case, as well as other on-going challenges to ICWA are part of a broader effort to attack the foundations of Federal Indian Law.  The recognition that the AI/AN classification is political classification rather than racial is a critical underpinning of not just ICWA, but many laws that relate to housing, healthcare, education, and employment. This political classification goes back to the 19th Century and has been upheld by Courts at multiple levels. Acknowledging the importance of tribal citizenship, AI/ANs are classified by this citizenship, not by their race. However, publications from the organizations supporting this lawsuit and others, including  the Cato Institute and the Goldwater Institute, make clear that they view Native identity as being a matter of race, not political identity and citizenship.  If overturned, the repeal of ICWA would not only upend a law in place for more than 40 years but undercut the heart of tribal sovereignty and the federal government’s trust responsibility to Native communities.  A successful attack on ICWA would have far-reaching implications on all areas of Federal Indian Law and policy.

Next Steps

  • Oral argument for Brackeen is scheduled for November 9, 2022.
  • The Supreme Court will issue a decision by June 30, 2023.
  • NCUIH will continue to closely monitor updates in this case and alert UIOs and stakeholders to what a decision could mean for urban Indian communities. NCUIH will track the upcoming Supreme Court term for updates on Brackeen.

Health Equity and Accountability Act (HEAA) Includes Key Provisions for Urban Indian Health

On June 23, Senator Cory Booker (D-NJ), Senator Raphael Warnock (D-GA), and Representative Robin Kelly (D-IL-02) reintroduced the Health Equity and Accountability Act of 2022 (HEAA) (S. 4486/H.R. 7585). The bill aims to address racial and ethnic health disparities by creating a more equitable health care system through systemic changes. After much advocacy from the National Council of Urban Indian Health (NCUIH), the bill included critical provisions for urban Indian health, such as 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs), urban Indian inclusion in the Community Health Aide Program (CHAP), and the first-ever legislative text establishing an urban confer policy with the Department of Veteran Affairs (VA).

Bill Highlights for Urban Indian Health

100% FMAP for Services at UIOs

Congress authorized 100% FMAP for Indian Health Service (IHS) and Tribal health facilities in the Indian Health Care Improvement Act (IHCIA) in order to supplement chronic underfunding of IHS and thus better fulfill the federal government’s trust responsibility to provide safe and quality healthcare to American Indians/Alaska Natives (AI/ANs). UIOs were not included in the IHCIA amendments as an oversight, and therefore services provided at a UIO were not eligible for 100% FMAP. For decades, urban Indian leaders and NCUIH advocated how critical this provision would be in enhancing the ability of UIOs to provide services for IHS-Medicaid beneficiaries. In 2021, NCUIH was successful in securing two years of 100% FMAP in the American Rescue Plan Act (ARPA) and has continued to advocate for an indefinite extension. This bill includes the permanent authorization for UIOs to receive 100% FMAP, bringing them into parity with other providers in the Indian healthcare system.

Conferring with Urban Indian Organizations

This bill includes legislation for both a confer policy with HHS, as well as the first-ever legislative text establishing an urban confer policy with the VA. An urban confer is an established mechanism for dialogue between federal agencies and UIOs. Urban confer policies are a response to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that have resulted in 70% of AI/AN people living outside of Tribal jurisdictions, thus making urban confer integral to address the care needs of most AI/AN persons. Currently, only IHS has a legal obligation to confer with UIOs.

NCUIH was successful in passing urban confer for the Department of Health and Human Services (HHS) (H.R. 5221) in the House and has introduced a companion bill in the Senate (S. 4323). This type of policy would ensure the many branches and divisions within HHS and all agencies under its purview establish a formal confer process to dialogue with UIOs on policies that impact them and their AI/AN patients living in urban centers. A clear communication pathway between federal health agencies and UIOs is imperative, especially during the ongoing COVID-19 pandemic that has disproportionately impacted AI/ANs. Missed opportunities for awareness and information provided to UIOs regarding AI/AN healthcare can be easily avoided through a confer process. For example, key information regarding vaccine distribution for the initial COVID-19 vaccine rollout in December of 2020 was poorly communicated to UIOs and created unnecessary hardships. HHS addressed initial communications only to Tribes and did not direct it to the UIO component of the IHS system. When HHS was asked about whether UIOs needed to similarly decide between an IHS or state vaccine allocation, it was unclear for weeks as to whether they were expected to make such a decision. Eventually, HHS asked UIOs to decide between receiving their vaccine distribution from either their state jurisdiction or IHS on the same day as the initial deadline (which thankfully HHS subsequently extended for several days). Some UIOs were informed of the deadline by their Area office with no formal national communication. Consequently, UIOs were prevented from providing input, resulting in many clinics experiencing serious delays in vaccine distribution. For example, Native American LifeLines, the Baltimore UIO, did not receive vaccines until just 5 days before the general public was eligible. This had dire consequences, as the pandemic took the lives of AI/ANs at the highest rates of any population. Ultimately, this flawed process could have been easily avoided with an urban confer policy.

NCUIH has also been advocating for the creation of an urban confer with the VA. AI/ANs have a long history of distinguished service to this country. Per capita, AI/ANs serve at a higher rate in the Armed Forces than any other group of Americans and have served in all the nation’s wars since the Revolutionary War. In fact, AI/ANs served in several wars before they were even recognized as U.S. citizens. According to a VA report, 140,507 Veterans identify themselves as AI/AN, and a higher percentage of AI/AN Veterans served in the Pre-9/11 period (17.7%) compared to Veterans of all other races (14.0%). The report also showed significant disparities between AI/AN veterans and other Veterans including that AI/AN Veterans had lower personal incomes than Veterans of other races, the percentage of AI/AN Veterans who were unemployed was higher than the percentage of Veterans of other races who were unemployed, AI/AN Veterans were more likely to lack health insurance than Veterans of other races, and AI/AN Veterans were more likely to have a service-connected disability than Veterans of other races. As the VA continues to work more closely with UIOs to increase access to health care services for AI/AN Veterans and address these disparities, it is imperative that a formal confer process is established for the VA.

The HEAA addresses these key parity issue and provides a forum for important feedback from AI/AN stakeholders to HHS and the VA.

Inclusion of UIOs in the National Community Health Aide Program (CHAP)

The legislation includes UIOs as eligible entities for CHAP. This inclusion will increase the availability of health workers in AI/AN communities. Currently, IHS asserts that UIOs are excluded simply because they are not explicitly included in the statutory language of the nationalization of CHAP. Securing UIO inclusion in CHAP is a policy priority for NCUIH in 2022.

Commissions and Committees

HEAA adds UIOs to commissions and committees relating to various health equity provisions. Urban Indian health representatives were added as members of the Commission on Ensuring Data for Health Equity” to provide clear and robust guidance to improve the collection, analysis, and use of demographic data in responding to future public health emergencies.

Commission/Committee Description Urban Indian Inclusion
Commission on Ensuring Data for Health Equity Urban Indian health representatives were added as members of the Commission to provide clear and robust guidance to improve the collection, analysis, and use of demographic data in responding to future public health emergencies.
CREATING MODEL PROGRAMS FOR THE CARE OF INCARCERATED INDIVIDUALS IN THE PRENATAL AND POSTPARTUM PERIODS:

“The Attorney General, acting through the Director of the Bureau of Prisons (in this subsection referred to as the “Director”), shall establish, in not fewer than 6 Bureau of Prisons facilities, programs to optimize maternal health outcomes for pregnant and postpartum individuals incarcerated in such facilities.”

The Grant allows for the establishment of partnerships with local public entities, including urban Indian organizations, to establish or expand pretrial diversion programs as an alternative to incarceration for pregnant and postpartum individuals.

 

Appropriations: $10,000,000 for each of fiscal years 2023 through 2027.

GRANTS TO PROMOTE REPRESENTATIVE COMMUNITY ENGAGEMENT IN MATERNAL MORTALITY REVIEW COMMITTEES:

The Secretary may, using funds made available to assist an applicable maternal mortality review committee of a State, Indian tribe, tribal organization, or Urban Indian organization

Appropriations: $10,000,000 for each of fiscal years 2023 through 2027.

 

Tribal Set-Aside: Of the amount made available under the preceding sentence for a fiscal year, not less than $1,500,000 shall be reserved for grants awarded under subsection (d)(9) to Indian tribes, tribal organizations, or Urban Indian organizations.

Next Steps

HEAA has been referred to the Senate Finance Committee and the House Subcommittee on Health, where it awaits consideration.

Resources

Additional Bill Funding for Urban Indian Organizations

HEAA also includes other appropriations for UIOs discussed in greater detail below:

Grant Description Grant Amount
EXPANDING CAPACITY FOR MATERNAL HEALTH OUTCOMES:

 The Secretary shall award grants to eligible entities to evaluate, develop, and expand the use of technology-enabled collaborative learning and capacity-building models and improve maternal health outcomes.

UIOs are included as eligible entities.

Appropriations: $6,000,000 for each of fiscal years 2023 through 2027.
GRANT PROGRAM TO PROTECT VULNERABLE MOTHERS AND BABIES FROM CLIMATE CHANGE RISKS:

The Secretary of HHS shall establish a grant program to protect vulnerable individuals from risks associated with climate change.

Appropriations: $100,000,000 for fiscal years 2023 through 2026.
HOUSING FOR MOMS GRANT PROGRAM:

 The Secretary of Housing and Urban Development shall establish a Housing for Moms grant program under this subsection to make grants to eligible entities to increase access to safe, stable, affordable, and adequate housing for pregnant and postpartum individuals and their families.

UIOs included as eligible entities.

Appropriations: $10,000,000 for fiscal year 2022, which shall remain available until expended.
GRANT PROGRAM FOR HEALTHY FOOD AND CLEAN WATER FOR PREGNANT AND POSTPARTUM INDIVIDUALS:

An eligible entity shall use grant funds awarded under this paragraph to deliver healthy food, infant formula, clean water, or diapers to pregnant and postpartum individuals located in areas that are food deserts, as determined by the Secretary using data from the Food Access Research Atlas of the Department of Agriculture.

Appropriations: $5,000,000 to carry out this paragraph for fiscal years 2022 through 2024.
MATERNAL MENTAL HEALTH EQUITY GRANT PROGRAM:

SAMHSA will establish a program to award grants to eligible entities to address maternal mental health conditions and substance use disorders with respect to pregnant and postpartum individuals, with a focus on racial and ethnic minority groups.

Appropriations: $25,000,000 for each of fiscal years 2023 through 2026.
Grants For Innovative Approaches:

HRSA in collaboration with other agencies, including IHS, will award grants to eligible entities for developing and implementing innovative approaches to improve maternal and child health outcomes of victims of domestic violence, dating violence, sexual assault, stalking, human trafficking, sex trafficking, child sexual abuse, or forced marriage.

Appropriations: $25,000,000 for the period of fiscal years 2023 through 2025.
TELEHEALTH AND RURAL ACCESS PILOT PROJECTS:

The Secretary of Veterans Affairs, in cooperation with the Secretary of Defense and the Secretary of Health and Human Services (referred to in this subsection collectively as the “Secretaries”) shall establish 4-year telehealth pilot projects for the purpose of analyzing the clinical outcomes and cost-effectiveness associated with telehealth services in a variety of geographic areas that contain high proportions of medically underserved populations, including African Americans, Latinos or Hispanics, American Indians or Alaska Natives, and those in rural areas.

Appropriations: There is authorized to be appropriated to carry out this section for the period of fiscal years 2023 through 2027 an amount equal to the amount of savings for the Federal Government projected to be achieved over such period by implementation of this section.

Urban Indian Organizations Encouraged to Apply for Healthy Lifestyles in Youth Cooperative Agreement

On August 12, 2022, the Indian Health Service (IHS) announced a request for applications for the Healthy Lifestyles in Youth (HLY) grant program. Aimed at improving the health of American Indian and Alaska Native (AI/AN) youth, the program supports health promotion and education programs, to address healthy lifestyle development, and emphasizes nutrition and physical activity for AI/AN children 7 to 11 years old. IHS will issue one award under this announcement, and the project period for the program will be five years. The identified funding for FY 2022, the first budget year for the grant, is $1,250,000. Applications for this cooperative agreement should be submitted by September 15, 2022, through grants.gov. The earliest anticipated start date is September 30, 2022. Urban Indian organizations (UIOs) are eligible and encouraged to apply. For more details on the requirements for the application and the cooperative, see here.

Awardees of this cooperative agreement must take on the following:

  • Collaboration with selected Native American Boys and Girls Club sites using the “Together Raising Awareness for Indian Life” (TRAIL) curriculum
  • Administer health and physical education programs
  • Support youth in achieving and maintaining healthy lifestyles through participation in fitness programs
  • Help youth acquire a range of physical skills
  • Facilitate the development of a sense of teamwork and cooperation amongst youth

Background

Through the HLY grant, facilities can offer a wide range of prevention and treatment services – exercise and physical activity programs, community gardens, culinary education programs, health and wellness fairs, culturally-relevant nutrition assistance, group exercise activities, garden spaces and youth-focused activities. Evidence-based early intervention strategies have been shown to reduce, or even halt, the increasing trend in obesity and diabetes among youth and young adults. The TRAIL curriculum was developed to educate the youth participating on good nutrition and to promote physical activity. Through a 3-month, 12-lesson program, the curriculum may help to curtail the effect of unhealthy behaviors surrounding food and physical activity, which can lead to obesity, diabetes, and/or other chronic illness throughout life.

Compared to the general Indian population, urban AI/AN communities experience exacerbated health problems due to lack of family and traditional cultural environments in major metropolitan areas. Urban AI/AN youth are at greater risks for serious mental health and substance abuse problems, suicide, gang activity, teen pregnancy, abuse, and neglect. Between 1994 and 2004, the type 2 diabetes rate for AI/AN youth 15 to 19 years old increased by 68%. Despite the disproportionately high rates of health disparities in urban AI/AN populations, UIOs have continued to provide critical services aimed at addressing and combatting negative health outcomes through grants and cooperative agreements. For example, as of 2022, 30 of the 41 UIOs received funding through the Special Diabetes Program for Indians.

Call to Action

NCUIH encourages interested UIO leaders to submit application materials to IHS via grants.gov by September 15, 2022. UIOs are uniquely positioned, in part thanks to their work through the Special Diabetes Program for Indians grants, to already have established programs focused on exercise and physical activity, culturally relevant nutrition programs, and youth programs.

Please contact NCUIH’s Policy department at policy@ncuih.org if you would like assistance with the submission, or if you plan to apply.

House Passes Major Mental Health Legislation with over $3.5 billion for Urban Indian Health and Inclusion in Opioid Grants

On June 22, 2022, the House passed the Restoring Hope for Mental Health and Well-Being Act (H.R. 7666) in a vote of 402-20. The bill includes over $3.5 billion in funding for behavioral health activities and programs eligible to urban Indian organizations (UIOs). After much NCUIH advocacy, UIOs were included as eligible entities for State Opioid Response (SOR) grants in this legislation. Urban Indians continue to disproportionately suffer from behavioral health issues at a rate much higher than the general population, which has only been exacerbated by the COVID-19 pandemic. This mental health package allows UIOs to have greater access to vital resources necessary to address the critical health needs of urban Indians and brings the federal government closer to fulfilling its trust obligations to American Indian/Alaska Native (AI/AN) populations.

Bill Highlights for Urban Indian Organizations

Behavioral Health

AI/AN populations are at a substantially higher risk for behavioral health issues than the general population. AI/ANs had the second-highest rate of opioid overdose out of all U.S. racial and ethnic groups in 2017, and the second and third highest overdose death rates from heroin and synthetic opioids, respectively, according to the Centers for Disease Control and Prevention. AI/ANs residing in urban areas face significant behavioral health disparities – for instance, 15.1% of urban AI/ANs report frequent mental distress as compared to 9.9% of the general public, and the AI/ AN youth suicide rate is 2.5 times that of the overall national average.

Reauthorizing the Tribal Behavioral Health (Native Connections) Grant

The Tribal Behavioral Health grant (known as Native Connections) is a five-year grant authorized by the Substance Abuse and Mental Health Services Administration (SAMSHA) that helps AI/AN communities identify and address the behavioral health needs of Native youth. The program aims to help reduce suicidal behavior among Native youth, easing the impacts of substance use, mental illness, and trauma in tribal communities.

H.R. 7666 reauthorizes this grant in Section 121 and will allow UIOs to provide culturally appropriate mental health and substance use disorder prevention, treatment, and recovery services to AI/ANs. This bill authorizes $599,036,000 in appropriations for each of FY 2023 through FY 2027, an increase from the $394,550,000 previously authorized.

Addressing The Native Behavioral Health Access Improvement Act of 2021

In July of 2021, Congress introduced the Native Behavioral Health Access Improvement Act of 2021 (S. 2226) which would require the Indian Health Service (IHS) to allocate $200 million for the authorization of a program targeting behavioral health needs of AI/AN populations.

Inspired by the language of S. 2226, Section 201 of H.R. 7666 authorizes $40 million for FY 2023 through FY 2027 to eligible entities, including UIOs, for mental and behavioral health programs that focus on mental well-being. Although H.R. 7666 funds less than the amount proposed in S. 2226, it succeeds in establishing a program to allocate resources empowering UIOs to improve behavioral health for all Native Americans living in urban settings.

State Opioid Response Grant

Background: UIO Exclusion from Critical Opioid Grants

UIOs have repeatedly been excluded from funding designed to help AI/AN communities address the opioid crisis. Since FY 2018, Congress has enacted set-asides in SOR grants to help Native communities address this crisis. However, only Tribes and Tribal organizations were defined as eligible entities, meaning UIOs have been consistently denied the resources necessary to address the opioid epidemic in urban areas.

Last Spring, Congress introduced the State Opioid Response Grant Authorization Act of 2021 (H.R. 2379), which included a 5 percent set-aside of the funds made available for each fiscal year for Indian Tribes, Tribal organizations, and UIOs to address substance abuse disorders through public health-related activities. Yet, UIOs were ultimately removed from the language of the SOR Grant reauthorization bill, which saw a $5 million increase (9 percent increase from FY 2021), included in the Consolidated Appropriations Act of 2022 (H.R. 2471) for FY 2022 (also known as “Omnibus”).

NCUIH Advocacy & Urban Indian Organization Inclusion

NCUIH has long advocated for UIOs to be included in SOR Grants given the severe extent of the opioid epidemic’s impact on urban AI/ANs. NCUIH worked closely with Congressional leaders to ensure the inclusion of UIOs in the funding set-asides outlined in H.R. 2379.  When the House passed H.R. 2379 on October 20, 2021, NCUIH stated that the exclusion of UIOs from such critical funding directly violated the trust obligation of the federal government. NCUIH increased its advocacy efforts throughout the year and ultimately revived the battle to include UIOs in SOR grants through notable contributions including:

  • NCUIH’s 2022 Policy Priorities encourages Congress to co-sponsor and enact the State Opioid Response Grant Authorization Act of 2021 (H.R. 2379) with amended language to include UIO’s as eligible entities for SOR Grants to fight the opioid epidemic.
  • On April 05, 2022, Maureen Rosette- a citizen of the Chippewa Cree Nation, board member of NCUIH, and Chief Operating Officer at NATIVE Project- testified before the House Natural Resources Oversight & Investigations Subcommittee for a hearing entitled “The Opioid Crisis in Tribal Communities.” Ms. Rosette reiterated the obligation of the United States government to provide health care resources for AI/AN people residing in urban areas while describing the major role that UIOs play in providing critical services. This testimony spurred support among Congressional leaders for expanding opioid funding to UIOs.
  • On May 10, 2022, NCUIH submitted written testimony to the Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies regarding FY 2023 funding for UIOs. NCUIH advocated for providing increased resources to Native health programs and the vital inclusion of UIOs in SOR grants.

Because of NCUIH’s advocacy efforts, H.R. 7666 includes language in Section 273 to define UIOs as eligible entities for SOR Grants and provides a five percent set aside totaling $87.5 million. Ultimately, H.R. 7666 marks a significant step forward in providing UIOs with greater accessibility to vital funding needed to address the opioid crisis in Indian Country.

Next Steps

On June 23, 2022, H.R. 7666 was referred to the Senate Committee on Health, Education, Labor, and Pensions. There have been no further actions taken.

NCUIH will continue to track H.R. 7666 in the Senate. Additionally, NCUIH continues to advocate for the full funding of mental and behavioral health programs in Indian Country and the inclusion of UIOs to improve the health of all AI/ANs living in urban settings.

Additional Bill Funding for Urban Indian Organizations

H.R. 7666 also includes other appropriations for UIOs discussed in greater detail below.

Bill Section
Amount Authorized
(Each FY 2023-FY 2027)
Section 111: Screening and Treatment for Mental Health and Substance Abuse Disorders $24,000,000
Section 121: Innovation for Mental Health $599,036,000 (Native Connections)
Section 122: Crisis Care Coordination $30,000,000 (Adult Suicide Prevention Grants)

*UIO’s defined as a “community-based primary care or behavioral health setting.”

Section 131: Maintaining Education and Training on Eating Disorders $1,000,000

*UIOs are not explicitly mentioned, but the bill text includes primary care and behavioral health care providers.

Section 151: Peer-Supported Mental Health Services $13,000,000
Section 201: Behavioral Health and Substance Use Disorder Services for Native Americans $40,000,000
Section 211: Grants for the Benefit of Homeless Individuals $41,304,000

*UIOs are not explicitly mentioned, but they fall under “community-based public and private nonprofit eligible entities.”

Section 212: Priority Substance Abuse Treatment Needs of Regional and National Significance $521,517,000
Section 214: Priority Substance Abuse Disorder Prevention Needs of Regional and National Significance $218,219,000

 

Section 216: Grants for Jail Diversion Programs $14,000,000

*UIOs are not explicitly mentioned, but they are included as a facility with a grant from IHS.

 

Section 219: Grants for Reducing Overdose Deaths $5,000,000

*Indian Health Services, Tribes or Tribal organizations, or UIOs (I/T/U) added as new eligible entities.

 

Section 220: Opioid Overdose Reversal Medication Access and Education Grants Programs $5,000,000

*I/T/U added as new eligible entities.

Section 222: Emergency Department Alternatives to Opioids Demonstration Grants $10,000,000

*UIOs are covered under Federal Qualified Health Centers (FQHCs).

Section 273: Grant Program for State and Tribal Response to Opioid and Stimulant Use and Misuse $1,750,000,000

5 percent set-aside ($87.5 million) for Indian Tribes, Tribal organizations, and Urban Indian organizations

Section 301: Increasing Uptake of the Collaborative Care Model $60,000,000

*I/T/Us are eligible under the definitions of a “health center” and FQHCs.

Section 311: Reauthorization of Programs Strengthening the Health Care Workforce $31,700,000 (Training Demonstration Project)
Section 402: Infant and Early Childhood Mental Health Promotion, Intervention, and Treatment $50,000,000

*UIOs are eligible under the specific definition of “nonprofit institutions employing a licensed medical professional with specialized training in early childhood mental health, and that provides evidence-based services or programs that show benefit from future applied development.”

Section 412: Substance Abuse Disorder Treatment and Early Intervention Services for Children $29,605,000

*UIOs included in the definition of health facilities in contract with IHS.

Section 421: Suicide Prevention Technical Assistance Center $9,000,000

*UIOs included under the definition of “nonprofit organizations.”

Section 422: Youth Suicide Early Intervention and Prevention Strategies $40,000,000

NCUIH 2022 Summer Legal Fellows and Public Policy Intern Reflect on Time as They Depart

NCUIH 2022 Summer Legal Fellows and Public Policy Intern

As the summer ends, the National Council of Urban Indian Health (NCUIH) must bid farewell to our lovely fellows and intern that we had the honor of working with over the past twelve weeks. All three of the students this summer were instrumental in the work that NCUIH accomplished while they were here. They attended hundreds of hours of calls, wrote NCUIH communication materials such as blogs and newsletter post, and were directly responsible for the creation of several graphics and discrete research as requested. NCUIH wishes them all the best as they continue their education and professional growth.

NCUIH 2022 Summer Legal Fellows and Public Policy Intern

If you, or someone you know, is interested in learning more about what it means to be an NCUIH Legal and Policy Fellow or an NCUIH Public Policy Intern, contact policy@ncuih.org.

NCUIH 2022 Summer Legal Fellows and Public Policy Intern NCUIH 2022 Summer Legal Fellows and Public Policy Intern

Summer Legal and Policy Fellows

Anna Schwartz, Summer Legal and Policy Fellows

NCUIH was a great fit for me because I was excited about being part of an organization with such an important role in driving social change and improving health rights, and the fellowship presented opportunities to develop legal and advocacy abilities under the guidance of an excellent team of lawyers and policy experts.” – Anna Schwartz

“My name is Anna Schwartz, and I am a rising second-year law student at the George Washington University Law School. I applied for a legal fellowship with NCUIH because I have a background in health policy research and political science, and I am interested in advancing health equity through law. NCUIH was a great fit for me because I was excited about being part of an organization with such an important role in driving social change and improving health rights, and the fellowship presented opportunities to develop legal and advocacy abilities under the guidance of an excellent team of lawyers and policy experts.

 Over the summer, I honed legal skills that I will take with me to the next steps of my career. First, I wrote comments to federal agencies and a letter to a tribal and federal workgroup about a proposed amendment to a policy. By digging into legislative provisions about the government’s trust responsibility, I was able to strengthen my statutory analysis skills. In addition, I authored a legal memo about the use of federal grant funds toward debt financing. This project included administrative policy and case law research which furthered my legal research and writing skills. Through other projects such as five blog posts about NCUIH’s comments, one blog post about the IHS circular on abortion policy, drafting a presentation to a federal agency, and a bill tracker assignment, I practiced breaking down complex legal concepts into laymen’s terms and increased my advocacy abilities. I also had the opportunity to visit the Senate and House buildings and meet House Representatives, as well as attend virtual Urban Confers, Tribal workgroup meetings, and federal agency policy sessions.

 Moreover, I was thoroughly impressed by the work that NCUIH does to advance the health rights of urban Native communities. It was amazing to be a part of NCUIH’s thoughtful, zealous advocacy, which during these past twelve weeks alone ranged from meeting with UIO leaders to understand their priorities and concerns, to submitting nine comments to federal agencies and facilitating dialogues with those agencies about how to serve UIOs, to advocating for legislative progress and bringing an Advance Appropriations bill to the House floor, to explaining the I/T/U system and the crucial role of UIOs to any stakeholder who will listen. I am grateful to the policy team for welcoming me into the world of Native health, including Meredith, Mary, Jenna, Jeremy, Jennifer, Sam, and Brooke. Special thanks to Alexandra, Chandos, and Rori for their guidance and mentorship, and to Adrianne for being the best co-fellow I could ask for!

 I look forward to applying the skills and knowledge I learned at NCUIH as I continue my career in health law and public interest. As a 2L this fall, I will be participating in the Health Rights Law Clinic at GW Law, and serving on the executive board of Lambda Law, the Moot Court Board, and the Federal Circuit Bar Journal.”

Adrianne Elliott, Summer Legal and Policy Fellows

The mentorship I received from the policy team proved invaluable to my professional and personal growth. I am passionate about advancing self-determination and sovereignty for Native peoples across the country and look forward to bringing this new knowledge and skillset into the next steps in my Indian law career to ensure all Natives are included in laws and policies that impact them and their wellbeing.” – Adrianne Elliott (Cherokee Nation of Oklahoma)

“Osiyo, my name is Adrianne Elliott, and I am a citizen of the Cherokee Nation entering my second year at Georgetown University Law Center. Prior to law school, I worked for five years to advance indigenous sovereignty and self-determination in educational opportunity for American Indians, Alaska Natives, and Native Hawaiians. Like education, healthcare is central to the well-being of Native peoples and to building strong Native nations. NCUIH’s work to represent urban Indian organizations and the 70 percent of American Indians and Alaska Natives living off-reservation is crucial to ensuring access to essential services and to upholding the federal trust responsibility to all Native peoples. I have been honored to join the policy team at NCUIH in this work.

 My summer began with the NCUIH Conference, which quickly introduced me to some of the most pressing healthcare issues facing Native peoples living in urban areas. Healthcare equity and the trust responsibility for all Native peoples is a complex issue that must Just like their families living on tribal lands, many Native peoples in large urban centers struggle to find equitable access to high-quality healthcare. In addition, most urban providers are not equipped to provide traditional treatment options. Urban Indian organizations fill this gap yet remain severely underfunded even within the Indian healthcare system. From blogs and confers to comments and memos, I had an opportunity to meaningfully contribute to NCUIH’s legal and policy issues while advancing my professional skills.

 Throughout the summer, I had the opportunity to hone analytic and writing skills by researching and developing a variety of memos, comments, and blog posts.  My most significant project centered on a memo to support NCUIH’s work on Brackeen v. Haaland, examining the definition of an Indian child and the impact of changes to this definition in the Indian Child Welfare Act, Indian Health Care Improvement Act, and the Centers for Medicaid and Medicare statutes. Further, I developed and contributed to federal comments to both the Department of Veterans Affairs and the Indian Health Service to improve the delivery of healthcare services to Native peoples living in urban areas.

 The mentorship I received from the policy team proved invaluable to my professional and personal growth. Through this process, I not only honed my legal skills but had the opportunity to dive deeper into areas like AIR and FMAP that deeply impact Native people living off-reservation. I am passionate about advancing self-determination and sovereignty for Native peoples across the country and look forward to bringing this new knowledge and skillset into the next steps in my Indian law career to ensure all Natives are included in laws and policies that impact them and their wellbeing.”

Summer Public Policy Intern

Brooke Schmoyer, Summer Public Policy Intern

I will take the writing skills, confidence, and knowledge of UIOs that I learned from this internship. I will also take the research skills I gained and apply them to my future opportunities. I eventually want to go to law school and become a health care attorney. From there, I hope to continue my work on Native health care, especially for urban Indians.” – Brooke Schmoyer (Choctaw Nation of Oklahoma)

“Hello! My name is Brooke Schmoyer, and I am the Public Policy intern for NCUIH. I am heading into my Senior year at Stanford University where I am majoring in political science and psychology. I am originally from San Antonio, TX and I am a member of the Choctaw Nation of Oklahoma. I became very interested in the health care system after I had five knee surgeries in the past two years. After my experience, I wanted to learn and advocate for Native health care. This past spring, I worked for the Senate Committee on Indian Affairs. There I learned about NCUIH, and it sparked my interest in advocating for Urban Indians. It was the perfect crossover: healthcare, native issues, and urban Indians. As an urban Indian myself, I wanted to give back and apply my interests in healthcare policy to further tribal sovereignty and ensure the trust responsibility that is owed to AI/AN.

The first fact that I was presented with was how many urban Indians there really are.  I never realized that 70% of AI/AN live in urban areas and how huge of an impact UIOs have. This was just the start of my learning experience. Aside from learning the importance of UIOs, I learned how to write blogs and letters to congress. This helped me better understand the needs of urban Indians such as advance appropriations and urban confer. Working on the Policy Team has allowed me to work with incredible people who are all so knowledgeable. They have taught me how to track legislation, about persistence, and how to have your voice heard. I am grateful for all their help and support.

I will take the writing skills, confidence, and knowledge of UIOs that I learned from this internship. I will also take the research skills I gained and apply them to my future opportunities. I eventually want to go to law school and become a health care attorney. From there, I hope to continue my work on Native health care, especially for urban Indians. I hope to stay connected to all the people I met.”