NCUIH Calls for Improved Data Accuracy, Partnerships with Other Agencies, and Urban Indian Health Inclusion in IHS Strategic Plan

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On June 28, 2024, the National Council of Urban Indian Health (NCUIH) submitted written comments to the Indian Health Service (IHS) Director, Roselyn Tso, in response to IHS’ May 2, 2024, Dear Urban Indian Organization (UIO) Leader Letter (DULL) and May 30, 2024, Urban Confer regarding IHS’ Draft Strategic Plan for Fiscal Years 2024-2028 (Draft Strategic Plan). In its comments, NCUIH requested that IHS include improved data accuracy and partnerships with other key agencies and stakeholders including the Office of Management and Budget in the agency’s Draft Strategic Plan.

Background on IHS Strategic Plan

The Draft Strategic Plan will establish IHS’ direction for the next five years. It is developed based on feedback received from Headquarters Offices and the Strategic Plan Workgroup and builds on the work of Headquarters Offices to determine appropriate measures. IHS is also incorporating input and feedback from other stakeholders including UIOs. The Draft Strategic Plan includes three Strategic Goals which consist of their own Strategic Objectives, Performance Goals, and Measures.

NCUIH’s Requests

In its comments in response to the May 2, 2024, DULL and May 30, 2024, Urban Confer, NCUIH requested that IHS:

Senator Casey Introduces NCUIH-Backed Legislation to Improve Community Health Worker Coverage

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On March 07, 2024, Senator Bob Casey (D-PA) introduced the NCUIH-endorsed Community Health Workers Access Act (S. 3892) which would improve local health workers’ ability to bridge gaps in health outcomes by improving Medicare coverage for their services, including personalized support for illness prevention and recovery. This bill would have a direct impact on Urban Indian Organizations (UIOs) by allowing them to bill Medicare and Medicaid for services provided by community health workers. It would also designate UIOs, community-based organization, nonprofit organizations, community health worker networks, federally qualified health centers, rural health clinics, local or State public health departments, academic institutions, health care providers, and any other organizations deemed appropriate by the Secretary as community health agencies, allowing them to bill Medicare for community health services.

Additionally, the bill encourages states to cover services provided by community health workers under their Medicaid programs. In fact, the bill would incentivize states to include community health workers under Medicaid by providing an enhanced Federal Medical Assistance Percentage (FMAP), to cover preventive services and services to address social needs furnished by community health workers.

This bill is endorsed by over 200 community health centers, Families USA, the American Cancer Society Cancer Action Network, and National Association for Community Health Workers.

NCUIH Advocacy on the Bill

NCUIH provided edits to the Senate Health, Education, Labor, and Pensions Committee, ensuring that UIOs were included in the definition of a community health agency. Last year, NCUIH also joined over 200 organizations in signing on to a letter sent to members of Congress encouraging support for this legislation.

Next Steps

The bill was referred to the Senate Committee on Finance. It currently awaits consideration.

Resources

Supreme Court Overturning of Chevron Doctrine May Have Major Impacts on Executive Agency Actions, Including IHS Actions

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On June 28, 2024, the Supreme Court ruled 6-2 in Loper Bright Enterprises v. Raimondo, overturning Chevron v. Natural Resources Defense Council. The court held that when the Administrative Procedure Act (APA) requires courts to exercise independent judgment when deciding whether an agency has acted within its statutory authority, and courts may not defer to agency interpretation of a law based solely on the statute being ambiguous. In making this ruling, the court has overturned Chevron deference, a precedent which has been followed by courts for 40 years.

Chief Justice Roberts delivered the majority opinion, finding that Chevron goes against the APA in its presumption that ambiguities in statutes create implicit delegation to agencies. Additionally, the opinion states that agencies are not more equipped or competent to resolve statutory ambiguities, which should be left for the courts to resolve. The opinion adds that agency interpretation can assist courts in their decision making, but it is not binding as Congress has not provided agencies with authority to be the final decision-maker on resolving statutory ambiguity. The opinion concludes by stating that Chevron has been unworkable since its creation, in that there is no clear definition of “ambiguity” and that the court has often had to provide clarity on its application.

Justice Kagan, in her dissent, references the original Chevron decision which found that “Judges are not experts in the field, and are not part of either political branch of the Government.” Explaining that the decision made 40 years ago was about respecting allocation of responsibility, which for regulatory matters was to agencies and not the courts. She raises concern over the power now given to courts, not provided by Congress or within any statute, and the dangers of allowing courts to be the sole decision-maker on important issues such as climate change or health care. She concludes by noting this decision is not a “one-off” as it is another example of the court rolling back agency authority, “despite congressional direction to the contrary.”

What is Chevron Deference?

The term was coined after the Supreme Court’s 1984 decision in Chevron v. Natural Resources Defense Council and is the legal precedent established by the Court to give judicial deference to administrative action. This rule was to be followed when Congress was unclear in statutory language, and provided that courts would defer to how the agency would interpret the statute, based on agencies having necessary expertise. In applying Chevron deference there are two steps:

  • First, asking if Congress has directly spoken to the question at issue?
  • If the answer is no, the court defers to agency interpretation if that interpretation is permissible or reasonable.

Over time, the Supreme Court narrowed the scope of Chevron deference, finding that only agency interpretations reached through formal proceedings can qualify for Chevron deference. These formal proceedings included adjudications and notice-and-comment rulemaking.

Impact of Chevron Being Overturned

Moving forward, when regulations are challenged in courts, there will be no requirement that agency expertise or interpretation is accepted. Instead, the court itself will interpret issues where a statute is ambiguous or silent. Although Chevron deference has not been applied by the Supreme Court since 2016, it is more often used by lower courts, especially at the Circuit level. Due to this ruling, lower courts may be backlogged with cases challenging administrative actions. To avoid cases being brought, Congress will now have to be more specific in their legislation and may engage more with agencies in the rulemaking process to provide explicit agency authority. This decision also requires Congress and judges to act as experts on specific issues such as technological advancements in AI or environmental concerns with climate change. It can mean that decisions may drastically differ from how an agency would have interpreted it, or time may be extended to allow for adequate knowledge to be incorporated when making decisions on lawsuits or legislation.

Allowing courts to have this power also means that if lawsuits are filed in more than one jurisdiction, there may be contradictory rulings. As a result, there may be confusion about which ruling is correct and cause different applications of rules across the country since decisions in one circuit court are not binding on other circuits. These conflicting rulings could then be resolved by the Supreme Court, taking time away from their caseload and impeding their ability to hear cases involving disputes unrelated to agency action. This process would extend the time for an agency rule to be implemented, not only because it requires waiting on a court’s opinion, but because it could result in an agency having to rewrite the rule to conform with the court’s interpretation.

As far as impacts to Health Policy, KFF has made note of potential impacts in their Issue Brief. Specific areas that are affected by regulations and therefore this ruling are: Medicaid and Medicare payment rates, drug price negotiations, pandemic response, pharmaceutical regulation, and coverage of mental health services.

It is not clear how these impacts extend to Indian Country as well as within the IHS/Tribal Organization/Urban Indian Organization (I/T/U) system. Currently, I/T/U facilities utilize ongoing communications with agencies to improve regulations and address pressing issues in American Indian and Alaska Native (AI/AN) communities. This includes Tribal Consultation and Urban Confer, as well as the ability to provide written comments on proposed agency rules. By the court not allowing agency interpretation to not have as much weight in legal challenges, it could change how agencies like CMS interact with I/T/U facilities. A concern is that agencies may not continue to prioritize Tribal Consultation and Urban Confer, and those processes may not hold as much weight in the rulemaking process. Instead, agencies may prioritize working with Congress to avoid legal challenges by ensuring proposed regulations are within the scope of federal statute. Another concern is that current regulations may be challenged in court, resulting in rollback of significant policy changes.

Related Administrative Law Decision

On July 1, 2024, the Supreme Court issued their ruling in Corner Post Inc. v. Board of Governors of the Federal Reserve System. The court ruled 6-3 and found that “an Administrative Procedures Act claim does not accrue for purposes of 28 U.S.C. § 2401(a) — the default 6-year statute of limitations applicable to suits against the United States — until the plaintiff is injured by final agency action.” This ruling extends the statute of limitations by allowing for suits to be brought within six years of when the plaintiff has been injured, regardless of when the agency rule was promulgated. This decision, in conjunction with overturning Chevron deference, will allow for more APA challenges to be brought that can overturn regulations that have existed and guided agency action for decades.

House Committee Advances Health Spending Bill with Increases for Indian Country Programs

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On July 10, 2024, the House Appropriations Full Committee passed the Fiscal Year (FY) 2025 appropriations bill for Labor, Health, and Human Services (LHHS), which was previously approved by the House LHHS subcommittee on June 27, 2024. The bill appropriates $107 billion for Health and Human Services (HHS), which is $8.5 billion below the FY24 levels and $14 billion below the President’s request. Despite the sizeable cut to the LHHS spending bill and reducing funding for nearly every account to below FY24 enacted levels, Indian Country priorities received increases. The cuts to the LHHS budget are partly due to the Appropriations Leadership reallocating funds from the LHHS bill to the Interior-Environment bill to meet the mandated increases as result of the recent Supreme Court decision on contract support costs (CSCs).

Next Steps

The bill will now be sent to the House floor for a vote. A vote is expected to be scheduled in the next two weeks. In addition, the Senate is working on their own Labor, Health and Human Services spending bill. NCUIH will continue to advocate to protect funding for Indian Country and maintain funding levels passed by the House of Representatives.

Funding Increases for Programs to Improve Cancer Outcomes, Health & Wellness, Behavioral Health, Substance Use, and Workforce in Indian Country

Key provisions of the bill include:

  • $15 million for the Improving Native American Cancer Outcomes program, an increase of $9 million from FY24
  • $30 million for the Good Health and Wellness in Indian Country program, a $6 million increase from FY24
  • $27.75 million for Tribal Behavioral Health Grants (Native Connections), a $5 million increase from FY24
  • $16.5 million for grants for Tribes and Tribal Organizations for Medication-Assisted Treatment for Prescription Drug and Opioid Addiction
  • Increases the Tribal set aside for Indian Health Service facilities, Tribally operated health programs, and Urban Indian Health Programs for the National Health Service Corps loan repayment program to 15%.

Funding Cuts for HIV/AIDS Programs

Unfortunately, the bill also includes severe cuts to HIV/AIDS funding. During the Full Appropriations Committee markup, Representative Barara Lee (D-CA-12) stated “The bill would slash HIV/AIDS prevention research program by a shocking 21% and limit the amount of research the office of AIDS research is able to carry out. Eliminates the Ending the HIV Epidemic initiative, zeros out funding for the Ryan White project of national significance grants. Reduce minority AIDS funding at HHS and eliminate minority AIDS funding at SAMHSA.” While the bill reduces the Minority HIV/AIDS fund by $15 million to $45 million, it increases the Tribal set-aside by $1 million, bringing the total to $6 million. Many UIOs receive funding through these programs and would be greatly impacted by any loss in funding, and thus affecting health equity for urban Natives. NCUIH will continue to advocate for additional HIV/AIDS funding as the appropriations process continues.

Self-Governance at HHS

The Committee also directed the Department of Health and Human Services to extend self-governance to all programs at HHS that are critical to Tribes. The bill report states “For over forty years, Indian Tribes have proven that utilizing self-governance through the Indian Self-Determination and Education Assistance Act in Federal funding is a successful approach for improving program performance. For decades, Indian Tribes have requested the Department to expand this authority beyond the Indian Health Service to other critical HHS programs serving Tribes. Over twenty years, multiple reports and workgroups have produced evidence of the feasibility of the expansion of self-determination and self-governance within the Department. The Committee directs HHS to work with Tribal representatives to provide a plan for the expansion of self-governance at HHS including specific actions the Department can take to advance this process. Such plan is due within 180 days of enactment of this Act. In addition, the Department shall report to the Committee the amount of funding that is going to Indian Tribes for the 4 largest block grants administered by HHS within 90 days of enactment of this Act.”

NCUIH Advocacy to Increase Funding for Indian Country Programs

NCUIH worked closely with Appropriators to advocate for increased funding for Indian Country. In written testimony, NCUIH advocated for $10 million for the Improving Native American Cancer Outcomes program, $30 million for the Good Health and Wellness in Indian Country program, and to protect funding for HIV/AIDS treatment and prevention. The Committee showed significant support for Indian Country through this appropriations process.

Bill Highlights:

Line Item FY 2024 Enacted FY 2025 President’s Budget Request FY 2025 Committee  Passed
Health Resources and Services Administration $8.9 billion $8.26 billion $7.64 billion
Substance Abuse and Mental Health Services Administration $7.4 billion $8.13 billion $7.54 billion
National Institute of Health $48.6 billion $50.77 billion $48.58 billion
Centers for Disease Control   $9.2 billion $11.64 billion $7.45 billion
Good Health and Wellness in Indian Country $24 million —————– $30 million
Improving Native American Cancer Outcomes $6 million —————– $15 million
Ryan White HIV/AIDS Program $2.57 billion $2.58 billion $2.38 billion
Ending the HIV Epidemic $165 million $175 million $0
Minority HIV/AIDS Fund $60 million $60 million $45 million
Minority HIV/AIDS Fund – Tribal Set Aside $5 million ———— $6 million
Tribal Behavioral Health Grants (Native Connections) $22.75 million ———— $27.75 million

Health Resources and Services Administration

Health Resources and Services Administration: $7.64 billion
  • Bill report pg. 30: The Committee recommendation for HRSA includes $7,373,110,000 in discretionary budget authority and $266,727,000 in mandatory funding.
Ryan White HIV/AIDS Program: $2.38 billion
  • Bill report pg. 48: The Ryan White Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) program funds activities to address the care and treatment of persons living with HIV/AIDS who need assistance to obtain treatment. The program provides grants to States and eligible metropolitan areas to improve the quality, availability, and coordination of health care and support services to include access to HIV-related medications; grants to service providers for early intervention outpatient services; grants to organizations to provide care to HIV infected women, infants, children, and youth; and grants to organizations to support the education and training of health care providers.
Federal Office of Rural Health Policy: $400.9 million
  • Bill report pg. 50: The Federal Office of Rural Health Policy’s (FORHP) programs provide funding to improve access, quality, and coordination of care in rural communities; for research on rural health issues; for technical assistance and recruitment of health care providers; for screening activities for individuals affected by the mining, transport, and processing of uranium; and for the outreach and treatment of coal miners and others with occupation-related respiratory and pulmonary impairments.
Native Hawaiian Health Care Program: $27 million
  • Bill report pg. 32: The Committee continues $27,000,000 for the Native Hawaiian Health Care Program. Of the total amount appropriated for the Native Hawaiian Health Care Program, not less than $10,000,000 shall be provided to Papa Ola Lokahi for administrative purposes authorized under 42 U.S.C. 11706, including expanded research and surveillance related to the health status of Native Hawaiians and strengthening the capacity of the Native Hawaiian Health Care Systems.
National Health Service Corps: $130 million
  • Bill report pg: 36 The Committee includes $130,000,000, which is $1,400,000 above the fiscal year 2024 enacted level and $4,400,000 above the fiscal year 2025 budget request, for the National Health Service Corps (NHSC) to support competitive awards to health care providers dedicated to working in underserved communities in urban, rural, and Tribal areas.
    • Tribal Set Aside.—The Committee also includes a set aside of 15 percent within the discretionary total provided for NHSC to support awards to participating individuals that provide health services in Indian Health Service facilities, Tribally-operated health programs, and Urban Indian Health programs.
National Center of Excellence for Eating Disorders: $5 million
  • Bill report pg. 133: The Committee provides $5,000,000 to improve the availability of health care providers to respond to the needs of individuals with eating disorders including the work of the National Center of Excellence for Eating Disorders to increase engagement with primary care providers, including pediatricians, to provide specialized advice and consultation related to the treatment of eating disorders. The Committee provides additional funding to support the development, in coordination with the departments of Defense and Veterans Affairs, of a Screening, Brief Intervention and Referral to Treatment model for service members, veterans, and their families.

Centers for Disease Control and Prevention

Good Health and Wellness in Indian Country: $30 million
  • $30 million for Good Health and Wellness in Indian Country for FY 2025. The recommendation is $15 million above FY24 enacted levels.

Office of the Secretary – General Departmental Management 

Minority HIV/AIDS Fund: $45 million – Tribal Set Aside: $6 million
  • Bill report pg. 196: The Committee includes $45,000,000 for the Minority HIV/AIDS Fund (MHAF), which is $15,000,000 below the fiscal year 2024 enacted level and the fiscal year 2025 budget request.
    • Bill report pg: 196: Tribal Set Aside.—The Committee notes that according to the CDC, HIV-positive status among Native Americans is increasing and nearly one-in-five HIV-positive Native Americans is unaware of their status. In addition, only three-in-five receive care and less than half are virally suppressed. To increase access to HIV/AIDS testing, prevention, and treatment, the Committee increases the Tribal set aside within the MHAF to $6,000,000, which is $1,000,000 above the fiscal year 2024 enacted level.

Substance Abuse and Mental Health Services Administration

Substance Abuse and Mental Health Services Administration: $7.54 billion
  • Bill report pg: 124: The Committee recommendation for the Substance Abuse and Mental Health Services Administration (SAMHSA) program level includes $7,398,400,000 in discretionary budget authority, $131,667,000 in PHS Evaluation Tap Funding, and $12,000,000 in transfers from the Prevention and Public Health Fund (PPHF).
Substance Abuse Prevention Services: $203.17 million
  • No report language.
Mental Health Services Block Grant: $1.02 billion
  • Bill report pg. 127: The Committee provides $1,022,571,000 for the Mental Health Services Block Grant (MHBG) which is $15,000,000 above the fiscal year 2024 enacted program level and $20,000,000 below the fiscal year 2025 budget request. The MHBG provides funds to States to support mental illness prevention, treatment, and rehabilitation services. Funds are allocated according to a statutory formula among the States that have submitted approved annual plans. The Committee continues the 10 percent set aside within the MHBG for evidence-based programs that address the needs of individuals with early serious mental illness, including psychotic disorders and the 5 percent set aside for crises-based services. The Committee notes that, consistent with State plans, communities may choose to direct additional funding to crises stabilization programs.
988 Suicide & Crisis Lifeline: $519.62 million
  • Bill report pg. 128: The Committee provides $519,618,000 for the 988 Suicide & Crisis Lifeline, which is the same as the fiscal year 2024 enacted program level, to support the national suicide hotline to continue to support State and local suicide prevention call centers as well as a national network of backup call centers and the national coordination of such centers.
Substance Use Prevention, Treatment, and Recovery Services Block Grant: $2.51 billion
  • Bill report pg. 134: The Committee includes $2,508,079,000, which is a $500,000,000 increase to the fiscal year 2024 enacted program level, for the Substance Use Prevention, Treatment, and Recovery Services (SUPTRS) Block Grant. The SUPTRS Block Grant is a critical component of each State’s publicly funded substance use disorder system designed to address all substance use disorders—including those related to alcohol. SUPTRS Block Grant funds may support initiatives related to alcohol in settings such as emergency rooms and primary care offices. In addition, States utilize SUPTRS Block Grant funds to support alcohol use disorder treatment services in outpatient, intensive outpatient, and residential programs. Further, the Committee is also aware that SUPTRS Block Grant funds may be allocated to support medications for the treatment of alcohol use disorders, an important tool that should be available to those in need. The Committee also understands SUPTRS Block Grant funds are utilized by States to support recovery community organizations to provide recovery support for those with alcohol use disorders.
State Opioid Response Grants: $1.575 billion
  • Bill report pg. 135: The Committee includes $1,575,000,000, which is the same as the fiscal year 2024 enacted program level, for State Opioid Response (SOR) grants. The Committee supports efforts from SAMHSA through SOR grants to expand access to SUD treatments in rural and underserved communities, including through funding and technical assistance.
    • Tribal Set Aside – 4%: Within the amount provided, the Committee includes a set aside for Indian Tribes and Tribal organizations of 4 percent.
Tribal Behavioral Grants (Native Connections): $27.75 million
  • Bill report pg. 132: The Committee provides $27,750,000, a $5,000,000 increase from the fiscal year 2024 enacted program level, to prevent and reduce suicidal behavior and substance use, reduce the impact of trauma, and promote mental health among AI/AN youth, through age 24.
Zero Suicide: $27.2 million
  • The Committee allocated $27,200,000 to Zero Suicide program, a $1 million include over FY24 enacted levels.
    • American Indian and Alaska Native Set Aside – The Committee allocated $4,400,000 to the American Indian and Alaska Native Set Aside, a $1 million increase over FY24 enacted levels.

National Institute on Minority Health and Health Disparities

Improving Native American Cancer Outcomes: $15 million
  • Bill report pg. 107: The Committee continues to be concerned that Native Americans experience overall cancer incidence and mortality rates that are strikingly higher than non-Native populations. The Committee includes $15,000,000, which is an increase of $9,000,000 above the fiscal year 2024 enacted level, to continue an initiative for Improving Native American Cancer Outcomes to support efforts including research, education, outreach, and clinical access related to cancer in Native American populations. The Committee further directs NIMHD to work with NCI to locate this initiative at an NCI-designated cancer center demonstrating partnerships with Indian Tribes and Tribal organizations to improve the screening, diagnosis, and treatment of cancers among Native Americans, particularly those living in rural communities.
Native Hawaiian/Pacific Islander Health Research Office: $5 million
  • Bill report pg. 108: —The Committee provides $5,000,000, which is an increase of $1,000,000 above the fiscal year 2024 enacted level, for the Native Hawaiian/ Pacific Islander Health Research Office (NHPIHRO) with a focus on both addressing Native Hawaiian and Pacific Islander (NHPI) health disparities, as well as supporting the pathway and research of NHPI investigators. The Committee encourages NHPIHRO to develop partnerships with academic institutions with a proven track record of working closely with NHPI communities and NHPI serving organizations located in states with significant NHPI populations to support the development of future researchers from these same communities.

Important Behavioral and Mental Health Provisions

Medication-Assisted Treatment for Prescription Drug and Opioid Addiction Tribal Set Aside: $16.5 million
  • $16.5 million for grants for Tribes and Tribal Organizations for Medication-Assisted Treatment for Prescription Drug and Opioid Addiction
Peer-Support Services: $15 million
  • Bill report pg. 39: The Committee supports community based experiential training for students preparing to become peer support specialists and other types of behavioral health-related paraprofessionals. The Committee includes a $1,000,000 increase for this activity.
Infant and Early Childhood Mental Health Program: $15 million
  • Bill report pg. 130: The Committee provides $15,000,000, which is the same as the fiscal year 2024 enacted program level, for the Infant and Early Childhood Mental Health program, for grants to human service agencies and nonprofit organizations to provide age-appropriate mental health promotion and early intervention or treatment for children with or with significant risk of developing mental illness including through direct services, assessments, and trainings for clinicians and education providers.

Following Supreme Court Ruling, Support to Transition Contract Support Costs to Mandatory Appropriations Grows

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On June 21, 2024, the National Council of Urban Indian Health (NCUIH), in partnership with the National Indian Health Board, National Congress of American Indians, and 25 other organizations, sent a letter urging Congressional Appropriations leaders to transition Contract Support Cost and 105(l) leases to mandatory appropriations. For over a decade, there has been significant pressure on Appropriators to transition Contract Support Costs to mandatory funding. In fact, in Fiscal Year (FY) 2014, the House and Senate Committees on Appropriations published a bipartisan, bicameral statement recognizing the mandatory nature and rapid growth of legally obligated Contract Support Costs (CSC) and expressing concern about the potential impact on the Interior bill. Since FY22, and included in FY25, the President’s budget has made a proposal to reclassify CSC and 105(l) payments as mandatory.

Federal and Congressional Support for Shifting CSCs and 105 (L) Leases to Mandatory Funding

Public statements by Department of Health and Human Services Secretary Becerra and Indian Health Service Director Tso urged “Congress to act on the FY 2025 President’s Budget proposal to shift the IHS budget from discretionary to mandatory funding starting in FY 2026 to protect the overall appropriation for the Indian Health Service and create more adequate and stable funding into the future”

Following the June 6, 2024, Supreme Court’s opinion in favor of Tribes in the Becerra v. San Carlos Apache case, several House Appropriators called for shifting Contract Support Costs and Section 105(l) Tribal Lease Payments as mandatory appropriations. House Appropriations Chair Tom Cole stated that additional Indian Health Service spending will be needed after the Supreme Court decision. He also emphasized that the shift to mandatory appropriations, while it might take time, will be essential to continue funding the Indian Health Service and Urban Indian Health.

For more information on the Supreme Court ruling, check out NCUIH’s policy update and FAQ.

Full Text of the Letter:

Re: Support for the President’s FY25 Proposal for Mandatory CSC and 105(l) Funding

Dear Chair Murray, Chair Cole, Vice Chair Collins, and Ranking Member DeLauro:

On behalf of the undersigned Tribal partner organizations and our members, we strongly support the proposal to reclassify Contract Support Costs and Section 105(l) Tribal Lease Payments as mandatory appropriations. We respectfully urge you to include the proposal in the FY25 Interior and Environment Appropriations bill (hereinafter “Interior bill”). The President’s budget request has consistently recommended this change since FY 2022.

Ten years ago, for FY14, the House and Senate Committees on Appropriations (hereinafter “Committees”) published a bipartisan, bicameral statement recognizing the mandatory nature and rapid growth of legally obligated Contract Support Costs (CSC) and expressing concern about the potential impact on the Interior bill. They stated:

“[T]he House and Senate Committees on Appropriations are in the untenable position of appropriating discretionary funds for the payment of any legally obligated contract support costs. Typically obligations of this nature are addressed through mandatory spending, but in this case since they fall under discretionary spending, they have the potential to impact all other programs funded under the Interior and Environment Appropriations bill, including other equally important tribal programs.”

Six years later, for FY20, the Committees published a similar statement regarding payments related to Tribal Lease Payments required by Section 105(l) of the Indian Self-Determination and Education Assistance Act (hereinafter “105(l) payments”.) The Committees expressed concern that 105(l) payments “are negatively impacting the ability to use discretionary appropriations to support core tribal programs, including health, education and construction programs, or provide essential fixed cost requirements.” The Committees called on the Department of the Interior and the Department of Health and Human Services (HHS) to “formulate long-term accounting, budget, and legislative strategies to address the situation, including discussions about whether, in light of the Maniilaq decisions, these funds should be re-classified as an appropriated entitlement.” Since FY22, the Departments of the Interior and HHS have requested that CSC and 105(l) payments be appropriated as mandatory, but Congress has not yet acted on this common-sense proposal.

 After the Committees highlighted the problem in FY20, the Interior bill has continued to struggle to simultaneously address historically underfunded Tribal programs while keeping up with the growth of CSC and 105(l) payments. In FY24, appropriations for CSC and 105(l) payments increased by $168 million (12%). However, these increases were offset by cuts to other Tribal programs in the Indian Health Service (IHS) and the Bureaus of Indian Affairs and Education. In all, the agencies received a combined $23 million topline cut and were denied the $421 million requested for fixed costs, inflation, and population growth to simply maintain current levels of service. FY25 is shaping up to be an even bigger challenge, with CSC and 105(l) payments estimated to increase by another $268 million (17%).

On June 6, 2024, the U.S. Supreme Court ruled that the IHS must pay contract support costs on revenue collected from 3rd party payers like Medicare, Medicaid, and private insurance. This will undoubtedly have major budget implications for the IHS CSC budget on top of the annual increases impacting the budget. The government argued that this decision could cost up to $2 billion annually, which would more than double the current CSC obligation. With the Fiscal Responsibility Act in place, domestic discretionary spending will increase by just 1%. This is not nearly enough to absorb these costs without further cuts to other essential services and programs. Now is the time to reclassify these costs appropriately, as mandatory funding.

Simply put, both programs will continue to grow as they continue to be utilized by Tribal nations throughout the United States, and the Interior bill will continue to fail to meet its trust and treaty obligations to Tribes under the budget structure and process currently in place. Reclassifying CSC and 105(l) payments as mandatory would be a positive step and would be consistent with budgeting for most other Federal legal obligations where full and timely payments minimize litigation risk. Moreover, as with other recently reclassified mandatory appropriations in the Interior bill, the Committees could retain oversight of the programs.

The President’s FY25 proposal to reclassify CSC and 105(l) payments as mandatory is reasonable, fair, and a direct response to the Committee’s bipartisan, bicameral calls for a long-term solution. Our organizations recognize and appreciate your strong leadership and bipartisan support over the years for Tribal self-determination. For the sake of continuing to improve the federal government’s commitments to meeting its trust and treaty obligations under your leadership, we urge you to include the President’s proposal in the FY25 Interior bill.

Sincerely,

National Indian Health Board
National Congress of American Indians
Self-Governance Communication and Education Tribal Consortium
National Council of Urban Indian Health
Alaska Federation of Natives
Alaska Native Health Board
Albuquerque Area Indian Health Board
Association of American Indian Physicians
Affiliated Tribes of Northwest Indians
United South and Eastern Tribes Sovereignty Protection Fund
Rocky Mountain Tribal Leaders Council
Seattle Indian Health Board
Rocky Mountain Tribal Leaders Council
Northwest Portland Area Indian Health Board
Great Lakes Area Tribal Health Board
Inter-Tribal Association of Arizona
California Rural Indian Health Board
California Tribal Chairmans Association
Coalition of Large Tribes
Southern Plains Tribal Health Board
Great Plains Tribal Leaders Health Board
Midwest Alliance of Sovereign Tribes
American Indian Higher Education Consortium
National American Indian Housing Council
National Indian Education Association
National Indian Child Welfare Association
National Native American Boarding School Healing Coalition
Navajo Nation

House Advances Interior Bill with a 23% Increase for the Indian Health Service and Maintained Advance Appropriations for IHS

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The House Appropriations Full Committee passed an Interior bill that includes $8.56 billion for IHS and $99.99 million for Urban Indian Health.

On July 9, 2024, the House Appropriations Full Committee passed the Fiscal Year (FY) 2025 appropriations bill for Interior, Environment, and Related Agencies, which was previously approved by the House Subcommittee on June 28, 2024. The bill authorizes $8.56 billion for the Indian Health Service (IHS)— an increase of $1.6 billion from FY24 and $561.64 million above the President’s request. The bill also provides $99.99 million for Urban Indian health, which is $9.5 million above the FY24 enacted amount and $5 million above the President’s budget request. The Committee report included language that affirmed the trust responsibility for all Native people including those who reside in urban areas.

Other key provisions include: maintaining advance appropriations for IHS for FY26 with an increase to $5.98 billion from $5.19 billion in FY25, $8 million for generators at IHS/Tribal Health Programs/Urban Indian Organizations (UIOs), $7 million, a $4 million increase, for the Produce Prescription Pilot Program for Tribes and UIOs to increase access to produce and other traditional foods, as well as $44.43 million, a $10 million increase, for Tribal Epidemiology Centers (TECs).

NCUIH recently worked closely with Representatives Gallego and Grijalva on leading a Congressional letter signed by 52 House members to the House Committee on Appropriations for FY 2025. The letter has bipartisan support and calls for support for Urban Indian Health based on the TBFWG’s recommendation and to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. NCUIH also joined the National Indian Health Board, National Congress of American Indians, and 25 other organizations on a letter urging Congressional Appropriations leaders to transition Contract Support Cost and 105(l) leases to mandatory appropriations.

Next Steps

The House is scheduled to vote on the Interior, Environment, and Related Agencies spending bill the week of July 22. The legislation is not expected to become law in its current form. House leadership will need to work with Senate Leadership to negotiate a final bill text for passage in both chambers. The Senate Appropriations Committee is tentatively scheduled to mark up the Senate Interior bill the week of July 22.

FY24 funding is set to end on September 30, 2024. If Congress cannot come to a funding agreement by that deadline, they will need to pass a Continuing Resolution to keep the funding levels at the FY24 level until they can reach an agreement. Should political disagreements lead to a government shutdown, UIOs and parts of IHS will be protected by Advance Appropriations.

Bi-Partisan Support for IHS Funding and Advance Appropriations in Bill Hearing

Throughout the appropriations process, there has been clear bipartisan support for the Indian Health Service:

“I refuse to balance the budget on the backs of tribes. I am proud this bill makes strong investments to further the federal government’s trust and treaty commitments to the Tribes.” – Chairman Mike Simpson (R-ID-2)

“The measure [Interior Bill] before us today impacts vast aspects of American Life. It also advances the federal commitment to honor our trust and treaty responsibilities to American Indian and Alaska Native communities. Essential resources are delivered at the total funding level at $38.4 billion,” said Appropriations Chairman Tom Cole (R-OK-4), “Delivering on our trust and treaty commitments are of critical importance to my home state of Oklahoma and to all people of Indian Country.”

“I want to show my pride and appreciation for the continued nonpartisan trust and treaty responsibility that’s the hallmark of this Interior bill. Chairman Cole I want to thank you for raising interior allocation to allow us to meet the increased responsibilities for contract support costs,” said Rep. Betty McCollum (D-MN-4), and she also acknowledged the inclusion of advance appropriations for IHS, “Chairman Simpson I appreciate you once again prioritizing funding for life, health and safety issues for Indian Country, including advance appropriations for the Indian Health Service for a third year in a row.”

Committee leadership also signified their support of the transition of Contract Support Costs to mandatory funding:

Ranking Member Pingree (D-ME-1) shared, “I want to acknowledge and thank Chairman Cole for adjusting the Interior Allocation to accommodate the $739 million increase required by the result of the Supreme Court decision on contract support costs. These costs will continue to rise, and I hope we can work together to make these funds mandatory.”

Appropriations Ranking Member Rosa De Lauro (D-CT-3), shared her support for funding contract support costs, “It is my hope that we can work together to see the funding needed to address rising contract support costs is made mandatory.”

Bill Highlights

LINE ITEM FY24 ENACTED FY25 TBFWG REQUEST FY25 PRESIDENT’S BUDGET FY25 HOUSE PROPOSED
URBAN INDIAN HEALTH $90,419,000 $965,254,000 $94,990,000 $99,992,000
INDIAN HEALTH SERVICE $6,961,914,000 $53,852,801,000 $8,000,000,000 $8,561,647,000
ADVANCE APPROPRIATIONS $5,190,000,000 ————————- $5,129,458,000 $5,975,150,000
PRODUCE PRESCRIPTION PILOT PROGRAM $3,000,000 ————————- —————————- $7,000,000
TRIBAL EPIDEMIOLOGY CENTERS $34,433,000 $34,433,000 $44,433,000
CONTRACT SUPPORT COSTS $1,051,000,000 Move to Mandatory $ 979,000,000 $2,036,000,000
105 (L) LEASES $149,000,000 $261,000,000 $349,000,000 $400,000,000
ALCOHOL AND SUBSTANCE ABUSE $266,636,000 $4,859,237,000 $291,389,000 $282,380,000
GENERATORS AT I/T/US $3,000,000 ————————- —————————- $8,000,000
MATERNAL HEALTH $2,000,000 ————————- —————————- $3,000,000
DENTAL HEALTH $252,561,000 $3,174,342,000 $276,085,000 $283,080,000
Indian Health Service: $8.56 billion
  • Bill Report, Pg.93: The recommendation includes $5,274,783,000 that is available for obligation in fiscal year 2025 for the Indian Health Services Account, $326,052,000 above the fiscal year 2024 enacted level. This includes $4,684,029,000 provided as a fiscal year 2025 advance and $590,754,000 recommended in this bill and available in this fiscal year. These funds are available for two years unless otherwise specified.
Urban Indian Health: $99.99 million
  • Bill Report, pg. 95: The Committee recognizes the Federal trust responsibility to provide health care services to American Indian and Alaska Native citizens and acknowledges that approximately seventy-one percent live in urban areas. The recommendation includes $99,992,000, $9,573,000 above the fiscal year 2024 enacted level and $5,000,000 above the President’s budget request, for Urban Indian Health programs.
Contract Support Costs – $2.036 billion and Tribal 105(l) leases – $400 million
  • Bill Report, pg. 96: The Committee recommends an indefinite appropriation estimated to be $2,036,000,000 for contract support costs incurred by the agency as required by law. It does not include the Administration’s request for Administrative Costs. The bill continues language making available such sums as are necessary to meet the Federal government’s full legal obligation and prohibiting the transfer of funds to any other account for any other purpose. In addition, the bill includes language specifying carryover funds may be applied to subsequent years’ contract support costs.
    • In a recent Supreme Court opinion, Becerra v. San Carlos Apache, found that self-determination contracts between Tribes and IHS require spending and collection of third-party revenue, therefore, by doing so and incurring administrative costs, IHS is then required to reimburse for those contract support costs.
  • Bill Report, pg. 96: The Committee recommends an indefinite appropriation estimated to be $400,000,000 for Payments for Tribal Leases incurred by the agency as required by law. It does not include the Administration’s request for Administrative Costs. The bill includes language making available such sums as necessary to meet the Federal government’s full legal obligation and prohibits the transfer of funds to any other account for any other purpose.
Hospitals and Health Clinics: $2.84 billion
  • Bill Report, pg. 93: The recommendation includes $2,845,868,000 for Hospitals and Health Clinics, $295,354,000 above the fiscal year 2024 enacted level.
Direct Operations: $105.96 million
  • No report language
Indian Health Care Improvement Fund: $75.47 million
  • Bill Report, pg. 96: The Committee does not accept the IHS’s proposal to move the Indian Health Care Improvement Fund within the Hospitals and Health Clinics funding. The recommendation provides $75,472,000 for the Indian Health Care Improvement Fund, which is $1,334,000 above the fiscal year 2024 enacted level.
Purchased and Referred Care: $1.04 billion
  • Bill Report, pg. 94: The recommendation includes $1,048,804,000, $52,049,000 above the fiscal year 2024 enacted level, for Purchase and Referred Care (PRC).
Public Health Nursing: $120.95 million
  • No report language.
Immunization AK: $2.3 million
  • No report language.
Indian Health Professions: $89.25 million
  • Bill Report, pg. 95: The recommendation includes $89,252,000 for Indian Health Professions programs, $8,684,000 above the fiscal year 2024 enacted level and $8,000,000 above the President’s budget request. The Committee continues to support Indian Health Professions programs and expects IHS to allocate the increase provided across all programs, including the Scholarship Program, Loan Repayment Program, Indians into Medicine Program (INMED), American Indians into Nursing (RAIN) Program, and the American Indians into Psychology Programs.
Tribal Management: $2.98 million
  • No report language.
Self-Governance: $6.18 million
  • No report language.
Maintenance and Improvement: $174.35 million
  • No report language.
Sanitation Facilities Construction: $127.96 million
  • Bill Report, pg. 97: The Committee continues advance appropriations for programs advanced in fiscal year 2024 and expands advance appropriations to the Indian Health Facilities Sanitation Facilities Construction and Health Care Facilities Construction accounts.
Health Care Facilities Construction: $185.7 million
  • Bill Report, pg. 97: The recommendation includes $185,702,000 for Health Care Facilities Construction, $3,023,000 above the fiscal year 2024 enacted level. The recommendation includes $14,000,000, for Staff Quarters, $3,000,000 above the fiscal year 2024 enacted level, for staff housing across the IHS health care delivery system to support the recruitment and retention of quality healthcare professionals across Indian country.
Facility and Environmental Health Support: $323.96 million
  • No report language.
Dental Health: $238 million
  • Bill Report, pg. 94: The recommendation includes $283,085,000 for Dental Health services, $30,524,000 above the fiscal year 2024 enacted level and $7,000,000 above the President’s budget request.
    • Also includes $8,000,000 to expand Dental Support Centers to all 12 service areas and $6,500,000 to install a electronic Dental Records System.
Equipment – Generators:  $8 million
  • Bill Report, pg. 97: To increase the resilience of these facilities, the recommendation includes $8,000,000 to purchase generators, $5,000,000 above the fiscal year 2024 enacted level, including for IHS, Tribal Health Programs, and Urban Indian Organizations located in areas impacted by de-energization events.
Bureau of Indian Affairs, Missing and Murdered Indigenous Women Initiative: $30 million
  • Bill Report, pg. 47: Within the increase provided, the recommendation includes an additional $13,500,000 for the Missing and Murdered Indigenous Women Initiative. A total of $30,000,000 is provided to address the crisis of missing and murdered indigenous women, including resources for criminal investigators, software platforms, and evidence recovery equipment. The Committee directs BIA to work with Tribal and Federal law enforcement agencies to facilitate sharing law enforcement and public records data and other technological tools to assist those agencies in finding missing individuals.
Community Health Representatives: $69.62 million
  • No report language.
Mental Health: $140.74 million
  • Bill Report, pg. 94: The recommendation includes $140,746,000 for Mental Health/Social Services, $10,981,000 above the fiscal year 2024 enacted level.
Alcohol and Substance Abuse: $282.38 million
  • Bill Report, pg. 94: The recommendation includes $282,389,000, $15,753,000 above the fiscal year 2024 enacted level, for Alcohol and Substance Abuse programs.
Produce Prescription Pilot Program: $7 million
  • Bill Report, pg. 93: The recommendation includes $7,000,000, $4,000,000 above the fiscal year 2024 enacted level, for IHS to expand, in coordination with Tribes and Urban Indian Organizations (UIOs), the Produce Prescription Pilot to implement a produce prescription model to increase access to produce and other traditional foods among its service population. The Committee encourages IHS to provide a briefing to the Committee not later than 90 days following the enactment of this Act on the distribution of funds and implementation efforts
Tribal Epidemiology Centers: $44.43 million
  • Bill Report, pg. 93: The Committee recognizes the importance of Tribal Epidemiology Centers (TEC) which conduct epidemiology and public health functions critical to the delivery of health care services for Tribal and urban Indian communities. The recommendation includes $44,433,000 for TECs, $10,000,000 above the fiscal year 2024 enacted level.
Maternal Health: $3 million
  • Bill Report, pg. 93: The recommendation includes $3,000,000, $1,000,000 above the fiscal year 2024 enacted level, for Improving Maternal Health.
Alzheimer’s Disease: $6 million
  • Bill Report pg. 93: The recommendation includes $6,000,000, $500,000 above the fiscal year 2024 enacted level, to continue Alzheimer’s and related dementia activities. These funds will enable awardees to continue to implement locally developed models of culturally appropriate screening, diagnostics, and management of people living with Alzheimer’s and other related dementia. This funding also supports the Dementia ECHO program, designed to support clinicians and caregivers to strengthen their knowledge and care around dementia for Tribal patients.
Background and Advocacy

On March 9, 2024, President Biden released his budget request for FY25 which included $8.2 billion for IHS and proposed mandatory funding for IHS from FY 2026 to FY 2034 to the amount of $288.9 billion over-ten years as well as exempting IHS from sequestration. This mandatory formula would culminate in $42 billion for IHS in FY 2033, to account for inflation, staffing increases, long-COVID treatment, and construction costs. On March 11, 2024, IHS published their FY 2024 Congressional Justification with the full details of the President’s Budget, which includes $95 million for urban Indian health – a 5% increase above the FY 2024 enacted amount of $90.42 million.

NCUIH also requested full funding for urban Indian health for FY 2025 at $963.5 million for urban Indian Health in FY25 in accordance with the Tribal Budget Formulation Workgroup recommendations. NCUIH requested that advance appropriations be maintained for the Indian Health Service (IHS) until mandatory funding is achieved. This budget recommendation is the result of Tribal leaders, over several decades, providing budget recommendations to phase in funding increases over 10-12 years to address growing health disparities that have largely been ignored.

On May 8, 2024, NCUIH Board Member and Executive Director of Helena Indian Alliance – Leo Pocha Clinic, Todd Wilson (Crow), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2025 funding. NCUIH requested full funding for IHS at $53.8 billion and $ 965.3 million for Urban Indian Health for FY 2025 as requested by the Tribal Budget Formulation Workgroup (TBFWG), maintain advance appropriations for IHS, and protecting IHS from sequestration.

NCUIH recently worked closely with Representatives Gallego and Grijalva on leading a Congressional letter signed by 52 House members to the House Committee on Appropriations for FY 2025. The letter has bipartisan support and calls for support for Urban Indian Health based on the TBFWG’s recommendation and to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. On May 14, 2024, a group of 20 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests.

VA Exempts Over 5,000 Native Veterans from Copayments, Reimburses $3 Million: VA Secretary McDonough Highlights Progress at NCUIH Conference

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On April 17, 2024, the Department of Veterans Affairs (VA) announced that more than 4,000 Native Veterans have been approved for the VA’s copayment exemption and has exempted and/or reimbursed over 168,000 copayments totaling more than $3 million for Native Veterans. During NCUIH’s Annual Conference on April 30, 2024, VA Secretary Denis McDonough highlighted these new numbers and noted an update – that over 6000 Native Veterans have applied and over 5000 had been approved.

Background

American Indians and Alaska Natives serve in the military at some of the highest rates in the country, and many Native veterans receive healthcare from the Veterans Health Administration (VHA), alongside IHS, Tribal, and urban Indian organization (UIO) facilities. Unfortunately, American Indian and Alaska Native Veterans generally face a higher rate of mental health disorders compared to White veterans.

On April 4, 2023, VA published a final rule in the Federal Register establishing the waiver process for Veterans to submit documentation to have their VA copays waived. This rule implements Section 3002 of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020 Public Law 116-315, signed into law on January 5, 2021, which prohibits collection of a health care copayment by the Secretary of Veterans Affairs from an American Indian and Alaska Native Veteran who meets the definitions of “Indian” or “urban Indian” under the Indian Health Care Improvement Act (IHCIA).

The copayment exemption is a crucial step in honoring the federal government’s trust responsibility to “maintain and improve the health of the Indians” and NCUIH has been a strong advocate for this policy. NCUIH continues to stress that Native Veterans are entitled to this copayment exemption due to the federal government’s responsibility to provide and support services for Native Veterans, fulfilling the trust responsibility for healthcare provisions for all American Indians and Alaska Natives. We remain committed to engaging with the VA on issues affecting American Indian and Alaska Native Veterans in urban areas.

See NCUIH resources on the VA Copayment Exemption for Native Veterans:

NCUIH Requests Inclusive Governance and Equitable Cohort Selection for Urban Indian Organizations in IHS’ Health Information Technology Modernization Efforts

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On March 7, 2024, and June 7, 2024, the National Council of Urban Indian Health (NCUIH) submitted written comments to the Indian Health Service (IHS) Director, Roselyn Tso, regarding the IHS’ January 18, 2024, Dear Tribal Leader and Urban Indian Organization Leader letter (DTLL/DULL) about the February 8, 2024, and May 9, 2024, Tribal Consultation and Urban Confer (TC/UC) sessions regarding Health Information Technology (HIT) Modernization. In its comments, NCUIH requested that HIT Modernization governance be inclusive of urban Indian organizations (UIOs) by ensuring Domain Groups reflect the scope of facility types, and that the cohort selection process is equitable by ensuring that cohort selection equally prioritizes all facility types.

NCUIH’s Requests

The purpose of the February 8 TC/UC session was for IHS to receive feedback from Tribes and UIOs concerning the HIT Modernization Enterprise Collaboration Group (ECG). The ECG will be a user-focused body that will inform system configuration in clinical and administrative areas.  It will review preferred, evidence-based practices and recommendations for operational aspects of the EHR implementation and deployment. IHS stated that one of the purposes of the ECG is to ensure users of the enterprise EHR drive the configuration of the system that they will use for patient care. It will also engage Tribes and UIOs and their users in enterprise EHR management. Within the ECG there will be Domain Groups which will be multi-disciplinary bodies comprised of EHR users from IHS, Tribal health centers and UIOs (I/T/U) and will be forums for clinical and business subject matter experts to make EHR design and configuration recommendations on behalf of the end users the represent.

For the presentation slides from the February 8 TC/UC session, please click here.

In its comments to this urban confer, NCUIH requested IHS:

  • Ensure all UIO facility types are represented in the ECG Domain Groups
  • Encourage consideration of interoperability by the ECG either through existing Domain Groups or a new Domain Group
  • Ensure Tribal and UIO representation on the ECG Executive Committee
  • Clarify expectations, scope, and outcomes for Domain Groups

The purpose of the May 9 TC/UC session was for IHS to receive feedback from Tribes and UIOs concerning HIT Modernization deployment and cohort planning. IHS presented on the proposed timeline for deployment implementation pathways and approach, and the steps Tribes and UIOs can take to prepare for implementation at their individual sites. IHS will begin the HIT Modernization process by first having implementation occur at IHS pilot sites and then begin implementation at cohorts using the lessons learned from pilot sites. The cohorts will be groups of facilities selected for simultaneous system implementation.

For the presentation slides from the May 9 TC/UC session, please click here.

In its comments to this urban confer, NCUIH requested IHS:

  • Clarify the cohort identification process
  • Ensure IHS accounts for challenges related to operational and financial costs
  • Develop training materials for I/T/U facilities to use as a planning base to prepare for transitioning to a new Electronic Health Record (EHR)
  • Ensure IHS address data integration and migration process for a new EHR

NCUIH Advocacy on HIT Modernization

NCUIH has previously submitted several comments to IHS on HIT Modernization:

NCUIH also submitted written testimony  to the House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies regarding the Fiscal year (FY) 2024 funding for UIOs in which NCUIH requested increased funding for EHR Modernization. Specifically, NCUIH requested support for the IHS’ transition to a new EHR system for IHS and UIOs by supporting the President’s budget request of $913 million in FY 2024 appropriations.

NCUIH will continue to closely follow IHS’s progress and policies with HIT Modernization.

Background on IHS HIT Modernization

During the November 8, 2023, Tribal Consultation and Urban Confer on HIT Modernization, IHS announced that it selected General Dynamics Information Technology, Inc. (GDIT) to build, configure, and maintain a new IHS enterprise Electronic Health Record (EHR) system utilizing Oracle Cerner technology. The new EHR will replace the Resource and Patient Management System.

For more information about HIT Modernization implementation, please click here.

IHS Releases New Quarterly Report Highlighting Progress on Urban Indian Health Priorities: 100% FMAP, Collaboration with Other Federal Agencies

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On May 21, 2024, the Indian Health Service’s (IHS) Office of Urban Indian Health Programs (OUIHP) released their 4th Quarterly Report outlining progress on the agency’s 2023 Work Plan to implement the goals from the 2023-2027 OUIHP Strategic Plan for urban Indian organizations (UIOs).

The quarterly report highlights the OUIHP accomplishments as of December 31, 2023, on the five pillars outlined in the Strategic Plan: provide effective, timely and transparent communication; improve OUIHP’s operational oversight and management; leverage partnerships to expand UIO resources; improve data quality; and expand the infrastructure and capacity of UIOs. The accomplishments include providing technical assistance to other federal agencies to engage UIO leaders in an IHS UIO Listening Session, collaborations with the Veterans Health Administration and the White House Council on Native American Affairs Health Committee, and providing technical assistance on 100% Federal Medical Assistance Percentage (100% FMAP) and the assignment of United States Public Health Service Commissioned Officers to UIOs.

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

Background

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

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

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

NCUIH’s Role

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

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

Illustration of Congress with empty speech bubbles

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)