President Biden Continues to Demonstrate Strong Commitment to Urban Indians, Proposes Over 50% Increase for Urban Indian Health for FY 2023

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The FY 2023 budget request includes $113 million for urban Indian health, a 53% increase over the FY 2022 enacted amount and mandatory appropriations for IHS.

On April 25, 2022, the Indian Health Service (IHS) published their Fiscal Year (FY) 2023 Congressional Justification with the full details of the President’s Budget, which includes $112.5 million for Urban Indian Health— a 53.2% increase above the FY 2022 enacted amount of $73.4 million. According to the IHS Congressional Justification, “This funding increase could support an estimated 1,072,935 health care, outreach, and referral services to Urban Indian users in FY 2023.” The President’s proposal included a total of $127.3 billion in discretionary funding for the Department of Health and Human Services (HHS) and, for the first time ever, $9.3 billion in mandatory funding for IHS for the first year, which includes $9.1 billion in proposed law funding and $147 million in current law funding for the Special Diabetes Program for Indians (SDPI). The budget proposes increased funding for IHS each year over ten years, building to $36.7 billion in FY 2032, to keep pace with population growth, inflation, and healthcare costs.

“The Indian Health System and urban Indian health have long been severely underfunded: only 1% of the Indian health budget goes to urban Indian health despite more than 70% of American Indians and Alaska Natives residing in urban areas. We are grateful for the President’s inclusion of $113 million for urban Indian health in FY 2023. President Biden has shown a strong commitment to urban Indian communities, and we recognize this Administration’s dedication to improving outcomes for all of Indian Country. As the final amount still falls well short of fully funding the Indian Health Service to properly provide health care services for all Natives in the United States to meet the trust responsibility, we will continue to push Congress to provide all the resources necessary to protect the lives of the entire Native population, regardless of where they live,”

– Francys Crevier (Algonquin), CEO, NCUIH

 

Line Item

FY21
Enacted

FY22 Enacted

FY23 TBFWG Request

FY23
President’s
Budget
Urban Indian Health  $62,684,000 $73,424,000  $949,900,000  $112,514,000
Indian Health Service $6,236,279,000 $6,630,986,000 $49,800,000,000 $9,100,000,000

 

The National Council of Urban Indian Health requested full funding for urban Indian health for FY 2023 at $949.9 million and at least $49.8 billion for IHS in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. The marked increase for FY23 is a 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. The Congressional Justification states, “IHS recognizes that we must continue to work in consultation with Tribes and confer with Urban Indian Organizations, and with our partners in Congress, to ensure the budget is structured and implemented correctly with the resources identified over the next 10 years.”

Background and Advocacy

On March 28, 2022, President Biden released his budget request for Fiscal Year FY 2023, pending the more detailed IHS budget request released April 25, which includes specifics on the IHS budget request, including the funding recommendations for urban Indian health.

On April 5, 2022, NCUIH President-Elect and CEO of the Indian Health Center of Santa Clara Valley, Sonya Tetnowski (Makah Tribe), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2023 funding for Urban Indian Organizations (UIOs). NCUIH requested $49.8 billion for the Indian Health Service and $949.9 million for Urban Indian Health for FY 2023 as requested by the TBFWG, Advance appropriations for IHS, and support of mandatory funding for IHS including UIOs.

NCUIH recently worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations in support of increasing the urban Indian health line item for FY 2023. The letter has bipartisan support and calls for the highest possible funding for Urban Indian Health up to the TBFWG’s recommendation of $949.9 million and advanced appropriations for IHS until such time that authorizers move IHS to mandatory spending.

Next Steps

The Appropriations Committees will review the President’s Budget for consideration as they craft their bills for FY 2023. NCUIH will continue to work with the Biden Administration and Congress to push for full funding of urban Indian health in FY 2023.

PRESS RELEASE: NCUIH Testifies at Two Congressional Hearings Regarding Critical Funding for Urban Indian Health

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Congressional leaders emphasized the need to increase resources for urban Indian health and provide opioid funding for urban Indian communities.

FOR IMMEDIATE RELEASE

NCUIH Contact: Meredith Raimondi, Vice President of Public Policy, mraimondi@ncuih.org, 202-417-7781

WASHINGTON, D.C. (April 5, 2022) – The National Council of Urban Indian Health (NCUIH) President-Elect and CEO of the Indian Health Center of Santa Clara Valley, Sonya Tetnowski (Makah Tribe), testified before the House Interior Appropriations Subcommittee as part of American Indian and Alaska Native (AI/AN) Public Witness Day hearing regarding Fiscal Year (FY) 2023 funding for Urban Indian Organizations (UIOs). Maureen Rosette (Chippewa Cree Nation), NCUIH board member and Chief Operating Officer of NATIVE Project, testified before the House Natural Resources Oversight & Investigations Subcommittee for a hearing entitled, “The Opioid Crisis in Tribal Communities.” In their testimonies, NCUIH leaders highlighted the critical health needs of urban Indians and the needs of the Indian health system.

NCUIH thanks the members of the subcommittees for the opportunity to testify on the needs of urban Indians and encourages Congress to continue to prioritize urban Indian health in FY 2023 and years to come.

House Appropriators Demonstrate Strong Commitment to Indian Health

NCUIH President-Elect Tetnowski testified before the House Appropriations Subcommittee along with Ms. Fawn Sharp for the National Congress of American Indians, Mr. Jason Dropik for the National Indian Education Association, and Mr. William Smith for the National Indian Health Board. The House Appropriations Committee uses testimony provided to inform the FY 2023 Appropriations decisions.

NCUIH requested the following:

  • $49.8 billion for the Indian Health Service (FY22 Enacted: $6.6 billion) and $949.9 million for Urban Indian Health (FY22 Enacted: $73.4 million) for FY 2023 as requested by the Tribal Budget Formulation Workgroup
  • Advance appropriations for the Indian Health Service (IHS)
  • Support of mandatory funding for IHS including UIOs

Full Funding for the Indian Health System a Priority for Congress

Many Members of Congress on both sides of the aisle noted the need to increase resources for Indian health in order to meet the trust responsibility. “The federal trust obligation to provide health care to Natives is not optional and must be provided no matter where they reside,” said Ms. Tetnowski in her testimony, “Funding for Indian health must be significantly increased if the federal government is, to finally, and faithfully, fulfill its trust responsibility.”

Ranking Member David Joyce (R-OH-14) agreed with Ms. Tetnowski, “There is still much to do to fulfill the trust responsibility.” Representative Mike Simpson (R-ID-02), also emphasized that more must be done so “there’s not disparity between Indian Health Services and other health services delivered by the federal government.”

President Sharp stated, “This subcommittee’s jurisdiction includes some of the most critical funding for Indian Country. As detailed in the 2018 Broken Promises Report, chronically underfunded and inefficiently structured federal programs have left some of the most basic obligations of the United States to tribal nations unmet for centuries. We call on this subcommittee in Congress to get behind the vision of tribal leaders for right these wrongs by providing the full and adequate funding for Indian country.”

The Case for Mandatory and Advance Appropriations for IHS

The Indian health system, including IHS, Tribal facilities and UIOs, is the only major federal provider of health care that is funded through annual appropriations. For example, the Veterans Health Administration at the Department of Veterans Affairs receives most of its funding through advance appropriations. 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. According to the Congressional Research Service, since FY 1997, IHS has once (in FY 2006) received full-year appropriations by the start of the fiscal year.

“During the most recent 35-day government shutdown at the start of FY 2019, the Indian health system was the only federal healthcare entity that shut down. UIOs are so chronically underfunded that several UIOs had to reduce services, lose staff, or close their doors entirely, forcing them to leave their patients without adequate care. Advance appropriations is imperative to provide certainty to the IHS system and ensure unrelated budget disagreements do not put lives at stake,” said Ms. Tetnowski.

Many Members of Congress were interested in hearing more about the differences between mandatory and advance appropriations. In her opening remarks, Chair Pingree pointed out that the mandatory funding proposal, if implemented, would remove the jurisdiction from the Appropriations Committee to the authorizing committees. Both NCAI President Sharp and NIHB Chair Smith also expressed support for the mandatory funding proposal from President Biden. Mr. Smith testified the President’s proposal is “a bold vision to end chronic underfunding and building a comprehensive Indian health care system. We urge Congress to support the request and work together with administrations and the tribes to see that as passed into law.”

Rep. Simpson sought to clarify whether both Advance Appropriations and Mandatory Appropriations remain priorities for Indian Country. President Sharp explained that “both [advance and mandatory funding] are critically important” in fulfillment of the trust responsibility while noting that basic health should be a mandatory expenditure of the United States government. President-Elect Tetnowski also stated that, “Advance appropriations would ensure that we weren’t shut down during any type of government closure. IHS is currently the only health care [provider] in the Federal government that does not have advanced appropriations.”

Resources

Congressional Leaders Express Support for Expanding Opioid Funding to Urban Indians

“Opioid overdose deaths during the pandemic increased more in Native American communities than in communities for any other racial or ethnic group,” said Representative Katie Porter (D-CA-45), “to address this crisis, we need to provide more resources for tribal governments and urban Indian health organizations to treat the opioid epidemic.” 

Urban Indians Left out of Opioid Grant Funding

Funding to assist AI/AN communities to address the opioid crisis have repeatedly left out urban Indians. UIOs were not eligible for the funding designated to help Native communities in the State Opioid Response (SOR) Grant reauthorization included in the recently passed FY 2022 Omnibus (H.R. 2471) despite inclusion of UIOs in the SOR bill (H.R. 2379) that passed the House on October 20, 2021. The final language in the omnibus (H.R. 2471) did not explicitly include “Urban Indian Organizations” as eligible and did not use the language from H.R. 2379. While this was likely a result of legislative text being copied from previous legislation, this prohibits urban Indian health providers from being able to access the critical funding needed to combat the opioid crisis.

“During the last government shutdown, one UIO suffered 12 opioid overdoses, 10 of which were fatal. This represents 10 relatives who are no longer part of our community,” Ms. Rosette emphasized, “These are mothers, fathers, uncles, and aunties no longer present in the lives of their families. These are tribal relatives unable to pass along the cultural traditions that make us, as Native people, who we are.”

Responding to a question from Rep. Stansbury (D-NM-01) on what the committee can do to help support UIO’s work on the ground to address the opioid crisis in Native communities, Ms. Rosette reiterated, “Funding is always an obstacle for us. Grants, like the state opioid response grant, would allow us to provide culturally appropriate treatment to our community, but we were not included. You have to specifically say “urban” along with “tribal” otherwise we are not allowed to get the funding.”

Opioid Epidemic in AI/AN Communities

Since 1974, AI/AN adolescents have consistently had the highest substance abuse rates than any other racial or ethnic group in the U.S. Urban AI/AN populations are also at a much higher risk for behavioral health issues than the general population. For instance, 15.1% of urban AI/AN persons report frequent mental distress compared to 9.9% of the general public.

Additionally, the opioid crisis and COVID-19 pandemic are intersecting with each other and presenting unprecedented challenges for AI/AN families and communities. On October 7, 2021, the American Academy of Pediatrics published a study on caregiver deaths by race and ethnicity. According to the study, 1 of every 168 AI/AN children experienced orphanhood or death of caregivers due to the pandemic and AI/AN children were 4.5 times more likely than white children to lose a parent or grandparent caregiver. Unfortunately, this has exacerbated mental health and substance use issues among our youth. In the age group of 15-24, AI/AN youth have a suicide rate that is 172% higher than the general population in that age group.

Resources

Next Steps

NCUIH will continue to advocate for full funding of Indian Health Service and urban Indian health at the amounts requested by Tribal leaders as well as for additional resources for the opioid response for Native communities.

Biden FY23 Budget Request Includes $9.1 Billion in Mandatory Funding for IHS

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On March 28, 2022, President Biden released his Fiscal Year (FY) 2023 Budget. The budget includes $9.1 billion in mandatory funding for the Indian Health Service (IHS) for the first year, an increase of $2.9 billion above FY 2021, and $40.7 billion less than requested by the Tribal Budget Formulation Workgroup (TBFWG). The budget proposes increased funding for IHS each year over ten years, building to $36.7 billion in FY 2032, to keep pace with population growth, inflation, and healthcare costs. Funding for Contract Support Costs and 105(l) leases also shifted from discretionary to mandatory funding in the FY 2023 budget. The President’s budget does not include advance appropriations for IHS, which was requested in the FY 2022 budget. Note: The urban Indian health amount has not yet been released and detailed agency requests are expected to be available in the coming days.

Mandatory Funding for IHS

The Budget Brief stated, “The Administration is committed to implementing long-term solutions to address chronic under-funding of IHS and finally delivering on the nation’s promises to Indian Country.” Further, it states, “Implementing this change to the IHS budget will make meaningful progress toward redressing health inequities and ensuring that the disproportionate impacts of the COVID-19 pandemic on AI/AN communities are never repeated.” About the budget for IHS, President Biden stated it, “makes high-impact investments that will expand access to healthcare services, modernize aging facilities and information technology infrastructure, and address urgent health issues, including HIV and Hepatitis C, maternal mortality, and opioid use. It also includes funding to improve healthcare quality, enhance operational capacity, fully fund operational costs for Tribal health programs to support tribal self-determination, and recruit and retain healthcare providers.”

Advancing health equity by providing high quality care in Indian country is a priority for Biden. The budget book states, “Historical trauma and chronic underinvestment significantly contributed to the perpetuation of health disparities in Indian Country. These stark inequities illustrate the urgent need for investments to improve the health status and quality of life of AI/ANs. In FY 2023, the budget includes $6.3 billion in the Services account, an increase of $1.6 billion above FY 2022 enacted. These increases will expand access to programs that provide essential health services and community-based disease prevention and promotion in tribal communities. This funding will support additional direct patient care services across the IHS system, including inpatient, outpatient, ambulatory care, dental care, and medical support services, such as laboratory, pharmacy, nutrition, behavioral health services, and physical therapy.”

Chart from the Budget Book with Projected Funding for IHS

From President Biden’s Strengthening America’s Public Health Infrastructure section in the Budget, it states the following, “Guarantees Adequate and Stable Funding for the Indian Health Service (IHS). The Budget significantly increases IHS’s funding over time, and shifts it from discretionary to mandatory funding. For the first year of the proposal, the Budget includes $9.1 billion in mandatory funding, an increase of $2.9 billion above 2021. After that, IHS funding would automatically grow to keep pace with healthcare costs and population growth and gradually close longstanding service and facility shortfalls. Providing IHS stable and predictable funding would improve access to high quality healthcare, rectify historical underfunding of the Indian Health system, eliminate existing facilities backlogs, address health inequities, and modernize IHS’ electronic health record system. This proposal has been informed by consultations with tribal nations on the issue of IHS funding and will be refined based on ongoing consultation.”

Tribal Consultation Included as a Priority

According to the Budget, Tribal Consultation and Reconvening the White House Council on Native American Affairs was also included as priority. In his first days in office, the President issued a memorandum making it a priority of his Administration to make respect for Tribal sovereignty and self-governance, commitment to fulfilling Federal trust and treaty responsibilities to Tribal Nations, and regular, meaningful, and robust consultation with Tribal Nations cornerstones of Federal Indian policy. Since then, the Administration has been regularly meeting with Tribal Nations on a range of Administration priorities, from implementing the Bipartisan Infrastructure Law to drafting the President’s Budget.

Background and Next Steps

The Appropriations Committees will review the President’s Budget for consideration as they craft their bills for FY23. NCUIH has requested $949.9 million for FY23 for urban Indian health with at least $49.8 billion for the Indian Health Service in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. NCUIH will continue to work with the Biden Administration and Congress to push for full funding of urban Indian health in FY 2023.

Overview of Budget Request

The budget request includes the following for American Indians/Alaska Natives:

Department of Health and Human Services (HHS)

  • The Budget requests $127.3 billion in discretionary funding for HHS, a $26.9 billion or 26.8 percent increase from the 2021 enacted level.

Indian Health Service

  • $9.1 billion in mandatory funding for the Indian Health Service (IHS) for the first year, an increase of $2.9 billion above FY 2021 and $40.7 billion less than requested by the TBFWG.
  • Ending HIV and Hepatitis C in Indian Country ($52 million): Provides $47 million above FY 2022 enacted to enhance access to HIV testing, promote linkages to care, provide treatment, and reduce the spread of HIV 37 Indian Health Service Indian Health Service through the prescribing of pre-exposure prophylaxis (PrEP). Funds will also support enhanced surveillance and data infrastructure to better track HIV, Hepatitis C, and sexually transmitted diseases through Tribal Epidemiology Centers.
  • Addressing Opioid Use ($20 million): Provides $9 million above FY 2022 enacted to enhance existing activities to provide prevention, treatment, and recovery services to address the impact of opioid use in AI/AN communities. This includes activities to increase knowledge and use of culturally appropriate interventions and encourage the use of medication-assisted treatment.

Maternal Health and Health Equity

  • The United States has the highest maternal mortality rate among developed nations, and rates are disproportionately high for Black and American Indian and Alaska Native women. The Budget includes $470 million to: reduce maternal mortality and morbidity rates; expand maternal health initiatives in rural communities; implement implicit bias training for healthcare providers; create pregnancy medical home demonstration projects; and address the highest rates of perinatal health disparities, including by supporting the perinatal health workforce. The Budget also extends and increases funding for the Maternal, Infant, and Early Childhood Home Visiting program, which serves approximately 71,000 families at risk for poor maternal and child health outcomes each year, and is proven to reduce disparities in infant mortality. To address the lack of data on health disparities and further improve access to care, the Budget strengthens collection and evaluation of health equity data. Recognizing that maternal mental health conditions are the most common complications of pregnancy and childbirth, the Budget continues to support the maternal mental health hotline and the screening and treatment for maternal mental depression and related behavioral disorders.
  • Improving Maternal Health ($10 million): Provides $4 million above FY 2022 enacted to improve maternal health in AI/AN communities. Funding supports preventive, perinatal, and postpartum care; addresses the needs of pregnant women with opioid or substance use disorder; and advances the quality of services provided to improve health outcomes and reduce maternal morbidity.

Department of the Interior (DOI)

  • The Budget requests $17.5 billion in discretionary funding for DOI, a $2.8 billion or 19.3 percent

increase from the 2021 enacted level.

    • $4.5 billion for the DOIs Tribal programs, a $1.1 billion increase above the 2021 enacted level.
    • $632 million in Tribal Public Safety and Justice funding at DOI, which collaborates closely with the Department of Justice, including on continued efforts to address the crisis of Missing and Murdered Indigenous Persons.

Bureau of Indian Affairs (BIA)

  • The Budget proposes to reclassify Contract Support Costs and Indian Self-Determination and Education Assistance Act of 1975 Section 105(l) leases as mandatory spending.
  • Contract Support Costs: Contract Support Costs are the necessary and reasonable costs associated with administering the contracts and compacts through which tribes assume direct responsibility for IHS programs and services. These are costs for activities the tribe must carry out to ensure compliance with the contract but are normally not carried out by IHS in its direct operation of the program. The budget proposes to fully fund Contract Support Costs at an estimated $1.1 billion through an indefinite mandatory appropriation to support these costs in FY 2023. The indefinite mandatory appropriation grows with inflation and is maintained across the 10-year budget window to ensure Contract Support Costs continue to be fully funded each year.
  • Tribal Leases: The Indian Self-Determination and Education Assistance Act requires compensation for reasonable operating costs associated with facilities leased or owned by tribes and tribal organizations to carry out health programs under the Act. In FY 2023, the budget proposes to fully fund section 105(l) leases, or tribal leases, at an estimated $150 million through an indefinite mandatory appropriation. The indefinite mandatory appropriation grows with inflation and is maintained across the 10-year budget window to ensure section 105(l) leases continue to be fully funded each year.

Bureau of Indian Education (BIE)

  • $156 million increase to support construction work at seven Bureau of Indian Education schools, providing quality facilities for culturally appropriate education with high academic standards.
  • $7 million for the Federal Boarding School Initiative.

NCUIH Joins NIHB and 70 Organizations Calling on Congress to include $8 Billion for IHS in FY 2022 and Advance Appropriations

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On March 9, 2022, the National Council of Urban Indian Health (NCUIH) joined the National Indian Health Board (NIHB), and over 70 Tribal nations, Tribal and national Indian organizations, and friends of Indian health in sending a series of joint letters to Congress amid their final negotiations of an omnibus appropriations bill for Fiscal Year (FY) 2022. The recommendations for reauthorization outlined in the letter include:

  • No less than the House-passed level of $8.114 billion for the Indian Health Service (IHS) in the final Appropriations bill for FY 2022
  • Advance Appropriations for the Indian Health Service (IHS)

The House-passed funding level would be an increase of $1.88 billion over the FY 2021 enacted level. The Senate Appropriations Committee FY 2022 funding bill included $6.6 billion in Advance Appropriations for IHS FY 2023.

Letters to Congress:

 

Background and Advocacy

NCUIH has long advocated for larger investments in AI/AN health care and has called on Congress to strengthen their commitment to Indian Country with increased funding in the FY 2022 appropriations:

NCUIH Submits Written Testimony to House Interior Appropriations with FY23 Budget Requests for Urban Indian Health

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The National Council of Urban Indian Health (NCUIH) submitted written testimony for Tribal Public Witnesses to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding Fiscal Year (FY) 2023 funding for Urban Indian Organizations (UIOs). On January 28, 2022, the Subcommittee Chair and Ranking Member requested information from “Indian Country on issues and needs” that is used to develop the annual appropriations bill.

NCUIH advocated in its testimony for additional resources for the Indian Health Service and urban Indian Health.

In the testimony, NCUIH requested the following:

  • $48 billion for the Indian Health Service and $950 million for Urban Indian Health for FY23 (as requested by the Tribal Budget Formulation Workgroup)
  • Advance appropriations for IHS
  • UIOs be insulated from unrelated budgetary disputes through a spend faster anomaly so that critical funding is not halted

NCUIH reiterated, “The federal government owes a trust responsibility to tribes and AI/ANs that is not restricted to the borders of reservations. Funding for Indian health must be significantly increased if the federal government is, to finally, and faithfully, fulfill its trust responsibility.”

NEXT STEPS:

The testimony will be read and considered by the subcommittee as the appropriations process goes forward for FY23. The Subcommittee has not yet announced dates for the hearings on the FY 23 budget.

Omnibus Bill Released with VAWA and Strides for Urban Indian Health

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The bill includes $73.4 million for urban Indian health and $6.6 billion for IHS

On March 9, 2022, the House Appropriations Committee released a draft of the Consolidated Appropriations Act, 2022 (H.R. 2471) for Fiscal Year (FY) 2022 (also known as the “Omnibus”) consisting of $1.5 trillion in discretionary spending and $15.6 billion to manage the COVID-19 pandemic. This bill comes after Congress passed three Continuing Resolutions maintaining the FY 2021 budget, with the most recent CR set to expire on March 11, 2022. The 2741-page omnibus bill authorizes $6.6 billion for the Indian Health Service (IHS) for FY 2022, a 6.3% increase above the FY 2021 enacted level; $73.4 million for urban Indian health for FY 2022, a 17.13% increase above the FY 2021 enacted level and the highest increase in the past 10 years; 2022 Violence Against Women Act (VAWA) Reauthorization with Tribal and urban Indian provisions; and COVID-19 supplementals to manage the pandemic domestically and abroad.

The Tribal Budget Formulation Workgroup (TBFWG) requested $12.8 billion for the Indian Health Service and the House included $8.1 billion in its passed legislation, however, the amount enacted would be the highest increase of any account for the Department of Interior and Related Agencies, which demonstrates a strong bipartisan commitment from Congress to improving health outcomes for American Indians and Alaska Natives. Unfortunately, though, the final amount still falls well short of fully funding the Indian Health Service to properly provide health care services for all American Indians and Alaska Natives in the United States to meet the trust responsibility. Additionally, the bill does not include Advance Appropriations despite robust advocacy from Tribes and Urban Indian Organizations.

Current Status and Next Steps

Funding for the federal government expires on March 11. Congress will likely approve the current continuing resolution through March 15. It is expected that the Omnibus will be approved by Congress and signed into law by the President. As of 2:45 p.m. ET today, the COVID-19 supplemental funding has been removed and Speaker Pelosi says the House will move forward to vote on the Omnibus without the COVID funding. The National Council of Urban Indian Health (NCUIH) will continue to monitor developments and provide more in-depth analysis as legislation continues to move forward.

Overview of IHS and Urban Indian Health Requests

Line Item FY21 Enacted FY22 TBFWG Request FY22
President’s
Budget		 FY22 House
 Passed		 FY22 Senate
Proposed		 FY22 Draft Omnibus
 Urban Indian
Health		  $62,684,000  $200,548,000  $100,000,000  $200,500,000  $92,684,000 $73,424,000
Indian Health Service $6,236,279,000 $12,759,004,000 $8,471,279,000 $8,100,000,000 $7,616,250,000 $6,630,986,000
Advance Appropriations – – – – $6,586,250,000 (FY23) –
Missing and Murdered Indigenous Women – – – – $24,900,000 –

Summary

In summary, the package includes the following NCUIH priorities for Urban Indian health:

  • $73.4 million for urban Indian health for FY 2022
  • Inclusion of UIOs in the 2022 VAWA reauthorization
  • $30 million annually from FY23-FY27 for grants for Creating Hope Through Outreach, Options, Services, and Education for Children and Youth (CHOOSE Children & Youth) grants to enhance the safety of youth and children who are victims of, or exposed to, domestic violence, dating violence, sexual assault, stalking, or sex trafficking and prevent future violence.
    • UIOs added as eligible entities.
  • $10 million annually for a new 3-year program (FY23-FY27) to award grants for the clinical training of sexual assault forensic examiners to administer medical forensic examinations and treatments to survivors of sexual assault. Of the $10 million, there is a set aside of 15 percent for purposes of making grants to entities that are affiliated with Indian Tribes or Tribal organizations or Urban Indian organizations.
    • UIOs included as eligible entities.
  • $5 million for a new 5-year demonstration grants (FY23-FY27) established for comprehensive clinical training of health care providers to provide generalist forensic services and trauma-informed care to survivors of interpersonal violence of all ages. Of the $5 million, there is a set-aside of 10 percent for purposes of making grants to support training and curricula that addresses the unique needs of Indian Tribes, Tribal organizations, Urban Indian organizations, and Native Hawaiian organizations.
    • UIOs included as eligible entities.
  • Title VIII “Safety for Indian Women” includes the following purposes:
    • to empower Tribal governments and Native American communities, including urban Indian communities and Native Hawaiian communities, with the resources and information necessary to effectively respond to cases of domestic violence, dating violence, stalking, sex trafficking, sexual violence, and missing and murdered Native Americans; and
    • to increase the collection of data related to missing and murdered Native Americans and the sharing of information among Federal, State, Tribal, and local officials responsible for responding to and investigating crimes impacting Indian Tribes and Native American communities, including urban Indian communities and Native Hawaiian communities, especially crimes relating to cases of missing and murdered Native Americans.

In summary, the bill provides the following for IHS, tribal organizations, and Urban Indian Organizations (UIOs):

  • $6.6 billion for the Indian Health Service for fiscal year 2022
  • $4.7 billion for the IHS health services account
  • Fully funds Contract Support Costs and Payments for Tribal Leases
  • $940 million for health facilities construction
  • $12 million from Substance Abuse and Mental Health Services Administration (SAMHSA) to Indian Tribes, Tribal Organizations, or consortia for Medication-Assisted Treatment for Prescription Drug and Opioid Addiction
  • Increase to SAMHSA State Opioid Response (SOR) Grants for tribes and tribal organizations
    • UIO are not included
  • $22.5 million for the Good Health and Wellness in Indian Country program
  • $15.6 million to make payments under the National Health Service Corps loan repayment program

Background and Advocacy

The National Council of Urban Indian Health (NCUIH) has long advocated for larger investments in AI/AN health care and has called on Congress to strengthen their commitment to Indian Country with increased funding in the FY 2022 appropriations:

Most recently, NCUIH joined the National Indian Health Board (NIHB) and 70 organizations in a letter to several Members of Congress and Congressional Committees urging for Advance Appropriations and no less than the House-passed level of $8.114 billion for IHS in the final Appropriations bill for FY 2022:

VAWA

NCUIH has been tirelessly advocating for an expansion of resources for all AI/ANs, including those who reside off-reservation, in the VAWA reauthorization. Since the passing of the House bill on VAWA (H.R. 1620) early last year which excluded support for off-reservation AI/ANs, NCUIH successfully advocated for urban Indian communities to be added in the Senate draft bill released on December 8, 2021. NCUIH, UIOs, and stakeholders supporting Indian health provided written comments to Senate Committee on Indian Affairs (SCIA) leadership to retain the provisions to assist all AI/ANs in the final VAWA reauthorization bill.

Tribal Leaders Highlight Need for Increased Urban Indian Health Funding in Fiscal Year 2024 Area Reports

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On January 26-27, 2022, the Indian Health Service (IHS) held their Area Report Presentations Webinar for Fiscal Year (FY) 2024 where Tribal leaders from 12 IHS Areas and leaders from three Native organizations, including the National Council of Urban Indian Health (NCUIH), presented on their budget requests. Many Tribal leaders spoke about the need to increase urban Indian health funding and establish designated funding for urban Indian health facilities and infrastructure.  Many Areas also highlighted mental health and substance abuse needs, Health IT modernization, and permanent authorization of the Special Diabetes Program for Indians (SDPI). As part of the trust responsibility to provide health care to all American Indians and Alaska Natives, Tribal Leaders present their funding needs each year to the Secretary of HHS and the Director of the Office of Management and Budget. The recommendations are formed through the Tribal Budget Formulation Work Group and serve as a framework for the Administration in setting budget amounts for their annual requests to Congress. This process ensures the federal government has the resources to provide health care to all American Indians and Alaska Natives in fulfillment of the trust responsibility.

 

Tribal Leaders Highlight the Need for Increased Urban Indian Health Funding

Urban Indian health was a priority in the Area report presentations. IHS Oklahoma Area Representative and President of the Wichita and Affiliated Tribes, Terri Parton, advocated for $509.963 million in funding for urban Indian health, citing that “Although 78% of AI/ANs reside in urban areas, the IHS funding allocation for urban Indian health only reflects close to 1% of the total annual IHS budget,” and “There are inadequate levels of funding to address the rising urban Indian population.”

 

Several Areas featured the work of UIOs in their presentations and advocated for increased allocation of funding and resources for urban Indian health.

  • IHS Phoenix Area recommended a $18.86 billion funding increase for Health Care Facilities Construction with $2 billion for urban Indian health facility renovation. The Phoenix Area Representative also highlighted that the urban Indian health program increase of $92.6 million identified in the FY 2023 budget recommendations remains a top concern in FY 2024, and recommended increased funding for Tribal and Urban Community Health Representative services.
  • IHS Bemidji Area stressed that UIOs are underfunded and rely heavily on grants which can be unstable and recommended $477 million for urban Indian health in FY 2024.
  • IHS Portland Area recommended approximately $1.8 billion in funding for the FY 2024 urban Indian health line item.
  • IHS Tucson Area listed urban Indian facilities renovations in their top health priorities and Wavalene Saunders, Vice Chairwoman of the Tohono O’odham Nation, highlighted Tucson Indian Center’s collaboration with the Pascua Yaqui Tribe and Tohono O’odham Nation to address COVID-19 vaccine and testing efforts.
  • The IHS Billings Area Representatives highlighted two Billings UIO success stories. Lane Spotted Elk, Councilman of Northern Cheyenne Tribal Council, highlighted the Billings Urban Indian Health and Wellness Center’s student mental health and suicide prevention efforts though collaboration with schools. The Indian Family Health Clinic’s food pantry efforts was also highlighted for receiving 5000 pounds of donated food and providing food boxes to patients, primarily seniors, during the pandemic.

 

NCUIH supports the average of the 12 IHS Areas recommendation of $1 billion for urban Indian health funding for FY 2024.

 

Meredith Raimondi, NCUIH’s Interim Vice President of Public Policy, presented the following urban Indian organization (UIO) funding priorities for FY 2024 during the Area Report Webinar:

  1. Urban Indian health funding amount of approximately $1 billion, which reflects the average of the Area budget formulation recommendations.
  2. Availability of funds for UIOs to spend on facilities and infrastructure needs (these funds would be exclusive to UIOs and would not impact the IHS facilities accounts).
  3. Behavioral health funding for UIOs.
  4. SDPI reauthorization and increase to at least $200 million.
  5. Community Health Representatives fund of $3 million for UIOs.

In addition to budget priorities, Raimondi highlighted several “hot topics” for urban Indian health:

  1. Safeguard IHS funding through advance appropriations and exception apportionment across the entire IHS/ Tribal/UIO system.
  2. Permanent increase in Medicaid dollars for Indian health through the permanent extension of 100% Federal Medical Assistance Percentage (FMAP) to UIOs and increased reimbursement rates.
    1. The American Rescue Plan Act authorized a temporary two-year extension of 100% FMAP to UIOs beginning April 1, 2021, however, UIOs have not received a single dollar of increased funding.
  3. Urban confer: establish a mechanism for dialogue and input between the Department of Health and Human Services agencies overseeing UIO programs and UIOs.

 

Next Steps

IHS will hold their FY 2024 National Tribal Budget Formulation Work Group on February 10-11, 2022. NCUIH will continue to advocate for $1 billion in funding for urban Indian health and increased resources for UIOs.

Policy Blast: Tribal Nations Summit Highlights Funding Needs for Indian Health including Urban Indian Health

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Administration leaders discussed new initiatives to address the needs of Indian Country, a memorandum of understanding to support Native languages, advance appropriations for IHS, and additional funding for urban Indian health

 

Last week, the White House convened for the 2021 Tribal Nations Summit for the first time since the Obama Administration. During the summit, remarks encompassed an array of topics all linking back to the health, wellness, and progression of Indian Country. This year’s summit brought together officials and leaders from the Federal government and federally recognized Tribes, to discuss ways to invest and continue to strengthen the Nation-to-Nation relationship.

 

  • During the live broadcast President Biden announced five new initiatives:
  1. Development of 17 departments and agencies to protect Tribal treaty rights in the work of the Federal government;
  2. Increase Tribal participation in management and stewardship of Federal lands;
  3. Institute the Biden Administration as the first to work to achieve comprehensive Tribal ecological knowledge into the Federal governments scientific approach in the fight of climate change;
  4. Take action to protect the greater Chaco landscape in northwestern New Mexico further protecting the area from new oil and gas leasing;
  5. Lastly, signed executive order “Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People”. This order has a heavy emphasis on policy and directs the departments of Justice, Interior, Homeland Security, and Health and Human Services to create and implement strategies that improve safety; additionally, addressing the ongoing crisis of missing or murdered Indigenous people. Strategies identified in the order call for support on enforcement strategies with prevention and response to violence; improved data collection, analysis, and information sharing; early intervention and victim survivor services; and increased consultation and engagement with Indigenous communities.

During the summit, acknowledgement was paid to the profound impact of COVID-19 to Indian country and the devastating consequences. Highlighting the lack of infrastructure, gaps in efficient health insurance access, high rates of unemployment, lack of foundational preschool education for children, and several other critical measures. Janet Yellen, U.S. Secretary of the Treasury, addressed that the goal is not to return Indian country to its pre-covid economic situation, that was already not efficient, but to truly “build back better.” Several mentions were made to the direct promotion of Urban Indian Organization (UIO) capacity and the health status of their patients. Secretary Xavier Becerra, U.S. Department of Health and Human Services, noted that “as of this week, IHS has administered over 1.78 million doses of the COVID-19 vaccine in Indian Country, through Tribal and urban Indian programs”. American Indians and Alaska Natives have an over three times higher infection rate than non-Hispanic whites, are four times more likely to be hospitalized, and have higher rates of mortality at younger ages, yet modeled with resilience in testing and prevention planning, Indian Country now leads the nation for having the highest vaccination rate!

 

First Lady Jill Biden announced a new memorandum of agreement on Native language, bringing governments together to promote and support the instruction and preservation of Native American languages. This investment will bring millions of dollars to enable the revitalization of many languages that are in danger of being forgotten due to the loss of elders during this pandemic. Such loss urges the need for protection of language and tradition more than ever.

Susan Rice, Director of the Domestic Policy Council, covered President Biden’s request for $29 billion for Indian Programs in the next year budget, indicating a 14% increase over last year’s request. Including for the first time, advance appropriations for Indian Health Service (IHS).

As the summit came to a close, IHS announced $9.34 million in funding, enhancing opportunities to support Tribal self-governance and urban Indian health. The Urban Indian Health Programs 4-in-1 Grant Program is for $8.5 million and aims to enhance capacity when developing programs that achieve the highest possible health status for urban Indians. Funding will be used to support four health program objectives:

  • Health promotion and disease prevention services
  • Immunization services
  • Alcohol and substance abuse related services
  • Behavioral health services

There are a total of 33 awards expected to be afforded, lasting the span of 5-years. Applications are due by February 8, 2022. Individual award amounts for the first year will be between $160,000 and $650,000. New applicants can apply for funding up to $200,000. This funding is only open to UIOs that are currently administering a contract or receiving a grant.

 

 

Background

The progress report, published in partnership with the Tribal Nations Summit, was released in advance of last week’s Summit and included the need to meet the obligations to urban Indians. In the report, it addressed that over 70 percent of AI/ANs live off reservation in an urban area. The report reinforces the Biden Administration’s commitment to elevating the voice of urban Indians, including UIOs, in Tribal listening sessions with topics pertinent to health, education, funding, housing, voting, and more, as well as addresses Urban Indian Health Organizations inclusion in 100 percent Federal Medical Assistance Percentages (FMAP).

OMB Urges Passage of Appropriations Bills as a Priority for Indian Health

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On November 12, 2021, The Office of Management and Budget (OMB) released a fact sheet urging Congress to pass their appropriations bills for 2022. The fact sheet includes 17 top priorities around pandemic response and other public health initiatives, national security and American leadership, education, and core citizen services. Of the 17, inclusion of Indian Health Service (IHS) funding and addressing American Indians and Alaska Natives health disparities was in the top 3 priorities:

 

  • Address health disparities among American Indians and Alaska Natives. The President’s Budget and the House and Senate appropriations bills provide funding for thousands more inpatient admissions and millions more outpatient visits at Indian Health Service (IHS) facilities, compared to continuing 2021 funding levels, and would allow IHS to fill hundreds of open medical and other staff positions.

 

Appropriation Bills Status

 

The House fiscal year (FY) 2022 Interior, Environment, and Related Agencies bill (H.R. 4372), which includes $200.5 million for urban Indian health and $8.1 billion for IHS, was part of a seven-bill package the House passed on July 29.

 

The Senate Appropriations Committee released its FY 2022 Interior, Environment, and Related Agencies bill, which includes $92.7 million for urban Indian health, $7.61 billion for IHS, an additional $6.58 billion in advance appropriations to IHS for FY23, and a facilities fix to allow urban Indian organizations to use existing IHS funding for facilities improvement and renovations. However, the Senate has yet to pass their appropriations bill.

NCUIH Endorses Bills Providing Advance Appropriations for IHS

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On October 12, 2021, Representatives Betty McCollum (D-MN-04) and Don Young (R-AK-1) introduced a pair of bipartisan bills that would amend the Indian Health Care Improvement Act (IHCIA) to provide advance appropriations to the Indian Health Service (IHS).

 

The Indian Programs Advance Appropriations Act of 2021 (H.R. 5567), introduced by Rep. McCollum, authorizes advance appropriations authority for certain accounts of the Bureau of Indian Affairs, Bureau of Indian Education, and IHS. The Indian Health Service Advance Appropriations Act (H.R. 5549), introduced by Rep. Young, authorizes advance appropriations authority for IHS.

 

NCUIH has long advocated for advance appropriations for IHS to insulate Indian health care providers from shutdowns and allow for long-term planning. A companion Senate bill, Indian Programs Advance Appropriations Act of 2021 (S. 2985), was introduced by Senators Ben Ray Luján (D-NM) and Martin Heinrich (D-NM) on October 7.

 

NCUIH welcomes the Members of Congress’ legislation to provide budget stability for IHS and strengthen the federal government’s commitment to uphold its trust and treaty responsibilities to American Indians and Alaska Natives.