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

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

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

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

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

Resolution 101 – Infertility Coverage

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

Resolution 206 – Indian Health Service Youth Regional Treatment Centers

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

Resolution 208 – Improving Supplemental Nutrition Programs

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

Resolution 209 – Native American Voting Rights

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

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

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

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

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

Resolution 305 – Public Service Loan Forgiveness Reform

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

Resolution 407 – Racial Misclassification

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

Resolution 408 – Indian Water Rights

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

Resolution 411 – Missing and Murdered Indigenous Persons

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

Resolution 420 – Equity in Dialysis Care

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

Resolution 502 – Tribally-Directed Precision Medicine Research

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

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

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

About the AMA House of Delegates (HOD)

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

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

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

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

Congress Underscores Importance of UIO Funding to Provide Health Care

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

Senator Merkley Emphasizes the Need to Safeguard IHS Funding from Sequestration

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

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

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

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

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1. What was the case about?

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

2. What did the Court decide?

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

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

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

4. What does this mean for CSCs?

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

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

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

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

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

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

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

8. How is IHS implementing the decision?

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

9. Will UIOs be affected?

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

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

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

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

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

Next Steps 

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

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

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

In the testimonies, NCUIH requested the following:

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

Next Steps:

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

Full Text:

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

We respectfully request the following:

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

NCUIH Supports Tribal Sovereignty

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Request: Protect Funding for HIV/AIDS Prevention and Treatment

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

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

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

Conclusion

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

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

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

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

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

[5] 25 U.S.C. § 1601(1)

[6] 25 USC § 1602.

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

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

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

[9] P.L. 118–31

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

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

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

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

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

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

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

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

Letter Highlights:

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

Full Text:

Dear Chairman Simpson and Ranking Member Pingree:

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

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

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

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

Health Professions Workforce needs

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

Making IHS loan repayment and scholarships tax free

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

Staff quarters                                                                                                  

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

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

Medical and diagnostic equipment

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

Electronic Health Records

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

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

Sincerely yours,

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

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

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

Background

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

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

NCUIH’s Recommendations

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

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

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

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

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

Read the Court’s Opinion here.

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

Summary of the Court’s Holding 

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

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

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

Impact on Urban Indian Organizations 

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

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

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

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

The $1 billion is allocated to:

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

Resources

Background on Substance Use in Urban Native Communities

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

Next Steps

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

DOJ and DOI Responses to the Not Invisible Act Commission’s Recommendations Includes MMIP Resources for Urban Indian Communities

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On March 5, 2024, the Department of Justice (DOJ) and the Department of Interior (DOI) (“the agencies”) released their response to the Not Invisible Act Commission’s (“Commission”) findings and recommendations on how to combat the missing or murdered Indigenous people (MMIP) and human trafficking (HT) crisis. The Commission’s findings and recommendations and the responses by the DOJ and DOI mention urban Indian organizations (UIOs) and urban American Indian and Alaska Native people and communities. Importantly, the agencies state that UIOs are eligible for funding under Office on Violence Against Women (OVW) programs.

Key Responses by the Agencies

UIOs are referenced in sections pertaining to law enforcement and investigative resources, coordinating resources, victim and family resources and services, and Alaska-specific issues. The following are key responses by the agencies to the Commission’s findings and recommendations.

Law Enforcement and Investigative Resources

In response to the Commission’s recommendation of the DOJ Office of Victims of Crime (OVC) and the Department of Health and Human Services (HHS) Office on Trafficking Persons (OTIP), the agencies stated that the Office of Justice Programs (OJP)/OVC’s Project Beacon: Increasing Access to Services for Urban American Indian and Alaska Native Victims of Human Trafficking, “currently funds five urban Indian centers that are working to increase their capacity to provide comprehensive services to Native victims through strategic collaborative partnerships with both Tribal and non-Tribal organizations and agencies.” The agencies also said that the DOJ “will work with other agencies as appropriate to further explore the recommendation regarding tracking and aggregating racially biased policing in and around Indian Country, of Indians in urban areas, and in Alaska”, which was a specific recommendation of the Commission.

Coordinating Resources

The Commission recommended that either the OVW or the OVC provide technical assistance to small-staff advocacy organizations by employing “user-friendly, virtual tutorials” to “enhance the [grant funding] application experience and…accommodate the diverse circumstances in Tribal and urban Indian communities (including communities lacking access to broadband.”

As part of their response, the agencies stated “DOJ’s OVW offers live and recorded pre-application webinars to go over application requirements in detail and answer questions about the application process.”

Victim and Family Resources and Services

The Commission found that “[t]here has been a historical lack of services for [American Indian and Alaska Native] victims and families of MMIP and HT that are Native-led, culturally specific, and trauma-informed” and that “[u]rban areas bear the burden of providing culturally-relevant resources to an extremely diverse population: 70 % of [American Indian and Alaska Native] people live in urban areas. Further, the system actors with whom urban Indian organizations interact are less likely to have any training or competence in providing culturally relevant services” which “exacerbates the trauma experienced within [American Indian and Alaska Native] communities.” The Commission recommended that “[s]ervices…be provided through an integrated care model utilizing a public health and safety approach, and include Native-led, culturally specific practices and care. Baseline funding to implement, strengthen, and seek TTA to provide continuum of care models for survivors and families of MMIP and HT, such as, First Nations Mental Wellness Continuum Framework, must be provided to [American Indian and Alaska Native] Tribal nations, Indigenous-led Community Based Organizations (CBO) and urban Indigenous organizations.”

The agencies responded by saying that the Bureau of Indian Affair’s (BIA) Tiwahe Program framework “is an Indigenous approach to thinking about well-being within a system, with the well-being of individuals, communities, Tribes, and the natural environment working in an interlinked and interdependent ways.” UIOs are one type of entity that can use this framework. Additionally, the OVC’s Tribal Victim Services Set-Aside Formula Grant Program (TVSSA) and other OJP/OVC funding opportunities provide “funding to support comprehensive, culturally appropriate, trauma-informed, victim-sensitive services” to both urban and Tribal community located American Indian and Alaska Native crime victims. Lastly, UIOs themselves are eligible for funding through OVW grant programs, including those supporting culturally specific services for survivors of domestic violence, dating violence, sexual assault, and stalking.

Alaska-Specific Issues

The Commission recommended that “[t]he MMIP Regional Outreach Program through the [Executive Office of the United States (U.S.) Attorneys (EOUSA)] must be expanded to include more than one coordinator and [Assistant U.S. Attorney (AUSA)] to serve Alaska.”

As part of their response, the agencies stated “[a]s program regions are fully staffed, the regional AUSAs and coordinators will begin regional outreach to federal, Tribal, state, and local law enforcement; victim- and MMIP-related governmental and nongovernmental organizations; and urban Indian organizations to provide information about the program’s resources, roles, and services provided and develop a regional resource list.”

Background on the Commission

The National Council of Urban Indian Health (NCUIH) along with other national Native organizations worked in support of the Not Invisible Act legislation, which was enacted in October 2020. The Act required the Secretary of the Interior, in coordination with the Attorney General to establish and appoint a joint commission on violent crime against American Indian and Alaska Native people. Secretary of the Interior Haaland was the lead sponsor of the Not Invisible Act when she served in Congress. The bill was passed unanimously by voice vote in both chambers of Congress.

Commissioner Sonya Tetnowski is a citizen of the Makah Tribe and CEO of the Indian Health Center of Santa Clara Valley. She currently serves as the President California Consortium of Urban Indian Health (CCUIH) and previously served as NCUIH’s Board President. Ms. Tetnowski works daily in support of the health and wellness services to American Indians and Alaska Natives living in urban areas. Violence against American Indians and Alaska Natives is a public health crisis and is considered a social determinant of health (SDOH). NCUIH is committed to the reduction of violence impacting Native communities.