NCUIH Urges Office of Management and Budget to Fully Fund IHS and Fund Critical Indian Health Programs

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On September 29, 2023, the National Council of Urban Indian health (NCUIH) submitted comments to the Office of Management and Budget (OMB) Director, Shalanda Young, regarding the formulation of the President’s Fiscal Year (FY) 2025 Budget. In its comments, NCUIH made seven key recommendations to fully fund and support health services for urban Indian organizations (UIOs) and urban American Indian and Alaska Native (AI/AN) people.

Background

OMB serves as a clearinghouse for budget formulation by developing overarching presidential priorities, coordinating across agencies, and publishing the annual President’s Budget. For more information on OMB, please click here.

NCUIH’s Recommendations

In its comments, NCUIH recommended that the President’s FY2025 budget:

  • Fully fund the Indian Health Service (IHS) and the Urban Indian Health Line Item , as recommended by the Tribal Budget Formulation Workgroup. Full funding for IHS in the President’s FY 2025 Budget will address the following UIO priorities:
    • Infrastructure and facility needs
    • Food security
    • Traditional Healing
    • Health information technology and electronic health record modernization
  • Safeguard IHS and UIO funding by transitioning the IHS budget from discretionary funding to mandatory funding and exempting IHS funding from sequestration.
  • Propose setting the Federal Medical Assistance Percentage (FMAP) at 100% for Medicaid services provided at UIOs.
  • Request inclusion of $80 million for the Native Behavioral Health Resource Program (NBHRP).
  • Propose permanent reauthorization of the Special Diabetes Program for Indians (SDPI) at $250 million, if not reauthorized in the FY 2024 budget.
  • Request a legislative fix permitting the U.S. Public Health Service Commissioned Corps Officers to be detailed to UIOs

NCUIH will continue to monitor the FY 2025 budget formulation process and report developments across federal agencies and in Congress.

NCUIH Publishes Update to Report on Recent Trends in Third-Party Billing at UIOs

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On December 1, 2023, the National Council of Urban Indian Health (NCUIH) published its report, “Recent Trends in Third-Party Billing at Urban Indian Organizations: A Focus on Primary Care Case Management and Indian Managed Care Entities.” This report serves as an update to NCUIH’s previous report on recent trends in third-party billing. The focus of this report is on the experience of UIOs enrolled in Medicaid and Children’s Health Insurance Program as either a primary care case manager (PCCM) or Indian Managed Care Entity (IMCE). On July 26, 2023, NCUIH staff (Chandos Culleen, Director of Federal Relations; Isaiah O’Rear, Health Policy Statistician; and Nahla Holland (Eastern Pequot Tribal Nation), Research Associate) presented the report and its findings to the Centers for Medicare & Medicaid Services (CMS) Tribal Technical Advisory Group.

Read the Report

Key findings related to UIO Experience with PCCM/IMCE include:

  • PCCM/IMCE benefited UIOs and their patients through improving continuity of care for Medicaid and CHIP enrollees.
  • PCCM/IMCE benefited UIOs by providing a comprehensive view of the patient’s care, reducing the need for self-advocacy and reporting.
  • UIOs reported a best practice of strong working relationships with state Medicaid offices, Tribal Relations Liaisons, and other partners.
  • Challenges faced by UIOs include insufficient capitation rate for UIOs providing PCCM services, poor communication with state Medicaid offices, and lack of 100% FMAP for UIOs resulting in UIO exclusion from PCCM program.

The findings of this report indicate that UIO participation as a primary case manager in Medicaid and CHIP provides resources that may enhance the level of care available for American Indian and Alaska Native beneficiaries. The benefits provided through PCCM/IMCE, such as improvement in care coordination, increased access to preventative care, and reduced reliance on patient self-advocacy, may be of interest to other Indian health care providers. However, further work is needed to address barriers identified in the report, including insufficient capitation rates, a need for improved communication with state Medicaid offices, and a need for further education regarding the roles of UIOs in the Indian healthcare system.

This report was completed during NCUIH’s third year of participating in a research project commissioned by CMS through a contract with NORC at the University of Chicago. NCUIH is thankful for this partnership between the Division of Tribal Affairs and Office of Minority Health at CMS and NORC, as it has made this project and subsequent report possible. We look forward to continued collaboration as we strive to achieve healthy equity for American Indian and Alaska Native people.

House Passes Bipartisan Bill that Includes the Reauthorization of the Special Diabetes Program for Indians at $170 Million

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On December 11, 2023, the House passed the Lower Costs, More Transparency Act (H.R. 5378) with a vote of 320-71. The bill has now been received in the Senate. The original sponsor, Rep. Cathy McMorris Rodger (R-WA-05) introduced this bipartisan legislation on September 8, 2023, which would extend funding for the Special Diabetes Program and the Special Diabetes Program for Indians (SDPI) through 2025, including $124.4 million for the rest of fiscal year (FY) 2024 and $170 million in FY 2025 for each program, plus $42.8 million for the remainder of calendar year 2025 for each program. The bill’s reauthorization of SDPI would allow for urban Indian organizations (UIOs) to continue to use grant funding to offer a wide range of diabetes treatment and prevention services, including but not limited to exercise programs and physical activity, nutrition services, community gardens, culinary education, physical education, health and wellness fairs, culturally relevant nutrition assistance, food sovereignty education, group exercise activities, green spaces, and youth and elder-focused activities. Under the FY 2024 Continuing Resolution (CR), SDPI is set to expire January 19, 2024, making this legislation even more crucial to avoid lapses in critical diabetes research and care funding.

Specifically, the bill increases transparency to the health care system and extends important public health legislation by:

  1. A 13 percent increase in funding for both the Special Diabetes Program (SDP) and the Special Diabetes Program for Indians (SDPI), to $170 million each year for fiscal years 2024 and 2025
  2. Codifying the Hospital Price Transparency rule and the Transparency in Coverage rule, which requires hospitals to make public all standard charges for all items and services, and requires insurers to make public their negotiated in-network provider rates for all items and services
  3. Extending these price transparency requirements to other providers and services, including labs, imaging providers, and ambulatory surgical centers
  4. A 10 percent increase in mandatory funding for Community Health Centers (CHCs)
  5. A 13 percent increase in funding for the National Health Service Corps (NHSC)
  6. A seven-year reauthorization for the Teaching Health Centers Graduate Medical Education (THCGME) program
  7. Lowering health care costs and reducing seniors’ cost-sharing by ensuring that Medicare beneficiaries are not paying more for drug administration if a drug is administered in a hospital outpatient department instead of a physician’s office
  8. Prohibiting the use of “spread pricing,” or markups charged by PBMs, for prescription drugs in Medicaid, and including provisions to help ensure that Medicaid payments to pharmacies are adequate and accurate
  9. Increasing access to affordable generic drugs by requiring the Food and Drug Administration to provide more information to generic drug manufacturers during the development process, speeding their path to market and increasing competition.

 This bill is endorsed by The Alliance to Fight for Health Care, Better Solutions for Healthcare, Families USA, The Leukemia & Lymphoma Society, the National Association of Community Health Centers, the American Association of Teaching Health Centers, the American Association of Colleges of Osteopathic Medicine, the American Academy of Family Physicians, Advocates for Community Health, AARP, American Benefits Council, Small Business Majority, the National Alliance of Healthcare Purchaser Coalitions, the Purchaser Business Group on Health (PBGH), The ERISA Industry Committee, EmployersRx, Consumers First, Consumers for Fair Hospital Pricing, and United States of Care, and more.

Need for a Crucial Investment in SDPI

SDPI is set to expire on January 19, 2024, with first funding deadline for the current FY 2024 Continuing Resolution. SDPI’s integrated approach to diabetes healthcare and prevention programs in Indian country has become a resounding success and is one of the most successful public health programs ever implemented. SDPI has demonstrated success with a 50% reduction in diabetic eye disease rates, drops in diabetic kidney failure, and 50% decline in End Stage Renal Disease.  Additionally, the reduction in end stage renal disease between 2006 and 2015 led to an estimated $439.5 million dollars in accumulated savings to the Medicare program, 40% of which, of $174 million, can be attributed to SDPI.

Currently, 31 UIOs are in this program and are at the forefront of diabetes care. Facilities use these funds to offer a wide range of diabetes treatment and prevention services, including but not limited to exercise programs and physical activity, nutrition services, community gardens, culinary education, physical education, health and wellness fairs, culturally relevant nutrition assistance, food sovereignty education, group exercise activities, green spaces, and youth and elder-focused activities.

SDPI has been funded at $150 million since 2004, despite significant inflation and increases in healthcare expenditures over the past twenty years. With the program set to expire in January 2024, the permanent reauthorization of SDPI at a minimum of $170 million requested in the President’s FY 2024 budget with automatic annual funding increases tied to the rate of medical inflation is essential to continue the success of preventing diabetes-related illnesses for all of Indian Country.

NCUIH Advocacy

The National Council of Urban Indian Health (NCUIH) has long supported the permanent reauthorization of SDPI and will continue to advocate for the UIOs’ requested amount of $250,000,000. On September 12, 2023, the National Indian Health Board (NIHB), the NCUIH, and 15 other Tribal partners sent a letter to House and Senate leadership requesting the reauthorization of the SDPI and brought for consideration for a floor vote by the time the program expired, on September 30, 2023. On September 14, 2023, NCUIH also released an action alert regarding SDPI to assist Indian Health Advocates in contacting congress about the potential lapse in SDPI funding.

Next Steps

This bill has been received in the Senate. NCUIH will continue to monitor the bill’s progress.

NCUIH Endorses Bicameral Bill to Secure Funding for Native Mothers and Infants

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On May 15, 2023, Senator Cory Booker (D-NJ) and Representative Lauren Underwood (D-IL-14) reintroduced the National Council of Urban Indian Health (NCUIH)-endorsed bicameral Black Maternal Health Momnibus (H.R.3305/S.1606), which now awaits consideration in the House and Senate. The bill addresses the United States’ highest maternal mortality rate of any high-income country through historic investments that comprehensively address every driver of maternal mortality, morbidity, and disparities in the United States. Specifically, the legislation includes urban Indian organizations (UIOs) as eligible entities for multiple grant programs that support Native American and Alaksa Native mothers and infants.

Specifically, the Momnibus includes 13 individual bills that support mothers and infants to reduce maternal mortality:

  1. The Social Determinants for Moms Act
    1. (UIOs ARE ELIGIBLE) Makes critical investments in social determinants of health that influence maternal health outcomes, like housing, transportation, and nutrition.
  2. WIC Extension for New Moms Act
    1. Extends WIC eligibility in the postpartum and breastfeeding periods.
  3. Kira Johnson Act
    1. Provides funding to community-based organizations that are working to improve maternal health outcomes and promote equity.
  4. Maternal Health for Veterans Act
    1. Increases funding for programs to improve maternal health care for veterans.
  5. Perinatal Workforce Act
    1. Grows and diversifies the perinatal workforce to ensure that every mom in America receives maternal health care and support from people they trust.
  6. Data to Save Moms Act
    1. (UIOs ARE ELIGIBLE) Improves data collection processes and quality measures to better understand the causes of the maternal health crisis in the United States and inform solutions to address it.
  7. Moms Matter Act
    1. (UIOs ARE ELIGIBLE) Supports moms with maternal mental health conditions and substance use disorders.
  8. Justice for Incarcerated Moms Act
    1. (UIOs ARE ELIGIBLE) Improves maternal health care and support for incarcerated moms.
  9. Tech to Save Moms Act
    1. (UIOs ARE ELIGIBLE) Invests in digital tools to improve maternal health outcomes in underserved areas.
  10. IMPACT to Save Moms Act
    1. Includes innovative payment models to incentivize high-quality maternity care and non-clinical support during and after pregnancy.
  11. Maternal Health Pandemic Response Act
    1. (UIOs ARE ELIGIBLE) Invests in federal programs to address maternal and infant health risks during public health emergencies.
  12. Protecting Moms and Babies Against Climate Change Act
    1. (UIOs ARE ELIGIBLE) Invests in community-based initiatives to reduce levels of and exposure to climate change-related risks for moms and babies.
  13. Maternal Vaccination Act
    1. Promotes maternal vaccinations to protect the health of moms and babies.

Background on Native Mothers and Infant Health Disparities

According to the Office of Minority Health (OMH), Native infants have almost twice the infant mortality rate as non-Hispanic whites.  Native infants are also almost three times more likely than non-Hispanic whites to die from accidental deaths before the age of one year. Contributing factors to these disparities include cost, discrimination, and lack of cultural competency during prenatal care. Additional ongoing and historical trauma due to colonization, genocide, forced migration, and cultural erasure also contribute to health inequities, including pregnancy-related deaths and other maternal health conditions. Approximately 41% of American Indian and Alaska Native women cite cost as a barrier to receiving the recommended number of prenatal visits and 23% of American Indian and Alaska Native people report they have faced discrimination in clinical settings due to being an American Indian and Alaka Native. Consequently, American Indian and Alaska Native people are more likely to have underlying chronic health conditions, and they face systemic barriers to care including higher rates of poverty and needing to travel long distances to receive quality health care services.

NCUIH and UIO Work on Native Maternal and Infant Health

UIOs provide a range of services such as primary care, behavioral health, traditional, and social services— including those for infants, children, and mothers. At least 23 of these clinics provide care for maternal health, infant health, prenatal, and/or family planning. They also provide pediatric services and participate in maternal-child care programs such as WIC and the Health Resources and Services Administration (HRSA) Maternal, Infant, and Early Childhood Home Visiting program (MIECHV).

NCUIH has engaged in extensive advocacy on behalf of American Indian and Alaska Native mothers and infants and for increased funding and support to UIOs. Last year, NCUIH successfully advocated for the reauthorization of MIECHV and an increase to the Tribal set-aside from 3% to 6% for the Tribal Home Visiting Program in the FY 2023 final appropriations package, and continues to advocate on behalf of American Indian and Alaska Native mothers and infants.

Next Steps

This bill has been introduced in the House and Senate and awaits consideration. NCUIH will continue to monitor the bills’ progress.

Resource Update: America’s Disproportionate Investment in Healthcare for American Indians and Alaska Natives

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The National Council of Urban Indian Health (NCUIH) recently updated its resource document showcasing the disproportionate gaps in national healthcare investment for American Indian and Alaska Native people. The Indian Health Service (IHS) and Urban Indian Health budgets have long been underfunded. NCUIH’s research reveals a significant gap in funding for Urban Indian Health services. Specifically, for patients served by urban Indian organizations, the allocated funds amounted to just $891 per American Indian/Alaska Native patient from the IHS Urban Indian line item. This substantial difference between the overall healthcare expenditure and the funds designated for urban Indian populations raises critical questions about the equitable distribution of resources. In 2021, the United States witnessed a 2.7% growth in healthcare spending, reaching an astonishing $4.3 trillion, equivalent to $12,914 per person, according to findings by the Centers for Medicare & Medicaid Services.

View the Resource

The disparities in healthcare spending underscore the pressing need for a comprehensive review of funding mechanisms to address the unique healthcare challenges faced by American Indian and Alaska Native people in urban settings. NCUIH calls on policymakers, healthcare stakeholders, and the public to join in the effort to ensure that healthcare spending aligns with the federal trust responsibility to provide quality healthcare for all American Indian and Alaska Native people.

Tribal Leaders Diabetes Committee Meeting Highlights Portland Urban Indian Organization’s Exemplary Programming

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On December 5-6, 2023, the National Council of Urban Indian Health (NCUIH) represented urban Indian organizations (UIOs) as a technical advisor at the Indian Health Service (IHS) Tribal Leaders Diabetes Committee (TLDC) meeting in Portland, Oregon. During the two-day meeting, committee members discussed the status and future of the Special Diabetes Program for Indians (SDPI), received Portland Area diabetes programming updates and legislative updates, and had a discussion with IHS Deputy Director Benjamin Smith. The SDPI status updates from IHS were crucial as the current continuing resolution (CR) legislation has authorized the program for an additional $25.89 million, for a total of $46 million through January 19, 2024.

TLDC is planning on hosting the next in-person meeting on March 5-6 in Reno, Nevada. Details are forthcoming.

NARA NW, Portland UIO, Recognized for Exemplary Diabetes Programing

Native American Rehabilitation Association of the Northwest, Inc. (NARA)

During the TLDC meeting, the Native American Rehabilitation Association of the Northwest, Inc. (NARA), a Portland area urban Indian organization (UIO), was recognized for its work on diabetes treatment and prevention. NARA gave a presentation on its Saturday Diabetes Clinics, which started in 1999 and has since emerged as a highly successful program. NARA’s Saturday Diabetes Clinics are a multidisciplinary “one-stop-shop” for diabetes care offered once a month. Because this clinic is offered on the weekends, NARA has been able to increase involvement and attendance in the program with an average of 14-16 patients attending each session.

The monthly clinic offers comprehensive diabetes care, presenting a holistic approach to managing the disease. The process involved various healthcare professionals and services, beginning with a pharmacist and medical assistants to facilitate annual labs and vaccines. Patients also consult with an ophthalmologist, podiatrist, medical provider for a thorough review of the disease management and medication use, and a dietitian for personalized coaching lasting 20-30 minutes. Additionally, behavioral health support is provided, recognizing the often co-occurring challenges of diabetes and depression. The clinic integrates a cancer screening indicator and hosts a semi-annual eye exam clinic offered by the local university. Furthermore, dental services are offered, contributing to the overall well-being of the patients. The innovative and comprehensive nature of NARA NW’s Saturday Diabetes Clinics garnered enthusiastic support from TLDC members, who expressed their excitement and interest in replicating the model within their own Tribes.

Special Diabetes Program for Indians Updates and Planning

The current CR legislation has granted authorization for SDPI, allocating $46 million for the fiscal year (FY) 2024 until January 19, 2023. However, the full authorization for SDPI in 2024 remains pending, awaiting further legislative action. In response to the evolving funding landscape, the IHS has made decisions to optimize available resources. A portion of the one-time, unobligated SDPI funding, combined with the allocated $46 million from the FY2024 CR, will be utilized to fund all grant recipients for the first six months of the 2024 grant year, extending until June 20, 2024. The total available funds for this initiative amount to $69.5 million.

IHS has also initiated the implementation of another program, SDPI-2. This new grant program aims to extend SDPI funding to Tribes and UIOs that do not currently have an SDPI grant. Funded using unobligated and prior-year SDPI grant funding, SDPI-2 is structured as a four-year grant program. The application review process for SDPI-2 officially started on December 4, 2023 with the anticipated date for grant awards set for January 13, 2024. IHS noted that 9 applications were selected with one applicant being a UIO.

Members of TLDC discussed the potential funding outcomes for SDPI. These options included the reauthorization of SDPI with an allocation exceeding $150 million for one or more years, reauthorization at $150 million for one or more years, a scenario where SDPI is reauthorized with $147 million (reflecting a 2% reduction due to sequestration) for one or more years, and the possibility that SDPI may not be reauthorized at all.

Background on TLDC

The IHS Director established the TLDC in 1998. The TLDC makes recommendations to the IHS Director on broad-based policy and advocacy priorities for diabetes and related chronic conditions as well as recommends a process for the distribution of SDPI funds.

The TLDC consists of the following members:

  • One elected or duly-appointed Tribal Leader from each of the 12 IHS Areas serves as the primary representative.
  • Each Area also designates an alternate member to serve when the primary member is unavailable to do so.
    • TLDC elects one of its members to serve as the Tribal Co-Chair
  • One federal representative, who serves as the Federal Co-Chair
    • One technical advisor from each of the following American Indian/Alaska Native organizations serves in an advisory (non-voting) capacity to the TLDC: Direct Service Tribes Advisory Committee, National Congress of American Indians, National Council of Urban Indian Health, National Indian Health Board, and Tribal Self-Governance Advisory Committee.

White House 2023 Progress Report for Tribal Nations Highlights Commitment to Supporting Urban Native Communities

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The Biden-Harris Administration released the 2023 Progress Report for Tribal Nations (“Progress Report”) during the December 6-7, 2023, White House Tribal Nations Summit. The Progress Report touches on several areas of concern to urban Indian organizations (UIOs) as discussed in the National Council of Urban Indian Health’s (NCUIH) 2023 Policy Priorities. The Progress Report also highlights work done in partnership with UIOs, such as initiatives addressing Missing and Murdered Indigenous Peoples (MMIP), Native Veteran Health and Homelessness, Mental Health, Health Information Technology (HIT) Modernization, and Reproductive Health Care.

Successes with Urban Native Communities Highlighted MMIP

In January 2023, The Department of Health and Human Services (HHS) submitted the MMIP Prevention, Early Intervention, and Victim and Survivor Services Plan to the White House Domestic Policy Council and to the President. Developed in consultation with the Department of the Interior, Tribal Nations, research and community-based organizations and UIOs, it is a comprehensive plan to support prevention efforts that reduce risk factors for victimization of Native Americans and increase protective factors, including by enhancing the delivery of services for Native American victims and survivors as well as their families and advocates.

Native Veterans

In support of the Native American Veterans Homelessness Initiative, VA and other federal agencies engaged with UIOs to support and offer resources to AI/AN Veterans experiencing homelessness. The Initiative took the following actions in 2023:

  • VA and Indian Health Service (IHS) developed an informational brochure for Native American veterans experiencing homelessness and distributed these brochures to UIOs, IHS facilities, and external partners across the country.
  • VA and IHS developed and launched an interagency interactive map of UIOs and VA healthcare systems with points of contact information in June 2023.
  • VA developed and implemented training webinars for UIOs to raise awareness of VA homeless programs among Native American veterans and to build or increase effective, responsive, and collaborative relationships between UIOs and VA.
  • VA and various UIOs collaborated on Stand Down events in Seattle, Phoenix, Los Angeles, Albuquerque, and soon Alaska. These one-to-three-day events bring VA staff and volunteers together to provide food, clothing, and health screenings to homeless and at-risk veterans and receive referrals for healthcare, housing solutions, employment, substance use treatment, mental health counseling, and other essential services.

The Veterans Health Administration amended its medical regulations to implement a statute exempting eligible Indian and urban Indian veterans from copayment requirements. This change is based on a requirement within the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020. As of October 2023, 2,674 Native veterans have been approved for the copayment exemption, with copayment cancellations totaling just over $1.5 million.

Mental Health

HHS announced a new $35 million grant opportunity, enabled by the Bipartisan Safer Communities Act, to better support the 988 Suicide and Crisis Lifeline services in Tribal communities. One of the aims of the program is to facilitate collaborations between Tribal, state, and territory health providers, UIOs, law enforcement, and other first responders in a manner that respects Tribal sovereignty.

HIT Modernization

Throughout the process for selecting the new Electronic Health Record (EHR) vendor, IHS coordinated with Tribal and urban Indian organization partners through extensive Tribal engagement via Tribal consultations, listening sessions, urban confers, advisory committee meetings, an Industry Day, and the participation of hundreds of Tribal, urban Indian, and IHS system users in vendor product demonstrations. IHS ultimately awarded a 10-year contract to General Dynamics Information Technology to build, configure, and maintain a new enterprise EHR system utilizing Oracle Cerner technology.

Reproductive Health Care

In response to President Biden’s Executive Order on Strengthening Access to Affordable, High-Quality Contraception and Family Planning Services, IHS added new over-the-counter contraception options to the IHS National Core Formulary, which will expand access to high-quality contraception for patients. IHS encouraged Tribally or UIO operated IHS facilities to make the same options available to patients.

VA Responds to Advisory Committee on Tribal and Indian Affairs’ Recommendations to Improve Native Veteran Health

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The Department of Veterans Affairs (VA) released its consolidated responses to VA’s Advisory Committee of Tribal and Indian Affairs’ (ACTIA) November 2022 recommendations to VA Secretary Dennis McDonough regarding improvements to VA’s programs and services to better serve Native American veterans. These recommendations were finalized during the November 8-11, 2022, ACTIA Meeting and included several recommendations to improve the delivery of health services to Native veterans living in urban areas. These included suggestions regarding interagency collaboration under the Veteran Health Administration-Indian Health Service (VHA-IHS) memorandum of understanding (MOU), development of a VA Urban Confer policy, use of traditional healing practice for American Indian and Alaska Native (AI/AN) veterans, data on urban veteran behavioral health, and urban veteran homelessness. VA’s responding is a crucial step toward achieving the goal of supporting AI/AN veterans as whole people and meeting their needs.

Background on the ACTIA

The Committee was established in accordance with section 7002 of Public Law 116- 315 (H.R.7105 – Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020). Pursuant to Public Law 116-315, the Committee provides advice and guidance to the Secretary of Veterans Affairs on all matters relating to Indian Tribes, tribal organizations, Native Hawaiian organizations, and Native American Veterans. The Committee serves in an advisory capacity and, at least once a year, the Committee must submit recommendations to the Secretary of Veterans Affairs and relevant Congressional committees concerning legislative or administrative action to improve programs and services of the Department to better serve Native American Veterans.

Alongside partners from throughout Indian Country, the National Council of Urban Indian Health (NCUIH) played a critical role in getting this legislation passed in 2020. In a December 4, 2020 letter NCUIH signed with other National Native organizations regarding the ACTIA, NCUIH emphasized the importance of establishing the ACTIA to improve programs and services for Native veterans.

NCUIH subsequently nominated NCUIH’s Board President, Ms. Sonya Tetnowski, to the ACTIA, where she serves as the Chair of the Health Subcommittee. Ms. Tetnowski is the CEO of the Indian Health Care Center of Santa Clara Valley and is an Army veteran.

Recommendations and Responses

The ACTIA submitted eleven recommendations to VA to improve the care of AI/AN veterans. NCUIH is highlighting VA’s response to five of those recommendations below. To read the full response, click here.

Recommendation 1C: Interagency Collaboration Under VHA-IHS MOU

VA Office of Tribal Government Relations (OTGR), Veterans Health Administration (VHA) Office of Tribal Health (OTH) and the Office of Rural Health concur in principle with the ACTIA recommendation to require annual partnership between Veterans Integrated Services Network Directors and at least one Indian Health Service (IHS), Tribal, Urban or Native Hawaiian Health program to meet a specific goal or objective as described in the current Veterans Health Administration (VHA) – IHS Memorandum of Understanding (VHA-IHS MOU). ACTIA recommended that this be implemented in FY 2023. OTGR, VHA OTH, and the Office of Rural Health recommend that Network Directors submit an annual report to the Executive Committee of the VHA/IHS MOU Interagency Workgroup documenting compliance with this recommendation. The VHA-IHS MOU Interagency Workgroup will then provide an annual summary report of these efforts to VA’s ACTIA.

Recommendation 1D: Urban Confer Policy

The ACTIA recommended that  VA develop an Urban Confer Policy in order to partner with UIOs more effectively in their provisions of health services of Native Veterans in urban areas.  The ACTIA stated that this recommendation should be implemented by December 2023.

VA will research the processes and authorities used by other federal agencies to create the urban confer policy that ACTIA recommended.

Recommendation 3A: Behavioral Health/Suicide Prevention

The ACTIA recommended that VA provide information on its efforts to collect data on:

(1) Veteran suicides that occur on tribal lands which can be included in the VA/IHS MOU operational plan; and

(2) AI/AN Veteran suicides that occur in urban areas.

The ACTIA stated that data concerning urban city in which Native Veteran suicides occur needs greater specificity to address issues such as how VA defines rural and urban. The ACTIA recommended VA begin collecting data by October 2023, publish its first report by October 2024, then annually publish the results at the beginning of each fiscal year thereafter in October of each calendar year.

VA stated that it supports the goals of this recommendation and requested the opportunity to discuss and coordinate regarding avenues for enhancing available data sources to broaden accurate and reliable reporting on suicides among AI/AN Veterans. VA stated that it is not aware of resources needed to identify whether Veteran suicide deaths occur on tribal lands and that Veteran suicide deaths are identified from joint VA/Department of Defense searches of the Centers for Disease Control and Prevention’s National Death Index (NDI). VA OTGR and VHA OTH will provide a plan of action by the end of the second quarter of FY 2024.

Recommendation 3B: Cultural Healers/Natural Helpers

As part of the ACTIA recommendations regarding cultural healers/natural helpers, the ACTIA recommended VA, incorporating input gathered in tribal consultation and urban confer, amend VA policy and relevant VHA Directives to champion and/or allow the use of traditional healing as a legitimate and evidence-based practice that promotes the wellbeing of American Indian, Alaska Native and Native Hawaiian Veterans. It stated that VA should complete this recommendation by October 2024.

VA responded by stating that VHA looks forward to supporting evidence-based traditional healing in alignment with VHA’s Whole Health System of Care. VA also stated that VHA suggested changes to language in this recommendation.

Recommendation 3C: Homelessness as a Health Disparity

The ACTIA recommended that VHA Homeless Programs Office (HPO) amend its Strategic Plan to target a 5% increase in Stand Downs located on tribal lands, rural communities, Native Hawaiian communities and in urban areas with a high population of AI/ANs.

It also recommended that VA should:

  • Create objectives in the operations plans of each region to ensure the target increase percentage in Stand Downs can be met.
  • Provide quarterly updates with information on progress made or a justification for why the goal was not reached.
  • Gather information on the number of American Indians, Alaska Natives and Native Hawaiians that attend each event, including their tribal affiliation.
  • Complete this recommendation by October 2025.

VA staff will ensure that messaging is provided to the Bureau of Indian Affairs when an event is planned, apply for VA specific purpose funding for local Stand Down events and work collaboratively with local providers to gather information on the number of American Indians, Alaska Natives and Native Hawaiians that attend each event, including their tribal affiliation.

VA stated that it is committed to increasing the number of Stand Downs in targeted areas with high populations of AI/AN. Starting in FY 2023, VA will begin sharing stand down data with the ACTIA.

VHA HUD-VA Supportive Housing agrees with the replacement of BIA with “IHS, Urban Indian Organizations and Tribal Health Programs.”

VHA Homeless Program Office (HPO) will:

  • encourage UIOs, IHS, and where appropriate, tribes to participate in existing stand down development and implementation.
  • collaborate with and support UIOs, IHS and tribes interested in developing Stand Downs.
  • provide an educational and outreach tool (VHA stand down presentation) it has developed to assist UIOs and IHS in developing tribal specific stand downs.

VHA HPO would recommend that Tribes who are interested in tribal specific Stand Downs request the assistance of VA OTGR.

For information on Stand Down events, please click here.

Next Steps

The National Council of Urban Indian Health (NCUIH) welcomes the VA’s response to the ACTIA’s recommendations. The ACTIA recommendations provide tangible programmatic changes that VA can make to better serve Native veterans. NCUIH looks forward to continuing to work with the ACTIA and VA to advance these changes and ensure that Native veterans have access to the benefits and services that the earned through their military services.

HHS Provides Update on Suspected Behavioral Health Treatment Center Fraud Targeting Native Americans in Arizona

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On November 14, 2023, the Department of Health and Human Services (HHS) sent a Dear Tribal Leader and Urban Indian Organization Leader Letter (DTLL/DULL) to provide an update on suspected behavioral health treatment center fraudulent activities in Arizona. The DTLL/DULL provided a list of resources to stay up to date on the matter and described a “whole of government” approach that the Indian Health Service (IHS), Tribal leaders, Urban Indian Health Program leaders, the Arizona Health Care Cost Containment System (AHCCCS), and the State of Arizona are working toward. Specifically, they have established mechanisms to help affected people receive care, transportation, and other needed services. HHS stresses the importance of staying vigilant in addressing this matter.

Background

Suspected fraudulent providers are believed to be targeting vulnerable American Indian and Alaska Native (AI/AN) people who are unsheltered and experiencing the impacts of substance use disorder (SUD) health conditions. Reports indicate the suspected fraudulent providers entice vulnerable individuals with food, money, shelter, and offer treatment and safe housing to lure them into facilities that do not provide treatment. Initially, suspected fraudulent providers focused on recruiting in reservation communities in Arizona and New Mexico, but more recently there are reports of recruitment efforts throughout Indian Country and direct solicitation to the IHS, Tribal Health Programs, and Urban Indian Health Programs in an effort to gain referrals.

On May 16, 2023, Arizona Governor Katie Hobbs and Attorney General Kris Mayes joined the AHCCCS Office of Inspector General (OIG) to announce payment suspensions against registered behavioral health providers of Medicaid services based on credible allegations of fraudulent billing activities. This first of many actions to stop these criminal activities was a coordinated effort by the Arizona Attorney General’s Healthcare Fraud and Abuse Section, the Federal Bureau of Investigation (FBI), HHS, the U.S. Attorney’s Office, and the Internal Revenue Service. The suspected false and fraudulent claims have been associated with unethical treatment practices, patient brokering, unnecessary services, and overcharging. These actions have led to the suspension of more than 100 unique registered behavioral health providers since the May 16 announcement, and the search for additional fraudulent providers continues.

Resources to Stay Up to Date

IHS will provide regular communication, new information, and additional details as they become available. Several resources are immediately available:

Should you have any questions, please contact your IHS Area Office directly.

Bureau of Indian Education Seeks Nominations for Membership on the Advisory Board for Exceptional Children

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On December 4, 2023, the Bureau of Indian Education (BIE) issued a notice seeking nominations of individuals to serve on the Advisory Board for Exceptional Children (Advisory Board). There will be three positions available to specifically serve in the areas of Indian persons with disabilities; or State education officials; or State Interagency Coordinating Councils (for States having Indian reservations). Applications are due Wednesday, January 31, 2024.

Eligibility and Nomination Information

Nominations may come from individuals, organizations, and federally recognized Tribes. Interested individuals may also self-nominate. Nominees should have expertise and knowledge of the issues and/or needs of American Indian children with disabilities. A summary of the candidates’ qualifications (resume or curriculum vitae) must be included with a completed nomination application form. Nominees must have the ability to attend Advisory Board meetings, carry out Advisory Board assignments, participate in teleconference calls, and work in groups.

Please submit nominations to Ms. Jennifer Davis, Designated Federal Officer (DFO), Bureau of Indian Education, Division of Performance and Accountability, 2600 N Central Ave., Suite 800, Phoenix, AZ 85004; email to jennifer.davis@bie.edu; or fax to (602) 265–0293. Please click here for the nomination application on BIE’s website.

Background

The Advisory Board was established under the Individuals with Disabilities Education Act of 2004 (IDEA) in an effort to advise the Secretary of the Interior, through the Assistant Secretary-Indian Affairs, on the needs of Indian children with disabilities. Members of the Advisory Board will provide guidance, advice, and recommendations with respect to special education and related services for children with disabilities in BIE-funded schools in accordance with the requirements of IDEA.

The Advisory Board will also:

(1) Provide advice and recommendations for the coordination of services within the BIE and with other local, State and Federal agencies;

(2) Provide advice and recommendations on a broad range of policy issues dealing with the provision of educational services to American Indian children with disabilities;

(3) Serve as advocates for American Indian students with special education needs by providing advice and recommendations regarding best practices, effective program coordination strategies, and recommendations for improved educational programming;

(4) Provide advice and recommendations for the preparation of information required to be submitted to the Secretary of Education under 20 U.S.C. 1411 (h)(2);

(5) Provide advice and recommend policies concerning effective inter/intra agency collaboration, including modifications to regulations, and the elimination of barriers to inter- and intra-agency programs and activities; and

(6) Report and direct all correspondence to the Assistant Secretary—Indian Affairs through the Director, BIE with a courtesy copy to the Designated Federal Officer (DFO).

Membership

Pursuant to 20 U.S.C. 1411(h)(6), the Advisory Board is composed of up to fifteen individuals involved in or concerned with the education and provision of services to American Indian infants, toddlers, children, and youth with disabilities. The Advisory Board composition reflects a broad range of viewpoints and includes at least one member representing each of the following interests:

  • American Indians with disabilities;
  • teachers of children with disabilities;
  • American Indian parents or guardians of children with disabilities;
  • service providers;
  • State education officials;
  • local education officials;
  • State interagency coordinating councils (for States having Indian reservations);
  • Tribal representatives or Tribal organization representatives; and
  • other members representing the various divisions and entities of BIE.