Senate Committee Passes Bipartisan Bill to Reauthorize the Special Diabetes Program for Indians, Marking First Increase in Nearly Two Decades

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On June 15, 2023, the Senate Health, Education, Labor, and Pensions Committee passed the bipartisan Special Diabetes Program Reauthorization of 2023 (S.1855), introduced by Sen. Susan Collins (R-ME) and Sen. Jeanne Shaheen (D-NH). The bill would reauthorize the Special Diabetes Program for Type 1 Diabetes and the Special Diabetes Program for Indians (SDPI) at $170 million for fiscal years (FY) 24-25 for each program. This is the first time the program has seen an increase in funding, as the program has been funded at $150 million annually since 2004, and is set to expire in September 2023. The bill passed out of the committee with a 20-1 vote.

On May 17, 2023, the House Subcommittee on Health passed the bipartisan Special Diabetes Program for Indians Reauthorization Act (H.R. 2547), introduced by Representative Tom Cole (R-OK-04) and Representative Raul Ruiz (D-CA-25). Similar to S. 1855, the bill would reauthorize the program for fiscal years 2024 and 2025 at $170 million per year. The bill will now be moved to the full Energy and Commerce Committee.

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. Currently, 31 urban Indian organizations (UIOs) receive SDPI funding that enables UIOs to provide critical services that reduce the incidence of diabetes-related illness among urban Indian communities. The program is currently set to end in September 2023, and it remains critical that Congress reauthorizes SDPI to ensure there is no lapse in funding.

Bipartisan Letters from the Diabetes Caucus

In March 2023, The House Diabetes Caucus Leaders Rep. Diana DeGette (D-CO-1) and Rep. Gus Bilirakis (R-FL-12) sent a letter to Speaker McCarthy and Minority Leader Jeffries, and Senate Diabetes Caucus Leaders Sen. Susan Collins (R-ME) and Sen. Jeanne Shaheen (D-NH) sent a letter to Majority Leader Schumer and Minority Leader McConnell regarding the reauthorization of the Special Diabetes Program (SDP) comprised of Special Statutory Funding Program for Type 1 Diabetes Research and SDPI. The House Diabetes Caucuses letter closed with 238 signatures and the Senate Diabetes Caucus letter closed with 60 signatures.

The letter outlines that the programs fund research that led to new therapies improving the lives of those with diabetes and notes that “SDPI has been one of the most successful programs ever created to reduce the incidence and complications due to Type 2 diabetes.  Communities with SDPI-funded programs have seen substantial growth in diabetes prevention resources, and, for the first time, from 2013 to 2017, diabetes incidence in the AI/AN population decreased each year.” This funding invests in necessary research to develop a cure for diabetes as well as support programs, like SDPI, that help prevent and treat the disease and its complications.

The letter notes developments from the SDP and SDPI include:

  • Type 1 (T1D) Prevention Research
  • Artificial Pancreas (AP) System Research Led to the First Fully Automated Insulin-Dosing System Available to Patients
  • Kidney Disease Research on Reduction in End-Stage Renal Disease
  • Eye Therapy Research on Diabetic Eye Disease
  • Glucose Control Research for the American Indian/Alaska Native (AI/AN) Population that Reduced the Risk of Eye, Kidney, and Nerve Complications
  • Diabetes Prevention in the AI/AN Community that Leads to a Reduction in the Incidence and Complications due to Type 2 Diabetes

Background on SDPI and American Indians/Alaska Natives

SDPI includes research-based interventions for diabetes prevention and cardiovascular disease (CVD) risk reduction AI/AN community-based programs and healthcare settings. AI/ANs have the highest diabetes prevalence rates of all racial and ethnic groups in the United States, with AI/AN adults almost three times more likely than non-Hispanic white adults to be diagnosed with diabetes. The program has demonstrated success with a 50% reduction in diabetic eye disease rates, drops in diabetic kidney failure, and a 50% decline in End Stage Renal Disease. SDPI is therefore a critical program to address the disparate high rates of diabetes among AI/ANs.

The 31 UIOs currently receiving SDPI funding have used these funds to purchase blood sugar monitoring devices, medication, wound care, endocrinology, and retinal imaging services. Other projects include: a robust preventative education and support system and a Garden Project to teach classes about creating and maintaining a healthy diet.

NCUIH Action

The National Council of Urban Indian Health (NCUIH) has long supported SDPI and after conducting focus groups for the 2022 Policy Assessment, UIOs have requested an increase in SDPI funding from current FY23 levels of $150,000,000 to $250,000,000. NCUIH will continue to advocate for the UIOs’ requested amount of $250,000,000.

Resources

NCUIH Applauds Supreme Court Decision to Uphold Indian Child Welfare Act

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FOR IMMEDIATE RELEASE

WASHINGTON, D.C. (June 15, 2023) – The National Council of Urban Indian Health released the following statement on the Supreme Court’s decision to reject all challenges to the Indian Child Welfare Act (ICWA) in Haaland v. Brackeen.

“ICWA was enacted over 40 years ago to protect the best interests of Native children, by keeping them with their families and communities, and promote the stability and security of Tribes and Native families. ICWA requires state courts to respect Tribal sovereignty and to account for a child’s culture and community in child welfare proceedings. Today’s decision is a major win for all of Indian Country because it ensures that these protections remain in place. We applaud the tireless efforts of the Stand with ICWA campaign and the countless advocates who joined to fight for our children and for tribal sovereignty,” said NCUIH CEO Francys Crevier (Algonquin).

ICWA was created in 1978 by the federal government to re-establish Tribal authority over the adoption of Native American children. The Act aimed to strengthen and preserve Native American family structure and culture. Studies conducted in advance of ICWA’s drafting showed that between 25% and 35% of all Native children were being removed from their homes by state child welfare and private adoption agencies. Of those, 85% were placed with non-Native families, even when fit and willing relatives were available.

American Indian and Alaska Native children are overrepresented in state foster care systems. According to NICWA, AI/AN children are in foster care at a rate 2.7 times greater than their proportion in the general population. This means that while AI/AN children represent 0.9% of all children in the United States, they are 2.1% of all children placed in foster care. Because more than 70% of AI/AN people live in urban settings, this overrepresentation undoubtedly has an impact on urban AI/AN communities. Many health problems arise for AI/ANs living in urban settings because of mental and physical hardships due to the lack of family and the traditional cultural environments. Additionally, urban Indian youth are at a greater risk for serious mental health and substance abuse problems, suicide, increased gang activity, teen pregnancy, abuse, and neglect.

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

A full archive of our coverage on ICWA is available at: https://ncuih.org/policy-resource-center/#icwa.

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

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Resource: An Overview of the Impact of Medicaid on Health Care of American Indians and Alaska Natives

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The National Council of Urban Indian Health (NCUIH) recently released an infographic showcasing the impact of Medicaid on health care for American Indian and Alaska Native (AI/AN) people. This document highlights data and statistics on AI/AN Medicaid coverage and enrollment, the impact of Medicaid funding on Indian healthcare providers, information on COVID-19 and Medicaid unwinding, and how Medicaid affects Urban Indian Organizations (UIOs) and urban AI/ANs.

View the resource

About the Indian Health Service and Medicaid

Medicaid is a joint federal-state program that provides health insurance to eligible persons, including eligible AI/ANs. Indian healthcare providers bill Medicaid for services provided to Medicaid beneficiaries and Medicaid reimbursements are a critical source of funding to support the operation of the Indian Health system, comprised of the Indian Health Service (IHS), Tribal Health Programs, and UIOs. The federal government has a trust responsibility to provide federal health services to maintain and improve the health of AI/AN people. Due to historic underfunding of IHS, Medicaid is crucial to supporting healthcare services for AI/AN people and is critical to fulfilling the United States’ trust responsibility to maintain and improve AI/AN health.

Medicaid Coverage in AI/AN Communities

AI/AN people depend upon Medicaid to receive their healthcare coverage and services. In 2020, over 1.8 million AI/ANs were enrolled in Medicaid, meaning almost 1/5 of the AI/AN population is covered by Medicaid. Of which, 46.2% of Medicaid enrollees are AI/ANs from the ages of 0-18, and 46.5% are from the ages of 19-64.

Medicaid and Urban AI/AN Communities

UIOs help serve the approximately 70% of AI/AN people who live in urban areas. In 2019, Medicaid covered 1.3 million urban AI/ANs, including 30% of urban AI/AN adults under the age of 65. Comparatively, Medicaid covered 19.8% of all urban U.S. adults under the age of 65.

The Relocation and Termination Era and Federal Indian Boarding Schools have resulted in many AI/AN peoples living in metro areas, or cities. Below is a list of the metro areas that contain the highest population of AI/ANs who are enrolled in Medicaid. UIOs provide key services to almost all of the top metro areas where IHS-Medicaid beneficiaries live.

Medicaid: A Critical Source of Funding for Indian Health Care Providers

Medicaid reimbursements are a purely supplemental source of funding for IHS, as federal law prohibits appropriators from considering Medicaid revenue when determining IHS appropriations. Because the Medicaid program receives Mandatory appropriations and is not subject to the annual appropriations process, Medicaid revenue is particularly essential for Indian health providers when IHS funding is reduced or interrupted by budgetary disagreements.

Medicaid remains the largest secondary source of funding for UIO clinics. In 2020, 33% of the total population served at UIOs were Medicaid beneficiaries, and 35% of the AI/AN population served at UIOs were Medicaid beneficiaries.

Covid-19 and Medicaid Unwinding

In March 2020, the Families First Coronavirus Response Act (FFCRA) Medicaid and Children’s Health Insurance Program (CHIP) “continuous coverage” requirement allowed people to retain Medicaid coverage and receive needed care during the COVID-19 Pandemic Public Health Emergency (PHE).

In December 2022, the Consolidated Appropriations Act, 2023 was signed into law, separating the continuous coverage provision from the COVID-19 PHE and setting an end date for the provision on March 31, 2023. This means that states may resume reviewing all Medicaid enrollees’ eligibility for coverage, a process referred to as “unwinding,” on April 1, 2023, and will begin ending coverage for those found ineligible. States must meet certain federal reporting and other requirements during the unwinding period. NCUIH recently released a Medicaid unwinding toolkit for UIOs as they prepare for changes in Medicaid coverage.

Native people may be at an increased risk of disenrollment in Medicaid and CHIP programs during the Medicaid unwinding period. In fact, Medicaid coverage losses are estimated to take twice the toll on AI/AN communities than they will take among non-Hispanic white families. It is estimated that 12% of all AI/AN children and 6% of all AI/AN adults nationwide will lose CHIP or Medicaid coverage as state Medicaid programs return to normal operations. On April 24, NCUIH and 227 other organizations sent a multi-group letter to the Department of Health and Human Services (HHS) Secretary Xavier Becerra calling on the Administration to use their full powers provided in the Consolidated Appropriations Act of 2023 to safeguard Medicaid coverage and outlines specific steps the Administration can take to avoid wrongful terminations. Inadequate health insurance coverage is a significant barrier to healthcare access, and the loss of coverage may exacerbate the significant healthcare disparities faced by AI/AN communities.

Budget Formulation Workgroup Releases FY25 IHS Funding Recommendations with $965.3 Million for Urban Indian Health

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In April, at the Department of Health and Human Services (HHS) Annual Tribal Budget Consultation, the Tribal Budget Formulation Workgroup (TBFWG) presented their budget recommendations for Fiscal Year (FY) 2025, entitled Honor Trust and Treaty Obligations: A Tribal Budget Request to Address the Tribal Health Inequity Crisis. The recommendation for Indian Health Service (IHS) is full mandatory funding at $53.85 billion, a $46.75 billion increase above the FY 2023 enacted amount of $7.1 billion, and full funding for urban Indian health at $965.3 million, a $874.88 million increase above the FY 2023 enacted amount of $90.42 million.  American Indians and Alaska Natives (AI/ANs) experience major health disparities compared to the general U.S. populations, including lower life expectancy, infant and maternal mortality, and psychological or behavioral health issues. The federal government has a trust responsibility to provide federal health services to maintain and improve the health of AI/ANs. According to the TBFWG, fulfillment of this responsibility “remain[s] illusory due to chronically underfunded and woefully inadequate annual spending by Congress.”   The TBFWG recommends mandatory funding because “the only way to ensure resources are available to guarantee [the federal trust and treaty responsibility is fulfilled] is to provide complete, mandatory funding to the IHS.”

Additionally, the TBFWG’s recommendations emphasized the importance of full funding for UIOs:

“Full funding of the urban Indian health line item is necessary to address the growing American Indian and Alaska Native population in urban areas. Although more than 70% of AI/ANs reside in urban or suburban areas, historically only 1% of the underfunded IHS budget is spent on urban Indian health care. This growing population will require UIOs to increase access to care by hiring additional staff, expanding services, and opening new facilities to meet the growing need.”

The National Council of Urban Indian Health (NCUIH) presented UIO budget priorities for FY 2025 at the IHS Area Report Presentations Webinar earlier this year. Several of these priorities are included in the TBFWG’s recommendations, including: permanent authorization of the Special Diabetes Program for Indians (SDPI); expansion of advance appropriations to include all IHS accounts until Congress fulfills their duty and it becomes a mandatory obligation; and establishing permanent Federal Medical Assistance Percentage (FMAP) for UIOs.

About the IHS Budget Process and the Tribal Budget Formulation Workgroup:

Each year, IHS works with HHS to submit an annual budget proposal for inclusion in the President’s budget. IHS is required by the Indian Health Care Improvement Act, E.O. 14053, and its urban confer and tribal consultation policies to consult with Tribes and UIOs during the budget formulation process. IHS fulfills this requirement by hosting budget formulation workgroups at the area and national level and incorporating tribal and urban priorities into the final proposal.

The TBFWG consists of two Tribal representatives from each of the 12 IHS Areas. Additional representatives from Indian organizations, participate in the workgroup at the discretion of the Director of IHS. The workgroup provides input and guidance to the IHS Headquarters budget formulation team throughout the remainder of the budget formulation cycle for that fiscal year. The workgroup prepares the final set of tribal budget recommendations with an accompanying testimony on the results of the national budget work session and presents to the IHS Director as well as to the Department of Health and Human Services (HHS) senior officials at the annual HHS Tribal Consultation meeting.

NCUIH 2023 Policy Priorities Released

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NCUIH worked with UIOs to identify policy priorities in 2023 under three themes: upholding the highest health status of all American Indians and Alaska Natives, parity in the Indian Health System, and improving the IHS.

NCUIH 2023 Policy Priorities

The National Council of Urban Indian Health (NCUIH) is pleased to announce the release of its 2023 Policy Priorities document, which outlines a summary of urban Indian organization (UIO) priorities for the Executive and Legislative branches of the government for 2023. These priorities were informed by NCUIH’s 2022 Policy Assessment.

NCUIH hosted five focus groups to identify UIO policy priorities for 2023, as they relate to Indian Health Service (IHS)- designated facility types (full ambulatory, limited ambulatory, outreach and referral, and outpatient and residential). NCUIH worked with UIOs to identify policy priorities in 2023 under three themes: upholding the highest health status of all American Indians and Alaska Natives, parity in the Indian Health System, and improving IHS.

Read the 2023 Policy Priorities

2023 Policy Priorities:

Upholding the Highest Health Status for All American Indians and Alaska Natives

Fully Fund the Indian Health Service (IHS) and Urban Indian Health at the Amounts Requested by Tribes

  • Support the Tribal Budget Formulation Work Group request of $51.42 billion for IHS and $973.59 million for the Urban Indian Line Item for FY 2024.
  • Support Participation and Continued Inclusion of UIOs in the IHS Budget Formulation Process.

Improving Behavioral Health for All American Indians and Alaska Natives

  • Appropriate $80 Million for Behavioral Health and Substance Use Disorder Resources for Native Americans.
  • Ensure Critical Resources and Funding Opportunities Related to Behavioral Health and Substance Use Disorder are Inclusive of Urban Native Communities and the UIOs that Help Serve Them.

Protect Funding for Native Health from Political Disagreements 

  • Maintain Advance Appropriations for IHS to Insulate the Indian Health Service from Government Shutdowns and to Protect Patient Lives.
  • Transition IHS from Discretionary to Mandatory Appropriations.

“Nothing About Us Without Us”: Improving Health Outcomes Through Dialogue and Action

  • Increase Federal Agency Engagement with UIOs through Urban Confer Policies.
  • Identify the Needs of and Develop Strategies to Better Serve Urban Native Populations.

Improving Health Outcomes Through Traditional Healing and Culturally-Based Practices

  • Improve Funding Access for UIOs to Expand traditional Healing and Culturally Based Practices

Improving Native Veteran Health Outcomes

  • Establish an Urban Confer Policy at the Department of Veterans Affairs (VA).
  • Engage with UIOs to Successfully Implement the Interagency Initiative to Address Homelessness for Urban Native Veterans.
  • Increase Urban Native Access to VA Resources that Address Social Determinants of Health (SDOH).

Healing from Federal Boarding Schools

  • Support Federal Initiatives to allow the Indian Health Service to Support Healing from Boarding School Policies.
  • Study and Incorporate Findings of the Public Health Impact of Indian Boarding Schools on Urban Natives Today.

Fulfilling the Trust Responsibility 

  • Support Native Communities by Fully Honoring the Federal Trust Responsibility to Provide Healthcare to Native People.
  • Permanently Reauthorize and Increase Funding for the Special Diabetes Program for Indians (SDPI) at a Minimum of $250 Million Annually.

Tackling the Stigma and Advancing HIV Support Efforts in Native Communities

  • Increase Innovative Resources to Reduce Stigma and Fear around HIV in Native Communities and Increase Behavioral Health Support Resources at UIOs for Natives Living with HIV.

Improving Food Security for Urban American Indians and Alaska Natives

  • Increase access to U.S. Department of Agriculture (USDA) Resources and Funding Opportunities for Urban Native Communities and the UIOs that Help Serve Them.
  • Increase UIO access to fresh produce and other traditional foods for AI/ANs through the IHS Produce Prescription Pilot Program.

Ending the Epidemic of Missing or Murdered Indigenous Peoples (MMIP)

  • Reauthorize the Family Violence Prevention and Services Act (FVPSA) and Pass the BADGES for Native Communities Act.
  • Honor Executive Order 14053: Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People by Including UIOs in Prevention and Intervention Efforts.

Improving Native Maternal and Infant Health 

  • Include a Tribal and UIO Health Provider Representative on the Advisory Committee on Infant and Maternal Mortality to Complement the Work of the Standing IHS Ex-officio Member.
  • Increase the Health Resource Services Administration’s Engagement with UIOs through Urban Confer and UIO Listening Sessions Regarding the Provision of Healthcare to Native Mothers and Infants.

Achieving Parity in the Indian Health System

Increasing Resources to Support More Comprehensive Care for Medicaid-IHS Beneficiaries

  • Enact the Urban Indian Health Parity Act to Ensure Permanent Full (100%) Federal Medical Assistance Percentage (FMAP) to Expand Services Provided at UIOs.

Improving the Indian Health Workforce

  • Inclusion of UIOs in National Community Health Aide Program (CHAP).
  • Improve the Medicaid workforce through the Inclusion of UIOs in the VA’s Pilot Program on Graduate Medical Education and Residency Program (PPGMER).
  • Permit U.S. Public Health Service Commissioned Officers to be Detailed to UIOs.

Improving the Indian Health Service

Accurately Account for Provider Shortages

  • Engage with the Health Resources and Services Administration (HRSA) so that UIOs receive Health Professional Shortage Area (HPSA) Scores that Accurately Reflect the Level of Provider Shortage for UIO Service Areas.

 Data is Dollars: Improving Data in Indian Health 

  • Re-Introduce the Tribal Health Data Improvement Act.
  • Improve Reporting for UIO Data.
  • Improve Health Information Technology /Electronic Health Records.

Continuity in UIO Support from the Indian Health System

  • Improve Area Office Consistency with Respect to Oversight and Management.
  • Improve Communication at the IHS Area Level.

Elevate the Health Care Needs of American Indians and Alaska Natives Within the Federal Government

  • Re-Introduce the Stronger Engagement for Indian Health Needs Act to elevate the IHS Director to Assistant Secretary for Indian Health.

Policy Update: Congressional Hearing Demonstrates Need for HHS Urban Confer Policy

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The National Council of Urban Indian Health (NCUIH) CEO, Francys Crevier (Algonquin), testified before the House Natural Resources Subcommittee on Indian and Insular Affairs at a legislative hearing on the Urban Indian Health Confer Act (H.R. 630).

Congressional Hearing Reveals Critical Impact of Lack of Urban Confer Requirement on Urban Native Lives

NCUIH CEO Francys Crevier (Algonquin) testifies before the House Natural Resources Subcommittee on Indian and Insular Affairs.

NCUIH CEO Francys Crevier (Algonquin) testifies before the House Natural Resources Subcommittee on Indian and Insular Affairs.

WASHINGTON, D.C. (June 7, 2023) – On Wednesday, National Council of Urban Indian Health (NCUIH) CEO Francys Crevier (Algonquin) testified before the House Natural Resources Subcommittee on Indian and Insular Affairs in support of the Urban Indian Health Confer Act (H.R. 630), sponsored by Ranking Member Raúl Grijalva (D-AZ-7). This legislation passed by 406 votes in the last session of the House of Representatives and is up for consideration again this Congress. On March 29, 2023, the Senate Committee on Indian Affairs passed out of committee the Senate bipartisan companion bill (S.460) introduced by Senator Smith (D-MN) and Senator Mullin (R-OK). NCUIH will request a full House Committee markup and expeditious floor consideration.

Go deeper: The legislation, H.R. 630, would establish an urban confer requirement between Department of Health and Human Services (HHS) agencies and offices and urban Indian organizations (UIOs).

Crevier spoke on the critical importance of establishing a confer process within HHS in matters relating to the provision of healthcare to urban American Indians and Alaska Natives.

In her opening statement, Crevier called attention to the government’s violation of the trust obligation to Native people by not considering the health of those who reside in urban areas, “when we submit letters to HHS regarding our issues, they are not required to respond due to the lack of a confer policy, meaning 70% of our population often is not considered when it comes to HHS initiatives.”

Underscoring challenges faced during the COVID-19 pandemic that were exacerbated by a lack of confer, Crevier further highlighted the need for a clear communication pathway between federal health agencies and UIOs.

In particular, Crevier highlighted that key information regarding vaccine distribution for the initial COVID-19 vaccine rollout was miscommunicated which resulted in delayed distribution to many UIOs putting UIO patients at risk.

“The lack of an urban confer requirement between HHS and UIOs has resulted in missed opportunities for information and resources, endangering the lives of Native people.“

-NCUIH CEO, Francys Crevier (Algonquin)

What they’re saying:

In her opening remarks, Ranking Member Teresa Leger Fernández (D-NM-3) emphasized the barrier to UIOs in receiving life-saving vaccines for Native patients, noting that “the lack of communication between HHS and UIOs with the vaccine rollout illuminated the real problem when you don’t have a confer policy.”

Bipartisan Members of Congress Emphasized the Need for Urban Confer Legislation

Representative Grijalva, Sponsor of H.R. 630

Representative Grijalva, Sponsor of H.R. 630

Rep. Raúl M. Grijalva (D-AZ-7), who introduced this legislation, stressed its importance to urban Native communities, “[H.R. 630] is about correcting history and avoiding future problems.” –

What they’re saying:

In response to Crevier’s testimony, Chair Harriet Hageman (R-WY-AL) mentioned her conversations with HHS and the need for an urban confer policy, emphasizing that “we must do a better job at providing healthcare to our tribal members, we have got to do better…it is extremely important that we start fixing situations and that it is absolutely unacceptable in terms of the quality of health care to our tribal members.”

Remarks from HHS

In her opening statement, Melanie Egorin, HHS Assistant Secretary for Legislation, stated that “HHS is dedicated to enhancing the health and well-being for all Americans and affirming our relationship with AI/AN communities to improve the health and safety of tribal communities.”

Egorin further stated that “The Indian Health Service is the only agency within the federal government to implement this formal process, as a best practice, and is a critical partnership opportunity.”

Rep. Teresa Leger Fernández reaffirmed her support for this legislation, responding to Egorin’s remarks that “There may be good best practices, but we want to make sure that best practices become statutory to ensure a good anchor for these conversations to continue.”

Urban Confer in Practice

HR 630

Why it matters: This commonsense solution has garnered bipartisan support from Congress, as demonstrated by its passage in the House last Congress by 406 votes.

  • Currently, IHS is the only agency required to confer with UIOs on matters affecting Native people.
  1. Inclusivity and Representation: UIOs represent the interests and needs of American Indians and Alaska Natives living in urban areas, who make up over 70% of the Native population. By establishing an urban confer requirement, Congress would ensure that the voices of urban Native communities are heard and included in decision-making processes that impact their healthcare services.
  2. Responsive Policy-Making: Requiring urban confer would provide HHS with the opportunity to gather firsthand information and insights from UIOs regarding the challenges, priorities, and solutions necessary for improving the health and well-being of urban Native populations. This direct engagement facilitates more informed and responsive policy-making, leading to the development of effective legislation that addresses the unique needs of urban Native communities.
  3. Strengthening the Indian Healthcare System: UIOs play a crucial role in the Indian healthcare system by providing essential healthcare services to urban Native populations. By establishing an urban confer requirement, Congress would ensure that UIOs have direct communication channels with relevant federal health agencies, leading to improved coordination, collaboration, and resource allocation. This strengthens the overall Indian healthcare system, benefiting both UIOs and Tribal healthcare facilities.
  4. Access to Resources and Information: Urban confer sessions enable UIOs to access critical information, resources, and opportunities from federal health agencies. It helps prevent missed opportunities, miscommunication, and delays in the delivery of healthcare services to urban Native communities. By fostering open and free exchanges of information, urban confer sessions ensure that UIOs receive timely and accurate information, enhancing their ability to serve their patients effectively.
  5. Upholding Federal Trust Responsibility: The federal government has a trust responsibility to provide healthcare services to Native people, regardless of their geographic location. An urban confer requirement recognizes the federal government’s obligation to fulfill this responsibility and ensures that all agencies within HHS engage with UIOs. It establishes a formal process for meaningful consultation and collaboration, reinforcing the government’s commitment to improving healthcare for Native populations.

Go deeper:

Next Steps:

NCUIH will continue to advocate for passage of H.R. 630 and S. 460.

NCUIH Testimony at House Natural Resources Subcommittee on Indian and Insular Affairs

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NCUIH Testimony at House Natural Resources Subcommittee on Indian and Insular Affairs

June 7, 2023 | 10 a.m. EDT

On Wednesday, June 7, 2023, beginning at 10:00 a.m. EDT, NCUIH CEO Francys Crevier, JD (Algonquin), will be testifying before the Subcommittee on Indian and Insular Affairs at a legislative hearing on the Urban Indian Health Confer Act (H.R. 630), sponsored by Ranking Member Raúl Grijalva (D-AZ-7). NCUIH will speak in support of the NCUIH-endorsed legislation which would require agencies within the Department of Health and Human Services (HHS) to confer with urban Indian organizations (UIOs) on policies related to healthcare for urban American Indian/Alaska Natives (AI/ANs).

Watch Hearing

House Passes Final Debt-Limit Deal with Advance Appropriations Authority for IHS

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On May 31, 2023, after weeks of negotiations between President Biden and Congress, the House of Representatives passed by a margin of 314 to 117, The Fiscal Responsibility Act (H.R. 3746), which will suspend the debt ceiling through January 1, 2025.

The legislation includes spending caps on the total amount for non-defense discretionary funding for two years.

  • The Indian Health Service (IHS) falls under non-defense discretionary funding, however, how the caps impact the actual IHS budget has yet to be determined.

The bill also includes “claw backs” of some unobligated COVID-19 funding, however, the American Rescue Plan funding for the Indian Health Service (IHS) is protected from these rescissions.

The legislation included the budgetary authority to extend advance appropriations for IHS for FY25 and FY26 but limits the advance appropriation amount for each year to the FY 2024 appropriated amount.

Lastly, the deal includes expanding certain work requirements for federal nutrition and cash assistance programs but does not include new work requirements for Medicaid.

House of Representatives Passes Final Debt-Limit Deal with Advance Appropriations Authority for IHS

President Biden and Speaker McCarthy

Spending Caps for Non-Defense Discretionary Spending, including the Indian Health Service 

  • This legislation “caps” (limits) non-defense spending from FY23 through FY24 and only increases by 1% in FY25. The FY24 cap for non-defense discretionary spending is $704 billion, with $121 billion for veteran’s medical care and the rest of the $538 billion would be allocated to other areas, such as IHS.

Go deeper: The agreement authorized increased spending for Veterans’ healthcare but does not include a similar specific authorization for Indian Health Service.

By the numbers: IHS was funded at $6.9 billion in FY23 and Congressional appropriators still retain authority on how the capped spending will be appropriated across federal programs.

What’s it all mean? At this point, it is unclear how the IHS budget for FY24 will be impacted.

“Claw Backs” on COVID-19 Relief Funds

What’s a “claw back”? The agreement includes “claw backs” which rescinds unobligated balances (funds that have been appropriated for a program or other purpose but have not been spent) from some COVID-19 funding.

The bottom line: IHS funds from the American Rescue Plan Act are protected however, it remains unclear what remaining other COVID-19 unobligated balances exist for IHS and whether they would be protected.

  • For urban Indian organizations (UIOs), COVID-19 funds that the UIO has received will not be clawed back.
  • Certain other COVID-19 funds that have not been obligated are potentially subject to claw backs.

Yes, but: At this time, IHS has not issued guidance about the effects on non-ARPA IHS COVID-19 unobligated funds that may be clawed back.

Advance Appropriations for the Indian Health Service: The bill authorizes advance appropriations for IHS for FY25 and FY26.

What’s next: It is still up to Appropriations Committees to appropriate that advance appropriation, but this sets up and enables them to do so. The funding must stay at the FY24 spending level.

Work Requirements for Federal Programs 

The big picture: The bill adds some increased work requirements to qualify for the Supplemental Nutrition Assistance Program (SNAP).

  • The bill raises the age requirement to 51 years of age in FY23, 53 in FY24, and 55 in FY25.
  • However, the bill adds an exemption to work requirements for homeless individuals, veterans, and persons who are under 24 and were in a state foster care system until age 18 or any higher age as required by the state.
  • The bill does not include explicit work requirement exemptions for American Indian and Alaska Native recipients.
  • These amendments sunset on October 1, 2030.

What about Medicaid work requirements? Notably, the bill does not enact stricter work requirements for Medicaid, as in the House’s original debt limit legislation.

  • On May 8, 20223, NCUIH signed on to a Partnership for Medicaid letter to Congressional Leadership expressing concern about work requirements as a mandatory condition for Medicaid eligibility in the debt ceiling bill.
  • With over 1.8 million American Indians and Alaska Natives enrolled in Medicaid, NCUIH has worked diligently to ensure beneficiaries do not needlessly lose coverage.

How did we get here? The Fiscal Responsibility Act (H.R. 3746) comes after weeks of negotiation between President Biden and House Republicans after the House of Representatives previously passed the Limit, Save, Grow Act of 2023 (H.R. 2811) to lift the US debt limit for a year.

  • That legislation included several measures, including reverting federal spending to FY22 levels, limiting spending increases to 1% a year for the next 10 years, rescinding any unspent Covid-19 funds, and enacting stricter work requirements for social programs such as Medicaid.
  • The legislation was dead on arrival in the Democratic-led Senate as President Biden had indicated that he would veto the legislation.
  • In response to this legislation, NCUIH released a statement calling on Congressional leaders to safeguard Indian health funding from proposed cuts.

Looking Forward: This legislation will now be considered in the Senate, hoping to pass it by Friday, June 2. NCUIH will continue to advocate for the protection of the Indian Health Service.

Resources 

Urban Indian Organizations Encouraged to Apply to IHS Produce Prescription Pilot Program by June 8, 2023

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On April 24, 2023, the Indian Health Services (IHS) announced the availability of $2.5 million in funding to support the development of produce prescription programs for Native communities. The IHS produce prescription program is designed to assist American Indian and Alaska Native (AI/AN) individuals and families who are experiencing food insecurity and/or diet‑related health problems to more easily obtain fresh produce by receiving a prescription from a health care provider. Launching these programs in Native communities will support the efforts to reduce food insecurity, incorporate more traditional foods, and improve health outcomes among AI/AN people by increasing their access to healthy foods. Urban Indian Organizations (UIO) are eligible to apply. The application deadline is June 8, 2023, and the earliest anticipated start date is June 23, 2023. IHS anticipates issuing approximately six to eight awards for up to $500,000 for a performance period of five years.

Background

This pilot program is part of the IHS’s efforts to implement the Biden Administration’s National Strategy on Hunger, Nutrition, and Health (the Strategy). The program provides an opportunity to engage with UIOs by addressing food insecurity and decreasing the risk of diet-related illness among AI/ANs. By incorporating traditional foods, it also provides an opportunity to deliver culturally appropriate nutrition education for the more than 70% of AI/ANs living off-reservations. AI/AN people experience the highest rates of diabetes across all racial and ethnic groups compared to non-Hispanic whites. Moreover, diabetes and heart disease are among the top five leading causes of death for AI/AN people who live in urban areas and urban AI/AN people are more than three times more likely to die from diabetes than their white peers and have higher death rates attributable to heart disease than urban white people. Additionally, according to a report published in the Journal of Hunger & Environmental Nutrition, “[u]rban AI/ANs were more likely to experience food insecurity than rural AI/ANs.”

 NCUIH’s Role

NCUIH continuously advocates for health equity and advancement of urban AI/AN communities, including food security for AI/ANs living in urban areas. On July 15, 2022, NCUIH submitted comments to the Administration, the Department of Health and Human Services (HHS), and the US Department of Agriculture (USDA) and recommended that they support UIOs to promote food security, nutrition, and exercise; include urban AI/AN populations in future research efforts and government projects; and establish consistent Urban Confers regarding nutrition, hunger, and health. NCUIH also supports an increase in funding for maintaining Special Diabetes Program for Indians (SDPI) to enable the program to continued success in reducing diabetes and diabetes-related illnesses throughout Indian Country.

Further, in September 2022, Walter Murillo (Choctaw), CEO of NATIVE HEALTH and President-Elect of NCUIH, headlined a panel titled “Breaking Barriers: Bridging the Gap Between Nutrition and Health” at the White House Conference on Hunger, Nutrition, and Health, where they unveiled the Strategy. Mr. Murillo highlighted high rates of food insecurity in Indian Country, which intersects with other social determinants of health such as limited housing, employment, and lack of trust in health care systems in Native communities.

NCUIH will continue to advocate for the resources needed to reduce health disparities for AI/ANs, regardless of where they live.

Proposed Legislation to Lift US Debt Limit Threatens Native Health Care

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Happy May! In this month’s newsletter, we bring you important updates and information regarding our latest developments and initiatives within the Urban Indian Health Community.

  • May 10th – The Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies will hold a hearing on the FY24 budget request for Indian Country. Tune in at 10 a.m. EDT here.

1 Big Thing: Proposed Legislation to Lift US Debt Limit Threatens Native Health Care

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On April 17, 2023, Speaker of the House Kevin McCarthy (R-CA-20) proposed legislation to lift the US debt limit for a year, which passed the house by a vote of 215-217 on April 19.

The bottom line: The proposal includes several measures, including reverting federal spending to Fiscal Year (FY) 2022 levels, limiting spending increases to 1% a year for the next 10 years, rescinding any unspent Covid-19 funds, and enacting stricter work requirements for social programs such as Medicaid.

“The federal government must continue to work towards its trust and treaty obligation to maintain and improve the health of American Indians and Alaska Natives. Unfortunately, this legislation proposes senseless cuts at a time when our providers are making strides to improve the health of our communities. The United States’ promises to Native people are non-negotiable and our families should not be victims of DC politics over the debt ceiling,”

— Francys Crevier (Algonquin), NCUIH CEO.

Why it matters: These proposals would significantly impact healthcare access for Native communities. The federal government’s trust responsibility includes a duty to provide “federal health services to maintain and improve the health of the Indians.” The federal government cannot fulfill this responsibility if it does not provide the Indian health system with adequate funding.

By the numbers: If federal spending is reverted to FY 2022 levels, the Indian Health Service (IHS) line item would see a 4.7% reduction to $6.63 billion, while the urban Indian line item would see an 18.8% reduction.

  • Funding cuts have historically forced Indian health providers to make difficult decisions about the scope of the healthcare services they can offer to Native patients.

  • The $220 million reduction in IHS’ budget authority for FY 2013 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for AI/ANs.

  • According to the Tribal Budget Formulation Workgroup, the amount for FY 2024 IHS should be at least $51.4 billion.

What’s next: The bill now awaits a vote in the Senate. President Biden has indicated that he would veto the legislation should it pass through Congress.

NCUIH Testifies before Congress on Tribal Healthcare Delivery

On March 29, 2023, NCUIH Board member Maureen Rosette testified before the House Natural Resources Subcommittee on Indian and Insular Affairs at a hearing titled “Challenges and Opportunities for Improving Healthcare Delivery in Tribal Communities.” Ms. Rosette’s testimony focused on the lack of funding, and uncertainty in funding, impacts oversight and UIO’s ability to provide for their patients.

What they’re saying:

  • In her opening remarks, Chairwoman Harriett Hageman (R-WY- AL) reaffirmed the trust and treaty obligation to Native health care, stating that “the federal government has taken upon itself to provide for the care of American Indians and Alaska Natives.”

  • Ms. Rosette emphasized that advance funding for IHS is needed to provide stable and predictable funding to ensure the continuity of care for American Indian and Alaska Native people.

“Advance Appropriations will now allow IHS to make long-term cost-saving purchases and minimize the administrative burdens for the agency and UIOs. It will also improve accountability and increase staff recruitment and retention at IHS. When IHS distributes its funding on time, our UIOs can pay their doctors and providers- giving Native people the access to care and services they need to be thriving communities,”

-Maureen Rosette, NCUIH Board Member and NATIVE Project COO.

Go deeper:

NCUIH and Congressional Leaders Request Full Stable Funding for IHS and Urban Indian Health

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On April 8, 2023, NCUIH sent a letter to Chairman Jeff Merkley (D-OR) of the Senate Interior Appropriations Committee with funding requests for Indian health in FY 2024. On March 24, 2023, NCUIH also sent a letter to Chairman Kay Granger (R-TX-12) and Ranking Member Rosa DeLauro (D-CT-3) of the House Interior Appropriations Committee with the same requests.

In the letters, NCUIH requested the following:

  • Full funding at $51.42 billion for IHS and $973.59 million for Urban Indian Health for FY 2024, as requested by the Tribal Budget Formulation Workgroup (TBFWG).

  • Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration.

  • Appropriate $80 million for the Native Behavioral Health Resources Program.

NCUIH also worked with Members of Congress on leading letters to their colleagues to request full funding for urban Indian health in FY 2024 and advance appropriations for IHS.

  • On April 4, 2023, Sen. Tina Smith (D-MN) and 10 other Senators sent a letter to Chairman Jeff Merkley (D-OR) and Ranking Member Lisa Murkowski (R-AK) of the Senate Interior Appropriations Committee.

  • On March 24, 2023, a group of 38 Representatives sent a letter to the House Interior Appropriations Committee.

Go deeper:

IHS Policy & Guidance: Distribution Decision for IHS FY 2023 Funding Increase, Updated FTCA Guidance

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IHS Dear Urban Leader Letter on distribution decision for IHS FY 2023 Urban Indian Health funding increase:

  • IHS will distribute 90% of the funding equally to UIOs in the amount of $13.5 million. Funding will be transferred to UIOs via IHS contracts.

  • 10% will be distributed to the IHS Office of Urban Indian Health Programs in the amount of $1.5 million.​

IHS Updated Q&A on Federal Tort Claims Act (FTCA) Coverage​:

  • The FTCA is a federal law that allows parties claiming to have been injured by certain tortious actions of persons acting within the scope of their duties to present claims for property damage, personal injury, and/or wrongful death to the federal agency or agencies involved in the incident.

  • UIOs and their employees are covered by the FTCA. For a UIO employee’s actions to be covered by the FTCA, the tortious act or omission must be medical in nature (including the operation of an emergency vehicle) and have been committed by a covered employee within the scope of the employee’s official duties. ​

  • The main difference between the 2022 and 2023 FTCA guidance is that the 2023 guidance makes clear that non-medical malpractice tort claims are not eligible for FTCA coverage.​

NCUIH Priorities: 100% Federal Medical Assistance Percentage & Native Veterans

photo of Noelle Clough, Project Manager; and Robin Quiroz, Outreach and Engagement Specialist, Native American Connections

Noelle Clough, Project Manager; and Robin Quiroz, Outreach and Engagement Specialist, Native American Connections

100% FMAP for Medicaid Services at UIOs

  • On March 15-16, 2023, the Centers for Medicare & Medicaid Services (CMS) Tribal Technical Advisory Group (TTAG) held it’s Face-to-Face meeting with CMS leadership.

  • The TTAG approved 100% FMAP for Medicaid services at UIOs as a top Medicaid Legislative Policy Priority.

  • NCUIH staff attended as technical advisors to NCUIH President-Elect, Walter Murillo, who serves as the NCUIH representative on TTAG.

Native Veterans Homeless Initiative

  • On March 22, 2023, NCUIH met with the White House Council on Native American Affairs (WHCNAA) to discuss the Homeless Veteran Initiative for urban Native Veterans.

  • Department of Veterans Affairs (VA) is hosting stand down events in five areas: Phoenix, Seattle, Los Angeles, Albuquerque, and Alaska.

  • On April 28, 2023, Office of Urban Indian Health Programs Director Dr. Rose Weahkee attended the Maricopa County Stand Down event in Phoenix, AZ. Native American Connections set up a booth to offer a range of health care, behavioral health care, and housing services. The Stand Down event featured VA staff, community partners, and volunteers who provided food, clothing, and health screenings to homeless and at-risk Veterans. Veterans received referrals for health care, housing solutions, employment, substance use treatment, mental health counseling, and other essential services. Services were also offered to their pets.

NCUIH Leads Over 200 Organizations in Urging the Administration to Protect Healthcare Access for Families During Medicaid Unwinding

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On April 24, 2023, NCUIH, in collaboration with the Asian & Pacific Islander American Health Forum, the Coalition on Human Needs, The Leadership Conference on Civil and Human Rights, the National Association for the Advancement of Colored People, National Urban League, Protect Our Care, UnidosUS and 220 other organizations sent a letter to the Department of Health and Human Services (HHS) Secretary Xavier Becerra.

Did you know?: Since Medicaid unwinding may disproportionately harm vulnerable communities, the Consolidated Appropriations Act of 2023 included authorities to protect beneficiaries from losing Medicaid coverage for administrative reasons. For example, according to the Assistant Secretary for Planning and Evaluation, three-fourths of children losing Medicaid will remain eligible but be terminated because of state administrative requirements. The letter calls on the Administration to use the full extent of these authorities to safeguard Medicaid coverage and outlines specific steps the Administration can take to avoid wrongful terminations.

“The unwinding currently taking place will have devastating and disproportionate impacts on Native people. It is estimated that 12% of all Native American children and 6% of all Native adults will lose their Medicaid or CHIP coverage as state Medicaid programs unwind. There is no reason that our people should lose access to necessary healthcare services because of administrative barriers. The federal government must do everything in its power to honor the trust responsibility to Native people and ensure we are not left without coverage,”

— Francys Crevier (Algonquin), NCUIH CEO.

The letter requests the Administration take four key steps to protect families: 

  • CMS mitigation plans should prevent states from wrongfully terminating beneficiaries for purely procedural reasons.

  • CMS should hold state and local Medicaid agencies accountable for compliance with civil rights laws.

  • CMS should promote transparency and accountability by publishing state unwinding and performance indicator data as soon as possible.

  • CMS should hold states accountable for renewing coverage based on data matches “to the maximum extent practicable,” as required by Affordable Care Act.

Go deeper:

One last thing: NCUIH Visits Phoenix UIOs

photo of NCUIH staff at NATIVE HEALTH of Phoenix.

NCUIH staff visited NATIVE HEALTH of Phoenix.​

During NCUIH’s senior staff retreat in Phoenix, AZ, NCUIH staff visited NATIVE HEALTH and Native American Connections to see the important work they are doing for urban Indian health.

NATIVE HEALTH has grown over its forty-year history to offer a full array of health care and social services throughout the Phoenix metropolitan area by providing a wide range of programs, including primary medical, dental, behavioral health, WIC (available at four sites), and community health and wellness programs.

photo of NCUIH staff at Phoenix Indian School Visitor Center

NCUIH staff visited Phoenix Indian School Visitor Center

NCUIH staff also visited the Phoenix Indian School Visitor Center for a tour led by Patty Talahongva, a former student and former director of the center.​

photo of NCUIH staff at Native American Connections

NCUIH staff visited Native American Connections

Native American Connections owns and operates 22 sites throughout Phoenix offering a continuum of affordable housing, health, and community development services that touch and change the lives of over 10,000 individuals and families each year.

Upcoming Events and Important Dates​

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Upcoming Events:

  • May 8-9​ – California Consortium of Urban Indian Health Conference​
  • May 10 ​- Tribal Consultation and Urban Confer: IHS Health Information Technology Modernization Resources​
  • May 10 at 10am – Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies Hearing on the FY24 budget request for Indian Country. Tune here.
  • May 15-18 ​- NCUIH Annual Conference​
  • June 4-8 ​- NCAI 2023 Mid-Year Convention & Marketplace​
  • June 21 ​- Next NCUIH Monthly Policy Workgroup Meeting

Upcoming Comments and Submissions​:

  • May 19 – Comment deadline for HHS Budget Testimony​

ICYMI:

  • On March 3, NCUIH submitted comments to HHS Office of the Assistant Secretary of Health (OASH) on Strengthening Primary Care.
  • On April 7, NCUIH submitted comments to IHS on Health IT (HIT) Modernization: Preparing for Change.
  • On April 24, NCUIH submitted comments to IHS on Access to Federal Medical Supplies.