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

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

In the testimonies, NCUIH requested the following:

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

Next Steps:

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

Full Text:

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

We respectfully request the following:

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

NCUIH Supports Tribal Sovereignty

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Request: Protect Funding for HIV/AIDS Prevention and Treatment

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

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

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

Conclusion

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

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

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

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

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

[5] 25 U.S.C. § 1601(1)

[6] 25 USC § 1602.

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

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

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

[9] P.L. 118–31

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

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

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

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

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

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

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

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

Letter Highlights:

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

Full Text:

Dear Chairman Simpson and Ranking Member Pingree:

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

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

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

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

Health Professions Workforce needs

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

Making IHS loan repayment and scholarships tax free

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

Staff quarters                                                                                                  

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

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

Medical and diagnostic equipment

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

Electronic Health Records

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

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

Sincerely yours,

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

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

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

Background

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

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

NCUIH’s Recommendations

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

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

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

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

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

Read the Court’s Opinion here.

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

Summary of the Court’s Holding 

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

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

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

Impact on Urban Indian Organizations 

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

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

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

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

The $1 billion is allocated to:

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

Resources

Background on Substance Use in Urban Native Communities

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

Next Steps

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

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

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

Key Responses by the Agencies

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

Law Enforcement and Investigative Resources

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

Coordinating Resources

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

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

Victim and Family Resources and Services

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

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

Alaska-Specific Issues

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

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

Background on the Commission

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

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

NCUIH Requests that CMS Include UIOs in its Proposed Framework on Reimbursement for Traditional Healing Services

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On March 27, 2024, and April 29, 2024, the National Council of Urban Indian Health (NCUIH) submitted comments to the Centers for Medicare and Medicaid Services (CMS) Director of the State Demonstrations Group, Jacey Cooper, regarding the Proposed Framework for Traditional Health Care Practices in Section 1115 demonstrations (“Proposed Framework”) in response to CMS’s request for feedback. CMS sought advice and input on the scope of coverage of Traditional Health Care Practices that could be provided at Indian Health Service (IHS) and Tribal facilities, recommendations on provider qualifications, and monitoring and evaluation criteria. As part of its responses, NCUIH requested that CMS include urban Indian organizations (UIOs) in the Proposed Framework because UIOs are critical to providing Traditional Healing services to urban American Indian and Alaska Native populations.

Background

During a March 6, 2024, presentation, CMS provided an overview of the Section 1115(a) demonstration process and a high-level overview of the four pending demonstration proposals to cover Traditional Health Care Practices- Arizona, California, New Mexico, and Oregon. CMS discussed the development of a Proposed Framework for potential coverage of Traditional Health Care Practices, consistent with the authorities in the Indian Health Care Improvement Act. The presented Proposed Framework does not include UIOs as eligible facilities. CMS solicited feedback following the March 2024 presentation and an April 3, 2024, webinar on the Proposed Framework.

For more information on Section 1115 Demonstrations, please click here.

Funding is a Barrier for UIOs to Provide Traditional Healing Services to Native People

Inclusion of UIOs in CMS’ Proposed Framework is critical, as UIOs fill an essential gap in care for American Indian and Alaska Native people living off reservations by providing culturally sensitive and community-focused care options, including traditional healing services and programs. Funding continues to be a barrier for UIOs to provide traditional healing services to their Native patients. They have to work to stretch already limited dollars to include these vital services because healthcare funding sources, including Medicaid, do not adequately reimburse for traditional healing services.

NCUIH’s Requests and Recommendations

In its March 27 comments, NCUIH requested that CMS:

  • Include services delivered at UIOs to American Indian and Alaska Native Medicaid beneficiaries in the Proposed Framework.
  • Host Urban Confers or UIO Listening Sessions Consistently Throughout the Development of the Proposed Framework.

In its April 29, comments NCUIH recommended that CMS:

  • Include Traditional Healing services provided at UIOs in the Proposed Framework.
    • Allow Tribes, UIOs, and States the flexibility to develop a solution which serves all American Indian and Alaska Native beneficiaries.
    • Ensure the Proposed Framework reflects the requests of Tribes and UIOs.
    • Ensure the Proposed Framework does not create inequities in care.
  • Respect confidentiality for Traditional Healers and Traditional Healing practices.
  • Engage with UIOs by hosting an Urban Confer and continue to engage with Tribes.

NCUIH will continue to monitor the development of the Proposed Framework and advocate for UIO inclusion.

20 Senators Request Increased Resources and Stable Funding for Urban Indian Health in FY 2025

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On May 14, 2024, 20 Senators requested up to $965.3 million for urban Indian health in Fiscal Year (FY) 2025 and advance appropriations for the Indian Health Service (IHS).

Sen. Tina Smith (D-MN) and 19 other Senators sent a letter to Chairman Jeff Merkley (D-OR) and Ranking Member Lisa Murkowski (R-AK) of the Senate Interior Appropriations Committee requesting up to $965.3 million for urban Indian health as part of the Tribal Formulation Workgroup’s topline request of $53.85 billion for IHS in FY 2025. The letter also requests the Appropriations Committee maintain advance appropriations for IHS for FY26. The letter emphasizes the critical role that Urban Indian Organizations (UIOs) play in the health care delivery to American Indian and Alaska Native patients and the importance of providing UIOs with the necessary funding to continue to provide quality, culturally competent care to their communities. On May 1, 2024, a group of 52 Representatives sent a letter to the House Interior Appropriations Committee with the same requests.

The letter also notes that chronic underfunding of IHS and urban Indian health has contributed to the health disparities among American Indian and Alaska Native people living in urban areas that suffer greater rates of chronic disease, infant mortality, and suicide compared to other populations.

This letter sends a clear and powerful message to Chairman Merkley and Ranking Member Murkowski and the members of the Senate that funding for urban Indian health must be significantly increased to fulfill the federal government’s trust responsibility to provide quality healthcare to all American Indian and Alaska Native people.

NCUIH is grateful for the support of the following Senators:

  1. Tina Smith
  2. Tammy Baldwin
  3. Maria Cantwell
  4. Ben Luján
  5. Edward Markey
  6. Alex Padilla
  7. Jack Rosen
  8. Jon Tester
  9. Chris Van Hollen
  10. Elizabeth Warren
  11. Amy Klobuchar
  12. Catherine Cortez Masto
  13. Laphonza Butler
  14. Kyrsten Sinema
  15. Ron Wyden
  16. Mark Kelly
  17. Kirsten Gillibrand
  18. Richard Blumenthal
  19. Tammy Duckworth
  20. Michael Bennet

Full Letter Text

Dear Chairman Merkley and Ranking Member Murkowski,

We write to thank you for your proven commitment to the Indian health system, including Urban Indian Organizations (UIOs), and to request you continue your support by funding urban Indian health at the highest level possible, up to $965.3 million, and retaining advanced appropriations for the Indian Health Service (IHS) in the Fiscal Year (FY) 2025 Interior, Environment, and Related Agencies Appropriations Act.

These requests reflect the full need for urban Indian health determined by the Tribal Budget Formulation Workgroup, which is comprised of Tribal leaders representing all twelve IHS service areas. The Workgroup recommended this funding amount for urban Indian health as a part of a $53.85 billion topline recommendation for the Indian Health Service.

UIOs are an important part of the IHS, which oversees a three-prong system for the provision of health care: Indian Health Service, Tribal Programs, and Urban Indian Organizations (I/T/U).UIOs are on the front lines in working to provide for the health and well-being of American Indians and Alaska Natives living outside of Tribal jurisdictions. They serve patients from over 500 federally recognized Tribal Nations in 38 urban areas across the country. UIOs are not eligible for other federal line items that IHS and Tribal facilities are, like hospitals and health clinics, money, purchase and referred care dollars, or IHS dental services dollars. Therefore, this funding request is essential to providing quality, culturally-competent health care to AI/AN people living in urban areas.

Chronic underfunding of IHS and urban Indian health has contributed to the health disparities among AI/AN people. Additionally, AI/AN people living in urban areas suffer greater rates of chronic disease, infant mortality, and suicide compared to all other populations. Urban Native populations are less likely to receive preventive care and are less likely to have health insurance. Additional funding is critical to addressing this disparity.

In order to fulfill the federal government’s trust responsibility to all AI/AN people to provide quality healthcare, funding for urban Indian health must be significantly increased. It is also imperative that such an increase not be paid for by diminishing funding for already hard-pressed IHS and Tribal providers. The solution to address the unmet needs of urban Native and all AI/AN people is an increase in the overall IHS budget.

Thank you for your continued support of urban Indian health and your consideration of this important request.

Indian Health Service Report Finds that Urban Indian Organization Staff Must Increase by 136% to Meet Patient Demand by 2032

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On April 23, 2024, the Indian Health Service (IHS) Office of Urban Indian Health Programs (OUIHP) released the Urban Indian Organization (UIO) Infrastructure Study Report to Congress Fiscal Year 2023 (“UIO Infrastructure Study”). The report establishes future facility needs for the majority of the 41 UIOs and estimates the operational resources needed to serve each UIO Service Area’s future urban American Indian and Alaska Native population.

Key Findings

Some key findings address UIOs’ future services, staffing needs, operational budget, and facility requirements.

Regarding future services provided at UIOs, the UIO Infrastructure Study stated that “the majority of UIOs emphasize primary medical care services and aspire to be the culturally appropriate medical home for their patient population and community.” UIOs that offer primary care and provided data plan to have staff and resource capacity to support approximately 1,376,000 primary care visits in 2032, an increase from the current rate of approximately 463,000 provider visits per year. “Most UIOs see themselves offering a broader spectrum of outpatient services in the future to provide their patients with a one-stop shop of services.”

To reach the UIOs’ 2032 goals, the 39 UIOs that provided staffing data would need to grow from 3,420 Full-Time Equivalents (FTEs) to 6,275 FTEs, which is a 78% increase. “For overall patient service demand, the number of FTEs would need to grow to 8,083.” To fund the 2032 vision, IHS “contract and grant funding provided annually would need to increase by $1.37 billion for the Urban Indian population portion and overall would need to increase by $1.81 billion.” Lastly, UIOs need an additional 2.75 million building gross spare feet (BGSF) which would require $2.95 billion for facility design and construction and $4.4 billion to replace the entire inventory of UIOs’ space.

Background

In 2021, Congress allocated $1 million in funds for IHS to conduct an Urban Indian Infrastructure study through the Consolidated Appropriations Act, 2021. The purpose of the Infrastructure Study is to further understand the most critical deficiencies facing UIOs. IHS contracted with The Innova Group, a healthcare consultancy entity, to conduct the Infrastructure Study. On March 15, 2022, Congress provided $800,969 in additional funding to IHS for the Infrastructure Study through the Consolidated Appropriations Act, 2022.

NCUIH’s Advocacy

On August 23, 2022, NCUIH submitted comments to IHS in response to the June 16, 2022, Dear Urban Indian Organization Leader letter regarding the use of funding available for the Urban Indian Infrastructure Study.

NCUIH continues to advocate for transparency in the process of the UIO Infrastructure Study and greater support to address the critical infrastructure needs at UIOs. NCUIH will continue to keep UIOs informed as more information is made available from IHS.

New Medicaid Rule Emphasizes Mandate that States Must Consult with Tribes and UIOs

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On May 10, 2024, the Centers for Medicare and Medicaid Services (CMS) issued a final rule regarding ensuring access to Medicaid services. This final rule addresses access to care, quality and health outcomes, and better addressing health equity issues in the Medicaid program across fee-for-service (FFS), managed care delivery systems, and in home and community-based services (HCBS) programs. While the final rule was not responsive to comments submitted by the National Council of Urban Indian Health (NCUIH), CMS stated that states with one or more urban Indian organizations (UIOs) that furnish health care services must consult with the UIO(s) on a regular, ongoing basis. UIOs are also eligible to be on states’ Medicaid Advisory Committees (MACs).

Background

On May 3, 2023, CMS issued the proposed rule on ensuring access to Medicaid services. The proposed rule included both proposed changes to current requirements and newly proposed requirements that would advance CMS’s efforts to improve access to care, quality, and health outcomes, and better promote health equity for Medicaid beneficiaries across FFS and managed care delivery systems, including for home and community-based services provided through those delivery systems. These proposed requirements were intended to increase transparency and accountability, standardize data and monitoring, and create opportunities for states to promote active beneficiary engagement in their Medicaid programs.

NCUIH’s Advocacy and CMS’ Response

On July 3, 2023, NCUIH submitted written comments and recommendations to CMS Administrator, Chiquita Brooks-LaSure, in response to the May 2, 2023, request for comment on the CMS proposed rule regarding ensuring access to Medicaid services. In its comments, NCUIH asked that CMS:

  • Ensure UIO and American Indian and Alaska Native representation on each state Medicaid Advisory Committee (MAC) and Beneficiary Advisory Group (BAG)—now called the Beneficiary Advisory Council (BAC).
  • Ensure the rule does not impose additional burdensome reporting requirements on providers.
  • Engage with the Tribal Technical Advisory Committee (TTAG) to consider regulations or guidance to enforce the state consultation and confer requirements.
  • Support 100% Federal Medical Assistance Percentage (FMAP) for Medicaid services provided at UIOs to ensure American Indian and Alaska Native Medicaid beneficiaries receive appropriate, quality culturally competent care.

NCUIH will continue to advocate for CMS to ensure UIO American Indian and Alaska Native beneficiaries have continued access to Medicaid services.