VA Approves Copay Exemption for American Indian and Alaska Native Veterans

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On April 3, 2023 the Department of Veterans Affairs (VA) announced that American Indian and Alaska Native (AI/AN) veterans are exempt from copay requirements for urgent care or healthcare provided by VA. Under this new policy, the VA will reimburse copays paid on or after January 5, 2022, and it will waive future copays for AI/AN veterans. VA Secretary Denis McDonough stated “American Indian and Alaska Native Veterans deserve access to world-class health care for their courageous service to our nation. By eliminating copays, we are making VA health care more affordable and accessible — which will lead to better health outcomes for these heroes.” For years, the National Council of Urban Indian Health (NCUIH) has worked to remove copayment barriers for AI/AN veterans at the VA and recently provided comments to the VA’s Proposed Rule on the Copayment Exemption for AI/AN Veterans and was successful in getting the agency to remove a proposed cap on the amount of urgent care visits which qualify for the exemption. This is a significant victory that will directly impact the level of access to health care for AI/AN veterans. Current eligibility for the copay exemption is available to AI/AN Veterans who met the definition of “Indian” or “urban Indian” under the Indian Health Care Improvement Act.

Background

The copay exemption is a significant step to upholding the federal government’s trust responsibility to “maintain and improve the health of the Indians.” AI/ANs serve in the military at one of the highest rates of any group in the United States and many Native veterans receive healthcare from the Veterans Health Administration, an agency within VA, in addition to utilizing IHS, Tribal, and UIO facilities. Unfortunately, AI/AN veterans generally have a higher prevalence of mental health disorders compared with White veterans, and among all veterans, the prevalence of suicidal ideation is highest for those reporting a diagnosis of depression, anxiety, or post-traumatic stress disorder. Further, an estimated 86.2 percent of AI/AN veterans that live in urban areas generally have higher unemployment, lower education attainment, lower income, higher VA-service connected disability, and generally live in poorer housing conditions than non-Native veterans also living in urban areas.

NCUIH’s Role

NCUIH continuously advocates for Native veterans living in urban areas to ensure that they have access to the high-quality, culturally competent care the country owes to them for their military service and as a result of federal trust responsibility. In February 2023 NCUIH submitted comments to the VA regarding the copay exemption proposed rule and expressed VA copayments have historically represented a significant barrier to AI/AN veterans’ ability to access the healthcare this Nation owes them through VA facilities. NCUIH further recommended VA utilize self-attestation in determining eligibility for copay exemptions, VA cover all urgent care visits needed by Indian or urban Indian veterans, VA make clear that the copay exemption exists because of the trust responsibility, and VA host an Urban Confer and Tribal Consultation on the copay exemption. NCUIH appreciates the VA’s commitment to ensuring quality health care is more accessible for Indian and urban Indian veterans.

Medicaid and CHIP Enrollment Surges Amid Pandemic, Native People at Risk as Federal Continuous Enrollment Provision Expires

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Preliminary data for December 2022 shows that total Medicaid and CHIP enrollment grew by 21.2 million to a total of 92.3 million since February 2020. KFF estimates that Medicaid/CHIP enrollment will reach 95 million by March 2023.  This increase in enrollment is due, in part, to the continuous enrollment provision created by the Families First Coronavirus Response Act (FFCRA), which generally barred states from disenrolling Medicaid enrollees in exchange for receiving a temporary increase in the federal match rate. The federal continuous enrollment provision expired on March 31, 2023, meaning that states can now resume disenrollments, which had been paused since Congress passed FFCRA in March 2020. The Affordable Care Act (ACA) Medicaid expansion adults, other adults, and children experienced the most growth due to the continuous enrollment provision and are expected to see the largest enrollment declines after disenrollments resume.  Studies estimate that between 5% and 17% of current enrollees may lose their Medicaid coverage.

Increase in enrollment is concentrated in a small number of states with large populations, and therefore large Medicaid programs. One-third of the increase is found in California, New York, Texas, Florida, and Illinois. States who have implemented Medicaid expansion after 2020 – Oklahoma, Missouri, Nebraska, Utah, and Idaho – also have high enrollment growth. According to KFF “[h]ow states manage the large numbers of redeterminations during the “unwinding” of the continuous enrollment provision as well as how states engage with enrollees and other stakeholders, will impact the continuity of coverage for millions of Medicaid enrollees.”

Estimated Enrollment Growth From February 2020 to March 2023, by Eligibility Group and State

State CHIP Enrollees Children Under 19 ACA Adults Other Adults Adults Eligible Based on Disability or Age (65+) All
Arizona 42,300 223,300 221,100 159,700 -8,800 637,600
California -39,100 606,200 1,486,000 789,500 -13,100 2,829,500
Colorado -25,500 116,800 252,900 136,200 -16,000 464,400
Illinois -25,700 257,800 641,000 121,900 32,500 1,027,500
Kansas 19,100 71,100 N/A 42,800 11,000 144,000
Maryland 19,800 96,300 166,600 125,400 -14,400 393,700
Massachusetts 2,000 93,600 161,800 135,700 51,300 444,400
Michigan 57,100 154,200 369,500 187,200 22,100 790,100
Minnesota 600 121,900 117,000 111,400 8,800 359,700
Montana 2,100 17,500 46,600 14,000 -4,000 76,200
Nebraska 5,000 35,600 78,000 15,000 10,500 144,100
Nevada 10,900 70,200 164,300 54,900 -9,600 290,700
New Mexico 10,000 49,600 93,400 39,300 -18,500 173,800
New York -59,500 320,400 895,800 452,200 -2,400 1,606,500
Oklahoma 7,000 148,100 293,100 74,700 59,600 582,500
Oregon 47,900 31,200 241,500 103,400 -27,000 397,000
South Dakota 2,500 21,100 N/A 9,900 3,700 37,200
Texas -97,000 1,090,300 N/A 323,600 242,500 1,559,400
Utah -6,700 65,200 49,900 44,700 22,100 175,200
Washington 3,200 103,900 347,500 60,500 -8,700 506,400
Wisconsin 12,300 132,200 N/A 208,900 47,500 400,900
Medicaid Unwinding and American Indians and Alaska Natives (AI/ANs)

Native people may be at an increased risk of disenrollment in Medicaid and CHIP programs during the Medicaid unwinding period. Once disenrollments are completed, estimates say 12% of AI/AN children and 6% of AI/AN adults will lose CHIP or Medicaid coverage. There are also administrative barriers that may lead to a higher risk of losing coverage, such as geographical remoteness, limited access to internet or phone service, and language barriers.

Patients at Urban Indian Organizations (UIOs) may lose their Medicaid coverage as a result of the unwinding, and inadequate health insurance coverage or gaps in coverage may cause UIO patients to delay or avoid medical care altogether.  The federal government has a trust responsibility to provide federal health services to maintain and improve the health of AI/AN people. Medicaid and CHIP are critical to fulfilling the United States’ trust responsibility to maintain and improve AI/AN health.  NCUIH recently led over 200 organizations in urging the Administration to take concrete steps to ensure that eligible individuals and families do not lose Medicaid/CHIP coverage for purely administrative reasons during the unwinding period. You can read more about this effort here.

NCUIH Urges Senate and House Appropriations Committees to Provide Full Stable Funding for IHS and Urban Indian Health in FY 2024

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On April 8, 2023, the National Council of Urban Indian Health (NCUIH) sent a letter to Chairman Jeff Merkley (D-OR) and Ranking Member Lisa Murkowski (R-AK) of the Senate Interior Appropriations Committee requesting full funding for the Indian Health Service (IHS) and urban Indian health, advance appropriations for IHS, and resources for Native behavioral health in Fiscal Year (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.

The letter emphasizes the critical role that urban Indian organizations (UIOs) play in health care delivery to American Indian and Alaska Native (AI/AN) patients and the importance of providing UIOs with the necessary funding to continue to provide quality, culturally competent care to their communities. The requests included in the letter are efforts to achieve parity and uphold the federal trust responsibility for urban Natives.

In the letters, NCUIH requested the following:

  • $51.42 billion for IHS and $973.59 million for Urban Indian Health for FY24, 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

These requests come at an important time to protect funding for urban Indian health. Current debt ceiling negotiations by Congress include proposals to cut spending for domestic programs and return funding for federal agencies to FY 2022 levels. These proposals would be detrimental to the success of IHS, Tribal organizations, and UIOs and would roll back historic funding levels that contribute to better health outcomes for Native communities. It is important that members of the House and Senate work to protect the health of all American Indians and Alaska Natives.

Full Letter Text

On behalf of the National Council of Urban Indian Health (NCUIH), the national advocate for health care for the over 70% of American Indians and Alaska Natives (AI/ANs) living off-reservation and the 41 Urban Indian Organizations (UIOs) that help serve this population, we write to respectfully request that Congress honor the federal trust responsibility by ensuring the following asks for Indian Country in Fiscal Year (FY) 2024:

  • $51.42 billion for the Indian Health Service (IHS) and $973.59 million for Urban Indian Health for FY24, 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

We applaud the Committee’s longstanding leadership to ensure the trust responsibility for health care is upheld and honored for all AI/AN, especially last year with achieving advance appropriations for IHS.

UIOs Play a Critical Role in Providing Health Care for AI/ANs

UIOs are on the front lines in providing for the health and well-being of AI/ANs living off-reservation, many whom lack access to care that would otherwise be provided through on-reservation health care facilities. UIOs play a critical role in fulfilling the federal government’s responsibility to provide healthcare for AI/ANs and are an integral part of the Indian health system, which is comprised of the IHS, Tribal organizations, and urban Indian organizations (collectively, the I/T/U system). UIOs are critical health care access points to help serve the over 70% of AI/ANs in urban areas. Congress must do more to fully fund the IHS to improve health outcomes for all Native populations.

Need for Full Funding of the Indian Health System including Urban Indian Health

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.” This requires that funding for Indian health must be significantly increased if the federal government is to finally fulfill its trust responsibility. At a minimum, funding must be maintained and protected as budget-cutting measures are being considered. UIOs are reporting historic levels of patients, need funding to fulfill the needs of the majority of the AI/AN population. Full funding will empower UIOs to hire more staff, pay appropriate wages, as well as expand vital services, programs, and facilities. Congress must do more to increase funding as the current FY23 funding level of $90.49 million which is only 9.3% of the full FY24 amount requested by Tribes and UIOs to meet current need.

Retain Advance Appropriations for IHS until Mandatory Funding is Enacted and Protect IHS from Sequestration

We applaud this Committee for your work on the historic inclusion of advance appropriations in the FY23 Omnibus.  This is a crucial step towards ensuring long-term, stable funding for IHS. Previously, the I/T/U system was the only major federal health care provider funded through annual appropriations. It is imperative that this Committee retain advance appropriations and ensure that IHS is protected from sequestration.

The GAO cited a lack of consistent funding as a barrier for IHS. The Congressional Research Service stated that advance appropriations would lead to cost savings as continuing resolutions (CRs) “prohibits the agency from making longer-term, potentially cost-saving purchases.” Lapses in federal funding quite literally put lives at risk. During the shutdown at the start of FY 2019, the Indian health system was the only federal healthcare entity that shut down. UIOs are so chronically underfunded that several UIOS had to reduce services, lose staff, or close their doors entirely, forcing them to leave their patients without adequate care. It is imperative that advance appropriations provide certainty to the IHS system and ensure unrelated budget disagreements do not put lives at stake.

Advance appropriations will improve accountability and increase staff recruitment and retention at IHS. When IHS distributes their funding on time, our UIOs can pay their doctors and providers. During a pandemic that has ravaged Indian Country and devasted the workforce, being able to recruit doctors and pay them on time is a top priority.

While advance appropriations are a step in the right direction to avoid disruptions during government shutdowns and continuing resolutions (CRs), mandatory funding is the only way to assure fairness in funding and fulfillment of the trust responsibility. Until authorizers act to move IHS to mandatory funding, we request that Congress continue to provide advance appropriations to the Indian health system to improve certainty and stability.

Cuts from sequestration, the automatic spending cuts that occur through the withdrawal of funding for government programs, force I/T/U providers to make difficult decisions about the scope of healthcare services they can offer to Native patients. For example, 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. Therefore, we request that you exempt IHS from sequestration and other budget cutting measures as is required by the trust responsibility.

Appropriate $80 Million for the Native Behavioral Health Resources Program

Native people continue to face high rates of behavioral health issues caused by generational trauma and federal policies. Native people experience serious mental illnesses at a rate 1.58 times higher than the national average, and high rates of alcohol and substance abuse. In fact, between 1999 and 2015, the drug overdose death rates for Native populations increased by more than 500%. Native youth also experience the highest rates of suicide and depression, with the Native youth suicide rate being 2.5 times that of the national average.

In response to these chronic health disparities, Congress authorized $80 million to be appropriated for the Native Behavioral Health Resources Program for fiscal years 2023 to 2027. Despite authorizing an appropriation of $80 million for the Program, Congress did not appropriate that sum for FY 23.

We request that the authorized $80 million be appropriated to the Native Behavioral Health Resources Program for FY 24 and each of the remaining authorized years. Until the committee appropriates funding for this program, critical healthcare programs and services cannot operate to their full capability, putting Native lives at-risk. We ask that this essential step is taken to ensure our communities have access to the care they need.

Conclusion

Among the most sacred of the duties encompassed within the federal trust responsibility is the duty to provide for Indian health care. The United State’s failure to fulfill its obligations to provide health care to urban Indians has real and devastating effects on our communities. We urge Congress to act swiftly to redress this problem by appropriating $51.42 billion for the Indian Health Service and $973.59 million for Urban Indian Health in the FY24 Interior, Environment, and Related Agencies Appropriations. NCUIH looks forward to working with you as you craft a budget that upholds the trust responsibility to urban Indians.

Resources

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. 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. President Biden has indicated that he would veto the legislation should it pass through Congress.

In response to the proposed legislation, the National Council of Urban Indian Health (NCUIH) Chief Executive Officer, Francys Crevier (Algonquin) stated, “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.”

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. 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.

NCUIH is collaborating with Congressional leaders to safeguard Indian health funding, which faces potential reductions amidst the current budgetary deliberations. On March 24, 2023, a bipartisan group of 38 Congressional leaders submitted a letter stating, “Cuts from sequestration force [Indian Health Service, Tribal Programs, and UIOs] to make difficult decisions about the scope of healthcare services they can offer to Native patients…At a minimum, funding must be maintained and protected as budget-cutting measures are being considered.”

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

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

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The loss of coverage may exacerbate the significant healthcare disparities faced by Native communities.   

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

WASHINGTON, D.C. (April 24, 2023) – Today, the National Council of Urban Indian Health (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. 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. 

Impact on Native Health 

In 2019, Medicaid covered 1.3 million urban American Indians and Alaska Natives (AI/ANs), including 30% of urban AI/AN adults under age 65.1 Comparatively, Medicaid covered 19.8% of all urban U.S. adults under age 65.2 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. AI/ANs may be at an increased risk of losing Medicaid and CHIP coverage due to administrative barriers during the unwinding. AI/AN beneficiaries face several challenges in enrolling or retaining coverage such as geographical remoteness, limited access to internet or phone service, and language barriers. 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.   

The federal government has a trust responsibility to provide federal health services to maintain and improve the health of AI/AN people. Medicaid and CHIP are critical to fulfilling the United States’ trust responsibility to maintain and improve AI/AN health. Patients at Urban Indian Organizations (UIOs) may lose their Medicaid coverage as a result of the unwinding, and inadequate health insurance coverage or gaps in coverage may cause UIO patients to delay or avoid medical care altogether.  

Requests to the Administration in the Letter  

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. 

Background on Medicaid Unwinding 

In response to the COVID-19 pandemic, Congress passed a “continuous coverage” requirement which required states to keep beneficiaries continuously enrolled in Medicaid through the end of the COVID-19 public health emergency in return for enhanced federal funding. The Consolidated Appropriations Act of 2023 set an end date for the requirement on March 31, 2023, meaning that states may resume reviewing all Medicaid enrollees’ eligibility for coverage, a process referred to as “unwinding,” on April 1, 2023. As states begin these redeterminations, millions of eligible families, including AI/ANs, could lose coverage due to administrative barriers even though they are still eligible for Medicaid coverage. According to HHS, 15 million people could lose their current Medicaid or CHIP coverage.

Full Letter Text

The Honorable Xavier Becerra
Secretary, Department of Health and Human Services
200 Independence Ave., SW
Washington, D.C. 20201 

 

Dear Secretary Becerra: 

In just two years, the Biden-Harris Administration has made incredible progress promoting health equity and bringing millions of people the financial security and health care access that result from high-quality, affordable health coverage. We are grateful for your team’s extraordinary work, led by Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure and Deputy Administrators Daniel Tsai and Ellen Montz, to preserve struggling families’ health care as Medicaid continuous coverage requirements unwind. 

In light of these accomplishments, we remain concerned that unwinding could cause the largest Medicaid losses in history, with disproportionate harm experienced by communities of color, mothers, and children. To prevent a civil rights and health equity disaster, we urge you to make the strongest possible use of the powers recently granted by Congress for holding states accountable to preserve eligible families’ health care. 

Without vigorous federal intervention, state Medicaid programs are likely to operate as they did in the past. If that happens during the unwinding, the Assistant Secretary of Planning and Evaluation (ASPE) projects that 15 million people will be terminated. Such losses would greatly exceed the largest previous annual drop in Medicaid coverage, when the number enrolled fell by 2 million in 2018 and again in 2019. 

Unprecedented Medicaid terminations, focused on historically disadvantaged communities, would deepen already severe health inequities. More than half of those whom ASPE expects to lose Medicaid are people of color, including nearly 5 million Latinos, more than 2 million African Americans, and almost 1 million Asian Americans and Pacific Islanders. Other research suggests that nearly 7 million children are at risk of losing coverage, and that children of color are particularly vulnerable. Among all Black children in America, 13% will lose Medicaid if the program operates as it did in the past, as will 12% of all Native American children, 12% of all Latino children, 10% of all children who are Native Hawaiians or Pacific Islanders, and 6% of all Asian American children in the United States. 

Needless red tape and bureaucracy threaten to take a terrible toll. More than half of all people of color and three- fourths of all children losing Medicaid will remain eligible but be terminated because of state administrative requirements, according to ASPE. These projections fit recent history, when states like Tennessee, Texas, and Utah redetermined numerous families and saw huge coverage losses. In each state, more than 80% of all terminated families were dropped only because the state did not receive a response to its requests for information. This happened when forms were mailed to the wrong address or never delivered, the family did not understand the forms, the family could not reach a Medicaid call center to provide requested information, renewal procedures were not accessible to people with limited English proficiency or people with disabilities, or for other reasons. 

The Consolidated Appropriations Act, 2023, (CAA) gave you unprecedented authority to prevent such patterns from recurring on a vastly larger scale during the unwinding. If a state does not fulfill “all Federal requirements applicable to Medicaid redeterminations,” CMS can require a corrective action plan, reduce the state’s federal matching rates, impose civil monetary penalties, or place procedural terminations on “hold” pending corrective action. 

While many important strategies can limit coverage loss, such as measures to facilitate a smooth transition from Medicaid to CHIP, the Marketplace, or employer-based coverage, we urge you to take four key steps to prevent a tidal wave of paperwork terminations from ending health care for millions of eligible families: 

First, CMS mitigation plans should prevent states from wrongfully terminating beneficiaries for purely procedural reasons. CMS is working with states to remedy longstanding violations of federal legal requirements. If a state is implementing a “mitigation plan” to fix those violations, CMS will not use its CAA authority to cut federal matching rates. For a state to benefit from sanction suspension, we believe it should be barred from ending families’ coverage due to legal violations that have not yet been fixed. Accordingly, when a state’s violations threaten to cause procedural terminations of eligible people, its mitigation plan should forbid procedural terminations until the violations end. 

Second, CMS should hold state and local Medicaid agencies accountable for compliance with civil rights laws. In 5131(a)(4) and (b), the CAA authorizes CMS to use all enforcement tools if a state violates any “Federal requirement applicable to eligibility redeterminations.” Such requirements include regulations under Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act barring practices that have discriminatory effects, based on race or national origin, unless those practices are necessary to accomplish a substantial legitimate objective. The Administration has already made clear that a failure to make redetermination processes accessible to people with limited English proficiency and to people with disabilities violates federal civil rights laws. Those laws can also be violated by other renewal practices that threaten to trigger significant procedural terminations with discriminatory effects, such as:

  • Underfunding of call centers that causes prolonged delays and effectively prevents telephonic renewal. Families of color disproportionately need fully accessible call centers, as such families face systemic barriers to receiving and providing information on-line and in-person. Compared to others, people of color are less likely to have broadband access, digital fluency, and jobs that provide paid time off to meet with Medicaid staff. 
  • Using complex language on essential forms and notices that is incomprehensible to people with low literacy skills, who disproportionately include people of color and immigrants. 
  • Refusing to let Medicaid plans and providers help their members and patients renew coverage, including through completing forms telephonically. Without one-on-one assistance completing renewal forms that could be at least 8 pages long—longer than the long-form federal income tax return—families of color will suffer disproportionate terminations. As the White House Office of Management and Budget observed, administrative burdens like form completion “do not fall equally on all entities and individuals, leading to disproportionate underutilization of critical services…, often by the people and communities who need them the most. Burdens that seem minor … can have substantial negative effects for individuals already facing scarcity.” 

Third, CMS should promote transparency and accountability by publishing state unwinding and performance indicator data as soon as possible. Without rapid publication, stakeholders may be unable to intervene in time to prevent significant coverage losses. The consequences of delayed publication could be particularly serious in many of the states where most Medicaid beneficiaries are people of color. To prevent rapid, inequitable losses, CMS cannot let the risk of data errors deter the prompt release of preliminary numbers. Instead, CMS should publish state reports as soon as possible, noting that the numbers are preliminary and subject to later correction. America has long used this approach for employment statistics, releasing each month’s preliminary numbers during the first week of the following month. 

Fourth, CMS should hold states accountable for renewing coverage based on data matches “to the maximum extent practicable,” as required by Affordable Care Act (ACA) §1413(c)(3). This requirement, which applies to all beneficiaries, including older adults and people with disabilities, eliminates the need for eligible people to complete paperwork. Any state with data-based renewal rates far below its peers is, by definition, failing to achieve such rates at “maximum practicable” levels. We believe longstanding problems with a state’s eligibility system should not affect CMS’s determination of the maximum practicable level of data-based renewals. A state’s past refusals to modernize its systems should not be rewarded by lessening the state’s duties to protect its residents. Eligible people must not be terminated because they did not complete paperwork telling the state what it should have been able to learn on its own. 

The steps we urge would protect the Biden-Harris Administration’s extraordinary legacy of bringing quality, affordable health coverage to more people than ever before in our country’s history. Please know that the undersigned organizations stand ready to support your efforts to protect the more than 90 million people in America who now rely on Medicaid and CHIP for their health care. For further information, please feel free to contact Joyce Liu at the Asian & Pacific Islander American Health Forum (jliu@apiahf.org),  Deborah Weinstein at the Coalition on Human Needs (dweinstein@chn.org), Peggy Ramin at the Leadership Conference on Civil and Human Rights (ramin@civilrights.org), Lisa Malone at NAACP (lmalone@naacpnet.org), Chandos Culleen at the National Council of Urban Indian Health (cculleen@ncuih.org), Morgan Polk at the National Urban League (mpolk@nul.org), Andrea Harris at Protect Our Care (aharris@protectourcare.org), or Stan Dorn at UnidosUS (sdorn@unidosus.org). 

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About NCUIH 
The National Council of Urban Indian Health (NCUIH) is the national non-profit organization devoted to the support and development of quality, accessible, and culturally competent health and public health services for American Indians and Alaska Natives (AI/ANs) living in urban areas. NCUIH is the only national representative of the 41 Title V Urban Indian Organizations (UIOs) under the Indian Health Service (IHS) in the Indian Health Care Improvement Act (IHCIA). NCUIH strives to improve the health of the over 70% of the AI/AN population that lives in urban areas, supported by quality, accessible health care centers.   

NCUIH Joins Families USA and 230 other Partner Organizations in Sending a Letter to Congress to Protect Medicaid from Cuts

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On April 20, 2023, Families USA, with 230 national and state partner organizations, including the National Council of Urban Indian Health (NCUIH), sent a letter to Majority Leader Schumer, Minority Leader McConnell, Speaker McCarthy, and Minority Leader Jefferies to protect Medicaid from proposed cuts amid debt limit negotiations. This letter is important to show opposition to any cuts to a critical program for the health of 91 million Americans with Medicaid coverage.

The letter highlights the need to protect Medicaid coverage as it provides healthcare access to populations that the American Healthcare System historically underserves, including 1.8 million  American Indians and Alaska Natives (AI/ANs), communities of color, and vulnerable populations such as seniors and people with disabilities.

Medicaid is critical to fulfilling the United States’ trust responsibility to maintain and improve AI/AN health. Cuts to Medicaid can result in patients at Urban Indian Organizations (UIOs) having inadequate health insurance coverage or gaps in coverage may cause UIO patients to delay or avoid medical care altogether.

Full Letter Text

Dear Majority Leader Schumer, Minority Leader McConnell, Speaker McCarthy, and Minority Leader Jeffries:

As leading national, state, and local organizations dedicated to promoting the health and well-being of America’s families, we are writing to underscore the critical importance of the Medicaid program and to express our united opposition to any proposals to cut Medicaid funding as part of upcoming negotiations over the federal budget, debt limit, or any other legislative priorities. We urge you to protect this vital program from cuts or harmful changes in any budget negotiations or other legislative venue this year.

Our health should not depend on our wealth in this country. Efforts to undermine Medicaid would harm millions of families whose health hangs in the balance when they cannot get the care they need otherwise. Medicaid is a lifeline to 91 million Americans, providing insurance coverage for millions of children, veterans, and people who own and work at small businesses. The program is a critical source of coverage to people who have historically been egregiously underserved by our health care system including people of color, particularly in Black, Latino, Asian American, Native Hawaiian and Pacific Islander, and Indigenous communities, and people living in rural communities. It provides health insurance to 6.9 million seniors and over 10 million people with disabilities, and covers 54 percent of long-term care services and 42 percent of all births in the country. Additionally, more than 60 percent of adults with disabilities qualified for Medicaid without supplemental security income (SSI), largely through Medicaid expansion under the Affordable Care Act (ACA).

The evidence is clear that when people have a reliable source of high-quality health coverage, they can access critical health services, including preventive care and behavioral health services; experience improved health outcomes and better overall health; and are protected against unexpected medical expenses. After the upheavals associated with the COVID-19 epidemic over the past three years, it is clearer than ever how critical Medicaid is to our country’s health and financial well-being.

In recent years, proposals to cut the Medicaid program have been thinly disguised as policies such as “per capita spending caps,” “block grants,” “provider tax reforms,” and bureaucratic “work requirements.” Since the passage of the ACA thirteen years ago, there have been continued attempts to repeal or otherwise undermine Medicaid expansion, which covers 18 million people in 40 states and Washington D.C., many of whom would otherwise go uninsured. No matter how they are framed, the reality of these policy proposals is that they destabilize state budgets and local economies, take health care away from millions of children, older adults, working parents, people with disabilities, and people of color with cascading harmful effects on small businesses, rural communities, health care providers and others.

These ideas are not new: they were resoundingly rejected by people across the country when they were proposed as part of efforts to repeal the ACA in 2017. Unsurprisingly, the American public continues to strongly oppose them – new polling shows that 71 percent of Americans say it is important to prevent Medicaid cuts. Our collective message is as clear today as it was then: cuts to the Medicaid program are unacceptable.

Background

Medicaid: A Critical Source of Coverage for AI/ANs

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. According to a NCUIH analysis of American Community Survey (ACS) data, in 2019 Medicaid covered 1.3 million urban AI/ANs, including 30% of urban AI/AN adults under the age of 65. Medicaid and CHIP are important programs for addressing the significant disparities in insurance coverage which exist for AI/AN people.  For example, according to the Urban Institute, AI/AN children were uninsured at a rate of 8.9% in 2019, the highest rate for any ethnic group in the country.  AI/AN parents were uninsured at a rate of 18.7% in 2019, the second highest rate in the country. The Urban Institute reported that in 2019, AI/AN children remained more than twice as likely as white children to be uninsured and AI/AN were more than 2.5 times more likely to be uninsured than with white parents.

Medicaid is also an important source of funding for to support the operation of the Indian Health system, including UIOs  who help serve the approximately 70% of AI/AN people who live in urban areas.  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. As the Kaiser Family Foundation noted in 2017, “Medicaid funds are not subject to annual appropriation limits . . . since Medicaid claims are processed throughout the year, facilities receive Medicaid funding on an ongoing basis for covered services provided to AIANs.”  Because the Medicaid program receives Mandatory appropriations, Medicaid revenue is particularly essential for Indian health providers when IHS funding is reduced or interrupted by budgetary disagreements.

Representative Grijalva Introduces NCUIH-Endorsed Bill to Extend Federal Health Benefits to Urban Indian Organizations and Tribal Colleges and Universities

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On April 5, 2023, Representative Raúl M. Grijalva (D-AZ) introduced H.R. 2376, a bill that extends federal employee health benefits (FEHB) and dental and vision insurance to employees of urban Indian Organizations (UIOs) and Tribal Colleges and Universities (TCUs). Currently, UIOs and TCUs are considered public service employees, yet are largely ineligible for both FEHB and dental and vision insurance. Original co-sponsors of this bill include Rep. Stansbury (D-NM), Rep. Porter (D-CA), and Rep. Moore (D-WI).

The National Council of Urban Indian Health (NCUIH) worked closely with Representative Grijalva on this legislation to ensure UIOs were appropriately included in the expansion of this program. This legislation is an important step towards fulfilling the federal trust responsibility and ensuring UIO employees have parity with all public service employees.

“Employees at Urban Indian Organizations and Tribal Colleges and Universities are providing an invaluable service to better public health and education in Indian Country—they deserve to receive the same benefits as other public service employees.” – Representative Grijalva

“Access to the Federal Employee Health Benefits program has been instrumental to the Nebraska Urban Indian Health Council’s ability to provide our employees with quality health benefits. Expanding our access to dental and vision coverage will allow us to provide our employees with comprehensive coverage from a single source. We are grateful to Rep. Grijalva for introducing this legislation and for expanding care to ensure that urban Indian organizations are eligible for the program.” – Dr. Donna Polk, CEO of the Nebraska Urban Indian Health Council, a member organization of NCUIH

This bill has been endorsed by NCUIH, American Indian Higher Education Consortium (AIHEC), and Dr. Sandra Boham, President of Salish Kootenai College in Pablo, Montana.

Next Steps

The bill was referred to the House Energy and Commerce, Natural Resources, and Oversight and Accountability Committees. It currently awaits consideration.

Resources

11 Senators Request Increased Resources for Urban Indian Health in FY24

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On April 4, 2023, 11 Senators requested up to $973.59 million for urban Indian health in Fiscal Year (FY) 2024 and advance appropriations for the Indian Health Service (IHS).

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 requesting up to $973.59 million for urban Indian health in FY 2024 and maintaining advance appropriations for IHS. The letter emphasizes the critical role that urban Indian organizations (UIOs) play in health care delivery to American Indian and Alaska Native (AI/AN) patients and the importance of providing UIOs with the necessary funding to continue to provide quality, culturally-competent care to their communities. The National Council of Urban Indian Health (NCUIH) worked closely with the Senators on leading this letter to push for stable funding for IHS and the Tribal Formulation Workgroup’s requests of full funding for urban Indian health. On March 24, 2023, a group of 38 Representatives sent a letter to the House Interior Appropriations Committee with the same requests.

The letter also notes that while Congress has historically acknowledged that significant health disparities exist in Indian Country, IHS remains underfunded at an estimated $4,000 per patient, with UIOs receiving $726 per patient.

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 AI/AN people.

NCUIH is grateful for the support of the following Senators:

  1. Tina Smith
  2. Tammy Baldwin
  3. Maria Cantwell
  4. Diane Feinstein
  5. Ben Luján
  6. Edward Markey
  7. Alex Padilla
  8. Jacklyn Rosen
  9. Jon Tester
  10. Chris Van Hollen
  11. Elizabeth Warren

Full Letter Text

Dear Chairman Merkley and Ranking Member Murkowski,

We write to thank you for your proven commitment to urban Indian health and the 41 Urban Indian Organizations (UIOs) and to request you continue your support by funding urban Indian health at the highest level possible, up to $973.59 million, and retaining advanced appropriations for the Indian Health Service (IHS) in the Fiscal Year (FY) 2024 Interior, Environment, and Related Agencies Appropriations Act.

UIOs operate 77 facilities across the nation in 22 states, serving the approximately 70 percent of American Indian and Alaska Native (AI/AN) people who live in urban areas. 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 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.

Our request for $973.59 million for urban Indian health reflects the recommendation made by the Tribal Budget Formulation Workgroup (TBFWG), a group of Tribal leaders representing all twelve IHS service areas. The significantly increased request reflects the full funding needed for urban Indian health.

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. Yet, despite the historical acknowledgement from Congress of the significant health care disparities in Indian Country, IHS is underfunded at around $4,000 per patient, and UIOs receive just $726 per patient.

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.

Bipartisan Group of Thirty-Eight Congressional Leaders Request Increased Resources for Urban Indian Health and Support Mandatory Funding for Indian Health in FY24

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On March 24, 2023, 38 Congressional leaders requested up to $973.59 million for urban Indian health in FY24 and maintaining advance appropriations for the Indian Health Service (IHS) until mandatory funding is achieved.

Representatives Gallego and Grijalva again led a letter to Chairman Simpson and Ranking Member Pingree of the House Interior Appropriations Committee requesting up to $973.59 million for urban Indian health in FY24 and maintaining advance appropriations for IHS until authorizers move IHS to mandatory funding. The letter includes the Tribal Budget Formulation Workgroup (TBFWG)’s   findings stating the need for full funding for the urban Indian line item, “Due to historically low funding levels for urban Indian health, UIOs are chronically underfunded. Full funding of UIOs will directly benefit urban Indians that rely on UIOs to access culturally-competent care.”

The National Council of Urban Indian Health (NCUIH) has made continuous efforts to address the health disparities for Natives living in urban areas. Following the pandemic, Native life expectancy has decreased by almost 7 years, coupled with the highest rates of diabetes, infant mortality, and suicide. Despite these staggering statistics, Congress funds the IHS at around 10% of need.

The 38 Congressional leaders stated their support for the Appropriations Committee’s work on the historic inclusion of advance appropriations in the FY23 omnibus. Previously, IHS was the only federal health care provider funded through annual appropriations. Without advance appropriations, IHS is subject to the negative impacts of government shutdowns and continuing resolutions that can lead to serious disruptions in UIO’s ability to provide critical patient services. The inclusion of advance appropriations is a crucial step toward ensuring long-term stable funding for IHS. The letter also emphasizes that the urban Indian line item must be protected from sequestration and any budget-cutting measures being considered in Congress.

This letter sends a powerful and straightforward message to Chairman Simpson and Ranking Member Pingree, and members of Congress that in order to fulfill the federal government’s trust responsibility to all Natives to provide safe and quality healthcare, funding for urban Indian health must be significantly increased and protected.

NCUIH is grateful for the support of the following Representatives:

  1. Don Bacon
  2. Nanette Barragán
  3. Earl Blumenauer
  4. Shontel Brown
  5. Salud Carabjal
  6. Greg Casar
  7. Sharice Davids
  8. Diana DeGette
  9. Ruben Gallego
  10. Steven Horsford
  11. Jared Huffman
  12. Pramila Jayapal
  13. Dusty Johnson
  14. William Keating
  15. Ro Khanna
  16. Teresa Leger Fernandez
  17. Mike Levin
  18. Zoe Lofgren
  19. Doris Matsui
  20. Gwen Moore
  21. Eleanor Holmes Norton
  22. Ilhan Omar
  23. Mary Peltola
  24. Brittany Pettersen
  25. Deborah Ross
  26. Adam Schiff
  27. Kim Schrier
  28. Terri Sewell
  29. Adam Smith
  30. Melanie Stansbury
  31. Greg Stanton
  32. Jill Tokuda
  33. Gabe Vasquez
  34. Jasmine Crockett
  35. Chris Pappas
  36. Raul Ruiz
  37. Jesus “Chuy” Garcia
  38. Raul Grijalva

Full Letter Text

Dear Chairman Simpson and Ranking Member Pingree,

We write to thank you for your proven commitment to urban Indian health and Urban Indian Organizations (UIOs) and to request you continue your support by funding urban Indian health at the highest level possible, up to $973.59 million, and retaining advance appropriations for IHS in the FY 2024 Interior, Environment, and Related Agencies Appropriations Act.

UIOs provide health care for the over 70% of American Indians and Alaska Natives (AI/ANs) living off-reservation and are an important part of the Indian health system, which oversees a three-prong system for the provision of health care: the Indian Health Service, Tribal Programs, and UIOs (I/T/U). UIOs receive direct funding only from the Urban Health line item and do not receive direct funds from other distinct IHS line items, including the Hospital and Health Clinics, Indian Health Care Improvement Fund, Health Education, Indian Health Professions, or any of the line items under the IHS Facilities account.

Our FY24 request for $973.59 million for urban Indian health reflects the recommendation made by the Tribal Budget Formulation Workgroup (TBFWG), which is comprised of sovereign Tribal leaders representing all twelve IHS service areas. For FY23, the House passed $200 million for urban Indian health, reflecting the minimum investment we must make in urban Indian health. The marked increase between the FY23 and FY24 request is a result of Tribal leaders’ decision, over several decades, to provide budget recommendations based on a plan to phase in full funding for IHS and UIOs over 10-12 years to address growing health disparities that have largely been ignored. In FY24, Tribal leaders are unified in their request to fully fund UIO need at $973.59 million.

In its report, the TBFWG states that, “Due to historically low funding levels for urban Indian health, UIOs are chronically underfunded. Full funding of UIOs will directly benefit urban Indians that rely on UIOs to access culturally-competent care.” If urban Indian health funding continues to be funded at its current pace, it will continue to contribute to the severe health disparities. Due to this fact, we respectfully request the highest possible funding for Urban Indian Health up to TBFWG’s recommendation of $973.59 million, and no less than the FY23 House passed level of $200 million.

Underfunding not only impacts day-to-day operations of the 41 UIOs, it has resulted in entire sections of the United States lacking in culturally focused healthcare for AI/ANs living in urban areas. Currently, the entire Eastern seaboard, with an estimated urban Indian population of over 2 million, lacks full-ambulatory UIOs due to insufficient funding. The IHS has deemed the two remaining UIOs on the East Coast to be outreach and referral providers only. Two outreach and referral UIOs to serve all urban Indian patients on the entire East Coast of the country is undeniably inadequate to uphold the federal trust obligation to provide healthcare to AI/ANs. Without a significant increase to the urban Indian line item, UIOs will continue to be forced to operate on limited budgets that offer almost no flexibility to expand services or address facilities-related costs.

We applaud this Committee for your work on the historic inclusion of advance appropriations in the FY23 Omnibus. This is a crucial step towards ensuring long-term, stable funding for IHS. Previously, the I/T/U system was the only major federal health care provider funded through annual appropriations. It is imperative that this Committee retain advance appropriations and ensure that IHS is protected from sequestration.

Cuts from sequestration force I/T/U providers to make difficult decisions about the scope of healthcare services they can offer to Native patients. For example, 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. At a minimum, funding must be maintained and protected as budget-cutting measures are being considered.

We thank you for your consideration of our request to provide as high a funding level as possible for urban Indian health and the 41 Title V UIOs up to $973.59 million, and to retain advance appropriations for IHS in the FY 2024 Interior, Environment, and Related Agencies Appropriations Act.

NCUIH-Endorsed Bipartisan Bill to Elevate Native Health Care Within the Federal Government Re-introduced by Representative Stanton and Representative Joyce

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On April 6, 2023, Representative Greg Stanton (D-AZ) and Representative David Joyce (R-OH) re-introduced the Stronger Engagement for Indian Health Needs Act (H.R.2535). This bill would elevate the Indian Health Service (IHS) Director to Assistant Secretary for Indian health within the Department of Health and Human Services (HHS), increasing their authority within the federal government on the health care needs of the American Indian and Alaska Native (AI/AN) population.

The National Council of Urban Indian Health (NCUIH) worked closely with Representatives Stanton and Joyce on this legislation, which was originally introduced in January 2022 and is supportive of their efforts to improve representation for the health needs of AI/ANs.

“It is time for the government to recognize the importance of Indian health and uphold the federal trust responsibility to provide healthcare to all Native people. The elevation of the IHS Director to Assistant Secretary will uplift our voices in the Administration and is a critical step in reaching health equity in Indian country,” said Walter Murillo (Choctaw), President-elect of NCUIH and Chief Executive Officer of Native Health, based in Phoenix, Arizona. “We thank Representatives Greg Stanton and David Joyce for their commitment to improving health outcomes for Native people, and we urge Congressional leaders to support this vital legislation.”

Representative Stanton said, “The federal government has a trust obligation to provide quality health care to Tribal members, care that best fits their cultural and health needs…. Our bill does what should’ve been done years ago—elevates and centers native voices when it comes to making federal policy that affects American Indians and Alaska Natives.”

Representative Joyce added, “We know that federal American Indian and Alaska Native health programs continue to be plagued by challenges, and that many who rely on these services continue to experience health disparities and face barriers accessing care. By elevating the Indian Health Service Director position to Assistant Secretary for Indian Health within the U.S. Department of Health and Human Services, this bipartisan bill represents an important step as we seek to fulfill the federal government’s sacred trust and treaty obligations to American Indians and Alaska Natives.”

This bill has been endorsed by lead advocacy groups—including the National Health Board.

Next Steps

The bill was referred to the House Energy and Commerce and Natural Resources Committees. It currently awaits consideration.

Resources

  • Full Bill Text (117th Congress)