NCUIH Releases “2022 Annual Policy Assessment”

The Policy assessment informs urban Indian organization policy priorities in 2023, identifies traditional healing barriers, and addresses mental and behavioral health needs.

2022 Policy Assessment thumbnailThe National Council of Urban Indian Health (NCUIH) is pleased to announce the release of its 2022 Annual Policy Assessment. NCUIH hosted five focus groups to identify Urban Indian Organization (UIO) policy priorities for 2023, as they relate to the Indian Health Service (IHS) designated facility types (full ambulatory, limited ambulatory, outreach and referral, and outpatient and residential). The focus groups were held on October 18, 21, and 24, 2022. Additional information was also collected from the UIOs via a questionnaire sent out on November 15, 2022.

Together these tools allow NCUIH to work with UIOs to identify policy priorities in 2023 and identify barriers that impact delivery of care to Native patients and their communities.  Of 41 UIOs, 26 attended the focus groups and/or participated in the questionnaire. This is the third year that NCUIH has conducted the assessment via focus groups and follow up questionnaire. This is also the highest response from UIOs NCUIH has seen since following this process.

Overview of Policy Assessment

2022 Policy Assessment chartAfter the height of the COVID-19 pandemic, newfound priorities were identified for 2023, including workforce development and retention, increased funding for traditional healing, and expanded access to care and telehealth services. Existing priorities also remain a key focus across UIOs, especially increasing funding amounts for the urban Indian health line item and IHS, maintaining advance appropriations for IHS, establishing permanent 100% Federal Medical Assistance Percentage (FMAP) for UIOs, reauthorizing the Special Diabetes Program for Indians (SDPI), and increasing behavioral health funding.

 

Key findings from the discussions are as follows:

  • Funding Flexibility is Key to Expanding Services
  • Need for Funding Security Remains a Priority
  • Advance Appropriations Mitigates Funding Insecurities Generated by Government Shutdowns and Continuing Resolutions
  • Facility Funding Directly Impacting UIOs
  • Permanent 100% FMAP Increases Available Financial Resources to UIOs
  • Workforce Concerns Amidst Inflation and Market Changes
  • Traditional Healing Crucial to Advance Comprehensive Native Healthcare
  • Addressing Access and Quality of Native Veteran Care
  • Health Information Technology and Electronic Health Record Modernization
  • New Barriers Limit UIO Distribution of Vaccines
  • HIV, Behavioral Health, and Substance Abuse Report
  • Reauthorizing the Special Diabetes Program for Indians
  • UIOs Find Current NCUIH Services Beneficial

Next Steps

NCUIH will release a comprehensive document of the 2023 Policy Priorities in the coming weeks.

Past Resources:

Bipartisan Bicameral Urban Indian Health Confer Act Reintroduced by Senator Smith, Senator Mullin, and Representative Grijalva

On February 15, 2023, Senators Tina Smith (D-MN) and Markwayne Mullin (R-OK) re-introduced the Urban Indian Health Confer Act (S.460) This is part of an ongoing effort to rectify longstanding parity issues within the Indian health system. The legislation would require agencies and offices within the U.S. Department of Health and Human Services (HHS) to confer with Urban Indian Organizations (UIOs) on policies and initiatives related to healthcare for over 70% of American Indians and Alaska Natives (AI/ANs) that live off reservations. The National Council of Urban Indian Health (NCUIH) worked closely with the Senators on this bill which was originally introduced in May 2022 as S. 4323 by Sen. Smith, as well as with Representative Raúl Grijalva (D-AZ-7) on the House companion bill (H.R. 630), which was recently re-introduced on January, 30, 2023. The original House legislation, H.R. 5221, passed the House of Representatives by a vote of 406 to 17 on November 2, 2021.

NCUIH has long advocated for the importance of facilitating confer between UIOs and numerous federal branches within HHS to ensure access to high-quality health services for all AI/ANs. Currently, only the Indian Health Service (IHS) has a legal obligation to confer with UIOs.

“The Urban Indian Health Confer Act is a critically important step in addressing urban Indian health disparities. This bill will ensure that HHS, and HHS departments outside of the Indian Health Service, communicate directly with urban Indian organizations on matters relating to urban Native health. It will also ensure that our clinics are properly informed of policy changes and have a formal means of initiating discussion with HHS on policies and programs that affect the health of urban Indian communities. Open communication between HHS and UIOs will allow HHS to become more responsive to the needs of the over seventy percent of American Indians and Alaska Natives residing in urban areas and is necessary to improve urban Indian health.” -NCUIH CEO, Francys Crevier (Algonquin)

In a July 2022 Senate Committee on Indian Affairs (SCIA) hearing on the Urban Indian Confer Health Act, Representative Grijalva expressed the need for Urban Confer at HHS, stating that “HHS’ failure to communicate with UIOs about healthcare policies that impact urban Indian communities is inconsistent with the federal trust responsibility and contrary to sound public health policy. The Urban Indian Health Confer Act will establish direct communication for UIOs across the entire department and ensure that urban Indian communities are aware of healthcare policy changes.”

In the same SCIA hearing, this bill was shown support by urban Indian leader and CEO of the Indian Health Board of Minneapolis, Dr. Patrick Rock (Leech Lake Band of Ojibwe), who stated in his testimony that “…an urban confer policy across HHS agencies, including CMS, would be instrumental in ensuring that obstacles relating to programs and benefits that directly affect UIOs are addressed quickly so UIOs are better equipped to provide healthcare to their patients.”

Background

Urban Confer with HHS and UIOs

An Urban Confer is an established mechanism for dialogue between federal agencies and UIOs. Urban confer policies are a response to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that have resulted in 70% of AI/AN people living outside of Tribal jurisdictions, thus making Urban Confer integral to addressing the care needs of a majority of AI/ANs. An urban confer policy that includes all HHS agencies ensures that obstacles relating to programs and benefits that directly affect UIOs are addressed quickly so UIOs are better equipped to provide healthcare to their patients. NCUIH has long advocated for facilitating confer between numerous federal branches within HHS and UIO stakeholders. Currently, only IHS has a legal obligation to confer with UIOs. It is important to note that urban confer policies do not supplant or otherwise impact Tribal consultation and the government-to-government relationship between Tribes and federal agencies.

Such blatant disregard to communicate with UIOs is not only a failure to urban Indians and is inconsistent with the government’s responsibility, but it is contrary to sound public health policy. The bill would codify the intent of the Federal Trust Responsibility to ensure equitable health care access to AI/AN by amending legislative text in Section 514, Subsection (b) of the Indian Health Care Improvement Act (25 U.S.C. § 1660d) (IHCIA).

This bill would require the Secretary of HHS, to the maximum extent practicable, to confer with UIOs in carrying out the health services of the Department.

Next Steps

The Senate bill (S.460) was referred to the Senate Committee on Indian Affairs. The House companion bill (H.R.5221) was referred to the Committee on Natural Resources and the Committee on Energy and Commerce. It currently awaits consideration.

NCUIH continues to advocate for an established confer policy between all HHS agencies and UIOs to improve the delivery of health services to all AI/ANs living in urban settings.

Resources

HHS Issues Notice of Funding Opportunity for Native Language Preservation and Native American Cultural Preservation

The Administration for Children and Families (ACF) Administration for Native Americans (ANA) currently has three Notice of Funding Opportunities (NOFOs) open as grant applications related to Native language and cultural preservation. Urban Indian Organizations (UIOs) are eligible and encouraged to apply by March 31, 2023. The National Council of Urban Indian Health (NCUIH) has advocated for the sharing and use of Native languages in tribal communities as a method to strengthen community bonds and to support a sense of belonging.

The current grants accepting applications are:

Applications are due March 31, 2023.

Background on the Grants

The purpose of each grant below varies in objectives they serve related preservation of Native languages and cultures:

  • Native American Language Preservation and Maintenance (P&M)
    • The P&M program provides funding for projects designed to ensure continuing vitality of Native American languages. This program allows for a broad array of Native language related projects including establishing a language program, improvements to an existing program, and the development of language instruction and activities.
  • Native American Language Preservation and Maintenance – Esther Martinez Immersion (EMI)
    • The EMI program provides funding for community-based projects that ensure continuing vitality of Native languages through immersion-based instruction. Programs funded under the EMI NOFO must meet the requirements for either a Native American Language Nest, or a Native American Language Survival School, as defined by Esther Martinez Native American Languages Preservation Act
  • Social and Economic Development Strategies (SEDS)
    • This NOFO is focused on community-driven projects designed to grow local economies; strengthen Native American families, including the preservation of Native American cultures; and decrease the high rate of current challenges caused by the lack of community-based businesses and social and economic infrastructure in Native American communities.

How to Apply

Instructions for navigating the grant application process can be found here.  The search for locating each grant can be found here. Included below are details pertaining to each grant individually.

  • Native American Language Preservation and Maintenance (P&M)
    • Expected Number of Awards: 9
    • Estimated Total Program Funding: $2,000,000
    • Award Ceiling: $300,000
    • Award Floor: $100,000
  • Native American Language Preservation and Maintenance – Esther Martinez Immersion (EMI)
    • Expected Number of Awards: 5
    • Estimated Total Program Funding: $1,500,000
    • Award Ceiling: $300,000
    • Award Floor: $100,000
  • Social and Economic Development Strategies (SEDS)
    • Expected Number of Awards: 30
    • Estimated Total Program Funding: $9,500,000
    • Award Ceiling: $400,000
    • Award Floor: $100,000

GAO Report Finds that Tribes and Native Organizations Faced Barriers to Accessing Federal COVID-19 Relief Funds Due to Administrative Burdens

On December 15, 2022, the U.S. Government Accountability Office (GAO) issued a report that examined approaches federal agencies used to administer programs that provided COVID-19 funds under the Coronavirus Aid, Relief, and Economic Security (CARES) Act to tribal recipients and outlined lessons learned that could improve future federal relief to recipients. Tribal recipients included tribal entities, tribal members, urban Indian organizations (UIOs), and American Indian or Alaska Native individuals (AI/AN). Among the top lessons learned included prioritizing established mechanisms and structures to distribute relief funds to tribal recipients. The National Council of Urban Indian Health (NCUIH) has advocated extensively for emergency relief funding to UIOs in a manner consistent with GAO’s recommendations throughout the COVID-19 pandemic.

Background

GAO is an independent, non-partisan agency that works for Congress. GAO examines how taxpayer dollars are spent and provides Congress and federal agencies with objective, non-partisan, fact-based information to help the government save money and work more efficiently.

To do so, GAO conducts reviews of federal agencies and programs, including those that serve Tribes, their citizens, and descendants. (GAO generally does not audit Tribes’ activities). GAO reviews span a broad range of topics of concern to Tribes, including health care, education, economic development, environmental protection, justice, and infrastructure, among others including this report. GAO’s oversight of federal programs that serve Tribes and their citizens aims to help the Congress determine how best to meet the government’s longstanding commitments to federally recognized Tribes.

GAO conducted this report, in part, due to the disproportionate and devastating impact the COVID-19 pandemic has had on public health and economies of federally recognized Tribes and their members living both on and off reservation land including urban areas.  Additionally, the CARES Act includes a provision for GAO to conduct monitoring and oversight related to the COVID-19 pandemic. The report notes that Congress has appropriated at least $43.6 billion since March 2020 for federal programs serving Tribes, their members, and tribal organizations including UIOs. The report examined approaches select federal agencies, including the United States Department of Agriculture (USDA), Department of Health and Human Services (HHS), Interior, and the Treasury, used to administer programs that provided COVID-19 funds to tribal recipients and lessons learned that could improve future federal relief to these recipients. GAO reviewed federal agency documents and interviewed agency officials, tribal recipients, and representatives of tribal organizations selected amongst federal agencies.

Report Findings and Recommendations

GAO identified lessons learned from select federal agencies’ administration of COVID-19 relief funding that could improve future federal relief for tribal recipients. For example, using existing mechanisms, such as contracts and compacts, can enable agencies to quickly distribute funds to recipients and mitigate administrative burdens for agencies and Tribes. By enabling agencies to use existing mechanisms to distribute funds, Congress would better ensure that they distribute these funds more quickly and with minimal additional administrative burden on tribal recipients and agencies. This also allows agencies to maintain accountability in the use of the funds through existing reporting mechanisms. Additionally, GAO found that increasing federal capacity and expertise for working with tribal recipients could improve federal administration of future funding for tribal recipients. In accordance with a 2021 Presidential Memorandum, each selected agency is implementing an action plan that includes building capacity and expertise to better meet the unique needs of tribes and tribal communities. GAO recommends Congress should consider, when seeking to provide Tribes with emergency relief that it wants to be distributed as quickly as possible, providing this relief in a manner that enables agencies to distribute it through existing mechanisms and structures, such as self-determination contracts and self-governance compacts, as appropriate.

NCUIH Advocacy Results in New Guidance from HHS on 100% FMAP for Urban Indian Organizations

On December 27, 2022, the Center for Medicaid Services (CMS) released a State Medicaid Director Letter (SMDL) #22-006: “Additional Guidance on Section 9815 of the American Rescue Plan Act of 2021.” The SMDL provides additional guidance to states on Section 9815 of the America Rescue Plan Act of 2021 (ARPA), which amended Section 1905(b) of the Social Security Act to set the federal medical assistance percentage (FMAP) for Medicaid services provided at Urban Indian Organizations (UIOs) at 100% for eight fiscal quarters, starting on April 1, 2021. The National Council of Urban Indian Health (NCUIH) and UIO advocacy efforts helped secure the inclusion of Section 9815 in the ARPA, and NCUIH has called on the Administration to provide guidance to states to ensure this provision is implemented in the way intended by Congress. ARPA Section 9815’s 100% FMAP UIO extension ends on March 31, 2023, and UIOs have generally have not seen the benefit of the provision that was intended to increase resources for Indian healthcare providers.

Overview of Additional Guidance provided in SMD #22-006:

The guidance reiterates prior guidance issued by CMS, and invites individual State Medicaid Directors to reach out to CMS for additional information or guidance on implementing ARPA Section 9815. Below is a brief overview of the additional guidance relating to UIOs provided by SMD #22-006. The SMD:

  • Reiterates that CMS interprets ARPA’s 100% FMAP UIO extension to apply to Medicaid services received by all Medicaid beneficiaries through UIOs with a grant or contract with the Indian Health Service (IHS) under title V of the Indian Health Care Improvement Act
  • Provides that 100% FMAP is available for state expenditures on Medicaid services provided by a non-UIO provider but furnished under a qualifying care coordination agreement with UIOs for the ARPA period.
  • Reiterates that states have the discretion to set and adjust Medicaid provider payment rates if the state payment rates are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the state plan at least to the extent that such care and services are available to the general population in the geographic area. (42 U.S.C. 1396a(a)(30)(A))
  • Reiterates that states must comply with the provisions of section 1902(bb) of the Act when setting Medicaid payment rates for Federally Qualified Health Center (FQHC) services that are furnished by FQHCs.
  • Provides that CMS is available to provide technical assistance to states that believe adjusting their reimbursement rates to UIOs, Centers, or Systems is appropriate.
  • Encourages states needing technical assistance to contact their CMS state lead, and UIOs, Centers, and Systems needing technical assistance to contact their CMS Native American Contact.

ARPA Section 9815’s UIO 100% FMAP extension expires on March 31, which is less than two months away. NCUIH is continuing policy work to ensure that UIOs can benefit from this Section as was intended by Congress. NCUIH also is continuing efforts to secure permanent 100% FMAP for UIOs.

NCUIH Bill Helps Urban Indian Organization Purchase New Building for Women’s Health and Pediatric Services

In October 2022, the Oklahoma City Indian Clinic (OKCIC), one of the 41 Urban Indian Organizations (UIOs) serving the more than 70% of American Indian and Alaska Native (AI/AN) individuals living in urban areas, announced their purchase of a new clinic building in Oklahoma City, Oklahoma. “This building is larger than our other locations” says Oklahoma City Indian Clinic’s Chief Operating Officer Lysa Ross. “The extra space will give us more opportunities to expand services and continue providing excellent health care to American Indians.” In 2021, The National Council of Urban Indian Health (NCUIH) worked tirelessly to include the Padilla-Moran-Lankford Urban Indian Health amendment to the bipartisan infrastructure package which allows UIOs to use existing Indian Health Service (IHS) funding for facilities improvement and renovations.

The clinic plans to renovate the nearly 65,000 square foot structure, with six-stories, to hold primarily women’s health and pediatric services. Their pediatric department offers several specialty clinics, including an asthma and a foster care clinic. Well-child visits, same-day visits, physical examinations, immunizations, and vision and hearing checks will also be procedures provided in the new building. The women’s health department at Oklahoma City Indian Clinic offers birth control, preventative health and wellness services and prenatal care, including delivery options.

The new building is still undergoing renovations, but OKCIC plans to see patients at this new location in 2023.

Background

NCUIH has worked on a bipartisan basis for legislation that that would expand the use of existing IHS resources under Section 509 of the Indian Health Care Improvement Act (IHCIA) (25 U.S.C. § 1659) to increase the funding authority for renovating, constructing, and expanding UIOs. In August 2021, NCUIH successfully advocated for the Padilla-Moran-Lankford Urban Indian Health Amendment to be included in the bipartisan infrastructure package, which allows UIOs to use existing IHS funding for infrastructure projects.

Prior to the passage of the bipartisan infrastructure package with this amendment, IHS did not have funding allocated specifically for use toward UIO facilities, maintenance, sanitation or medical equipment, nor could UIOs use their contract funds to make such purchases or payments. At the height of the pandemic, while the whole IHS system transitioned to telehealth, negative pressurizing rooms and other facility renovations that were needed to safely continue to see patients, restrictions within the relevant statutory text would not allow UIOs to spend their funds to make similar such transition. Section 509 of the Indian Health Care Improvement Act (IHCIA), where the technical fix this amendment provided exists, only allowed IHS to provide UIOs with funding for minor renovations and to assist UIOs in meeting or maintaining compliance with The Joint Commission (TJC) accreditation standards.

Prior to the passage of the Padilla-Moran-Lankford amendment, in May, Congressmen Ruben Gallego (D-AZ) and Don Bacon (R-NE) introduced the Urban Indian health Facilities Provider Act (H.R. 3496) in the House of Representative, expanding the use of existing IHS resources under Section 509 to increase the funding authority for renovating, constructing, and expanding UIOs. An identical bill was introduced at the same time in the Senate (S. 1797) by Senators Alex Padilla (D-CA) and James Lankford (R-OK), with initial co-sponsors including Senators Moran (R-KS), Feinstein (D-CA) and Smith (D-MN) who is on the Senate Committee on Indian Affairs.

NCUIH also testified in support of the Urban Indian health Facilities Provider Act before both the House Natural Resources Subcommittee for Indigenous Peoples of the United States (SCIP) and the Senate Committee on Indian Affairs (SCIA) in May of 2021. Sonya Tetnowski (Makah Tribe), Chief Executive Officer of the Indian Health Center of Santa Clara Valley and the NCUIH President-Elect at the time of the hearing, testified before SCIP, and Robyn Sunday-Allen (Cherokee), Chief Executive Officer of the Oklahoma City Indian Clinic and NCUIH Vice President, testified before SCIA.

Fall 2022 Semester Law and Policy Fellows Depart and Reflect on Time with NCUIH

With the new semester of the school year well underway, the National Council of Urban Indian Health (NCUIH) bids farewell to the Law and Policy Fellows that worked with us throughout the semester. Both students were key collaborators within the work that NCUIH accomplished while they were with us. They attended hundreds of calls, wrote NCUIH communication materials such as blogs and newsletter posts, and were directly responsible for several discrete research projects. NCUIH wishes Adrianne and Palmer all the best as they continue their education and professional growth.

Headshot of Palmer Scott

 “NCUIH treated me like one of their own and I couldn’t imagine the cost of having missed an opportunity like this.” – Palmer Scott (Muscogee (Creek) Nation)

 Palmer Scott (Muscogee (Creek) Nation) leaves NCUIH to finish his 3L year at the University of Oklahoma College of Law, where he is the Vice President of the campus’ Native American Law Student Associate (NALSA) and is the Moot Court Administrator for the National Native American Law Student Association (NNALSA), among other extra curriculars. Here’s what he had to say about his fellowship with NCUIH:

“I am a citizen of the Muscogee Nation and an advocate for civil rights/social movements. As a third-year law student at the University of Oklahoma College of Law, I desired an externship at an organization that aligned with my morals and purpose. NCUIH was an easy contour to my passions for social justice. I attended a Native American Bar Association D.C. meeting with NCUIH where the CEO, Francys Crevier, asked for me to come work with them in the Fall. I applied to be a legal fellow while participating as a board member of the National Native American Law Students Association furthering my commitment to my communities.

I learned that around 70% of the Native American population lives in urban areas. The trust responsibility the federal government maintains with tribal nations extends into these urban areas. I am proud to witness Congress grant advance appropriations to the Indian Health Service, partly due to the advocacy and dedication of NCUIH team members. I also learned a lot of information regarding agency comment periods and the sweeping regulations involved in the healthcare industry.

The connections I made at NCUIH will last throughout my career. My supervisor Rori was always helpful, friendly, and supportive. The relations between a non-profit and the federal government were insightful. I witnessed many advocates from all over Indian Country speak about the issues their specific communities face. I plan to take the knowledge gained from the agency meetings and projects I completed with me for the rest of my career. NCUIH treated me like one of their own and I couldn’t imagine the cost of having missed an opportunity like this. Mvto!”

Headshot of Adrianne Elliott

The mentorship I received from the policy team proved invaluable to my professional and personal growth. I am passionate about advancing self-determination and sovereignty for Native peoples across the country and look forward to bringing this new knowledge and skillset into the next steps in my Indian law career to ensure all Natives are included in laws and policies that impact them and their wellbeing.” – Adrianne Elliott (Cherokee Nation of Oklahoma)

Adrianne Elliot (Cherokee Nation) was able to extend her summer Law and Policy Fellowship throughout the fall semester. NCUIH is honored that she wished to continue working with us, and that she was able to continue her invaluable work on behalf of urban Native Americans across the nation. To read her reflection from the summer, click here.

About NCUIH Law and Policy Fellowship

Available to undergraduate, graduate and law students as remote work, this opportunity allows students to work part-time throughout the semester, accommodating for classes and availability, or full time during the summer. Internships and Fellowships are available for academic credit or for compensation, dependent on funding. If you, or someone you know, is interested in learning more about what it means to be a NCUIH Law and Policy Fellow, please visit the NCUIH Internship and Fellowship Program webpage to learn more about the opportunities NCUIH offers.

Tribal Leaders Highlight Need for Increased Urban Indian Health Funding in Fiscal Year 2025 IHS Budget Requests

On January 25-26, 2023, the Indian Health Service (IHS) held its annual Area Report Presentations Webinar for Fiscal Year (FY) 2025 where Tribal leaders from all 12 IHS Areas and leaders from Native organizations, including the National Council of Urban Indian Health (NCUIH), presented on their budget requests. Many Tribal leaders emphasized the need to increase funding and resources for urban Indian health in the FY2025 budget. Navajo Nation President Buu Nygren stated: “The [Navajo] nation is also supporting the push to support urban Indian healthcare facilities and many Navajos live off the reservation should still be able to receive equitable healthcare through the IHS network system.” Areas also highlighted the need for increased funding for mental and behavioral health, as social isolation during the height of the pandemic negatively affected physical and emotional well-being. Additionally, Area leaders mentioned the critical need for increased funding for Health Information Technology (IT) modernization, permanent authorization of the Special Diabetes Program for Indians (SDPI), and permanent exemption from sequestration.

Background on Budget Formulation

As part of the trust responsibility to provide health care to all American Indians and Alaska Natives (AI/ANs), Tribal leaders present their funding needs each year to the Secretary of HHS and the Director of the Office of Management and Budget. The recommendations are formed through the Tribal Budget Formulation Work Group (TBFWG) and serve as a framework for the Administration in setting budget amounts for their annual requests to Congress. This process ensures the federal government has the resources to provide health care to all AI/ANs in fulfillment of the trust responsibility.

Area Report Highlights

Several Areas featured the work of urban Indian organizations (UIOs) in their presentations and advocated for increased allocation of funding and resources for urban Indian health.

  • IHS Phoenix Area highlighted the program increase of $92.6 million identified in FY2024 remains a top priority for FY2025 for urban Indian health. The Area advocated that services must be aligned and enhanced across the Indian health care system.
  • IHS Bemidji Area stressed that UIOs are underfunded and rely heavily on restrictive grants which can be financially unstable and recommended an increase of $23 million for urban Indian health in FY 2025.
  • IHS Oklahoma City Area stressed that although 78% of AI/AN people reside in urban areas, the funding allocation for urban Indian health only reflects approximately 1% of the IHS annual budget. They recommend that urban Indian health is prioritized as a part of tribal health priorities to advocate that Congress increase the budget to appropriate funding levels.
  • IHS Tucson Area highlighted that the urban Indian line item needs to be fully funded to address critical health disparities faced by AI/ANs residing in urban areas. They also shared multiple success stories such as the completion of a new housing development to address the housing shortage and a completed recreation center that brings water and electricity to rural communities.
  • The IHS Billings Area Representatives emphasized that the current funding level for the urban Indian population is inadequate and that leaving the reservation does not forfeit the rights to health care.

NCUIH Supports Full Funding of Urban Indian Health and Other Key UIO Priorities for FY2025

Chandos Culleen, NCUIH’s Director of Federal Relations, presented the following UIO priorities for FY 2025 during the Area Report Webinar:

  1. Urban Indian health funding amount of $977.4 million, an increase of $3.8 million over FY 2024 recommendations.
      1. This amount reflects the average of the draft 12 IHS Area recommendations and is critically needed to address health priorities for Natives in urban areas including:
        1. Ensuring Urban Indian Health funding keeps pace with population growth.
        2. Providing funding for UIO facilities and infrastructure.
        3. Expanding service offerings to Native patients in urban areas.
  2. Establishing permanent 100% Federal Medical Assistance Percentage (FMAP) for UIOs.
  3. Increased behavioral health funding for UIOs.
  4. Maintaining advance appropriations for IHS.
  5. Special Diabetes Project for Indians (SDPI) reauthorization.

Top Priorities

Mr. Culleen emphasized that UIOs only receive funding from one line item in the IHS budget, urban Indian health, which is historically underfunded and does not keep up with rising medical inflation costs. UIOs do not have access to other distinct IHS funding sources such as facilities improvements and upgrades, funding from Hospitals and Health Clinics, Purchase & Referred Care, and Contract Support Costs. Only an increase to the Urban Health line item assures increased service capacity for UIOs.

Next Steps

IHS will hold their FY 2025 National Tribal Budget Formulation Work Group on February 14-15, 2023 where tribal representatives from each Area come together to review and consolidate all the Area’s budget recommendations into a comprehensive set of national health priorities and budget recommendations. NCUIH will continue to advocate for full funding for urban Indian health and increased resources for UIOs.

NCUIH Recommendations Included in Report on Improving the Health and Safety of American Indian and Alaska Native Mothers and Infants

On December 7, 2022, the Health and Resources and Services Administration (HRSA) Advisory Committee on Infant and Maternal Mortality (ACIMM) submitted a report to the Health and Human Services (HHS) Secretary Xavier Becerra titled: “Making Amends: Recommended Strategies and Actions to Improve the Health and Safety of American Indian and Alaska Native Mothers and Infants.” The report offers a set of recommended actions that could be among the many steps the Federal government may take, both to reconcile past actions and to step up to the obligations to American Indians and Alaska Natives (AI/AN) that it has abrogated since the founding of our nation. The National Council of Urban Indian Health (NCUIH) played an integral role in the report to ensure the needs of off-reservation AI/AN mothers were included. The report offers an analysis of the historic issues and current conditions facing AI/AN women and infants in the United States, through the lens of poor birth outcomes for AI/AN mothers and babies. It highlights a toxic legacy of genocide and trauma and acknowledges centuries of detrimental policies and programs that have disadvantaged and decimated AI/AN populations.

NCUIH has advocated on the behalf of urban AI/AN maternal and infant health and has worked closely with the ACIMM on AI/AN maternal and infant health issues. On September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, testified before the HRSA ACIMM on urban Indian disparities and policy changes to address these disparities. Raimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.”

Background

ACIMM focused its work on the birth outcomes of AI/AN mothers and infants because AI/AN populations are often overlooked in programmatic and policy discussions and investments even though their birth outcomes are among the worst in the country. Reasons for this oversight are numerous, including small population size, dispersed populations, lack of representation in decision-making spaces, and Tribes being non-state entities. The plight of AI/AN mothers and infants in the United States is a human rights issue that must be urgently addressed.

ACIMM’s report recommended three areas for strategic action framed on the premises of having healthy social and physical environment and access to high-quality care are essential to good birth outcomes; racism and the devaluing of AI/AN women disproportionately affects this population which negatively impact maternal and infant health outcomes and mortality; and AI/AN people have inherently protective practices embedded in their culture that contribute to their ongoing resilience.

  1. Make the health and safety of AI/AN mothers and infants a priority for action.
  2. Improve the living conditions of AI/AN mothers and infants and assure universal access to high quality healthcare.
  3. Address urgent and immediate challenges that disproportionately affect AI/AN women before, during, and after pregnancy.

Infant and Maternal Health Disparities in Native Health

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

NCUIH’s work with AI/AN Maternal and Infant Health

The National Council of Urban Indian Health (NCUIH) has engaged in extensive advocacy on behalf of AI/AN mothers and infants and for increased funding and support to the UIOs which provide maternal health, infant health, prenatal, and family planning services to AI/AN mothers and infants.  In March 2022, NCUIH signed onto a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing HRSA’s Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and doubling the Tribal set-aside – which includes UIOs. Additionally, in August, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program. In our comments, we have continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations. NCUIH also released an infographic showcasing data on infant and maternal health disparities in AI/AN communities.

Supreme Court Held Oral Argument on Case Challenging the Indian Child Welfare Act

On November 9, 2022, the Supreme Court of the United States held oral argument in Haaland v. Brackeen, a case challenging the constitutionality of the Indian Child Welfare Act of 1978 (ICWA). The questions presented to the Court in Brackeen are: (1) Whether various provisions of ICWA violate the anticommandeering doctrine of the Tenth Amendment; (2) Whether the individual plaintiffs have Article III standing to challenge ICWA’s placement preferences for “other Indian families,” and for “Indian foster home[s];” (3) Whether the default placement preferences for Indian homes in adoption or foster care cases are rationally related to legitimate governmental interests and therefore consistent with equal protection. The Supreme Court’s decision in Brackeen will have far-reaching implications on all areas of Federal Indian Law and policy and the National Council of Urban Indian Health (NCUIH) continues to advocate for the protection of ICWA to safeguard American Indian/Alaska Native (AI/AN) children and families.

Summary of Oral Argument

Oral argument for Brackeen lasted over three hours and focused heavily on the scope of Congress’s constitutional authority to legislate on behalf of AI/ANs, the equal protection limitations on that power, and whether the requirements imposed on states by the ICWA, particularly the “active efforts” requirement, violates the anticommandeering doctrine. Oral argument began with the parties challenging ICWA, referred to as “plaintiffs.” Solicitor General Judd Stone argued on behalf of the state of Texas, and Matthew McGill, a partner at Gibson, Dunn & Crutcher, argued on behalf of the potential adoptive families. The plaintiffs’ arguments centered on the assertion that ICWA deprives Indian children and non-Indian prospective parents of the “best interest of the child” standard in child welfare proceedings in violation of the Equal Protection Clause. The parties defending ICWA, referred to as “defendants,” argued second. Deputy Solicitor General Edwin Kneeler argued on behalf of the federal defendants and Ian H. Gershengorn, a partner at Jenner & Block, LLC , argued on behalf of the intervening Tribes (the Cherokee Nation, Oneida Nation, Quinault Nation, and Morongo Band of Mission Indians).  The defendant’ arguments centered on the fact that Congress has broad power to legislate in Tribal affairs, and this power is limited only by other constitutional provisions or by the test set by Supreme Court precedent in Morton v. Mancari, 417 U.S. 535 (1974), which requires congressional action to be rationally related to the fulfillment of Congress’ unique obligations to Indians.

Background on Haaland v. Brackeen

Congress enacted the ICWA in 1978 to re-establish Tribal authority over the adoption of AI/AN children. ICWA is a procedural safeguard to “protect the best interests of Indian children and to promote the stability and security of Indian Tribes and families.” 25 U.S.C. § 1902. In Brackeen, Texas, Indiana, Louisiana, and individual plaintiffs (plaintiffs) sued the federal government in the U.S. District Court for the Northern District of Texas, arguing that ICWA and its implanting regulations are unconstitutional because they violate the equal protection and substantive due processes provisions of the Fifth Amendment and violate the anticommandeering doctrine of the Tenth Amendment.  The plaintiffs also argued that ICWA and the implementing regulations violate the nondelegation doctrine and the APA. The District Court ruled in favor of the plaintiffs, finding that the ICWA violates the Constitution’s guarantee of equal protection because it applies to all children eligible for membership in a Tribe, not just enrolled tribal members, and therefore operates as a race-based statute.  The District Court further held that ICWA violates the Tenth Amendment’s prohibition on the federal government issuing direct orders to states and unconstitutionally delegates Congress’s power by giving Tribes the authority to change adoption placement preferences and make states abide by them. On appeal, the Fifth Circuit reversed the District Court’s opinion in most respects. In a fractured ruling, the Fifth Circuit sitting en banc upheld portions of the District Court’s opinion and reversed other portions.

In early September 2021, the United States government, tribal defendants, as well as state and private plaintiffs filed petitions asking the United States Supreme Court to review the Fifth Circuit’s decision. The U.S. Supreme Court agreed to review the Fifth Circuit’s decision in Brackeen v. Haaland on February 28, 2022, and held oral argument on November 9, 2022.

NCUIH Advocacy

On August 19, 2022, NCUIH and five urban Indian organizations (UIOs) (Nebraska Urban Indian Health Coalition, Inc., Sacramento Native American Health Center, Fresno American Indian Health Project, All Nations Health Center, and Oklahoma City Indian Clinic) signed on to the National Indigenous Women’s Resource Center’s (NIWRC) amicus brief to the Supreme Court in support of the constitutionality of ICWA in the  Haaland v. Brackeen case. NCUIH worked directly with NIWRC to engage with UIOs to ensure that the submitted brief was inclusive of urban AI/ANs. On September 7, NCUIH submitted written comments to the Bureau of Indian Affairs (BIA) and the Administration for Children and Families (ACF) on the BIA and ACF’s efforts to promote the consistent application of ICWA) and protect children, families, and Tribes.

NCUIH previously provided an in-depth analysis on the impact of ICWA and will continue to monitor ongoing developments.

Next Steps

The Supreme Court will hand down a decision by the end of the 2022 term on July 1, 2023. Due to the complex nature of the case, a decision is not expected until the Spring. The Supreme Court’s decision in Brackeen will have far-reaching implications on all areas of Federal Indian Law and policy. The recognition that the AI/AN classification is political classification rather than racial is a critical underpinning of not just ICWA, but many laws that relate to housing, healthcare, education, and employment. This political classification goes back to the 19th Century and has been upheld by Courts at multiple levels. Acknowledging the importance of tribal citizenship, AI/ANs are classified by this citizenship, not by their race.  If overturned, the repeal of ICWA would not only upend a law in place for more than 40 years but undercut the heart of tribal sovereignty and the federal government’s trust responsibility to Native communities.