Senators Reiterate Trust Responsibility and Highlight Necessity of Mandatory Funding in IHS FY 2024 Appropriations Hearing

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On May 10, 2023, the Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies held a hearing, chaired by Senator Merkley, to review the President’s Budget for Fiscal Year (FY) 2024 for the Indian Health Service (IHS). Testimony was provided by Roselyn Tso, IHS Director and Bryan Newland, Assistance Secretary for Indian Affairs within the Department of the Interior. Topics addressed include the proposal to shift from discretionary to mandatory spending, which Director Tso highlighted as the most appropriate long-term solution to the historical underfunding of IHS. The National Council of Urban Indian Health continues to advocate for full funding for IHS and Urban Indian Health and maintain advance appropriations until mandatory funding is enacted in FY 24.

Updates from IHS and Director Tso

Director Roselyn Tso was questioned directly by Senators on various initiatives and programs. The biggest issue raised by Senator Merkley was the proposal to shift contract support costs and 105(l) leases to mandatory funding. Senator Murkowski expanded on this and inquired about any statutory language or legal definition of what these costs are, which would be helpful for Congress when working to reclassify them. Director Tso discussed the importance of contract support costs and 105(l) leases as tools for tribal self-governance.

Senator Murkowski reiterated her support for advanced appropriations but wanted an update as to any authorizing language regarding this legislative proposal to shift to mandatory funding. Jillian Curtis (Director of the Office of Finance and Accounting at IHS) informed that they will work with the Office of Management and Budget (OMB) on a tribal consultation which took place in June, with the goal that it will inform a better legislative package.

Other updates include:

  • Senator Merkley raised the issues of vacancy rates and employee retention, specifically the nurse preceptorship program, which was highlighted as an important goal of IHS. Their request is 1 million dollars to provide training development and support to replenish the workforce they have lost with older generations, as well as integrate recent graduates. IHS is also requesting the elimination of the tax related to loan repayment.
  • Senator Merkley also inquired about the Community Health Aide Program (CHAP) Expansion to the lower 48 states and how this proposed expansion would be implemented. IHS is moving forward with Portland Area expansion and have plans for the Billings Area as well. They are planning to work closely with the Alaska program to uplift the program nationally.
  • Director Roselyn Tso’s Full Testimony

Senator Merkley Emphasized the Importance of a Funding Increase to Eliminate the Health Care Gap

Through his remarks, Senator Merkley pointed to IHS receiving a $2.5 billion increase as a solution to the health care disparities faced within the American Indian and Alaska Native community. He also mentioned how advanced appropriations were a significant achievement for FY 23, and that they would like to build off of this. Within the IHS budget proposal for FY 24, there is a mandatory reclassification proposal for contract support costs and 105(l) leases, which he supports, because reclassifying funds as mandatory would promote and allow for tribal self-governance.

Senator Murkowski Reflected on the Importance of Upholding the Trust Responsibility as a Bipartisan Priority

Senator Murkowski opened her remarks by stating, “this subcommittee has always worked together to fund essential programs that serve our Tribes and Native communities…I think we have made upholding the federal government’s trust responsibility a bipartisan priority. It needs to continue to be so.”  She then highlighted how FY 24 increases almost every budget line, but she noted her disappointment that the budget proposal doesn’t focus on successful implementation of advanced appropriations, but instead proposes mandatory funding for IHS beginning in 2025 without any accompanying legislative text. She also listed her important IHS priorities that have remained unchanged:

  • Funding for VBCs (Village Built Clinics);
  • Facilities construction accounts;
  • Programs that support Alaska Dental Health Therapy;
  • Community Aide Health Programs;
  • Contract Support Costs; and
  • 105(l) lease payments

She emphasized that due to ongoing questions surrounding costs for these programs and initiatives, it has spurred additional court cases and created budget uncertainty. IHS currently has an unobligated balance that needs to be addressed, so the Senator urged IHS to be open and transparent during their conversations so that the best services possible are provided.

Senator Murray Remarked on the Importance of Committing to Federal Investments  

Senator Murray discussed the importance of these programs and how we cannot let partisan infighting negatively impact them. She emphasized this point by discussing the Default on America Act and its impact on IHS, by cutting funding by nearly a billion dollars and taking care away from 2.5 million people. The work being done in the Subcommittee is an opportunity to demonstrate a commitment to tribal communities, so any support needs to be reflected through funding. She reiterated this by stating, “it is important we are holding this hearing today to make sure our nation meets its obligations to our Tribes—honoring their sovereignty and providing the federal investments that we have promised.”

June Policy Updates: Supreme Court Rules on ICWA, Federal Updates, and Upcoming Events

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Welcome to the June edition of our monthly policy newsletter, delivering the latest updates and insights on key developments.

(ICWA) Upheld in a 7-2 Supreme Court decision

Illustration of two gavels forming an x in front of the Supreme Court building

Haaland v. Brackeen (ICWA)

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

 – NCUIH CEO Francys Crevier (Algonquin).

On June 15, ICWA was upheld in a 7-2 Supreme Court decision. ​

“But the bottom line is that we reject all of petitioners’ challenges to the statute, some on the merits and others for lack of standing,“​ – Justice Amy Coney Barrett.

The Court held: ​

  •  ICWA is not beyond Congress’s constitutional powers to effectuate​.
  • ICWA does not violate the anti-commandeering clause by making states follow federal law.​
  •  Neither the foster parents or the state of Texas had standing to bring the equal protection arguments related to the third placement preferences.​
  • They did not rule on any merits regarding equal protection and ICWA. ​

What does this mean for ICWA moving forward?​

  • ICWA continues to apply as it has prior to the Brackeen decision.​
  • Because the Equal Protection Issues were rejected on standing, they are not precluded from being addressed in a future case brought by parties with standing. ​

Read NCUIH’s Statement Here

Other Supreme Court Updates

Supreme Court building with columns made out of raised fists

Other Supreme Court Updates:

1. Lac du Flambeau Band of Lake Superior Chippewa Indians v. Coughlin ​

  • On June 15, the Court held in an 8-1 decision that the Bankruptcy Code abrogates Tribal Sovereign Immunity. ​
  • “We conclude that the Bankruptcy Code unequivocally abrogates the sovereign immunity of any and every government that possesses the power to assert such immunity. Federally recognized tribes undeniably fit that description; therefore, the Code’s abrogation provision plainly applies to them as well.”​

Why is this significant?​

  • This holding is a departure from previous Supreme Court precedent that required that Congress “unequivocally express” its intent to abrogate Tribal sovereign immunity in order for a statute to do so. ​
  • This holding lowers the required standard for abrogation. ​

2. Health and Hospital Corporation of Marion County v. Talevski​

Background:  ​

  • Court held in a 7-2 decision that private parties have the right to sue under Section 1983 when federally funded programs aren’t properly administered.​
  • Talevski raised concerns that the Court would overrule and change existing law relating to the ability to sue to enforce Spending Clause legislation under 42 U.S.C. §1983.​
  •  The §1983 law at issue is the primary way community health centers, such as UIOs, sue to enforce Medicaid payment rights. ​

Why is this significant?​

  • Talevski’s holding ensures the preservation of federal Medicaid guarantees as privately enforceable legal rights.​

3. Navajo Nation v. Department of Interior

  • On June 22, the Court held in a 5-4 decision the United States owes no “affirmative duty” to the Navajo Nation to secure water.
  • Court held that the 1868 treaty establishing the Navajo Reservation reserved necessary water to accomplish the purpose of the Navajo Reservation but did not require the United States to take affirmative steps to secure water for the Tribe.

Why is this significant?​

  • This means that the government does not have an enforceable trust responsibility to secure water for the Tribe under the Treaty.
  • This holding places further limitations on the scope of the trust responsibility’s enforceability.

NCUIH Youth Council Meets with Rep. Sharice Davids

NCUIH YC

NCUIH Youth Council NCUIH Youth Council members and Representative Sharice Davids (D-KS)

During NCUIH’s annual conference last month, Youth Council members had the opportunity to visit Capitol Hill and meet with elected officials, including Representative Sharice Davids and Senator Tina Smith, to discuss matters dear to them such as voting and access to mental health resources.

“It was a great discussion because it helped me and my fellow council members realize how important representation of Native voices in government is,”

– Elinor Ascher Handlin, 2023 NCUIH Youth Council Member.

NCUIH Provides Urban Indian Health Updates at Native Conferences

NCUIH logo

NCUIH at CCUIH

NCUIH CEO, Francys Crevier, alongside Board President Sonya Tetnowski and Federal Relations Manager, Alexandra Payan.

NCUIH CEO, Francys Crevier, gave policy updates at The California Consortium of Urban Indian Health Annual Conference on May 8-9 in Sacramento, California. ​

Chandos at IHB

Chandos Culleen, NCUIH Director of Federal Relations, Public Policy visits the Indian Health Board in Minneapolis, Minnesota.

Meredith Raimondi

NCUIH Vice President Meredith Raimondi presents at NCAI Mid-Year Conference.

The National Congress of American Indians (NCAI) held its Mid-Year Conference on June 4-9 in Prior Lake, MN where Meredith Raimondi, VP of Public Policy and Communications, gave NCUIH/Urban Indian Health updates. NCUIH also had the opportunity to visit the Indian Health Board.

Congress Passes Legislation to Address the Debt Limit with Advance Appropriations Authority for IHS​

An Act of Congress

On June 2, Congress passed the Fiscal Responsibility Act (H.R. 3746) to address the debt limit.

  • This bill suspends the debt ceiling through January 1, 2025 and includes spending caps on the total amount for non-defense discretionary funding for two years.​

Impact on Indian Healthcare:

  • Includes “claw backs” of some unobligated COVID-19 funding, however, the American Rescue Plan funding for the Indian Health Service (IHS) is protected from these rescissions. ​
  • The legislation included the budgetary authority to extend advance appropriations for IHS for Fiscal Year (FY) 25 and FY26 but limits the advance appropriation amount for each year to the FY 2024 appropriated amount.​

Another thing:

  • The deal includes the expansion of certain work requirements for federal nutrition and cash assistance programs but does not include new work requirements for Medicaid.​

Special Diabetes Program for Indians & Indian Boarding School Bills Pass Committee

Congress

Special Diabetes Program Reauthorization of 2023 (S.1855)

On June 15, 2023, by a 20-1 vote, the Senate Health, Education, Labor, and Pensions (HELP) Committee passed the bipartisan Special Diabetes Program Reauthorization of 2023 (S.1855), introduced by Sen. Susan Collins (R-ME) and Sen. Jeanne Shaheen (D-NH).

Why it matters: The bill would reauthorize the Special Diabetes Program for Type 1 Diabetes and the Special Diabetes Program for Indians (SDPI) at $170 million for FYs 24-25 for each program.

Did you know?: This is the first time the program has seen an increase in funding, as the program has been funded at $150 million annually since 2004, and is set to expire in September 2023.

Bipartisan Letters from the Diabetes Caucus

In March 2023, The House Diabetes Caucus Leaders Rep. Diana DeGette (D-CO-1) and Rep. Gus Bilirakis (R-FL-12) sent a letter to House leadership, and Senate Diabetes Caucus Leaders Sen. Susan Collins (R-ME) and Sen. Jeanne Shaheen (D-NH) sent a letter to Senate Leadership regarding the reauthorization of the program.

The House Diabetes Caucuses letter closed with 238 signatures and the Senate Diabetes Caucus letter closed with 60 signatures.

What they’re saying: “SDPI has been one of the most successful programs ever created to reduce the incidence and complications due to Type 2 diabetes.  Communities with SDPI-funded programs have seen substantial growth in diabetes prevention resources, and, for the first time, from 2013 to 2017, diabetes incidence in the AI/AN population decreased each year.”

Go deeper:

Truth and Healing Commission on Indian Boarding School Policies Act (S.1723)

On June 7, 2023, the Senate Committee on Indian Affairs (SCIA) held a business meeting where they unanimously passed the NCUIH-endorsed legislation, the Truth and Healing Commission on Indian Boarding School Policies Act (S.1723) with amendments.

Why it matters: This legislation establishes a formal commission to investigate, document, and acknowledge past injustices of the federal government’s Indian Boarding School Policies. The Commission would develop recommendations for Congress to promote the healing of historical and intergenerational trauma caused by boarding schools and provide an environment for Native people to speak about their personal experiences.

What they’re saying:

SCIA Chairman, Senator Schatz (D-HI), highlighted that “for over a century, the federal government knowingly perpetuated violence and trauma with the goal of assimilating Native children by destroying family and communal bonds, their languages, their cultures, and their very identities. The impacts of this shameful history are felt by survivors and their descendants to this day. Without the guidance and support of Native communities across the country on this important bill, a culturally respectful and meaningful path to truth and healing would not be possible.”

SCIA Vice Chairman, Senator Murkowski (R-AL), echoed the importance of the legislation, stating, “This Commission will help document what happened and then develop recommendations on how to heal from these harms. I commend the work of the committee staff and members for their efforts to address the calls for justice by advocates while making bipartisan improvements to the bill.”

What’s next: This legislation has been read twice and referred to the Committee on Indian Affairs.

Go deeper:

NCUIH Provides Comments on FY 2025 Budget & IHS on Health Information Technology Modernization​​

IHS

On May 19, NCUIH submitted comments to the Department of Health and Human Services (HHS) on the FY 2025 Budget Testimony. NCUIH provided a comment template for UIOs.​​

Our thought bubble: NCUIH recommended that HHS take the following actions:

  • Propose $965.3 million for the Urban Health line item in the HHS FY 2025 Budget and $53.85 billion for IHS overall.
  • Safeguard IHS and UIO funding by proposing mandatory appropriations, exception apportionment for UIOs, and exempting IHS from proposed sequestration.
  • Propose a legislative fix setting the Federal Medical Assistance Percentage (FMAP) at 100% for Medicaid services provided at UIOs.
  • Propose $80 million for the Native Behavioral Health Resources Program.
  • Request permanent reauthorization of SDPI at a minimum $250 million.
  • Request a legislative fix permitting U.S. Public Health Service Commissioned Corps Officers to be detailed to UIOs.
  • Establish an Urban Confer Policy.

On June 10, NCUIH submitted comments to IHS on Health Information Technology (HIT) Modernization. NCUIH provided a comment template for UIOs. 

  • Incorporate necessary new capabilities in the modernized Electronic Health Record (EHR) solution.
  • Ensure that the new EHR contains the full suite of EHR Capabilities.
  • Supports the unique interoperability needs of UIOs.
  • Develop a timeline for IHS, Tribal, and UIO facilities to use as a planning base to prepare for the transition to a new system.
  • Take all necessary and practicable steps to secure funding for EHR reimbursement.

Upcoming Comments and Submissions:

  • June 30 – Comment deadline to Office of Management and Budget (OMB) on IHS Mandatory Funding​
  • July 3 – Comment deadline to Center for Medicaid and Medicare Services (CMS) on Ensuring Access to Medicaid​
  • July 3 – Comment deadline to CMS on Access to Managed Care ​

NCUIH & Partnership for Medicaid Advocate to Protect Medicaid Recipients from Work Requirements

Medicaid partnership

  • On May 8, 20223, NCUIH signed on to a Partnership for Medicaid letter to Congressional Leadership expressing concern about work requirements as a mandatory condition for Medicaid eligibility in the debt ceiling bill.​
  • This letter urges Congress to build on the policies that have enhanced and expanded coverage for the individuals, children, and families enrolled in Medicaid these last couple of years and opposes budget driven changes that would limit eligibility and coverage and cause unintended harm to many beneficiaries.

Go deeper: Read the letter

One Last Thing: Pride Beyond Pride Month

NCUIh Pride

As we celebrate Pride Month this June, we embrace the vibrant tapestry of diversity within the urban Native community, honoring the contributions and resilience of LGBTQ+ individuals and acknowledging the important presence of Two-Spirit people among us. This month, and every day after, we recognize the intersections of identity and strive to create inclusive spaces that empower all members of our community, ensuring their voices are heard and respected. Join us in promoting equality, love, and acceptance as we stand united in the spirit of Pride.

Upcoming Events and Important Dates

Calendar with events on it

Upcoming Events:

  • VA extended eligibility for VA health care for certain Veterans of the Vietnam, Gulf War, and post-9/11 eras pursuant to the Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act. SUBMIT your PACT Act claim by August 9 to be eligible for backdated benefits back to August 10, 2022.
  • July 11 – IHS Meeting on Overview of Updated Policy on Conferring with Urban Indian Organizations
  • July 19th- NCUIH Monthly Policy Workgroup Meeting

ICYMI:

  • June 26-29- IHS Tribal Self-Governance Advisory Committee (TSGAC) held its Annual Conference. ​
  • June 20-21​- IHS National Tribal Advisory Committee (NTAC) on Behavioral Health held its meeting.
  • June 14 – NCUIH attended the While House Council on Native American Affairs (WHCNAA), Department of Veterans Affairs (VA), IHS, Housing and Urban Development (HUD) joint AI/AN Homelessness Initiative Workgroup.
  • June 2 – NCUIH attended a meeting with Center for Medicaid and CHIP Services (CMCS) to discuss the Medicaid Unwinding Process and its impact on vulnerable communities. ​
  • May 10 – IHS held Tribal Consultation (TC) and Urban Confer (UC) on IHS Health Information Technology Modernization Resources. ​Comments were submitted June 10. There will be two more TC/UC in August and November of this year.

Thank you for all your hard work and advocacy!

NCUIH Joins Partnership for Medicaid in Letter to Congressional Leadership on Concerns with Work Requirements in Debt Ceiling Negotiations

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On May 8, 2023, the Partnership for Medicaid (Partnership) and the National Council of Urban Indian Health (NCUIH) sent a letter to House and Senate leadership expressing concerns with broad-based work requirements in Medicaid and Debt Ceiling negotiations. In the letter, they requested that Congress work together to build on the policies that have enhanced and expanded coverage for the individuals, children and families enrolled in Medicaid these last couple of years.

Read the Full Letter

Full Letter Text:

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

The members of the Partnership for Medicaid — a nonpartisan, nationwide coalition of organizations representing clinicians, health care providers, safety net health plans and counties — are writing about our concerns on legislation around the debt ceiling which could include broad-based work requirements as a mandatory condition for Medicaid eligibility.

Instead, we ask that Congress work together to build on the policies that have enhanced and expanded coverage for the individuals, children and families enrolled in Medicaid these last couple of years. We know that the bipartisan improvements that ensured continuous eligibility for the 44 million children in Medicaid and CHIP, the one year of postpartum coverage for mothers and babies, significant investments in Medicaid funding for the U.S. territories and the ability to coordinate the care of justice involved youth are significant and equitable steps forward for our health care system. The Partnership for Medicaid strongly supported these longstanding policies.

Any Medicaid work requirement proposals arrive at a time when the program is “unwinding” from previous coverage expansions tied to covid-19 Public Health Emergency (PHE) declarations that could leave as many as 15 million low-income Americans without health insurance coverage. Our members are at the frontlines of any policies that could result in coverage loss for Medicaid beneficiaries. Our specific concern is that the Medicaid “unwinding” process required by the Consolidated Appropriations Act passed last year, combined with the work requirements under consideration will limit access to health services while producing a wave of uncompensated care straining the capacity of Medicaid safety net providers already dealing with severe workforce crises.

The Partnership has long supported thoughtful Medicaid policy reforms that will improve the program by producing both fiscal savings for states and the federal government along with better clinical results and support for beneficiaries. At the same time, for nearly two decades, the coalition has always maintained that Medicaid reforms should be driven by better programmatic outcomes.

The Partnership for Medicaid stands ready as a resource to engage in policy driven reforms to the Medicaid program, but strongly opposes budget driven changes that would limit eligibility and coverage and cause unintended harm to many beneficiaries.

 

Sincerely,

The Partnership for Medicaid
www.partnershipformedicaid.org

About the Partnership for Medicaid

NCUIH is a member of the Partnership for Medicaid, which is a nonpartisan, nationwide coalition of organizations representing clinicians, health care providers, safety-net health plans, and counties. The goal of the coalition is to preserve and improve the Medicaid program. Members of this coalition include:

Background and NCUIH Advocacy

On April 20, 2023, Families USA with 230 national and state partner organizations, including NCUIH, sent a letter to House and Senate leadership requesting Medicaid be protected from proposed cuts amid debt limit negotiations. The letter emphasizes how critical the Medicaid program is to our country’s health and financial well-being following the COVID-19 Pandemic and the policy proposals for the debt ceiling can take healthcare away from millions of people, including American Indians and Alaska Natives (AI/ANs).

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.

Senate Committee on Indian Affairs Passes NCUIH Endorsed Truth and Healing on Indian Boarding School Policies Act

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On June 7, 2023, the Senate Committee on Indian Affairs (SCIA) held a business meeting where they unanimously passed the National Council of Urban Indian Health (NCUIH)-endorsed legislation, the Truth and Healing Commission on Indian Boarding School Policies Act (S.1723) with amendments. This legislation establishes a formal commission to investigate, document, and acknowledge past injustices of the federal government’s Indian Boarding School Policies. The Commission would develop recommendations for Congress to promote the healing of historical and intergenerational trauma caused by boarding schools and provide an environment for American Indian/Alaska Native (AI/AN) people to speak about their personal experiences.

SCIA Chairman, Senator Schatz (D-HI), highlighted that “for over a century, the federal government knowingly perpetuated violence and trauma with the goal of assimilating Native children by destroying family and communal bonds, their languages, their cultures, and their very identities. The impacts of this shameful history are felt by survivors and their descendants to this day. Without the guidance and support of Native communities across the country on this important bill, a culturally respectful and meaningful path to truth and healing would not be possible.”

SCIA Vice Chairman, Senator Murkowski (R-AL), echoed the importance of the legislation, stating, “This Commission will help document what happened and then develop recommendations on how to heal from these harms. I commend the work of the committee staff and members for their efforts to address the calls for justice by advocates while making bipartisan improvements to the bill.”

The adopted amendments reflect feedback from over 100 survivors, descendants, Tribal leaders, advocates, churches, local governments, and experts, who provided testimony for the record following last year’s hearing. These amendments include requiring the online publication of final reporting, giving the Attorney General authority to prevent the issuance of a defective subpoena after providing the opportunity to cure, enabling the Commission to use data provided by the Department of the Interior to prevent duplication, clarifying that the Commission may not use federal funds to purchase property, requiring that subpoenas get a unanimous vote on the five-member Commission, and ensuring the commissioner is serving as the traditional cultural authority is recognized as such by their respective native community.

Re-Introduction of the Bill

This legislation was previously introduced by Congresswomen (now Secretary of Interior) Deb Haaland (D-NM) in 2020 as H.R. 8420 and Senator Elizabeth Warren and Representatives Sharice Davids (D-KS-03) and Tom Cole (R-OK-04) in 2021 as H.R. 5444/S.2907. On May 18, 2023, Senator Warren (D-MA) re-introduced the bill as S.1723 with bipartisan support and 26 co-sponsors.

The bill is endorsed by the National Native American Boarding School Healing Coalition (NABS), National Congress of American Indians (NCAI), National Indian Education Association (NIEA), National Indian Health Board (NIHB), National Indian Child Welfare Association (NICWA), American Indian Higher Education Consortium (AIHEC), National Indigenous Women’s Resource Center (NIWRC), Seattle Indian Health Board (SIHB), Jesuit Conference of Canada and the United States, Friends Committee on National Legislation (FNCL), and United South and Eastern Tribes Sovereignty Protection Fund (USET SPF).

Background

The federal government funded these boarding schools as recently as the 1960s to wipe out Indigenous cultures. Children were forcibly removed from their families and experienced horrific emotional, physical, and sexual abuse while in the custody of these schools. The Commission not only highlights the government’s role in the abuse but will also build on the work of Secretary Deb Haaland and the Department of the Interior in examining what happened at these schools.

On June 22, 2022, the Senate Committee on Indian Affairs held a hearing to consider Truth and Healing Commission on Indian Boarding School Policies in the United States Act, S. 2907 and on June 15, 2022, the House Committee on Natural Resources held a markup to consider a series of bills, including the House companion bill . Several Members of Congress, such as Senator Cortez Masto (D-NV) and Representative McCollum (D-MN-04), expressed concerns and grievances about the horrific occurrences within boarding schools.

On December 23, 2021, NCUIH submitted comments to the Department of the Interior regarding the agency’s Federal Boarding School Initiative, reiterating its ongoing support for the Administration’s efforts to address the legacy of boarding school programs while urging the Administration to use the Initiative to address the public health impact of boarding schools on urban AI/ANs.

NCUIH Action

NCUIH worked with Senator Elizabeth Warren (D-MA) on this landmark legislation to begin the healing process from Indian Boarding School policies and ensure the inclusion of urban Indian organizations in the Commission. This bill ensures that the stories of AI/ANs that live in urban areas are included. NCUIH exists partly because of the historical oppression of the AI/AN population, including federal boarding schools that resulted in the growing AI/AN populations in cities, and has continuously advocated for substantial efforts to address the historical trauma and public health impact that boarding schools have on urban AI/ANs.

On December 23, 2021, NCUIH submitted comments to the Department of the Interior regarding the agency’s Federal Boarding School Initiative, reiterating its ongoing support for the Administration’s efforts to address the legacy of boarding school programs while urging the Administration to use the Initiative to address the public health impact of boarding schools on urban AI/ANs.

On May 26, 2022, NCUIH submitted written testimony to the House Natural Resources Subcommittee for Indigenous Peoples of the United States in support of the Truth and Healing Commission on Indian Boarding School Policies in the United States Act (S. 2907/H.R. 5444).

Next Steps

This legislation has been read twice and referred to the Committee on Indian Affairs. NCUIH will continue to monitor the bill’s progress.

Resources

New IHS/VA Map Tool Connects Native Veterans to Healthcare and Support Services Nationwide, Including at Urban Indian Organizations

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The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) launched an interagency map tool, called Find Health Care & Resources for Native Veterans, to make healthcare more accessible for American Indian and Alaska Native (AI/AN) veterans. This map hosts location data from 41 urban Indian organizations (UIOs) with 82 locations and 1,500 VA healthcare facilities and is an easy way for AI/AN veterans to find health and support services ranging from dental care centers to substance abuse help. The tool also identifies resources to address homelessness and was developed as a part of the Native American Veteran Homelessness Initiative whose goal, in partnership with UIOs, is to provide education on resources from the VA and IHS and to encourage Native veterans to access those services. Ending veteran homelessness was labeled as a top priority of the Biden administration. In accordance with this, the tool labels as many Veterans Health Administration (VHA) sites as possible, usable by all Native and non-Native veterans. The map helps Native veterans from around the country get connected to services they need and deserve.

Access the tool here

Background

Native Veteran Disparities

Native Americans have served for the United States military at higher rates than any other group in almost every armed conflict in the nation’s history. However, Native veterans face significantly higher disparities once transitioned back to civilian life. For example, Native veterans are more likely to be uninsured and have a service-connected disability than other veterans. Urban Native veterans generally have lower incomes, higher unemployment, lower education attainment, higher VA-service connected disability, and generally live in poorer housing conditions than non-Native urban veterans.  The National Council of Urban Indian Health (NCUIH) estimates that there are about 8 Native veterans experiencing homelessness per 1000 veterans, compared to about 1.5 white veterans per 1000 veterans. Urban Native veterans are greatly impacted by this, as NCUIH estimates that 86.2% of the veteran population identifying as Native lives in urban areas.  Homelessness is a key Social Determinant of Health and a lack of stable housing can lead to an increased risk of premature death, preterm delivery, exposure to disease vectors like vermin, and other negative health impacts.

NCUIH and the VA

NCUIH has highlighted in several written comments to the VA and in meetings with agency representatives, the need for the VA to address and provide services to Native veterans living in urban areas. VA data currently indicates that Native veterans use VA benefits or services at a lower percentage than other veterans. To address these disparities, NCUIH has provided the VA with several recommendations and administrative guidance on how to improve Native veteran health through collaboration with the VA. This map tool will also help eligible AI/AN veterans access VA health care, where they are no longer required to make copayments for health care and urgent care. For years, 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. 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.

NCUIH is also working to address homelessness among urban Native veterans and works closely with the VA, Department of Health and Human Services (HHS), Housing and Urban Development (HUD), and the White House Committee on Native American Affairs on the implementation of the interagency Native American Veteran Homelessness Initiative. Sonya Tetnowski (Makah), Chair of Veterans Health Administration Subcommittee within the VA Advisory Committee on Tribal and Indian Affairs Committee, Army veteran, NCUIH President, and CEO of the Indian Health Center for Santa Clara Valley, highlighted the importance of looking at the whole person and making sure that their needs are being met during a Committee meeting in January. She also brought forth potential subcommittees, including unhoused urban Veterans, Native Healer utilization, and Behavioral Health and Substance Use. On August 17, 2022, the Committee held a meeting where Ms. Tetnowski presented five priority areas, including homelessness and housing as a priority. In addition, NCUIH submitted comments to HUD, encouraging the agency to incorporate urban Natives in its FY22-26 Strategic Plan and focus areas. HUD provides housing resources and funding for Tribes, but these resources are very limited when it comes to urban AI/ANs, or not applicable at all. These efforts have emphasized the critical importance of working with UIOs to reach and serve the significant portion of Native veterans living in urban areas.

 

Bureau of Indian Education’s Advisory Board for Exceptional Children to Host Two-Day Meeting This Week, UIOs Encouraged to Attend 

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The Bureau of Indian Education (BIE) announced that the Advisory Board for Exceptional Children will be hosting a two-day in-person and online meeting on Thursday, June 22, 2023, from 8 a.m. to 3:15 p.m., Pacific Daylight Time (PDT) and Friday, June 23, 2023, from 8 a.m. to 4:30 p.m., Pacific Daylight Time (PDT). The National Council of Urban Indian Health encourages interested urban Indian organization (UIO) leaders to attend.

All Advisory Board activities and meetings will be conducted in-person with corresponding online access. The onsite meeting location will be at the Chemawa Indian School located at 3700 Chemawa Road NE, Salem, Oregon. To attend remotely, please register using this link: https://www.zoomgov.com/​meeting/​register/​vJIsd-2urTIoGYqvBQdLsCW2XyFzejJriFU. Once registered, attendees can attend both meeting events.

Background

The Advisory Board was established under the Individuals with Disabilities Act of 2004 in an effort to advise the Secretary of the Interior, through the Assistant Secretary-Indian Affairs, on the needs of Indian children with disabilities.

The purpose of the meeting is to meet the mandates of the Individuals with Disabilities Education Act of 2004 (IDEA) for Indian children with disabilities. The following agenda items will be for the two-day meeting. The reports are regarding special education topics.

  • Chemawa Indian School—School leadership team, teachers, school improvement team, parent advisory board. Report on the successes and concerns at your school. What do you see as an opportunity to improve services for children and families in the local community?
  • A panel discussion with BIE Off Reservation Board Schools (ORBS), Chemawa Indian School, Flandreau Indian School, Riverside Indian School, and Sherman Indian School. Discussions will include the COVID pandemic and post-COVID, how it affected the school’s ability to provide educational services to all students and specifically students with disabilities?
  • BIE Special Education Program. Dr. Eugene Thompson, Supervisory Education Specialist. Provide updates about BIE regional conferences, progress update about the U.S. Government Accountability Office (GAO) 2020 report regarding Students with Disabilities Receiving Special Education Services, update about the BIE’s Special Education Policy and Procedures Manual, and report on the special education findings regarding the BIE’s Fiscal and Programmatic Monitoring for SY22–23.
  • State Departments Office of Indian Education. Tribal-State liaison Offices of Indian Education Panel. To discuss services and supports provided to BIE funded schools in each state. Discuss the relationship between the State’s Office of Indian Education and BIE funded schools within each state. What funding does the state provide to BIE funded schools when a student does not meet Indian School Equalization Program (ISEP) eligibility criteria?
  • Advisory board members will work on identifying priority topics for problems that could be creating barriers for children with disabilities within the BIE school system.
  • Advisory board members will work on developing the agenda for the next board meeting scheduled for September 21–22, 2023.
  • Four Public Commenting Sessions will be provided during both meeting days.

Public comments can be emailed to the Designated Federal Officer (DFO) at Jennifer.davis@bie.edu; or faxed to (602) 265–0293 Attention: Jennifer Davis, DFO; or mailed or hand delivered to the Bureau of Indian Education, Attention: Jennifer Davis, DFO, 2600 N Central Ave., 12th floor, Suite 250, Phoenix, AZ 85004.

More information, please use this link: Federal Register :: Advisory Board of Exceptional Children.

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

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

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

SDPI’s integrated approach to diabetes healthcare and prevention programs in Indian Country has become a resounding success and is one of the most successful public health programs ever implemented. Currently, 31 urban Indian organizations (UIOs) receive SDPI funding that enables UIOs to provide critical services that reduce the incidence of diabetes-related illness among urban Indian communities. The program is currently set to end in September 2023, and it remains critical that Congress reauthorizes SDPI to ensure there is no lapse in funding.

Bipartisan Letters from the Diabetes Caucus

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

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

The letter notes developments from the SDP and SDPI include:

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

Background on SDPI and American Indians/Alaska Natives

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

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

NCUIH Action

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

Resources

NCUIH Applauds Supreme Court Decision to Uphold Indian Child Welfare Act

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FOR IMMEDIATE RELEASE

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

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

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

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

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

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

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

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

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

View the resource

About the Indian Health Service and Medicaid

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

Medicaid Coverage in AI/AN Communities

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

Medicaid and Urban AI/AN Communities

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

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

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

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

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

Covid-19 and Medicaid Unwinding

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

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

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

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

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

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

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

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

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

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

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