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

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

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

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

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

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

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

-NCUIH CEO, Francys Crevier (Algonquin)

What they’re saying:

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

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

What they’re saying:

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

Remarks from HHS

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

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

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

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

• Currently, IHS is the only agency required to confer with UIOs on matters affecting Native people.

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

Go deeper:

• Watch the Full Hearing
• Read NCUIH’s Testimony

Next Steps:

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

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

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

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

— Francys Crevier (Algonquin), NCUIH CEO.

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

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

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

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

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

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

NCUIH Testifies before Congress on Tribal Healthcare Delivery

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

What they’re saying:

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

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

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

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

Go deeper:

• Read NCUIH’s written testimony.

• Watch NCUIH’s testimony.

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

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

In the letters, NCUIH requested the following:

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

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

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

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

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

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

Go deeper:

• NCUIH Letter to House Appropriations Committee
• NCUIH Letter to Senate Appropriations Committee
• Senate “Dear Colleague” letter
• House “Dear Colleague” letter

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

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

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

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

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

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

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

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

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

100% FMAP for Medicaid Services at UIOs

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

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

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

Native Veterans Homeless Initiative

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

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

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

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

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

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

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

— Francys Crevier (Algonquin), NCUIH CEO.

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

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

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

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

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

Go deeper:

• Full Multi-Group Letter to HHS

One last thing: NCUIH Visits Phoenix UIOs

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

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

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