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

April 24, 2023/0 Comments/in Policy Blog, Press Release/by NCUIH

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

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

WASHINGTON, D.C. (April 24, 2023) – Today, the National Council of Urban Indian Health (NCUIH), in collaboration with the Asian & Pacific Islander American Health Forum, the Coalition on Human Needs, The Leadership Conference on Civil and Human Rights, the National Association for the Advancement of Colored People, National Urban League, Protect Our Care, UnidosUS and 220 other organizations sent a letter to the Department of Health and Human Services (HHS) Secretary Xavier Becerra. Since Medicaid unwinding may disproportionately harm vulnerable communities, the Consolidated Appropriations Act of 2023 included authorities to protect beneficiaries from losing Medicaid coverage for administrative reasons. For example, according to the Assistant Secretary for Planning and Evaluation, three-fourths of children losing Medicaid will remain eligible but be terminated because of state administrative requirements. The letter calls on the Administration to use the full extent of these authorities to safeguard Medicaid coverage and outlines specific steps the Administration can take to avoid wrongful terminations.

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

Impact on Native Health

In 2019, Medicaid covered 1.3 million urban American Indians and Alaska Natives (AI/ANs), including 30% of urban AI/AN adults under age 65.1 Comparatively, Medicaid covered 19.8% of all urban U.S. adults under age 65.2 Native people may be at an increased risk of disenrollment in Medicaid and CHIP programs during the Medicaid unwinding period. In fact, Medicaid coverage losses are estimated to take twice the toll on AI/AN communities than they will take among non-Hispanic white families. It is estimated that 12% of all AI/AN children and 6% of all AI/AN adults nationwide will lose CHIP or Medicaid coverage as state Medicaid programs return to normal operations. AI/ANs may be at an increased risk of losing Medicaid and CHIP coverage due to administrative barriers during the unwinding. AI/AN beneficiaries face several challenges in enrolling or retaining coverage such as geographical remoteness, limited access to internet or phone service, and language barriers. Inadequate health insurance coverage is a significant barrier to healthcare access, and the loss of coverage may exacerbate the significant healthcare disparities faced by AI/AN communities.

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

Requests to the Administration in the Letter

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

CMS mitigation plans should prevent states from wrongfully terminating beneficiaries for purely procedural reasons. 
CMS should hold state and local Medicaid agencies accountable for compliance with civil rights laws.
CMS should promote transparency and accountability by publishing state unwinding and performance indicator data as soon as possible.
CMS should hold states accountable for renewing coverage based on data matches “to the maximum extent practicable,” as required by Affordable Care Act.

Background on Medicaid Unwinding

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

Full Letter Text

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

Dear Secretary Becerra:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

April 20, 2023/0 Comments/in Policy Blog/by Mary Jomia

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

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

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

Full Letter Text

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

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

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

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

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

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

Background

Medicaid: A Critical Source of Coverage for AI/ANs

AI/AN people depend upon Medicaid to receive their healthcare coverage and services. In 2020, over 1.8 million AI/ANs were enrolled in Medicaid. According to a NCUIH analysis of American Community Survey (ACS) data, in 2019 Medicaid covered 1.3 million urban AI/ANs, including 30% of urban AI/AN adults under the age of 65. Medicaid and CHIP are important programs for addressing the significant disparities in insurance coverage which exist for AI/AN people. For example, according to the Urban Institute, AI/AN children were uninsured at a rate of 8.9% in 2019, the highest rate for any ethnic group in the country. AI/AN parents were uninsured at a rate of 18.7% in 2019, the second highest rate in the country. The Urban Institute reported that in 2019, AI/AN children remained more than twice as likely as white children to be uninsured and AI/AN were more than 2.5 times more likely to be uninsured than with white parents.

Medicaid is also an important source of funding for to support the operation of the Indian Health system, including UIOs who help serve the approximately 70% of AI/AN people who live in urban areas. Medicaid remains the largest secondary source of funding for UIO clinics. In 2020, 33% of the total population served at UIOs were Medicaid beneficiaries, and 35% of the AI/AN population served at UIOs were Medicaid beneficiaries. As the Kaiser Family Foundation noted in 2017, “Medicaid funds are not subject to annual appropriation limits . . . since Medicaid claims are processed throughout the year, facilities receive Medicaid funding on an ongoing basis for covered services provided to AIANs.” Because the Medicaid program receives Mandatory appropriations, Medicaid revenue is particularly essential for Indian health providers when IHS funding is reduced or interrupted by budgetary disagreements.

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

April 19, 2023/0 Comments/in Policy Blog/by Jeremy Grabiner

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

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

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

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

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

Next Steps

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

Resources

11 Senators Request Increased Resources for Urban Indian Health in FY24

April 19, 2023/0 Comments/in Policy Blog/by Jeremy Grabiner

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

Sen. Tina Smith (D-MN) and 10 other Senators sent a letter to Chairman Jeff Merkley (D-OR) and Ranking Member Lisa Murkowski (R-AK) of the Senate Interior Appropriations Committee requesting up to $973.59 million for urban Indian health in FY 2024 and maintaining advance appropriations for IHS. The letter emphasizes the critical role that urban Indian organizations (UIOs) play in health care delivery to American Indian and Alaska Native (AI/AN) patients and the importance of providing UIOs with the necessary funding to continue to provide quality, culturally-competent care to their communities. The National Council of Urban Indian Health (NCUIH) worked closely with the Senators on leading this letter to push for stable funding for IHS and the Tribal Formulation Workgroup’s requests of full funding for urban Indian health. On March 24, 2023, a group of 38 Representatives sent a letter to the House Interior Appropriations Committee with the same requests.

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

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

NCUIH is grateful for the support of the following Senators:

Tina Smith
Tammy Baldwin
Maria Cantwell
Diane Feinstein
Ben Luján
Edward Markey
Alex Padilla
Jacklyn Rosen
Jon Tester
Chris Van Hollen
Elizabeth Warren

Full Letter Text

Dear Chairman Merkley and Ranking Member Murkowski,

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

UIOs operate 77 facilities across the nation in 22 states, serving the approximately 70 percent of American Indian and Alaska Native (AI/AN) people who live in urban areas. UIOs are an important part of the IHS, which oversees a three-prong system for the provision of health care: Indian Health Service, Tribal Programs, and Urban Indian Organizations (I/T/U). UIOs are not eligible for other federal line items that IHS and Tribal facilities are, like hospitals and health clinics money, purchase and referred care dollars, or IHS dental services dollars. Therefore, this funding request is essential to providing quality, culturally-competent health care to AI/AN people living in urban areas.

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

Chronic underfunding of IHS and urban Indian health has contributed to the health disparities among AI/AN people. Additionally, AI/AN people living in urban areas suffer greater rates of chronic disease, infant mortality, and suicide compared to all other populations. Urban Native populations are less likely to receive preventive care and are less likely to have health insurance. Yet, despite the historical acknowledgement from Congress of the significant health care disparities in Indian Country, IHS is underfunded at around $4,000 per patient, and UIOs receive just $726 per patient.

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

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

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

April 10, 2023/0 Comments/in Policy Blog/by Jeremy Grabiner

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

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

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

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

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

NCUIH is grateful for the support of the following Representatives:

Don Bacon
Nanette Barragán
Earl Blumenauer
Shontel Brown
Salud Carabjal
Greg Casar
Sharice Davids
Diana DeGette
Ruben Gallego
Steven Horsford
Jared Huffman
Pramila Jayapal
Dusty Johnson
William Keating
Ro Khanna
Teresa Leger Fernandez
Mike Levin
Zoe Lofgren
Doris Matsui
Gwen Moore
Eleanor Holmes Norton
Ilhan Omar
Mary Peltola
Brittany Pettersen
Deborah Ross
Adam Schiff
Kim Schrier
Terri Sewell
Adam Smith
Melanie Stansbury
Greg Stanton
Jill Tokuda
Gabe Vasquez
Jasmine Crockett
Chris Pappas
Raul Ruiz
Jesus “Chuy” Garcia
Raul Grijalva

Full Letter Text

Dear Chairman Simpson and Ranking Member Pingree,

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

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

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

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

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

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

Cuts from sequestration force I/T/U providers to make difficult decisions about the scope of healthcare services they can offer to Native patients. For example, the $220 million reduction in IHS’ budget authority for FY 2013 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for AI/ANs. At a minimum, funding must be maintained and protected as budget-cutting measures are being considered.

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

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

April 10, 2023/0 Comments/in Policy Blog/by Jeremy Grabiner

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

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

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

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

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

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

Next Steps

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

Resources

Full Bill Text (117^th Congress)

Bill Providing Additional Support for Not Invisible Act Commission’s Activities to Address MMIP Signed into Law

April 10, 2023/0 Comments/in Policy Blog/by Chelsea Gutierrez

On December 22, 2022, the House of Representatives passed Bill S.5087, an amendment to the Not Invisible Act of 2019. The Act was created to address the Missing and Murdered Indigenous Peoples (MMIP) crisis in the United States, through the creation of a commission or advisory committee. S.5087 extends the Commission and its termination deadline by an additional 18 months. The deadline for the Commission to make available and submit recommendations to establish best practices for state, tribal, and federal law enforcement, was also extended from 18 months to now a total of 36 months by this bill. Additionally, this amendment will provide more support to the Commission through enabling them to accept and use gifts or donations from Indian Tribes or tribal entities, academic institutions, or non-profit organizations to carry out their duties as outlined in the Act. It was then signed by President Biden on January 5, 2023, becoming Public Law No. 117-359.

Background

The Department of Interior and Department of Justice Joint Commission on Reducing Violent Crime Against American Indians and Alaska Natives was created in the original Not Invisible Act of 2019, authored by then-Rep. Deb Haaland and sponsored by Sen. Catherine Cortez Masto (D-NV). The Commission is composed of law enforcement, tribal leaders, federal partners, service providers, and most importantly – survivors. The purpose of the Commission is to improve federal and tribal coordination efforts and establish best practices to reduce violent crime within Indian lands and against Indians. This will be done by the commission creating recommendations, making them publicly available, and submitting them to:

the Secretary of the Interior
the Attorney General
the Committee on the Judiciary of the Senate
the Committee on Indian Affairs of the Senate
the Committee on Natural Resources of the House of Representatives; and
the Committee on the Judiciary of the House of Representatives

In late February of this year, the first in-person plenary session of the Not Invisible Act Commission was held at the U.S. Department of the Interior and hosted by Deputy Attorney General Lisa Monaco and Secretary Deb Haaland. During consultations, the Department of Justice was able to use information obtained through consultations with Tribal representatives and subject-matter experts to secure more Indian country law enforcement resources to address the MMIP crisis in fiscal year 2023. Attorney General Monaco also emphasized the Department’s commitment to offer support and partnership to the Commission during its recommendation process.

Commission Hearings to Gather Input on Crisis Response Recommendations

Through the work of six subcommittees, the Commission is developing recommendations to improve coordination and improve best practices to bolster resources for survivors and victim’s families, and to combat the epidemic of missing persons, murder, and trafficking of American Indian and Alaska Natives. The subcommittees have selected specific locations to hold field hearings to hear directly from the public in areas most affected by the MMIP crisis:

April:

Tulsa, Oklahoma
Anchorage, Alaska

May:

Flagstaff, Arizona

June:

Minneapolis, Minnesota
Northern California
Albuquerque, New Mexico

July:

Billings, Montana

Recently, the commission released details about their first hearing in Tulsa, Oklahoma. It will be held on April 11, discussing the topic of “Law Enforcement and Investigative Resources to Identify and Respond to Cases of MMIP and HT.” A national, virtual field hearing will be held later in Summer 2023 with details to follow. The hearings will have panel discussions and a public comment period. Specific topics, as well as logistical details and information, will be provided to the public as the date of each hearing approaches. The information gathered during these field hearings will be used in the Commission’s final report to Secretary Haaland, Attorney General Merrick Garland, and Congress.

NCUIH Requests HHS Prioritize Urban Native Communities in Initiatives Aimed at Improving Health Equity

April 6, 2023/0 Comments/in Policy Blog/by Colin Tompson

On March 3, 2023, the National Council of Urban Indian Health (NCUIH) submitted comments to the Health and Human Services (HHS) Office of the Assistant Secretary for Health (OASH) regarding the HHS Initiative to Strengthen Primary Health Care (the Initiative). The Initiative aims to improve health equity and reduce barriers to care for traditionally underserved populations, included American Indians and Alaska Natives (AI/ANs). As part of the Initiative, OASH has hosted listening sessions with Urban Indian Organizations (UIOs) and tribal leaders to collect input and inform HHS regarding the needs of AI/AN stakeholders and beneficiaries.

Background

Launched in September 2021, the goal of the Initiative is to develop a federal foundation for the provision of primary health care aimed to improve health outcomes and advance health equity for the improved health and wellness of patients, families/caregivers, and communities. Access to high-quality primary health care has been shown to improve health equity and health outcomes, and is essential for addressing key priorities, including mental and substance use disorder prevention and care, prevention and management of chronic conditions, addressing the impact of gender-based violence, and maternal and child health and well-being.

Generally, AI/ANs throughout the country experience the most significant health disparities of any group, when compared to the general population. Further, AI/ANs living in urban areas experience greater rates of chronic disease, maternal and infant mortality, and suicide compared to all other populations and they are less likely to receive preventive care and are less likely to have health insurance.

NCUIH’s Role

NCUIH recent comment and recommendations to OASH regarding the Initiative are based on NCUIH’s consultations with UIOs, and listening session held with UIO leaders on February 2, 2023, and NCUIH’s subject matter expertise. NCUIH reiterated that input from UIOs is vital for OASH effectively gather comprehensive feedback, share critical information, and build mutual trust.

Recommendations

In NCUIH’s comments to OASH regarding the Initiative, NCUIH recommended the following priorities:

Develop a better understanding of the health inequities pervasive in Native communities
Ensure primary care is culturally competent
Improve CMS Programs ability to serve American Indian and Alaska Native beneficiaries
Address workforce shortages at UIOs
Ensure that notices of funding opportunities are accurate and that UIOs have the technical assistance necessary to apply
Facilitate referrals of AI/AN patients in and out of the Indian health system, as well as within it
Establish an agency-wide Urban Confer Policy

NCUIH thanks OASH for hosting a UIO listening session and greatly appreciates the opportunity to provide feedback on the Initiative. We are heartened by HHS’ commitment to improving health equity and reducing barriers to care for the AI/AN community. We are especially grateful that OASH demonstrated this commitment by addressing NCUIH’s prior recommendation to host a meeting with UIOs regarding the Initiative.

NCUIH Calls for Full Funding and Increased Resources for Urban Indian Health in FY 2024 Written Testimony to House Appropriations Subcommittee

April 5, 2023/0 Comments/in Policy Blog/by Jeremy Grabiner

On March 23, 2023, The National Council of Urban Indian Health (NCUIH) submitted outside written testimony to the House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies regarding Fiscal Year (FY) 2024 funding for Urban Indian Organizations (UIOs). NCUIH advocated in its testimony for full funding for the Indian Health Service (IHS) and urban Indian health and increased resources for Native health programs.

In the testimony, NCUIH requested the following:

$51.42 billion for the Indian Health Service and $973.59 million for Urban Indian Health for FY24 (as requested by the Tribal Budget Formulation Workgroup)
Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
Permanent 100% Federal Medical Assistance Percentage for services provided at UIOs
Increase funding for Electronic Health Record Modernization
Increase funding to $30 million for Good Health and Wellness in Indian Country (GHWIC)
Ensure UIOs are appropriately included in grant programs relating to Indian health
Appropriate $80 million for the Native Behavioral Health Resources Program
Work with Authorizers to Reauthorize the Special Diabetes Program for Indians

Full Text of Testimony:

My name is Francys Crevier, I am Algonquin and the Chief Executive Officer of the National Council of Urban Indian Health (NCUIH), the national representative of urban Indian organizations receiving grants under Title V of the Indian Health Care Improvement Act (IHCIA) and the American Indians and Alaska Native (AI/ANs) patients they serve. On behalf of NCUIH and these 41 Urban Indian Organizations (UIOs), I would like to thank Chair Aderholt, Ranking Member DeLauro, and Members of the Subcommittee for your leadership to improve health outcomes for urban Indians. We respectfully request the following:

$51.42 billion for the Indian Health Service and $973.59 million for Urban Indian Health for FY24 (as requested by the Tribal Budget Formulation Workgroup)
Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
Permanent 100% Federal Medical Assistance Percentage for services provided at UIOs
Increase funding for Electronic Health Record Modernization
Ensure UIOs are appropriately included in grant programs relating to Indian health
Appropriate $80 million for the Native Behavioral Health Resources Program
Work with Authorizers to Reauthorize the Special Diabetes Program for Indians

We want to acknowledge that your leadership was instrumental in providing the greatest investments ever for Indian health and urban Indian Health, especially the inclusion of advance appropriations. It is important that we continue in this direction to build on our successes.

The Beginnings of Urban Indian Organizations

The Declaration of National Indian Health Policy in the Indian Health Care Improvement Act states that: “Congress declares that it is the policy of this Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.” In fulfillment of the National Indian Health Policy, the Indian Health Service funds three health programs to provide health care to AI/ANs: IHS sites, tribally operated health programs, and Urban Indian Organizations (referred to as the I/T/U system).

As a preliminary issue, “urban Indian” refers to any American Indian or Alaska Native (AI/AN) person who is not living on a reservation, either permanently or temporarily. UIOs were created in the 1950s by American Indians and Alaska Natives living in urban areas, with the support of Tribal leaders, to address severe problems with health, education, employment, and housing caused by the federal government’s forced relocation policies. Congress formally incorporated UIOs into the Indian Health System in 1976 with the passage of the Indian Health Care Improvement Act (IHCIA). Today, UIOs continue to play a critical role in fulfilling the federal government’s responsibility to provide health care for AI/ANs and are an integral part of the Indian health system. UIOs serve as a cultural hub for and work to provide high quality, culturally competent care to the over 70% of AI/ANs living in urban settings.

Request: $51.42 billion for Indian Health Service and $973.59 million for urban Indian health

The federal government owes a trust obligation to provide adequate healthcare to AI/ANs. It is the policy of the United States “to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to affect that policy.” This requires that funding for Indian health must be significantly increased if the federal government is to finally fulfill its trust responsibility. At a minimum, funding must be maintained and protected as budget-cutting measures are being considered.

We thus request Congress honor the Tribal Budget Formulation Workgroup (TBFWG) FY24 recommendations of $51.42 billion for IHS and $973.59 million for urban Indian health. That number is much greater than the FY23 enacted amounts of $6.9 billion for IHS and $90.4 million for urban Indian health. The significant difference between the enacted and requested amount underscores the need for Congress to significantly increase funding to IHS to meet the Indian Health System’s level of need. Additionally, IHS has been consistently underfunded in comparison to other major federal health agencies. In 2018, the Government Accountability Office (GAO-19-74R) reported that from 2013 to 2017, IHS annual spending increased by roughly 18% overall and approximately 12% per capita. In comparison, annual spending at the Veterans Health Administration (VHA), which has a similar charge to IHS, increased by 32% overall, with a 25% per capita increase during the same period. In fact, even though the VHA service population is only three times that of IHS, their annual appropriations are roughly thirteen times higher. In other words, it is imperative that Congress fully fund the IHS at the amount requested by the TBFWG to fulfill its trust responsibility and to improve health outcomes for AI/ANs no matter where they live.

The IHS is chronically underfunded, and the Urban Health line item historically is just one percent (1%) of that underfunded budget. UIOs receive direct funding only from the Urban Health line item and do not receive direct funds from other distinct IHS line items. As a result, in FY 2018 U.S. healthcare spending was $11,172 per person, but UIOs received only $672 per AI/AN patient from the IHS budget. Without a significant increase to the urban Indian line item, UIOs will continue to be forced to operate on limited budgets that offer almost no flexibility to expand services or address facilities-related costs. For example, one UIO, Native American Lifelines, is made up of two programs that run in both Boston and Baltimore with an annual budget of just $1.6 million for a service population of over 55,000 people.

Despite this underfunding, UIOs have been excellent stewards of the funds allocated by Congress and are effective at ensuring that increases in appropriations correlate with improved care for their communities. Last Congress, with the help of this committee, the Infrastructure Investment and Jobs Act now allows UIOs to utilize their existing IHS contracts to upgrade their facilities. With funding increases from this Committee and this new allowance, six UIOs opened new facilities in the past year, and an additional 16 UIOs have plans to open new facilities in the next two years. The increased investments in urban Indian health by this committee will continue to result in the expansion of health care services, increased jobs, and improvement of the overall health in our communities.

Request: Maintain Advance Appropriations for IHS Until Mandatory Funding Is Enacted

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

The GAO cited a lack of consistent funding as a barrier for IHS. The Congressional Research Service stated that advance appropriations would lead to cost savings as continuing resolutions (CRs) “prohibits the agency from making longer-term, potentially cost-saving purchases.” Advance appropriations will improve accountability and increase staff recruitment and retention at IHS. When IHS distributes their funding on time, our UIOs can pay their doctors and providers. During a pandemic that has ravaged Indian Country and devasted the workforce, being able to recruit doctors and pay them on time is a top priority.

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

Cuts from sequestration force I/T/U providers to make difficult decisions about the scope of healthcare services they can offer to Native patients. For example, the $220 million reduction in IHS’ budget authority for FY 2013 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for AI/ANs. Therefore, we request that you exempt IHS from sequestration and other budget cutting measures as is required by the trust responsibility.

Request: Work with Authorizers for Permanent 100% Federal Medical Assistance Percentage (FMAP) for services provided at UIOs

The federal medical assistance percentage (FMAP) refers to the percentage of Medicaid costs covered by the federal government and reimbursed to states. With states already receiving 100% FMAP for services provided at IHS and Tribal facilities, the American Rescue Plan Act (ARPA) temporarily shifted the responsibility of UIO Medicaid cost obligation from state governments to the federal government. This provision finally brought a form of parity to UIOs by setting FMAP for Medicaid services provided at UIOs at 100% for eight fiscal quarters, while offering cost savings to states, and finally creating a sense of consistency in how the federal government honors its obligations to urban Native healthcare. The provision expires this month on March 31, 2023. During this short provision, states have been able to work with UIOs to provide increased funding to help begin construction of a new clinic, youth services center, and establish a new behavioral health unit.

Permanent 100% FMAP will bring some fairness to the I/T/U system and increase available financial resources to UIOs and support them in addressing critical health needs of urban Native patients. Again, we request that the committee work with authorizers for permanent 100% FMAP.

Request: Increase Funding for Electronic Health Record Modernization

We request your support for the Indian Health Service’s (IHS) transition to a new electronic health record (EHR) system for IHS and UIOs. UIOs have expended significant funds for the replacement, upgrade and maintenance of IHS’ Health Information Technology (HIT) systems due to the federal government’s failure to keep pace with HIT development in the wider healthcare industry. This has resulted in UIOs having no choice but to purchase expensive off-the-shelf-replacement systems to ensure that they can continue to provide high-quality and culturally-focused health care to AI/AN patients. As EHR modernization moves from planning to fruition, it is critically important that appropriations continue to increase, and any language included in appropriations must allow funding to be used to reimburse Tribal Organizations and UIOs associated with the cost of EHR modernization. NCUIH requests the committee to support this transition by supporting the President’s budget request of $913 million in FY24 appropriations.

Request: Ensure UIOs are appropriately included in grant programs relating to Indian health

Failure to explicitly include UIOs in legislative programmatic authorizations often effectively prohibits UIOs from accessing the related funding, even if the exclusion was unintentional and UIOs would otherwise be an appropriate addition to program eligibility. UIOs are already severely underfunded and rely on grant funding to support the provision of life-saving services to their patients. Excluding UIOs from grant funding reduces the ability of UIOs to provide and expand service options for their patients. For example, UIOs are left out of statutory language in the nationalization of the Community Health Aide Program (CHAP), which is meant to increase the availability of healthcare workers in Native communities. Because of this legislative oversight, IHS interprets this as UIOs are not eligible to participate in the program, and therefore UIOs cannot utilize the program to ease the burden caused by limited provider availability for the Indian Health System.

Many programs in the Health and Human Services appropriations bills include language for Indian Tribes and Tribal organizations, but not for urban Indian organizations. Urban Indian Organizations are not considered Tribal organizations, which is a common misconception. While UIOs may fall within general terms such as “non-profit organization,” there are times when a general grant to non-profits is not appropriate, but a grant to UIOs would be. For example, if the grant is intended to serve Indian Healthcare facilities, including UIOs in grant funding would be appropriate, while including non-profit organizations generally would not be. Therefore, it is essential that you explicitly include UIOs when they intend UIOs to be included in the program. We request that any addition of UIOs to a program should include a corresponding appropriation increase to ensure that funding for Tribes and Tribal Organizations are not reduced. We emphasize that we acknowledge and respect the government-to-government relationship between Tribes and the United States and understand that there are times when it is not appropriate to add UIOs into legislation directed at Tribes and Tribal Organizations.

Request: Appropriate $80 Million for the Native Behavioral Health Resources Program

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

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

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

Request: Work with Authorizers to Re-authorize the Special Diabetes Program for Indians (SDPI)

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. SDPI has demonstrated success with a 50% reduction in diabetic eye disease rates, drops in diabetic kidney failure, and 50% decline in End Stage Renal Disease. Additionally, the reduction in end stage renal disease between 2006 and 2015 led to an estimated $439.5 million dollars in accumulated savings to the Medicare program, 40% of which, of $174 million, can be attributed to SDPI.

Currently, 31 UIOs are in this program and are at the forefront of diabetes care. Facilities use these funds to offer a wide range of diabetes treatment and prevention services, including but not limited to exercise programs and physical activity, nutrition services, community gardens, culinary education, physical education, health, and wellness fairs, culturally-relevant nutrition assistance, food sovereignty education, group exercise activities, green spaces, and youth and elder-focused activities.

With the program set to expire this year, we request that the committee work with authorizers to permanently reauthorize SDPI at a minimum of $250 million requested in the President’s FY24 budget with automatic annual funding increases tied to the rate of medical inflation, to continue the success of preventing diabetes-related illnesses for all Indian Country.

Conclusion

These requests are essential to ensure that urban Indians are appropriately cared for, in the present and in future generations. 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. We urge Congress to take this obligation seriously and provide UIOs with all the resources necessary to protect the lives of the entirety of the Native population, regardless of where they live.

President Biden Continues to Demonstrate Strong Commitment to Urban Indians, Proposes a 27% Increase for Urban Indian Health for FY 2024

April 3, 2023/0 Comments/in Policy Blog/by Jeremy Grabiner

The FY 2024 budget request includes $115 million for urban Indian health, a 27% increase over the FY 2023 enacted amount, mandatory funding through FY 2033, and an IHS exemption from sequestration.

On March 17, 2023, the Indian Health Service (IHS) published their Fiscal Year (FY) 2024 Congressional Justification with the full details of the President’s Budget, which includes $115 million for urban Indian health – a 27% increase above the FY 2023 enacted amount of $90.42 million. The President’s proposal included a total $144.3 billion in discretionary funding for the Department of Health and Human Services (HHS) and $9.7 billion in total funding for IHS— which maintains the $5.1 billion in advance appropriations enacted in the FY 2023 omnibus and includes $1.6 billion in proposed mandatory funding for Contract Support Costs, Section 105(l) Leases, and the Special Diabetes Program for Indians.

The budget proposes full mandatory funding for IHS from FY 2025 to FY 2033 to the amount of $288 billion over ten-years, as well as exempting IHS from sequestration. This mandatory formula would culminate in $44 billion for IHS in FY 2033, to account for inflation, staffing increases, long-COVID treatment, and construction costs. This move from discretionary to mandatory funding is essential as noted in the IHS Congressional Justification, “While the progress achieved through the enactment of advance appropriations will have a lasting impact on Indian Country, funding growth beyond what can be accomplished through discretionary spending is needed to fulfill the federal government’s commitments to Indian Country.”

Line Item	FY22 Enacted	FY23 Enacted	FY24 Tribal Request	FY24 President’s Budget
Urban Indian Health	$73.43 million	$90.42 million	$973.6 million	$115 million
Indian Health Service	$6.6 billion	$6.9 billion	$51.4 billion	$9.7 billion
Advance Appropriations	———————	$5.13 billion	———————	———————
Hospitals and Clinics	$2.3 billion	$2.5 billion	$12.2 billion	$3.5 billion
Tribal Epidemiology Centers	$24.4 million	$34.4 million	——————–	$34.4 million
Electronic Health Record System	$145 million	$217.5 million	$491.9 million	$913.1 million
Community Health Representatives	$63.6 million	$65.2 million	$1.2 billion	$74.5 million
Mental Health	$121.9 million	$127.1 million	$3.4 billion	$163.9 million
Cancer Moonshot Initiative	———————	———————	———————	$108 million
HIV & Hepatitis	———————	———————	———————	$47 million

The National Council of Urban Indian Health (NCUIH) requested full funding for urban Indian health for FY 2024 at $973.59 million and at least $51.42 billion for IHS in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. The marked increase for FY 2024 is due to Tribal leaders’ budget recommendations to address health disparities that have historically been ignored. The Congressional Justification states the importance of addressing these disparities, “The COVID-19 experience in Indian Country illustrates the urgent need for large-scale investments to improve the overall health status of AI/ANs and ensure that the disproportionate impacts experienced during the pandemic are never repeated.”

Overview of Budget

Key Provisions for IHS, Tribal Organizations, and Urban Indian Organizations (UIOs)

$9.7 billion for IHS for FY 2024
$115 million for urban Indian health for FY 2024
$5.1 billion in Advance Appropriations for FY 2024
$1.2 billion in mandatory funding for Contract Support Costs
$153 million in mandatory funding for Section 105(l) Leases
$250 million in mandatory funding for Special Diabetes Program for Indians (SDPI)

Other Budget Highlights

Addressing Targeted Public Health Challenges
- $47 million for HIV and Hepatitis C.
  - UIOs eligible
- $3 million for improving maternal health.
  - UIOs eligible
- $9 million for addressing opioid use.
  - UIOs eligible
Cancer Moonshot Initiative
- $108 million
  - Develops a coordinated public health and clinical cancer initiative to implement best practices and prevention strategies to address the incidence of cancer and mortality among AI/ANs.
    - UIOs eligible
Division of Telehealth
- $10 million
  - Manages and oversees a comprehensive telehealth program at IHS that will expand telehealth services, develop governance structures, provide training to users, and integrate with clinical services.
Division of Graduate Medical Education
- $4 million
  - Expands and supports Graduate Medical Education programs to create a pathway for future physicians to address longstanding vacancy issues at IHS.
Indian Health Professions
- $13 million
  - Offers additional IHS Scholarship and Loan Repayment awards, bolstering recruitment and retention efforts through these two high demand programs.
    - UIOs eligible

Legislative Proposal

Once again, the legislative proposal to amend federal law to permit the U.S. Public Health Service Commissioned Officers to be detailed to UIOs was proposed. This amendment to the Public Health Service Act would provide IHS the discretionary authority to detail officers directly to an UIO to perform work related to the functions of HHS.

Currently, there are 1,614 officers of the U.S. Public Health Service assigned to IHS. There are only 5 of these officers who are assigned to States, who have duty stations at UIOs.

The permittance of officers to be detailed directly to UIOs addresses the staff shortage that hinders the capacity of UIOs to improve access to health care for urban Natives. The strengthening of the IHS workforce will contribute to better health outcomes and reduce disparities.

Background and Advocacy

On March 9, 2023, President Biden released his budget request for Fiscal Year 2024, pending the more detailed IHS budget request released on March 17, including the funding recommendation for urban Indian Health.

On March 9, 2023, NCUIH Chief Executive Officer, Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding for UIOs. NCUIH requested funding in accordance with the requests of the TBFWG at funding levels of $973.59 million for urban Indian health and $51.42 billion for IHS, maintain advance appropriations until mandatory funding is achieved, and appropriate $8o million the Native Behavioral Health Resources Program. On March 24, NCUIH sent a letter to House Appropriations leadership, Chair Kay Granger and Raking Member Rosa DeLauro, reiterating these requests

Next Steps

The Appropriations Committees will review the President’s Budget for consideration as they craft their bills for FY 2024. NCUIH will continue to work with the Biden Administration and Congress to push for full funding of urban Indian health in FY 2024.