Senate Amendment Includes Major Report on Indian Boarding Schools

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On October 11, 2022, the Senate filed an amendment to the National Defense Authorization Act (NDAA) for Fiscal Year 2023 (H.R. 7900). This amendment includes a major report from the Department of Defense (DoD) on Indian boarding schools and institutions under the control of the DoD.

Amendment Highlights

Section 5302 of the Senate-filed amendment includes a report from the DoD on “former Indian boarding schools and institutions under their jurisdiction or control.” In general, the Secretary of Defense would be required to submit a report to the appropriations committees of Congress providing the following information:

  • An account of all schools or institutions that were located on land that was under the control of the DoD (currently or at the time of operation of a school or institution).
  • Provide a description of the role and actions the Department took in facilitating these schools, including complete accountings, engagements, and actions, the identification of marked and unmarked burial grounds, and the repatriation of the remains of Native students who died while attending a school.

This amendment would also require the Secretary of Defense to consult and engage with Indian Tribes and Native Hawaiian organizations so that a comprehensive report is created in less than one year. Finally, the Secretary would ultimately brief the Congressional appropriations committees on the report’s findings.

Background

The National Council of Urban Indian Health (NCUIH) has continuously advocated for substantial efforts to address the historical trauma and public health impact that boarding schools had on urban American Indian and Alaskan Natives (AI/ANs) and to better understand how this intergenerational trauma has impacted urban AI/AN communities.

In December of 2021, NCUIH submitted comments to the Department of the Interior (DOI) regarding the agency’s Federal Boarding School Initiative, led by Secretary Deb Haaland, the first Native American cabinet holder of DOI. Through that initiative, the DOI would begin to identify boarding school sites, locations of known and possible student burial sites located at or near school facilities, and identify the children and their tribal affiliations to bring them home to their families. NCUIH reiterated its ongoing support for the Administration’s efforts to address the impact of boarding school programs and emphasized the importance of studying not only the impact of boarding school programs for survivors but also the lasting impact of the intergenerational trauma caused by boarding schools within urban AI/AN communities.

In June of 2021, Francys Crevier (Algonquin), NCUIH CEO, issued a statement in response to the discovery of unmarked graves at Kamloops Indian Residential School in Canada. She noted that “Indian Country’s social determinants of health demonstrate the connection to the historical trauma inflicted by these governments that caused tremendous health consequences for our people – most recently with the COVID-19 pandemic taking the lives of many of our relatives.”  NCUIH applauded Secretary Haaland for the administration’s efforts, noting the necessity of the United States and Canada to take responsibility for these horrific actions so the healing process may begin.

Finally, on June 15, 2022, the House Committee on Natural Resources held a markup to consider a series of bills, including the Truth and Healing Commission on Indian Boarding School Policies in the United States Act (H.R. 5444/S.2907). NCUIH worked closely with Senator Elizabeth Warren (D-MA) on this landmark legislation to begin the healing process and ensure the inclusion of UIOs in the creation of a Truth and Healing Commission on Indian Boarding School Policies.  In May of 2022, NCUIH also submitted written testimony to the House Subcommittee for Indigenous Peoples of the United States in support of H.R. 5444. During the hearing, 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. Members from both parties agreed there was a need for an established commission, and four amendments were introduced on subpoena power (the compensation of commission members, the wording around funds, and the possibility for reparations). However, the only amendment to be accepted was the amendment editing, “such sums as may be necessary”. The bill passed the committee and now awaits a full hearing on the House floor.

Next Steps

NCUIH continues to advocate for legislation that addresses and rectifies the centuries of historical oppression against Native people and begins the healing process. NCUIH will continue to monitor this amendment and provide any updates on its movement.

NCUIH Requests Committee Action to Extend Medicaid Provisions Expiring in 2023

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On September 20, 2022, The National Council of Urban Indian Health (NCUIH) sent a letter to Chair Frank Pallone and Ranking Member Cathy McMorris Rodgers on the House Committee on Energy and Commerce requesting a markup on the Improving Access to Indian Health Services Act (H.R. 1888). This bill would establish permanent 100% Federal Medical Assistance Percentage (FMAP) for services provided to American Indian/Alaska Native (AI/AN) Medicaid beneficiaries at urban Indian Organizations (UIOs).  The American Rescue Plan (ARP) authorized 8 fiscal quarters of 100% FMAP to UIOs. However, the ARP provision expires in less than 5 months, and UIOs are not seeing the benefit of this provision. States are generally not increasing their Medicaid reimbursement rates to UIOs, resulting in states seeing the 100% FMAP savings intended to go to UIOs.

Full Letter Text

Dear Chair Pallone and Ranking Member McMorris Rodgers,

On behalf of the National Council of Urban Indian Health (NCUIH), the national advocate for health care for the over 70% of American Indians and Alaska Natives (AI/ANs) living off-reservation and the 41 Urban Indian Organizations (UIOs) that serve these populations, we write to request the markup of H.R. 1888. This bill would permanently establish a 100% federal matching rate, also known as the Federal Medical Assistance Percentage (FMAP), for Medicaid services provided at UIOs.  This bill would also permanently expand Medicaid coverage to include clinical services provided outside of a clinic by an Indian Health Service (IHS) facility, a tribe or tribal organization, or UIO.

Extending FMAP to UIOs

FMAP refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. In 1976, Congress passed the Indian Health Care Improvement Act (IHCIA) which amended the Social Security Act to add Section 1911. Section 1911 authorized reimbursement by Medicaid for services provided to AI/AN Medicaid beneficiaries at Indian Health Service (IHS) and Tribal health care facilities.1 In addition,  ICHIA amended section 1905(b) of the SSA to set the FMAP at 100% for Medicaid services received through an IHS facility, whether operated by IHS or by an Indian Tribe. When Congress first authorized 100% FMAP for the Indian healthcare system in 1976, it did so because it recognized that “Medicaid payments are . . . a much needed supplement to a health care program which has for too long been insufficient to provide quality health care to” AI/ANs and because “the Federal government has treaty obligations to provide services to Indians, it has not been a State responsibility.”2 Unfortunately, the IHCIA amendments to the SSA were not inclusive of UIOs, meaning that services provided at UIOs were not eligible for 100% FMAP under IHCIA’s authority.

In March of 2021, Congress enacted the American Rescue Plan Act of 2021 (ARPA). Section 9815 of ARPA authorized eight (8) fiscal quarters of 100% FMAP coverage for Medicaid services at provided UIOs. Congress intended Section 9815 in part to increase the financial resources available to UIOs and support the provision of critically needed health services to urban AI/ANs during the COVID-19 pandemic. However, the ARPA’s 100% FMAP extension to UIOs ends in less than 6 months, and UIOs have generally not seen any increased financial support because of this extension. Unfortunately, states are not increasing their Medicaid reimbursement rates to UIOs, citing the short-term authorization for the UIO 100% FMAP extension as a reason not to increase their reimbursement rates.

On March 23, 2021, the House Committee on Energy and Commerce held a legislative hearing on the Affordable Care Act, which included H.R. 1888. At the hearing, Representative Raul Ruiz emphasized that there is no sound policy reason for excluding UIOs from eligibility for 100% FMAP and advocated for the Committee to pass this critical piece of legislation to address this longstanding issue.  There has been strong support for the expansion of 100% FMAP to UIOs across Indian Country. For example, both the National Congress of American Indians and the National Indian Health Board have passed resolutions in support of extending 100% FMAP to UIOS. Additionally, there has been longstanding bipartisan congressional support for extending 100% FMAP to UIOs, with over 17 pieces of legislation having been introduced since 1999 on this issue.

The federal government has a trust responsibility to provide “[f]ederal health services to maintain and improve the health of the Indians.3 The federal government owes that duty to all AI/ANs, no matter where they live, and Congress has declared it the policy of the United States “to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.”4 Permanent 100% FMAP for UIOs will further the U.S. government’s trust responsibility to AI/ANs by increasing the available financial resources to UIOs and supporting them in addressing the critical health needs of their AI/AN patients. We request the markup of H.R. 1888 to honor this trust responsibility and progress the health of all AI/AN people, regardless of their location. Thank you for your attention to this urgent matter.

FMAP Background

FMAP refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. In 1976, Congress passed the Indian Health Care Improvement Act (IHCIA) which authorized reimbursement by Medicaid for services provided to AI/AN Medicaid beneficiaries at IHS and Tribal health care facilities. This set FMAP at 100% for Medicaid services received through an Indian Health Service (IHS) facility, whether operated by IHS or by an Indian Tribe.

Congress first authorized 100% FMAP for the Indian healthcare system in 1976 because it recognized that “Medicaid payments are . . . a much needed supplement to a health care program which has for too long been insufficient to provide quality health care to AI/ANs.” However, UIOs were not included in this IHCIA authorization as an oversight, meaning that services provided at UIOs were not eligible for 100% FMAP.

ARPA FMAP Provision and Permanent 100% FMAP for UIOs

In March of 2021, Congress enacted the ARP, which authorized two years of 100% FMAP coverage for Medicaid services provided at UIOs. Congress did this in part to increase the financial resources available to UIOs and support the provision of critically needed health services to urban AI/ANs during the COVID-19 pandemic. However, ARPA’s 100% FMAP extension to UIOs expires in less than 6 months, and states are generally not increasing their Medicaid reimbursement rates to UIOs, citing short-term authorization as a reason not to increase their reimbursement rates. H.R. 1888 would remedy this problem and establish a permanent 100% FMAP rate for services provided at UIOs to ensure they can continue providing critical health services to their AI/AN patients.

This bill would also permanently expand Medicaid coverage to include clinical services provided outside of a clinic by an IHS facility, Tribe, tribal organization, or UIO. This has been a critical priority identified by Indian Country to ensure that services provided through an Indian health care program are eligible for reimbursement at the IHS all-inclusive rate, no matter where that service is provided.

Support for 100% FMAP to UIOs

On March 23, 2021, the House Committee on Energy and Commerce held a legislative hearing on the Affordable Care Act, which included H.R. 1888. At the hearing, Representative Raul Ruiz emphasized that there is no sound policy reason for excluding UIOs from eligibility for 100% FMAP and advocated for the Committee to pass this critical piece of legislation to address this longstanding issue.  Additionally, there has been longstanding bipartisan congressional support for extending 100% FMAP to UIOs, with over 17 pieces of legislation having been introduced since 1999 on this issue.

 There has also been strong support for the expansion of 100% FMAP to UIOs across Indian Country. For example, both the National Congress of American Indians and the National Indian Health Board passed resolutions along with NCUIH in support of extending 100% FMAP to UIOs.

The federal government has a trust responsibility to provide health services to maintain and improve the health of all AI/ANs, no matter where they live.  Congress has also declared it the policy of the United States to ensure the highest possible health status for AI/ANs and to provide all resources necessary to do so. H.R. 1888 is a critical piece of legislation that would further the federal government’s trust responsibility to AI/ANs by increasing the available financial resources to UIOs to better address the critical health needs of their patients and ultimately bolster the entire Indian Health system.

Next Steps

NCUIH will continue to advocate for the markup of H.R. 1888 and provide updates on its movement within Congress.

NCUIH Signs Tribal Partner Organization Letter Requesting Legislative Fix to Carcieri v. Salazar

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On October 7, 2022, NCUIH signed on to a letter submitted by the United South and Eastern Tribes (USET) Sovereignty Protection Fund (SPF) to Senate Majority Leader Schumer. The letter calls on the Senate to pass a legislative fix addressing the Supreme Court’s decision in Carcieri v. Salazar, 222 US 379 (2009). The full text of this letter is available here.

Background

Carcieri v. Salazar Impact on Indian Country

In 2009, the Supreme Court issued its decision in Carcieri v. Salazar.  The case considered whether the Secretary of the Interior could use their authority pursuant to the Indian Reorganization Act (IRA) to take land into trust for the Narragansett Tribe.  The Court held that the IRA Act did not apply to Tribes that were not recognized by the federal government at the time the statute was enacted in 1934.  Since the Narragansett were not formally recognized by the federal government until 1983, the Court also held that the Secretary of the Interior did not have the authority to take land into trust for the Tribe.

 

According to testimony provided by Larry Echo Hawk, the Assistant Secretary for Indian Affairs in 2011, “The Carcieri decision was inconsistent with the longstanding policy and practice of the United States under the Indian Reorganization Act of 1934 to assist federally recognized tribes in establishing and protecting a land base sufficient to allow them to provide for the health, welfare, and safety of tribal members, and to treat tribes alike regardless of their date of federal acknowledgment.”  The Supreme Court’s decision has significantly impacted the federal government’s fee-to-trust process requiring the Department of the Interior (DOI) to engage in extensive legal and historical research prior to taking land into trust. In some cases, it has also stopped the DOI from taking land into trust for some tribes altogether.

Letter Highlights

In their October letter, USET notes that more than 13 years have passed since the Carcieri v. Salazar ruling, arguing that this decision jeopardizes the ability of federally recognized Tribal Nations to rebuild their communities and provide essential governmental programs. Tribal land bases are considered the foundation of Tribal sovereignty, and this ruling has sparked legal challenges, many of which threaten Tribal lands that have been in trust for decades, that aim to dismantle Tribal sovereignty altogether.  If this decision remains unaddressed, USET states that substantial litigation over existing trust lands will ensue.

In addition, USET explains that Tribal Nations have been expressing a desire for a legislative fix to Carcieri v. Salazar with two specific components. The first component is a restoration of the Secretary’s authority to take land into trust for all Tribal Nations. The second component is to reaffirm the existing Tribal government trust lands and the actions of the Secretary to take land into trust.

The letter also recognizes that H.R. 4352 (To amend the Act of June 18, 1934, to reaffirm the authority of the Secretary of the Interior to take land into trust for Indian Tribes, and for other purposes) is a critical piece of legislation necessary to stop the growing legal challenges threatening Tribal authority and overall sovereignty. In addition, USET goes on to express their support of enacting S. 4830 (A bill to reaffirm actions taken by the Secretary of the Interior for the benefit of Indian Tribes, and for other purposes). These bills would enable Tribal Nations and the Department to move forward in restoring their Tribal homelands. Congress has enacted similar legislation for specific Tribal Nations over the years, but this would make it so that Congress does not have to consider individual bills in a piecemeal fashion.

Next Steps

As a passionate supporter of Tribal sovereignty and strong Tribal economies, NCUIH was proud to sign the Tribal Partners Organization letter. NCUIH also signed on to a similar letter in April with other leading American Indian and Alaska Native advocacy organizations.

NCUIH urges Congress to pass legislation that restores the Secretary of the Interior’s authority to take land into trust for all federally recognized Tribes and which reaffirms the status of existing Tribal trust lands.

Bivalent COVID-19 Targeting Vaccine Formula Approved as Booster for 5-11 Year Olds

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On October 12, 2022, the US Food and Drug Administration (FDA) amended the previously issued emergency use authorizations (EUAs) for both the Moderna COVID-19 and Pfizer-BioNTech COVID-19 bivalent vaccine formulas, authorizing their use as a single booster dose for those 5-11 years old. Following FDA’s announcement, Centers for Disease Control (CDC) released a decision memo, signed by Director Rochelle Walensky, expanding the recommendations for the use of bivalent vaccines matching the EUA expansions. As such, the Moderna formulation is now available for use in children six and older, at least two months post-completion of a primary series or previous booster dose. The Pfizer formulation is now authorized for use in children five and older, at least two months post-completion of a primary series or booster dose.

Background

American Indians and Alaska Natives (AI/ANs) have been disproportionately affected by the COVID-19 pandemic. At the height of it, AI/ANs were 3.5 times more likely to test positive, 3.2 times more likely to be hospitalized, and 2.2 times more likely to die due to COVID-19. Indian country has had highly successful vaccine rollouts and urban Indian organizations (UIOs) have been instrumental in the success of vaccinating AI/AN populations in urban areas. As of October 2022, AI/ANs have some of the highest vaccination administration rates in the US with 75.7% of AI/ANs having received at least one dose, and 62.9% having completed the primary series. However, just under half of AI/ANs (47.3%) have received their first booster, and even less have received the second booster dose (37.4%), per CDC data.

The National Council of Urban Indian Health (NCUIH) will continue to monitor and provide updates on any changes in COVID-19 vaccine guidance, or other COVID-19 updates. For more information on the changes to COVID-19 vaccine guidance or the success UIOs have had with the vaccine rollout, see below:

Action Alert: Save Native Lives – Contact Congress Today to Take Action

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Contact Congress │ Social Media Campaign │ Advance Appropriations One-Pager │ Find Out if Your Member of Congress Supports Advance Appropriations


Dear Indian Health Advocates,

The National Council of Urban Indian Health is advocating tirelessly to Congress to ensure advance appropriations for the Indian Health Service (IHS).

We need your help again contacting Congress to support securing advance appropriations and mandatory funding for IHS. The Indian health system, including IHS, Tribal facilities, and urban Indian organizations (UIOs), is the only major federal health care provider funded through annual appropriations.

If IHS were to receive advance appropriations, it would ensure continuity of care for American Indians and Alaska Natives and complement President Biden’s budget request to honor commitments to Tribal nations and communities. In fact, Native communities have experienced deaths due to government shutdowns in the past and according to a recent study, Native Americans experienced the biggest drop in life expectancy— decreasing by 6.6 years between 2019-2021. The lives of Native people should not be subject to politics. We need this to protect Native people and preserve access to health care.

We urge you to contact your Member of Congress and request that they support including advance appropriations for IHS in the Fiscal Year (FY) 2023 final spending package. You can use the text below as a template to call and/or email your Members of Congress.

Thank you for your leadership. Your outreach on this is invaluable to providing greater access to health care for all American Indians and Alaska Natives.

Sincerely,

The National Council of Urban Indian Health

STEPS TO CONTACT CONGRESS

  • Step 1:Copy the email below.
  • Step 2: Find your Representative here and your Senator here.
  • Step 3:Paste the email into the form on your Member of Congress’ contact page and send. Please contact Meredith Raimondi (policy@ncuih.org) with questions.
Email to Your Representative and Senators

Dear [Member of Congress],

As an Indian health advocate, I respectfully request you ensure the inclusion of advance appropriations for the Indian Health Service (IHS) in the upcoming Fiscal Year (FY) 2023 final spending package until mandatory funding for the agency can be achieved.

The Indian health system, including IHS, Tribal facilities, and urban Indian organizations (UIOs), is the only major federal health care provider funded through annual appropriations. If IHS were to receive advance appropriations, it would not be subject to government shutdowns and continuing resolutions as its funding for the next year would already be in place. We need this to protect Native lives!

I respectfully ask that you honor the federal trust obligation to American Indians and Alaska Natives by ensuring advance appropriations for IHS can finally be made a reality this year.

Thank you for your leadership and your commitment to upholding the United States trust responsibility.

Sincerely,

[contact information]

POST ON SOCIAL MEDIA

Use this graphic to call on your Member of Congress to take action!

Advance Indian Health  Native Lives Can't Wait_Advance Appropriations Now

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Tribal Budget Formulation Workgroup Releases FY24 IHS Funding Recommendations with $974 Million for Urban Indian Health

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Other priorities include permanent 100% FMAP to services provided at urban Indian organizations (UIOs) and UIO inclusion in the nationalization of the Community Health Aide Program.

On September 7, 2022, the Tribal Budget Formulation Workgroup (TBFWG) released its Fiscal Year (FY) 2024 budget recommendations for the Indian Health Service, entitled Advancing Health Equity Through the Federal Trust Responsibility: Full Mandatory Funding for the Indian Health Service and Strengthening Nation-to-Nation Relationships. The FY 2024 National Tribal Budget Recommendation for the Indian Health Service (IHS) is full mandatory funding at $51.42 billion, a 675.45% increase above the FY 2022 enacted amount of $6.6 billion, and full funding for urban Indian health at $973.59, a 1226% increase above the FY 2022 enacted amount of $73.4 million. This stark increase compared to the current enacted amount demonstrates how far we have to go to reach the level of need for Indian health.

In addition, the recommendations include advance appropriations for IHS in all budget requests at no less than $9.1 billion for IHS until mandatory funding is enacted; permanent reauthorization of the Special Diabetes Program for Indians (SDPI) with increased funding to $250 million per year; and dedicated funding be provided to implement the new authorities and provisions of the Indian Health Care Improvement Act (IHCIA).

The TBFWG stated:

“UIOs receive direct funding primarily from one line item — urban Indian health — and do not receive direct funds from other distinct IHS line items, including the Hospital and Health Clinics, Mental Health, Alcohol and Substance Abuse, Indian Health Care Improvement Fund, Health Education, Indian Health Professions, or any of the line items under the IHS Facilities account. Due to historically low funding levels for urban Indian health, UIOs are chronically underfunded. Full funding of UIOs will directly benefit urban AI/ANs that rely on UIOs to access care.”

Other TBFWG priorities for Urban Indian Health were:

  • Increased funds for UIO facilities
  • UIOs eligibility for cost-saving measures available to the other components of the IHS/Tribal/Urban system, including, among others, Community Health Aide Program (CHAP), and permanent 100% Federal Medical Reimbursement Percentage (FMAP) for services provided at UIOs.
  • Retain eligibility for IHS UIOs to participate in grant programs
  • No funding from Urban Indian Health line item withheld or reprogrammed from UIOs

Status of FY 2023 Appropriations

A Continuing Resolution was recently enacted on September 30 to avoid a government shutdown while Congress continues negotiations on the final FY 2023 appropriations bill, extending current funding levels for all normal government programs until December 16, 2022. UIOs must continue to operate on less than the FY 2022 funding levels for FY 2023 despite rising costs of healthcare. On July 28, 2022, former Acting Director of IHS, Liz Fowler, stated in her testimony before the House Natural Resources Subcommittee for Indigenous Peoples, “While the IHS has received an exception apportionment to provide the full-year recurring base amounts to Tribal Health Programs operating their own programs through ISDEAA Title I contracts and Title V compacts since FY 2020, this option is not available during government shutdowns, and it is not available at all to IHS-operated health programs, or Urban Indian Organizations. As a result, Direct Service tribes, and American Indians and Alaska Natives served by Urban Indian Organizations are disproportionately affected by disruptions in federal appropriations.”

For FY 2023, which has not been funded yet, the House passed $8.1 billion for IHS and $200 million for urban Indian health and the Senate proposed $7.38 billion for IHS and $80.4 million for urban Indian health. While the House failed to include advance appropriations for IHS, the Senate provides $5.577 billion of advance appropriations for IHS for FY 2024.

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

The annual budget request of the IHS is the result of the budget formulation and consultation process that involves IHS, Tribal, and urban Indian health program representatives and providers from the local to the national level.

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.

Senators Request Congressional Leadership Support Advance Appropriations to Stabilize the Indian Health Service

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On September 30, 2022, six members of the Senate Committee on Indian Affairs (SCIA) sent a letter to House leadership, Senate leadership, and the Appropriations Committee requesting advance appropriations for the Indian Health Service (IHS) in the final upcoming appropriations bill. This letter comes as a continued effort by the National Council of Urban Indian Health (NCUIH) and Indian Country to secure advance appropriations for IHS and ensure stable and predictable funding for healthcare services provided to American Indians/Alaska Natives (AI/ANs). Due to this robust advocacy, the Senate FY 2023 funding bill provides $5.577 billion of advance appropriations for IHS for FY 2024, however, the House bill failed to include advance appropriations.

Senators Brian Schatz (D-HI), Maria Cantwell (D-WA), John Tester (D-MT), Catherine Cortez Masto (D-NV), Tina Smith (D-MN), and Ben Ray Lujan (D-NM) urged Congressional leadership to include advance appropriations for IHS for FY 2024 in the final FY 2023 omnibus bill to protect IHS from temporary lapses in appropriations and continuing resolutions (CRs). The Senators emphasized that during the 2019 government shutdown, “IHS was the only federal health care entity forced to operate without appropriations, causing some Urban Indian Organizations to close their doors completely. This funding disruption resulted in some health providers being unable to provide patients with critical care and medication.” A CR was recently enacted on September 30 to avoid a government shutdown while Congress continues negotiations on the final FY 2023 appropriations bill, extending current funding levels for all normal government programs until December 16, 2022. Urban Indian organizations (UIOs) must continue to operate on less than the FY 2022 funding levels for FY 2023 despite rising costs of healthcare. On July 28, 2022, former Acting Director of IHS, Liz Fowler, stated in her testimony before the House Natural Resources Subcommittee for Indigenous Peoples, “While the IHS has received an exception apportionment to provide the full-year recurring base amounts to Tribal Health Programs operating their own programs through ISDEAA Title I contracts and Title V compacts since FY 2020, this option is not available during government shutdowns, and it is not available at all to IHS-operated health programs, or Urban Indian Organizations. As a result, Direct Service tribes, and American Indians and Alaska Natives served by Urban Indian Organizations are disproportionately affected by disruptions in federal appropriations.”

Full Text of Letter:

Dear Senate and House Leadership,

As members of the Senate Committee on Indian Affairs, we write to urge including advance appropriations for the Indian Health Service (IHS) for fiscal year 2024 (FY24) in the final fiscal year 2023 (FY23) appropriations bill. Providing advance appropriations will ensure that the federal government continues to uphold its trust and treaty obligations to 2.7 million American Indians and Alaska Natives who receive healthcare services at more than 600 IHS hospitals, clinics, and health stations throughout the nation.[1]

The Indian Health Care Improvement Act, along with the Snyder Act of 1921, provides the foundational basis for providing healthcare to American Indians and Alaska Natives through IHS, in partial fulfillment of the United States’ trust and treaty obligations. Yet, unlike the Veterans Health Administration (VHA) at the Department of Veteran’s Affairs, which receives the majority of its funding through advance appropriations, IHS is funded through annual appropriations.[2] We were therefore pleased to see $5.577 billion in advance appropriations included in the Senate-released draft Interior and Environment subcommittee appropriations bill.

Advance appropriations, particularly during temporary lapses in appropriations and continuing resolutions, would provide continued budget certainty and enable long term planning to maintain orderly and continuous operations of critical health programs for Native American communities. Budgetary uncertainty risks interruption of health services and reduction in quality of care. During the partial government shutdown in 2019, for example, IHS was the only federal health care entity forced to operate without appropriations, causing some Urban Indian Organizations to close their doors completely. This funding disruption resulted in some health providers being unable to provide patients with critical care and medication.[3] Additional, and preventable, funding uncertainty impacts include risk of downgraded credit ratings on commercial loans secured by Tribes and Urban Indian Organizations; challenges related to recruitment and retention of healthcare providers; increased administrative burden and costs, such as employee furloughs and terminations; and other negative financial effects on Tribes.[4]

It is critical that advance appropriations are included in the FY23 omnibus appropriations bill. Given the impacts of uncertain funding, the lack of parity with VHA, and the unique trust relationship between the United States and American Indians and Alaska Natives, future year funding is necessary. We look forward to working with you to pass this critical legislation.

Thank you for your consideration of our request.

Background on Advance Appropriations for IHS

Advance appropriations are appropriations that become available one year or more after the year for which the appropriations act is passed. The Indian healthcare system, which includes IHS facilities, Tribal facilities, and UIOs, is the only major federal healthcare provider funded through annual appropriations. Funding through annual appropriations leads to funding uncertainty because the availability and amount of the appropriation is subject to the annual budget negotiation process. If IHS were to receive advance appropriations, it would not be subject to government shutdowns, automatic sequestration cuts, and CRs as its funding for the next year would already be in place. Congress recently enacted a CR, which passed the House by a vote of 230-201 and Senate by a vote of 75-25, to keep the government funded until December 16. UIOs must continue to operate on FY 2022 funding levels for FY2023 despite rising costs of healthcare.

Lapses in federal funding risk AI/AN lives. Every year, on average, Congress passes five continuing resolutions to keep the government open while Congress reaches a budget agreement, and there were long government shutdowns in 1996, 2013, and 2019. During the FY 2019 shutdown, several UIOs did not have adequate funding to maintain normal operations and were required to reduce services, lose staff, or close their doors entirely, putting the health and well-being of their patients at risk. In a UIO shutdown survey, five out of thirteen UIOs indicated that they could only maintain normal operations for 30 days without federal funding. One UIO suffered seven opioid overdoses, five of which were fatal.

Resources on Advance Appropriations for IHS:

NCUIH and Indian Country Advocacy

NCUIH, along with three other national Native organizations, the National Indian Health Board (NIHB), National Congress of American Indians (NCAI), United South and Easter Tribes (USET), have been advocating on behalf of advance appropriations for almost a decade and have passed resolutions supporting advance appropriations for IHS.

On January 17, 2019, NCUIH sent a letter to the Vice Chairman of the Senate Committee on Indian Affairs (SCIA), Tom Udall, in support of IHS advance appropriations legislation. On March 9, 2022, NCUIH joined NIHB and over seventy Tribal nations and national Indian organizations in sending a series of joint letters to Congress requesting advance appropriations for IHS in the FY 2022 omnibus. On June 16, 2022, NIHB and NCAI published a legislative action alert requesting that SCIA support and include IHS advance appropriations in the current FY 2023 appropriations bill. Most recently, NCUIH sent letters to Speaker Pelosi, House Minority Leader McCarthy, Senate Majority Leader Schumer, Senate Minority Leader McConnell, Senate Interior Appropriations Committee,  and SCIA to support advance appropriations for IHS.

Federal and Congressional Support

There has also been strong long-standing support from Congress on this issue. Before the recent SCIA letter to Congressional leadership urging advance appropriations for IHS in the final FY 2023 appropriations bill, the Native American Caucus also sent a letter to House Appropriations Committee Chair DeLauro and Ranking Member Granger requesting that advance appropriations for IHS for FY 2023 be included in the final FY 2022 appropriations bill on January 12, 2022. On June 3, the Native American Caucus sent another letter encouraging the Committee to work towards shifting IHS from discretionary to mandatory funding and requesting that, while this shift is underway, the Committee include advanced appropriations for IHS  in the final FY 2023 Appropriations bill.

On April 25, 2022, a bipartisan group of 28 Representatives requested up to $949.9 million for urban Indian health in FY 2023 and advance appropriations for IHS until such time that authorizers move IHS to mandatory spending, and 12 Senators sent a letter with the same requests. Last year, for the first time ever, the Senate Appropriations Committee included an additional $6.58 billion in advance appropriations to IHS for FY 2023 in its FY 2022 Interior, Environment, and Related Agencies bill.

Back in 2014, SCIA held its first hearing on advance appropriation bill Indian Health Service Advance Appropriations Act of 2013 (S. 1570). In a 2019 House Natural Resources Subcommittee for Indigenous Peoples (SCIP) hearing on advance appropriations bills H.R. 1128 and H.R. 1135, former IHS Principal Deputy Director, Rear Admiral Michael Weahkee, reaffirmed Indian Country’s repeated request for advance appropriations stating that “[t]hrough the IHS’s robust annual Tribal Budget Consultation process, Tribal and Urban Indian Organization leaders have repeatedly and strongly recommended advance appropriations for the IHS as an essential means for ensuring continued access to critical health care services. The Department continues to hear directly from tribes advocating support for legislative language that would provide the authority of advance appropriations for the IHS. The issues that Tribes have identified present real challenges in Indian Country and we are eager to work with Congress on a variety of solutions.” More recently on July 28, 2022, IHS Acting Deputy Director Elizabeth Fowler reaffirmed IHS’s support for advance appropriations during a SCIP hearing on the Indian Health Service Advance Appropriations Act (H.R. 5549) stating that  “[IHS] remain[s] firmly committed to improving quality, safety, and access to health care for American Indians and Alaskan Natives. Mandatory funding and advanced appropriations are necessary and critical steps toward that goal… [I] urge the House to act on advanced appropriations through the appropriations process with or without the authorizing legislation that is the subject of this hearing.”

The U.S. Commission on Civil Rights report from 2018, “Broken Promises: Continuing Federal Funding Shortfall for Native Americans” serves as another benchmark of support by including advance appropriations for IHS as a key recommendation to the federal government to ensure greater funding stability for IHS.

History of Advance Appropriations Bills

Legislation on this effort has been introduced in 11 bills since 2013:​

  •  10/2013 – Indian Health Service Advance Appropriations Act of 2013 (3229/S. 1570) ​
    • Sponsor: Rep. Don Young/Sen. Lisa Murkowski ​
  •  1/2015 – Indian Health Service Advance Appropriations Act of 2015 (395)    ​
    • Sponsor: Rep. Don Young ​
  • 1/2017 – Indian Health Service Advance Appropriations Act of 2017 (235) ​
    •  Sponsor: Rep. Don Young ​
  •  2/2019 – Indian Programs Advance Appropriations Act (1128/S. 229) ​
    • Sponsor: Rep. Betty McCollum/Sen. Tom Udall ​
  • 2/2019 – Indian Health Service Advance Appropriations Act of 2019 (1135/S. 2541) ​
    • Sponsor: Rep. Don Young/Sen. Lisa Murkowski​
  •  10/2021 – Indian Health Service Advance Appropriations Act (5549) ​
    • Sponsor: Rep. Don Young ​
  • 10/2021 – Indian Programs Advance Appropriations Act of 2021 (5567/S. 2985) ​
    • Sponsor: Rep. Betty McCollum/Sen. Ben Ray Lujan​

Next Steps

Congress will have until December 16, 2022 to pass a longer-term spending package for FY 2023. In the meantime, NCUIH will continue to advocate for advance appropriations in the final FY 2023 omnibus.

 

[1] Hybrid SCIP Legis. Hearing – July 28, 2022 Before the Subcomm. on Indigenous Peoples, 117th Cong. 2 (2022) (statement of Elizabeth Fowler, Acting Dir., Indian Health Serv.).

[2] ELAYNE HEISLER & KATE MCCLANAHAN, CONG. RESEARCH SERV., R46265, ADVANCE APPROPRIATIONS FOR THE INDIAN HEALTH SERVICE: ISSUES AND OPTIONS FOR CONGRESS (2020).

[3] Hybrid SCIP Legis. Hearing – July 28, 2022 Before the Subcomm. on Indigenous Peoples, 117th Cong. 2 (2022) (statement of Maureen Rosette, Chief Operating Officer, NATIVE Project).

[4] GAO-18-652 (Sept. 2018), INDIAN HEALTH SERVICE: CONSIDERATIONS RELATED TO PROVIDING ADVANCE APPROPRIATIONS AUTHORITY, available at https://www.gao.gov/assets/700/694625.pdf.

NCUIH Submits Recommendations to HHS to include Support for Urban Native Communities in its Initiative to Strengthen Primary Health Care

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On August 1, 2022, the National Council of Urban Indian Health (NCUIH) submitted written comments to the Department of Health and Human Services (HHS) Office of the Assistant Secretary for Health (OASH) in response to its request for information (RFI) regarding the HHS Initiative to Strengthen Primary Care. NCUIH supports HHS’ efforts to promote health equity and reduce barriers to care for underserved populations, including American Indians/Alaska Natives (AI/ANs). AI/ANs, including those in urban areas, face significant health disparities attributable in part to a lack of access to high-quality, culturally competent care. NCUIH strongly supports the purpose and scope of the Initiative in establishing a federal foundation that supports advancement towards the stated “goal state” of the practice of primary health care.

NCUIH made the following specific recommendations to HHS OASH:
  • Support UIO models for health care delivery already in place at UIOs:
    • NCUIH recommended that HHS address the need for continued and expanded support for UIOs.
    • UIOs are a fundamental and inseverable component of the IHS, Tribal Health Program, and UIO (I/T/U) system. UIOs “are an important support to Native families and individuals seeking to maintain their values and ties with each other and with their culture,” which exist to provide “a wide range of culturally sensitive programs to a diverse clientele.”
  • Address barriers to the delivery of care at UIOs like insufficient funding and resources:
    • Presently, the ability of UIOs to expand upon their current offerings is severely limited by the chronic underfunding of the Indian health system generally, and UIOs in particular. In 2018, the average health care spending was $11,172 per person nationally, yet UIOs only received $672 per AI/AN patient.
    • NCUIH requested that HHS engage with other federal agencies and Congress to advocate for advance appropriations for the IHS. In addition to a lack of funding, UIOs also face significant barriers to providing primary care to AI/ANs in urban areas due to uncertainty over the consistency and timing of federal funding.
    • NCUIH requested that HHS consider supporting UIO recruitment efforts and increasing funding for staff at UIO facilities. UIOs have long faced understaffing issues that reduce the number of patients they can serve and the quality of service at each facility.
  • Establish an Urban Confer Policy
    • NCUIH recommended that HHS establish an Urban Confer policy to seek UIO input to guide HHS actions to strengthen primary health care. An Urban Confer is an established mechanism for dialogue between federal agencies and UIOs. Urban Confers are responses to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that resulted in 70 percent of AI/AN people living outside of Tribal jurisdictions, thus making Urban Confers integral to addressing the care needs of most AI/AN persons.
    • The development of an HHS Urban Confer policy will help coordinate and integrate care between UIOs and HHS, including the relevant agencies and Departments within HHS that have a trust responsibility to provide care to AI/ANs no matter where they live.
    • An urban confer policy will also help HHS fulfill the United States’ national policy, set forth by Congress, “to ensure maximum Indian participation in the direction of health care services so as to render the persons administering such services and the services themselves more responsive to the needs and desires of Indian communities.”
Background on the HHS Initiative to Strengthen Primary Care

Access to high-quality primary health care has been shown to improve health equity and health outcomes, however, the United States’ primary health care foundation is weakening and in need of support: primary health care is under-resourced; the workforce is shrinking; workforce well-being is in peril; and many practices face reimbursement challenges that may result in financial instability. In response to this, OASH launched the Initiative in September 2021 to develop a federal foundation for the provision of primary health care for all that supports improved health outcomes and advanced health equity.  The goals of the Initiative are to:

The first task of the Initiative is to develop an initial HHS plan for strengthening primary health care that will delineate specific actions that HHS agencies and offices may take to achieve the aims, within the current legislation and funding environment. The plan will also include actions that establish an infrastructure in HHS to continue its focus on strengthening primary health, develop subsequent HHS plans that build on the initial plan, and monitor progress and impact. The purpose of OASH’s June 15 RFI was to provide OASH with diverse perspectives, experiences, and knowledge that may inform the development of the initial plan for HHS, as well as future steps for the Initiative.

NCUIH remains committed to advocating for the health rights of urban AI/ANs and continues to respond to requests for information when applicable.

Resource: Data on Infant and Maternal Health Disparities in Native Communities

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The National Council of Urban Indian Health (NCUIH) recently released an infographic showcasing data on infant and maternal health disparities in American Indian/Alaska Native (AI/AN) communities. Unfortunately, AI/AN communities throughout the country, including urban AI/AN communities, experience significant maternal and infant health disparities compared to the general population.

View the resource

AI/AN Infant and Maternal Health Disparities

A report by the National Center for Health Statistics noted that between 2005 and 2014, American Indian/Alaska Native was the only racial or ethnic group that did not experience a decline in infant mortality.[1]

AI/AN Infant and Maternal Health Disparities

Urban AI/AN Infant and Maternal Health Disparities

Over half of urban Indian organizations (UIOs) provide care for maternal health, infant health, prenatal, and/or family planning. A study of Natives in UIO service areas found that while birth rates, in general, were lower in the urban Native population (12.8 and 16.5 per 1,000 population, respectively), premature birth rates for both urban and non-urban AI/AN were higher than those of all other races and ethnicities combined (12.3% of live births among AI/AI in urban areas and 10.9% among the general population in the same area).[2]

AI/AN Infant and Maternal Health Disparities

Contributing Factors to AI/AN Infant and Maternal Health Disparities

AI/AN Infant and Maternal Health Disparities

  • Cost, discrimination, and lack of cultural competency are all contributing factors to the stark infant and maternal health disparities among AI/ANs.
  • 41% of AI/AN women cite cost as a barrier to receiving the recommended number of prenatal visits.[3]
    • AI/AN women are 3-4x more likely to begin prenatal care in the third trimester.[4]
  • 21% of AI/AN women ages 15-44 are uninsured, compared to 8% of white women.[5]
  • 23% of AI/ANs report they have faced discrimination in clinical settings due to being an AI/AN.[6]
    • 15% report avoiding medical care for themselves or family members due to fear of discrimination.[7]
  • Access to culturally appropriate care can be difficult for AI/ANs living in urban areas, as most IHS clinics and hospitals, as well as Tribal healthcare facilities, are located on reservations.[8]

UIO and NCUIH work in AI/AN Infant and Maternal Mortality

UIOs provide a range of services such as primary care, behavioral health, traditional, and social services— including those for infants, children, and mothers. At least 23 of these clinics provide care for maternal health, infant health, prenatal, and/or family planning. They also provide pediatric services and participate in maternal-child care programs such as WIC and the Health Resources and Services Administration (HRSA) Maternal, Infant, and Early Childhood Home Visiting program (MIECHV).

NCUIH has engaged in extensive advocacy on behalf of AI/AN mothers and infants and for increased funding and support to the UIOs which provide maternal health, infant health, prenatal, and family planning services to AI/AN mothers and infants. On March 9, 2022,  NCUIH signed on to a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing HRSA’s Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and doubling the Tribal set-aside— which includes UIOs.

Also, in March, NCUIH submitted comments to the HRSA Advisory Committee on Infant and Maternal Mortality (ACIMM), which advises the Secretary of Health and Human Services (HHS) on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and severe maternal morbidity, and improving the health status of infants and women before, during, and after pregnancy. In August, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program in August. In our comments, we have continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations.

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

  • Reauthorize MIECHV at a higher amount and double the Tribal set-aside from 3% to 6%.
  • ACIMM and other stakeholders should collaborate with UIOs to gather critical and accurate information on urban AI/AN populations.
  • Advise the HHS Secretary to lead the establishment of an urban confer policy across all HHS agencies.
  • Include a Tribal and UIO health provider representative on the ACIMM and create an ACIMM subcommittee dedicated to addressing AI/AN infant and maternal health disparities.

 

 

[1] Mathews TJ, Driscoll AK, Trends in infant mortality in the United States, 2005–2014, (2017) available at: https://www.cdc.gov/nchs/data/databriefs/db279.pdf

[2]Castor ML, Smyser MS, Taualii MM, Park AN, Lawson SA, Forquera RA. “A nationwide population-based study identifying health disparities between American Indians/ Alaska Natives and the general populations living in select urban counties.” Am J Public Health, 2006;96(5)

[3] National Partnership for Women and Families, American Indian and Alaska Native Women’s Maternal Health: Addressing the Crisis, (2019), https://www. nationalpartnership.org/our-work/resources/health-care/maternity/american-indian-and-alaska.pdf

[4] Urban Indian Health Institute, Community Health Profile: National Aggregate of Urban Indian Health Program Service Areas, (2016), http://www.uihi.org/wp-content/ uploads/2017/08/UIHI_CHP_2016_Electronic_20170825.pdf

[5] National Partnership for Women and Families, American Indian and Alaska Native Women Face Pervasive disparities in Access to Health Insurance, (2019), https:// www.nationalpartnership.org/our-work/resources/health-care/AIAN-health-insurance-coverage.pdf

[6] Harvard T.H. Chan School of Public Health, Poll finds more than one-third of Native Americans report slurs, violence, harassment, and being discriminated against in the workplace (2017), https://www.hsph.harvard.edu/news/press-releases/poll-native-americans-discrimination/

[7] Id.

[8] See Mental Health America, Native and Indigenous Communities and Mental Health – Prevalence, https://www.mhanational.org/issues/native-and-indigenouscommunities-and-mental-health (last accessed Aug. 20, 2022).

NCUIH Submits Comments to the Indian Health Service on the Creation of an Urban Indian Interagency Workgroup

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On September 12, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to the Indian Health Service (IHS) regarding the formation of an Urban Interagency Workgroup with other federal agencies. The agency held an Urban Confer on July 13, in response to a letter sent to President Biden and Vice President Harris from several Senators, requesting the formation of such a workgroup. NCUIH supports the development of an Interagency Workgroup and believes that this would be a key step to increasing support and resources to American Indians/Alaska Natives (AI/ANs) living in urban areas.

NCUIH Recommendations to IHS

NCUIH noted in the comments that Tribes have a unique government-to-government relationship with the federal government and it is essential that any group does not disrupt this. Furthermore, NCUIH supports the federal government in its attempts to better uphold the trust responsibility it has to AI/ANs living in urban areas, which requires more complete involvement of urban Indian organizations (UIOs). However, this does not mean that resources and funding should come at the expense of Tribes. Rather, the government should broaden and deepen the services it provides to all AI/ANs while additionally further meeting the trust responsibility to urban-dwelling AI/ANs.

NCUIH provided the following recommendations to IHS in response to the Urban Confer:

  • Respect Tribal Sovereignty and the government-to-government relationship in the formation of an Interagency Workgroup.
  • Create a committee within the White House Council on Native American Affairs (WHCNAA) focused on how federal agencies can better serve AI/ANs living in urban areas.
    • The White House Council on Native American Affairs (WHCNAA) was established to improve outcomes for AI/AN communities through a stronger relationship between the federal government and Native people.
    • Developing an Interagency Oversight Committee on Urban Indian Affairs within WHCNAA would allow cross-collaboration across all agencies and ensure that all other WHCNAA committees are accurately incorporating urban Indian communities into their work.
  • IHS should provide technical assistance to federal agencies to develop Urban Confer policies.
    • Urban Confer policies or UIO-specific consultations do not supplant or otherwise alter Tribal Consultations and the government-to-government relationship between Tribes and federal agencies. IHS should provide support and assistance to federal agencies as they begin the development of such policies.

Background

The formation of an Urban Indian Interagency Work Group to identify the needs and develop strategies to better serve urban AI/AN populations has been a priority for NCUIH. On February 3, 2022, Senator Van Hollen, along with Senators Alex Padilla (D-CA), Catherine Cortez Masto (D-NV), Tina Smith (D-MN), Dianne Feinstein (D-CA), Elizabeth Warren (D-MA), Ed Markey (D-MA), Mark Kelly (D-AZ), Amy Klobuchar (D-MN), Patty Murray (D-WA), Tammy Baldwin (D-WI), Jacky Rosen (D-NV), Jeff Merkley (D-OR), and Jon Tester (D-MT) sent a letter to the Biden Administration requesting the establishment of this workgroup. NCUIH worked closely with Senator Padilla on this letter and supports the effort to bring better representation for the needs of AI/ANs who do not reside on Tribal land.

The Senate Appropriations Subcommittee directed IHS to continue to explore the formation of this interagency working group in its Fiscal Year 2023 Interior Appropriations bill, noting that “in addition to the Indian Health Service, the working group should consist of the U.S. Department of Health and Human Services, U.S. Department of Housing and Urban Development, U.S. Department of Agriculture, U.S. Department of Justice, U.S. Department of Education, U.S. Department of Veteran Affairs, U.S. Department of Labor, the Small Business Administration, the Economic Development Agency, FEMA, the U.S. Conference of Mayors, and others as identified by UIOs.”

The Work Group would help identify federal funding strategies to better address the needs of urban AI/ANs, advance the development of a wellness-centered framework to inform health services, strengthen support for practice-based traditional healing approaches, improve Urban Confer policies at Health and Human Services and associated agencies, and ensure that Urban Indian Organizations can regularly meet with federal agencies to address relevant topics of concern.

NCUIH will continue to monitor for any further development on the formation of an Urban Interagency Workgroup. NCUIH will also continue to engage with IHS, the White House, and Congress on moving this proposal forward.