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

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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

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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:

  1. Tina Smith
  2. Tammy Baldwin
  3. Maria Cantwell
  4. Diane Feinstein
  5. Ben Luján
  6. Edward Markey
  7. Alex Padilla
  8. Jacklyn Rosen
  9. Jon Tester
  10. Chris Van Hollen
  11. 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

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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:

  1. Don Bacon
  2. Nanette Barragán
  3. Earl Blumenauer
  4. Shontel Brown
  5. Salud Carabjal
  6. Greg Casar
  7. Sharice Davids
  8. Diana DeGette
  9. Ruben Gallego
  10. Steven Horsford
  11. Jared Huffman
  12. Pramila Jayapal
  13. Dusty Johnson
  14. William Keating
  15. Ro Khanna
  16. Teresa Leger Fernandez
  17. Mike Levin
  18. Zoe Lofgren
  19. Doris Matsui
  20. Gwen Moore
  21. Eleanor Holmes Norton
  22. Ilhan Omar
  23. Mary Peltola
  24. Brittany Pettersen
  25. Deborah Ross
  26. Adam Schiff
  27. Kim Schrier
  28. Terri Sewell
  29. Adam Smith
  30. Melanie Stansbury
  31. Greg Stanton
  32. Jill Tokuda
  33. Gabe Vasquez
  34. Jasmine Crockett
  35. Chris Pappas
  36. Raul Ruiz
  37. Jesus “Chuy” Garcia
  38. 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

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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 (117th Congress)

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

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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

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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

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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

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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.

NCUIH Testifies Before House Oversight Committee on Improving Healthcare Delivery for Native People

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The National Council of Urban Indian Health (NCUIH) Board Member and Chief Operations Officer (COO) of the NATIVE Project, Maureen Rosette (Chippewa Cree Nation), testified before the House Natural Resources Subcommittee on Indian and Insular Affairs oversight hearing titled “Challenges and Opportunities for Improving Healthcare Delivery in Tribal Communities.”

NCUIH Testifies at Congressional Hearing on Tribal Healthcare Delivery and Funding for IHS

Maureen Rosette, NATIVE Project and NCUIH

NCUIH Board Member and COO of the NATIVE Project, Maureen Rosette (Chippewa Cree Nation), testifies before the House Natural Resources Subcommittee on Indian and Insular Affairs.

On Wednesday, March 29, NCUIH Board Member and NATIVE Project COO, Maureen Rosette, testified before the Subcommittee on Indian and Insular Affairs in their oversight hearing titled “Challenges and Opportunities for Improving Healthcare Delivery in Tribal Communities.”

  • Additional witnesses included: Ms. Janet Alkire, Board Member
    of the National Indian Health Board, Ms. Jerilyn Church, Executive Director of the Great Plains Tribal Leaders Health Board, and Ms. Laura Platero, Executive Director of the Northwest Portland Area Health Board.

What they’re saying:

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

  • Rosette emphasized the importance of the Indian Health Service (IHS) and urban Indian organizations (UIOs) to the Indian health system in providing health care to Native people.

“I lived and grew up on my reservation and I was a consumer of my own Tribally-operated health program at the age of 28. I moved to Spokane to go to law school. I had no health insurance. I had two little kids, a three-year-old and a five-year-old and we had no health insurance. At the time, if NATIVE Project had medical services, we would at least had access to health care, but we didn’t at the time. I just hoped and prayed that none of us got sick. Now, I have insurance and can go anywhere I want, but our family has chosen to be consumers of NATIVE Project because of the excellent healthcare we get there. And it’s culturally appropriate, that’s what we want. Today, there are 41 UIOs, which are a fundamental and necessary component of the Indian health system, and we work hand in hand with IHS to help provide the resources necessary to provide healthcare to Native people.”

-Maureen Rosette, NCUIH Board Member and NATIVE Project COO

The importance of care for Native people by Native people was also reiterated in the hearing including by Ms. Laura Platero:

“While American Indian and Alaska Native people were disproportionality impacted by COVID-19, due to underlying health disparities and the lack of infrastructure in many communities, Tribal innovation and response to COVID prevailed. When Tribes are given the resources and the control of those resources, they know how to respond to meet the needs of their community.”

-Laura Platero, Executive Director, Northwest Portland Area Indian Health Board

The bottom line: The IHS including UIOs are a critical resource for Native people to access healthcare services.

Proposed Cuts to IHS Funding Risks Native Lives

Witnesses and Members of Congress at hearing on Indian Health Service oversight.

Witnesses and Members of Congress at hearing on Indian Health Service oversight.

Rosette, along with fellow witnesses, provided valuable insight into the realities that Native communities experience at home in their call for more reliable funding for IHS.

  • Addressing Challenges: The shortage of healthcare professionals and facilities in rural and urban areas, coupled with the difficulty recruiting and retaining them, makes it difficult for patients to access quality healthcare. The lack of adequate resources, poor infrastructure, and low salaries have resulted in a shortage of healthcare professionals in these areas. Native leaders spoke about the importance of supporting Native healthcare administrators in their effort to be innovative and creative care providers for their people.

“Congress must live up to its treaty commitments, bring IHS facilities to modern standards, and increase IHS funding. After this hearing, I will return home to our financially starved IHS hospital covered in snow and running on boiler heat in below-freezing temperatures. I will give all my time and energy to help my people in need, working my vision for a new medical facility… I will be waiting for this subcommittee and Congress to finally take action, Congress must pay its overdue debts and provide American Indians and Alaska Natives the healthcare we deserve and the healthcare we were promised.”

-Janet Alkire, National Indian Health Board

Advanced funding for IHS is needed to provide stable and predictable funding to ensure the continuity of care for American Indian and Alaska Native people.

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

-Maureen Rosette, NCUIH Board Member and NATIVE Project COO

What they’re saying:

Maureen Rosette, NATIVE Project and NCUIH

“GOP proposed cuts to IHS would have to reduce outpatient services by nearly 1.6 million visits. 1.6 million visits will go away. Dental visits would be reduced by 120,000, mental health visits by nearly 90,000 and outpatient services by 4,000.”

–Rep. Leger Fernandez. (D-NM-3)

Go deeper:

Next Steps: The Committee is expected to review the testimony as they propose oversight legislation related to the Indian Health Service this year. NCUIH will continue to advocate for full and flexible funding for the Indian Health Service.

NCUIH Participates in SAMHSA’s Native Veterans Expert Panel Discussion

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Expert Panel veterans

On February 15-16, 2023, the National Council of Urban Indian Health (NUCIH) Federal Relations Manager, Alexandra Payan, represented NCUIH at the Substance Abuse and Mental Health Services Administration’s (SAMHSA) American Indian and Alaska Native (AI/AN) Veterans Expert Panel Discussion. The purpose of this two-day meeting was to have a collaborative conversation around the development of a virtual training tool related to AI/AN military and veteran suicide prevention. The proposed tool will be available for states, territories, and communities to use as they work to implement their efforts. NCUIH was invited to participate in the Expert Panel Discussion to provide insight on the unique needs of AI/AN veterans who reside in urban areas.

Expert Panel’s Work to Support the Governor’s Challenge

Expert Panel with CAPT HearodThe Expert Panel Discussion was an opportunity to ensure broad representation of AI/AN veterans in the Governor’s Challenge to Prevent Suicide Among Service Members, Veterans, and their Families (Governor’s Challenge). Through collaboration with the VA, SAMHSA and SAMHSA’s SMVF Technical Assistance Center, the Governor’s Challenge seeks to provide a forum for teams to consider how existing policies, practices, infrastructure, and resources influence the effectiveness of the systems that support SMVF. Teams develop state and territory-wide plans based on a comprehensive public health approach and the National Strategy for Preventing Veteran Suicide (National Strategy).  During the Expert Panel Discussion, the team engaged in initial steps to develop a virtual toolkit aimed at addressing suicide in AI/AN veteran communities to supplement the Governor’s Challenge. Once created, the virtual toolkit will serve as instruments of change, providing a best-practice public health model that demonstrates meaningful results in suicide prevention for AI/AN veterans.

Urban Indian Organizations and Native Veteran Support

Sadly, AI/AN veterans have a higher prevalence of mental health disorders compared with White veterans and among all veterans the prevalence of suicidal ideation is highest for those reporting a diagnosis of depression, anxiety, or post-traumatic stress disorder. While there is limited data and research on suicide among AI/AN veterans, the 2020 National Veteran Suicide Prevention Annual Report documents growing AI/AN veteran suicide rates from 2005-2018.

UIOs are essential partners in serving AI/AN veterans and reducing AI/AN veteran suicides. UIOs are critical in improving care and access to services for AI/AN veterans because of their deep ties to the AI/AN community in urban areas. UIOs currently serve seven of the ten urban areas with the largest AI/AN veteran populations, including Phoenix, Arizona; Los Angeles, California; Seattle, Washington; Dallas, Texas; Oklahoma City, Oklahoma; New York City, New York; and Chicago, Illinois. Many AI/AN veterans prefer to receive care at IHS facilities, or may only have access to an IHS, Tribal, or UIO facility.

UIOs are uniquely positioned to assist agencies, such as the VA, SAMHSA, and HHS, in improving health care access for AI/AN people. Several UIOs already provide mental health and substance abuse disorder services and all UIOs provide numerous other social and community services to AI/ANs living in urban areas. NCUIH looks forward to continuing to work with SAMHSA, VA, and other agencies to improve the quality of care available to Native veterans in urban areas.

NCUIH’s work with the VA and Native Veterans in Urban Areas

NCUIH continues to work on behalf of Native veterans living in urban areas to ensure that they have access to the high-quality, culturally competent care the country owes to them for their military service and as a result of the trust responsibility.

For more information on NCUIH’s efforts please visit: