Senate Committee on Indian Affairs Advances Nomination of Roselyn Tso as Director of IHS, Awaits Full Senate Consideration

/0 Comments/in /by

On May 25, 2022, the Senate Committee on Indian Affairs (SCIA) met to consider the nomination of Roselyn Tso as Director of the Indian Health Service (IHS) who was nominated by President Biden in March. After the resignation of Rear Admiral Michael Weahkee in January of 2021, IHS is currently led by interim Acting Director Liz Fowler. On July 13, 2022, SCIA voted to advance the nomination of Ms. Tso in a business meeting after she appeared before the Committee for her nomination hearing in May. Her nomination now awaits full consideration by the Senate.

Roselyn Tso: Background and Experience

Ms. Tso is a citizen of the Navajo Nation. She began working for IHS in 1984 and currently serves as the Director of the Navajo Area, the largest IHS regional area. Prior to her work in IHS, much of her professional career was spent in Portland, where she served in several capacities, including working with the three urban programs in the Portland Area that provide services ranging from community health to comprehensive primary health care services.

SCIA Hearing: Confirmation Needed to Address Health Disparities & Tribal Needs

The absence of a confirmed IHS Director has prevented Tribes, Tribal organizations, and urban Indian organizations (UIOs) from addressing the health care needs of their Native American populations, which directly falls under the responsibility of IHS. Since the resignation of Rear Admiral Weahkee, there have been countless requests from Indian Country calling on Congress and the Administration to nominate a new IHS director to address the growing health disparities experienced by American Indian and Alaska Natives (AI/ANs). The National Council of Urban Indian Health has previously stressed the importance of appointing a permanent IHS Director and called for the elevation of the role to Assistant Secretary.

During the SCIA hearing to consider her nomination as Director of IHS, Ms. Tso highlighted how Native communities have been disproportionately impacted by COVID-19, which has been made worse given the absence of a confirmed Director. She stated, “I am reminded of the many health disparities facing American Indians and Alaskan Natives – health disparities that in many cases were made worse by COVID-19. For example, sadly, today, too many Navajo families still do not have access to running water in their homes. Access to clean, safe drinking water is essential to the health and well-being of our people.”

In addition, Ms. Tso stated during the hearing that she intends to utilize IHS resources to not only address the disparities caused by COVID-19, but to also “improve the physical, mental, social, and spiritual health and well-being of all American Indians and Alaskan Natives served by the Agency.” To achieve this goal, Ms. Tso said she would prioritize strengthening and streamlining business operations to create a more unified health care system, develop centralized systems to improve patient outcomes, accountability, and transparency, and finally address the needs and challenges experienced by the workforce. To conclude her testimony, Ms. Tso said that if confirmed as the Director of IHS, she would update agency policies and programs, as well as utilize the oversight authority of IHS to best serve each Tribal community.

As of August 16, 2022, there have been no updates on the anticipated date for the full Senate consideration for the nomination of Ms. Tso as Director of IHS, which would be the last step in her confirmation process.

Next Steps

NCUIH will continue to monitor and provide updates on the full Senate consideration of the nomination of Ms. Tso as Director of IHS.

NCUIH Submits Comments to the Administration, the Department of Health and Human Services, and the US Department of Agriculture on the National Strategy for Hunger, Nutrition, and Health

/0 Comments/in /by

On July 15, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to the Administration, the Department of Health and Human Services (HHS), and the US Department of Agriculture (USDA) on hunger, nutrition, and health. This comment was in response to correspondence from the Administration, HHS, and USDA dated May 27, 2022, which sought input on the development and implementation of the national strategy on hunger, nutrition, and health. NCUIH recommended that the Administration, HHS, and USDA support UIO programs to promote food security, nutrition, and exercise, include urban AI/AN populations in future research efforts and government projects, and establish consistent Urban Confers regarding nutrition, hunger, and health.

Background

AI/AN people face high levels of food insecurity and diseases related to lack of access to healthy foods, including diabetes and heart disease. Furthermore, AI/AN people who live in urban settings are especially likely to experience food insecurity. According to a 2017 report published in the Journal of Hunger & Environmental Nutrition, “[u]rban AI/ANs were more likely to experience food insecurity than rural AI/ANs.” The high rates of food insecurity in urban AI/AN communities are likely a result of “AI/ANs living on reservations… [having] access to tribally provided food and health care resource services that may not be accessible to AI/ANs living in urban areas.”[1]

NCUIH’s Actions

As a result of the high rates of food insecurity in urban AI/AN communities, and in effort to highlight the programs already in place at UIOs that address hunger, nutrition, and physical exercise, NCUIH made the following recommendations to the Administration, HHS and USDA:

  • NCUIH recommended that the Administration, HHS, and USDA support UIO programs to promote food security, nutrition, and exercise.
    • Many UIOs operate programs to improve food security and nutrition, such as: food banks, meal services, community gardens, cultural cooking and nutrition classes, community workout groups, facilities, and events, and counseling and classes about diabetes prevention and care. Through their offerings, UIOs incorporate cultural knowledge and traditional practices, address other social needs, and strengthen community bonds.
    • Recognizing that UIOs face chronic underfunding which limits them from expanding their offerings, NCUIH urged the Administration, HHS, and USDA to support the maintenance and expansion of UIO programs related to hunger and nutrition.
  • NCUIH requested that the Administration, HHS, and USDA support further research efforts and include urban AI/AN populations in future framing documents and government projects.
    • The inclusion of data about urban AI/AN populations in future research projects about food security and nutrition will contribute to a more comprehensive and reflective understanding of AI/AN experiences and needs.
    • Any and all efforts to include UIOs and urban populations in government research projects should be complementary to the inclusion of Tribal governments and should not supplant or otherwise alter Tribal representation. Research efforts should also respect tribal sovereignty.
  • NCUIH requested that HHS and USDA establish consistent Urban Confers with UIOs regarding nutrition, hunger, and health.
      • Urban Confers are not only integral to addressing the care needs of urban AI/AN persons and fulfilling the government’s trust responsibility, but also sound public policy.
    • Meeting regularly with UIO through Urban Confers will help HHS and the USDA ensure that AI/ANs in urban areas are able to voice their needs and priorities to both agencies.
    • Urban Confer policies or inclusion of UIOs in UIO-specific consultations do not supplant or otherwise alter Tribal Consultation and the government-to-government relationship between Tribes and federal agencies.


NCUIH will continue to closely follow the Administration’s development and implementation of the national strategy on hunger, nutrition, and health. NCUIH will also continue to advocate for the resources needed to reduce health disparities for AI/ANs, regardless of where they live.

[1] Id. at 5-6. See also Castor M.L., Smyser M.S., Taualii M.M., et al., A nationwide population-based study identifying health disparities between American Indians/Alaska Natives and the general populations living in select urban counties. 96 Am. J. Public Health. 1478-84 (2006).

Indian Health Service Publishes Circular No. 22-15 Clarifying Abortion Policies for Indian Country

/0 Comments/in /by

On June 30, 2022, the Indian Health Service (IHS) published Circular No. 22-15 (the Circular) about the agency’s policy on the use of IHS funds for abortions in light of Dobbs v. Jackson Women’s Health Organization. Although Roe v. Wade had historically protected the right to abortions, this right has been restricted in Indian Country for decades by the Hyde Amendment, with well-established exceptions. IHS maintains that it will continue to uphold the codified exceptions to the Hyde Amendment, pursuant to authority given to IHS and HHS by Congress over federal health care spending.

The Circular clarifies that IHS funds may be used to pay for or otherwise, provide for abortions if: (1) a physician certifies that “the pregnant person suffers from a physical disorder, injury, or illness that would place that patient in danger of death unless an abortion is performed” or (2) a physician certifies that the pregnancy is the result of an act of rape or incest. Furthermore, the Circular clarifies that federal funds may be used to pay non-IHS providers who perform medical procedures, including abortions, during pregnancy to IHS beneficiaries. Finally, the Circular emphasizes that it does not prevent IHS from providing accommodations to providers who maintain a sincerely held religious objection to abortion.

Background

IHS provides important background and legal reasoning to support the policies in the Circular:

In 1982, the Hyde Amendment restricted appropriations for the Department of Health and Human Services (HHS) and the agencies within HHS so that federal funds could not be spent on abortions. In compliance with this Amendment, IHS passed regulations in the same year to prohibit most abortions. Notably, IHS regulations made an exception to allow abortions when a physician certified that the life of the mother would be endangered if the fetus were carried to term.

Around a decade later, new exceptions were added to the Hyde Amendment. These included pregnancies that were the result of rape or incest, and cases where the pregnant person suffered from a physical disorder, injury, or illness, and a physician certified that the patient would be in danger of death unless an abortion was performed. Congress also clarified that these exceptions are applicable to IHS. As a result of this update, IHS regulations from a decade earlier were inconsistent with the Hyde Amendment. IHS published the Circular to help resolve this inconsistency.

IHS notes that states cannot interfere with its authority over abortion policies or the use of federal funds toward abortions because this area of regulation is preempted by federal law. In other words, Congress vested the authority to control federal spending for health care in HHS and IHS through the Snyder Act and 42 U.S.C. § 2001; states cannot usurp that authority. In turn, IHS asserts that states cannot (1) compel IHS federal staff to act inconsistently with the scope of their official duties, (2) prohibit the use of IHS funds from authorized services, (3) prevent IHS patients from accessing authorized services, or (4) compel access to IHS records.

NCUIH appreciates the clear, consistent communication from IHS through the Circular and will continue to monitor access to abortion rights in Indian Country.

House Passes Fiscal Year 2023 Appropriations Minibus with $200 million for Urban Indian Health

/0 Comments/in , /by

On July 21, 2022, the House passed H.R. 8294, a package of six fiscal year (FY) 2023 federal funding bills, by a 220 to 207 vote. Included within the package is the FY 2023 Interior, Environment, and Related Agencies Appropriations bill, which includes $8.1 billion for the Indian Health Service (IHS) and $200 million for urban Indian health, but fails to include advance appropriations for IHS.

Background

On June 28, 2022, the House Appropriations Subcommittee on Interior, Environment, and Related Agencies released the Committee Bill Report for the FY 2023 budget with $200 million for urban Indian health. The report and bill were considered by the full House Appropriations Committee on June 29, 2022, after being approved by the House Subcommittee on Interior on June 21, 2022. The bill authorizes $8.1 billion for IHS— an increase of $1.5 billion from FY22 but $1 billion below the President’s budget request. Despite robust advocacy from Tribes and Urban Indian Organizations (UIOs), the bill does not include advance appropriations for IHS. Other key provisions include $17 million for generators for IHS/Tribal Health Programs/UIOs and $3 million for a Produce Prescription Pilot Program for Tribes and UIOs to increase access to produce and other traditional foods. A more detailed analysis follows below.

The President’s budget proposed to shift IHS from discretionary funding to mandatory funding in FY 2023. In the meantime, Native health advocates requested Advance Appropriations until mandatory funding is implemented. To much disappointment, the House bill does not provide (or even mention) advance appropriations for IHS. Advance appropriations is a long-standing priority for Indian Country and advocates have been requesting Congress to provide stable funding for IHS, especially considering the COVID-19 pandemic which has had tremendous, adverse impacts on American Indians and Alaska Natives. In the past month alone, NCUIH sent a letter to request Speaker Pelosi and Minority Leader McCarthy to allow for advance appropriations, and NCAI and NIHB also sent an action alert to request the Appropriations Committee include advance appropriations. Previously, NCUIH, along with 28 Representatives and 12 Senators requested advanced appropriations for IHS until such time that authorizers move IHS to mandatory spending.

Status of Senate Interior Appropriations Bill

The Senate has yet to release their appropriations bills, and it is unlikely they will pass their bills before the current September 30 deadline. Congress will need to rely on a Continuing Resolution to avoid a government shutdown.

Bill Highlights

Indian Health Service: $8.1 billion

  • $8.1 billion for the Indian Health Service, an increase of $1.5 billion above the FY 2022 enacted level.

Urban Indian Health: $200 million

  • Bill Report: “The recommendation includes $200,000,000 for Urban Indian Health, $126,576,000 above the enacted level and $200,000,000 above the budget request. This amount includes $31,000 transferred from the Alcohol and Substance Abuse Program as part of the for NIAAA program. The Committee expects the Service to continue including current services estimates for Urban Indian health in annual budget requests.”

Mandatory Funding:

  • Bill Report: “For fiscal year 2023, the Administration proposed reclassifying IHS accounts as mandatory and did not submit a discretionary budget proposal. However, IHS did not provide implementation language and at the time of writing this report, the authorizing committees have not enacted the President’s proposal. Because the authorizing committees have not acted, the Committee is providing discretionary funds for IHS for fiscal year 2023 to ensure health care for Native Americans is not negatively impacted.”
  • Note: There is no mention of advance appropriations for IHS in this bill.

Equipment: $118.5 million

  • Bill Report: “The recommendation includes $118,511,000 for Equipment, $88,047,000 above the enacted level and $118,511,000 above the budget request. The bill continues $500,000 for TRANSAM.
  • The report further states: “The Committee is aware that the increasing severity and frequency of extreme weather events has motivated certain jurisdictions to adopt de-energization protocols to reduce the risks of catastrophic wildfires. While these protocols are useful in limiting loss of life in affected communities, they can also have dire consequences for Tribal Health Programs located in impacted areas. To increase the resilience of these facilities, the recommendation includes an additional $17,000,000 to purchase generators for IHS, Tribal Health Programs, and Urban Indian Organizations located in areas impacted by de-energization events. In procuring backup generators, the Indian Health Service is directed to determine the most cost-effective method, which may include leasing. In determining the most cost-effective procurement method, the Service shall account for life-cycle maintenance costs associated with direct ownership and clinics’ capabilities to maintain these generators.”

Electronic Health Records: $284.5 million

  • Bill Report: “To improve the current IT infrastructure system to support deployment of a new modern electronic health records (EHR) solution, the recommendation includes $284,500,000 for Electronic Health Records, $139,481,000 above the enacted level and $284,500,000 above the budget request.
  • The report further states: “The Committee urges IHS to continue moving forward with modernizing its aging EHR system by replacing it with a solution that is interoperable with the new EHR at the Department of Veterans Affairs and with systems purchased by Tribes and UIOs. Modernization should include robust Tribal consultation and planning to ensure that Tribes and UIOs are enabled to take full advantage of resulting modern health information technology and are not unduly burdened during this process.”

Mental Health: $130 million

  • Bill Report: “The recommendation includes $129,960,000 for Mental Health, $8,014,000 above the enacted level and $129,960,000 above the budget request.”

Alcohol and Substance Abuse: $264 million

  • Bill Report: “The Committee provides $264,032,000 for Alcohol and Substance Abuse, $5,689,000 above the enacted level and $264,032,000 above the budget request. This amount transfers $31,000 to Urban Indians from the former National Institute on Alcohol Abuse and Alcoholism (NIAAA). Funding for Substance Abuse and Suicide Prevention grants is continued at fiscal year 2022 enacted levels.”

Community Health Aide Program (CHAP): $25 million

  • Bill Report: “[…] an additional $20,000,000 is provided to expand the Community Health Aide Program to the lower 48 states with direction for IHS to report within 90 days of enactment of this Act on how funds will be distributed”

Tribal Epidemiology Centers: $34,433,361

  • Bill Report: “[…] an additional $10,000,000 is for Tribal Epidemiology Centers”

Hepatitis C, HIV/AIDS and STDs Initiative: $52 million

  • Bill Report: “[…] an additional $47,000,000 is for the Hepatitis C, HIV/AIDS and STDs initiative.”

Maternal Health: $10 million

  • Bill Report: “The recommendation also includes an additional $4,000,000 to improve maternal health with continued direction to report to the Committee within 180 days of enactment of this Act on use of funds, updates on staff hiring, status of related standards, and the amount of training provided with these funds.”

Alzheimer’s Disease: $5.5 million

  • Bill Report: “The recommendation maintains $5,500,000 to continue Alzheimer’s and related dementia activities at IHS. These funds will further efforts on Alzheimer’s awareness campaigns tailored for the AI/AN perspective to increase recognition of early signs of Alzheimer’s and other dementias; quarterly, competency-based training curriculum, either in-person or virtually, for primary care practitioners to ensure a core competency on assessing, diagnosing, and managing individuals with Alzheimer’s and other dementias; pilot programs to increase early detection and accurate diagnosis, including evidence based caregiver services within Indian Country, inclusive of urban Indian organizations (UIO); and an annual report to the Committee with data elements including the prevalence of Alzheimer’s incidence in the preceding year, and access to services within 90 days of the end of each fiscal year. The Committee continues direction to develop a plan, in consultation with Indian Tribes and urban confer with UIOs, to assist those with Alzheimer’s, the additional services required, and the costs associated with increasing Alzheimer’s patients and submit this information to Congress within 270 days of enactment of this Act.”

Produce Prescription Pilot Program:

  • Bill Report: “The Committee continues $3,000,000 for IHS to create, in coordination with Tribes and UIOs, a pilot program to implement a produce prescription model to increase access to produce and other traditional foods among its service population. Within 60 days of enactment of this Act, the Committee expects IHS to explain how the funds are to be distributed and the metrics to be used to measure success of the pilot, which shall include engagement metrics, and may include appropriate health outcomes metrics, if feasible.”

Headache Disorders Centers of Excellence:

  • Bill Report: “The Committee recognizes that over 560,000 people under IHS care are living with migraine or severe headache disorders and that AI/AN communities have the highest prevalence of both disabling headache disorders and concussion/mild traumatic brain injuries, among any racial or ethnic group in the United States. The Committee is concerned that AI/AN patients with chronic migraine, post-traumatic headache, and other disabling headache disorders often do not receive necessary specialty care. The IHS is encouraged to consider the feasibility of IHS Headache Centers of Excellence and if feasible, developing a budget proposal to establish IHS Headache Centers of Excellence to provide direct care, telehealth, and consultation patient services, as well as education and training.”

Senate Proposes $80.4 million for Urban Indian Health, Includes $5.6 billion in Advance Appropriations for IHS for FY 2023

/0 Comments/in , /by
The bill will not receive committee markups and includes $7.38 billion for IHS, $1.72 billion less than the amount requested by the President.

WASHINGTON, D.C. (July 29, 2022): The Senate Appropriations Subcommittee has released its fiscal year (FY) 2023 Interior, Environment, and Related Agencies bill with $80.4 million for urban Indian health— $7 million above the current enacted level, and $32 million below the President’s request. The bill also authorizes $7.38 billion for the Indian Health Service (IHS), an increase of $762 million from FY 2022, but $1.72 billion below the President’s request. Thanks to the robust advocacy efforts from NCUIH, Urban Indian Organizations (UIOs) and Tribes alike, the bill text provides $5.577 billion of advance appropriations for IHS for FY 2024. The bill will not receive any committee markups. Other key provisions include $9 million to improve maternal health, increased funding for mental health programs, and expanded funding for community health representatives. A more detailed analysis follows below.

The Committee is not going to conduct markups and it is expected that there will be a continuing resolution when FY22 funding expires on September 30, 2022. NCUIH will continue to advocate for full funding for IHS and urban Indian health with Advance Appropriations for FY23 as negotiations proceed later in the year.

“NCUIH is grateful for the Committee’s inclusion of $80 million for urban Indian health for Fiscal Year 2023, but disappointed to see the reduced request from last year given all the growing costs of inflation. While the proposed amount would not fully fund the Indian Health Service, we are grateful for the inclusion of critical advance appropriations.  We thank all members of the Committee for their efforts to provide resources for Native healthcare and achieve advance appropriations. The Indian Health Service has worked with inadequate and unstable funding for too long, and we hope that the federal government can finally fulfill its trust responsibility to Natives and provide the care we need” – Francys Crevier (Algonquin), CEO, NCUIH.

Advance appropriations is a long-standing priority for Indian Country. Advocates have continuously requested that Congress provide stable funding for IHS, especially considering the impact of the COVID-19 pandemic, which disproportionately affected American Indians and Alaska Natives (AI/ANs) who lost their lives at the highest rates of any population. The President’s budget proposed to shift IHS from discretionary funding to mandatory funding in FY 2023. During this time, Native health advocates requested advance appropriations. During the last few months alone, NCUIH sent letters to request Senate and House leadership to allow for advance appropriations, and the National Congress of American Indians (NCAI) and the National Indian Health Board (NIHB) sent an action alert to request advance appropriations by the House Appropriations Committee. In addition, NCUIH, along with 28 Representatives and 12 Senators, requested advanced appropriations for IHS until such time that authorizers move IHS to mandatory spending.

Line Item FY22 Enacted   FY23 TBFWG Request FY23
President’s
Budget		 FY23
House Proposed		 FY23 Senate Proposed
Urban Indian Health $73,424,000   $949,900,000 $112,514,000 $200,000,000 $80,424,000
Indian Health Service $6,630,986,000   $49,800,000,000 $9,100,000,000 $8,100,000,000 $7,380,000,000
House Appropriations Status

The House passed H.R. 8294 as part of six-bill package on July 21, 2022. The bill included $200 million for urban Indian health, but fails to include advance appropriations for IHS.

Background and Advocacy

On March 28, 2022, President Biden released his budget request for FY 2023 which included, for the first time ever, $9.1 billion in mandatory funding for IHS for the first year with increased yearly funding over the next ten years, and $112.5 million for Urban Indian Health— a 53.2% increase above the FY 2022 enacted amount of $73.4 million.

Full Funding, Advance Appropriations, and Mandatory Funding a Priority

NCUIH requested $49.8 billion for the Indian Health Service and $949.9 million for Urban Indian Health for FY 2023 (as requested by the Tribal Budget Formulation Workgroup (TBFWG) recommendations), Advance appropriations for IHS, and support of mandatory funding for IHS (including UIOs).The considerable increase for FY 2023 is a result of Tribal leaders providing budgetary recommendations for gradual funding increases over the last 10-12 years to address growing health disparities that have gone largely ignored by the federal government. ), advance appropriations for IHS, and support of mandatory funding for IHS (including UIOs).The considerable increase for FY 2023 is a result of Tribal leaders providing budgetary recommendations for gradual funding increases over the last 10-12 years to address growing health disparities that have gone largely ignored by the federal government.

On April 5, 2022, NCUIH President and CEO of the Indian Health Center of Santa Clara Valley, Sonya Tetnowski (Makah Tribe), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2023 funding for UIOs. Most recently, on July 28, 2022, NCUIH testified before the House Subcommittee for Indigenous Peoples in the United States in support of authorizing advance appropriations authority to IHS. In her testimony, Maureen Rosette, NCUIH Board member and Chief Operations Officer of NATIVE Project, emphasized how advance appropriations would no longer subject IHS and Tribal health facilities, especially UIOs, to government shutdowns, automatic sequestration cuts, and continuing resolutions.

NCUIH also worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations in support of increasing the urban Indian health line item for FY 2023. The letter had bipartisan support and called for the highest possible funding for Urban Indian Health up to the TBFWG’s recommendation of $949.9 million and advanced appropriations for IHS until such time that authorizers move IHS to mandatory spending.

Senate Bill Highlights

Indian Health Service: $7.38 billion
  • Bill Report: “For fiscal year 2023, the Administration proposed mandatory funding for all IHS accounts, however at this time no such change has been enacted into law. Therefore, the Committee recommendation provides $7,380,063,000 for IHS for fiscal year 2023 discretionary funding, an increase of $749,077,000 to the enacted level and a decrease of $1,528,937,000 to the requested level of mandatory funding.”
Urban Indian Health: $80.424 million
  • Bill Report: “The recommendation includes $80,424,000 for the Urban Indian Health program, $7,000,000 above the enacted level and $32,089,000 below the budget request.”
  • UIO Interagency workgroup: “The Committee is committed to improving the health and wellbeing of American Indians and Alaska Natives [AI/AN] living in urban Indian communities. Despite the excellent efforts of Urban Indian Organizations, AI/AN populations continue to be left out of many Federal initiatives. Therefore, the Committee directs the Indian Health Service to continue to explore the formation of an interagency working group to identify existing Federal funding supporting Urban Indian Organizations [UIOs] and determine where increases are needed, where funding is lacking, or what programs should be amended to allow for greater access by UIOs; to develop a Federal funding strategy to build out and coordinate the infrastructure necessary to pilot and scale innovative programs that address the needs and aspirations of urban AI/ANs in a holistic manner; develop a wellness centered framework to inform health services; and meet quarterly with UIOs to address other relevant issues. 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.”
Advance Appropriations for IHS: $5.577 billion
  • Bill Report: “The Committee recommendation provides advance appropriations for the Indian Health Services and Indian Health Facilities accounts totaling $5,577,077,000 for fiscal year 2024. That amount is equal to the fiscal year 2023 recommendation for those accounts with the exception of funding provided for Electronic Health Records, Sanitation Facilities Construction, and Health Care Facilities Construction which are provided only an annual appropriation in recognition of the project-based nature of those accounts. Overall, the vast majority of Indian Health Service funding, and all such funding supporting the provision of health services to Native Americans such as patient care and medical equipment, is provided an advance appropriation. The Committee recognizes that budget uncertainty due to temporary lapses of appropriations and continuing resolutions have an effect on the orderly operations of critical healthcare programs for Native American communities. Existing challenges related to recruitment and retention of healthcare providers, administrative burden and costs, and financial effects on Tribes were identified areas of concern in a Government Accountability Office [GAO] study (GAO–18–652). This budgetary change will enable IHS to continue to provide health services without interruption or uncertainty, improving the quality of care and providing peace of mind for patients and medical providers.”
Improving Maternal Health: $9 million
  • Bill Report: “$9,000,000 has been included for the maternal health initiative, as estimated in the mandatory proposal. Pregnancy-related deaths have increased generally in the United States with pregnancy-related deaths among Native American women more than twice the non-Hispanic white women rate. The Committee continues to direct IHS to submit a report to the Committee within 180 days of enactment of this act on use of funds, updates on staff hiring, status of related standards, and the amount training provided with these funds.”
Dental Therapy Education Program: $2 million
  • Bill Report: “Within the funds provided, $2,000,000 is to be used for the dental health therapy education program that currently trains students in Alaska, Washington, Idaho, and Oregon. The Committee also directs the Service to continue the cooperative agreement with the National Indian Health Board from within existing funds.”
Dental Health: $260.326 million
  • Bill Report: “The recommendation includes $260,326,000 for dental health, an increase of $24,538,000 above the enacted level. The Service is encouraged to coordinate with the Bureau of Indian Education [BIE] to integrate preventive dental care at schools within the BIE system.”
Electronic Health Records: $190 million
  • Bill Report: “The Committee is aware there is a need for a new electronic health record system to improve the overall interoperability, efficiency, and security of the Service’s information technology system and provides $190,000,000 for this effort. Further, the Committee understands many Tribes recently upgraded computer systems for the new Department of Veterans Affairs [VA] system, and it is important these systems are compatible. It is the Committee’s expectation that the Service will be able to use the compiled information gathered during this recent effort with VA to inform both the Service and the Committee on which Tribes use their own system and the estimated costs. Finally, the Committee notes that the Electronic Health Records is excluded from the advance appropriation for fiscal year 2024 as specified in the bill.”
Produce Prescription Pilot Program
  • Bill Report: “The recommendation maintains fiscal year 2022 funding to implement a produce prescription program to increase access to produce and other traditional foods in accordance with the explanatory statement accompanying the Consolidated Appropriations Act, 2022, Public Law 117–103.”
Mental Health: $127 million
  • Bill Report: “The recommendation includes $127,088,000 for mental health programs, an increase of $5,142,000 above the enacted level. The bill maintains $6,946,000 for the behavioral health integration initiative to better integrate treatment programs for mental health and substance abuse problems and $3,600,000 for the suicide prevention initiative.”
Alcohol and Substance Abuse: $270.49 million
  • Bill Report: “The recommendation includes $270,490,000 for alcohol and substance abuse programs, an increase of $12,147,000 above the enacted level.”
Opioid Grants: $13 million
  • Bill Report: “To better combat the opioid epidemic, the recommendation includes $13,000,000 to continue a Special Behavioral Health Pilot Program, as authorized by Public Law 116–6. The Director of IHS, in coordination with the Assistant Secretary for Mental Health and Substance Abuse, shall award grants for providing services, provide technical assistance to grantees under this section, and evaluate performance of the program.”
Community Health Representatives: $67 million; CHAP Expansion: $5 million
  • Bill Report: “The recommendation includes $67,000,000 for the community health representatives program, an increase of $3,321,000 above the enacted level. The Committee recommendation includes $5,000,000 for the Community Health Aide Program [CHAP] expansion with instruction that this expansion should not divert funding from the existing CHAP program which shall continue at current levels.”
Headache Centers of Excellence
  • Bill Report: “The Committee recognizes that over 560,000 people under IHS care are living with migraine or severe headache disorders and that American Indian and Alaskan Native [AI/AN] communities have the highest prevalence of both disabling headache disorders and concussion/mild traumatic brain injuries among any racial or ethnic group in the United States. The Committee is concerned that AI/AN patients with these and other disabling headache disorders often do not receive necessary specialty care. There are currently no IHS-affiliated physicians certified with training in the specialty field of Headache, and there is an insufficient number of IHS neurologists overall. The Committee encourages IHS to consider the feasibility of establishing Headache Centers of Excellence in future fiscal years.”

HHS to hold Tribal Consultation on Proposed Rule to Strengthen Nondiscrimination in Health Care

/0 Comments/in /by

On July 25, 2022, the Department of Health and Human Services (HHS) announced a proposed rule to implement Section 1557 of the Affordable Care Act. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, and disability in certain health programs and activities. The proposed rule strengthens and restores civil rights protections for patients, beneficiaries, and consumers in certain federally funded health programs and other HHS programs.

The rulemaking affirms protections against discrimination on the basis of sex, inclusive of sexual orientation and gender identity, consistent with the US Supreme Court holding in Bostock v Clayton County. The rulemaking also reinforces protections against discrimination in seeking reproductive health care services.

A Tribal Consultation on the proposed rule will be held on August 31 at 2:00 pm EDT. Click here to register in advance. Public comment in response to the proposed rule is due September 23, 60 days after the notice.

Background

Under the Trump Administration, HHS issued final regulations on the implementation of Section 1557 in early June of 2020, which narrowed the scope of the rule by:

  • Eradicating prohibition on discrimination based on gender identity and sex-stereotyping
  • Embracing blanket religious freedom and abortion exemptions for health care providers
  • Removing the provision preventing health insurers from varying benefits that discriminate against certain marginalized groups of individuals
  • Lessening protections for individuals with limited English proficiency
  • Eliminating prohibitions against discrimination based on gender identity and sexual orientation in ten other federal health care regulations.

On June 15, 2020, the US Supreme Court published its decision on Bostock v. Clayton County. Under this ruling, sex discrimination includes discrimination based on sexual orientation and gender identity. While the case is specific to an employment context, it has since been used in support of nondiscrimination efforts that include sexual orientation and gender identity. Given the ruling in this case, a number of federal courts issued nationwide preliminary injunctions to block parts of the 2020 Final rule.

The Section 1557 rule was first issued under the Obama Administration in 2016.

Call to Action

Section 1557 Notice of Proposed Rulemaking (NPRM) seeks to address gaps identified in prior regulations. In order to advance protections under this rule it:

  • Reinstates the scope of Section 1557 to cover HHS’ health programs and activities.
  • Clarifies the application of Section 1557 nondiscrimination requirements to health insurance issuers that receive federal financial assistance.
  • Aligns regulatory requirements with Federal court opinions to prohibit discrimination on the basis of sex including sexual orientation and gender identity.
  • Makes clear that discrimination on the basis of sex includes discrimination on the basis of pregnancy or related conditions, including “pregnancy termination.”
  • Ensures requirements to prevent and combat discrimination are operationalized by entities receiving federal funding by requiring civil rights policies and procedures.
  • Requires entities to give staff training on the provision of language assistance services for individuals with limited English proficiency (LEP), and effective communication and reasonable modifications to policies and procedures for people with disabilities.
  • Requires covered entities to provide a notice of nondiscrimination along with a notice of the availability of language assistance services and auxiliary aids and services.
  • Explicitly prohibits discrimination in the use of clinical algorithms to support decision-making in covered health programs and activities.
  • Clarifies that nondiscrimination requirements applicable to health programs and activities include those services offered via telehealth, which must be accessible to LEP individuals and individuals with disabilities.
  • Interprets Medicare Part B as federal financial assistance.
  • Refines and strengthens the process for raising conscience and religious freedom objections.

American Indians/Alaska Natives (AI/ANs) are historically marginalized and underserved when it comes to healthcare. The Section 1557 notice of proposed rulemaking finds that: AI/ANs under 65 have an uninsured rate of 28 percent, higher than any other racial or ethnic group; AI/ANs received worse care than white individuals in the areas of patient safety, person-centered care, care coordination, the effectiveness of care, healthy living, and affordable care for 40 percent of 108 quality measures; more research is needed to determine the root causes of maternal mortality among AI/AN women, but a recent study suggests that provider-related factors, including implicit bias, must be addressed to reduce AI/AN maternal mortality; and there is uneven representation in minority populations, including AI/ANs, in Alzheimer’s research and clinical trials.

HHS encourages all stakeholders, including patients and their families, health insurance issuers, health care providers, health care professional associations, consumer advocates, and government entities, to submit comments through regulations.gov.

NCUIH will continue to closely monitor the proposed rule and related issues, concerns, and comments.

CDC Endorses Fourth COVID-19 Vaccine for Adults

/0 Comments/in /by

On Tuesday, July 19, 2022, the Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky, MD, MPH, endorsed the CDC Advisory Committee on Immunization Practices’ recommendation for Novavax’s COVID-19 vaccine as another primary series option for adults 18 and older. Novavax’s vaccine, Adjuvanted, was granted an emergency use authorization on July 13, 2022, by the US Food and Drug Administration.

The Novavax vaccine, Adjuvanted, is another two-dose vaccine that will be available to administer to adults 18 and older in the coming weeks. The Novavax vaccine is administered three weeks apart and uses a more traditional technology for vaccine delivery. In total, there are now four different COVID-19 vaccines for adults 18 and older to choose from; Moderna, Pfizer, Johnson & Johnson, and Novavax.

Background

American Indians and Alaska Natives (AI/ANs) have been disproportionately affected by the COVID-19 pandemic. At the height of the pandemic, 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 due to du COIVD-19.

Indian Country has had highly successful vaccine rollouts and Urban Indian Organizations have been instrumental in the success of vaccinating AI/AN populations in urban Areas. As of July 2022, AI/ANs have the highest vaccination administration rates in the US with 73% of AI/ANs having received at least one dose of one of the three previously available COVID-19 vaccines, per CDC data.

Urban Indian Leaders Encouraged to Apply for New Environment Protection Agency Advisory Committee on Children’s Health

/0 Comments/in /by

On July 7, 2022, the Environment Protection Agency (EPA) announced a  request for applications to fill vacant seats on the Children’s Health Protection Advisory Committee (CHPAC).  Appointed members of the CHPAC serve a three-year term and the expected workload is approximately 10-15 hours per month. The CHPAC provides policy advice and recommendations to EPA on issues associated with regulations, economics, and outreach/communications to address the prevention of adverse health effects to children, as well as critical policy and technical issues relating to children’s health. The CHPAC meets two to three times annually and the EPA reimburses members for travel and other incidental expenses. As both health care providers and non-governmental organizations, leaders from Urban Indian Organizations (UIOs) are eligible to apply for an appointment to the Committee. Nominations should be submitted by August 15, 2022, to EPA_CHPAC@icfi.com and Nguyen.Amelia@epa.gov. For details on what is required in the nomination package, see here. The EPA intends to fill vacancies on CHPAC by March 1, 2023.

CHPAC Objectives and Scope

Chartered under the Federal Advisory Committee Act (FACA), CHPAC was established in 1997 to provide independent advice to the EPA Administrator on a wide range of environmental issues and their impact on children’s health. According to the CHPAC Charter, the CHPAC  is composed of approximately 24-30 members who provide policy advice, information, and recommendations to assist EPA in the development of regulations, guidance, and policies to address children’s environmental health. Committee members generally serve as Representatives of non-Federal interests. The CHPAC  is looking for candidates from industry; Federal, State, local, and Tribal governments; school systems; academia; healthcare providers; and non-governmental organizations. . In considering nominees for the CHPAC, the EPA is looking for background and experience that will contribute to the diversity of perspectives on the committee.

Call to Action

NCUIH encourages interested UIO leaders to submit nomination materials to EPA by August 15, 2022. Because American Indians/Alaska Natives living in urban areas experience the kind of health complications due to environmental issues that the EPA seeks to address, UIO leaders have the experience and expertise to be valuable committee members. The EPA intends to fill vacancies on the CHPAC by March 1, 2023.

Please contact NCUIH policy at policy@ncuih.org if you would like assistance with submission or if you plan to apply.

NCUIH Submits Comments to the Indian Health Service on Improving Urban Indian Health Program Policy, Procedures, and Effectiveness

/0 Comments/in /by

On June 17, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to the Indian Health Service (IHS) about the Indian Health Program Policy  (the Policy) in the Indian Health Manual (IHM), Chapter 19, “Urban Indian Health Program.” These comments responded to the agency’s Dear Urban Indian Organization Leader letter dated April 14, 2022, initiating an Urban Confer and seeking recommendations for improving the Urban Indian Health Program policy, procedures, and effectiveness. NCUIH outlined recommendations for IHS, including improvements to the Policy’s oversight and management, improvements to the communication procedures, the addition of an appeals process for UIO annual reviews, clarification of reporting requirements, and general assistance to other federal agencies. NCUIH also requested that IHS develop additional sections about Health Information Technology (HIT) systems, data collection, and the use of federal government facilities and sources of supply.

Background

The main purpose of the Policy is to “establish policy, procedures and responsibilities for the Urban Indian Health Program,” as authorized by the Snyder Act. The government and UIOs use guidance from the Policy “to ensure access to high-quality and safe health care services for Urban Indians; to support health promotion and disease prevention programs targeted to urban populations; and to assess program performance to evaluate whether Urban Indian community needs are met.” In its comment, NCUIH noted that IHS has not updated the Policy since 1994. In the intervening 28 years, UIOs have undergone tremendous growth and change, including rapid adjustments in the last two years in response to the COVID-19 pandemic. The recommendations below, which come directly from UIOs’ experience with the Policy, will inform IHS on necessary areas of improvement.

NCUIH supports a collaborative process in which UIOs and IHS engage in open dialogue concerning the Policy to create a comprehensive document. A thorough process will serve UIOs and IHS, and guide all parties in their pursuit to provide high-quality and culturally focused healthcare to AI/ANs living in urban areas.

NCUIH’s Recommendations to IHS

NCUIH recommended the following improvements and additions to the Policy:

  • Improve the Policy’s consistency concerning oversight and management
    • NCUIH shares UIOs’ concerns that the current language in the Policy needs to be strengthened, and the roles and responsibilities of the IHS and UIOs need to be more clearly defined.
    • There is also a general need to improve consistency across all levels of IHS concerning oversight and management, including disbursement of funds, communication, IT support, and more.
    • Over one year after enacting the American Rescue Plan Act, several UIOs still do not have the entirety of the funding, and the discrepancies between areas can vary greatly. Delayed funding due to the bureaucracy of a specific geographic region flies in the face of the federal trust responsibility to provide the highest level of health care to all AI/ANs regardless of residence.
    • NCUIH notes that many UIOs report strong working relationships with their Areas. As such, IHS should work with UIOs to identify best practices and distribute lessons learned across the Areas and Headquarters levels to improve the current inconsistencies UIOs are experiencing.
  • Incorporate improved communication and annual training for Area Offices
    • NCUIH requests that IHS provide language on improved communication between Area Offices and UIOs as well as annual training for Area Offices.
  • Provide more transparent communication regarding supplemental funding
    • NCUIH requests that IHS modify Section 3-19.3 G – H and Section 3-19.4 “Grants Programs” to clarify the processes and procedures for supplemental funding.
    • NCUIH also suggests that OUIHP develop one-pagers associated with each round of funding and its allowability for UIOs to utilize as they create Scopes of Work and update their contracts.
    • For future health emergencies, NCUIH recommends that IHS establish a plan to communicate funding changes to UIOs through webinars and resources to avoid dissemination of conflicting information.
  • Include an appeals process for UIO Annual Reviews
    • NCUIH recommends that IHS include an Appeals Process for UIOs in Section 3-19.3 (F) “Program Evaluation and Review” to give UIOs recourse for program evaluations, opportunities to report UIO noncompliance or satisfactory performance, and a platform to voice their concerns.
  • Clarify and update reporting requirements
    • NCUIH requests that Section 3-19.5 “Reports” be modified to further clarify what requirements are needed for UIOs to report.
  • Provide general assistance to other federal agencies
    • As NCUIH works with other federal agencies to encourage them to implement Urban Confer mechanisms, we request that IHS similarly support these efforts to the maximum extent practicable.

In addition to the preceding recommendations regarding the current Policy, NCUIH also requested that IHS develop additional sections, including:

  • Health Information Technology (HIT) Systems
    • NCUIH requests the updated Policy also include a section on Health Information Technology (HIT) systems and the IHS modernization process.
  • Data Collection
    • UIOs have noted that the current Policy does not address data collection and request that this be included as a stand-alone section. Additionally, NCUIH asks that any section on data clearly outline how IHS will use the data and if there would be additional reporting requirements from UIOs.
  • Use of Federal Government Facilities and Sources of Supply
    • The Policy should clarify how provisions related to utilization and acquisition of government facilities are carried out, the proper process for UIOs to request these resources, and IHS’ role in transferring any requested property.

NCUIH will continue to closely follow updates to the Policy and assess program performance to evaluate whether urban Indian community needs are met.

Challenge to Indian Child Welfare Act Advances at Supreme Court

/0 Comments/in /by

The Supreme Court is preparing to hear a constitutional challenge to the Indian Child Welfare Act (ICWA) that consolidates four petitions to review the Fifth Circuit’s April 2021 en banc decision in Brackeen v. Haaland. In this decision, the United States Court of Appeals for the Fifth Circuit upheld the overall constitutionality of ICWA. However, it overturned certain ICWA processes and provisions that concern placement preferences of Native children in Indian homes. On May 26, 2022, the Court received amicus briefs from supporters of the ICWA challengers. The challengers and their amici argue that ICWA violates several constitutional provisions including equal protection, anticommandeering, and nondelegation. The next round of amicus briefs in support of ICWA and Tribal intervenors are due by August 12, 2022, and oral arguments are expected to begin after the Supreme Court term starts in October.

Background

ICWA represents the gold standard in child welfare proceedings, strengthening and preserving American Indian and Alaska Native (AI/AN) family structure and culture. When it was established in 1978, studies showed that between 25% and 35% of all Native children were removed from their homes by state child welfare and private adoption agencies. Of those, 85% were placed with non-Native families, even when fit and willing relatives were available. ICWA re-established tribal authority to safeguard against such practices by requiring that Native children be placed with extended family members, other tribal members, or other Native families prior to placement in non-Indian homes.

Today, Native children continue to be overrepresented in state foster care systems at a rate 2.7 times higher than their non-Native peers. Because more than 70% of AI/AN people live in urban settings, this overrepresentation undoubtedly has an impact in urban AI/AN communities. According to the Indian Health Service (IHS), Native youth living off-reservation often face a higher risk of health problems, including mental health and substance abuse, suicide, gang activity, teen pregnancy, abuse, and neglect. Additionally, IHS found that urban Indian populations experience the same health problems as the general Indian population, but these problems are exacerbated by a lack of access to family and traditional cultural environments.  Challenges to ICWA threaten to place urban Native youth at even greater risk if they enter foster or adoption systems that do not offer protections to keep them from being further removed from their communities and culture.

NCUIH previously provided an in-depth analysis on the impact of ICWA. We will continue to monitor ongoing developments as Brackeen v. Haaland proceeds to oral argument, and to provide updates on how the case impacts urban Indian communities.