President Announces Interagency Initiative to Address Homelessness for Urban Native Veterans

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VA, HHS, HUD, through the White House Committee on Native American Affairs, to increase access to care and services for Native veterans experiencing or at risk of homelessness in urban areas.

Last week, President Biden convened the White House Tribal Nations Summit where he released the Tribal Nations Summit Progress Report, which outlined a new initiative aimed to assist Native veterans experiencing or at risk of homelessness. During the White House Tribal Nations Summit on December 1, 2022, the Department of Veterans Affairs (VA) Secretary McDonough announced that the VA, in partnership with the Departments of Health and Human Services (HHS), Housing and Urban Development (HUD), and the White House Committee on Native American Affairs are launching an interagency initiative to increase access to care and services for American Indian and Alaska Native (AI/AN) veterans experiencing or at risk of homeless in urban areas. According to Secretary McDonough, “the initiative will involve enhanced partnerships with 41 urban Indian organizations and will focus on intake and referral services to ensure that Native veterans are aware of and have access to resources already set aside for them.”

“I am encouraged by the VA’s commitment to improving the health and well-being of Native veterans, including those of us living in urban areas. Natives serve in the military at a higher rate than any other population in the U.S., but we experience some of the largest health disparities when we complete our service. As we all know, housing is a key social determinant of health, and homelessness in our community is a contributing factor to the health inequities Native veterans face. I look forward to being involved in the partnership between urban Indian organizations and the VA, HHS, HUD, and White House Council on Native American Affairs to bring housing resources to urban Native veterans.”– Sonya Tetnowski (Makah), CEO, Indian Health Center of Santa Clara Valley and NCUIH President.

Background

Native Veteran Disparities 

Native veterans have served in the United States military in every armed conflict in the Nation’s history and have traditionally served at a higher rate than any other population in the United States. Unfortunately, Native veterans suffer significant disparities when they transition to civilian life. For example, Native veterans are more likely to be uninsured and have a service-connected disability than other veterans. Native veterans suffer these disparities no matter where they live. Native veterans living in urban areas experience the same poor physical and mental health outcomes as Native veterans in rural areas. In addition, urban Native veterans generally have lower incomes, higher unemployment, lower education attainment, higher VA-service connected disability, and generally live in poorer housing conditions than non-Native urban veterans.

This initiative is critical given that the National Council of Urban Indian Health (NCUIH) estimates that there are about 8 Native veterans experiencing homelessness per 1000 veterans, compared to about 1.5 white veterans per 1000 veterans. Urban Native veterans are greatly impacted by this, as NCUIH estimates that 86.2% of the veteran population identifying as Native lives in urban areas.  Homelessness is a key Social Determinant of Health (SDOH) and a lack of stable housing can lead to an increased risk of premature death, preterm delivery, exposure to disease vectors like vermin, and other negative health impacts.  Without consistent access to stable housing for all of our Native veterans, who have answered the call to make the ultimate sacrifice on behalf of this Nation, they will remain at risk of the health disparities associated with unstable housing.

Urban Indian Organizations Provide Critical Housing Support 

UIOs are essential partners in serving AI/AN veterans and are vital to this initiative to improve 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 the following areas: Phoenix, Arizona; Los Angeles, California; Seattle, Washington; Dallas, Texas; Oklahoma City, Oklahoma; New York City, New York; and Chicago, Illinois.  Due to the cultural competency of the health care available at UIOs, many Native veterans prefer to receive their health care from a UIO provider, as well as at IHS and Tribal facilities, over a VHA facility.

UIOs are uniquely positioned to assist agencies, such as the VA, HHS, and HUD, in improving housing access for AI/AN people. Some UIOs already provide housing services and all UIOs provide numerous other social and community services to AI/ANs living in urban areas. As such, the partnership with UIOs announced in this initiative has the potential to improve the quality of care and well-being to Native veterans in urban areas, but it is also consistent with the United States’ trust responsibility to provide services and resources to improve the health of all AI/ANs.

Sonya Tetnowski, Chair of Veterans Health Administration Subcommittee within the VA Advisory Committee on Tribal and Indian Affairs Committee, Army veteran, NCUIH President, and CEO of the Indian Health Center for Santa Clara Valley, highlighted the importance of looking at the whole person and making sure that their needs are being met during a Committee meeting in January. She also brought forth potential subcommittees, including unhoused urban Veterans, Native Healer utilization, and Behavioral Health and Substance Use. On August 17, 2022, the Committee held a meeting where Ms. Tetnowski presented five priority areas, including homelessness and housing as a priority.

NCUIH and the VA 

NCUIH continues to advocate on behalf of AI/AN veterans living in urban areas and to strengthen its partnership with VA. Thanks to NCUIH’s work with the VA, UIOs are now eligible to enter the VA IHS/THP/UIO Reimbursement Agreements Program, which provides VA reimbursement to IHS, THP, and UIO health facilities for services provided to eligible AI/AN Veterans. NCUIH also played a critical role in getting the legislation that established the VA Advisory Committee on Tribal and Indian Affairs passed in 2020 and nominated Ms. Tetnowski to be a representative on the Committee.

NCUIH has highlighted in several written comments to the VA and in meetings with agency representatives, the need for the VA to address and provide services to Native veterans living in urban areas. VA data currently indicates that Native veterans use VA benefits or services at a lower percentage than other veterans. To address these disparities, NCUIH has provided the VA with several recommendations and administrative guidance on how to improve Native veteran health through collaboration with the VA. In the last year alone, NCUIH has raised various issues such as the lack of VA services provided to Native veterans who reside in urban areas as well as the lack of culturally competent VA health care providers in these areas. In July, NCUIH wrote to comments to the VA urging the agency to improve the medical workforce at UIOs through the Pilot Program on Graduate Medical Education and Residency (PPGMER). Moreover, NCUIH recently provided comments and recommendations for the VHA and IHS in collaboration to improve their outreach and services to urban Native veterans.

In addition to working with the VA, NCUIH submitted comments to HUD, encouraging the agency to incorporate urban Natives in its FY22-26 Strategic Plan and focus areas. HUD provides housing resources and funding for Tribes, but these resources are very limited when it comes to urban AI/ANs, or not applicable at all. These efforts have emphasized the critical importance of working with UIOs to reach and serve the significant portion of Native veterans living in urban areas.

Senator Warren and Representative Kilmer Introduce NCUIH-Endorsed Bill to Honor Promises to Native People with Key Provisions for Urban Indian Health

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On December 5, 2022, Senator Elizabeth Warren (D-MA) and Representative Derek Kilmer (D-WA-6) introduced the Honoring Promises to Native Nations Act, which will address the underfunding and barriers to sovereignty in Indian Country acknowledged in the 2018 U.S. Commission on Civil Rights report, Broken Promises: Continuing Federal Funding Shortfall for Native Americans. The legislation reaffirms the federal government’s trust obligation to all American Indians and Alaska Natives (AI/ANs) to strengthen federal programs and support Native Communities. This legislation guarantees mandatory, full, and inflation-adjusted funding that can support healthcare, education, housing, and economic development and is cosponsored by national Indian organizations such as the National Council of Urban Indian Health (NCUIH), the National Congress of American Indians, and the National Indian Health Board.

NCUIH worked closely with Senator Warren’s office on this landmark policy platform, which includes permanent 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs) and modifying an existing policy to allow the Secretary of the Department of Health and Human Services (HHS) to better communicate on issues affecting urban Indian health. Additionally, the legislation includes mandatory-adjusted funding for the Indian Health Service (IHS), advance appropriations for IHS, increased long-term funding for Special Diabetes Programs for Indians (SDPI) to $300 million through fiscal year (FY) 2032 (currently expiring in FY 2023 and only funded at $150 million annually), and exempting Indian programs from sequestration.

“For generations, the U.S. government has clearly failed to fulfill its commitments to Tribal Nations. This bill is sweeping in ambition to make good on those commitments and empower Native communities, and it provides a much-needed legislative blueprint to deliver significant, long-term funding for the advancement of Native Americans. I won’t stop fighting to ensure the U.S. government honors its promises,” said Senator Warren. 

 “Congress and the federal government have a moral and a legal obligation to fulfill the promises made to Indian Country. That’s why I’m proud to introduce this legislation with Senator Warren to help reverse the decades-long pattern of systemic funding shortfalls to Native communities and to strengthen federal programs that support Indian Country. Congress should move swiftly to get this legislation enacted. It is long overdue.” said Representative Kilmer. “

 “The health of our people has suffered due to the failure of the government to uphold the trust responsibility of providing health care to all American Indians and Alaska Natives. It is time that we address the needs of Indian Country and enact the recommendations included in the 2018 Broken Promises report, including improving health care for all Native people. The National Council of Urban Indian Health is grateful for the inclusion of Urban Indians in this legislation, especially regarding permanent 100% FMAP for urban Indian organizations and Urban Confer within HHS, both of which have been top priorities for NCUIH. We fully support this bill and believe that this Act is fundamental in honoring the federal government’s trust responsibility to American Indian and Alaska Natives,” – Francys Crevier (Algonquin), CEO, NCUIH.

 “On behalf of the nearly 1/4 UIOs in California, CCUIH endorses the Honoring Promises to Native Nations Act because it will increase health access for American Indians no matter where they live.  California is home to the largest population of American Indians, with more than 90% living in an urban area.  Full, mandatory, inflation-adjusted funding for the Indian Health Service; funding for the Special Diabetes Programs for Native Americans; permanent FMAP for Urban Indian Health Programs; and Medicaid coverage of any services provided by Indian health care providers will offer critical funding necessary to address the continued disparities in health experienced by American Indians,” – Virginia Hedrick (Yurok), Executive Director, California Consortium for Urban Indian Health, Inc.

 “The American Indian Health Service of Chicago, Inc. is pleased to endorse the Honoring Promises to Native Nations Act, as it will enable the 70% of American Indians and Alaska Natives who live in Urban Areas to continue to receive the same level of care that is received by other federally funded health programs, while slowly moving toward true health equity with the rest of the United States. With hope that Urban Programs will be able to receive an increase in the funding to be able to offer additional services (such as dental, podiatry, imaging, and women’s wellness) to the American Indian and Alaska Native Chicago based population. AIHSC also appreciates the efforts to increase the Special Diabetes Program for Indians, as our percentages of AI/AN who are diagnosed with diabetes increase,” – RoxAnne M LaVallie-Unabia (Turtle Mountain Band of Chippewa Indians), Executive Director, American Indian Health Service of Chicago.

 “South Dakota Urban Indian Health enthusiastically supports the Honoring Promises to Native Nations Act. This bill secures funding for essential health services and through the inclusion of Medicaid reimbursements for substance use disorder facilities, recognizes the urgency of addiction for our relatives. For generations, Native Americans have persevered through forced assimilation, forced removal from our ancestral lands, and broken promises from the United States government. Despite these challenges, we remain a thriving group of sovereign nations and peoples across the geographic United States. This bill is a stride toward health equity for the more than 70% of Native Americans who live in urban areas of the United States.” – Michaela Seiber (Sisseton-Wahpeton Dakota), CEO, South Dakota Urban Indian Health.

 “Native Health endorses the Honoring Promises to Native Nations Act because it will provide resources to fulfill the Federal Government’s obligation to provide health care to AI/ANs. The bill supports urban Indian organizations through 100% FMAP and SDPI reauthorization. These measures are especially needed by the underserved AI/AN urban community. In the current environment, UIOs are overwhelmed by the rising demand and the rising costs of providing health care,” – Walter Murillo (Choctaw Nation of Oklahoma), CEO, Native Health.

 “The Honoring Promises to Native Nations Act is a major step forward in recognizing the trust and treaty obligations to Tribes and American Indian and Alaska Native peoples,” – Jacqueline Mercer, CEO, Native American Rehabilitation Association of the Northwest (NARA).

 “Hunter Health endorses the Honoring Promises to Native Nations Act because it will increase access to quality healthcare services and allows Urban Indian Organizations to work with their state to expand services for Native American people living in their community,” – Rachel Mayberry, Chief Advancement Officer, Hunter Health.

 “The Indian Health Center of Santa Clara Valley is pleased to endorse Senator Warren’s Honoring Broken Promises Act. This bill addresses priorities for urban Indian organizations such as mandatory funding, 100% FMAP, increased SDPI funding, and urban confer. This bill contributes to health equity for American Indians and Alaska Natives and moves forward with the federal government’s trust and treaty responsibility by improving AI/AN health services,” – Sonya Tetnowski (Makah), CEO, Indian Health Center of Santa Clara Valley.

 “Denver Indian Health and Family Services endorses the Honoring Promises to Native Nations Act because it will allow all Urban Indian Organizations (UIOs) to leverage their services and sustain their funding despite many healthcare challenges. (i.e., the pandemic, the opioid crisis, suicide prevention, etc.). It is time the federal government met its trust and treaty obligations to Native peoples, particularly regarding federal spending. Failing to fund Indian Health Service (IHS) fully and UIOs fails to fulfill the federal government’s trust responsibilities. As recipients of less than 1% of the Indian Health Service budget, inadequate funding requires UIOs to depend on every dollar of federal funding and find creative ways to stretch limited resources. The Act will cover a wide range of issues that impact Indian Country; specifically, urban confer for HHS and the VA; 100% FMAP for UIOs; and Special Diabetes for Indians, reauthorized at $300 million for ten years,” – Adrianne Maddux (Hopi Tribe), Executive Director, Denver Indian Health and Family Services.

 “The Oklahoma City Indian Clinic (OKCIC) endorses the Honoring Promises to Native Nations Act because it will provide promised and necessary funding for Indian Health Care services.  The OKCIC is the largest Urban Indian Health Care Center in the United States, serving 22,000 patients from over 200 Tribes. Many of our patients are chronically ill and require high levels of expensive medical care.  To provide that care it is very important that Title II of the Honoring Promises to Native Nations Act, specifically a full, mandatory and inflation-adjusted funding for the Indian Health Service and permanent adequate funding for the Special Diabetes Program for Indians is not only necessary but vital to maintaining the good health of our people,” – Robyn Sunday-Allen (Cherokee), CEO, Oklahoma City Indian Clinic.

Bill Highlights for Urban Indian Organizations

Mandatory Funding and Advance Appropriations for the Indian Health Service

The Indian health system, including IHS, Tribal facilities, and UIOs, is the only major federal provider of health care that is funded through annual appropriations. If IHS were to receive mandatory funding or, at the least, advance appropriations, it would not be subject to the harmful effects of government shutdowns and continuing resolutions (CRs) as its funding for the next year would already be in place. This is needed as lapses in federal funding put lives at risk. Without funding certainty during government shutdowns can cause UIOs to reduce services, close their doors, or force them to leave their patients without adequate care.  During the last government shutdown, UIOs reported at least 5 patient deaths and significant disruptions in patient services. Securing stable funding for IHS has been a major priority for Indian Country and NCUIH has taken part in extensive advocacy to ensure the continuation and delivery of health services to all Native people regardless of where they live.

This bill authorizes $50,138,679,000 in mandatory appropriations for FY 2023, $51,416,373,000 for FY 2024, and for FY 2025 and each fiscal year thereafter, “an amount equal to the sum of the amount appropriated for the previous fiscal year, as adjusted annually to reflect the change in the medical care component of the consumer price index for all urban consumers (U.S. city average); and, as applicable, 1.8 percent of the amount appropriated for the previous fiscal year.” The bill also provides advance appropriations for IHS.

Special Diabetes Programs for Indians

The SDPI Demonstration Project includes research-based interventions for diabetes prevention and cardiovascular disease (CVD) risk reduction into AI/AN community-based programs and health care settings. The program has demonstrated success with a 50% reduction in diabetic eye disease rates, drops in diabetic kidney failure, and a 50% decline in End Stage Renal Disease. Many UIOs receive SDPI funding and the program has directly enabled UIOs to provide critical services to their AI/AN patients, in turn significantly reducing the incidence of diabetes and diabetes-related illnesses among urban Indian communities. These successes are impactful, as AI/ANs have the highest diabetes prevalence rates of all racial and ethnic groups in the United States, with AI/AN adults almost three times more likely than non-Hispanic white adults to be diagnosed with diabetes. According to the Centers for Disease Control and Prevention, 13.7% of adults in urban Native communities are diagnosed with diabetes. SDPI is a critical program to address the high rates of diabetes among AI/ANs and requires secure funding to continue its success. NCUIH has long advocated for SPDI to be fully funded. On May 16, 2022, NCUIH submitted comments and recommendations to IHS emphasizing the importance of SDPI in reducing health disparities related to diabetes for AI/AN populations. These comments included increasing SDPI funding with built-in automatic annual medical inflationary increases and that IHS ensures the SDPI remains inclusive of UIOs.

This legislation will reauthorize SDPI at $300,000,000 for each fiscal year beginning in 2023 through 2032.

Permanent 100% Federal Medical Assistance Percentage (FMAP)

FMAP refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. Permanent 100% FMAP for UIOs will further the government’s trust responsibility to AI/ANs by increasing available financial resources to UIOs and support them in addressing critical health needs of AI/AN patients. In March of 2021, Congress enacted the American Rescue Plan Act of 2021 (ARPA) which authorized eight fiscal quarters of 100% FMAP coverage for UIOs. Unfortunately, with only 3 months until the provision expires, most UIOs have not received any increase in financial support because many states have not increased their Medicaid reimbursement rates to UIOs, citing short-term authorization concerns.

There has been strong support for the expansion of 100% FMAP to UIOs across Indian Country and NCUIH has tirelessly advocated to permanently fix this parity issue. The National Congress of American Indians and the National Indian Health Board passed resolutions along with NCUIH in support of extending 100% FMAP to UIOs. Additionally, there has been longstanding bipartisan congressional support, with over 17 pieces of legislation having been introduced since 1999 on this issue. NCUIH recently sent a letter to the House Committee on Energy and Commerce leadership requesting a markup on the Improving Access to Indian Health Services Act (H.R. 1888), which would establish permanent 100% FMAP for services provided to AI/ANs Medicaid beneficiaries at UIOs.

This bill amends the Social Security Act by including UIOs as eligible entities to receive permanent 100% FMAP.

 Urban Confer with HHS and UIOs

An Urban Confer is an established mechanism for dialogue between federal agencies and UIOs. Urban confer policies are a response to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that have resulted in 70% of AI/AN people living outside of Tribal jurisdictions, thus making Urban Confer integral to addressing the care needs of a majority of AI/ANs. An urban confer policy that includes all HHS agencies, including the Centers for Medicare & Medicaid Services (CMS), ensures that obstacles relating to programs and benefits that directly affect UIOs are addressed quickly so UIOs are better equipped to provide healthcare to their patients. NCUIH has long advocated for facilitating confer between numerous federal branches within HHS and UIO stakeholders. Currently, only IHS has a legal obligation to confer with UIOs. It is important to note that urban confer policies do not supplant or otherwise impact Tribal consultation and the government-to-government relationship between Tribes and federal agencies.

This bill would require the Secretary of HHS, to the maximum extent practicable, to confer with UIOs in carrying out the health services of the Department.

 Office of Management and Budget Office of Native Nations

The bill establishes an Office of Native Nations within the Office of Management (OMB), which coordinates with the rest of OMB and the Executive branch on matters of funding for federal programs and policy affecting AI/ANs and Native Hawaiians. The Administrator, a career position, of the office is responsible for matters such as compiling data on all federal funding for federal programs affecting AI/ANs and Native Hawaiians; ensuring that the budget requests of IHS and the Bureau of Indian Affairs indicate how much funding is needed for programs affecting AI/ANs and Native Hawaiians to be fully funded and how far the federal government is from achieving that full funding; and preparing a crosscutting document each fiscal year containing detailed information, based on data from all federal agencies, on the amount of federal funding that is reaching Indian Tribes, tribal organizations, Native Hawaiian organizations, and UIOs. The bill directs the Administrator to consult with Indian Tribes, collaborate with Native Hawaiian organizations, and confer with UIOs annually to ascertain how the crosscutting document can be modified to make it more useful to Indian Tribes, Native Hawaiian organizations, and UIOs.

On September 12, 2022, after recommendations from NCUIH and Tribal leaders, the Biden administration created a position of a Tribal Policy Advisor within OMB to communicate the needs of Indian Country and AI/ANs. This position was an important first step in ensuring that Native voices are heard during the budget process, and we are grateful that this bill works to further consider the needs of Native programs in federal funding.

Next Steps

Senator Warren and Congressman Kilmer invite comments and feedback on how to refine and improve the legislation in the next Congress. Written input can be submitted at HonoringPromises@warren.senate.gov.

Background

Broken Promises

On December 20, 2018, the Broken Promises report was released and addressed areas where the federal government has failed to fulfill its trust responsibility, including criminal justice and public safety, health care, education, housing, and economic development. Specifically, the report requests advance appropriations for the IHS and funding to implement the Indian Health Care Improvement Act, including job training programs to address chronic shortages of health professionals in Indian Country and a mental health technician training program to address the suicide crisis in Indian Country. The report also recommends direct, long-term funding to Tribes, analogous to the mandatory funding Congress provides to support Medicare, Social Security, and Medicaid, avoiding pass-through of funds via states.

The proposal for this bill was first introduced in August 2019 by Congresswoman Deb Haaland (D- N.M.) and Senator Warren. Lawmakers then took feedback from tribal governments and citizens, tribal organizations, UIOs, experts, and other stakeholders which informed the development of this current legislation.

Partnership for Medicaid Advocates for Key Urban Indian Health Priority in Omnibus Request

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On October 28, 2022, the Partnership for Medicaid (Partnership) sent a letter to House and Senate leadership urging that several Medicaid policy proposals be prioritized as Congress considers an end-of-year health care package. In the letter, they requested that Congress seek to include legislation that would extend 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs) and Native Hawaiian Health Systems for another two years. After advocacy from the National Council for Urban Indian Health (NCUIH), the American Rescue Plan Act (ARPA) authorized 8 fiscal quarters of 100% FMAP to UIOs, which is set to expire in just 3 months.

Full Letter Text

Dear Leader Schumer, Speaker Pelosi, Minority Leader McConnell, and Minority Leader McCarthy:

On behalf of the Partnership for Medicaid (Partnership), thank you for your continued commitment to the Medicaid program. Our member organizations are eager to collaborate with you to build upon efforts to sustain and strengthen Medicaid.

The Partnership – a nonpartisan, nationwide coalition made up of organizations representing clinicians, health care providers, safety net plans, and counties –appreciates initiatives from Congress throughout the COVID-19 pandemic to bolster the Medicaid program and support the health care safety net. Your continued attention has not only allowed the program to meet the needs of millions of Americans during a public health crisis but has also reinforced the importance of investing in Medicaid now to protect and sustain its promise for the future.

As the Congress considers an end-of-year health care package, the Partnership urges lawmakers to prioritize policy proposals to strengthen Medicaid and ensure its stability for underrepresented populations who rely on this critical program. Congress should seek to include legislation that would:

  • building on provisions included in the FY 2022 Continuing Resolution, create a permanent and sustainable Medicaid financing solution for Puerto Rico and other territories;
  • permanently ensure that all pregnant individuals on Medicaid and the Children’s Health Insurance Program (CHIP) keep their health coverage during the critical first year postpartum;
  • provide one year of continuous eligibility for children covered by Medicaid and CHIP;
  • appropriately fund the Medicaid program in a manner that supports states to set competitive rates necessary for garnering equitable access for Medicaid, as undervaluing Medicaid payments—and consequently, the patients Medicaid serves—perpetuates systemic barriers to health and health care and worsens health disparities;
  • invest in and improve access to Medicaid home-and community-based services (HCBS) and mental health services, including for children, while strengthening the direct care workforce;
  • provide Medicaid coverage to eligible, justice-involved individuals 30 days prior to release;
  • extend the 100 percent federal medical assistance percentage (FMAP) for Urban Indian Organizations and Native Hawaiian Health Systems for another two years;
  • make permanent Medicaid’s Money Follows the Person program and the Protection Against Spousal Impoverishment.
  • permanently fund CHIP; and
  • close the Medicaid coverage gap for Americans living in states that have yet to expand Medicaid and still lack access to health insurance

Taken together, these proposed improvements to Medicaid and CHIP represent an opportunity to stabilize and expand access to health care and long-term services and supports for millions of low-income Americans, from older adults, people with disabilities, children, pregnant and postpartum individuals, and their families, and more.

Furthermore, for Medicaid issues legislatively tied to the public health emergency, we urge Congress to proceed with caution when applying imminent, static sunsets to policies stakeholders rely upon to help mitigate COVID-19’s ongoing impact. For example, Congress should create a predictable, evidence-informed wind down of the enhanced FMAP and continuous coverage provisions included in the Families First Coronavirus Response Act that provides sufficient guardrails to protect beneficiaries while also reflecting the trajectory of the COVID-19 pandemic.

We remain grateful for your leadership and commitment to the Medicaid program and the populations it serves. If you have questions or seek any additional information, please contact Jonathan Westin at the Jewish Federations of North America, First Co-Chair of the Partnership for Medicaid at Jonathan.Westin@jewishfederations.org.

Sincerely,

America’s Essential Hospitals
American College of Obstetricians and Gynecologists
American Dental Education
Association American Network of Community Options and Resources (ANCOR)
Associations of Clinicians for the Underserved
Catholic Health Association of the United States
Children’s Hospital Association
Easterseals
Jewish Federations of North America
National Association of Counties
National Association of Pediatric Nurse Practitioners
National Association of Rural Health Clinics (NARHC)
National Council for Mental Wellbeing
National Council of Urban Indian Health
National Health Care for the Homeless Council
National Rural Health Association

About the Partnership for Medicaid

NCUIH is a member of the Partnership for Medicaid, which is a nonpartisan, nationwide coalition of organizations representing clinicians, health care providers, safety-net health plans, and counties. The goal of the coalition is to preserve and improve the Medicaid program. Members of this coalition include:

Background and NCUIH Advocacy on Medicaid

100% FMAP for UIOs

FMAP refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. Permanent authorization or an extension of the 100% FMAP for UIOs provision will further the government’s trust responsibility to American Indians/Alaska Natives (AI/ANs) by increasing available financial resources to UIOs and support them in addressing critical health needs of AI/AN patients. In March of 2021, Congress enacted ARPA which authorized eight fiscal quarters of 100% FMAP coverage for UIOs. Congress did this in part to increase the financial resources available to UIOs and support the provision of critically needed health services to urban AI/ANs during the COVID-19 pandemic. Unfortunately, with only 3 months until the provision expires, most UIOs have not received any increase in financial support because many states have not increased their Medicaid reimbursement rates to UIOs, citing short-term authorization concerns.

There has been strong support for the expansion of 100% FMAP to UIOs across Indian Country and NCUIH has tirelessly advocated to permanently fix this parity issue. The National Congress of American Indians and the National Indian Health Board passed resolutions along with NCUIH in support of extending 100% FMAP to UIOs. Additionally, there has been longstanding bipartisan congressional support, with over 17 pieces of legislation having been introduced since 1999 on this issue. NCUIH recently sent a letter to the House Committee on Energy and Commerce leadership requesting a markup on the Improving Access to Indian Health Services Act (H.R. 1888), which would establish permanent 100% FMAP for services provided to AI/ANs Medicaid beneficiaries at UIOs.

NCUIH and Partnership for Medicaid Priority: Medicaid Unwinding

After the COVID-19 Public Health Emergency (PHE), states will resume normal operations, which includes processing eligibility renewals and ending coverage for individuals no longer eligible for Medicaid and Children’s Health Insurance Program (CHIP) in a process known as “unwinding.” The Partnership for Medicaid advocates for protections against the potential loss of coverage for millions of Medicaid beneficiaries at the end of the PHE. NCUIH recently released a Medicaid unwinding toolkit for UIOs as they prepare for changes in Medicaid coverage. This document outlines the impact of Medicaid unwinding on AI/ANs and the steps UIOs can take to assist their patients with their coverage, such as working with their state, Tribes, federal agencies, and their community.

RESOURCE: COVID-19 Public Health Emergency Medicaid Unwinding Toolkit Released

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The National Council of Urban Indian Health (NCUIH) recently released a Medicaid unwinding toolkit for urban Indian organizations (UIOs) as they prepare for changes in Medicaid coverage at the end of the COVID-19 pandemic Public Health Emergency (PHE). After the PHE, states will resume normal operations, which includes processing eligibility renewals and ending coverage for individuals no longer eligible for Medicaid and CHIP in a process known as “unwinding.” This document outlines the impact of Medicaid unwinding on American Indians/Alaska Natives (AI/ANs) and the steps UIOs can take to assist their patients with their coverage, such as working with their state, Tribes, federal agencies, and their community.

View the resource

Background

Medicaid Unwinding Toolkit

Prior to the pandemic’s PHE, Medicaid provided health insurance for more than one-third of AI/AN adults.  At the beginning of the pandemic, the Families First Coronavirus Response Act (FFCRA) Medicaid and Children’s Health Insurance Program (CHIP) “continuous coverage” requirement  allowed people to retain Medicaid coverage and receive needed care during the PHE.

Medicaid Unwinding Toolkit

After the PHE, states will resume normal operations, which includes processing eligibility renewals and ending coverage for individuals no longer eligible for Medicaid and CHIP in a process known as “unwinding.” According to the Department of Health and Human Services (HHS), nearly 15 million people could lose their current coverage. This will be the single largest health coverage transition event since the first open enrollment period of the Affordable Care Act (ACA). This process is expected to disproportionately impact AI/ANs, particularly those living off-reservation.

While the unwinding process will vary by state, each state will have up to 12 months to start an eligibility renewal for every individual enrolled in their entire Medicaid and CHIP population. The unwinding process will create several challenges and will result in a loss or gaps in coverage for individuals.

Impact on AI/AN Communities

Medicaid Unwinding Toolkit

AI/ANs may be at an increased risk of disenrollment in Medicaid and CHIP programs once the PHE ends. Medicaid coverage losses are estimated to take twice the toll on AI/AN communities than they will take among non-Hispanic white families. Disenrollment of AI/ANs from Medicaid and CHIP will have significant consequences for the health and well-being of Native people – these programs are critical to fulfilling the United States’ trust responsibility to maintain and improve AI/AN health. Inadequate health insurance coverage is a significant barrier to healthcare access and often causes patients to delay or avoid medical care altogether. Alarmingly, when the PHE expires, 12% of all AI/AN children and 6% of all AI/AN adults nationwide are expected to lose CHIP or Medicaid coverage.

Medicaid Unwinding Toolkit

Medicaid-eligible AI/ANs face challenges in enrolling coverage due geographical remoteness, limited access to internet or phone service, language barriers, cultural factors, distrust of government programs, lack of knowledge of the benefits of coverage, or movement between non-reservation and reservation land.

Medicaid Unwinding and UIOs

UIOs play an important role in enrolling AI/ANs in Medicaid and CHIP as well as treating Medicaid beneficiaries, and will therefore, be critical in informing and helping eligible AI/AN maintain enrollment if eligible or explore other options. NCUIH’s resource highlights ways in which UIOs can work with states and other partners including Tribes and Tribal organizations, federal agencies like CMS and Indian Health Service (IHS), and their local communities:

Work with Your State

  • Request a meeting your state regarding unwinding.
  • Request that your state share renewal data via a spreadsheet or database so that you can speak with beneficiaries who utilize your services.
  • Work with your state to develop targeted communication for AI/AN communities about the state’s unwinding activities.
    • States can leverage Unwinding Communications Toolkit materials published by the Centers for Medicare & Medicaid Services (CMS).
    • Ask your state to provide AI/AN-specific guidance on maintaining coverage through Affordable Care Act (ACA) Marketplace plans for those no longer eligible for Medicaid. AI/AN beneficiaries may have access to low-cost zero and limited cost-sharing plans on the Exchanges.
  • Advocate that your state apply for Section 1902(e)(14)(a) waivers if necessary and applicable.

Work with Tribes

  • Collaborate with Tribes to request a meeting with your state regarding unwinding.
  • Develop partnerships with Tribes to provide necessary information to AI/AN beneficiaries.

Work with CMS, Indian Health Service (IHS), and Partner Organizations

  • Request consultation and confer with CMS and IHS to discuss coverage loss concerns and oversight.
  • Culturally appropriate materials are available through CMS, IHS, and the National Indian Health Board.

Work with Your Community

  • Work with beneficiaries to ensure that their contact information is updated with the state Medicaid office, including addresses, emails, and phone numbers, to ensure that individuals receive information on renewals.
  • Screen for potential Medicaid eligibility for all patients and refer current Medicaid recipients to your benefit specialists to update applications.
  • Engage community partners, health plans, and the provider community to encourage individuals to update their contact information and to provide assistance with renewals.
  • Educate patients, including utilizing outreach and educational materials in your clinic waiting rooms, patient rooms, and patient registration/in-take desks, regarding the unwinding and the risk of a loss in coverage.

CDC Seeking Nominations from Urban Indian Organizations for Project on Anti-Racism Practices and Policies

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The Centers for Disease Control and Prevention Seeks Nominations of Health Care Organizations Currently Implementing Anti-Racism Practices and Policies

The Centers for Disease Control and Prevention (CDC) Division for Heart Disease and Stroke Prevention (DHDSP) is seeking nominations of health care organizations that are currently implementing anti-racism practices and policies with the potential to reduce health disparities and improve outcomes related to heart disease, stroke, and other cardiovascular disease conditions.  In partnership with NORC at the University of Chicago (NORC), the purpose of this project is to evaluate the impact of anti-racist practices on the delivery of health care and health equity. Eligible nominees include any health care organization or system, Tribal and Urban Indian health centers, school-based health centers, and outpatient community centers currently implementing anti-racism practices. Nominations are due by December 9, 2022 and should be submitted (2 pages or less) via email to: AntiRacismEval@norc.org.

Background

CDC’s DHDSP works with partners across government, public health, health care, and private sectors to improve prevention, detection, and control of heart disease and stroke risk factors, with a focus on high blood pressure and high cholesterol. DHDSP also works to improve recognition of the signs and symptoms of a heart attack or stroke and the quality of care following these events. Through its scientific and programmatic investments, DHDSP advances strategies such as using electronic health records to identify patients at risk and treat them appropriately and caring for patients with teams of clinicians, pharmacists, community health workers, and others outside of the doctor’s office. The division also promotes strategies that link patients to community programs and resources that help them take their medicines consistently, manage their risk factors, and make healthy lifestyle changes, such as quitting smoking or losing weight.

Nomination Eligibility and Information 

Any health care organization or system, including Tribal and Urban Indian health centers, school-based health centers, and outpatient community centers, that is currently implementing an anti-racism practice at the organizational, community, interpersonal and/or individual level. The intervention:

  • Focuses on dismantling racism, advancing health equity, or reducing health disparities among racial and ethnic minorities.
  • Focuses on cardiovascular disease or other chronic diseases
  • Has not yet undergone a comprehensive evaluation and has been implemented for at least 12 months.

Interested health organizations should include the following information:

  • Name and contact information for the primary point of contact
  • Description of the patient population at the location(s) where the anti-racism practice is being implemented, including the size of patient population, the percentage of patients that identify as non-white, and other demographic and social determinants of health characteristics.
  • A description of the anti-racism practice, including:
    • The anti-racism name
    • Implementation of the anti-racism practice began
    • The location(s) where the anti-racism practice is being implemented
    • The primary goals and the activities that comprise the anti-racism practices
    • The level(s) the implementation operates (i.e. individual, interpersonal, community, etc.)
    • The involvement of community members in the development and/or implementation of the anti-racism practice
    • The health condition(s) on which the anti-racism practice focuses
  • Any monitoring or evaluation history of the anti-racism practice including outcomes currently being monitored, methods used to monitor, and/or plans to monitor outcomes in the future.
  • The types of data available to support an evaluation of the anti-racism practice, such as EHR data, payer claims, registry data, or administrative records
  • A description of staff and data systems capacity to retrieve and share quantitative data reports on the anti-racism practice delivery, patient social determinants of health, and patient clinical outcomes with NORC’s evaluation team

When the nomination is complete, CDC will select up to six sites to participate in an evaluability assessment. Based on the outcome of the assessment, CDC will select up to three sites to participate in a rapid case study evaluation to further assess the impact of the anti-racism practice on the delivery of health care, health care access, and heart disease, stroke, or chronic disease outcomes.

All nomination sites will receive a selection decision by January 2023. If selected, virtual site visits and interviews will be scheduled in February 2023.

AI/AN Cardiovascular Health

American Indian and Alaska Native (AI/AN) populations are disproportionately affected by cardiovascular disease (CVD), coronary heart disease (CHD), and overall poorer heart health. Stroke is also the sixth-leading cause of death for AI/ANs, who have the highest reported history of stroke compared with other US racial and ethnic groups.  According to the Health and Human Services Office of Minority Health report, in 2018, AI/ANs were 50 percent more likely to be diagnosed with coronary heart disease than their white counterparts.  Moreover, AI/AN adults were 10 percent more likely than white adults to have high blood pressure.  Compared to the general AI/AN population, urban AI/AN communities experience exacerbated health problems due to lack of family and traditional cultural environments in metropolitan areas. Recent studies of the urban AI/AN population have also documented poorer health status and reveal lack of adequate health care services as serious problems.

Call to Action 

Despite the disproportionate high rates of health disparities in AI/AN populations and specifically cardiovascular health, urban Indian organizations (UIOs) have continued to provide critical services aimed at addressing and combatting negative health outcomes through culturally competent care and programs. NCUIH encourages interested UIO leaders to submit nomination materials to antiracismeval@norc.org.

NCUIH Submits Comments to HRSA to Improve Access to Pediatric Health Care in Urban Native Communities

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On August 31, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments to the Health Resources and Services Administration (HRSA) on the Pediatric Mental Health Care Access (PMCHA) Program. In a July 27 Dear Tribal Leader Letter, HRSA explicitly sought feedback from Urban Indian Organizations (UIOs) about how to increase access to and improve pediatric behavioral health care through telehealth and the PMCHA program’s development and implementation. NCUIH’s comments address the essential role of access to pediatric mental health care for American Indian/Alaska Native (AI/AN) communities across the country, including AI/AN communities in urban areas.

Background

According to the Indian Health Service (IHS), Native youth living off-reservation share similar health problems to their AI/AN peers nationwide, which are exacerbated by lack of access to family and traditional cultural environments. Notably, the AI/AN youth suicide rate is 2.5 times that of the national average.

UIOs are actively engaged in overcoming, addressing, and preventing mental and behavioral health issues in urban AI/AN youth. Virtually every UIO offers mental and behavioral health services, which became critically important during the height of the pandemic for families to continue accessing needed health care services to keep their doors open in the wake of reduced in-person visits. Since then, UIOs have continued to provide telehealth services to their patients, especially for mental and behavioral health programs.

Recommendations

NCUIH provided the following recommendations to HRSA regarding pediatric mental health care and telehealth services:

  • Facilitate UIO Participation in the PMHCA Program
    NCUIH urged HRSA to facilitate UIO participation in the PMHCA program. Although UIOs are a critical source of health care for urban AI/AN communities, they are often left underfunded and under resourced because federal grant programs unintentionally exclude UIOs. Accordingly, NCUIH suggested that whenever HRSA is asked to provide technical assistance on the PMHCA program to Congress, it advises Congress of this exclusion and a legislative fix to expand eligibility to UIOs. Any expansion of eligibility should be accompanied by a similar expansion in funding for the PMHCA program to ensure that there is no decrease in funding available for Tribes or Tribal organizations.
  • Continue to Engage with UIOs and Develop an Urban Confer Policy
    NCUIH recommended that HRSA continues to foster its relationship with UIOs through consistent and timely communication to UIOs. We further encouraged HRSA to cultivate meaningful partnerships between other federal agencies and stakeholders to notify UIOs when they are eligible for certain programs. Finally, NCUIH urged HRSA to develop an Urban Confer Policy, which would ensure HRSA’s services are more responsive to the needs and desires of urban AI/AN communities.

We will continue to monitor ongoing implementation of HRSA’s pediatric behavioral and mental health care programs that serve Indian Country.

NCUIH Resource: Tribal Nations Summit Briefing Book on Urban Indian Health Issues

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On Novemeber 29, 2022, the National Council of Urban Indian Health (NCUIH) collaborated on the White House Tribal Nations Summit Briefing held by the National Indian Health Board (NIHB) and National Congress of American Indians (NCAI) for Indian Country leaders to prepare for the upcoming White House Tribal Nations Summit. As the organization that advocates for the health and well-being of urban Native Americans, NCUIH prepared a resource that highlights key priorities for urban Indian organizations (UIOs).

View the resource

One of the main priorities for NCUIH is tribal sovereignty. The organization stands in strong support of consultation and the nation-to-nation relationships between Tribes and the United States government. NCUIH also supports the work of the Tribal Budget Formulation Workgroup, which crafts a budget request for Congress and the Administration each year. NCUIH also advocates for the US government to uphold the Declaration of National Indian Health Policy in the Indian Health Care Improvement Act. This policy states that it is the responsibility of the US government to ensure the highest possible health status for Indians and urban Indians and to provide the necessary resources to do so.

UIOs and urban Indians face unique challenges when it comes to access to healthcare. There are 41 UIOs that serve Indian Health Service beneficiaries at over 90 locations, but these organizations receive significantly less funding per patient than other healthcare facilities. On average, the health care spending in the US is $11,172 per person, while tribal and Indian Health Service (IHS) facilities receive only $4,078 per patient from the IHS budget. UIOs receive even less, at just $672 per patient.

Despite these challenges, UIOs serve a significant portion of the Native American population. Over 95% of UIO patients are tribal citizens, and over 70% of Native Americans do not live on federally recognized tribal land. NCUIH is advocating for 100% Federal Medical Assistance Percentage for UIOs to help address these disparities in healthcare access.

NCUIH is also advocating for advance appropriations for IHS— a top priority across Indian Country. The Indian healthcare system, including IHS, Tribal facilities, and UIOs, is the only major federal healthcare provider funded through annual appropriations and is not protected from government shutdowns and continuing resolutions. This policy is needed to save Native lives, as lapses in federal funding puts lives at risk. During the 2019 government shutdown, several UIOs had to reduce services or close their doors entirely, forcing them to leave their patients without adequate care which unfortunately led to fatalities. Advance appropriations is critical to provide certainty to the IHS system and ensure unrelated budget disagreements do not risk lives.

The Full Resource:

Urban Indian Health Issues
White House Tribal Nations Summit Briefing Book

National Council of Urban Indian Health (NCUIH)

  • Tribal sovereignty is a top priority for the National Council of Urban Indian Health (NCUIH). We know all too well that the promises made to American Indians and Alaska Natives are often broken. NCUIH stands in strong support of Consultation and the Nation-to-Nation relationships of Tribes and the United States government.
  • NCUIH strongly supports the work of the Tribal Budget Formulation Workgroup to craft a budget request for Congress and the Administration each year. NCUIH follows the guidance and requests of the Workgroup in its recommendations to Congress.
  • NCUIH advocates for the US government to uphold the Declaration of National Indian Health Policy in the Indian Health Care Improvement Act: “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.”

Urban Indian Organizations and Urban Indians

  • 41 Urban Indian Organizations serve IHS beneficiaries at over 90 locations
  • The average health care spending in the United States is $11,172 per person, however, Tribal and Indian Health Service (IHS) facilities receive only $4,078 per American Indian/Alaska Native (AI/AN) patient from the IHS budget. Urban Indian Organizations (UIOs) receive just $672 per AI/AN patient from the IHS budget.
  • 95% of Urban Indian Organization patients are Tribal citizens
  • Over 70% of AI/AN citizens do not reside on Federally Recognized Tribal Land.

100% Federal Medical Assistance Percentage for Urban Indian Organizations

Background of 100% Federal Medical Assistance Percentage (FMAP) for UIOs:
  • FMAP is the percentage of Medicaid costs covered by the federal government, through reimbursement to state Medicaid programs. As a baseline, FMAP cannot be less than 50% of the cost of services provided.
  • In 1976, Congress passed the Indian Health Care Improvement Act (IHCIA) amended section 1905(b) of the Social Security Act to set the FMAP at 100% for Medicaid services “received through an Indian Health Service (IHS) facility whether operated by the Indian Health Service or by an Indian tribe or tribal organization.”
  • Congress authorized 100% FMAP for IHS facilities so that Medicaid payments could supplement the chronically underfunded IHS annual appropriation and provide IHS with additional financial resources to better fulfill the federal government’s trust responsibility to provide safe and quality healthcare to American Indians/Alaska Natives (AI/ANs).
  • Despite being an integral part of the Indian healthcare system, UIOs were overlooked in the original legislation authorizing 100% FMAP for IHS and Tribal healthcare providers. As a result, the federal government is not paying its fair share for Medicaid-IHS beneficiaries and is skirting the trust responsibility.
What is the issue?
  • In March 2021, Congress authorized 8 fiscal quarters of 100% FMAP coverage for Medicaid services at UIOs for IHS beneficiaries through the American Rescue Plan Act of 2021 (ARPA).
  • Since 2021, the federal government has been covering 100% match for IHS-Medicaid beneficiaries but starting on March, States will have to go back to paying for a portion of services received from IHS-Medicaid beneficiaries at UIOs.
  • Congress needs to hear from Tribes that 100% FMAP provision for UIOs needs to be permanently authorized or at least extended to provide adequate care for tribal citizens living in urban areas.
How Tribes Can Support
  • Create a resolution supporting permanent 100% FMAP for UIOs.
  • Support 100% FMAP in Fiscal Year 2023 Omnibus bill.
  • Contact your Members of Congress before it expires in 4 months to support an extension to the provision in the end-of-year Omnibus.
  • If your Tribe is interested in supporting 100% FMAP for UIOs, please contact policy@ncuih.org
What Needs to be Done Now?
  • Tell the Administration that the federal government must fulfill its trust responsibility for all IHS beneficiaries by making 100% FMAP permanent.
  • The 100% FMAP provision for UIOs is going to expire in four months and the federal government will no longer be honoring its trust responsibility to IHS-Medicaid beneficiaries who receive care at urban Indian organizations.
  • Congress needs to hear from Tribes that 100% FMAP provision for UIOs needs to be permanently authorized or at least extended to provide adequate care for tribal citizens living in urban areas.
What Tribes Can do to Support

If your Tribe is interested in supporting 100% FMAP for UIOs, please contact policy@ncuih.org

Tribal Support
➤     Create a resolution supporting permanent 100% FMAP for UIOs.
Congressional Advocacy
➤     Support 100% FMAP in the Fiscal Year 2023 Omnibus bill.

  • Contact your Members of Congress before it expires in 4 months to support an extension to the ARPA provision in the end-of-year Omnibus.

Tribe and Tribal Organization Support for 100% FMAP for UIOs

Advance Appropriations

Advocacy
  • On January 17, 2019, NCUIH sent a letter to the Vice Chairman of the Senate Committee on Indian Affairs, Tom Udall, in support of IHS advance appropriations legislation.
  • On March 9, 2022, NCUIH joined NIHB and over 70 Tribal nations and national Indian organizations in sending a series of joint letters to Congress requesting advance appropriations for IHS in the Fiscal Year (FY) 2022 omnibus.
  • On June 16, 2022, NIHB and NCAI requested that the Committee support and include IHS advance appropriations in the current FY 2023 appropriations bill in an action alert.
  • On June 24, NCUIH issued a call to action to reach out to Speaker Pelosi for House support of advance appropriations.
  • On June 24 and July 1, 2022, NCUIH sent a letters to Speaker Pelosi and House Minority Leader McCarthy to support advance appropriations for IHS.
  • On June 29, 2022, NCUIH sent letters to the Senate Interior Appropriations Committee and the Senate Committee on Indian Affairs to support advance appropriations for IHS.
  • On June 30 and July 1, 2022, NCUIH sent letters to Senate Majority Leader Schumer and Senate Minority Leader McConnell to support advance appropriations for IHS.
  • On August 19, NCUIH issued a second call to action to reach out to Speaker Nancy Pelosi for House support of advance appropriations.
  • On August 22, 2022, NCUIH launched a website with educational resources on advance appropriations.
  • On October 26, 2022 NCUIH launched an advance appropriations social media campaign and toolkit with the hashtag #AdvanceIndianHealtht.
  • On October 28, 2022, NCUIH released an advance appropriations advocacy toolkit.
  • In November 2022, NCUIH signed-on to NIHB’s intertribal and inter-organization Congressional and White House letters requesting advance appropriations for the FY 2023.

Urban Indian Leader, Walter Murillo, Speaks at White House Conference on Hunger, Nutrition, and Health

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On September 28, 2022, Walter Murillo, CEO of NATIVE Health and President-Elect of the National Council of Urban Indian Health (NCUIH), headlined a panel titled “Breaking Barriers: Bridging the Gap Between Nutrition and Health” at the White House Conference on Hunger, Nutrition, and Health. Mr. Murillo highlighted high rates of food insecurity in Indian Country, which intersects with other social determinants of health such as limited housing, employment, and lack of trust in health care systems in Native communities. In the Phoenix area, NATIVE Health has engaged with partners to create community gardens, teach traditional seeding and recipes, and deliver food boxes to elders during the height of COVID to support access to healthy and nutritious meals for urban American Indians/Alaska Natives (AI/ANs).

Video of the panel: https://www.youtube.com/watch?v=U1_iLHCOAeY

Background

UIOs provide essential access to nutrition, food, and health resources for the more than 70 percent of AI/ANs living off-reservation. AI/AN people experience the highest rates of diabetes across all racial and ethnic groups (14.5 percent), compared to 7.4 percent of non-Hispanic Whites. 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.” Moreover, diabetes and heart disease are among the top five leading causes of death for AI/AN people who live in urban areas. Additionally, urban AI/AN people are more than three times more likely to die from diabetes than their White peers and have higher death rates attributable to heart disease than urban White people.

It’s been more than 50 years since the first and only White House Conference on Food, Nutrition, and Health was held in 1969. At the Conference, the Administration announced a National Strategy that identifies steps the government will take and catalyzes the public and private sectors to address the intersections between food, hunger, nutrition, and health. The Administration sought input on the development and implementation of this national strategy and initiated Tribal Consultation on June 28, 2022.  On July 15, 2022, NCUIH submitted comments to the Administration, the Department of Health and Human Services (HHS), and the US Department of Agriculture (USDA) and recommended that they support urban Indian organizations (UIOs) 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.

DAY OF ACTION: Save Native Lives – Show Your Support on November 30!

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Contact Congress │ Access the Social Media Toolkit │ NCUIH Advance Appropriations Website │ Advance Appropriations One-Pager

The National Council of Urban Indian Health is hosting a Day of Action in support of Native communities on November 30.

  • Who: National Council of Urban Indian Health and all supporters of stable funding for the Indian Health Service (IHS)
  • What: Day of Action on Social Media
  • When: November 30, 2022 – Native American Heritage Month is quickly drawing to a close and it’s time for the United States government to truly honor Native communities by stabilizing health care funding and ending the budget delays that hinder health services. The White House is also hosting an in-person Tribal Nations Summit on November 30 and December 1. Meanwhile, Congress is hard at work finalizing the end of year legislation and this is a top priority that Native communities have requested for inclusion to help Native communities.
  • Where: Online and on Capitol Hill
  • Why: During the last government shutdown, 5 Indian Health Service patients died as health clinics dealt with the lapse of funding. IHS is the only major federal provider of health care solely funded through regular annual appropriations. IHS is the only major federal provider of health care vulnerable to government shutdowns and temporary, “stopgap” budgets. Congress can change this by providing a FY2024 level-funded advance appropriation for most of the IHS.
  • How: You can get involved by using our social media toolkit and sending letters to Congress to support stable funding for the Indian Health Service this year.
  • Social Media Toolkit

Watch and Share the Explainer Video

DAY OF ACTION PLAN

POST ON SOCIAL MEDIA – Share you support for stable funding for IHS with your followers!

WHEN: Tuesday, November 30, 2022, beginning at 9 am EST.

HOW: Use these graphics and our toolkit to post on social media and call on your Member of Congress to take action!

Access the Social Media Toolkit

  Advance Indian Health

Advance Appropriations

EMAIL YOUR MEMBER OF CONGRESS

STEPS TO CONTACT CONGRESS

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

Email to Your Representative and Senators

Dear [Member of Congress],

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

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

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

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

Sincerely,
[contact information]

Background

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

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

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

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

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

NCUIH Statement on Letter from IHS on Protecting Native Patients From Funding Delays and Government Shutdowns

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FOR IMMEDIATE RELEASE

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

WASHINGTON, D.C. (November 16, 2022) – The National Council of Urban Indian Health (NCUIH) received a letter from the Indian Health Service (IHS) in response to a request to allow urban Indian organizations (UIOs) to receive an exception apportionment, which would protect them from a government shutdown by providing the full-year base funding amounts.

Today, NCUIH Chief Executive Officer, Francys Crevier (Algonquin), released the following statement in response to the IHS letter:

 “During the last government shutdown in 2019, five patients died. These are five relatives— mothers, fathers, grandparents— who are no longer part of our community and unable to pass on our cultural traditions that they hold, all because of federal budget disputes. It is atrocious and tragic that the government expects Indian health providers to continue providing services to the most vulnerable population in the country without an enacted budget. Congress regularly fails to reach a budget agreement in time year after year, and Native people are the ones that suffer. Budget delays hinder healthcare delivery and it’s unacceptable. To truly honor its commitment to Native people, the government must act to end budget delays that cost lives. Indian Country has tirelessly advocated for secure funding through advance appropriations for IHS, which is the only major federal healthcare provider funded through annual appropriations. The federal government continues to prove that the safety of Native lives is not a concern, as the government fails to fund IHS in a timely manner and does not provide exception apportionment to the programs that carry out healthcare services to the over 70% Native population living in urban areas.”

Background

IHS has only once, in 2006, received full-year appropriations by the start of the fiscal year. In the absence of an exception apportionment during these budget disputes that may cause the government to shut down, UIOs are subject to the shut down too. Federal shutdowns require UIOs to lay off staff, reduce hours and services, and even close their doors, ultimately leaving their patients without adequate health care.

IHS received an exception apportionment to provide the full-year Secretarial Amount to Tribal Health Programs with Indian Self-Determination and Education Assistance Act contracts and compacts, but this exception does not apply to IHS-operated health programs or UIOs. IHS states, “IHS-operated health programs continue to provide services in the absence of appropriations, even if the health programs are unable to pay health care professionals and related staff, pay invoices for referred care, and purchase supplies and medicines.”

Take Action

NCUIH has been working with our partners to #AdvanceIndianHealth and has more information on how to get involved here: https://ncuih.org/advance/. We will continue to push for including advance appropriations for IHS in the final Fiscal Year 2023 spending bill to provide funding certainty to the Indian healthcare system.

Full Text of IHS Letter

Dear Ms. Crevier:

I am responding to your September 23, 2022, letter, regarding an exception apportionment for Urban Indian Organizations (UIOs). The Indian Health Service (IHS) is committed to hearing concerns about the effect of the Fiscal Year (FY) 2023 Continuing Resolution on UIOs.

Urban Indian Organizations are a critical component of the Indian health care system. The Indian Health Service’s top priority is to avoid disruptions in operations and to lift the unnecessary administrative burden that comes with Continuing Resolutions (CRs), sequestration, and government shutdowns for the entire Indian health system, including UIOs.

In your letter, you highlight actions that the current and prior Administrations implemented to limit budgetary uncertainty and ensure continuity of operations for IHS and Tribal Health Programs during government shutdowns. You also request that the IHS seek an exception apportionment under the “safety of human life” justification to provide UIOs with funding above the pro-rata amount appropriated under a CR.

An exception apportionment describes a type of account-specific apportionment that can be issued for operations under a CR in lieu of the Office of Management and Budget (OMB) issued automatic apportionment, which provides the pro-rata funding level available under a CR. Exception apportionments must be requested and approved by OMB each year. The IHS has received an exception apportionment for a portion of its funding since FY 2020.

The exception apportionment allows the IHS to provide the full year Secretarial Amount to Tribal Health Programs with Indian Self-Determination and Education Assistance Act (ISDEAA) contracts and compacts with performance periods that start under the period of a given CR, as opposed to the pro-rata funding amount that is otherwise available under a CR. The exception apportionment does not apply to IHS-operated health programs or UIOs. It is important to note that the IHS exception apportionment does not fall under the “safety of human life” exception for apportionments.

The OMB Circular No. A-11: Preparation, Submission, and Execution of the Budget, the basis for a Safety of Human Life and Protection of Federal Property (“life and safety”) establishes that exception apportionments may be granted in extraordinary circumstances where the safety of human life or protection of Federal property is a concern during a government-wide lapse of appropriations.

Instead, the IHS exception apportionment authority is rooted in the unique nature of ISDEAA funding agreements, and the timing of such funding agreements. This is why the exception apportionment only applies to Tribal Health Programs whose ISDEAA agreements have a performance period that begins during the period of the CR. Urban Indian Organizations receive their funding through Federal Acquisition Regulation (FAR) contracts, consistent with Title V of the Indian Health Care Improvement Act, and therefore are not eligible for funding above the pro-rata amount available during a CR under this exception apportionment authority.

Your letter references “excepted programs” under the Antideficiency Act (ADA) during the 2018 – 2019 government shutdown. Indian Health Service operated health care programs are “excepted” during a government shutdown, which means that IHS-operated health programs must continue to provide direct health care services in the absence of an appropriation. The exception under a government shutdown does not provide additional funding during the period of a government shutdown. This exception only applies to Federal functions, and does not apply to Tribal Health Programs. Under this exception, IHS-operated health programs continue to provide services in the absence of appropriations, even if the health programs are unable to pay health care professionals and related staff, pay invoices for referred care, and purchase supplies and medicines.

The criteria for safety of human life excepted programs under a government shutdown is not always the same as the criteria for receiving a safety of human life exception apportionment. Programs that are excepted for safety of human life reasons under a government shutdown generally do not receive exception apportionments. For example, although IHS-operated health programs are excepted during a government shutdown and must continue providing direct health care services in the absence of appropriations, IHS-operated health programs do not receive an exception apportionment. The safety of human life exception for apportionment purposes is used in very narrow circumstances.

The exception apportionment authority provides a partial solution to the unpredictability of Federal appropriations for the IHS, and is likely the extent of what the Agency can achieve within existing authorities. While an exception apportionment does resolve some of the unpredictability in the IHS budget for some Tribal Health Programs, it is not a full solution to the challenges the IHS faces as a result of continuing resolutions. The exception apportionment also does nothing to prevent the negative consequences of government shutdowns for IHS-operated health programs and UIOs; it only prevents those consequences for Tribal Health Programs in some circumstances. The consequences of a government shutdown directly impact the ability of IHS-operated health programs, Tribal Health Programs, and UIOs to provide high quality health care to the American Indian and Alaska Native communities we serve.

The Biden Administration has taken the historic steps of requesting advance appropriations in FY 2022 and a fully mandatory budget in FY 2023 for the IHS to fundamentally change the way the Agency receives its appropriations and resolve the negative impacts of budget uncertainty. We sincerely appreciate your support as we work toward achieving these goals.

Thank you for your continued support on our shared mission to raise the health status of urban Indians to the highest possible level. If you have additional concerns, please directly contact Ms. Jillian Curtis, Chief Financial Officer, Office of Finance and Accounting, IHS, by telephone at (301) 443-0167, or by e-mail at jillian.curtis@ihs.gov.

Sincerely,
Roselyn Tso
Director