NCUIH Submits Comments to HHS about Missing and Murdered Indigenous People and Violent Crime Against Native People

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On May 19, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to Health and Human Services (HHS) about Executive Order (EO) 14053— Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People. These comments responded to correspondence, dated April 4, 2022, initiating a Tribal Consultation on the policy directives outlined in EO 14053. NCUIH outlined recommendations for HHS including communication and collaboration with UIOs, engagement with UIOs as critical stakeholders in HHS’ comprehensive plan to address the MMIP Crisis and violent crime, and the establishment of an agency-wide Urban Confer policy.

History of MMIP and EO 14053

According to the National Missing and Unidentified Persons System (NamUs), as of August 1, 2021, data demonstrates that most missing and unidentified cases involving AI/AN persons occur off tribal land. Still, relevant data on violence and crime in urban AI/AN communities is significantly lacking. What data does exist demonstrates a troubling situation for urban AI/AN communities. At least seventy percent (70%) of violent victimization experienced by AI/ANs is committed by persons not of the same race – a substantially higher rate of interracial violence than experienced by white or black victims. Furthermore, a 2019 report from the Minnesota Statistical Analysis Center found that AI/AN persons made up twenty percent (20%) of all victims of sex trafficking in Minnesota in 2017. Additionally, according to the California Consortium of Urban Indian Health’s Red Women Rising initiative, sixty-five percent (65%) of urban Indian women experienced interpersonal violence, forty percent (40%) experienced multiple forms of violence, and forty-eight percent (48%) experienced sexual assault. An October 2021 report by the Government Accountability Office (GAO) on the Missing or Murdered Indigenous Women noted that “tribal organization officials told [GAO] that AI/AN individuals who leave rural villages to move to urban, nontribal areas are at a higher risk of becoming victims to violent crime, including human trafficking, which they stated is a serious concern related to the MMIP crisis.”

NCUIH has consistently advocated for violent crime perpetrated against AI/ANs and the MMIP crisis to be treated as more than solely criminal justice or public safety issues.  Crime and violence are key Social Determinants of Health (SDOH) that both affect the immediate victims and cause negative health impacts throughout AI/AN communities.  Also, according to HHS, “[a]ddressing exposure to crime and violence as a public health issue may help prevent and reduce the harms to individual and community health and well-being.” A 2019 NCUIH survey found that sixty-six percent (66%) of UIOs said the most significant risk factors leading to AI/AN patients missing in their communities are: homelessness, foster system transitioning, domestic violence, substance misuse, and human trafficking, among others.  In turn, the federal government’s trust responsibility to provide “[f]ederal health services to maintain and improve the health of the Indians” requires it to address violent crime against AI/ANs and the MMIP crisis through a holistic and inter-agency approach that supports and improves the health of AI/AN communities and individuals

EO 14053 is a landmark pledge “to strengthen public safety and criminal justice in Indian Country and beyond, to reduce violence against Native American people, and to ensure swift and effective Federal action that responds to the problem of missing or murdered indigenous people.” In EO 14053, the federal government committed to “[c]onsistent engagement, commitment, and collaboration,” with AI/AN people and communities to “drive long-term improvement to public safety for all Native Americans.” EO 14053 specifically directs the federal government to “build on existing strategies to identify solutions directed toward the particular needs of urban Native Americans,” because “approximately 70 percent of American Indian and Alaska Natives live in urban areas and part of this epidemic of violence is against Native American people in urban areas.” In addition, EO 14053 directs the federal government to “work closely with Tribal leaders and community members, Urban Indian Organizations, and other interested parties to support prevention and intervention efforts that will make a meaningful and lasting difference on the ground.”  Pursuant to Section 5 of EO 14053, HHS must “develop a comprehensive plan to support prevention efforts that reduce risk factors for victimization of Native Americans and increase protective factors, including by enhancing the delivery of services for Native American victims and survivors, as well as their families and advocates.”

NCUIH’s Requests to HHS

NCUIH issued the following comments and recommendations regarding the creation of HHS’ comprehensive plan and its implementation of EO 14053:

  • NCUIH requests that HHS honor EO 14053 through consistent and clear communication, as well as collaboration, with UIOs.
    • In EO 14053, the federal government committed to “[c]onsistent engagement, commitment, and collaboration,” with AI/AN people and communities to “drive long-term improvement to public safety for all Native Americans.” This includes working with Tribal leaders and UIOs to drive meaningful prevention and intervention efforts.
    • Communication and collaboration with UIOs is not only required by EO 14053, but also sound public policy. Working with UIOs will help HHS make local connections, source, share, and analyze data, better understand the extent and causes of violent crime against AI/ANs and the MMIP epidemic, and evaluate the adequacy of research and data collection efforts at CDC and NIH.
    • NCUIH is ready, willing, and able to assist HHS communicate with UIOs and develop ongoing relationships to support this work.
  • NCUIH requests that HHS engage UIOs as critical stakeholders in its comprehensive plan to support prevention efforts that reduce risk factors for the victimization of Native Americans and increase protective factors.
    • NCUIH is appreciative that IHS recently held an Urban Confer on EO 14053 with UIOs. However, NCUIH emphasizes that it is the responsibility of the Secretary, and HHS as a whole, not just IHS, to work with urban AI/AN communities to reduce violent crime and address the MMIP epidemic.
    • UIOs are already engaged in culturally focused, community-based prevention efforts such as projects funded through the Domestic Violence Prevention Program, partnerships to provide services for victims of crime, and direct services for substance abuse disorders, mental health, and behavioral health.
  • NCUIH requests that HHS establish an Urban Confer policy to set the necessary policies and procedures for direct and clear communication with UIOs.
    • Urban Confer policies are a response to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that resulted in 70 percent of AI/AN people living outside of Tribal jurisdictions. Urban Confers are integral to addressing the care needs of most AI/AN persons and fulfilling the government’s trust responsibility.
    • Developing and implementing an Urban Confer policy for HHS is sound public health policy. Given the gravity of MMIP and violence against AI/ANs, it is imperative that HHS as a whole address these problems holistically and agency-wide, not solely at the IHS level. Urban Confers would enable UIOs to share feedback, recommendations, and testimony on the unique needs of their UIOs.

NCUIH will continue to closely follow HHS’ implementation EO 14053 and advocate for the resources needed to address the MMIP crisis and violent crime against AI/ANs, regardless of where victims live.

NCUIH Joins Tribal Partner Organizations Letter Urging Carcieri Fix

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On April 14, 2022 the United South and Eastern Tribes Sovereignty Protection Fund submitted a letter to the Senate Committee on Indian Affairs (SCIA) calling on the Senate to pass a legislative fix addressing the Supreme Court’s decision in Carcieri v. Salazar, 222 US 379 (2009).  The National Council of Urban Indian Health (NCUIH) joined in this letter, along with the National Congress of American Indians, the National American Rights Fund, the National Indian Gaming Association, and the National Indian Health Board, among other Native advocacy organizations.  The full text of this letter is available here.

Carcieri v. Salazar and its Impact on Indian Country

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

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

Tribal Partner Organizations Letter Urges Carcieri Fix

The April 14, 2022 letter urged SCIA “as the Senate committee tasked with leading strong U.S.-Tribal Nation diplomatic relations and protecting the principles of our sovereign status, to work toward enactment of legislation that would reaffirm the status of existing Tribal trust lands and restore certainty and fairness to the Tribal land into trust process by fixing the flawed Carcieri decision.”  The letter notes that twice during the 117th Congress, the House of Representatives had passed legislation to address Carcieri, and that it is time for the Senate to also pass similar legislation.

As a passionate supporter of Tribal sovereignty and strong Tribal economies, NCUIH was proud to join the Tribal Partners Organization letter with other leading American Indian and Alaska Native advocacy organizations.  NCUIH urges Congress to pass legislation which restores the Secretary of the Interior’s authority to take land into trust for all federally recognized Tribes and which reaffirms the status of existing Tribal trust lands.

12 Senators Request Increased Resources for Urban Indian Health and Support Mandatory Funding for Indian Health in FY23

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On May 27, 2022, 12 Senators requested up to $949.9 million for urban Indian health in FY23 and advanced appropriations for the Indian Health Service (IHS) until such time that authorizers move IHS to mandatory spending.

Senator Tina Smith (D-MN) and 11 other Senators requested up to $949.9 million for urban Indian health in FY23 and advanced appropriations for IHS until such time that authorizers move IHS to mandatory in a letter to Chair Merkley and Ranking Member Lisa Murkowski of the Senate Interior Appropriations Committee. The letter emphasizes that increasing funding “is essential to providing quality, culturally-competent health care to AI/AN people living in urban areas.” On April 26, 2022, a group of 28 Representatives sent a letter to the House Interior Appropriations Committee with the same requests.

This letter comes as a continued effort by the National Council of Urban Indian Health (NCUIH) to address acute health disparities for American Indians/Alaska Natives (AI/ANs) living in urban areas, who suffer greater rates of chronic disease, infant mortality and suicide compared to all other populations that have only been exacerbated by COVID-19. Congress has acknowledged these significant health care disparities in Indian Country, but continuously underfunds IHS at around $4,000 per patient, and urban Indian organizations (UIOs) at less than $700 per patient even though AI/ANs living in urban areas comprise over two-thirds of the total AI/AN population.

The senators also stated their support for the President’s proposal of mandatory funding. The Indian health system is currently not shielded from the negative impacts of government shutdowns, continuing resolutions, and automatic sequestration cuts. Already underfunded, these disruptions can have serious consequences to UIOs’ ability to provide critical patient services.

This Appropriations letter sends a powerful and straightforward message to Chair Merkley and Ranking Member Lisa Murkowski, and members of the Senate that in order to fulfill the federal government’s trust responsibility to all AI/ANs to provide safe and quality healthcare, funding for urban Indian health must be significantly increased.

NCUIH is grateful for the support of the following Senators:

  1. Tina Smith
  2. Dianne Feinstein
  3. Tammy Baldwin
  4. Chris Van Hollen
  5. Amy Klobuchar
  6. Catherine Cortez Masto
  7. Maria Cantwell
  8. Alex Padilla
  9. Ben Ray Lujan
  10. Jacky Rosen
  11. Elizabeth Warren
  12. Bernard Sanders

Full Letter Text

Dear Chairman Merkley and Ranking Member Murkowski,

We write to thank you for your proven commitment to urban Indian health and the 41 Urban Indian Organizations (UIOs) and to request you continue your support by appropriating $949.9 million for urban Indian health, supporting the President’s proposal for mandatory funding for the Indian Health Service (IHS), and securing advance appropriations for IHS in the Fiscal Year (FY) 2023 Interior, Environment, and Related Agencies Appropriations Act.

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

Our request for $949.9 million for urban Indian health reflects the recommendation made by the Tribal Budget Formulation Workgroup (TBFWG), a group of Tribal leaders representing all twelve IHS service areas. The significantly increased request for FY23 reflects the full funding needed for urban Indian health. Tribal leaders are unified in this request for full funding.

Chronic underfunding of IHS and urban Indian health has contributed to the health disparities among AI/AN people. Additionally, AI/AN people living in urban areas suffer greater rates of chronic disease, infant mortality and suicide compared to all other populations. Urban Native populations are less likely to receive preventive care and are less likely to have health insurance.

Yet, despite the historical acknowledgement from Congress of the significant health care disparities in Indian Country, IHS is underfunded at around $4,000 per patient, and UIOs receive less than $700 per patient.

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

As a result of the COVID-19 pandemic, UIOs are reporting historic numbers of new patients. Should funding return to pre-pandemic levels, UIOs would not have the staff or resources to continue to meet the community need. A budget increase would allow UIOs, as well as IHS and Tribal facilities, to hire more staff, pay appropriate wages, and expand vital services, programs, and facilities.

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

CDC Expands Eligibility of COVID-19 Boosters for Youth

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On Thursday, May 19th, the Centers for Disease Control and Prevention (CDC) expanded eligibility of COVID-19 vaccine boosters for everyone 5-years and older. This expansion follows a meeting of the Advisory Committee on Immunization Practices’ (ACIP) and its recommendations. With this expansion of eligibility, the CDC recommendations for children are the following:

  • Children 5-11 years old should receive a booster shot 5 months post initial series of the Pfizer-BioNTech vaccine
  • Children 12 and older, who are immunocompromised, should receive a second booster at least 4 months after their first booster.

If you are eligible for a booster, be it the first or second dose of such, and you have not had one since December 2021, now is the time to do so. To see if you are eligible for a booster, click here.

COVID-19 and Native Communities

American Indians and Alaska Natives (AI/ANs) have been disproportionately affected by the COVID-19 pandemic. At the height of it, AI/ANs were 3.5 times more likely to test positive, 3.2 times more likely to be hospitalized, and 2.2 times more likely to die due to COVID-19. Since the pandemic began, nearly 5 million kids, ages 5 to 11, have been diagnosed with COVID, 15,000 have been hospitalized, and over 180 have died.

Indian Country has had highly successful vaccine rollouts and Urban Indian Organizations (UIO) have been instrumental in the success of vaccinating AI/AN populations in urban areas. As of June 2022, AI/ANs have the highest vaccination administration rates in the U.S with 73% of AI/ANs having received at least one dose of the COVID-19 vaccine, according to CDC Vaccine Administration Data. As of June 2022, UIOs that use IHS vaccine distribution have administered over 174,105 doses of the COVID-19 vaccine and fully vaccinated 67,883 people.

Request for Nominations for Government Accountability Office Tribal Advisory Council, UIO Leaders Invited to Apply

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On April 7, 2022 the U.S. Government Accountability Office (GAO) issued a request for nominations to form its first standing Tribal Advisory Council (TAC) expected to be composed of a diverse group of tribal leaders (elected or appointed by Tribes); an elected or appointed leader of a state-recognized Tribe and/or Native Hawaiian Organization; and advisors who are experts on tribal and indigenous issues. Urban Indian leaders are encouraged to submit nominations to elevate the voices of the over 70% of American Indians/Alaska Natives (AI/ANs) living in urban areas. Nominations should be submitted to TAC@gao.gov no later than May 20, 2022, to ensure adequate opportunity for review and consideration.

Background on GAO TAC

GAO is an independent, non-partisan agency that works for Congress. GAO examines how taxpayer dollars are spent and provides Congress and federal agencies with objective, non-partisan, fact-based information to help the government save money and work more efficiently.

To do so, GAO conducts reviews of federal agencies and programs, including those that serve Tribes, their citizens, and descendants. (GAO generally does not audit Tribes’ activities.) GAO reviews span a broad range of topics of concern to Tribes, including health care, education, economic development, environmental protection, justice, and infrastructure, among others. GAO’s oversight of federal programs that serve Tribes and their citizens aims to help the Congress determine how best to meet the government’s longstanding commitments to federally recognized Tribes.

The TAC will advise GAO on vital and emerging issues affecting Tribes and Indigenous peoples and provide input into GAO’s strategic goals and priorities with respect to the agency’s related work. This may include informing GAO of emerging topics of interest or concern, helping identify relevant stakeholders to ensure GAO work includes a diverse range of tribal and indigenous perspectives, and providing advice to GAO on its process for working with Tribes.

The TAC is expected to be composed of up to 15 members including elected or appointed leaders from federally recognized Tribal entities; an elected or appointed leader of a state recognized Tribe and/or Native Hawaiian organization; and technical advisors who may be representatives of a national or regional tribal or Native-serving organizations or subject matter experts on topics relevant to Tribes and Indigenous peoples.

Call to Action

NCUIH encourages interested UIO leaders to submit nomination materials to GAO by May 20, 2022. AI/ANs living in urban areas face many of the same barriers to accessing resources or representation that AI/ANs living in Tribal communities and reservations face. NCUIH also notes that because approximately 70 percent of AI/ANs live in urban areas, including leaders from urban AI/AN communities will help GAO build on existing strategies to identify solutions directed toward the particular needs of all AI/ANs.

NCUIH Submits Written Testimony to Senate Appropriations Subcommittee with FY 2023 Budget Requests for Urban Indian Health

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On May 10, 2022, The National Council of Urban Indian Health (NCUIH) submitted outside written testimony to the Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies regarding Fiscal Year (FY) 2023 funding for Urban Indian Organizations (UIOs). NCUIH advocated in its testimony for full funding for the Indian Health Service (IHS) and urban Indian Health and increased resources for Native health programs.

In the testimony, NCUIH requested the following:

  • Fully fund IHS at $49.8 billion and Urban Indian Health at $949.9 million for FY23 (as requested by the Tribal Budget Formulation Workgroup)
  • Advance appropriations for IHS until mandatory funding is enacted
  • Increase funding for Electronic Health Record Modernization
  • Increase funding to $30 million for Good Health and Wellness in Indian Country (GHWIC)
  • Permanently reauthorize Native Connections (Tribal Behavioral Health Grant)
  • Include urban Indians in language for all health programs
  • Include UIOs in critical opioid grants

Full Text of Testimony:

National Council of Urban Indian Health – Testimony for Senate LHHS on FY2023 Health and Human Services Appropriations Bill

My name is Francys Crevier, I am Algonquin and the Chief Executive Officer of the National Council of Urban Indian Health (NCUIH). On behalf of NCUIH, the national advocate for health care for the over 70% of American Indians and Alaska Natives (AI/ANs) living off-reservation and the 41 Urban Indian Organizations (UIOs) that serve these populations, I would like to thank Chairwoman Murray, Ranking Member Blunt, and Members of the Subcommittee for the opportunity to submit public witness testimony regarding Fiscal Year (FY) 2023 appropriations. We respectfully request the following:

  • Fully fund the Indian Health Service (IHS) at $49.8 billion and Urban Indian Health at $949.9 million for FY23 (as requested by the Tribal Budget Formulation Workgroup)
  • Advance appropriations for IHS until mandatory funding is enacted
  • Increase funding for Electronic Health Record Modernization
  • Increase funding to $30 million for Good Health and Wellness in Indian Country (GHWIC)
  • Permanently reauthorize Native Connections (Tribal Behavioral Health Grant)
  • Include urban Indians in language for all health programs
  • Include UIOs in critical opioid grants
Fully fund the Indian Health Service at $49.8 billion and Urban Indian Health at $949.9 million for FY23 (as requested by the Tribal Budget Formulation Workgroup)

While your leadership was instrumental in providing the greatest investments ever for Indian health and urban Indian health, it is important that we continue in this direction to build on our successes. The average health care spending is around $12,000 per person, however, Tribal and IHS facilities receive only around $4,000 per patient.  UIOs receive just $672 per IHS patient – that is only 6 percent of the per capita amount of the national average. That’s what our organizations must work with to provide health care for urban Indian patients.

The federal trust obligation to provide health care to Natives is not optional, and we thus request Congress honor the Tribal Budget Formulation Workgroup (TBFWG) FY23 recommendations of $49.8 billion for IHS and $949.9 million for urban Indian health. That number is much greater than the FY21 enacted amount of $63.7 million, which truly demonstrates how far we have to go to reach the level of need for urban Indian health. At an IHS Area Report meeting where Tribal leaders presented their budget requests, one Oklahoma Tribal leader stated that “There are inadequate levels of funding to address the rising urban Indian population.” Congress must do more to fully fund the IHS in order to improve health outcomes for all Native populations at the amount requested.

In 2018 the Government Accountability Office (GAO-19-74R) reported that from 2013 to 2017, IHS annual spending increased by roughly 18% overall, and roughly 12% per capita. In comparison, annual spending at the Veterans Health Administration (VHA), which has a similar charge to IHS, increased by 32% overall, with a 25% per capita increase during the same period. Similarly, spending under Medicare and Medicaid increased by 22% and 31% respectively. In fact, even though the VHA service population is only three times that of IHS, their annual appropriations are roughly thirteen times higher.

Currently, the entire Eastern seaboard is without any full-ambulatory UIOs due to lack of funding. The IHS has deemed the two remaining UIOs on the East Coast to be outreach and referral only, with a combined less than two-million-dollar budget. Unfortunately, the pandemic has shown that two outreach and referral UIOs to serve all urban Indians on the entire East Coast of the country is a failure to uphold the federal trust obligation. It is evident the UIO line item is insufficient to allow IHS to authorize our East Coast UIOs to open fully operational clinics. Native American Lifelines is actually two programs run in both Boston and Baltimore with an annual budget for both cities of $1.6 million.  During the height of the pandemic, that meant Native people living in urban areas on the East Coast had to go back to reservations to get their vaccine to take advantage of the IHS authority that would give them the vaccine early and hopefully not become a mortality statistic.

The federal government owes a trust responsibility to tribes and AI/ANs that is not restricted to the borders of reservations. Funding for Indian health must be significantly increased if the federal government is, to finally, and faithfully, fulfill its trust responsibility.

Advance Appropriations for IHS Until Mandatory Funding Is Enacted

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, automatic sequestration cuts, and continuing resolutions (CRs). When IHS is funded through a CR, the IHS can only expend funds for the duration of a CR, which prohibits longer term purchases, disrupts the contracts that allow UIOs to provide health care, and quite literally puts lives at risk. Because UIOs must rely on every dollar of limited federal funding they receive to provide critical patient services, any disruption has significant and immediate consequences.

NCUIH supports the President’s proposal in the FY 2023 Budget to fund the IHS through mandatory appropriations and to exempt IHS from proposed law sequestration.   The ten years of appropriated mandatory funding in the FY 2023 Budget will ensure predictability that will allow the I/T/U system to engage in long-term and strategic planning. The lack of consistent and clear funding creates significant barriers on the already underfunded IHS system. Until authorizers act to move IHS to mandatory funding, we request that Congress provide advance appropriations to the Indian health system to improve certainty and stability.

Increase funding for Electronic Health Record Modernization

We request your support for the Indian Health Service’s (IHS) transition to a new electronic health record (EHR) system for IHS and UIOs. As EHR modernization moves from planning to fruition, it is vitally important that appropriations continue to increase as appropriate to provide for its success. NCUIH Requests the committee to support this transition with $355.8 million in FY23 appropriations. NCUIH is also supportive of the inclusion of report language suggested by members of Congress in a letter to the House appropriations committee.[1]

CDC: Good Health and Wellness in Indian Country – $30 Million Good Health and Wellness in Indian Country (GHWIC)

The GHWIC program is CDC’s single largest investment in Indian Country. The program funds a total of 27 Tribes, Tribal organizations, and UIOs to improve chronic disease prevention efforts, expand physical activity, and reduce commercial tobacco use. The FY 2023 President’s Budget proposes maintaining at current levels of $22 million. NCUIH requests the Committee support the GHWIC program by increasing funding to $30 million for FY2023.

SAMHSA: Tribal Behavioral Health Grant (Native Connections) – $23.2 Million

The Tribal Behavioral Health Grant (known as Native Connections) is a five-year grant program that helps American Indian and Alaska Native communities identify and address the behavioral health needs of Native youth. The program supports grantees in reducing suicidal behavior and substance use among Native youth up to age 24, easing the impacts of substance use, mental illness, and trauma in tribal communities, and supporting youth as they transition into adulthood.

As of June 2021, SAMHSA had awarded 242 five-year grants to eligible AI/AN entities including UIOs. The program is up for reauthorization in 2022 and the FY23 President’s budget has a request of $23.2 million for the program, an increase of $2.5 million from the FY 2022 Annualized Continuing Resolution. NCUIH requests the committee support addressing the behavioral health needs of our Native communities by reauthorizing this critical program.

Include Urban Indians in Language for All Health Programs

The Declaration of National Indian Health Policy in the Indian Health Care Improvement Act states that: “Congress declares that it is the policy of this Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.” In fulfillment of the National Indian Health Policy, the Indian Health Service funds three health programs to provide health care to AI/ANs: IHS sites, tribally operated health programs, and Urban Indian Organizations (referred to as the I/T/U). Unfortunately, this system has been hampered by decades of chronic underfunding. Additionally, while the majority of the Native population resides in urban areas, only 1% of the entire Indian health budget is provided for urban Indian health.

When urban Indians are not specifically mentioned in programmatic language they are most often excluded from participating in such programs. Many programs in the Health and Human Services appropriations bills include language for Indian Tribes and Tribal organizations, but not for urban Indian organizations. Urban Indian Organizations are not considered Tribal organizations, which is a common misconception. Therefore, UIOs must be explicitly included to receive funding. UIOs also do not have access to other IHS line items like IHS and Tribal facilities and do not receive hospitals and health clinics money, purchase and referred care dollars, or IHS dental services dollars, and are not eligible for the IHS facilities fund.

As one advocate stated, “The language everywhere has to include the word ‘urban’ – urban Indian or urban Native. They have to say it, they have to write it and then it’ll reach a critical mass, eventually. Because they don’t get it, you know. We’re just invisible.”[2]

Include UIOs in Critical Opioid Grants

UIOs have repeatedly been left out of funding designed to help AI/AN communities address the opioid crisis. To address the opioid overdose epidemic in Indian Country by increasing access to culturally appropriate and evidence-based treatment, Congress provided funding for Tribal Opioid Response grants. NCUIH has long advocated for UIOs to be added to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) State Opioid Response (SOR) grants given the extent of the impact of the opioid epidemic on all AI/ANs regardless of residence. Since FY 2018, Congress has enacted set asides in opioid response grants to help Native communities address this crisis. However, it was only available for Tribes and Tribal organizations, meaning UIOs working against the same problem are left without the resources necessary to reach the highest health status for all AI/ANs as required of the federal government. This is a failure of equity. Without the necessary funding to address health crises in Indian Country, urban AI/AN people will again be left out of the equation.

Last Spring, Congress introduced the State Opioid Response Grant Authorization Act of 2021 (H.R. 2379), which included a 5 percent set-aside of the funds made available for each fiscal year for Indian Tribes, Tribal organizations, and UIOs to address substance abuse disorders through public health-related activities such as implementing prevention activities, establishing or improving prescription drug monitoring programs, training for health care practitioners, supporting access to health care services, recovery support services, and other activities related to addressing substance use disorders. NCUIH worked closely with Congressional leaders to ensure the inclusion of urban Indians in the funding set-aside outlined in this bill, which eventually passed the House on October 20, 2021. Despite this effort, UIOs were removed from the SOR Grant reauthorization, which saw a $5 million increase (9 percent increase from FY 2021), included in the recently passed FY 2022 Omnibus (H.R. 2471). The final language in the Omnibus only listed “Indian Tribes or Tribal organizations” as eligible and did not use the language from H.R. 2379. When UIOs are not explicitly stated as eligible entities, we are excluded from critical resources and grants, which is a violation of the trust obligation.

We were disappointed to yet again be left out of this key resource as our communities are plagued by the opioid crisis. Inclusion in this program could have enabled UIOs to expand services or workforce or to help address the catastrophic impacts of the opioid epidemic in Indian Country.  We urge you to work to ensure funding designated to help AI/AN communities have the proper language to prevent UIOs from lacking access to these critical funds.

Conclusion

These requests are essential to ensure that urban Indians are properly cared for, both during this crisis and in the critical times following. It is the obligation of the United States government to provide these resources for AI/AN people residing in urban areas. This obligation does not disappear in the midst of a pandemic, instead it should be strengthened, as the need in Indian Country is greater than ever. We urge Congress to take this obligation seriously and provide UIOs with all the resources necessary to protect the lives of the entirety of the AI/AN population, regardless of where they live.

[1] https://files.constantcontact.com/a3c45cb9201/562eb81b-dee4-48b8-8519-69bcbebb0ff2.pdf?rdr=true
[2] https://www.usatoday.com/story/news/politics/2022/03/07/opioids-native-americans-funding/9380063002/?gnt-cfr=1

NCUIH Sends Letter in Support of the IHS Request to Detail Public Health Service Commissioned Officers to Urban Indian Organizations

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On May 24, 2022, the National Council of Urban Indian Health (NCUIH) sent a letter to the Chairs of the House and Senate Appropriations Committees, Representative Chellie Pingree (D-ME-1), and Senator Jeff Merkley (D-OR), and to the Ranking Members Representative David Joyce (R-OH-14) and Senator Lisa Murkowski (R-AK), expressing NCUIH’s support for detailing Public Health Service Commission Officers (PHSCOs) to Urban Indian Organizations (UIOs). Detailing officers to UIOs would assist UIO personnel in providing skilled, culturally competent healthcare, help address workforce shortages, and increase collaboration across the federal healthcare system.

Amending the law would provide the Indian Health Service (IHS) with the discretionary authority to detail PHSCOs directly to a UIO to perform work related to the functions of the Service. Such authority would be comparable to the existing authority to detail Officers to Indian Self Determination and Education Assistance Act (ISDEAA) contractors and compactors for the purpose of carrying out the provisions of their ISDEAA contracts (section 7 of the Act of August 5, 1954 (42 U.S.C. § 2004b). The bill would support the 41 UIOs that serve the 70% of American Indians and Alaska Natives that live outside of reservations. Currently, UIOs only get 1% of IHS funding, so to fully staff UIOs, Public Health Service Commissioned Officers need to be deployed.

The Biden Administration and IHS support this deployment of PHSCOs to UIOs by including the provision in their Fiscal Year 2023 budget. NCUIH urges Chair Pingree and Merkley and Ranking Members Joyce and Murkowski to support this provision in the 2023 budget, and if not feasible, to support this provision in the next budget or in a stand-alone bill.

Background

Section 215 of the Public Health Service Act (PHSA) authorizes the Secretary of Health and Human Services (HHS) to detail officers to federal agencies and state health or mental health authorities. While UIOs have requested that officers be detailed to them to fill many roles related to the functions of the Public Health Service, subsection (c) of Section 215 (42 U.S.C. 215(c)) prevents UIOs from receiving detailed officers because they do not fall within the requirement that non-profits eligible for detailing be educational or research non-profits, or non-profits engaged in health activities for special studies and dissemination of information.” UIOs do not qualify under the current statutory language. Changing this language would allow IHS to detail officers to UIOs to perform work related to the functions of the Indian Health Service.

NCUIH Submits Comments to IHS on the Special Diabetes Program for Indians for Fiscal Year 2023

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On May 16, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to the Indian Health Service (IHS) about the Special Diabetes Program for Indians (SDPI). These comments responded to the Dear Urban Indian Organization Leader correspondence initiating Area Urban Confers on the SDPI, dated April 15, 2022. In the comments, NCUIH emphasized the importance of SDPI and its impact in reducing health disparities related to diabetes for AI/AN populations. NCUIH also proposed recommendations for fiscal year (FY) 2023 including an increase in funding to at least $250 million with built-in automatic annual medical inflationary increases and additional support for UIOs seeking supplemental funding sources for diabetes-related care.

SDPI and Its Importance to Indian Country

As a grant program inclusive of all three components of the IHS/Tribal Health Program/Urban Indian Organization (I/T/U) system, SDPI has been a resounding and demonstrable success in reducing diabetes and diabetes-related illnesses in Indian Country. The National Indian Health Board has called SDPI “the nation’s most strategic, comprehensive and effective effort to combat diabetes and its complications.” SDPI remains a critical program to continue to address disparately high rates of diabetes among AI/ANs.

SDPI 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. As of 2022, 30 out of the 41 UIOs received SDPI funding. Facilities use these funds to offer a wide range of diabetes treatment and prevention services, including but not limited to exercise programs and physical activity, nutrition services, community gardens, culinary education, physical education, health and wellness fairs, culturally-relevant nutrition assistance, food sovereignty education, group exercise activities, green spaces, and youth and elder-focused activities.

NCUIH’s Requests to IHS

NCUIH made the following comments and recommendations about the SDPI:

  • SDPI should be permanently reauthorized and funding increasing to $250 million, with built-in automatic annual medical inflationary increases
    • SDPI funding has been stagnant at $150 million since 2004. Due to inflation and increases in health care costs, the level of funding has effectively reduced over the past nearly twenty years. This places the onus on Indian Health Care Providers to make up the funding difference to ensure the continued success of SDPI.
    • The federal government’s trust responsibility to AI/ANs requires that the government provide services and resources to improve the health of AI/AN citizens and the United States has pledged to provide all resources necessary to eradicate the health disparities between AI/ANs and the general population of the United States. Because AI/ANs have the highest diabetes prevalence rates of all racial and ethnic groups in the United States, SDPI falls well within the federal government’s trust responsibility to AI/ANs, and it is the duty of the United States, not Tribes and UIOs, to reconcile funding concerns with programmatic need.
    • In addition, NCUIH urges the federal government to collaborate with other federal agencies to create or identify supplemental funding sources and communicate the availability of these funds to UIOs.
  • NCUIH requests that IHS ensure that SDPI remains inclusive of UIOs, especially if IHS is considering structural changes to SDPI.
    • NCUIH asks that IHS communicate any potential recommendations to UIOs as soon as possible and hold proper and timely Urban Confer sessions, as is required by the federal trust responsibility and the Indian Healthcare Improvement Act, prior to making any formal recommendations to Congress.

NCUIH will continue to closely follow IHS’s progress and policies with SDPI and advocate for future of this vital program.

Government Accountability Office Calls on Agencies to Improve Information on Federal Funds for Native Communities and the Budget Formulation Process

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On May 19, 2022, the Government Accountability Office (GAO) published a new report calling for immediate action to improve transparency for federal funding that benefits American Indians and Alaska Natives (AI/ANs), including AI/ANs living in urban areas. GAO found divergent interpretations of the Office of Management and Budget’s (OMB) guidance for identifying and providing information on federal funding related to the Native American crosscut. GAO also found that three of the agencies whose budgets are captured in the crosscut do not have formal processes for incorporating Tribal input into their budget proposals and do not develop budgets that reflects the needs of Tribes.  The report recommends seven key agency actions to improve budget formulation and reporting processes for programs that serve AI/AN communities, including urban Indian organizations (UIOs) and the 70 percent of AI/ANs living in urban areas.

The Native American Crosscut and The Beginning of GAO’s Investigation

GAO is an independent, nonpartisan federal agency tasked by Congress with examining how taxpayer dollars are spent and provides both Congress and federal agencies fact-based recommendations to help the government save money and work more efficiently. GAO reviews federal programs across a broad range of topics and concerns, including health care, education, economic development, environmental protection, justice, and infrastructure. Agency oversight supports federal efforts to uphold the trust responsibility.

The U.S. Commission on Civil Rights published a 2018 report detailing broken promises to AI/ANs, which recommended regular assessment of unmet needs for both urban and rural AI/AN communities. Shortly thereafter, GAO launched an investigation of agency failures to keep accurate, consistent, and comprehensive records of federal programs benefiting AI/ANs, and transparency mechanisms to facilitate monitoring of such funding. This included a review of consultation, data collection, and reporting practices at OMB. OMB serves as a clearinghouse for budget formulation and reporting across federal agencies and publishes the most comprehensive annual report of federal funding that benefits Native peoples across federal agencies, known as the Native American crosscut. GAO also investigated the extent to which pertinent agencies have formal processes for incorporating Tribal input when developing their budget proposals and the extent to which their budget proposals reflects Tribal needs

GAO’s Recommendations Regarding the Native American Crosscut and Budget Formulation

GAO published seven recommendations to improve federal practices related to budget formulation, data sharing, transparency, and oversight:

  1. The Director of OMB should issue clear guidance as part of the annual budget data request for the Native American Crosscut that directs agencies to provide detailed information about how they collected data to report and selected programs to include; and
  2. The Director of OMB should publish in the Native American Crosscut a statement of its purpose and detailed information that it receives from agencies in response to its budget data request; and
  3. The Director of OMB should establish a formal process to regularly solicit and assess feedback about the Native American Crosscut from tribal stakeholders and relevant federal agencies, and to incorporate such feedback into guidance; and
  4. The Secretary of Transportation should ensure that the Deputy Assistant Secretary for Intergovernmental Affairs develops a formal process to ensure meaningful and timely input from tribal officials when formulating budget requests and program reauthorization proposals for programs serving tribes and their members; and
  5. The Secretary of Education should ensure that the department develops a formal process to ensure meaningful and timely input from tribal officials when formulating budget requests for programs serving tribes and their members; and
  6. The Secretary of Agriculture should ensure that the Office of Tribal Relations and the Office of Budget and Program Analysis develop a formal process to ensure meaningful and timely input from tribal officials when formulating budget requests and program reauthorization proposals for programs serving tribes and their members; and
  7. The Director of OMB should update OMB’s annual budget guidance to direct federal agencies to assess, in consultation with tribes, tribal needs for federal programs serving tribes and their members, and submit this information as part of their publicly available budget documents.

Though the report did not provide explicit recommendations for the Department of Health and Human Services (HHS) or the Department of the Interior (DOI), GAO noted the failure to provide public notice in Indian Health Service budget formulation sessions and concerns that inclusion of urban Indian organizations in such processes remains discretionary.

In response to the published recommendations, OMB expressed overall agreement, shared general plans to better capture and report on funding that benefits Native peoples, and is currently considering new consultation recommendations. The Department of Transportation and the Department of Education agreed with the relevant recommendations, while the Department of Agriculture neither agreed nor disagreed.  DOI provided no comments.

NCUIH will continue to monitor ongoing efforts to improve the budget formulation process, and to provide updates to budget formulation and reporting practices across federal agencies.

NCUIH Submits Comments on Fiscal Year 2023 Appropriations Priorities to the Office of Management and Budget

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On May 18, 2022, NCUIH submitted written comments and recommendations in response to the Office of Management and Budget (OMB) Dear Tribal Leader letter seeking Tribal consultation on appropriations priorities for programs and services that serve Tribal governments, organizations, and peoples in Fiscal Year (FY) 2023. Though NCUIH noted recent investments in the Indian Health Service (IHS) discretionary budget, the comments highlighted evidence that funding falls far short of documented need and fails to address inflation in the cost of medical care, particularly for the 70 percent of American Indians/Alaska Natives living in urban areas. NCUIH made six key recommendations to fully fund and support health services for Native organizations and communities, including urban Indian organizations (UIOs).

Background

OMB serves as a clearinghouse for budget formulation by developing overarching presidential priorities, coordinating across agencies, and publishing the annual President’s Budget. Last year’s Presidential Memorandum on Tribal Consultation and Strengthening Nation-to-Nation Relationships established an ongoing priority to uphold the federal trust responsibility through tribal engagement and consultation. Consistent with this memorandum, the OMB initiated a Tribal consultation to promote tribal priorities in the FY 2023 President’s Budget on April 25, 2022. Officials sought comment on programs that serve Tribal governments, organizations, and communities. In particular, the agency noted interest in feedback on shifting funding for IHS from discretionary to mandatory and reclassifying 105(l) Lease costs.

Current Action

NCUIH made six recommendations to improve delivery of health services to AI/ANs living in urban areas through the FY 2023 budget, including:

  1. Fully Fund Urban Indian Health at $949.9 million for FY 2023.
    As of FY 2018, the average health care spending is $11,172 per person, however, Tribal and IHS facilities receive $4,078 per IHS-eligible patient. UIOs receive just $672 per AI/AN patient from the IHS budget, significantly below federal per capita spending levels. This forces UIOs to operate on very slim margins, causing significant difficulty during unforeseen events.
  1. NCUIH supports the President’s FY 2023 Budget proposal for mandatory funding for the IHS.
    Since 1997, IHS has only once received full-year appropriations by the start of the fiscal year (FY 2006). This leaves the IHS subject to government shutdowns, automatic sequestration cuts, and continuing resolutions, which negatively impact patient care. For instance, during the 35-day government shutdown at the start of FY 2019, UIOs were forced to lay-off staff, reduce hours, reduce services, and some, unfortunately, had to temporarily close their doors due to the lack of funding. Mandatory funding for IHS is necessary and long overdue to ensure stable and predictable funding for AI/AN healthcare that is exempt from the political process.
  1. NCUIH requests that OMB hold a separate urban confer with UIOs to discuss the budget request for urban Indian health programs.
    IHS is the only federal agency with an Urban Confer Policy—no other agency, including agencies under the Department of Health & Human Services (HHS) that oversee programs for UIOs, has an established mechanism for dialogue with UIOs. Outside of the IHS Urban Confer process, urban AI/ANs have no specific representation with federal agencies regarding health care matters that affect them, leaving them on the margins of critical conversations on AI/AN health care that occurs across the Executive Branch.
  1. Create a Tribal Office and a Tribal Advisory Committee with UIO Representation
    During the recent virtual OMB consultations, Tribal leaders asked for a permanent position within OMB dedicated to AI/AN health care, a liaison between Indian Country and OMB, and/or an Office of Tribal Affairs within OMB. This new position or office would help coordinate communication and facilitate outreach to address budgetary shortfalls. NCUIH supports this request and stresses that UIO consultation and involvement is imperative to fulfill the President’s vision to improve health equity for AI/ANs. NCUIH also supports the request that OMB establish an OMB Tribal Advisory Committee with UIO representation.
  1. NCUIH requests that OMB provide an exception apportionment that is inclusive of the entire I/T/U system.
    In the absence of an exception apportionment, if Congress does not reach a budget agreement in time and the federal government must shut down, UIOs are subject to the shutdown. Federal shutdowns require UIOs to lay off staff, reduce hours and services, and even shut their doors, ultimately leaving their patients without adequate health care. During the 2019 shutdown, multiple patients died while an East Coast UIO was closed.
  1. Improve data accuracy for urban AI/ANs
    OMB’s Office of Information and Regulatory Affairs (OIRA) oversees the implementation of federal government-wide policies in the areas of information policy, privacy, and statistical policy. In this field of practice, the establishment of statistical standard practices is a critical government function. When searching for and comparing health indicators, assessing the health status of entire AI/AN communities, testing academic research using vital statistics, and conducting epidemiological studies in support of public health, it is very common to wrestle with misclassifications of race for AI/AN people. This is due, at least in part, to the fact that tribal membership or descendancy is a political status classification, not a racial category.  .NCUIH requests that OMB consult with NCUIH and UIOs to ensure that OIRA’s statistical standard practices appropriately account for urban AI/ANs. Additionally, NCUIH requests that OMB commit to continuously consulting and working with NCUIH and UIOs to improve OIRA’s data accuracy for urban AI/ANs

NCUIH will continue to monitor the FY 2023 budget formulation process and report developments across federal agencies and in Congress.