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

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

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

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

The TBFWG stated:

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

Other TBFWG priorities for Urban Indian Health were:

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

Status of FY 2023 Appropriations

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

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

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

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

The TBFWG consists of two Tribal representatives from each of the 12 IHS Areas. Additional representatives from Indian organizations, participate in the workgroup at the discretion of the Director of IHS. The workgroup provides input and guidance to the IHS Headquarters budget formulation team throughout the remainder of the budget formulation cycle for that fiscal year. The workgroup prepares the final set of tribal budget recommendations with an accompanying testimony on the results of the national budget work session and presents to the IHS Director as well as to the Department of Health and Human Services (HHS) senior officials at the annual HHS Tribal Consultation meeting.

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

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

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

Full Text of Letter:

Dear Senate and House Leadership,

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

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

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

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

Thank you for your consideration of our request.

Background on Advance Appropriations for IHS

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

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

Resources on Advance Appropriations for IHS:

NCUIH and Indian Country Advocacy

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

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

Federal and Congressional Support

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

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

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

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

History of Advance Appropriations Bills

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

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

Next Steps

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

 

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

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

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

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

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

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

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

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

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

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

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

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

View the resource

AI/AN Infant and Maternal Health Disparities

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

AI/AN Infant and Maternal Health Disparities

Urban AI/AN Infant and Maternal Health Disparities

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

AI/AN Infant and Maternal Health Disparities

Contributing Factors to AI/AN Infant and Maternal Health Disparities

AI/AN Infant and Maternal Health Disparities

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

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

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

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

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

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

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

 

 

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

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

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

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

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

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

[7] Id.

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

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

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

NCUIH Recommendations to IHS

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

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

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

Background

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

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

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

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

VA Expands Health Care Eligibility for Veterans under the PACT Act, Native Veterans Encouraged to Check Eligibility for Benefits

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On September 28, 2022, the Department of Veterans Affairs (VA) announced that it will expand and extend eligibility for VA health care for certain Veterans of the Vietnam, Gulf War, and post-9/11 eras pursuant to the Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act (S. 3373). As a result of the PACT Act, generations of Veterans will now have access to VA health care and benefits they earned and deserve, including American Indian/Alaska Native (AI/AN) Veterans who serve in the military at a higher rate than any other population. For more information on how to apply for health care or learn more about what the PACT Act means for Veterans or their families visit: VA.gov/PACT.

Expansion Details:

Beginning on October 1, 2022, post-9/11 Veterans who did not previously enroll in VA health care will have a 1-year window to enroll if they:

  • Served on active duty in a theater of combat operations during a period of war after the Persian Gulf War, or
  • Served in combat against a hostile force during a period of hostilities after Nov. 11, 1998, and
  • Were discharged or released from active service between Sept. 11, 2001, and Oct. 1, 2013.

The following groups of Veterans will also be eligible for care beginning October 1:

  • Gulf War Veterans who served on active duty in a theater of combat operations during a period of war after the Persian Gulf War. This includes Veterans who, in connection with service during such period, received the Armed Forces Expeditionary Medal, Service Specific Expeditionary Medal, Combat Era Specific Expeditionary Medal, Campaign Specific Medal, or any other combat theater award established by federal statute or executive order.
  • Vietnam-era Veterans who served in the following locations and time periods : The Republic of Vietnam between Jan. 9, 1962, and May 7, 1975 Thailand at any U.S. or Royal Thai base between Jan. 9, 1962, and June 30, 1976; Laos between Dec. 1, 1965, and Sept. 30, 1969; Certain provinces in Cambodia between April 16, 1969, and April 30, 1969; Guam or American Samoa (or their territorial waters) between Jan. 9, 1962, and July 31, 1980 ; Johnston Atoll (or on a ship that called there) between Jan. 1, 1972, and Sept. 30, 1977

Background on the PACT ACT

On August 10, 2022, President Biden signed the bipartisan PACT Act into law, authorizing one of the largest expansions of VA health care and benefits in U.S. history.  Before the PACT Act’s passage, many Veterans’ claims for healthcare services and other benefits were denied by VA because Veteran claimants had difficulty proving a connection between their ailment and their service. The PACT Act is intended to remove barriers to Veterans getting care, expanding the number of Veterans who are eligible for care and streamlining the process for proving a service connection for certain conditions related to toxic exposure.

The PACT Act will bring the following changes:

  • Expands and extends eligibility for VA health care for Veterans with toxic exposures and Veterans of the Vietnam, Gulf War, and post-9/11 eras
  • Adds more than 20 new presumptive conditions for burn pits and other toxic exposures
  • Adds more presumptive-exposure locations for Agent Orange and radiation
  • Requires VA to provide a toxic exposure screening to every Veteran enrolled in VA health care
  • Helps VA improve research, staff education, and treatment related to toxic exposures

AI/AN Veterans

There is an urgent need to ensure that all AI/AN Veterans have access to the benefits they earned through their service.  According to a 2020 VA Report, AI/AN Veterans served in the Pre-9/11 period at a higher percentage than other Veteran populations.  Despite a distinguished record of service, VA’s statistics also show that AI/AN Veterans were more likely to be unemployed, were more likely to lack health insurance, and were more likely to have a service-connected disability when compared to Veterans of other races.  In addition, in Fiscal Year 2017, AI/AN Veterans used Veterans Benefits Administration benefits or services at a lower percentage than veterans of other races.

NCUIH and the VA

The National Council of Urban Indian Health (NCUIH) has continued 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 VA, urban Indian organizations (UIOs) are now eligible to enter the VA Indian Health Service/Tribal Health Program (THP)/UIO Reimbursement Agreements Program, which provides VA reimbursement to IHS, THP, and UIO health facilities for services provided to eligible AI/AN Veterans. In October 2021, Sonya Tetnowski, President of NCUIH and CEO of the Indian Health Center of Santa Clara Valley, Army Veteran, and member of the Makah Tribe was appointed to the VA’s first-ever Advisory Committee on Tribal and Indian Affairs to represent the voice of urban Indians.

NCUIH Attends Swearing-In of New IHS Director Roselyn Tso

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Group photo of Francys Crevier, Roselyn Tso, Walter MurilloOn September 27, 2022, NCUIH attended the swearing-in of the new Indian Health Service (IHS) Director Roselyn Tso (Navajo). NCUIH’s CEO Francys Crevier (Algonquin) and Board President-Elect and CEO of Native Health in Phoenix, Arizona Walter Murillo (Choctaw) were in attendance. Prior to Director Tso’s swearing-in, IHS was without a permanent director for 21 months.

Director Tso is a citizen of the Navajo Nation. She began working for IHS in 1984 and most recently served as the Director of the Navajo Area and Director of the Office of Direct Services and Contracting Tribes until her confirmation. Prior to her work in IHS, much of her professional career was spent in Portland, where she served in several capacities, including working with the three urban programs in the Portland Area that provide services ranging from community health to comprehensive primary health care services. Director Tso holds a Bachelor of Arts in interdisciplinary studies and a master’s degree in organizational management from Marylhurst University in Portland, Oregon. As the IHS Director, Tso is responsible for administering a nationwide health care delivery program that is responsible for providing comprehensive health care services to AI/ANs through IHS, Tribes, Tribal organizations, and urban Indian organizations (UIOs).

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

“We are delighted by the recent swearing-in of Roselyn Tso as the Director of the Indian Health Service. We look forward to working with Ms. Tso to achieve the highest health status for all American Indians and Alaska Natives and move us closer to fulfilling the federal government’s trust responsibility to our people. We will continue to advocate for the elevation of this position to Assistant Secretary for Indian Health within HHS to bring better representation for the health needs of Natives,” – Francys Crevier (Algonquin), CEO, NCUIH.

Next Steps

NCUIH looks forward to building a working relationship with Director Tso as we continue to work towards our shared goal of improving the health of urban American Indians and Alaska Natives.

NCUIH Submits Comments on Executive Order 14053 About Missing and Murdered Indigenous People

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On September 8, the National Council of Urban Indian Health (NCUIH) submitted comments on Executive Order 14053 “Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People.” This comment was in response to the Department of Homeland Security’s (DHS) correspondence dated May 25, 2022, seeking input and recommendations on the policy directives outlined.

NCUIH requested the following:

  • NCUIH requested that DHS honor E.O. 14053 by including urban Indian organizations (UIOs) in policies, procedures, and projects to address Missing and Murdered Indigenous People (MMIP).
    • Working with UIOs is specifically required by E.O. 14053 itself
    • According to the National Missing and Unidentified Persons System (NamUs), as of August 1, 2021, most missing and unidentified cases involving American Indian/Alaska Native (AI/AN) persons occurred off tribal land. AI/AN individuals living in urban areas face many, if not all, of the same violent crime and MMIP issues as AI/ANs living on reservations or tribal Iand.
    • In particular, UIOs can be critical partners in DHS’ efforts to address cross-border and jurisdiction issues.
    • We note that UIOs have already been working on addressing human trafficking through programs and services to victims and their families. For example, First Nations Community Healthsource in Albuquerque, New Mexico, has an Education and Advocacy against Sex Trafficking (EAST) program dedicated to supporting AI/AN victims of sex trafficking in the area and surrounding Tribal communities.
  • NCUIH recommended that DHS hosts an Urban Confer Regarding DHS’ Plan to Address MMIP.
    • To assist DHS collaboration with UIOs in fulfillment of the goals and directives of E.O. 14053, NCUIH recommends that DHS host an Urban Confer with UIOs regarding E.O. 14053. Urban Confers are an established mechanism for dialogue between the federal government and UIOs that are a response to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that resulted in seventy percent (70%) of AI/AN people living outside of Tribal jurisdictions, thus making Urban Confer integral to address the care needs of most AI/AN persons.

Background

EO 14053

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.” NCUIH is particularly encouraged by DHS’s efforts to communicate with Tribes as DHS continues to grow its efforts to support public safety in Tribal communities. NCUIH agrees with the Biden-Harris Administration that challenges faced by Tribes are best met by Tribally-driven solutions and appreciates that the DHS hosted several Tribal Consultation sessions from July to August 2022 seeking input and recommendations concerning DHS’ efforts to address the unacceptably high rate of violent crime in AI/AN communities. These efforts advance President Biden’s directive in E.O. 14053, to engage in “[c]onsistent engagement, commitment, and collaboration,” with AI/AN people and communities to “drive long-term improvement to public safety for all Native Americans” is essential to ensure AI/AN voices are included in issues that directly affect their communities at dipropionate rates.

E.O. 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.” Furthermore, E.O. 14053 also instructs 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.” Despite E.O. 14053 recognizing that the federal government must develop solutions for AI/ANs living in urban areas and that UIOs must be included in the development of these solutions to address the unacceptably high rate of violent crime and MMIP, DHS has not made any efforts to work with UIOs to date.

  • NCUIH Efforts on MMIP On May 19, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments on Executive Order (EO) 14053— Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People.  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.
  • May 5, National MMIP Awareness Day, Secretary of the Interior Deb Haaland and Deputy Attorney General Lisa Monaco hosted an event to announce the U.S. Department of the Interior (DOI)’s Not Invisible Act Commission (Commission). The Commission is led by the Departments of the Interior and Justice and is aimed at reducing violent crime against American Indians and Alaska Natives. Members of the Commission include Sonya Tetnowski (Makah), the National Council of Urban Indian Health’s President-Elect and the Chief Executive Officer of the Indian Health Center of Santa Clara Valley. NCUIH supported the nomination of Ms. Tetnowski who also serves on the S. Department of Veterans Affairs (VA) Advisory Acommittee on Tribal and Indian Affairs Commision Member Tetnowski said “I am honored and proud to be appointed to the Not Invisible Act Commission. In this role, I will work hard to shed light on the devastating impact of violence against American Indians and Alaska Natives (AI/ANs) living in urban areas.
  • On April 15, 2022, NCUIH submitted written comments and recommendations in response to the Department of Justice’s (DOJ) Dear Tribal Leader Letter seeking stakeholder input on DOJ’s efforts to address the unacceptably high rates of violent crime in American Indian and Alaska Native communities and the missing and murdered Indigenous persons (MMIP) crisis. In its comments, NCUIH noted the need for the federal government to also work with Urban Indian Organizations (UIOs) to address these issues. NCUIH further offered to assist DOJ in establishing strong working relationships with UIOs as it works to address these pressing public safety issues.

Next Steps

NCUIH will continue to advocate for and comment on UIO inclusion in addressing the MMIP crisis.

NCUIH Submits Comment on Consistent Application of the Indian Child Welfare Act

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On September 7, the National Council of Urban Indian Health(NCUIH) submitted written comments to the Bureau of Indian Affairs (BIA) and the Administration for Children and Families (ACF) on the BIA and ACF’s efforts to promote the consistent application of the Indian Child Welfare Act (ICWA) and protect children, families, and Tribes.

In the submitted comments, NCUIH made the following specific comments, requests, and recommendations to ACF and BIA in response to the July 8, 2022 correspondence:

  • Ensure that urban child welfare and judicial systems are aware of and able to implement ICWA appropriately
    • According to the National Indian Child Welfare Association (NICWA), American Indian/Alaska Native(AI/AN) children continue to be overrepresented in the state foster care system at a rate 7 times higher than their non-Native peers. Because more than 70% of AI/AN people live in urban settings, this overrepresentation undoubtedly includes AI/AN children living in urban areas.
    • To properly implement ICWA, state courts must determine whether a child is an “Indian Child” for the purposes of ICWA as a threshold determination in the proceedings. There are states with experience in the application of ICWA and making applicability determinations. However, some state courts and child protective agencies may not be aware of this requirement or may make incorrect assumptions about a child’s “Indian child” status based on physical appearance or distance from their Tribe. This process needs to be standardized across all states to ensure the safety of these children
    • An AI/AN child’s physical location should not affect whether they receive ICWA’s protections. Specifically, NCUIH requests that ACF and BIA provide technical assistance on ICWA to state social service and child welfare agencies and courts located in urban areas.
  • Actively inform urban child welfare and judicial systems about urban Indian organizations (UIOs) as a potential resource for ICWA proceedings
    • NCUIH recommended that, as part of their efforts to strengthen and implement ICWA, ACF and BIA actively inform state child welfare and judicial systems located in urban areas about UIOs as a potential ICWA resource.
    • While UIOs are healthcare organizations, they often provide culturally competent services that state child welfare services and courts can refer parents to in accordance with ICWA’s “active efforts” requirements. For example, various UIOs provide the following services: family support services, parenting classes and groups, gender-based violence programs, and breastfeeding support.
    • Because UIOs are AI/AN organizations, they may be able to provide useful contacts or other information when a state child welfare agency throughout the child welfare process, including during the initial “Indian child” determination phase.
    • The UIO connection may be particularly useful in areas, such as Chicago, where there is an active UIO but no federally recognized Tribes nearby, and urban systems may not know where to start with the ICWA process.

Background

Congress enacted ICWA in 1978 to re-establish tribal authority over the adoption of Native American children (25 U.S.C. § 1903.) The goal of the Act was to strengthen and preserve Native American family structure and culture. Studies conducted in advance of ICWA’s drafting showed that between 25% and 35% of all Native children were being removed from their home by state child welfare and private adoption agencies. Of those, 85% were placed with non-Native families, even when fit and willing relatives were available. ICWA was established as a safeguard that requires:

  1. Recognition of Tribal jurisdiction over decisions for their Indian children;
  2. Establishment of minimum Federal standards for the removal of Indian children from their families;
  3. Establishment of preferences for placement of Indian children with extended family or other Tribal families; and
  4. Institution of protections to ensure that birth parents’ voluntary relinquishments of their children are truly voluntary.

According to NICWA, ICWA “[l]essens the trauma of removal by promoting placement with family and community . . . [p]romotes the best interest of Indian children by keeping them connected to their culture, extended family, and community, which are proven protective factors . . . [and] [p]romotes placement stability by ensuring that voluntary adoptions are truly voluntary.”

Next Steps

NCUIH will continue to advocate for  the appropriate application of ICWA to all welfare proceedings involving AI/AN children, regardless of whether the child is located in an urban or rural community.

 

 

USDA Publishes 2022 Tribal Resource Guide

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On August 16, 2022, the United States Department of Agriculture (USDA) released the 2022 edition of the USDA Resource Guide for American Indians and Alaska Natives (Resource Guide). The Resource Guide provides information regarding USDA resources and services available to tribal governments, citizens, and organizations. The Resource Guide covers four categories of USDA programs: 1) agriculture, food sovereignty, and traditional foods; 2) Indian Country economic development; 3) conservation and forestry; and 4) research, extension, and outreach. Additionally, the USDA released the Native Youth Resource Guide (Youth Guide). The Youth Guide summarizes USDA scholarship opportunities, internship programs, cultural summer camps for Native youth, afterschool activities, and resources for employment in the federal government.

Background

The USDA is a federal executive department responsible for food, agriculture, natural resources, rural development, nutrition, and related issues within the United States. The USDA plays an important role in the development of tribal nations and self-governance.  Funding from the USDA helps grow new tribal agricultural ventures, promote traditional food ways, and benefit Indigenous health through foods tailored to American Indian/Alaska Native dietary needs. As a federal agency, the USDA helps advance the federal trust responsibility to Native American communities.

The newly published Resource Guides seek to provide transparency to tribal nations. “These guides can introduce our tribal nation partners to the many USDA funding opportunities and resources that can benefit them and their communities,” remarked Secretary of Agriculture, Tom Vilsack. NCUIH recommends tribal nations use the Resource Guides to help facilitate growth within Indian Country.