Urban Indian Organizations Encouraged to Apply for Healthy Lifestyles in Youth Cooperative Agreement

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On August 12, 2022, the Indian Health Service (IHS) announced a request for applications for the Healthy Lifestyles in Youth (HLY) grant program. Aimed at improving the health of American Indian and Alaska Native (AI/AN) youth, the program supports health promotion and education programs, to address healthy lifestyle development, and emphasizes nutrition and physical activity for AI/AN children 7 to 11 years old. IHS will issue one award under this announcement, and the project period for the program will be five years. The identified funding for FY 2022, the first budget year for the grant, is $1,250,000. Applications for this cooperative agreement should be submitted by September 15, 2022, through grants.gov. The earliest anticipated start date is September 30, 2022. Urban Indian organizations (UIOs) are eligible and encouraged to apply. For more details on the requirements for the application and the cooperative, see here.

Awardees of this cooperative agreement must take on the following:

  • Collaboration with selected Native American Boys and Girls Club sites using the “Together Raising Awareness for Indian Life” (TRAIL) curriculum
  • Administer health and physical education programs
  • Support youth in achieving and maintaining healthy lifestyles through participation in fitness programs
  • Help youth acquire a range of physical skills
  • Facilitate the development of a sense of teamwork and cooperation amongst youth

Background

Through the HLY grant, facilities can offer a wide range of prevention and treatment services – exercise and physical activity programs, community gardens, culinary education programs, health and wellness fairs, culturally-relevant nutrition assistance, group exercise activities, garden spaces and youth-focused activities. Evidence-based early intervention strategies have been shown to reduce, or even halt, the increasing trend in obesity and diabetes among youth and young adults. The TRAIL curriculum was developed to educate the youth participating on good nutrition and to promote physical activity. Through a 3-month, 12-lesson program, the curriculum may help to curtail the effect of unhealthy behaviors surrounding food and physical activity, which can lead to obesity, diabetes, and/or other chronic illness throughout life.

Compared to the general Indian population, urban AI/AN communities experience exacerbated health problems due to lack of family and traditional cultural environments in major metropolitan areas. Urban AI/AN youth are at greater risks for serious mental health and substance abuse problems, suicide, gang activity, teen pregnancy, abuse, and neglect. Between 1994 and 2004, the type 2 diabetes rate for AI/AN youth 15 to 19 years old increased by 68%. Despite the disproportionately high rates of health disparities in urban AI/AN populations, UIOs have continued to provide critical services aimed at addressing and combatting negative health outcomes through grants and cooperative agreements. For example, as of 2022, 30 of the 41 UIOs received funding through the Special Diabetes Program for Indians.

Call to Action

NCUIH encourages interested UIO leaders to submit application materials to IHS via grants.gov by September 15, 2022. UIOs are uniquely positioned, in part thanks to their work through the Special Diabetes Program for Indians grants, to already have established programs focused on exercise and physical activity, culturally relevant nutrition programs, and youth programs.

Please contact NCUIH’s Policy department at policy@ncuih.org if you would like assistance with the submission, or if you plan to apply.

House Passes Major Mental Health Legislation with over $3.5 billion for Urban Indian Health and Inclusion in Opioid Grants

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On June 22, 2022, the House passed the Restoring Hope for Mental Health and Well-Being Act (H.R. 7666) in a vote of 402-20. The bill includes over $3.5 billion in funding for behavioral health activities and programs eligible to urban Indian organizations (UIOs). After much NCUIH advocacy, UIOs were included as eligible entities for State Opioid Response (SOR) grants in this legislation. Urban Indians continue to disproportionately suffer from behavioral health issues at a rate much higher than the general population, which has only been exacerbated by the COVID-19 pandemic. This mental health package allows UIOs to have greater access to vital resources necessary to address the critical health needs of urban Indians and brings the federal government closer to fulfilling its trust obligations to American Indian/Alaska Native (AI/AN) populations.

Bill Highlights for Urban Indian Organizations

Behavioral Health

AI/AN populations are at a substantially higher risk for behavioral health issues than the general population. AI/ANs had the second-highest rate of opioid overdose out of all U.S. racial and ethnic groups in 2017, and the second and third highest overdose death rates from heroin and synthetic opioids, respectively, according to the Centers for Disease Control and Prevention. AI/ANs residing in urban areas face significant behavioral health disparities – for instance, 15.1% of urban AI/ANs report frequent mental distress as compared to 9.9% of the general public, and the AI/ AN youth suicide rate is 2.5 times that of the overall national average.

Reauthorizing the Tribal Behavioral Health (Native Connections) Grant

The Tribal Behavioral Health grant (known as Native Connections) is a five-year grant authorized by the Substance Abuse and Mental Health Services Administration (SAMSHA) that helps AI/AN communities identify and address the behavioral health needs of Native youth. The program aims to help reduce suicidal behavior among Native youth, easing the impacts of substance use, mental illness, and trauma in tribal communities.

H.R. 7666 reauthorizes this grant in Section 121 and will allow UIOs to provide culturally appropriate mental health and substance use disorder prevention, treatment, and recovery services to AI/ANs. This bill authorizes $599,036,000 in appropriations for each of FY 2023 through FY 2027, an increase from the $394,550,000 previously authorized.

Addressing The Native Behavioral Health Access Improvement Act of 2021

In July of 2021, Congress introduced the Native Behavioral Health Access Improvement Act of 2021 (S. 2226) which would require the Indian Health Service (IHS) to allocate $200 million for the authorization of a program targeting behavioral health needs of AI/AN populations.

Inspired by the language of S. 2226, Section 201 of H.R. 7666 authorizes $40 million for FY 2023 through FY 2027 to eligible entities, including UIOs, for mental and behavioral health programs that focus on mental well-being. Although H.R. 7666 funds less than the amount proposed in S. 2226, it succeeds in establishing a program to allocate resources empowering UIOs to improve behavioral health for all Native Americans living in urban settings.

State Opioid Response Grant

Background: UIO Exclusion from Critical Opioid Grants

UIOs have repeatedly been excluded from funding designed to help AI/AN communities address the opioid crisis. Since FY 2018, Congress has enacted set-asides in SOR grants to help Native communities address this crisis. However, only Tribes and Tribal organizations were defined as eligible entities, meaning UIOs have been consistently denied the resources necessary to address the opioid epidemic in urban areas.

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. Yet, UIOs were ultimately removed from the language of the SOR Grant reauthorization bill, which saw a $5 million increase (9 percent increase from FY 2021), included in the Consolidated Appropriations Act of 2022 (H.R. 2471) for FY 2022 (also known as “Omnibus”).

NCUIH Advocacy & Urban Indian Organization Inclusion

NCUIH has long advocated for UIOs to be included in SOR Grants given the severe extent of the opioid epidemic’s impact on urban AI/ANs. NCUIH worked closely with Congressional leaders to ensure the inclusion of UIOs in the funding set-asides outlined in H.R. 2379.  When the House passed H.R. 2379 on October 20, 2021, NCUIH stated that the exclusion of UIOs from such critical funding directly violated the trust obligation of the federal government. NCUIH increased its advocacy efforts throughout the year and ultimately revived the battle to include UIOs in SOR grants through notable contributions including:

  • NCUIH’s 2022 Policy Priorities encourages Congress to co-sponsor and enact the State Opioid Response Grant Authorization Act of 2021 (H.R. 2379) with amended language to include UIO’s as eligible entities for SOR Grants to fight the opioid epidemic.
  • On April 05, 2022, Maureen Rosette- a citizen of the Chippewa Cree Nation, board member of NCUIH, and Chief Operating Officer at NATIVE Project- testified before the House Natural Resources Oversight & Investigations Subcommittee for a hearing entitled “The Opioid Crisis in Tribal Communities.” Ms. Rosette reiterated the obligation of the United States government to provide health care resources for AI/AN people residing in urban areas while describing the major role that UIOs play in providing critical services. This testimony spurred support among Congressional leaders for expanding opioid funding to UIOs.
  • On May 10, 2022, NCUIH submitted written testimony to the Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies regarding FY 2023 funding for UIOs. NCUIH advocated for providing increased resources to Native health programs and the vital inclusion of UIOs in SOR grants.

Because of NCUIH’s advocacy efforts, H.R. 7666 includes language in Section 273 to define UIOs as eligible entities for SOR Grants and provides a five percent set aside totaling $87.5 million. Ultimately, H.R. 7666 marks a significant step forward in providing UIOs with greater accessibility to vital funding needed to address the opioid crisis in Indian Country.

Next Steps

On June 23, 2022, H.R. 7666 was referred to the Senate Committee on Health, Education, Labor, and Pensions. There have been no further actions taken.

NCUIH will continue to track H.R. 7666 in the Senate. Additionally, NCUIH continues to advocate for the full funding of mental and behavioral health programs in Indian Country and the inclusion of UIOs to improve the health of all AI/ANs living in urban settings.

Additional Bill Funding for Urban Indian Organizations

H.R. 7666 also includes other appropriations for UIOs discussed in greater detail below.

Bill Section
Amount Authorized
(Each FY 2023-FY 2027)
Section 111: Screening and Treatment for Mental Health and Substance Abuse Disorders $24,000,000
Section 121: Innovation for Mental Health $599,036,000 (Native Connections)
Section 122: Crisis Care Coordination $30,000,000 (Adult Suicide Prevention Grants)

*UIO’s defined as a “community-based primary care or behavioral health setting.”
Section 131: Maintaining Education and Training on Eating Disorders $1,000,000

*UIOs are not explicitly mentioned, but the bill text includes primary care and behavioral health care providers.

Section 151: Peer-Supported Mental Health Services $13,000,000
Section 201: Behavioral Health and Substance Use Disorder Services for Native Americans $40,000,000
Section 211: Grants for the Benefit of Homeless Individuals $41,304,000

*UIOs are not explicitly mentioned, but they fall under “community-based public and private nonprofit eligible entities.”
Section 212: Priority Substance Abuse Treatment Needs of Regional and National Significance $521,517,000
Section 214: Priority Substance Abuse Disorder Prevention Needs of Regional and National Significance $218,219,000

 
Section 216: Grants for Jail Diversion Programs $14,000,000

*UIOs are not explicitly mentioned, but they are included as a facility with a grant from IHS.

 
Section 219: Grants for Reducing Overdose Deaths $5,000,000

*Indian Health Services, Tribes or Tribal organizations, or UIOs (I/T/U) added as new eligible entities.

 
Section 220: Opioid Overdose Reversal Medication Access and Education Grants Programs $5,000,000

*I/T/U added as new eligible entities.
Section 222: Emergency Department Alternatives to Opioids Demonstration Grants $10,000,000

*UIOs are covered under Federal Qualified Health Centers (FQHCs).
Section 273: Grant Program for State and Tribal Response to Opioid and Stimulant Use and Misuse $1,750,000,000

5 percent set-aside ($87.5 million) for Indian Tribes, Tribal organizations, and Urban Indian organizations
Section 301: Increasing Uptake of the Collaborative Care Model $60,000,000

*I/T/Us are eligible under the definitions of a “health center” and FQHCs.
Section 311: Reauthorization of Programs Strengthening the Health Care Workforce $31,700,000 (Training Demonstration Project)
Section 402: Infant and Early Childhood Mental Health Promotion, Intervention, and Treatment $50,000,000

*UIOs are eligible under the specific definition of “nonprofit institutions employing a licensed medical professional with specialized training in early childhood mental health, and that provides evidence-based services or programs that show benefit from future applied development.”
Section 412: Substance Abuse Disorder Treatment and Early Intervention Services for Children $29,605,000

*UIOs included in the definition of health facilities in contract with IHS.
Section 421: Suicide Prevention Technical Assistance Center $9,000,000

*UIOs included under the definition of “nonprofit organizations.”
Section 422: Youth Suicide Early Intervention and Prevention Strategies $40,000,000

NCUIH 2022 Summer Legal Fellows and Public Policy Intern Reflect on Time as They Depart

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NCUIH 2022 Summer Legal Fellows and Public Policy Intern

As the summer ends, the National Council of Urban Indian Health (NCUIH) must bid farewell to our lovely fellows and intern that we had the honor of working with over the past twelve weeks. All three of the students this summer were instrumental in the work that NCUIH accomplished while they were here. They attended hundreds of hours of calls, wrote NCUIH communication materials such as blogs and newsletter post, and were directly responsible for the creation of several graphics and discrete research as requested. NCUIH wishes them all the best as they continue their education and professional growth.

NCUIH 2022 Summer Legal Fellows and Public Policy Intern

If you, or someone you know, is interested in learning more about what it means to be an NCUIH Legal and Policy Fellow or an NCUIH Public Policy Intern, contact policy@ncuih.org.

NCUIH 2022 Summer Legal Fellows and Public Policy Intern NCUIH 2022 Summer Legal Fellows and Public Policy Intern

Summer Legal and Policy Fellows

Anna Schwartz, Summer Legal and Policy Fellows

“NCUIH was a great fit for me because I was excited about being part of an organization with such an important role in driving social change and improving health rights, and the fellowship presented opportunities to develop legal and advocacy abilities under the guidance of an excellent team of lawyers and policy experts.” – Anna Schwartz

“My name is Anna Schwartz, and I am a rising second-year law student at the George Washington University Law School. I applied for a legal fellowship with NCUIH because I have a background in health policy research and political science, and I am interested in advancing health equity through law. NCUIH was a great fit for me because I was excited about being part of an organization with such an important role in driving social change and improving health rights, and the fellowship presented opportunities to develop legal and advocacy abilities under the guidance of an excellent team of lawyers and policy experts.

 Over the summer, I honed legal skills that I will take with me to the next steps of my career. First, I wrote comments to federal agencies and a letter to a tribal and federal workgroup about a proposed amendment to a policy. By digging into legislative provisions about the government’s trust responsibility, I was able to strengthen my statutory analysis skills. In addition, I authored a legal memo about the use of federal grant funds toward debt financing. This project included administrative policy and case law research which furthered my legal research and writing skills. Through other projects such as five blog posts about NCUIH’s comments, one blog post about the IHS circular on abortion policy, drafting a presentation to a federal agency, and a bill tracker assignment, I practiced breaking down complex legal concepts into laymen’s terms and increased my advocacy abilities. I also had the opportunity to visit the Senate and House buildings and meet House Representatives, as well as attend virtual Urban Confers, Tribal workgroup meetings, and federal agency policy sessions.

 Moreover, I was thoroughly impressed by the work that NCUIH does to advance the health rights of urban Native communities. It was amazing to be a part of NCUIH’s thoughtful, zealous advocacy, which during these past twelve weeks alone ranged from meeting with UIO leaders to understand their priorities and concerns, to submitting nine comments to federal agencies and facilitating dialogues with those agencies about how to serve UIOs, to advocating for legislative progress and bringing an Advance Appropriations bill to the House floor, to explaining the I/T/U system and the crucial role of UIOs to any stakeholder who will listen. I am grateful to the policy team for welcoming me into the world of Native health, including Meredith, Mary, Jenna, Jeremy, Jennifer, Sam, and Brooke. Special thanks to Alexandra, Chandos, and Rori for their guidance and mentorship, and to Adrianne for being the best co-fellow I could ask for!

 I look forward to applying the skills and knowledge I learned at NCUIH as I continue my career in health law and public interest. As a 2L this fall, I will be participating in the Health Rights Law Clinic at GW Law, and serving on the executive board of Lambda Law, the Moot Court Board, and the Federal Circuit Bar Journal.”

Adrianne Elliott, Summer Legal and Policy Fellows

“The mentorship I received from the policy team proved invaluable to my professional and personal growth. I am passionate about advancing self-determination and sovereignty for Native peoples across the country and look forward to bringing this new knowledge and skillset into the next steps in my Indian law career to ensure all Natives are included in laws and policies that impact them and their wellbeing.” – Adrianne Elliott (Cherokee Nation of Oklahoma)

“Osiyo, my name is Adrianne Elliott, and I am a citizen of the Cherokee Nation entering my second year at Georgetown University Law Center. Prior to law school, I worked for five years to advance indigenous sovereignty and self-determination in educational opportunity for American Indians, Alaska Natives, and Native Hawaiians. Like education, healthcare is central to the well-being of Native peoples and to building strong Native nations. NCUIH’s work to represent urban Indian organizations and the 70 percent of American Indians and Alaska Natives living off-reservation is crucial to ensuring access to essential services and to upholding the federal trust responsibility to all Native peoples. I have been honored to join the policy team at NCUIH in this work.

 My summer began with the NCUIH Conference, which quickly introduced me to some of the most pressing healthcare issues facing Native peoples living in urban areas. Healthcare equity and the trust responsibility for all Native peoples is a complex issue that must Just like their families living on tribal lands, many Native peoples in large urban centers struggle to find equitable access to high-quality healthcare. In addition, most urban providers are not equipped to provide traditional treatment options. Urban Indian organizations fill this gap yet remain severely underfunded even within the Indian healthcare system. From blogs and confers to comments and memos, I had an opportunity to meaningfully contribute to NCUIH’s legal and policy issues while advancing my professional skills.

 Throughout the summer, I had the opportunity to hone analytic and writing skills by researching and developing a variety of memos, comments, and blog posts.  My most significant project centered on a memo to support NCUIH’s work on Brackeen v. Haaland, examining the definition of an Indian child and the impact of changes to this definition in the Indian Child Welfare Act, Indian Health Care Improvement Act, and the Centers for Medicaid and Medicare statutes. Further, I developed and contributed to federal comments to both the Department of Veterans Affairs and the Indian Health Service to improve the delivery of healthcare services to Native peoples living in urban areas.

 The mentorship I received from the policy team proved invaluable to my professional and personal growth. Through this process, I not only honed my legal skills but had the opportunity to dive deeper into areas like AIR and FMAP that deeply impact Native people living off-reservation. I am passionate about advancing self-determination and sovereignty for Native peoples across the country and look forward to bringing this new knowledge and skillset into the next steps in my Indian law career to ensure all Natives are included in laws and policies that impact them and their wellbeing.”

Summer Public Policy Intern

Brooke Schmoyer, Summer Public Policy Intern

“I will take the writing skills, confidence, and knowledge of UIOs that I learned from this internship. I will also take the research skills I gained and apply them to my future opportunities. I eventually want to go to law school and become a health care attorney. From there, I hope to continue my work on Native health care, especially for urban Indians.” – Brooke Schmoyer (Choctaw Nation of Oklahoma)

“Hello! My name is Brooke Schmoyer, and I am the Public Policy intern for NCUIH. I am heading into my Senior year at Stanford University where I am majoring in political science and psychology. I am originally from San Antonio, TX and I am a member of the Choctaw Nation of Oklahoma. I became very interested in the health care system after I had five knee surgeries in the past two years. After my experience, I wanted to learn and advocate for Native health care. This past spring, I worked for the Senate Committee on Indian Affairs. There I learned about NCUIH, and it sparked my interest in advocating for Urban Indians. It was the perfect crossover: healthcare, native issues, and urban Indians. As an urban Indian myself, I wanted to give back and apply my interests in healthcare policy to further tribal sovereignty and ensure the trust responsibility that is owed to AI/AN.

The first fact that I was presented with was how many urban Indians there really are.  I never realized that 70% of AI/AN live in urban areas and how huge of an impact UIOs have. This was just the start of my learning experience. Aside from learning the importance of UIOs, I learned how to write blogs and letters to congress. This helped me better understand the needs of urban Indians such as advance appropriations and urban confer. Working on the Policy Team has allowed me to work with incredible people who are all so knowledgeable. They have taught me how to track legislation, about persistence, and how to have your voice heard. I am grateful for all their help and support.

I will take the writing skills, confidence, and knowledge of UIOs that I learned from this internship. I will also take the research skills I gained and apply them to my future opportunities. I eventually want to go to law school and become a health care attorney. From there, I hope to continue my work on Native health care, especially for urban Indians. I hope to stay connected to all the people I met.”

Indian Health Service Accepting Applications for Funding of the Special Diabetes Program for Indians

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On July 29, 2022, the Indian Health Service (IHS) issued a notice of funding opportunity for the Special Diabetes Program for Indians (SDPI). The total funding identified for fiscal year (FY) 2023 is approximately $136 million. Individual award amounts for the first budget year are anticipated to be between $12,500 and $7.5 million. Current SDPI awardees should budget for the same amount as they received in FY 2022. However, funding amounts may change. New SDPI award applicants should apply for a $12,500 base amount. Approximately 325-450 awards will be issued under this program announcement with a 5-year period of performance. The application deadline is October 7, 2022, with the earliest anticipated start date on January 1, 2023.  NCUIH continues to advocate for an increase in SDPI funds and encourages urban Indian organizations (UIOs) not currently receiving SDPI funds to apply for the FY2023 funding opportunity.

Background

In 2004, Congress established the SDPI Demonstration Projects to translate research-based interventions for diabetes prevention and cardiovascular disease (CVD) risk reduction into American Indian/Alaska Native (AI/AN) community-based programs and health care settings. The SDPI Demonstration Projects successfully translated diabetes science and reduced the risk of diabetes in high risk individuals, and reduced CVD risk factors in people with diabetes. The SDPI Demonstration Projects consist of two initiatives: the SDPI Diabetes Prevention Program and the SDPI Healthy Heart Project. In fiscal year (FY) 2020, there were 301 SDPI program sites located in 35 states and collectively serving more than 780,000 AI/AN people.

Since the inception of SDPI, it has achieved real, demonstrable success, with a 50% reduction in diabetic eye disease rates, drops in diabetic kidney failure, and a 54% decline in End Stage Renal Disease. Given the high rates of diabetes and diabetes-related illnesses AI/ANs face, it is imperative that SDPI is administered in a way that continues to reduce these rates – and in a manner that is inclusive of UIOs. AI/ANs have the highest diabetes prevalence rates of all racial and ethnic groups in the United States, with AI/AN adults almost three times more likely than non-Hispanic white adults to be diagnosed with diabetes. According to 2018 data from the Centers for Disease Control and Prevention, AI/ANs were 2.3 times more likely than non-Hispanic whites to die from diabetes and twice as likely to be diagnosed with end stage renal disease than non-Hispanic whites. SDPI is therefore a critical program to address the disparate 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 supports maintaining SDPI as mandatory spending to enable the program to continue to achieve success in reducing diabetes and diabetes-related illnesses in Indian Country.

NCUIH Submits Comments to the Department of Veterans Affairs on a New Medical Residency Pilot Program

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On July 5, NCUIH submitted comments to the U.S. Department of Veterans Affairs (VA) on the Pilot Program on Graduate Medical Education and Residency (PPGMER). Congress authorized this program under Section 403 of the VA Mission Act of 2018, which sought to provide high-quality, culturally sensitive healthcare options by expanding veterans’ access to medical care and enabling veterans to seek quality healthcare outside of VA facilities. Placement of residents in UIOs through this program is essential to building a highly trained, culturally competent medical workforce to provide equitable access to high-quality healthcare for the estimated 67% of AI/AN veterans living in urban areas.

Recommendations

NCUIH provided the following recommendations for implementation of the PPGMER that supports AI/AN veterans:

  • Add UIOs as covered facilities consistent with legislative intent and flexibility provided under Section 403 of the Mission Act.

Listing UIOs as covered facilities will help VA ensure that it carries out Congress’ intent to expand veterans’ access to medical care and enable veterans to seek quality health care outside of VA. NCUIH estimates that 67 percent of the veteran population identifying as AI/AN alone lives in metropolitan areas. UIOs are particularly well placed to help VA meet the needs of AI/AN veterans living in urban areas.  UIOs fill the gap to ensure all AI/AN veterans have access to critical healthcare options, particularly amid a global pandemic that has disproportionately impacted AI/AN communities.

  • Consider a consortium for residence focusing on the Indian Health Service, Tribal, and Urban (I/T/U) system.

NCUIH recommends extending eligibility criteria for covered facilities to consortia of IHS, Tribal, and UIO (I/T/U) healthcare facilities under Section 403(a)(2)(F) of the Mission Act. The VA, IHS, and Tribal partners have achieved significant success through joint workgroups on increasing care coordination, health care services, and reimbursement for training and cultural competency for eligible Veterans. While those partnerships are successful, many AI/AN veterans are still not being served as noted in a 2020 VA Report, which found that 7.4 percent of AI/AN veterans lack health insurance compared to 2.9 percent of non-AI/AN veterans. Residency consortia represent a unique opportunity to train physicians on the intricacies of the Indian healthcare system and the provision of culturally sensitive health services across the I/T/U system.

  • Establish two additional consideration factors for placement of residents that consider the provision of culturally sensitive healthcare and ongoing staffing shortages in facilities that provide healthcare to underserved veteran demographics, including AI/ANs.

UIOs fill an essential gap by providing culturally sensitive and community-focused care options to AI/AN veterans with shorter wait and travel times. Even in cities that have greater numbers of providers serving AI/AN veterans, there is no guarantee that these providers will be culturally competent. Despite their essential role in the healthcare of AI/AN veterans across the nation, UIOs have long faced understaffing issues that reduce the number of patients each facility can serve.  UIOs have frequently expressed their inability to retain or hire staff due to their inability to pay competitive salaries. Medical residents at UIOs have the potential to dramatically increase healthcare options for AI/AN veterans and their families.

  • Utilize the VA Tribal Advisory Committee in the review process for regulations that support the VA PPGMER prior to publication.

The Advisory Committee provides guidance on all matters related to tribes, tribal organizations and AI/AN veterans. Inclusion of the Committee in regulatory review processes for the PPGMER would demonstrate the VA’s commitment to the United States’ national policy “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.”

We will continue to monitor ongoing implementation of the VA PPGMER and provide updates on how the program impacts urban Indian communities.

Link to resource.

Resources: Timeline of Advocacy and History on Advance Appropriations for the Indian Health Service

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The National Council of Urban Indian Health (NCUIH) released a document on the history of advance appropriations for the Indian Health Service (IHS), which explains the necessity of advance appropriations and provides a timeline on the advocacy, congressional and federal support, and legislative efforts since 2013. The Indian healthcare system, including IHS, Tribal facilities, and urban Indian organizations (UIOs), is the only major federal healthcare provider funded through annual appropriations.

Unfortunately, discretionary budget funding for IHS is repeatedly delayed. Since Fiscal Year (FY) 1996, there has only been one occurrence of timely funding, and that was in FY 2006.

What Is Advance Appropriation

View the resource

View the timeline

Advocacy

Advance appropriations has been a priority for Indian Country for years and we have seen broad support on this issue from Native health advocates. Over the past 10 years, there have been five resolutions in support of advance appropriations from the United South and Eastern Tribes (USET), the Inter-Tribal Council of the Five Civilized Tribes (ITC), the National Indian Health Board (NIHB), the National Congress of American Indians (NCAI), and the American Bar Association. 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 70 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. and on June 16, 2022, NIHB and NCAI requested that the Committee support and include IHS advance appropriations in the current FY 2023 appropriations bill in an action alert. 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.

  • In 2013, the United South and Eastern Tribes, Inc. passed a resolution in support of advance appropriations for IHS.
  • In 2014, the Inter-Tribal Council of the Five Civilized Tribes passed Resolution No. 14-05 requesting advance appropriations for IHS.
  • In 2014, the National Indian Health Board (NIHB) passed Resolution 14-03 to support advance appropriations for IHS.
  • In 2019, the National Congress of American Indians (NCAI) passed Resolution 19-001 to support advance appropriations for the Bureau of Indian Affairs and IHS.
  • In 2019, the American Bar Association passed a resolution urging Congress to enact advance appropriations legislation for IHS.
  • On March 9, 2022, NCUIH joined NIHB and over 70 Tribal nations and national Indian organizations in sending a series of joint letters to Congress requesting advance appropriations for IHS in the Fiscal Year (FY) 2022 omnibus.
  • On June 16, 2022, NIHB and NCAI requested that the Committee support and include IHS advance appropriations in the current FY 2023 appropriations bill in an action alert.
  • On June 24, 2022, NCUIH sent a letter to Speaker Pelosi to support advance appropriations for IHS.
  • On June 30 and July 1, 2022 NCUIH sent letters to Senate Majority Leader Schumer and Senate Minority Leader McConnell to support advance appropriations for IHS

Congressional and Federal Support

There has also been strong long-standing support from Congress on this issue. On January 12, 2022, the Native American Caucus 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, and again on June 3 requesting that, while the process of shifting IHS to mandatory appropriations is underway, advanced appropriations for IHS be included 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 House Natural Resources Subcommittee for Indigenous Peoples (SCIP) hearing held during the last Congress 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.” Most recently on July 28, SCIP held a hearing on the Indian Health Service Advance Appropriations Act (H.R. 5549) where IHS Acting Deputy Director Elizabeth Fowler reaffirmed IHS’s support for advance appropriations stating that “We remain 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.

Legislation

Since 2013, legislation on this effort has been introduced in 11 bills:

  1. 10/2013 – Indian Health Service Advance Appropriations Act of 2013 (R. 3229/S. 1570) o Sponsor: Rep. Don Young/Sen. Lisa Murkowski
  2. 1/2015 – Indian Health Service Advance Appropriations Act of 2015 (R. 395) o Sponsor: Rep. Don Young
  3. 1/2017 – Indian Health Service Advance Appropriations Act of 2017 (R. 235) o Sponsor: Rep. Don Young
  4. 2/2019 – Indian Programs Advanced Appropriations Act (R. 1128/S. 229) o Sponsor: Rep. Betty McCollum/Sen. Tom Udall
  5. 2/2019 – Indian Health Service Advance Appropriations Act of 2019 (R. 1135/S. 2541) o Sponsor: Rep. Don Young/Sen. Lisa Murkowski
  6. 10/2021 – Indian Health Service Advance Appropriations Act (R. 5549) o Sponsor: Rep. Don Young
  7. 10/2021 – Indian Programs Advance Appropriations Act of 2021 (R. 5567/S. 2985) o Sponsor: Rep. Betty McCollum/Sen. Ben Ray Lujan

NCUIH has persistently advocated for advance appropriations for IHS by sending letters to Congress and creating educational materials describing the necessity of this important issue impacting Indian Country.

Government Shutdowns Disproportionately Impact UIOS

During the recent SCIP, IHS Acting Director Liz Fowler testified that UIOs are disproportionally impacted by government shutdowns. She stated, “Urban Indian Organizations (UIO) are funded through a different mechanism than our tribal programs. They’re funded through contracts and grants and the contracts are federal acquisition regulation contracts.” She highlighted that, unlike tribal programs, UIOs are unable to get full funding during continuing resolutions (CR).

View the Testimony Here.

Advance Appropriations Save Native Lives

On July 28, 2022, NCUIH recently released a short video showcasing why advance appropriations is critical to insulate IHS, UIOs, and other Tribal health facilities from the negative consequences engendered by delayed funding when there are government shutdowns, automatic sequestration cuts, and continuing resolutions. The video calls on Congress to enact advance appropriations to prevent the loss of  American Indian and Alaska Native (AI/AN) lives by detailing the difficult circumstances resulting from the most recent government shutdown that began at the start of FY 2019, which lasted 35 days. Kerry Lessard, Executive director of the Native American LifeLines of Baltimore, described the experience of her UIO, citing that “We were several months without being paid and that meant services that we had to deny” during the FY2019 shutdown. The impact on AI/ANs was severe, as the Native American Lifelines of Baltimore received seven overdose patients after they were forced to close their doors, five of which were fatal.

View the Video Here.

Action Alert: Save Native Lives – Contact Speaker Pelosi Today to Take Action

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Dear Urban Indian Health Advocates,

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

We need your help again contacting Congress to support securing Advance Appropriations and mandatory funding for the Indian Health Service (IHS). The Indian health system, including IHS, Tribal facilities, and urban Indian organizations (UIOs), is the only major federal health care provider funded through annual appropriations.

If IHS were to receive advance appropriations, it would ensure continuity of care for Native Americans and complement President Biden’s budget request to honor commitments to tribal nations and communities. In fact, there have been Native deaths due to government shutdowns in the past, and the lives of Native people should not be subject to politics. We need this to protect Native people and preserve access to health care.

We encourage you to contact Speaker Pelosi and request that she support including advance appropriations for IHS in the Fiscal Year (FY) 2023 final spending package. You can use the text below as a template to call and/or email Speaker Pelosi.

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

Sincerely,

The National Council of Urban Indian Health

STEPS TO CONTACT CONGRESS

  • Step 1: Copy the email below.
  • Step 2: Find Speaker Pelosi’s contact here.
  • Step 3: Paste the email into the form and send. Please contact Meredith Raimondi (policy@ncuih.org) with questions.

Email to Speaker Pelosi

Dear Speaker Pelosi,

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

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

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

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

Sincerely,
[contact information]

POST ON SOCIAL MEDIA

Facebook

Post your support on your Facebook.

  • Example post:
    • The Indian health system, including IHS, Tribal facilities, and urban Indian organizations, is the only major federal health care provider funded through annual appropriations. If IHS were to receive mandatory funding, or at the least, advance appropriations, it would not be subject to government shutdowns and continuing resolutions. You can make a difference! Call Speaker Pelosi to support advance appropriations in the FY23 funding bills.

TWITTER

From your Twitter account, tweet to Speaker Pelosi.

  • Example tweet:
    • Dear @ SpeakerPelosi, please support advance appropriations for IHS in FY23 #IndianHealth #urbanIndianhealth @ncuih_official.

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

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

Roselyn Tso: Background and Experience

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

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

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

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

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

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

Next Steps

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

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

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

Background

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

NCUIH’s Actions

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

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


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

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

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

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

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

Background

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

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

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

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

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