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

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

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

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

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

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

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

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

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

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

Background

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

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

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

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

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

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

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

Background

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

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

Status of Senate Interior Appropriations Bill

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

Bill Highlights

Indian Health Service: $8.1 billion

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

Urban Indian Health: $200 million

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

Mandatory Funding:

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

Equipment: $118.5 million

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

Electronic Health Records: $284.5 million

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

Mental Health: $130 million

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

Alcohol and Substance Abuse: $264 million

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

Community Health Aide Program (CHAP): $25 million

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

Tribal Epidemiology Centers: $34,433,361

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

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

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

Maternal Health: $10 million

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

Alzheimer’s Disease: $5.5 million

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

Produce Prescription Pilot Program:

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

Headache Disorders Centers of Excellence:

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

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

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

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

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

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

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

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

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

Background and Advocacy

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

Full Funding, Advance Appropriations, and Mandatory Funding a Priority

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

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

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

Senate Bill Highlights

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