HHS to hold Tribal Consultation on Proposed Rule to Strengthen Nondiscrimination in Health Care

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On July 25, 2022, the Department of Health and Human Services (HHS) announced a proposed rule to implement Section 1557 of the Affordable Care Act. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, and disability in certain health programs and activities. The proposed rule strengthens and restores civil rights protections for patients, beneficiaries, and consumers in certain federally funded health programs and other HHS programs.

The rulemaking affirms protections against discrimination on the basis of sex, inclusive of sexual orientation and gender identity, consistent with the US Supreme Court holding in Bostock v Clayton County. The rulemaking also reinforces protections against discrimination in seeking reproductive health care services.

A Tribal Consultation on the proposed rule will be held on August 31 at 2:00 pm EDT. Click here to register in advance. Public comment in response to the proposed rule is due September 23, 60 days after the notice.

Background

Under the Trump Administration, HHS issued final regulations on the implementation of Section 1557 in early June of 2020, which narrowed the scope of the rule by:

  • Eradicating prohibition on discrimination based on gender identity and sex-stereotyping
  • Embracing blanket religious freedom and abortion exemptions for health care providers
  • Removing the provision preventing health insurers from varying benefits that discriminate against certain marginalized groups of individuals
  • Lessening protections for individuals with limited English proficiency
  • Eliminating prohibitions against discrimination based on gender identity and sexual orientation in ten other federal health care regulations.

On June 15, 2020, the US Supreme Court published its decision on Bostock v. Clayton County. Under this ruling, sex discrimination includes discrimination based on sexual orientation and gender identity. While the case is specific to an employment context, it has since been used in support of nondiscrimination efforts that include sexual orientation and gender identity. Given the ruling in this case, a number of federal courts issued nationwide preliminary injunctions to block parts of the 2020 Final rule.

The Section 1557 rule was first issued under the Obama Administration in 2016.

Call to Action

Section 1557 Notice of Proposed Rulemaking (NPRM) seeks to address gaps identified in prior regulations. In order to advance protections under this rule it:

  • Reinstates the scope of Section 1557 to cover HHS’ health programs and activities.
  • Clarifies the application of Section 1557 nondiscrimination requirements to health insurance issuers that receive federal financial assistance.
  • Aligns regulatory requirements with Federal court opinions to prohibit discrimination on the basis of sex including sexual orientation and gender identity.
  • Makes clear that discrimination on the basis of sex includes discrimination on the basis of pregnancy or related conditions, including “pregnancy termination.”
  • Ensures requirements to prevent and combat discrimination are operationalized by entities receiving federal funding by requiring civil rights policies and procedures.
  • Requires entities to give staff training on the provision of language assistance services for individuals with limited English proficiency (LEP), and effective communication and reasonable modifications to policies and procedures for people with disabilities.
  • Requires covered entities to provide a notice of nondiscrimination along with a notice of the availability of language assistance services and auxiliary aids and services.
  • Explicitly prohibits discrimination in the use of clinical algorithms to support decision-making in covered health programs and activities.
  • Clarifies that nondiscrimination requirements applicable to health programs and activities include those services offered via telehealth, which must be accessible to LEP individuals and individuals with disabilities.
  • Interprets Medicare Part B as federal financial assistance.
  • Refines and strengthens the process for raising conscience and religious freedom objections.

American Indians/Alaska Natives (AI/ANs) are historically marginalized and underserved when it comes to healthcare. The Section 1557 notice of proposed rulemaking finds that: AI/ANs under 65 have an uninsured rate of 28 percent, higher than any other racial or ethnic group; AI/ANs received worse care than white individuals in the areas of patient safety, person-centered care, care coordination, the effectiveness of care, healthy living, and affordable care for 40 percent of 108 quality measures; more research is needed to determine the root causes of maternal mortality among AI/AN women, but a recent study suggests that provider-related factors, including implicit bias, must be addressed to reduce AI/AN maternal mortality; and there is uneven representation in minority populations, including AI/ANs, in Alzheimer’s research and clinical trials.

HHS encourages all stakeholders, including patients and their families, health insurance issuers, health care providers, health care professional associations, consumer advocates, and government entities, to submit comments through regulations.gov.

NCUIH will continue to closely monitor the proposed rule and related issues, concerns, and comments.

CDC Endorses Fourth COVID-19 Vaccine for Adults

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On Tuesday, July 19, 2022, the Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky, MD, MPH, endorsed the CDC Advisory Committee on Immunization Practices’ recommendation for Novavax’s COVID-19 vaccine as another primary series option for adults 18 and older. Novavax’s vaccine, Adjuvanted, was granted an emergency use authorization on July 13, 2022, by the US Food and Drug Administration.

The Novavax vaccine, Adjuvanted, is another two-dose vaccine that will be available to administer to adults 18 and older in the coming weeks. The Novavax vaccine is administered three weeks apart and uses a more traditional technology for vaccine delivery. In total, there are now four different COVID-19 vaccines for adults 18 and older to choose from; Moderna, Pfizer, Johnson & Johnson, and Novavax.

Background

American Indians and Alaska Natives (AI/ANs) have been disproportionately affected by the COVID-19 pandemic. At the height of the pandemic, AI/ANs were 3.5 times more likely to test positive, 3.2 times more likely to be hospitalized and 2.2 times more likely to due to du COIVD-19.

Indian Country has had highly successful vaccine rollouts and Urban Indian Organizations have been instrumental in the success of vaccinating AI/AN populations in urban Areas. As of July 2022, AI/ANs have the highest vaccination administration rates in the US with 73% of AI/ANs having received at least one dose of one of the three previously available COVID-19 vaccines, per CDC data.

Urban Indian Leaders Encouraged to Apply for New Environment Protection Agency Advisory Committee on Children’s Health

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On July 7, 2022, the Environment Protection Agency (EPA) announced a  request for applications to fill vacant seats on the Children’s Health Protection Advisory Committee (CHPAC).  Appointed members of the CHPAC serve a three-year term and the expected workload is approximately 10-15 hours per month. The CHPAC provides policy advice and recommendations to EPA on issues associated with regulations, economics, and outreach/communications to address the prevention of adverse health effects to children, as well as critical policy and technical issues relating to children’s health. The CHPAC meets two to three times annually and the EPA reimburses members for travel and other incidental expenses. As both health care providers and non-governmental organizations, leaders from Urban Indian Organizations (UIOs) are eligible to apply for an appointment to the Committee. Nominations should be submitted by August 15, 2022, to EPA_CHPAC@icfi.com and Nguyen.Amelia@epa.gov. For details on what is required in the nomination package, see here. The EPA intends to fill vacancies on CHPAC by March 1, 2023.

CHPAC Objectives and Scope

Chartered under the Federal Advisory Committee Act (FACA), CHPAC was established in 1997 to provide independent advice to the EPA Administrator on a wide range of environmental issues and their impact on children’s health. According to the CHPAC Charter, the CHPAC  is composed of approximately 24-30 members who provide policy advice, information, and recommendations to assist EPA in the development of regulations, guidance, and policies to address children’s environmental health. Committee members generally serve as Representatives of non-Federal interests. The CHPAC  is looking for candidates from industry; Federal, State, local, and Tribal governments; school systems; academia; healthcare providers; and non-governmental organizations. . In considering nominees for the CHPAC, the EPA is looking for background and experience that will contribute to the diversity of perspectives on the committee.

Call to Action

NCUIH encourages interested UIO leaders to submit nomination materials to EPA by August 15, 2022. Because American Indians/Alaska Natives living in urban areas experience the kind of health complications due to environmental issues that the EPA seeks to address, UIO leaders have the experience and expertise to be valuable committee members. The EPA intends to fill vacancies on the CHPAC by March 1, 2023.

Please contact NCUIH policy at policy@ncuih.org if you would like assistance with submission or if you plan to apply.

NCUIH Submits Comments to the Indian Health Service on Improving Urban Indian Health Program Policy, Procedures, and Effectiveness

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On June 17, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to the Indian Health Service (IHS) about the Indian Health Program Policy  (the Policy) in the Indian Health Manual (IHM), Chapter 19, “Urban Indian Health Program.” These comments responded to the agency’s Dear Urban Indian Organization Leader letter dated April 14, 2022, initiating an Urban Confer and seeking recommendations for improving the Urban Indian Health Program policy, procedures, and effectiveness. NCUIH outlined recommendations for IHS, including improvements to the Policy’s oversight and management, improvements to the communication procedures, the addition of an appeals process for UIO annual reviews, clarification of reporting requirements, and general assistance to other federal agencies. NCUIH also requested that IHS develop additional sections about Health Information Technology (HIT) systems, data collection, and the use of federal government facilities and sources of supply.

Background

The main purpose of the Policy is to “establish policy, procedures and responsibilities for the Urban Indian Health Program,” as authorized by the Snyder Act. The government and UIOs use guidance from the Policy “to ensure access to high-quality and safe health care services for Urban Indians; to support health promotion and disease prevention programs targeted to urban populations; and to assess program performance to evaluate whether Urban Indian community needs are met.” In its comment, NCUIH noted that IHS has not updated the Policy since 1994. In the intervening 28 years, UIOs have undergone tremendous growth and change, including rapid adjustments in the last two years in response to the COVID-19 pandemic. The recommendations below, which come directly from UIOs’ experience with the Policy, will inform IHS on necessary areas of improvement.

NCUIH supports a collaborative process in which UIOs and IHS engage in open dialogue concerning the Policy to create a comprehensive document. A thorough process will serve UIOs and IHS, and guide all parties in their pursuit to provide high-quality and culturally focused healthcare to AI/ANs living in urban areas.

NCUIH’s Recommendations to IHS

NCUIH recommended the following improvements and additions to the Policy:

  • Improve the Policy’s consistency concerning oversight and management
    • NCUIH shares UIOs’ concerns that the current language in the Policy needs to be strengthened, and the roles and responsibilities of the IHS and UIOs need to be more clearly defined.
    • There is also a general need to improve consistency across all levels of IHS concerning oversight and management, including disbursement of funds, communication, IT support, and more.
    • Over one year after enacting the American Rescue Plan Act, several UIOs still do not have the entirety of the funding, and the discrepancies between areas can vary greatly. Delayed funding due to the bureaucracy of a specific geographic region flies in the face of the federal trust responsibility to provide the highest level of health care to all AI/ANs regardless of residence.
    • NCUIH notes that many UIOs report strong working relationships with their Areas. As such, IHS should work with UIOs to identify best practices and distribute lessons learned across the Areas and Headquarters levels to improve the current inconsistencies UIOs are experiencing.
  • Incorporate improved communication and annual training for Area Offices
    • NCUIH requests that IHS provide language on improved communication between Area Offices and UIOs as well as annual training for Area Offices.
  • Provide more transparent communication regarding supplemental funding
    • NCUIH requests that IHS modify Section 3-19.3 G – H and Section 3-19.4 “Grants Programs” to clarify the processes and procedures for supplemental funding.
    • NCUIH also suggests that OUIHP develop one-pagers associated with each round of funding and its allowability for UIOs to utilize as they create Scopes of Work and update their contracts.
    • For future health emergencies, NCUIH recommends that IHS establish a plan to communicate funding changes to UIOs through webinars and resources to avoid dissemination of conflicting information.
  • Include an appeals process for UIO Annual Reviews
    • NCUIH recommends that IHS include an Appeals Process for UIOs in Section 3-19.3 (F) “Program Evaluation and Review” to give UIOs recourse for program evaluations, opportunities to report UIO noncompliance or satisfactory performance, and a platform to voice their concerns.
  • Clarify and update reporting requirements
    • NCUIH requests that Section 3-19.5 “Reports” be modified to further clarify what requirements are needed for UIOs to report.
  • Provide general assistance to other federal agencies
    • As NCUIH works with other federal agencies to encourage them to implement Urban Confer mechanisms, we request that IHS similarly support these efforts to the maximum extent practicable.

In addition to the preceding recommendations regarding the current Policy, NCUIH also requested that IHS develop additional sections, including:

  • Health Information Technology (HIT) Systems
    • NCUIH requests the updated Policy also include a section on Health Information Technology (HIT) systems and the IHS modernization process.
  • Data Collection
    • UIOs have noted that the current Policy does not address data collection and request that this be included as a stand-alone section. Additionally, NCUIH asks that any section on data clearly outline how IHS will use the data and if there would be additional reporting requirements from UIOs.
  • Use of Federal Government Facilities and Sources of Supply
    • The Policy should clarify how provisions related to utilization and acquisition of government facilities are carried out, the proper process for UIOs to request these resources, and IHS’ role in transferring any requested property.

NCUIH will continue to closely follow updates to the Policy and assess program performance to evaluate whether urban Indian community needs are met.

Challenge to Indian Child Welfare Act Advances at Supreme Court

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The Supreme Court is preparing to hear a constitutional challenge to the Indian Child Welfare Act (ICWA) that consolidates four petitions to review the Fifth Circuit’s April 2021 en banc decision in Brackeen v. Haaland. In this decision, the United States Court of Appeals for the Fifth Circuit upheld the overall constitutionality of ICWA. However, it overturned certain ICWA processes and provisions that concern placement preferences of Native children in Indian homes. On May 26, 2022, the Court received amicus briefs from supporters of the ICWA challengers. The challengers and their amici argue that ICWA violates several constitutional provisions including equal protection, anticommandeering, and nondelegation. The next round of amicus briefs in support of ICWA and Tribal intervenors are due by August 12, 2022, and oral arguments are expected to begin after the Supreme Court term starts in October.

Background

ICWA represents the gold standard in child welfare proceedings, strengthening and preserving American Indian and Alaska Native (AI/AN) family structure and culture. When it was established in 1978, studies showed that between 25% and 35% of all Native children were removed from their homes by state child welfare and private adoption agencies. Of those, 85% were placed with non-Native families, even when fit and willing relatives were available. ICWA re-established tribal authority to safeguard against such practices by requiring that Native children be placed with extended family members, other tribal members, or other Native families prior to placement in non-Indian homes.

Today, Native children continue to be overrepresented in state foster care systems at a rate 2.7 times higher than their non-Native peers. Because more than 70% of AI/AN people live in urban settings, this overrepresentation undoubtedly has an impact in urban AI/AN communities. According to the Indian Health Service (IHS), Native youth living off-reservation often face a higher risk of health problems, including mental health and substance abuse, suicide, gang activity, teen pregnancy, abuse, and neglect. Additionally, IHS found that urban Indian populations experience the same health problems as the general Indian population, but these problems are exacerbated by a lack of access to family and traditional cultural environments.  Challenges to ICWA threaten to place urban Native youth at even greater risk if they enter foster or adoption systems that do not offer protections to keep them from being further removed from their communities and culture.

NCUIH previously provided an in-depth analysis on the impact of ICWA. We will continue to monitor ongoing developments as Brackeen v. Haaland proceeds to oral argument, and to provide updates on how the case impacts urban Indian communities.

House Appropriations Committee Approves Labor-HHS Bill with Funding Increases for Indian Country

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On June 30, 2022, the House Appropriations Committee approved its fiscal year (FY) 2023 Labor, Health and Human Services, Education, and Related Agencies funding bill by a 32-24 vote. The bill authorizes $124.2 billion for the Department of Health and Human Services (HHS)— an increase of $15.6 billion above the FY 2022 enacted level and $298 million below the President’s budget request. Other key provisions include a set-aside at the same FY 2022 funding levels of $15.6 million for IHS facilities/Tribally-Operated Health Programs/Urban Indian Health Programs under the National Health Service Corps (NHSC) Loan Repayment Program, increased funding for the Good Health and Wellness in Indian Country (GHWIC) program, increased funding for the Native Connections grant for behavioral health, and increased American Indian/Alaska Native (AI/AN) set-aside funding for Zero Suicide grants. A more detailed analysis follows below.

Despite advocacy by the National Council of Urban Indian Health and Congressional support, urban Indian organizations (UIOs) were not included in the Substance Abuse and Mental Health Services Administration (SAMHSA) State Opioid Response (SOR) grant, which is increased by $250 million above the FY 2022 enacted level in the Committee’s funding bill for FY 2023. The tribal set-aside for this grant was increased by $15 million above the FY 2022 enacted level. The opioid epidemic impacts all AI/ANs regardless of residence and NCUIH will continue to advocate for UIO inclusion in these critical opioid grants.

Bill Highlights

Centers for Disease Control and Prevention (CDC)

  • Bill Report: “The Committee recommendation for the Centers for Disease Control and Prevention (CDC) program level includes $9,540,696,000 in discretionary budget authority, $55,358,000 in mandatory funds under the terms of the Energy Employees Occupational Illness Compensation Program Act, and $903,300,000 in transfers from the Prevention and Public Health (PPH) Fund.” The bill funds the CDC at $10.5 billion, an increase of $2 billion above the FY 2022 enacted level and $231 million below the President’s budget request.
GHWIC
  • Bill Report: “The Committee’s recommended level includes an increase of $4,000,000 for Good Health and Wellness in Indian Country.”

National Institute of Health (NIH)

  • Bill Report: “The Committee recommendation for the National Institutes of Health (NIH) program level includes $46,038,300,000 in discretionary appropriations and $1,420,700,000 in Public Health Service Act (PHS Act) section 241 evaluation set-aside transfers.” The bill provides a total of $47.5 billion for NIH, an increase of $2.5 billion above the FY 2022 enacted level.
Improve Native American Cancer Outcomes
  • Bill Report: “The Committee continues to be concerned that Native Americans experience overall cancer incidence and mortality rates that are strikingly higher than non-Native populations and encourages NCI to expand research efforts to reduce American Indian cancer disparities and improve outcomes. The Committee notes NCI’s successful efforts through the Cancer Moonshot’s Accelerating Colorectal Cancer Screening and Follow-Up through Implementation Science (ACCSIS) program, and parallel efforts by NCI Designated Cancer Centers collaborating with American Indian communities, that are improving colorectal cancer screening, follow-up, and referral for care among populations that have low colorectal cancer screening rates. The Committee encourages NCI to continue efforts such as the ACCSIS initiative to develop durable capacity for tribally-engaged cancer disparities research through an integrated program of research, education, outreach, and clinical access.”

SAMHSA

  • Bill Report: “The Committee recommendation for the Substance Use And Mental Health Services Administration (SAMHSA) program level includes $9,024,713,000 in discretionary budget authority, $133,667,000 in Public Health Service (PHS) Act section 241 evaluation set-aside transfers, and $12,000,000 in transfers from the Prevention and Public Health Fund (PPHF).” The bill funds SAMHSA at $9.2 billion – an increase of $2.6 billion above the FY 2022 enacted level.
State Opioid Response Grants:
  • Bill Report: “The Committee includes $1,775,000,000 for State Opioid Response (SOR) grants, an increase of $250,000,000. The Committee further directs SAMHSA to ensure that these resources continue to be managed by State alcohol and drug agencies defined as the agency that manages the Substance Use Prevention and Treatment Block Grant under part B of title X of the PHS Act. This approach will ensure continuity of funding, effective coordination of efforts, and decrease fragmentation within each State system. The Committee supports efforts from SAMHSA through SOR grants to expand access to SUD treatments in rural and underserved communities, including through funding and technical assistance. The Committee encourages SAMHSA to continue to focus on expanding access to evidence-based MOUD in counties that lack providers who are actively dispensing or prescribing MOUD.” The bill provides $1.8 billion for State Opioid Response Grants, an increase of $250 million above the FY 2022 enacted level, and $65 million for Tribes, an increase of $15 million above the FY 2022 enacted level.
    • Does not apply to UIOs
Zero Suicide Grants
  • Bill Report: “The Committee includes an increase of $5,000,000 for the implementation of the National Strategy for Suicide Prevention, including raising suicide awareness, establishing emergency room referral processes, and improving clinical care practice standards. In addition, funding will further support the Zero Suicide model, a comprehensive, multi-setting approach to suicide prevention in health care systems. The Committee also includes an increase of $1,000,000 for the American Indian/Alaska Native (AI/AN) Suicide Prevention Initiative.” The bill funds the Zero Suicide AI/AN set-aside at $3.4 million.
Medication Assisted Treatment
  • Bill Report: “The Committee includes an increase of $35,500,000 for Medication Assisted Treatment (MAT) for Prescription Drug and Opioid Addiction; an increase of $4,500,000, for grants to Indian Tribes, tribal organizations, or consortia; and an increase of $224,000 for general Targeted Capacity Expansion activities.”
Tribal Behavioral Grants (Native Connections)
  • Bill Report: “The Committee includes an increase of $4,250,000 to expand efforts to address the high incidence of substance misuse and suicide among AI/AN populations.” The bill provides a total of $25 million for Native Connection grants.

Health Resources and Services Administration (HRSA)

  • Bill report: “The Committee recommendation for HRSA includes $9,295,951,000 in discretionary budget authority, $256,370,000 in mandatory funding and $15,200,000 in trust fund appropriations for the Vaccine Injury Compensation Program Trust Fund, and $7,000,000 for the Countermeasures Injury Compensation Program.” The bill includes $9.6 billion for HRSA, an increase of $683 million above the FY 2022 enacted level and $792 million above the President’s budget request.
Health Centers Program
  • Bill Report: “The Committee recommends $1,945,772,000 for the Health Centers program, $198,000,000 above the fiscal year 2022 enacted level and $107,750,000 above the fiscal year 2023 budget request. Health Centers deliver affordable, accessible, quality, and cost-effective primary health care to millions of people across the country regardless of their ability to pay. Programs supported by this funding include community health centers, migrant health centers, health care for the homeless, and public housing health service grants.”
NHSC
  • Bill Report: “The Committee includes $155,600,000, an increase of $34,000,000 above the fiscal year 2022 enacted level, for NHSC to support competitive awards to health care providers dedicated to working in underserved communities in urban, rural, and tribal areas. Within this total, the Committee includes an increase of $10,000,000 for loan repayment for mental and behavioral health providers, including peer support specialists, that serve in crisis centers, as described in the fiscal year 2023 budget request. The Committee also includes $15,600,000, the same as the fiscal year 2022 enacted level, within the total to support NHSC awards to participating individuals that provide health services in IHS facilities, Tribally-Operated Health Programs, and Urban Indian Health Programs.”

Resource: America’s Disproportionate Investment in Healthcare for American Indians and Alaska Natives

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The National Council of Urban Indian Health recently published a one-pager showcasing the disproportionate gaps in national healthcare investment for American Indians and Alaska Natives (AI/ANs). The Indian Health Service (IHS) and Urban Indian Health budgets have long been underfunded. In the agency’s Fiscal Year (FY) 2023 Performance Budget Submission to Congress, IHS highlighted these disparities, noting that the “Indian health system is chronically underfunded compared to other healthcare systems in the U.S.” NCUIH’s analysis of FY 2018 appropriations shows that the US spends $11,172 in healthcare costs per person. In contrast, Tribal and IHS facilities receive $4,078 per IHS eligible patient, while Urban Indian Organizations (UIOs), which support the over 70% of AI/ANs living off-reservation, receive just $672 per AI/AN patient from the IHS budget. NCUIH data further shows that the gap between tribal budgetary needs submitted via requests to Congress and eventual appropriations has continued to skyrocket over recent years, thereby increasing discrepancies in per-person healthcare spending at UIOs.

Link to resource.

Chart showing America’s Disproportionate Investment in Healthcare for American Indians and Alaska Natives

 

House Releases FY 2023 Appropriations Bill with $200 Million for Urban Indian Health, Fails to Include Advance Appropriations

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The bill is to be considered by Full Committee this week and includes $8.1 billion for IHS, $1 billion less than the amount requested by the President.

Today, June 28, 2022, the House Appropriations Subcommittee on Interior, Environment, and Related Agencies released the Committee Bill Report for the fiscal year (FY) 2023 budget with $200 million for urban Indian health. The report and bill will be considered by the full House Appropriations Committee tomorrow morning and was approved by the House Subcommittee on Interior on June 21, 2022. The bill authorizes $8.1 billion for the Indian Health Service (IHS)— an increase of $1.5 billion from FY22 but $1 billion below the President’s request. Despite robust advocacy from Tribes and Urban Indian Organizations (UIOs), the bill does not include advance appropriations. 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.

“NCUIH is grateful for the Committee’s inclusion of $200 million for urban Indian health for Fiscal Year 2023, but disappointed to see the reduced request from last year given all of the effects of COVID-19 and the growing costs of inflation. Unfortunately, the proposed amount would not fully fund the Indian Health Service and does not include critical advance appropriations. We especially thank Congresswoman McCollum and Ranking Member Joyce for their continued efforts to provide resources for Native healthcare and achieve advance appropriations. Too many Native lives have been lost during times of funding instability and we have had enough. We hope that House leaders will hear the calls of Indian Country to prioritize equity and provide stable funding for our health in accordance with the trust responsibility.” – Francys Crevier (Algonquin), CEO, NCUIH.

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. 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 for American Indians and Alaska Natives. In the past month alone, NCUIH sent a letter to request Speaker Pelosi to allow for advance appropriations and NCAI and NIHB 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.

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

Background and Advocacy

On March 28, 2022, President Biden released his budget request for Fiscal Year FY 2023 which included, for the first time ever, $9.3 billion in mandatory funding for IHS for the first year with increased funding each year over ten years. On April 25, 2022, the Indian Health Service (IHS) published their FY 2023 Congressional Justification with the full details of the President’s Budget, which included $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 full funding for urban Indian health for FY 2023 at $949.9 million and at least $49.8 billion for IHS in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. The marked increase for FY23 is a result of Tribal leaders, over several decades, providing budget recommendations to phase in funding increases over 10-12 years to address growing health disparities that have largely been ignored.

On April 5, 2022, NCUIH President-Elect 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. 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 TBFWG, Advance appropriations for IHS, and support of mandatory funding for IHS including UIOs.

NCUIH recently 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 has bipartisan support and calls 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. On May 27, 2022, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests.

During last week’s House Interior Subcommittee markup on the FY2023 funding bill, Rep. Chellie Pingree said of mandatory funding: “This shift requires legislative action by the authorizing committee, the House Committee on Natural Resources. In the absence of that legislation, I have included discretionary funding in this bill to ensure that there is no risk of a disruption in healthcare while that process is underway.”

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.”

House Advances NCUIH-Endorsed Truth and Healing Commission on Indian Boarding Schools Bill

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On June 15, 2022, the House Committee on Natural Resources held a markup to consider a series of bills, including H.R. 5444. Several Members of Congress, such as Senator Cortez Masto (D-NV) and Representative McCollum (D-MN-04), expressed concerns and grievances about the horrific occurrences within boarding schools. Both the Majority and Minority agree that there needs to be a commission, however, four amendments were introduced on subpoena power, the compensation of commission members, the wording around funds, and the possibility for reparations. The only amendment to be accepted was the amendment editing, “such sums as may be necessary”. The bill has passed the committee and will be heading to The House floor.

NCUIH Submitted Testimony in Support of the Act

On May 26, 2022, the National Council of Urban Indian Health (NCUIH) submitted written testimony to the House Natural Resources Subcommittee for Indigenous Peoples of the United States in support of the Truth and Healing Commission on Indian Boarding School Policies in the United States Act (S. 2907/H.R. 5444), which would create a Truth and Healing Commission on Indian Boarding School Policies (the Commission).

Background

NCUIH worked with Senator Elizabeth Warren (D-MA) on this landmark legislation to begin the healing process from Indian Boarding School policies and ensure the inclusion of UIOs in the Commission. This ensures that the stories of the 70% of American Indians/Alaska Natives (AI/ANs) that live in urban areas will be included. NCUIH exists in part because of the historic oppression of the AI/AN population including federal boarding schools that resulted in the growing AI/AN populations in cities.

On September 30, 2021, in recognition of the National Day of Remembrance, Senator Elizabeth Warren (D-MA), Congresswoman Sharice Davids (D-KS-3), and Congressman Tom Cole (R-OK-4) introduced the Truth and Healing Commission on Indian Boarding School Policies in the United States Act.

Tasked with investigating and documenting the Indian boarding school policies and the historical and ongoing trauma that resulted, the Commission provides an environment for Native people to speak about their personal experiences and will provide recommendations to the government. Working in collaboration with other agencies, the Commission would also develop recommendations for the federal government on how to acknowledge the trauma and help Native communities heal.

The federal government funded these boarding schools as recently as the 1960s, specifically to wipe out Indigenous cultures. Children were forcibly removed from their families and experienced horrific emotional, physical, and sexual abuse while in custody of these schools. The Commission not only highlights the government’s role in the abuse but will also build on the work of Secretary Debra Haaland and the Department of the Interior in examining what happened at these schools.

On December 23, 2021, NCUIH submitted comments to the Department of the Interior regarding the agency’s Federal Boarding School Initiative reiterating its ongoing support for the Administration’s efforts to address the legacy of boarding school programs, while urging the Administration to use the Initiative to address the public health impact of boarding schools on urban AI/ANs.

Full Text of Testimony:

National Council of Urban Indian Health –Testimony for House Natural Resources Subcommittee for Indigenous Peoples of the United States in Support of Truth and Healing Commission on Indian Boarding Schools

My name is Francys Crevier, I am Algonquin and the Chief Executive Officer of the National Council of Urban Indian Health (NCUIH). On behalf of NCUIH, the national advocate for health care for the over 70% of American Indians and Alaska Natives (AI/ANs) living off-reservation and the 41 Urban Indian Organizations (UIOs) that serve these populations, we hereby submit this public witness testimony in support of legislation that would create a Truth and Healing Commission on Indian Boarding Schools in the United States. NCUIH exists in part because of the historic oppression of the AI/AN population including federal boarding schools that resulted in the growing AI/AN populations in cities.

Background and Impact of Indian Boarding School Policies on AI/ANs

The federal government funded boarding schools as recently as the 1960s, specifically to wipe out Indigenous cultures. The horrific aim was to “kill the Indian and save the man.” The United States Government’s Indian boarding school policy authorized the forced removal of hundreds of thousands of Native children, as young as five years old, relocating them from their homes in Tribal communities to one of the 408 Indian Boarding Schools across 30 states[1]. Between 1819 and 1969, the United States federal government stole Native children from their families to destroy their Indigenous identities, beliefs, and traditional languages to assimilate them into white American culture through federally funded Christian-run schools[2]. Children were forcibly removed from their families and experienced horrific emotional, physical, and sexual abuse while in the custody of these schools. The Relocation and Termination Era and Federal Indian Boarding Schools are inextricably linked to the urbanization of Native people today and the effects are profound.

Creating a Truth and Healing Commission Remains a Critical Priority for AI/ANs

NCUIH was pleased to work with Senator Elizabeth Warren on her landmark legislation to begin a healing process from Indian Boarding School policies. On September 30, 2021, in recognition of the National Day of Remembrance, Senator Elizabeth Warren (D-MA), Congresswoman Sharice Davids (D-KS-3), and Congressman Tom Cole (R-OK-4) Introduced the Truth and Healing Commission on Indian Boarding School Policies in the United States Act (H.R. 5444/S.2907).

Tasked with investigating and documenting the Indian boarding school policies and the historical and ongoing trauma that resulted, the Commission provides an environment for Native people to speak about their personal experiences and will provide recommendations to the government. Working in collaboration with other agencies, the Commission would also develop recommendations for the federal government on how to acknowledge the trauma and help Native communities heal. Senator Warren (D-MA) worked alongside NCUIH to promote UIO inclusion in this legislation. NCUIH is grateful for their support and the support of all co-sponsors for this Commission and for promoting the inclusion of UIOs. Their support has ensured that a longtime priority for UIOs may now become a reality.

Inclusion of UIOs in Truth and Healing Commission

NCUIH thanks the committee and the bill’s sponsors for including UIOs as one of the options for representation on the Commission. This ensures that the stories of the 70% of AI/ANs that live in cities will be included. Urban Indians are often left behind in legislation regarding AI/ANs and it is a sign of your hard work that urban AI/ANs now receive the inclusion they deserve. We thank you for your support of this inclusion provision.

Urban Indians have faced brutal treatment from the government through their forced removal to federally funded boarding schools. In order to truly heal from this experience, urban Indians must be included in efforts to come to terms with the historical trauma experienced by so many urban AI/ANs. In the future, we request that UIO inclusion be made mandatory in legislation impacting the legacy of these boarding schools. UIOs face the legacy of this historical trauma and the voices of urban AI/ANs must be heard.

Conclusion

In order to address these abuses, the Truth and Healing Commission must be formed. The truth of what happened to these AI/AN children must be acknowledged, witnessed, and validated. The government must take accountability for the horrors it oversaw. This Commission would allow AI/ANs to speak about their experiences at federally-funded boarding schools. This Commission will empower AI/AN voices by allowing them to provide recommendations to the federal government. No longer will AI/AN voices be silenced, rather, through this Commission, they would be uplifted. It is NCUIH’s hope that this will usher in a new era where the trust responsibility is better upheld to all Indigenous people, including the over 70% of AI/ANs who reside in urban areas as a result of policies like federal boarding schools.

NCUIH once again thanks this Committee, Senator Warren (D-MA), Congresswoman Sharice Davids (D-KS-3), and Congressman Tom Cole (R-OK-4) for their support of the Truth and Healing Commission on Indian Boarding School Policies. This bill would begin the healing necessary to make amends for past historical injustices. You have the unique opportunity to empower AI/ANs who were subject to the cruelty of these schools. I urge you to take this opportunity to make the changes so desperately needed.

[1] https://www.bia.gov/sites/default/files/dup/inline-files/bsi_investigative_report_may_2022_508.pdf

[2] Ibid.

NCUIH Submits Comments to IHS on Resource and Patient Management System Replacement and Health Information Technology Modernization Focus Groups

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On June 3, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to the Indian Health Service (IHS) about Health Information Technology (HIT) Modernization Governance regarding the replacement of the Resource and Patient Management System (RPMS). These comments responded to the joint Tribal Consultation and Urban Confer on May 3, 2022 and request for comments. NCUIH thanked the IHS for hosting the joint Tribal Consultation and Urban Confer and for planning two additional Tribal Consultation and Urban Confer sessions in 2022 to address HIT Modernization. Furthermore, NCUIH recommended that IHS ensure HIT Modernization focus groups are representative of the entire IHS/Tribal/Urban Indian Organization (I/T/U) system, identify specific statutes and/or regulations that prevent convening the focus groups before IHS purchases the new Resource and Patient Management System (RPMS), and prioritize interoperability in the RPMS replacement system.

Background

HIT Modernization for the I/T/U system is long overdue. Although HIT is necessary to provide critical services and benefits to American Indians/Alaska Natives (AI/AN) patients, IHS has historically faced challenges in managing clinical patient and administrative data through the RPMS. Initially developed specifically for the IHS, years of underfunding and a resulting failure to keep pace with technological innovation have left the RPMS impractical by current HIT standards. RPMS has been in use for nearly 40 years and has developed significant issues and deficiencies during this time, especially in recent years as HIT systems have rapidly advanced in sophistication and usefulness. As the Department of Health and Human Services (HHS) Office of the Chief Technology Officer (OCTO) and IHS found in the 2019 Legacy Assessment, systemic challenges with RPMS “across all of the IHS ecosystem currently prevent providers, facilities and the organization from leveraging technology effectively.” Because HIT is so critical to modern provision of healthcare services, this in turn makes it difficult for AI/AN healthcare providers to provide continuous, consistent care to the already marginalized AI/AN community. Accordingly, NCUIH appreciates that IHS has chosen to fully replace RPMS. Appropriate implementation of HIT Modernization will be a long-term project requiring consistent communication and collaboration between IHS and the entire I/T/U system.

NCUIH’s Requests to HHS

Accordingly, NCUIH makes the following specific comments, requests, and recommendations to IHS:

  • IHS must ensure that HIT Modernization focus groups are representative of the entire I/T/U system.
    • Inclusion of urban Indian organizations (UIOs) in the HIT Modernization process is consistent with, and required by, the federal government’s trust responsibility and the Indian Health Care Improvement Act (IHCIA). Furthermore, it is sound public policy. The UIO experience with RPMS and their needs from the modernization process must be accounted for, because they will inherently differ from the rest of the I/T/U system.
    • NCUIH urges the IHS IT office to proactively reach out to individual UIOs and NCUIH for recommendations on persons willing and able to serve as UIO representatives on the HIT Modernization focus groups. IHS Headquarters should also use Area Offices to reach out to UIOs, as they will have pre-existing local relationships with relevant UIO IT staff.
    • NCUIH offers its assistance if needed to facilitate communication with UIOs relating to the HIT Modernization focus groups or HIT modernization.
  • NCIUH requests that IHS identify the specific provisions of the Federal Acquisition Regulation, as well as any other relevant statutes and/or regulations, which it believes prevent convening the HIT Modernization focus groups at this time.
    • Based on the May 3 Tribal Consultation and Urban Confer, NCUIH understands that IHS identified legal concerns with convening focus groups prior to purchasing a RPMS replacement system and is seeking to minimize the risk of bid protests.
    • NCIUH asks that IHS identify relevant statutes and/or regulations which it believes prevent convening the focus groups at this time, so that Tribes, UIOs, and relevant national organizations may understand IHS’ concerns and provide pertinent feedback.
    • In addition, NCUIH requests an explanation from IHS on how it will utilize the focus groups if a RPMS replacement system is purchased prior to their convening.
  • IHS must prioritize interoperability in the RPMS replacement system.
    • Advancing interoperability is a key component of the 2020-2025 Federal Health IT Strategic Plan and is critical for creating a longitudinal health record that can be used to provide and improve care to AI/ANs.
    • NCUIH and UIOs are concerned that purchasing a RPMS replacement system without utilizing the interoperability focus group runs the risk of recreating RPMS’ existing interoperability problems.
    • If IHS insists on purchasing a RPMS replacement system prior to convening the interoperability focus group, it must use all data gathering tools at its disposal, including surveying I/T/U providers, hosting further Tribal Consultations and Urban Confers, internal technical analysis, and more, to ensure that the RPMS replacement system will prove to be a comprehensive solution for all I/T/U facilities.

NCUIH looks forward to the upcoming listening sessions and is confident that UIOs will be valuable subject matter experts in the HIT Modernization focus groups.