Bipartisan Group of Over Two Dozen Congressional Leaders Request Increased Resources for Urban Indian Health and Support Mandatory Funding for Indian Health in FY23

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On April 26, 2022, 28 Congressional leaders requested up to $949.9 million for urban Indian health in FY23 and advanced appropriations for the Indian Health Service (IHS) until such time that authorizers move IHS to mandatory spending.

Reps. Grijalva and Gallego requested up to $949.9 million for urban Indian health in FY23 and advanced appropriations for IHS until such time that authorizers move IHS to mandatory in a letter to Chairwoman Pingree and Ranking Member Joyce of the House Interior Appropriations Committee. The letter stated that “this increase in funding is necessary to address health disparities in the American Indian and Alaska Native (AI/AN) population. AI/ANs are 3.2 times more likely to be hospitalized for COVID-19 and 2.2 times more likely to die from the virus when compared with white patients.”

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

The Congressional leaders also stated their support for the President’s proposal of mandatory funding. The Indian health system is currently not shielded from the negative impacts of government shutdowns, continuing resolutions, and automatic sequestration cuts. Already underfunded, these disruptions can have serious consequences to UIOs’ ability to provide critical patient services. The letter states that, “until authorizers act to move IHS to mandatory funding, we request that your subcommittee provide advance appropriations to the Indian health system to improve certainty and stability.”

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

NCUIH is grateful for the support of the following Representatives:

  1. Ruben Gallego
  2. Raul Grijalva
  3. Don Bacon
  4. Nanette Barragán
  5. Shontel Brown
  6. Salud Carbajal
  7. Sharice Davids
  8. Diana DeGette
  9. Chuy García
  10. Sylvia Garcia
  11. Steven Horsford
  12. Pramila Jayapal
  13. Ro Khanna
  14. Teresa Leger Fernandez
  15. Zoe Lofgren
  16. Doris Matsui
  17. Donald McEachin
  18. Jerry McNerney
  19. Gwen Moore
  20. Eleanor Norton
  21. Tom O’Halleran
  22. Raul Ruiz
  23. Kim Schrier
  24. Terri Sewell
  25. Adam Smith
  26. Melanie Stansbury
  27. Greg Stanton
  28. Rashida Tlaib

Full Letter Text

Dear Chairwoman Pingree and Ranking Member Joyce:

We write to thank you for your proven commitment to urban Indian health and Urban Indian Organizations (UIOs) and to request you continue your support by funding urban Indian health at the highest level possible up to $949.9 million and supporting advance appropriations for IHS in the FY 2023 Interior, Environment, and Related Agencies Appropriations Act.

UIOs provide health care for the over 70% of American Indians and Alaska Natives (AI/ANs) living off-reservation and are an important part of the Indian Health Service (IHS), which oversees a three-prong system for the provision of health care: the Indian Health Service, Tribal Programs, and UIOs (I/T/U). UIOs do not have access to other federal line items that IHS and Tribal facilities do, like hospitals and health clinics money, facilities funds, purchase and referred care (PRC) dollars, or IHS dental services dollars.

Our FY23 request for $949.9 million for urban Indian health reflects the recommendation made by the Tribal Budget Formulation Workgroup (TBFWG), which is comprised of sovereign Tribal leaders representing all twelve IHS service areas. For FY22, the House accepted and passed the TBFWG’s recommendation of $200.5 million for urban Indian health, reflecting the minimum investment we must make in urban Indian health. The marked increase between the FY22 and FY23 request is a result of Tribal leaders’ decision, over several decades, to provide budget recommendations based on a plan to phase in full funding for IHS and UIOs over 10-12 years to address growing health disparities that have largely been ignored. In FY23, Tribal leaders are unified in their request to fully fund UIO need at $949.9 million.

In its report, the TBFWG states that “Due to historically low funding levels for urban Indian health, UIOs are chronically underfunded. Full funding of UIOs will directly benefit urban Indians that rely on UIOs to access culturally-competent care.” If urban Indian health funding continues to be funded at its current pace, it will continue to contribute to the severe health disparities. Due to this fact, we respectfully request the highest possible funding for Urban Indian Health up to TBFWG’s recommendation of $949.9 million, and no less than the FY22 House passed level of $200.5 million.

This increase in funding is necessary to address health disparities in the American Indian and Alaska Native (AI/AN) population. AI/ANs are 3.2 times more likely to be hospitalized for COVID-19 and 2.2 times more likely to die from the virus when compared with white patients. Even before the pandemic, the population served by UIOs and IHS was particularly vulnerable. Pre-pandemic life expectancy for AI/ANs was more than four years below the national average and re-occurring health problems are more acute for AI/ANs living in urban areas, who suffer greater rates of chronic disease, infant mortality, and suicide. Yet, despite the historical acknowledgement from Congress of the significant health care disparities in Indian Country and among urban Indians, IHS is underfunded at around $4,000 per patient, with UIOs receiving less than $700 per patient. In order to fulfill the federal government’s trust responsibility to all AI/ANs to provide safe and quality healthcare, funding for urban Indian health must be significantly increased. It is also imperative that such an increase not be paid for by diminishing funding for already hard-pressed IHS and Tribal providers.

We also support the President’s proposal to make IHS funding mandatory. The Indian health system, including IHS, Tribal facilities and UIOs, is the only major federal provider of health care that is funded through annual appropriations. If IHS were to receive mandatory funding or, at the least, advance appropriations, it would not be subject to the harmful effects of government shutdowns, automatic sequestration cuts, and continuing resolutions (CRs). When IHS is funded through a CR, the IHS can only expend funds for the duration of a CR, which prohibits longer term purchases, disrupts the contracts that allow UIOs to provide health care, and quite literally puts lives at risk. Because UIOs must rely on every dollar of limited federal funding they receive to provide critical patient services, any disruption has significant and immediate consequences. Until authorizers act to move IHS to mandatory funding, we request that your subcommittee provide advance appropriations to the Indian health system to improve certainty and stability.

We thank you for your consideration of our request to provide as high a funding level as possible for urban Indian health and the 41 Title V UIOs up to $949.9 million and to support advance appropriations for IHS in the FY 2023 Interior, Environment, and Related Agencies Appropriations Act.

NCUIH 2022 Policy Priorities Released

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The 2022 policy priorities were informed by NCUIH’s 2021 Annual Policy Assessment containing information collected from a series of focus groups held with urban Indian organization (UIO) leaders and a questionnaire to UIOs.

NCUIH is pleased to announce the release of its 2022 Policy Priorities, which outlines the most pressing Congressional and Federal issues for UIOs. These priorities were informed by NCUIH’s 2021 Policy Assessment.

Last year, NCUIH hosted five focus groups to identify UIO policy priorities for 2022, as they relate to Indian Health Service (IHS)-designated facility types (full ambulatory, limited ambulatory, outreach and referral, and outpatient and residential). Information was also collected from UIOs via a questionnaire. This is the second year that NCUIH has conducted focus groups and sent a questionnaire to UIOs to formulate key legislative priorities for the following year.

Overview

Upholding the highest health status for all American Indians/Alaska Natives (AI/ANs), parity in the Indian health system, and improving IHS are the overall themes for the 2022 priorities. New priorities were identified, such as achieving full funding for IHS and urban Indian health, advancing HIV efforts in AI/AN communities, improving data in Indian health, and improving IHS area office consistency. Existing priorities also remain a key focus across the UIOs, especially funding flexibility, improving federal dialogue with all AI/ANs through urban confer policies, and parity issues such as permanent 100% Federal Medical Assistance Percentage (FMAP).

2022 Policy Priorities:

Upholding the Highest Health Status for All American Indians and Alaska Natives (AI/ANs)

  • Fully Fund the Indian Health Service (IHS) and Urban Indian Health at the Amounts Requested by Tribes
    • FY 2023 Request for IHS: $49.8 billion.
    • FY 2023 Request for the Urban Indian Line Item: $949.9 million.
  • Improving Behavioral Health for All American Indians and Alaska Natives
    • Enact the Native Behavioral Health Access Improvement Act (H.R. 4251/S. 2226) to Provide at Least $200 million Annually to Indian Health Care Providers.
    • Enact the State Opioid Response Grant Authorization Act of 2021 (H.R. 2379) to Provide Critical Investments to Tribes, Tribal Organizations, and UIOs to Fight the Opioid Epidemic.
  • Attain Advance Appropriations for Indian Health and Improve Funding Certainty
    • Enact the Indian Programs Advance Appropriations Act (H.R. 5567/S. 2985) and Indian Health Service Advance
      Appropriations Act (H.R. 5549) to Insulate Indian Health Care Providers from Shutdowns.
    • Allow UIOs to Receive all Funds at the Start of a Continuing Resolution (Exception Apportionment)
  • “Nothing About Us Without Us”: Improving Health Outcomes Through Dialogue
    • Enact the Urban Indian Health Confer Act (H.R. 5221) to Establish an Urban Confer for the Department of Health and Human Services (HHS).
    • Include UIOs in Advisory Committees that Focus on Indian Health.
    • Establish an Urban Indian Interagency Work Group to Identify the Needs and Develop Strategies to Better Serve Urban AI/AN Populations.
  • Improving Native Veteran Health Outcomes
    • Establish an Urban Confer for the Department of Veterans Affairs (VA).
    • Enact the STRONG Veterans Act of 2022 (H.R.6411).
  • Special Diabetes Program for Indians: A Proven Case of Decreased Diabetes Prevalence and Improved
    Health Outcomes for AI/AN People

    • Permanently Reauthorize Special Diabetes Program for Indians (SDPI) at a Minimum of $250 Million Annually.
  • Healing from Federal Boarding Schools
    • Enact the Truth and Healing Commission on Indian Boarding School Policies in the United States Act
      (H.R.5444/S.2907).
  • Ending the Pandemic of Missing and Murdered Indigenous Peoples (MMIP)
    • Enact the Violence Against Women Act Reauthorization Act of 2022 (S. 3623).
  • Improving Data in Indian Health
    • Enact the Tribal Health Data Improvement Act (H.R. 3841).
  • Improving the Response to the COVID-19 Pandemic for AI/ANs
    • Enact the Tribal Medical Supplies Stockpile Access Act of 2022 (H.R. 6372/S. 3444).
  • Tackling the Stigma and Advancing HIV Efforts in AI/AN Communities
    • Increase Innovative Resources to Reduce Stigma and Fear Around HIV in AI/AN Communities.
    • Increase Behavioral Health Support Resources at UIOs for AI/ANs Living with HIV.

Parity in the Indian Health System

  • Increasing Resources Supporting Medicaid-IHS Beneficiaries
    • Enact the Urban Indian Health Parity Act (H.R. 1373 or H.R. 1888) to Ensure Permanent Full (100%) Federal Medical Assistance Percentage (FMAP) for Services Provided at UIOs.
  • Improving the Indian Health Workforce
    • Inclusion of UIOs in National Community Health Aide Program (CHAP).

Improving the Indian Health Service

  • Data is Dollars: Ensuring Accurate Data Collection in the Indian Health System
    • Health IT/Electronic Health Record (EHR) Improvement and IHS National Data Warehouse Reporting
  • Continuity in the Indian Health System
    • Improve Area Office Consistency.
  • Elevate the Health Care Needs of Native Americans Within the Federal Government
    • Enact the Stronger Engagement for Indian Health Needs Act (H.R. 6406) to elevate the IHS Director to Assistant Secretary for Indian Health.

Read the 2022 Policy Priorities

Read the 2021 Policy Assessment

NCUIH Endorses Bipartisan Bill to Make Indian Health Service Loan Repayment Assistance Tax-Exempt

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On April 18, 2022, Representatives Gwen Moore (D-WI-04) and Tom Cole (R-OK-4) reintroduced the bipartisan Indian Health Service Health Professions Tax Fairness Act of 2022 (H.R. 7539). The bill would amend the Internal Revenue Code for payments under the Indian Health Service (IHS) Loan Repayment Program and the Indian Health Professions Scholarships Program to provide health care professionals who receive student loan repayments from IHS the same tax-free status enjoyed by individuals under other similar programs such as the National Health Service Corps (NHSC) loan repayment program. The Indian Health Service Health Professions Tax Fairness Act of 2022 is co-sponsored by Representatives Andre Carson (D-IN-7), David Joyce (R-OH-14), and Eleanor Norton (D-DC-1). The bill has been endorsed by leading Native American advocacy groups— including the National Indian Health Board, AI/AN Health Partners, and NCUIH.

“The National Council of Urban Indian Health (NCUIH) is pleased to endorse Rep. Moore and Rep. Cole’s Indian Health Service Health Professions Tax Fairness Act of 2022. This bill would assist with the challenges faced by Indian Country to recruit and retain quality health care providers by the IHS and at urban Indian organizations (UIOs). The entire IHS I/T/U system (Indian Health Service, Tribal, and UIO) struggles to hire the essential staff needed to provide culturally competent health care and to fill vacancies for physicians, nurses, dentists, and pharmacists.” – Francys Crevier (Algonquin), CEO, NCUIH.

“It is critical that Congress addresses health care provider shortages in IHS facilities, especially given they provide care to the majority of Native Americans and Alaskan Natives,” said Congresswoman Moore. “One way to reduce inequities facing these communities and combat this challenge is to exempt these programs from federal income tax requirements, which already exist for similar programs. This change will remove unfair financial barriers preventing IHS from filling crucial jobs and increasing staff retention and will help increase the quality of care for patients. With our bipartisan bill, we help Native Americans enter health professions and invest in the health of their communities.”

“To ensure the federal government meets its trust and treaty obligations to provide health care services to Native Americans and eliminate health care disparities, it is important to improve the ability to recruit and retain health care professionals in Indian country,” said Congressman Cole. “While IHS already offers scholarships and loan repayment assistance, making this assistance tax exempt, as it is for other federally-operated health care loan repayment programs, would be an important tool to help address the severe workforce shortages in Native American communities. I am proud to join in the bipartisan introduction of this commonsense legislation that supports tribal health and economic prosperity.”

Next Steps

The bill was referred to the House Ways and Means Committee. It currently awaits consideration. This bill has been added to the NCUIH legislative tracker and can be found here.

Background

IHS faces challenges with provider recruitment and retention. In 2018, the U.S. Government Accountability Office (GAO) released a report finding that IHS suffers from long-standing vacancy rates and faces ongoing challenges in filing provider vacancies. GAO estimated an average vacancy rate for physicians, nurses, and other care providers of 25%. To address this issue, IHS provides financial aid to qualified American Indian/Alaska Native (AI/AN) students through the Indian Health Professions Scholarships Program, and loan repayment assistance to health professionals through the IHS Loan Repayment Program. The IHS Loan Repayment Program (LRP) can help dedicated health professionals at Indian Health Service facilities, Tribally-Operated 638 Health Programs, and Urban Indian Organizations. The LRP funds IHS clinicians to repay their eligible health profession education loans — up to $40,000 — in exchange for an initial two-year service commitment to practice in health facilities serving American Indian and Alaska Native communities. Opportunities are based on Indian health program facilities with the greatest staffing needs in specific health profession disciplines. Under current law, amounts received from IHS are included in gross income for students under the Indian Health Professions Scholarships Program and for providers under the IHS Loan Repayment Program. The Indian Health Service Health Professions Tax Fairness Act of 2022 brings parity to IHS by excluding gross income amounts received under both programs and allowing for a tax-free status similar to other federal scholarship and loan repayment programs.

NCUIH has long supported this parity effort to assist IHS health professionals. In 2019, NCUIH endorsed Senator Tom Udall’s identical bill, the Indian Health Service Health Professions Tax Fairness Act of 2019 (S. 2871).

NCUIH Endorses Bipartisan, Bicameral Bill to Improve Public Health Emergency Preparedness for Indian Health Care Providers

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On March 31, 2022, Senator Elizabeth Warren (D-Mass.), Representative Ruben Gallego (D-Ariz.), Senator Martin Heinrich (D-N.M.), and Representative Tom Cole (R-Okla.) introduced the Centers for Disease Control and Prevention (CDC) Tribal Public Health Security and Preparedness Act (S. 3968). The bill would allow Tribes  to apply directly to the Centers for Disease Control and Prevention (CDC) for Public Health Emergency Preparedness (PHEP) program funds. Currently, only states and certain local entities may apply for PHEP funds to respond to public health emergencies. The bill  authorizes $750 million for each of fiscal years 2023 through 2025 for the PHEP program 5% tribal set-aside of the total CDC PHEP funds.  Additionally, urban Indian organizations (UIOs) are included in several important consultation provisions in the bill that would ensure they are included in crafting public health plans.

“The National Council of Urban Indian Health (NCUIH) is pleased to endorse Rep. Gallego’s CDC Tribal Public Health Security and Preparedness Act which provides Tribes access to Public Health Emergency Preparedness (PHEP) program funds and includes urban Indian organization input on the development of public health plans. The COVID-19 pandemic has had devastating impacts on Native communities, and this bill’s equitable access to critical preparedness funds will ensure Indian Country will be better prepared to respond to future public health emergencies.” – Francys Crevier (Algonquin), CEO, NCUIH.

The CDC Tribal Public Health Security and Preparedness Act is cosponsored by Senators Tina Smith (D-Minn.), Amy Klobuchar (D-Minn.), Cory Booker (D-N.J.), Tammy Baldwin (D-Wisc.), and Bernie Sanders (I-Vt.). The bill has been endorsed by leading Native American advocacy groups— including the National Congress of American Indians, National Indian Health Board, and NCUIH. It currently awaits consideration.

This bill has been added to the NCUIH legislative tracker and can be found here.

Background

Inequities in access to public health resources has caused the COVID-19 pandemic to have a disproportionate impact on Indian Country. The CDC Tribal Public Health Security and Preparedness Act helps address this issue by:

  • Allowing   to apply directly to the CDC PHEP program;
  • Requiring the CDC to fund at least ten tribes for emergency preparedness and include a
  • Exempting tribes   needing to match funds and waive many of the reporting requirements to minimize the administrative burden on tribal nations; and
  • Requiring grant recipients to include tribes, tribal organizations, and urban Indian organizations in their consultation process in their development of public health plans.

 

Senate Text of Bill

Senator Warren’s Press Release

 

President Biden Continues to Demonstrate Strong Commitment to Urban Indians, Proposes Over 50% Increase for Urban Indian Health for FY 2023

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The FY 2023 budget request includes $113 million for urban Indian health, a 53% increase over the FY 2022 enacted amount and mandatory appropriations for IHS.

On April 25, 2022, the Indian Health Service (IHS) published their Fiscal Year (FY) 2023 Congressional Justification with the full details of the President’s Budget, which includes $112.5 million for Urban Indian Health— a 53.2% increase above the FY 2022 enacted amount of $73.4 million. According to the IHS Congressional Justification, “This funding increase could support an estimated 1,072,935 health care, outreach, and referral services to Urban Indian users in FY 2023.” The President’s proposal included a total of $127.3 billion in discretionary funding for the Department of Health and Human Services (HHS) and, for the first time ever, $9.3 billion in mandatory funding for IHS for the first year, which includes $9.1 billion in proposed law funding and $147 million in current law funding for the Special Diabetes Program for Indians (SDPI). The budget proposes increased funding for IHS each year over ten years, building to $36.7 billion in FY 2032, to keep pace with population growth, inflation, and healthcare costs.

“The Indian Health System and urban Indian health have long been severely underfunded: only 1% of the Indian health budget goes to urban Indian health despite more than 70% of American Indians and Alaska Natives residing in urban areas. We are grateful for the President’s inclusion of $113 million for urban Indian health in FY 2023. President Biden has shown a strong commitment to urban Indian communities, and we recognize this Administration’s dedication to improving outcomes for all of Indian Country. As the final amount still falls well short of fully funding the Indian Health Service to properly provide health care services for all Natives in the United States to meet the trust responsibility, we will continue to push Congress to provide all the resources necessary to protect the lives of the entire Native population, regardless of where they live,”

– Francys Crevier (Algonquin), CEO, NCUIH

 

Line Item

FY21
Enacted

FY22 Enacted

FY23 TBFWG Request

FY23
President’s
Budget
Urban Indian Health  $62,684,000 $73,424,000  $949,900,000  $112,514,000
Indian Health Service $6,236,279,000 $6,630,986,000 $49,800,000,000 $9,100,000,000

 

The National Council of Urban Indian Health 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. The Congressional Justification states, “IHS recognizes that we must continue to work in consultation with Tribes and confer with Urban Indian Organizations, and with our partners in Congress, to ensure the budget is structured and implemented correctly with the resources identified over the next 10 years.”

Background and Advocacy

On March 28, 2022, President Biden released his budget request for Fiscal Year FY 2023, pending the more detailed IHS budget request released April 25, which includes specifics on the IHS budget request, including the funding recommendations for urban Indian health.

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 Urban Indian Organizations (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.

Next Steps

The Appropriations Committees will review the President’s Budget for consideration as they craft their bills for FY 2023. NCUIH will continue to work with the Biden Administration and Congress to push for full funding of urban Indian health in FY 2023.

Tribal Veteran Advocate Conference To Be Held May 2-3, 2022

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The Department of Veterans Affairs (VA) will be hosting a two-day Tribal Veteran Advocate Conference on May 2 and 3, 2022 from 10 a.m. to 3 p.m. PST (1 p.m. to 6 p.m. EST). This conference will involve training on understanding VA benefits and programs and will provide updates about the latest news affecting American Indian and Alaska Native Veterans. Topics which will be addressed during the training include: specially adapted housing grants, advance care planning, Program of Comprehensive Assistance for Family Caregivers (PCAFC), and Native Veteran spouses and dependency.

To register for the virtual training, click here.

NCUIH Submits Comments to DOJ on Missing and Murdered Indigenous People

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On April 15, 2022, the National Council of Urban Indian Health (NCUIH) submitted written comments and recommendations in response to the Department of Justice’s (DOJ) Dear Tribal Leader letter seeking stakeholder input on DOJ’s efforts to address the unacceptably high rates of violent crime in American Indian and Alaska Native communities and the missing and murdered Indigenous persons (MMIP) crisis. In its comments, NCUIH thanked the DOJ for its commitment to working with Tribes to develop and support Tribally-driven solutions to violent crime and MMIP, while noting the need for the federal government to also work with Urban Indian Organizations (UIOs) to address these issues.  NCUIH emphasized that working with all AI/AN communities across the United States is required by both Executive Order 14053, Executive Order on Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People (E.O. 14053), and Deputy Attorney General Monaco’s Memorandum establishing the DOJ’s Steering Committee to Address the Crisis of Missing or Murdered Indigenous Persons.  NCUIH further offered to assist DOJ in establishing strong working relationships with UIOs as it works to address these pressing public safety issues.

E.O. 14053 and Deputy Attorney General Monaco’s Memorandum: Inclusion of Urban AI/AN Communities

AI/AN people are the victims of violence, murder, and rape at rates higher than the national average.  As part of the federal government’s response to these issues, President Biden signed E.O. 14053, on November 15, 2021.  E.O. 14053 directs the federal government to “to strengthen public safety and criminal justice in Indian Country and beyond, to reduce violence against Native American people, and to ensure swift and effective Federal action that responds to the problem of missing or murdered indigenous people.”  E.O. 14053 committed the federal government’s to “[c]onsistent engagement, commitment, and collaboration,” with AI/AN people and communities to “drive long-term improvement to public safety for all Native Americans.”  E.O. 14053 specifically directed the federal government to “build on existing strategies to identify solutions directed toward the particular needs of urban Native Americans,” because “approximately 70 percent of  American Indian and Alaska Natives live in urban areas and part of this epidemic of violence is against Native American people in urban areas.”  In addition, E.O. 14053 directed the federal government to “work closely with Tribal leaders and community members, Urban Indian Organizations, and other interested parties to support prevention and intervention efforts that will make a meaningful and lasting difference on the ground.”

With respect to DOJ, Section 4 of E.O. 14053, contained the following directives:

  • “The Attorney General, in coordination with the Secretary of the Interior and the Secretary of Health and Human Services (HHS), as appropriate, shall sustain efforts to improve data collection and information-sharing practices, conduct outreach and training, and promote accurate and timely access to information services regarding crimes or threats against Native Americans, including in urban areas.”
  • “The Attorney General, in coordination with the Secretary of the Interior and the Secretary of HHS, shall develop a strategy for ongoing analysis of data collected on violent crime and missing persons involving Native Americans, including in urban Indian communities, to better understand the extent and causes of this crisis.”

In addition, on November 15, 2021 Deputy Attorney General Monaco signed a Memorandum establishing a Steering Committee to Address the Crisis of Missing or Murdered Indigenous Persons.  Deputy Attorney General Monaco ordered the Steering Committee to review the Department’s current guidance, policies, and practices with respect to MMIP, recommend any changes necessary to better facilitate the DOJ’s work on MMIP, and to develop a comprehensive plan to strengthen the Department’s work to address the issues of MMIP.  Deputy Attorney General Monaco also directed the Steering Committee to seek and consider the views of stakeholders including UIOs.

NCUIH’s Comments to DOJ

In its comments, NCUIH requested that DOJ ensure its compliance with E.O. 14053’s requirement to “work closely with Tribal leaders and community members, Urban Indian Organizations, and other interested parties to support prevention and intervention efforts that will make a meaningful and lasting difference on the ground,” by engaging in consistent and clear communication with UIOs and providing UIOs with notice of future consultations held pursuant to E.O. 14053.  NCUIH further urged DOJ to provide specificity regarding its plans to incorporate UIOs into the policies, procedures, and projects set forth in E.O. 14053 and in Deputy Attorney General Monaco’s Memorandum.

NCUIH noted collaboration with UIOs is not only required by E.O. 14053 and Deputy Attorney General’s Memorandum, but it is also sound public policy.  AI/AN individuals living in urban areas face many, if not all, of the same violent crime and MMIP issues as AI/ANs living on reservations or trust Iand.  UIOs are active and important partners in combatting crime and promoting violence prevention in urban AI/AN communities.  UIOs are also working together to develop innovative partnerships to provide services for victims of crime across jurisdictions.  As a result, UIOs are an integral partner to eradicating these pandemics of violent crime and MMIP.

NCUIH also requested that DOJ establish an Urban Confer policy to set the necessary policies and procedures for direct and clear communication with UIOs.  An Urban Confer is an established mechanism for dialogue between the federal government and UIOs. Urban Confer policies are a response to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that resulted in seventy percent (70%) of AI/AN people living outside of Tribal jurisdictions, thus making Urban Confer integral to address the care needs of most AI/AN persons.

NCUIH will continue to monitor the DOJ’s work on violent crime in Indian Country and MMIP.  NCUIH will also continue to advocate for the inclusion of UIO’s in DOJ’s efforts to ensure that E.O. 14053’s directive to “build on existing strategies to identify solutions directed toward the particular needs of urban Native Americans,” is met.

NCUIH Submits Comments to SAMHSA on SUD Patient Confidentiality Rules, 42 CFR Part 2

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On April 6, 2022, the National Council of Urban Indian Health (NCUIH) submitted written comments and recommendations in response to the Substance Abuse Mental Health Services Administration (SAMHSA)’s Dear Tribal Leader letter regarding the federal requirements for confidentiality of Substance Use Disorder (SUD) patient records found at 42 CFR Part 2 (Part 2). In its comments NCUIH emphasized the importance of including Urban Indian Organizations (UIOs) in discussions on rules and policies, like Part 2, which apply to both UIOs and Tribal healthcare facilities. NCUIH also highlighted that a strong Urban Confer policy and improved communications with UIOs will assist SAMHSA, HHS, NCUIH, and UIOs in collaborating to ensure the highest level of substance abuse treatment and mental health treatment for all American Indian and Alaska Natives (AI/ANs).

NCUIH’s Recommendations to SAMHSA

On March 10, 2022 NCUIH attended SAMHSA’s Tribal Consultation on federal requirements for confidentiality of SUD patient records found at 42 CFR Part 2.  Following the Tribal Consultation, NCUIH submitted written comments to SAMHSA on behalf the 41 Urban Indian Organizations (UIOs) it represents.  In its written comments, NCUIH noted that almost every UIO provides behavioral health, mental health, or SUD care to American Indians and Alaska Natives living in Urban Areas.  In fact, in 2021, 6 UIOs were awarded grants through the SAMHSA-funded Tribal Behavioral Health Grant Program, which is aimed at increasing the support and delivery of culturally-tailored suicide and substance abuse prevention services to AI/AN youth to the age of 24.  NCUIH also noted that because UIOs operate under contracts with the Indian Health Service, and receive other forms of federal funding, Part 2 rules on SUD patient records apply to UIOs which provide SUD counseling to patients.

Accordingly, NCUIH requested that HHS host an Urban Confer with UIOs regarding changes to Part 2.  Informing UIOs of the Part 2 changes and receiving UIO feedback is especially important given the vital work UIOs do to reduce the impact of substance abuse in AI/AN communities.  As providers of culturally focused health care, UIOs are well placed to address and treat SUD in AI/AN patients.  The work UIOs do to combat substance abuse in urban AI/AN communities is essential, given that rural and urban AI/ANs need SUD treatment at virtually the same rate and almost seventy percent (70%) of the AI/AN population lives in urban areas.

NCUIH further recommended that SAMHSA, and HHS more broadly, establish an Urban Confer policy.  Establishing an Urban Confer policy is consistent with the federal government’s trust responsibility to improve the health of AI/ANs.  Urban Confers are also sound public health policy as they will allow SAMHSA and HHS to gain a greater understanding of the AI/AN patient population and increase collaboration with the entire Indian Health Care system.

NCUIH is looking forward to working more closely with SAMHSA on urban AI/AN health and will continue to keep UIOs updated on SAMHSA’s most recent policies and practices that impact their work and affect AI/AN communities.

NCUIH Submits Comments to IHS on Urban Indian Organization On-Site Review Manual

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On April 12, 2022, the National Council of Urban Indian Health (NCUIH) submitted written comments and recommendations in response to the Indian Health Service’s (IHS) February 11, 2022 notice and request for comment on the information collection titled “Urban Indian Organization On-Site Review,” Office of Management and Budget Control Number 0917-00XX.  NCUIH requested that the on-site review manual be updated regularly, that IHS provide UIOs with a consolidated list of required documents prior to the on-site review, and that IHS enable UIOs to use existing administrative or site visit data in meeting the requirements of the Manual. NCUIH also encouraged the Office of Urban Indian Programs (OUIHP) to host an Urban Confer to personally hear UIO input on and experience with the on-site review process.

IHS On-Site Review Manual

The Indian Health Care Improvement Act (IHCIA) requires the Secretary of Health and Human Services, through the IHS, “to conduct an annual onsite evaluation of each urban Indian organization which has entered into a contract or received a grant under section 1653,” of the IHCIA.   As part of this statutorily mandated process the IHS Office of Urban Indian Health Programs (OUIHP) drafts and publishes the Manual, which is used to accomplish the annual review of UIOs.

In the nine years that the current Manual has been in use, UIOs have experienced significant changes, including adapting to the COVID-19 pandemic, and relevant standards of national healthcare accrediting organizations like the Association for Ambulatory Health Care (AAAHC) have changed.  Accordingly, NCUIH submitted comments, drawn directly from UIOs’ experience with the Manual and the annual review process, to inform the IHS on necessary areas of modification in the Manual.  NCUIH’s comments also included general recommendations concerning the annual review process.

NCUIH’s Recommendations to IHS

In its comments, NCUIH made the following requests, and recommendations based on NCUIH’s consultations with UIOs and NCUIH’s subject matter expertise:

  • Update the Manual regularly and as needed to remain consistent with other relevant accreditation processes
  • Provide greater flexibility in the Manual to accommodate diverse UIO program/facility goals and services
  • IHS to provide a consolidated list of requirement documents to UIOs prior to the on-site review
  • Ensure that UIOs can use existing administrative or site visit data in meeting the requirements of the Manual

In addition to the preceding recommendations regarding the Manual itself, NCUIH also requested that OUIHP host an Urban Confer with UIOs to learn about their experiences with the on-site review process.  NCUIH also submitted the following general recommendations concerning the annual review process for consideration:

  • Provide a timeline for processing information collected in the annual review process
  • Improve overall review by ensuring reviewers are licensed medical providers
  • Improve instructions on the limited annual waiver process

NCUIH looks forward to an updated On-Site Review Manual that will provide valuable information for UIOs and IHS.  NCUIH will continuing to monitor development and revision of the On-Site Review Manual and inform UIOs of pertinent information.

NCUIH Submits Comments to IHS on Health Information Technology Modernization

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On April 8, 2022 the National Council of Urban Indian Health (NCUIH) submitted written comments to the Indian Health Service (IHS) on Health Information Technology (HIT) Modernization. The comments were submitted in response to the IHS’s Dear Tribal Leader and Dear Urban Indian Organization letter dated February 22, 2022.  In its comments, NCUIH thanked the IHS for its commitment to a collaborative HIT modernization process while urging the IHS to advance the HIT Modernization Project to select the best HIT solutions for the for the Indian Health Service/Tribal/Urban Indian Organization (I/T/U) system at the best possible speed.   NCUIH also requested that IHS provide resources, both both human and financial, to continuously evaluate, support, and evolve I/T/U HIT systems as new technology and processes become available; ensure that the RPMS replacement system meets the technical needs of the whole I/T/U system, including UIOs; and requested that IHS continue to be transparent in this long-term, financially significant project, while also prov ensure consistent engagement with all I/T/U providers of all facility types to establish and maintain transparency with UIOs and responsiveness to concerns across the I/T/U system.

The Need for HIT Modernization

HIT “is a broad concept that encompasses an array of technologies to store, share, and analyze health information.” This includes, but is not limited to, “the use of computer hardware and software to privately and securely store, retrieve, and share patient health and medical information.”  HIT Modernization for the I/T/U system is long overdue. Although HIT is necessary to provided critical services and benefits to AI/AN patients, the IHS has historically faced challenges in managing clinical patient and administrative data through the Resource Management System (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.”

In addition,

NCUIH’s Requests to the IHS

NCUIH made the following specific comments, requests, and recommendations in response to your February 22, 2022, correspondence and March 10, 2022, Tribal Consultation and Urban Confer:

  • IHS must provide resources, both human and financial, to continuously evaluate, support, and evolve I/T/U HIT systems as new technology and processes become available
    • NCUIH requests that IHS provide sufficient funding for off-the-shelf costs of HIT modernization, including maintenance and IT support costs
    • NCUIH advises IHS that it must account for additional delays and costs in its support for I/T/U HIT modernization
    • NCUIH recommends that IHS dedicate a full-time staff person to support UIOs in the Office of IT (OIT) to improve training, support, and personnel in replacing the current RPMS, implementing new systems, and continuing support for UIOs utilizing any other commercial off-the-shelf (COTS) systems
    • NCUIH urges IHS to work with Congress to address budgetary constraints and fiscal law restrictions blocking reimbursement of HIT modernization costs to Tribes and UIOs
  • IHS must ensure that the RPMS replacement system meets the technical needs of the whole I/T/U system, including UIOs
    • NCUIH recommends that the RPMS replacement system provides full support for data exchange and interoperability both within and external to the I/T/U system
    • NCUIH advises IHS that the RPMS replacement system must support data reporting required for regulatory compliance
    • NCUIH requests that the RPMS replacement system provide a user-friendly experience that decreases the burden on I/T/U staff to access, make updates, and work in the new EHR system
  • IHS must ensure consistent engagement with all I/T/U providers of all facility types to establish and maintain transparency with UIOs and responsiveness to concerns across the I/T/U system

NCUIH will continue to closely follow IHS’s progress and policies with HIT Modernization and looks forward to participating in the additional Tribal Consultation and Urban Confer session later in the year.