NCUIH Submits Comments to DOJ OVC on the Tribal and Victims Services Set-Aside

On March 15, 2022 the National Council of Urban Indian Health (NCUIH) submitted comments to the Department of Justice (DOJ) Office for Victims of Crimes (OVC) in response to their December 13, 2021 correspondence seeking written comment on the Tribal Set-Aside from the Crime Victims Fund (Tribal Set-Aside) for Fiscal Year (FY) 2022. The Tribal Victim Services Set-Aside Formula grant program (TVSSA Program) is a key source of funding for American Indian/Alaska Native (AI/AN) communities working to enhance services for victims of crime, with over $532 million made available through FYs 18, 19, 20, and 21. NCUIH emphasized the critical services urban Indian organizations (UIOs) provide victims of crime and the importance of extending more funding opportunities for UIO.

NCUIH’s Role

Because many AI/AN victims of crime reside off reservations and because many seek care from Urban Indian Organizations (UIOs), NCUIH made the following specific comments, requests, and recommendations:

  • DOJ should provide Congress with technical assistance to support expansion of the Tribal Set-Aside and TVSSA Program to include UIOs.  Expansion of the percentage of the Tribal Set-Aside should be commensurate with inclusion of UIOs to ensure that funding to Tribes from the Tribal Set-Aside is not reduced.
  • OVC should formally invite UIOs to all future events in the TVSSA program consultation process.
    • OVC, and DOJ more broadly, should consider adopting an Urban Confer Policy.
  • OVC must ensure that all AI/ANs are served by its funding opportunities by expanding its definition of eligible awardees for all programs to the broadest extent permissible by law.

NCUIH will continue to closely follow the DOJ OVC policies and opportunities for AI/AN communities. NCUIH will also continue to advocate for more funding opportunities for UIOs that provide services to victims of crimes.

NCUIH Submits Comments to HRSA Advisory Committee on Infant and Maternal Mortality

On March 10, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments to the Health Resources Services Administration (HRSA) Advisory Committee on Infant and Maternal Mortality (ACIMM). The comments were submitted in advance of the ACIMM’s March 15-16 meeting focusing on program updates, race-concordant care, health of Indigenous mothers and babies, and the impact of violence on infant and maternal mortality. In the comments, NCUIH reiterated the need for an Urban Confer policy at the Department of Health and Human Services (HHS) and the importance of collaborating with urban Indian organizations (UIOs) for accurate data collection. NCUIH also recommended that the ACIMM include a Tribal and UIO representative among the ACIMM’s membership and create an ACIMM subcommittee on American Indian/Alaska Native (AI/AN) infant and maternal health disparities.

The Advisory Committee on Infant and Maternal Mortality

Formed in 1991, the ACIMM advises the Secretary of Health and Human Services (HHS) on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and sever maternal morbidity, and improving the health status of infants and women before, during, and after pregnancy. The ACIMM consists of public and private members and provides advice on how to coordinate governmental efforts to improve infant mortality, related adverse birth outcomes, and maternal health, as well as influence similar efforts in the private and voluntary sectors. With its focus on underlying causes of the disparities and inequities seen in birth outcomes for women and infants, the ACIMM advises the Secretary on the health, social, economic, and environmental factors contributing to the inequities and proposes structural, policy, and/or systems level changes.

American Indian and Alaska Native Infant and Maternal Mortality

According to HHS Office of Minority Health AI/ANs have almost twice the infant mortality rate as non-Hispanic whites. AI/AN infants are also 2.7 times more likely than non-Hispanic white infants to die from accidental deaths before the age of one year and AI/AN infants are 50 percent more likely to die from complications related to low birthweights as compared to the same group. AI/AN mothers are also disproportionately represented in maternal mortality. In 2019, AI/AN mothers were almost three times as likely to receive late or no prenatal care as compared to non-Hispanic white mothers.

NCUIH’s Role

NCUIH has engaged in extensive advocacy on behalf of AI/AN mothers and infants and for increased funding and support to the UIOs which provide maternal health, infant health, prenatal, and family planning services to AI/AN mothers and infants.  In its comments to the ACIMM, NCUIH made the following recommendations:

  • Advise the Secretary of HHS (Secretary) to lead the establishment of an Urban Confer policy to ensure that urban AI/ANs can provide pertinent guidance to HHS on department activities, partnerships, policies, and programs directed at reducing infant and maternal mortality, severe maternal morbidity, and improving the health status of infants and women before, during, and after pregnancy.
  • Advise the Secretary to collaborate with UIOs to gather accurate data on urban AI/AN infant and maternal health
  • Improve AI/AN representation on the ACIMM by including a tribal and UIO health provider representative on the ACIMM to complement the work of the standing IHS ex-officio member
    • NCUIH recommends that there be two seats, a Tribal and a UIO seat, so that ACIMM can receive a variety of viewpoints regarding the provision of health care to diverse AI/AN communities
  • Create an ACIMM subcommittee dedicated to addressing AI/AN infant and maternal health disparities

In addition to submitting comments, NCUIH attended the ACIMM’s session on the health of Indigenous mothers and babies.  During this session Alexandra Payan, NCUIH’s Federal Relations Associate, connected with several ACIMM members regarding their interest in improving AI/AN maternal and infant health.  NCUIH will continue to closely follow the ACIMM’s important work on AI/AN mothers and infants and seek opportunities for collaboration.

NCUIH Signs on to Letter Urging Reauthorization of Maternal, Infant, and Early Childhood Home Visiting Program with Tribal Set-Aside Increase

Last week, the National Council of Urban Indian Health signed-on to a letter to Congress led by the National Home Visiting Coalition in support of the reauthorization of the Health Resources & Services Administration (HRSA) Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV). The recommendations for reauthorization outlined in the letter include:

  • Increase MIECHV funding over the next five years to reach more families and better support the workforce
  • Double the Tribal MIECHV set-aside from three to six percent
  • Continue to allow virtual home visits with model fidelity as an option for service delivery
Read the Full Letter

NCUIH Submits Written Testimony to House Interior Appropriations with FY23 Budget Requests for Urban Indian Health

The National Council of Urban Indian Health (NCUIH) submitted written testimony for Tribal Public Witnesses to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding Fiscal Year (FY) 2023 funding for Urban Indian Organizations (UIOs). On January 28, 2022, the Subcommittee Chair and Ranking Member requested information from “Indian Country on issues and needs” that is used to develop the annual appropriations bill.

NCUIH advocated in its testimony for additional resources for the Indian Health Service and urban Indian Health.

In the testimony, NCUIH requested the following:

  • $48 billion for the Indian Health Service and $950 million for Urban Indian Health for FY23 (as requested by the Tribal Budget Formulation Workgroup)
  • Advance appropriations for IHS
  • UIOs be insulated from unrelated budgetary disputes through a spend faster anomaly so that critical funding is not halted

NCUIH reiterated, “The federal government owes a trust responsibility to tribes and AI/ANs that is not restricted to the borders of reservations. Funding for Indian health must be significantly increased if the federal government is, to finally, and faithfully, fulfill its trust responsibility.”

NEXT STEPS:

The testimony will be read and considered by the subcommittee as the appropriations process goes forward for FY23. The Subcommittee has not yet announced dates for the hearings on the FY 23 budget.

Department of Veterans Affairs Seeks Comments on Tribal Representation Expansion Project and Designation of Individuals to Represent AI/AN Veterans in VA Benefit Claims

On February 14, the Department of Veterans Affairs (VA) released a notice of Tribal consultation regarding the VA’s Tribal Representation Expansion Project (T.REP). Through this consultation and an additional written comment period, VA is seeking comments on three general areas.  First, whether Tribal communities have access to representation for VA benefit claims.  Second, for Tribes that are underserved in terms of representation, VA is also seeking comments regarding whether their Tribal government is interested in collaborating with VA to designate an individual within the community as authorized to prepare, present, and prosecute VA benefit claims.  Third, VA is seeking comments and recommendations on any issues, concerns or processes Tribes believe should be addressed in T.REP to better ensure that it is successful in expanding access to representation for AI/N veterans on their benefit claims before VA.

In addition to these general areas, VA has posed the following seven questions to be addressed through written comments:

  1. Are Native American Veterans in your community receiving any Start Printed Page 8343 assistance in pursuing their VA benefit claims? Are they being represented before VA on their VA benefit claims? Who is providing those services? For example, those claims services may be provided by: (a) A person employed by the Tribal government; (b) a member of your Tribe or Tribal community; (c) a VA-recognized organization or a representative of a VA-recognized organization; or (d) an agent or attorney. Please provide details as to the extent of the assistance provided and whom we may credit if your Tribal community currently has access to benefit claims assistance and/or representation before VA.
  2. If Veterans within your Tribal community have access to representation for their VA benefit claims, do you consider the option(s) for representation to be culturally competent representation? Please explain.
  3. If Veterans and their families within your Tribal community are not being adequately represented on their VA benefit claims, is there someone employed by, or affiliated, with your Tribal government that is currently, or could be, positioned to serve Veterans? For example, such individual may currently be serving Veterans and their families as a Tribal Veterans Service Officer (TVSO) or as a Tribal Veterans Representative (TVR).
  4. Are there barriers to Veterans and their family members within your Tribal community in accessing representation on their VA claims? For example, barriers may include: (a) Location or environmental obstacles; (b) language difficulties; (c) cultural differences; (d) distrust of the Federal or State government; (e) difficulties in finding training; (f) difficulties in securing office equipment and internet services; or (g) other circumstances.
  5. Do you believe that your Tribal government may want to collaborate with VA to identify someone affiliated with your government to be authorized to represent Veterans and their families on benefit claims before VA?
  6. Are you interested in being contacted by VA’s Office of General Counsel to learn more about the project?
  7. Are there issues, concerns, or processes that should be addressed in T. REP so that the project functions effectively in support of access to representation for Native American Veterans within your Tribal government and/or community? If so, how do you recommend VA address those matters in this project?

VA will be holding a virtual tribal consultation session on March 23, 2022, from 3:00-5:00 p.m. (Eastern Time). Written comments may also be submitted to VA by March 30, 2022. Written comments may be submitted by email to tribalgovernmentconsultation@va.gov, as well as through other methods listed in the Federal Register Notice.  To access the virtual consultation session, participants must register by clicking here.

Background

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

In 2017, VA amended its regulations governing recognition of organizations permitted to provide assistance on VA benefit claims in 2017 to permit the VA Secretary to recognize Tribal organizations in a similar manner as state organizations.  VA also amended its regulation to allow employees of Tribal governments to become accredited through recognized State organizations in a similar manner as a County Veterans’ Service Officer.  Despite a request that VA amend its regulations to also recognize UIOs, VA declined to do so.  VA stated that UIOs should consider applying for VA recognition as a regional or local organization.

VA’s T.REP represents VA’s most recent effort to ensure that AI/AN veterans and their families have access to appropriate representation in the preparation, presentation, and prosecution of their VA benefit claims. The aim of this program is to focus on Tribal communities that are being underserved in terms of representation. VA’s current T.REP focus is collaborating with Tribal governments to identify “an individual who is affiliated with their government, is of good character and reputation, and, who, after proper training on VA benefits, would be fit to be authorized by the VA General Counsel to represent on VA benefit claims.”  According to VA, if a tribal government identifies such a person “[t]he General Counsel then plans to use his discretionary authority, pursuant to 38 CFR 14.630, to specially authorize such individuals to prepare, present, and prosecute VA benefit claims before VA.”

Inclusion of UIOs in T.REP Would Benefit AI/ANs living in Urban Areas

NCUIH encourages UIOs to submit comments to VA by March 30, 2022 concerning T.REP, the needs of AI/AN veterans living in urban areas, and whether VA should consider including UIOs in T.REP.  AI/AN veterans living in urban areas face many of the same barriers to accessing competent representation in VA claims that AI/AN veterans face on reservations.  For example, VA cites cultural and language barriers as being two of the main deterrents for AI/AN veterans seeking representation on VA benefit claims.  AI/AN veterans living in urban areas also face cultural and language barriers when searching out representation on their claims.

Further, current estimates show that 67 percent of the veteran population identifying as AI/AN alone lives in metropolitan areas. UIOs currently serve six of the ten urban counties with the largest veteran AI/AN alone populations, including Maricopa County, Arizona; Los Angeles County, California; San Diego County, California; Bernalillo County, New Mexico; Oklahoma County, Oklahoma; and Tulsa County, Oklahoma. AI/AN veterans regularly prefer to see UIOs over other health care providers thanks to the provision of culturally competent care (including traditional healing services), community and familial relationships, shorter wait times, and shorter distance to travel.  Given the large portion of the AI/AN veteran population living in urban areas and UIOs’ ability to reach AI/AN veterans, inclusion of UIOs in T.REP would help VA accomplish its goal of “ensur[ing] that Native American Veterans and their families have access to responsible, qualified representation in the preparation, presentation, and prosecution of their benefit claims before VA.”

NCUIH Releases “2021 Policy Assessment: Setting Policy Priorities for 2022”

The policy assessment informs urban Indian organization policy priorities in 2022, identifies HIV care needs, reviews COVID-19 funding disbursements, and addresses data accuracy needs.

NCUIH is pleased to announce the release of its 2021 Policy Assessment. NCUIH hosted five focus groups to identify Urban Indian Organization (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). The focus groups were held on the following dates in 2021: November 18, 19, and 22. Information was also collected from UIOs via a questionnaire sent out on December 1, 2021. Together these tools allowed NCUIH to work with UIOs to identify policy priorities in 2022; identify HIV prevention, treatment, and care needs at UIOs; review disbursements of COVID-19 funding; and determine the accuracy of the data reported by the IHS National Data Warehouse (NDW). Of 41 UIOs, 25 UIOs attended the focus groups or participated in the questionnaire. This is the second year that NCUIH has conducted focus groups and sent a questionnaire to UIOs.

Overview

The COVID-19 pandemic renewed the focus on priorities such as funding for UIO facilities, funding for behavioral health, and funding transparency. Existing priorities also remain a key focus across the UIOs, especially increasing funding amounts for the urban Indian health line item, funding flexibility, and parity issues such as permanent 100% Federal Medical Assistance Percentage (FMAP).

Key findings from the discussions are as follows:

  • Overall Funding, Facilities and Infrastructure, and FMAP Parity Top Priority Lists for UIOs
  • Area Office Inconsistencies Affect Staffing, Funding, and Resources
  • UIOs Need Health IT Guidance from IHS to Reflect their Unique Systems and Cite Data Accuracy Concerns
  • UIOs Need Community Health Representatives (CHRs)
  • Contract Flexibility and Funding Security
  • Facility Funding Necessary for UIOs Amid the COVID-19 Pandemic
  • COVID-19 Pandemic and Vaccine Impacts on UIOs
  • Need for Permanent 100% FMAP for UIOs
  • UIOs Identified a Need for Additional HIV, Behavioral Health, and Substance Abuse Support
  • Special Diabetes Program for Indians (SDPI) Reauthorization Remains a Priority
  • NCUIH Services Benefit UIOs and Opportunities to Expand Identified

Read the 2021 Policy Assessment: Setting Policy Priorities for 2022

Past Resources

2020 Policy Assessment

2021 Policy Priorities

CMS Requesting Information on Access to Coverage and Care in Medicaid and CHIP

Last month, the Centers for Medicare and Medicaid Services (CMS) issued a Request for Information (RFI) entitled Access to Coverage and Care in Medicaid and CHIP.  CMS is seeking input on topics related to healthcare access in Medicaid and the Children’s Health Insurance Program (CHIP).  This includes enrollment in coverage, maintaining coverage, and access to services and support. For the full list of questions included in the RFI click here. The comment deadline is April 18, 2021.  NCUIH urges UIOs to respond to this RFI to provide feedback to CMS regarding the barriers to access to coverage and care in Medicaid and CHIP in AI/AN communities.

CMS Strategic Vision for Medicaid and CHIP and Role of this RFI

This RFI is one of CMS’ first steps in developing a comprehensive access strategy for Medicaid and CHIP.  CMS has established three key areas for its strategic visions for Medicaid and CHIP: (1) coverage and access, (2) equity, and (3) innovation and whole-person care. CMS will use the feedback from this RFI to inform its future policy, monitoring, and regulatory approaches in all three key areas of the strategic vision.

CMS has set forth five objectives to be addressed in the RFI.

  1. Medicaid and CHIP reaches people who are eligible and who can benefit from such coverage.
    • CMS is interested in identifying strategies to ensure that individuals eligible for Medicaid and CHIP are aware of coverage options and how to apply for and retain coverage. Eligible individuals should be able to apply, enroll in, and receive benefits in a timely and streamlined manner that promotes equitable coverage.
  2. Medicaid and CHIP beneficiaries experience consistent coverage.
    • CMS is seeking input on strategies to ensure that beneficiaries are not inappropriately disenrolled and to minimize gaps in enrollment due to transitions between programs. These strategies are particularly important during and immediately after the COVID-19 Public Health Emergency (PHE) and can include opportunities that promote beneficiaries’ awareness of requirements to renew their coverage as well as states’ eligibility assessment processes, which can facilitate coverage continuity and smooth transitions between eligibility categories or programs (e.g., students eligible for school-based Medicaid services are assessed for Supplemental Security Income (SSI)/Medicaid eligibility at age 18, or youth formerly in foster care are assessed for other Medicaid eligibility after age 26).
  3. Whether care is delivered through fee-for-service or managed care, Medicaid and CHIP beneficiaries have access to timely, high-quality, and appropriate care in all payment systems, and this care will be aligned with the beneficiary’s needs as a whole person.
    • CMS is seeking feedback on how to establish minimum standards or federal “floors” for equitable and timely access to providers and services, such as targets for the number of days it takes to access services. These standards or “floors” would help address differences in how access is defined, regulated, and monitored across delivery systems, value-based payment arrangements, provider type (e.g., behavioral health, pediatric subspecialties, dental, etc.), geography (e.g., by specific state regions and rural versus urban), language needs, and cultural practices.
  1. CMS has data available to measure, monitor, and support improvement efforts related to access to services (i.e., potential access; realized access; and beneficiary experience with care across states, delivery systems, and populations).
    • CMS is interested in feedback about what new data sources, existing data sources (including Transformed Medicaid Statistical Information System [T-MSIS], Medicaid and CHIP Core Sets, and home and community based services (HCBS) measure set), and additional analyses could be used to meaningfully monitor and encourage equitable access within Medicaid and CHIP programs.
  2. Payment rates in Medicaid and CHIP are sufficient to enlist and retain enough providers so that services are accessible.
    • Section 1902(a)(30)(A) of the Social Security Act (the “Act”) requires that Medicaid state plans “assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.” Section 1932 of the Act includes additional provisions related to managed care. Section 2101(a) of the Act requires that child health assistance be provided by States “in an effective and efficient manner….” CMS is interested in leveraging existing and new access standards to assure Medicaid and CHIP payments are sufficient to enlist enough providers to ensure that beneficiaries have adequate access to services that is comparable to the general population within the same geographic area and comparable across Medicaid and CHIP beneficiary groups, delivery systems, and programs. CMS also wants to address provider types with historically low participation rates in Medicaid and CHIP programs (e.g., behavioral health, dental, etc.). In addition, CMS is interested in non-financial policies that could help reduce provider burden and promote provider participation.

Need to Address Uninsured Rates Among American Indians and Alaska Natives

Medicaid and CHIP are important programs for addressing the significant disparities in insurance coverage which exist for AI/AN people.  For example, according to the Urban Institute, AI/AN children were uninsured at a rate of 8.9% in 2019, the highest rate for any ethnic group in the country.  AI/AN parents were uninsured at a rate of 18.7% in 2019, the second highest rate in the country.  The Urban Institute reported that in 2019, AI/AN children remained more than twice as likely as white children to be uninsured and AI/AN were more than 2.5 times more likely to be uninsured than with white parents.

Medicaid is also an important source of revenue for facilities like UIOs which provide healthcare to AI/ANs.  As the Kaiser Family Foundation noted in 2017, “Medicaid funds are not subject to annual appropriation limits . . . since Medicaid claims are processed throughout the year, facilities receive Medicaid funding on an ongoing basis for covered services provided to AIANs.”  While UIOs had hoped to see an increase in Medicaid funds in light of Congress’ authorization for eight quarters of 100% Federal Matching Assistance Percentage for UIOs, this has so far failed to result in higher rates of reimbursement for UIOs.

Indian Health Service Issues Guidance on Changes Due to Infrastructure Bill Fix for Urban Indian Organizations

On February 18, 2022, the Indian Health Service (IHS) Office of Urban Indian Health Programs (OUIHP)  shared a document answering several questions regarding the Indian Health Care Improvement Act (IHCIA) provision at 25 U.S.C. § 1659, which previously authorized the IHS to make funds available to Urban Indian Organizations (UIOs) to make minor renovations to facilities or construction or expansion of facilities, including leased facilities, but only to assist UIOs in meeting or maintaining accreditation standards of The Joint Commission (TJC).

Background and Advocacy

Urban Indian Organizations (UIO) are a fundamental, inseverable component of the Indian Health Service/Tribal Health Program/UIO (I/T/U) system, face chronic underfunding. The National Council of Urban Indian Health (NCUIH) has long advocated for adequate funding for all three parts of the I/T/U system to better serve the American Indian and Alaska Natives (AI/AN).

Section 509 of the Indian Health Care Improvement Act (IHCIA) previously only permitted IHS to provide UIOs with funding for minor renovations by mandating that funding only be provided to UIOs that meet or maintain compliance with the accreditation standards set forth by The Joint Commission (TJC). These restrictions on facilities funding have ultimately prevented UIO facilities from obtaining the funds necessary to improve the safety and quality of care provided to AI/ANs in urban settings.

COVID-19 has exacerbated failing infrastructures at UIOs due to longstanding needs without funding.  for UIOs to have funding flexibility for facility renovations and upgrades to comply with COVID regulations. The Padilla-Moran-Lankford amendment included in the Infrastructure Investment and Jobs Act (IIJA) removed this restriction to allow UIOs to use existing federal dollars on necessary facility needs. NCUIH has worked closely on a bipartisan basis for the past year on the technical legislative fix to support health care for tribal members who reside off of reservations. In addition to the amended provision at 25 U.S.C. § 1659, there are portions of the Coronavirus Response and Relief Supplemental Appropriations Act (CRRSAA) and American Rescue Plan Act (ARPA), which may be used for facilities-related purposes.

ICWA’s Constitutionality Challenged and Review by the Supreme Court Underway

On February 28, 2022 the U.S. Supreme Court agreed to hear a case challenging the constitutionality of the Indian Child Welfare Act (ICWA). ICWA came under intense scrutiny in an April 2021 en banc decision of the United States Court of Appeals for the Fifth Circuit. In Brackeen v. Haaland, the Fifth Circuit considered a challenge to the constitutionality of ICWA brought by Texas, Louisiana, Indiana, and several individual plaintiffs.  A sharply divided court generally upheld the constitutionality of ICWA.  However, as a result of its divided ruling, the Court also upheld the lower court’s decision that certain provisions concerning the placement preferences of Native children for Indian homes as well as certain ICWA processes violated the Constitution.  Finally, the Court ruled that the corresponding provisions of the law’s implementing regulations violated the Administrative Procedures Act (APA). The Supreme Court has now granted, and consolidated, four petitions for a writ of certiorari that raise overlapping questions on several constitutional doctrines, including equal protection, standing, anticommandeering, and nondelegation, as well as APA considerations. The case is expected to be argued in the fall 2022.

Purpose of the ICWA and Its Success for AI/AN Children

ICWA was created in 1978 by the federal government to re-establish tribal authority over the adoption of Native American children. The goal of the Act was to strengthen and preserve Native American family structure and culture. Studies conducted in advance of ICWA’s drafting showed that between 25% and 35% of all Native children were being removed from their home by state child welfare and private adoption agencies. Of those, 85% were placed with non-Native families, even when fit and willing relatives were available. ICWA was established as a safeguard that requires placement cases involving Native American children be heard in tribal courts, if possible, and permits a child’s tribe to be involved in state court proceedings. It also requires testimony from expert witnesses who are familiar with Native American culture before a child can be removed from his or her home. If a child is removed, either for foster care or adoption, the law requires that Native American children be placed with extended family members, other tribal members, or other Native American families prior to placement in non-Indian homes.  For a more complete explanation of the requirements of ICWA, please visit the Native American Rights Fund’s “Practical Guide to the Indian Child Welfare Act.”

As eighteen leading national child welfare organizations, including Casey Family Programs and the Child Welfare League of America, attested to the Supreme Court, ICWA represents “the gold standard for child welfare policies and practices that should be afforded to all children.”  According to the National Indian Child Welfare Association (NICWA), ICWA “[l]essens the trauma of removal by promoting placement with family and community . . . [p]romotes the best interest of Indian children by keeping them connected to their culture, extended family, and community, which are proven protective factors . . . [and] [p]romotes placement stability by ensuring that voluntary adoptions are truly voluntary,” among other benefits.  Positive and continuing connections to one’s family, community, and culture, are key factors in ensuring health and well-being.

However, despite the progress which has been made since 1978, the need for ICWA remains today.  According to NICWA, “Native children are removed from their homes at 2–3 times the rate of their white counterparts and often are not placed with relatives or other Indian families, even when such placements are available and appropriate.  In addition, “Native families are the most likely to have children removed from their homes as a first resort, and the least likely to be offered family support interventions intended to keep children within the home.”

Legal Proceedings and Opposition to ICWA

In Brackeen, Texas, Indian, Louisiana, and individual plaintiffs sued the federal government, arguing that ICWA and its implanting regulations are unconstitutional because they violate the equal protection and substantive due processes provisions of the Fifth Amendment and violate the anticommandeering doctrine of the Tenth Amendment.  The plaintiffs also argued that ICWA and the implementing regulations violate the nondelegation doctrine and the APA.

The initial 2018 ruling by Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas, held that ICWA (including its implementing regulations) is unconstitutional, and the regulations violate the APA.  Specifically, Judge O’Connor held that ICWA violates the Constitution’s guarantee of equal protection because it applies to all children eligible for membership in a Tribe, not just enrolled tribal members, and therefore operates as a race-based statute.  Judge O’Connor further held that ICWA violates the Tenth Amendment’s prohibition on the federal government issuing direct orders to states and unconstitutionally delegates Congress’s power by giving tribes the authority to change adoption placement preferences and make states abide by them.

The Fifth Circuit overturned the District Court’s decision in most respects. The Fifth Circuit found that Congress had the authority to enact the law. The majority opinion also held that ICWA’s application to all children eligible for tribal citizenship is not a race-based classification and therefore ICWA does not violate equal protection. This reaffirms that the status of “Indian child” is not an unconstitutional racial classification. However, the court was equally divided as to whether references to “other Indian families” and “Indian foster home” are an unconstitutional racial classification. Because the Court was equally divided on this holding the District Court’s ruling was upheld, but it was without precedential authority.  Further, the Court affirmed the District court’s conclusion that several of the “active efforts” required under ICWA violated the Tenth Amendment, which prohibits the federal government from imposing duties on state officials. The Court was again equally divided on whether ICWA’s placement preferences violate the Tenth Amendment.  This narrow but lengthy decision, which was over 300 pages and decided by a divided 16-judge court, creates confusing precedent for those trying to navigate the law and makes the case ripe for review by the Supreme Court.   The Fifth Circuit also addressed APA challenges to the Bureau of Indian Affairs rules implementing ICWA.

Supreme Court to Review

In early September, 2021, the United States government, tribal defendants, as well as state and private plaintiffs filed petitions asking the United States Supreme Court to review the Fifth Circuit’s April decision. In their petitions, the States and private individuals stated that ICWA places “various legal mechanisms that play favorites based on race” and that the Supreme Court should “reject the United States’ and tribes’ efforts to artificially narrow this court’s review of these mechanisms.”  While the tribes and the federal government agree with the Fifth Circuit’s decision that ICWA is generally constitutional and accords with long-standing precedent, they also believe that review of this decision is appropriate due to the Court’s narrow interpretation and decision to overturn specific provisions regarding placement preferences and processes.

This will be the Supreme Court’s first ruling on ICWA since the 2013 decision in Adoptive Couple v. Baby Girl , in which a 5-4 court ruled that a Cherokee father couldn’t rely on ICWA to block his biological child’s adoption. Since that time, the structure of the Supreme Court has changed and there is the possibility that a case like this could be another opportunity for Justice Neil Gorsuch to again serve as a swing vote on AI/AN issues and provide the decisive vote to uphold ICWA. Because ICWA has long received bi-partisan support, the government and tribes’ positions could potentially sway the politically divided Supreme Court to uphold the constitutionality of the long-standing law.  Indeed, the Fifth Circuit found it notable that the Plaintiff States (including Ohio which filed an amicus brief on their behalf) “are home to only about 1% of the total number of federally recognized Indian tribes and less than 4% of the national American Indian and Alaska Native population,” while the States which filed amicus briefs supporting ICWA “are collectively home to 94% of federally recognized Indian tribes and 69% of the national American Indian and Alaska Native population.”

ICWA and Urban Populations

AI/AN children are overrepresented in state foster care systems. According to NICWA, AI/AN children are in foster care at a rate 2.7 times greater than their proportion in the general population. This means that while AI/AN children represent 0.9% of all children in the United States, they are 2.1% of all children who are placed in foster care. Because more than 70% of AI/AN people live in urban settings, this overrepresentation undoubtably has an impact in urban AI/AN communities. Many health problems arise for AI/ANs living in urban settings because of mental and physical hardships due to the lack of family and the traditional cultural environments. Additionally, urban Indian youth are at a greater risk for serious mental health and substance abuse problems, suicide, increased gang activity, teen pregnancy, abuse, and neglect.

If the Supreme Court were to uphold the Fifth Circuit’s decision and declare portions of ICWA unconstitutional or go even further and declare the entire statute unconstitutional, urban AI/AN youth who may already feel isolated and disconnected from their cultural ties may be even more at risk if they enter the foster or adoption systems and there are no protections to keep them from being further removed from their communities and culture.

ICWA as a Vehicle to Challenge Federal Indian Law

It is also important to recognize that this case, as well as other on-going challenges to ICWA are part of a broader effort to attack the foundations of Federal Indian Law.  The recognition that being Native is a political classification is a critical underpinning of not just ICWA, but many laws that relate to housing, healthcare, education, and employment.   However, publications from the organizations supporting this lawsuit and others, including the Cato Institute and the Goldwater Institute, make clear that they view Native identity as being a matter of race, not political identity and citizenship.  If overturned, the repeal of ICWA would not only upend a law in place for more than 40 years but undercut the heart of tribal sovereignty and the federal government’s trust responsibility to Native communities.  A successful attack on ICWA would have far reaching implications on all areas of Federal Indian Law and policy.

NCUIH will continue to closely monitor updates in this case and alert UIOs and stakeholders to what a decision could mean for urban Indian communities.

VA Issues Proposed Rule on the Pilot Program on Graduate Medical Education and Residency

On February 4, 2022 the Department of Veterans Affairs (VA) issued a proposed rule to revise its medical regulations to establish a new pilot program on graduate medical education and residency (PPGMER). The proposed rule would implement the PPGMER to place residents in existing or new residency programs in covered facilities, as required by section 403 of the MISSION Act of 2018 (Public Law 115-182).  In addition, Section 403 requires that placement of pilot program residents be prioritized in Indian Health Service facilities, Indian tribal or tribal organization facilities, certain underserved VA facilities, or other covered facilities.  VA is inviting invites public comments on the PPGMER by April 5, 2022.

The PPGMER and Proposed Structure and Operating Procedures

VA anticipates that the PPGMER will operate under the same basic structure as its current Graduate Medical Education (GME) program.  In VA’s GME program, VA provides for resident positions to be filled in VA facilities but does not place residents itself.  To provide for the education of residents, VA forms academic affiliations with sponsoring institutions and enters into other agreements to delineate funding of residency program educational costs and the resident stipend and benefits costs.  Accordingly, for the PPGMER VA plans to form agreements with sponsoring institutions and the covered facilities in which residents would be placed.

VA proposes to place residents through a request for proposal (RFP) process.  The process will begin by VA Central Office issuing an RFP to VA health care facilities to announce PPGMER placement opportunities.  VA health care facilities would then work in collaboration with covered facilities to submit responses to the RFP to VA Central Office.  Only VA health care facilities will be permitted to submit responses to the RFP.  VA Central Office will then evaluate the responses to the RFP from VA health care facilities and determine which covered facilities will receive residents.

VA will evaluate several factors when determining which covered facilities receive residents: the ratio of veterans to VA providers in a county, the range of clinical specialties of VA and non-VA providers in an area, whether a provider in a covered facility is included in a specialty in the most recent VA staffing shortage determination, whether the covered facility is located in a community with an underserved VA facility, if the covered facility is located in a Health Professional Shortage Area, or in a rural or remote area. The VA will also take into consideration other factors like the distance between a covered facility and the closest VA facility, and the ability of the program to maintain a sustainable residency program.

As part of the pilot program, the MISSION Act authorizes the VA to pay residents stipends and benefits at non-VA facilities along with the educational costs associated with their training, while in the program. Covered costs may include certain startup costs of new residency programs. As part of their training residents may treat non-veteran patients. The law requires prioritization of placement of residents in facilities operated by the Indian Health Service, American Indian tribes, or tribal organizations, as well as certain underserved VA facilities and other covered facilities.

Need for UIO Providers

As with other facilities in the Indian Health Service, Tribal, and Urban (I/T/U) system, UIOs are suffering from staffing shortages.  While the Indian Health Professions Program has had great success in assisting AI/AN programs to recruit and retain health care providers, IHS reports that it cannot fund all of the loan scholarship applicants.  Access to residents funded by the PPGMER could assist UIOs in addressing these staffing shortages.  Inclusion of UIOs in this program would be especially appropriate given the services which UIOs provide to AI/AN veterans.  Many AI/AN veterans often prefer to obtain health care service through UIOs because they provide culturally competent care, shorter wait times, community and family relations, and shorter distance to travel.

Because of these factors, NCUIH believes that the PPGMER could be a valuable opportunity to serve the AI/AN veteran population and ease staffing shortages.  NCUIH encourages UIO leaders to submit written comments to VA regarding this program, UIOs’ interest in participating, and the importance of VA considering inclusion of UIOs as covered facilities for placement of residents in the proposed regulations.