NCUIH advocacy was critical to the inclusion of Urban Indian Organizations and urban Native Americans in these Administrative efforts.

On November 15, 2021, President Biden signed Executive Order 14053 (E.O.) on Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing and Murdered Indigenous People (MMIP) during the White House Tribal Nations Summit. Also on the same day, President Biden released a Progress Report highlighting the Administration’s commitment to address the needs of Indian Country and included a special section on “Urban Native Americans”. The Administration also mentioned the priority of ensuring 100% FMAP. Advocacy by the National Council of Urban Indian Health (NCUIH) was critical to urban Natives being prioritized by the White House and our work had a significant impact on Urban Indian Organizations (UIOs) being included in the E.O and the Progress Report.

NCUIH is pleased to see that the E.O. specifically mentions the Department of Health and Human Services (HHS) and the Secretary of the Interior conferring with UIOs on developing a comprehensive plan to support initiatives related to MMIP. NCUIH has been working on an urban confer bill, the Urban Indian Health Confer Act (H.R. 5221), that recently passed the House (406-17) with overwhelming support. NCUIH is pleased to see that the E.O. specifically mentions the Department of Health and Human Services (HHS) and the Secretary of the Interior conferring with UIOs on developing a comprehensive plan to support initiatives related to MMIP. We are also pleased to see that the E.O. highlights the need for improved data surrounding this crisis as it relates to urban Indian communities. NCUIH has voiced the importance of gathering more data on these communities, specifically on Missing and Murdered Indigenous Women. On July 2, 2021, NCUIH submitted comments to the Department of Justice on Savannah’s Act requesting UIOs and urban Indians to be incorporated into improving data relevancy, access, and resources.

The Progress Report, released by the White House ahead of the Tribal Nations Summit, highlights the Administration’s commitment to address the needs of Indian Country, including the needs of the 70% American Indians/Alaska Natives (AI/ANs) living in urban areas. NCUIH has emphasized that 70% of AI/ANs reside in urban areas and rely on UIOs to provide them with culturally competent health care. NCUIH is pleased to see that the Progress Report highlights the Administration’s commitment to ensuring UIOs receive 100% Federal Medicaid Assistance Percentage (FMAP) and include urban Indian issues within the context of public safety and justice. Over this past year, NCUIH advocacy has secured 2 years of 100% FMAP for UIOs in the American Rescue Plan Act, and the House recently passed the Build Back Better Act which includes an additional 8 fiscal quarters of 100% FMAP for UIOs.

Executive Order

The E.O. includes the following for American Indian and Alaska Natives living in urban areas and the role of UIOs in addressing these issues:

• Given that 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, we must continue that work on Tribal lands but also build on existing strategies to identify solutions directed toward the particular needs of urban Native Americans.
• Earlier this year, the Secretary of the Interior and the Attorney General announced a Joint Commission, established pursuant to the Not Invisible Act, that includes: representatives of Tribal, State, and local law enforcement; Tribal judges; Native American survivors of human trafficking; health care and mental health practitioners who have experience working with Native American survivors of human trafficking and sexual assault; Urban Indian Organizations focused on violence against women and children; and family members of missing or murdered indigenous people.
• The Federal Government must prioritize addressing this issue and its underlying causes, commit the resources needed to tackle the high rates of violent crime that Native Americans experience over the long term, coordinate and provide resources to collect and analyze data, and 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.
• 4. Improving Data Collection, Analysis, and Information Sharing.
  • (a) 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, such as through the National Crime Information Center, the Next Generation Identification system, and the National Violent Death Reporting System, as appropriate and consistent with applicable law.
  • (c) 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. Within 240 days of the date of this order, the Attorney General, the Secretary of the Interior, and the Secretary of HHS shall report jointly to the President on the strategy they have developed to conduct and coordinate that analysis and shall identify additional resources or other support necessary to implement that strategy.

(e) The Secretary of HHS shall evaluate the adequacy of research and data collection efforts at the Centers for Disease Control and Prevention and the National Institutes of Health in accurately measuring the prevalence and effects of violence against Native Americans, especially those living in urban areas, and report to the President within 180 days of the date of this order on those findings and any planned changes to improve those research and data collection efforts.

• 5. Strengthening Prevention, Early Intervention, and Victim and Survivor Services.
  • (a) The Secretary of HHS, in consultation with the Secretary of the Interior and Tribal Nations and after conferring with other agencies, researchers, and community-based organizations supporting indigenous wellbeing, including Urban Indian Organizations, as appropriate, shall develop a comprehensive plan to support prevention efforts that reduce risk factors for victimization of Native Americans and increase protective factors, including by enhancing the delivery of services for Native American victims and survivors, as well as their families and advocates.

 

Progress Report

The Progress Report included the following sections and features urban Indians:

• Meeting Obligations to Urban Native Americans
  • According to the US Census Bureau, over 70 percent of Native Americans live in urban cities away from Tribal lands. President Biden is ensuring that the Administration supports and is giving a voice to the urban Indian population. The Administration has included Urban Indian Organizations in Tribal listening sessions on topics and issues such as health care, education, funding, housing, maternal care and voting rights, to name a few. It has also ensured that Urban Indian Health Organizations (UIHOs) receive 100 percent Federal Medical Assistance Percentages (FMAP) for Medicaid and included urban Indian issues within the context of public safety and justice. President Biden has also ensured that payments from Tribal governments to Tribal members from the CARES Act and the ARP do not count as income for purposes of Social Security Income benefits and included budget increases that will go directly to UIHO’s to provide much needed health care to the urban Indian population. And the Build Back Better Plan will provide families, especially children, with the much needed support for early childhood education and child tax credits for families – which will positively impact the urban Indian population.
• Responding to the COVID-19 Pandemic in Indian Country
  • In the height of the pandemic, per capita COVID-19 infection rates for American Indians and Alaska Natives were three times higher than for all Americans. These disparities also produced higher mortality rates. To address these disparities, with the assistance of Tribal Nations, Urban Indian Organization health facilities, and Alaska Native health corporations, the Administration through the Department of Health and Human Services and Indian Health Service, implemented an effective COVID-19 plan in Indian Country and succeeded in making Native Americans the most vaccinated group in the United States.
  • Investing ARP Funds to Combat COVID-19 in Indian Country
    • $84 million for Urban Indian Organizations
  • Improving Health Care Delivery for Native Americans Through the ARP
    • The ARP required the Centers for Medicaid to provide a 100 percent federal Medicaid match to Urban Indian Health Programs, rather than limiting them to receive the regular Medicaid match rate for the state in which they are located.
  • Providing Access to the Strategic National Stockpile
    • President Biden signed Executive Order 14001, “A Sustainable Public Health Supply Chain,” allowing access to the Strategic National Stockpile for Tribal governments, IHS healthcare providers, and Urban Indian Organizations.
  • Vaccine Distribution in Indian Country
    • Working with Tribal communities and Urban Indian Organization health facilities, the IHS has administered more than 1.7 million doses to patients, health care employees, essential workers, and others in Native communities
  • Initiative on Ending the HIV Epidemic
    • The President’s FY 2022 budget request includes $27 million to support HIV prevention, care, and treatment services to help accelerate and strengthen the HIV response in Indian Country. HIV disproportionately affects American Indian and Alaska Native Men who have sex with Men (MSM). In 2018, 67 percent of diagnoses among American Indian and Alaska Native people were among MSM. The proposed increase for the IHS will support HIV care teams located in geographic areas of the U.S. serviced by IHS, Tribal, and Urban Indian Organization (I/T/U) facilities. Funds will scale-up clinical support programs designed to increase HIV prevention medication uptake and to meet viral suppression goals for primary antiretroviral therapy programs served by I/T/U facilities in Indian Country.
  • White House Engagement with Tribal Leaders
    • Community Development: Traditional Food, Subsistence, and Community Level Food and Feeding Programs; the National American Housing; Urban Indian Issues; Buy Indian Act; and Native Language Immersion Schools and Language Preservation.

The Build Back Better Act maintained $100 million for UIO facilities and extension of key Medicaid parity provision for UIOs.

On November 19, 2021, the House passed President Biden’s Build Back Better (BBB) Act with a 220-213 vote. The BBB Act, allocates $2.347 billion to the Indian Health Service (IHS), $100 million for Urban Indian Health facilities, and extension of an additional 8 fiscal quarters of 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs) beginning April 1, 2021. As Congress negotiated the Reconciliation bill from $3.5 trillion to $1.75 trillion, funding for Indian Country was significantly reduced from the original reconciliation instruction allocation of $20.5 billion. Earlier this week, the President signed into law the bipartisan infrastructure bill which allows UIOs to use existing resources to fund infrastructure projects.

“Adequate funding for Indian Country is crucial now more than ever, especially as the COVID-19 pandemic has, and continues to be, the deadliest for American Indian and Alaska Native communities. We are grateful for our House champions who ensured that urban Indian health was a priority. We cannot build back better without Indian Country and encourage the Senate to retain these critical provisions.” said Francys Crevier, CEO of NCUIH (Algonquin).,

Background and Advocacy

UIOs, which 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/Alaska Native (AI/AN) population.

NCUIH initially advocated for $200 million dollars on August 1, 2021. The draft reconciliation bill released on September 27 included $100 million for UIO facilities. Since 1986, $13.3 billion in facilities funding has been allocated to IHS, however UIOs are not eligible for the IHS Facilities or Sanitation line items. The allocation of $100 million for UIO facilities in BBB is historic and long overdue.

NCUIH and UIO advocacy to Congressional leadership helped retain provisions in the BBB Act affecting UIOs that were at risk of cuts during Congress’ negotiations to reduce the cost of the budget reconciliation bill. However, the overall stark decrease in the funding commitment for Indian Country is disappointing for AI/ANs and does not uphold the trust and treaty obligations of the federal government. This past week, NCUIH sent a letter to Speaker Pelosi’s office urging the passage of the BBB Act with support for Indian Country.

• NCUIH letter to Speaker Pelosi urging passage of BBB Act (November 16, 20201)
• NCUIH Policy Alert: House Draft of Build Back Better Includes Long Needed Infrastructure Funds for Urban Indian Health
• NCUIH letter to Speaker Pelosi and Majority Leader Schumer urging Congress to retain $20.5 billion for Indian Country and $42 million for UIOs in Build Back Better plan (October 25, 2021)
• NCUIH letter to Congressional leadership requesting $21 billion for Indian health infrastructure in the budget reconciliation package (August 1, 2021)
• Joint letter led by the National Congress of American Indians (NCAI) and signed by NCUIH requesting $21 billion for Indian health infrastructure among countless other Tribal priorities (April 13, 2021)

 

Next Steps

The Reconciliation bill will now be sent to the Senate for consideration. NCUIH will also be requesting that the Senate retain the $100 million for UIO facilities and extension of 100% FMAP.

 

Budget Reconciliation Bill Highlights

Committee on Natural Resources

Indian Health Service

• “MAINTENANCE AND IMPROVEMENT.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $945,000,000, to remain available until September 30, 2031, for maintenance and improvement of facilities operated by the Indian Health Service pursuant to a self-determination contract (as defined in subsection (j) of section 4 of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304(j))) or a self-governance compact entered into pursuant to subsection (a) of section 404 of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5364(a)).”
• “MENTAL HEALTH AND SUBSTANCE USE DISORDERS.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $123,716,000, to remain available until September 30, 2031, for mental health and substance use prevention and treatment services, including facility renovation, construction, or expansion relating to mental health and substance use prevention and treatment services.
• “PRIORITY HEALTH CARE FACILITIES.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $1,000,000,000, to remain available until September 30, 2031, for projects identified through the health care facility priority system established and maintained pursuant to subparagraph (A) of paragraph (1) of subsection (c) of section 301 of the Indian Health Care Improvement Act (25 U.S.C. 1631(c)(1)(A)).”
• “SMALL AMBULATORY.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $40,000,000, to remain available until September 30, 2031, for small ambulatory construction.”
• “URBAN INDIAN ORGANIZATIONS.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $100,000,000, to remain available until September 30, 2031, for, notwithstanding the restrictions described in section 509 of the Indian Health Care Improvement Act (25 U.S.C. 1659), the renovation, construction, expansion, equipping, and improvement of facilities owned or leased by an Urban Indian organization (as defined in item (29) of section 4 of that Act (25 U.S.C. 1603(29))).”
• “EPIDEMIOLOGY CENTERS.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $25,000,000, to remain available until September 30, 2031, for the epidemiology centers established under paragraphs (1) through (2) of subsection (a) of section 214 of the Indian Health Care Improvement Act (25 U.S.C. 1621m(a)(1)–(2)).”
• “ENVIRONMENTAL HEALTH AND FACILITIES SUPPORT ACTIVITIES.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $113,284,000, to remain available until September 30, 2031, for environmental health and facilities support activities of the Indian Health Service.”

Committee on Education and Labor

Grants to Support the Direct Care Workforce

• “GRANTS AUTHORIZED.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $1,000,000,000, to remain available until September 30, 2031, for awarding, on a competitive basis, grants to eligible entities to carry out the activities described in subsection (c) with respect to direct support workers.
  • Urban Indian Organizations are listed as eligible entities for this grant to “provide competitive wages, benefits, and other supportive services, including transportation, child care, dependent care, workplace accommodations, and workplace health and safety protections, to the direct support workers served by the grant”

Committee on Energy and Commerce

Extension of 100 Percent Federal Medical Assistance Percentage for Urban Indian Health Organizations and Native Hawaiian Health Care Systems

• “The third sentence of section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) is amended— (1) by striking ‘‘for the 8 fiscal year quarters beginning with the first fiscal year quarter beginning after the date of the enactment of the American Rescue Plan Act of 2021’’ and inserting ‘‘for the period of the 16 fiscal year quarters that begins on April 1, 2021’’; and (2) by striking ‘‘such 8 fiscal year quarters’’ and inserting ‘‘such period of 16 fiscal year quarters.”

Funding for Palliative Care and Hospice Education and Training

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $25,000,000, to remain available until expended, to support the establishment or operation of programs that— (1) support training of health professionals in palliative and hospice care (including through traineeships or fellowships); and (2) foster patient and family engagement, integration of palliative and hospice care with primary care and other appropriate specialties, and collaboration with community partners to address gaps in health care for individuals in need of palliative or hospice care.”
  • UIOs are mentioned as eligible applicants for funding

Funding for Local Entities Addressing Social Determinants of Maternal Health

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $100,000,000, to remain available until expended, for carrying out a program to award grants or contracts to community-based organizations, Indian Tribes and Tribal organizations, Urban Indian organizations, Native Hawaiian organizations, or other nonprofit organizations working with a community-based organization, or consortia of any such entities, operating in areas with high rates of adverse maternal health outcomes or with significant racial or ethnic disparities in maternal health outcomes.”

Funding to Grow and Diversify the Doula Workforce

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $50,000,000, to remain available until expended, for carrying out a program to award grants or contracts to health professions schools, academic health centers, State or local governments, territories, Indian Tribes and Tribal organizations, Urban Indian organizations, Native Hawaiian organizations, or other appropriate public or private nonprofit entities (or consortia of any such entities, including entities promoting multidisciplinary approaches), to establish or expand programs to grow and diversify the doula workforce, including through improving the capacity and supply of health care providers.”

Funding to Grow and Diversify the Maternal Mental Health and Substance Use Disorder Treatment Workforce

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $75,000,000, to remain available until expended, for carrying out a program to award grants or contracts to health professions schools, academic health centers, State or local governments, territories, Indian Tribes and Tribal organizations, Urban Indian organizations, Native Hawaiian organizations, or other appropriate public or private nonprofit entities (or consortia of any such entities, including entities promoting multidisciplinary approaches), to establish or expand programs to grow and diversify the maternal mental health and substance use disorder treatment workforce, including through improving the capacity and supply of health care providers.”

Funding for Maternal Mental Health Equity Grant Programs

• IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $100,000,000, to remain available until expended, for carrying out a program to award grants or contracts to community-based organizations, Indian Tribes and Tribal organizations, Urban Indian organizations, Native Hawaiian organizations, health care providers, accredited medical schools, accredited schools of nursing, teaching hospitals, accredited midwifery programs, physician assistant education programs, residency or fellowship programs, or other nonprofit organizations, schools, or programs determined appropriate by the Secretary, or consortia of any such entities, to address maternal mental health conditions and substance use disorders with respect to pregnant, lactating, and postpartum individuals in areas with high rates of adverse maternal health outcomes or with significant racial or ethnic disparities in maternal health outcomes.”

Funding for Expanding the Use of Technology-Enabled Collaborative Learning and Capacity Building Models for Pregnant and Postpartum Individuals

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $30,000,000, to remain available until expended, for carrying out a program to award grants or contracts to community-based organizations, Indian Tribes and Tribal organizations, Urban Indian organizations, health care providers, accredited medical schools, accredited schools of nursing, teaching hospitals, accredited midwifery programs, physician assistant education 15 programs, residency or fellowship programs, or other 16 schools or programs determined appropriate by the Secretary, or consortia of any such entities, that are operating in health professional shortage areas designated under section 332 of the Public Health Service Act (42 U.S.C. 254e) with high rates of adverse maternal health outcomes or significant racial and ethnic disparities in maternal health outcomes, to evaluate, develop, and expand the use of technology-enabled collaborative learning and capacity building models (as defined in section 330N of the Public Health Service Act (42 U.S.C. 254c–20)).”

Funding for Promoting Equity in Maternal Health Outcomes Through Digital Tools

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $30,000,000, to remain available until expended, for carrying out a program to award grants or contracts to community-based organizations, Indian Tribes and Tribal organizations, Urban Indian organizations, health care providers, accredited medical schools, accredited schools of nursing, teaching hospitals, accredited midwifery programs, physician assistant education programs, residency or fellowship programs, or other schools or programs determined appropriate by the Secretary, or consortia of any such entities, that are operating in health professional shortage areas designated under section 332 of the Public Health Service Act (42 U.S.C. 254e) with high rates of adverse maternal health outcomes or significant racial and ethnic disparities in maternal health outcomes to reduce racial and ethnic disparities in maternal health outcomes by increasing access to digital tools related to maternal health care.”

Funding for Community Violence and Trauma Interventions

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary, for fiscal year 2022, out of any money in the Treasury not otherwise appropriated $2,500,000,000, to remain available until expended, for the purposes described in subsection (b):
  • (b) USE OF FUNDING.—The Secretary, acting through the Director of the Centers for Disease Control and Prevention, and in consultation with the Assistant Secretary for Mental Health and Substance Use, the Administrator of the Health Resources and Services Admin1istration, the Deputy Assistant Secretary for Minority Health, and the Assistant Secretary for the Administration for Children and Families, shall use amounts appropriated by subsection (a) to support public health-based interventions to reduce community violence and trauma, taking into consideration the needs of communities with high rates of, and prevalence of risk factors associated with, violence-related injuries and deaths, by—
    • (1) awarding competitive grants or contracts to local governmental entities, States, territories, Indian Tribes and Tribal organizations, Urban Indian organizations, hospitals and community health centers, nonprofit community-based organizations, culturally specific organizations, victim services providers, or other entities as determined by the Secretary (or consortia of such entities) to support evidence-informed, culturally competent, and developmentally appropriate strategies to reduce community violence, including outreach and conflict mediation, hospital-based violence intervention, violence interruption, and services for victims and individuals and communities at risk for experiencing violence, such as trauma-informed mental health care and counseling, social-emotional learning and school-based mental health services, workforce development services, and other services that prevent or mitigate the impact of trauma, build appropriate skills, or promote resilience”