Vaccines: Preparing for the 2021-2022 Flu Season

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New Guidance: Preparing for the 2021-2022 Flu Season

On September 9, 2021 the Centers for Disease Control (CDC) shared recommendations and guidance on co-administration of vaccines with COVID-19 vaccines. The updates provided coverage to the Advisory Committee on Immunization Practices (ACIP) recommendations for the 2021-2022 season, general vaccine guidance during the COVID-19 pandemic, and clinical considerations. During the 2019-2020 season, the CDC estimated that influenza caused 38 million illnesses, 400,000 hospitalizations, and 22,000 associated deaths. Flu vaccination prevents millions of illnesses and deaths each year and is the best way to ensure protection!

Interim Recommendations for the 2021-2022 Season

The Advisory Committee on Immunization Practices (ACIP) released Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States. The current guidance states that COVID-19 vaccines should and can be administered without regard to timing of other vaccines. When administering vaccines at the same time a provider should do so at different sites by at least one inch or more. If a COVID-19 vaccine is given with vaccines that may cause a topical reaction, such a pneumonia, it should be done on separate limbs. This guidance can also be found on NCUIH’s Coronavirus Resource Center webpage.

This year’s flu vaccines are all quadrivalent and contain 4 layers of viral protection. Their administration guidance is restricted to age group usage.

Strategies for Vaccination Catch-up

Across all regions, the COVID-19 pandemic impacted general healthcare, including vaccination administration. With reduced vaccine administration, unvaccinated and under vaccinated individuals are at a greater risk to acquiring preventable illnesses and placing communities at risk for outbreak. Strategies should be implemented to promote vaccine schedule adherence and use of recall systems to identify patients who have missed vaccine doses. Immunization systems and electronic health records can support this work. Co-administration considerations can be applied to all patients but are paramount if a patient is behind/at risk of becoming behind on the recommended vaccine schedule or at a greater risk of vaccine-preventable disease.

Clinical Considerations

The CDC maintains a comprehensive surveillance system covering virus surveillance, ambulatory and emergency care, rates of hospitalization, and associated mortality rates.

In preparation for the 2021-2022 season the CDC is expecting for seasonal flu and COVID-19 to co-circulate, along with other respiratory viruses. A report (MMWR) recently released is already showing an uptick in virus spread, like respiratory syncytial virus (RSV).

Co-infection of flu virus strains can occur. There are often overlapping signs, symptoms, and differences with either infection. Community-acquired bacterial co-infection appears more common with influenza than COVID-19 (MRSA, MSSA, pneumococcus, group strep)

  • Incubation period is shorter for influenza (1-3 days) than COVID-19 (2-14 days)
  • Viral shedding of viral RNA detection is generally shorter for influenza
  • Ageusia/dysgeusia are more common with COVID-19 than influenza
  • Onset of disease complications is earlier with influenza
  • High-risk groups for influenza and COVID-19 are similar
  • Testing is needed to distinguish influenza from COVID-19 in addition to observation of clinical clues
  • Antiviral medications for influenza have no effect on COVID-19

No one has time for the flu!

At getmyflushot.org the urgency stresses that flu, COVID-19, and other illnesses do not discriminate, everyone is at risk. Getting your vaccines for influenza annually is critical as flu viruses are constantly changing and updated protection is the best practice to optimize protection. As COVID-19 vaccination is on the rise, one does not have to delay additional adherence to important lifesaving vaccines!

Patient Protection and Affordable Care Act- Updated Payment Parameters and Improving Health Insurance Markets for 2022 & Beyond

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Final Rule: Patient Protection and Affordable Care Act; Updating Payment Parameters, Section 1332 Waiver Implementing Regulations, and Improving Health Insurance Markets for 2022 and Beyond.

 

On September 27, the Department of the Treasury, collectively with HHS (the Departments), issued a final rule revising the 2022 user fee rates for issuers offering qualified health plans (QHPs) through federally-facilitated Exchanges and State-based Exchanges. This rule finalizes policies designed to promote greater access to comprehensive health insurance coverage, consistent with applicable law and with the administration’s policy priorities detained in recent Presidential executive orders (EO 14009 and EO 13985).

 

NCUIH submitted comments regarding the proposed regulations, the equity goals proposed by the Administration, and how these goals should permeate each policy consideration by HHS and other agencies. These comments included how CMS should provide specific guidance and examples of how agencies and state officials can assess and address systemic barriers within their healthcare systems. Additionally, NCUIH commented on section 1332 waiver regulations and was pleased to that the new waiver regulations aim to explicitly analyzes and prioritize health equity by encouraging states to evaluate their proposed section 1332 waivers in line with E.O. 13985. Urban Indian organizations are severely impacted by social determinants of health and experience significant health disparities compared to other racial groups.[1] Because of these disparities, NCIUH hoped to see explicit analysis of how proposed state waivers will improve the healthcare access of AI/AN people. In response to NCUIH’s comments, the Departments responded that, while the comment was outside the scope of the rule, HHS is actively seeking ways to engage with stakeholders to advance health equity- and address the social determinants of health that disparately impact communities of color.

 

This rule also finalizes modifications to Section 1332 Waivers for State Innovation of the ACA. Through section 1332 waivers, the Departments aim to assist states with developing health insurance markets that expand coverage, lower costs, and make high-quality health care accessible for every American. The Departments also encourage states to develop their own waiver proposals that reduce barriers for individuals to access benefits. For example, states may propose waiver programs that increase plan options for comprehensive coverage, reduce premiums, improve affordability, and address social determinants of health.

 

By rescinding the policies and interpretations outlined in the  ) and repealing the previous codification of its guardrail interpretations in part 1 of the 2022 Payment Notice final rule; the Departments believe that these new policies and interpretations will align with the Administration’s goals to strengthen the ACA. Thusly, increasing enrollment opportunity in comprehensive, affordable health coverage among the remaining underinsured and uninsured. Moreover, these policies will further advance this Administration’s goal of increasing access to coverage by empowering states to develop innovated health coverage options for their residents through section 1332 waivers that best fit the states’ individual Notably, section 1332 provides the Secretary of HHS and the Secretary of the Treasury the discretion to approve or deny waivers when appropriate even if an application meets the four statutory guardrails.

 

The Departments received 262 comments on the section 1332 waiver proposals from a mix of stakeholders, including general advocacy organizations, disease advocacy organizations, states, issuers, providers, individuals, and other entitles. The overwhelming majority of stakeholders supported the section 1332 waiver proposals and encouraged the Departments to finalize the policies as proposed.

 

In order to encourage states to develop innovative waivers, the Departments are finalizing the policies, interpretations and regulatory amendments as proposed.  This final rule is effective on November 26, 2021.

 

[1] Monique Adakai et al., Health Disparities Among American Indians/Alaska Natives – Arizona, 2017, 67 Morbidity and Mortality Weekly Report 1314 (2018).

NCUIH Endorsed Indigenous Peoples’ Day Act Introduced in House and Senate

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On September 30th, a group of Members of Congress introduced bipartisan, bicameral legislation to replace the term Columbus Day with Indigenous Peoples’ Day across all federal law and regulations. This legislation would also establish Indigenous Peoples’ Day as a public holiday. The NCUIH endorsed bill would allow the federal government to follow in the footsteps of at least 13 states and over 100 cities across the nation.

The Indigenous Peoples’ Day Act (H.R. 5473) was introduced by Representatives Torres, DelBene, Bonamici, and Davids within the House and currently has 64 total co-sponsors. The Senate partner bill (S. 2919) was introduced by Senators Lujan and Heinrich and currently has 7 total co-sponsors.

Please contact your Members of Congress and ask them to co-sponsor the Indigenous Peoples’ Day Act.

SENATE RELEASES FY22 FUNDING BILLS WITH HISTORIC INCREASE FOR URBAN INDIAN HEALTH, INDIAN HEALTH SERVICE, ADVANCE APPROPRIATIONS, MMIW AND UIO FACILITY FIX

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The Senate bill includes a $30 million increase above the FY21 enacted level for urban Indian health.

On October 11, 2021, the Senate Appropriations Committee released its fiscal year (FY) 2022 Interior, Environment, and Related Agencies bill, with $92.7 million for urban Indian health. The bill would authorize $7.61 billion for the Indian Health Service (IHS) for FY22, an increase of $1.38 billion above the FY21 enacted level and $593 million below the President’s request. Other key provisions include an additional $6.58 billion in advance appropriations to IHS for FY23 and a facilities fix to allow Urban Indian Organizations (UIOs) to use existing IHS funding for facilities improvement and renovations.

“After decades of being ignored and forgotten, we applaud the Senate Appropriations Committee for the robust legislation proposed to improve outcomes for Indian Country. We are especially encouraged to see the commitment to ensure equitable consideration for all Native communities. We are grateful for all Members of Congress who supported the request for full funding for Indian health, including urban Indian health, especially Senators Schatz, Feinstein, Murkowski, Tester, Moran, Merkley, Hoeven, Van Hollen, Heinrich, and Murray,” said NCUIH CEO Francys Crevier.  

Background 

The National Council of Urban Indian Health (NCUIH) and the Tribal Budget Formulation Workgroup (TBFWG) requested $12.759 billion for the Indian Health Service (IHS) with an urban Indian health line item of $200.5 million for FY 2022. Additionally, 28 Congressional leaders requested $200.5 million for urban Indian health in FY 2022 from the House Appropriations Committee.  

House Appropriations Status 

The House bill (HR 4372) included $200.5 million for urban Indian health and was advanced by subcommittee June 28, and $8.1 billion for the Indian Health Service. The measure was part of a seven-bill package the House passed on July 29.  

Senate Bill Highlights 

Appropriations Chairman Patrick Leahy stated in the bill summary, “The bill makes an unprecedented investment to fulfill the federal government’s treaty and trust responsibilities to Native Americans by providing $18.1 billion for tribal programs and – for the first time – securing advanced appropriations for the Indian Health Service (IHS). The advance appropriation for IHS for fiscal year 2023 will enable IHS to continue to provide health services without interruption or uncertainty, improving the quality of care and providing peace of mind for patients and medical providers.”  

Indian Health Service 

  • $7,616,250,000 for IHS for fiscal year 2022, an increase of $1,379,971,000 to the enacted level and a decrease of $593,029,000 to the request 

Urban Indian Health 

  • $92,684,000 for the Urban Indian Health program, $30,000,000 above the enacted level and $7,316,000 below the budget request. 

Facilities Fix for Urban Indian Health 

  • “SEC. 435. The Secretary of Health and Human Services may authorize an urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603) that is awarded a grant or contract under title V of that Act (25 U.S.C. 1651 et seq.) to use funds provided in such grant or contract for minor renovations to facilities or construction or expansion of facilities, including leased facilities, to assist the urban Indian organization in meeting or maintaining standards issued by Federal or State governments or by accreditation organizations.” 

Advance Appropriations for IHS 

  • $6,586,250,000 in advance appropriations for fiscal year 2023, equal to the fiscal year 2022 Committee recommendation in accordance with the Concurrent Resolution on the Budget for Fiscal Year 2022
       
  • “The Committee recommendation also provides, for the first time, advanced appropriations for Indian Health Services and Indian Health Facilities. The bill includes $6,586,250,000 in advance appropriations for fiscal year 2023, equal to the fiscal year 2022 Committee recommendation in accordance with the Concurrent Resolution on the Budget for Fiscal Year 2022. The Committee recognizes that budget uncertainty due to temporary lapses of appropriations and continuing resolutions have an effect on the orderly operations of critical healthcare programs for Native American communities. Existing challenges related to recruitment and retention of healthcare providers, administrative burden and costs, and financial effects on Tribes were identified areas of concern in a Government Accountability Office [GAO] study (GAO–18–652).” 

Contract Support Costs and 105(l) Leases 

  • “The Committee strongly supports revising the budgetary classification for Contract Support Costs and Payments for Tribal Leases with the goal of including the language needed to codify such a change in the final appropriations Act for fiscal year 2022.” 


Bureau of Indian Affairs – Missing and Murdered Indigenous Women 

  • Missing and Murdered Indigenous Women: $24.9 million  
  • “The Committee is concerned about the crisis of missing, trafficked, and murdered indigenous women that has plagued Native communities. Native American women face high rates of violence and the lack of data on the number of women and girls who go missing or murdered further complicates the Nation’s ability to address this crisis. The Committee recommendation includes both funding and directives under the Bureau of Indian Affairs and the Indian Health Service in order to improve the Federal response to this epidemic.”
      
  • Note: It is unclear at this time if UIOs would be eligible for the funding resources provided to IHS under this provision. 

Bureau of Indian Education – Native Boarding School Initiative 

  • Native Boarding School Initiative: $7 million 

“In June 2021, the Department announced an investigation into the Federal government’s past oversight of Native boarding schools. The past policies of forcing children into these schools tore families apart and led to a loss of culture and identity for generations of Native American youth. The Committee applauds the efforts of the Department to reexamine this era and looks forward to the findings. The bill provides $7,000,000 for these efforts.” 

   

Next Steps 

Congress is likely to pass another continuing resolution before the current spending expires on December 3, 2021. If Democrats quickly begin “top-line” budget negotiations, it’s possible they could pass an omnibus funding package in the Senate.  

RETURNING TO SCHOOL: WHAT HEALTH LEADERS NEED TO KNOW

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With the start of the 2021-22 school year around the corner and some schools starting this week, the entire country is again facing thousands of local decisions about under what conditions schools will reopen, in view of the major upheaval caused by the delta variant of coronavirus.  This strain is highly contagious, on the same level as measles and chickenpox, therefore public health officials are urging strict enforcement for mask wearing, physical distancing and vaccination.  To increase support for vaccines we must double down on containment and mitigation measures, including extensive testing, isolation, use of masks and social distancing of 3 feet at school campuses, under CDC guidelines.  To quote Dr. Rachel Levine, Assistant Secretary for Health at HHS, “We must cocoon a child surrounded by vaccinated adults.” This means that all teachers must be vaccinated, and children must wear masks while in school.  We all play a role and what the pandemic has taught us is that we are all interconnected.

Other Vulnerable Groups

Amidst these decisions weighing heavily on the minds of elected officials and public health officers, one piece of good news is that Pfizer will be seeking another Emergency Order Authorization in the fall for its new COVID-19 vaccine for children ages 5 to 11 years old.  (Younger than 5-yrs-old groups will take longer, because of the size of clinical trials and the cautious approach to de-escalate dosage when treating toddlers and infants).

Dr. Anne Edwards with the American Academy of Pediatrics reported on a national call with HHS and the CDC that pediatricians are seeing a lot of respiratory illness in medical offices, the ICU and regular hospital beds.  She and all medical staff strongly encourage everyone in the 12-and-older age group who are eligible to get vaccinated.  Studies show that no one is more trusted than Pediatricians, therefore the physician should take the time during medical visits to clear up any questions for the family.  We all need your help as trusted leaders in your community.  Dr. Amy Mullins, from the American Academy of Family Physicians, added that when confronting vaccine hesitancy, data shows that there is no single public message that will always overcome.

In addition, evidence about the safety of COVID-19 vaccination during pregnancy has been growing, including in the early months of pregnancy.  There is a trove of surveillance data, according to Dr. Peter Marks from the Federal Drug Administration (FDA).  Pregnant and recently pregnant women are more likely to get severely ill compared with non-pregnant people.  These data strongly point to the conclusion that the benefits of receiving a COVID-19 vaccine outweigh any known or potential risks of vaccination during pregnancy.  During the week of August 11, the Centers for Disease Control advanced this information and posted recommendations on their website.  Learn More.

Vaccine Boost

The FDA recently authorized a third dose or boost of the MRNI-type vaccine for those people who are immune-compromised, ages 15 and over.  Further, the evidence and rationale for taking this next step tells us that if a patient is only taking two medications for the underlying health condition, there is very little risk when taking a third dose.  The Advisory Committee on Immunization Practices (ACIP) will have to issue final guidance on this matter.

When administering immunizations, providers may wish to separate the administration of shots, especially when dealing with live viral vaccines and fever is present).  Soon the CDC will disclose real world evidence.

We ALL need your Help and the enlistment of public and private employers to take extra steps, such as time off from work to get vaccinated and providing free rides to vaccination sites.

NCUIH Endorsed Bill Introduced by Sen. Warren, Rep. Davids and Rep. Cole on National Day of Rememberance

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On September 30th, 2021, in recognition of the National Day of Remembrance, Senator Elizabeth Warren (D-MA), Congresswoman Sharice Davids (D-KS-3) and Congressman Tom Cole (R-OK-4) Introduced the Truth and Healing Commission on Indian Boarding School Policies in the United States Act. This NCUIH endorsed bill would create a Truth and Healing Commission on Indian Boarding School Policies in the United States. Tasked with investigating and documenting the Indian boarding school policies and the historical and ongoing trauma that resulted, the Commission provides an environment for Native people to speak about their personal experiences and will provide recommendations to the government.  Working in collaboration with other agencies, the Commission would also develop recommendations for the federal government on how to acknowledge the trauma and help Native communities heal.

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

Please contact your congressmembers and ask them to co-sponsor the Truth and Healing Commission on Indian Boarding School Policies in the United States Act.

NCUIH President-Elect Statement for the Record for VA Hearing on Veteran Suicide Prevention

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On Wednesday, September 22, the House Committee on Veterans’ Affairs (VA) held an oversight hearing entitled, “Veteran Suicide Prevention: Innovative Research and Expanded Public Health Efforts.” The National Council of Urban Indian Health’s (NCUIH) President-Elect, Sonya Tetnowski (Makah Tribe), submitted a written statement for the record for the hearing to address mental health care and suicide prevention for Native Veterans living in urban areas.

Representative Ruben Gallego gave remarks during the hearing, highlighting his bill to end copayments for Native American Veterans that passed as part of the Isakson and Roe Act last Congress and inquired about the VA’s current timeline for full implementation of this provision. Dr. Kameron Matthews, the VA’s Assistant Under Secretary for Health for Clinical Services, said that Gallego’s provision is moving forward, however, there were some nuances about the definition of urban Indian and the VA has been working with the Indian Health Service, the Department of Health and Human Services, and other Tribal organizations to get that language correct.

NCUIH expressed support for Rep. Gallegos bill last year in a letter to Congress that urged for passage of several Tribal Veteran bills.

Watch the full committee hearing here.

STATEMENT FOR THE RECORD

House Committee on Veterans Affairs

Chairman Mark Takano and distinguished Committee members, I would like to thank you for inviting me to provide written testimony today regarding care for urban Indian Veterans. My name is Sonya Tetnowski, I am a member of the Makah Tribe, and a Native Veteran of the U.S. Army where I served as a U.S. Paratrooper (Airborne). I am currently the President-Elect of the National Council of Urban Indian Health (NCUIH), which represents the 41 Urban Indian Organizations (UIOs) with 77 facilities. UIOs provide high-quality, culturally competent care to the more than 70% of American Indians and Alaska Natives (AI/ANs) that reside in urban areas. I also service as the President of the California Consortium of Urban Indian Health with 10 members servicing over 100 thousand members.

Additionally, I am the Chief Executive Officer of the Indian Health Center of Santa Clara Valley (IHC) in San Jose, California. IHC provides culturally competent health and wellness services including comprehensive medical care, dental, behavioral health, fitness, nutrition, and family programing to our nearly 23 thousand patients annually, representing over 114 different tribes.

AI/ANs have a long history of distinguished service to this country. Per capita, AI/ANs serve at a higher rate in the Armed Forces than any other group of Americans and have served in all the nation’s wars since the Revolutionary War. In fact, AI/ANs served in several wars before they were even recognized as U.S. citizens. Despite this esteemed service, AI/AN Veterans have lower personal incomes, higher unemployment rates, higher homeless rates and are more likely to lack health insurance than other Veterans.

NCUIH and I as the president elect, have made it a priority to ensure that UIOs are included in the Indian Health Service (IHS) and Department of Veterans Affairs (VA) Memorandum of Understanding (MOU) to help provide health care to AI/AN Veterans. As a Native Veteran myself, I understand the importance of coming home and knowing I have a safe space to receive care. Respectfully, AI/AN Veterans often prefer to use Indian Health Care Providers (IHCPs), including UIOs, for reasons such as cultural competency, community and familial relations, shorter wait times, and shorter distance to travel.

AI/ANs residing in urban areas face significant behavioral health disparities with 15.1% of urban AI/ANs reporting frequent mental distress as compared to 9.9% of the general public, and suicide being the second leading cause of death among AI/ANs. The COVID-19 pandemic had only exacerbated these numbers, as AI/ANs feel the dire impacts of social isolation and the inability to participate in many cultural activities. Adequate reimbursement for behavioral health care and suicide prevention efforts for Native Veterans is critical to fulfil the IHS and VA trust responsibility to urban AI/ANs.

Recommendation: Expeditiously Fully Implement the VA-IHS MOU with UIO inclusion in the Reimbursement Agreement Program (RAP) so UIOs Can Provide Critical Mental Health Care to Native Veterans.

We were grateful for your assistance with the passage of the Health Care Access for Urban Native Veterans Act of 2019 as part of Consolidated Appropriations Act, 2021. Previously, the VA had deemed UIOs as ineligible to be reimbursed for the services they provide to AI/AN Veterans. With this legislative fix, Congress has enabled the VA to reimburse UIOs for services to VA beneficiaries. While the VA has initiated discussions with UIOs, to date, the VA has yet to fully implement the VA IHS-MOU with UIOs. NCUIH requests immediate implementation of the VA-IHS MOU with UIO reimbursement agreements to support care delivery and increase the availability of services to urban AI/AN Veterans.

Additionally, UIOs provide various culturally centered mental health care services to urban Indians and Native Veterans, including operating residential substance use disorder (SUD) programs with inpatient treatment. Clarity around reimbursement for UIO SUD programs must be outlined in the VA-IHS MOU as it is currently unclear on whether UIO residential SUD programs would be reimbursed: 1) based on the prospective payment system Medicare inpatient payments like IHS hospital facilities; 2) the IHS all-inclusive rate (Inpatient Hospital Per Diem Rate) with additional payment available to the extent that physician and practitioner services are provided; or 3) the IHS all-inclusive rate for Medicare Part B Inpatient Ancillary Per Diem Rate.

In addition to SUD programs, UIOs provide traditional healing services to address mental health in urban Indian patients. Traditional healing activities are imperative in addressing mental health challenges in the AI/AN community and should be fully reimbursed by the VA to Native Veterans who receive these services at UIOs.

Recommendation: Ensure Clear and Official Communication from VA to UIOs and Establish an Urban Confer Policy

NCUIH has long advocated for parity for health services for urban Indians, including the establishment of an urban confer policy between the VA and UIOs. Currently, only IHS has a legal obligation to confer with UIOs. As the VA continues to work more closely with UIOs to increase access to health care services for AI/AN Veterans, it is imperative that a formal confer process is established for the VA – a mechanism for regular dialogue with UIOs on policies that impact them and AI/AN Veterans. The absence of Urban Confer with the VA is inconsistent with the government’s responsibility and allows for unclear expectations and missed opportunity for important feedback from AI/AN stakeholders.

Most recently, NCUIH and UIOs had the opportunity to provide input to the VA on the Reimbursement Agreement Program (RAP) template and other issues affecting Native Veterans, however, the mechanism of soliciting stakeholder feedback can be a lesson learned. A letter in July requesting this feedback from UIOs included no information that would alert UIOs of a deadline or anticipated timeline for providing input on the template and this critical information was also not shared during the later listening session. Without clear official communication, VA and IHS cannot ensure that UIOs have a consistent understanding of the agencies’ expectations. This lack of communication can be avoided with the establishment of a confer policy. This confer policy would enable the agency to regularly and directly obtain input from UIOs and would foster a strong working relationship. Going forward we request written guidance containing this important information and deadlines would go a long way to achieving clear communication.

Clear communication practices between the VA and UIOs will allow UIOs to provide feedback on various issues around Native Veteran health, including mental health care, and help ensure that Native Veterans residing in urban areas have access to the critical care they are owed.

Conclusion

The United States must honor its commitments to AI/AN Veterans by providing quality healthcare to urban Indian Veterans, which includes mental health care and suicide prevention efforts. It is no secret that Native Veterans disproportionately suffer from behavioral health disparities, and the recommendations contained in my testimony are necessary to address this burden and close the gap in health services to our Veterans.

We appreciate your continued efforts to ensure tribal members in urban areas are included in public health efforts. Thank you for allowing us to provide testimony and for your tireless efforts ensuring that the voices of tribal members living in urban areas are heard and acted upon. Losing even one Veteran to suicide is too much; help us reach these Veteran’s with our culturally appropriate care.