Brief of Senate Committee on Indian Affairs – Staff

Facts about Urban Indian Health Programs

  1. Urban Indian health programs (UIHPs) are the “U” in the Indian Health Service’s (IHS) I/T/U system.
  2. Tribes supported the establishment of UIHPs in 1972 to ensure that the Trust obligation followed their members so they could access high-quality, culturally competent health care off of reservations.
  3. The term “Urban Indian”, refers to the 78% of American Indians and Alaska Natives (AI/AN) who live off their reservations, often because of forced government relocation or economic need.
  4. Both the legislative and executive branches have acknowledged that the federal government’s Trust Responsibility to provide health care to AI/AN people follows them “beyond the borders of the reservation.”
  5. There are now 43 UIHPs in 19 states, which includes 7 NIAAAs currently being converted into the IHS Office of Urban Indian Health, which provide a wide range of health and social services, from outreach and referral to full ambulatory care.
  6. UIHPs are uniquely disadvantaged compared to IHS and Tribal facilities on key items, ranging from Medicaid to veterans care to malpractice insurance.

IHS Funding

  1. IHS provides slightly more than 1% of its budget for urban Indian health care.
  2. The Interior Appropriations Bill’s urban Indian health line item is the only one that provides funding to UIHPs, which derive no support from any other line item—from behavorial health or construction.
  3. Moreover, the urban Indian health line item must now also support 7 National Institute on Alcoholism and Alcohol Abuse programs, which means whatever increases the line item gets has to be split 7 additional ways. Increases to funding should take into account the increase in programs that will have to divide that small pot of money to ensure the continuance of quality care.
  4. IHS has identified 17 potential new sites for UIHPs with the highest AI/AN populations not currently served by the I/T/U system but has no mechanism for development.
  5. NCUIH works with Tribes and Tribal organizations and does not advocate boosting support for UIHPs by diverting funding from IHS and Tribal facilities, but by increasing the urban line item and amend policies that would greatly impact UIHPs (100% FMAP, FTCA, Definition of Indian, etc.).
  6. The 2016 IHS urban Indian health care needs assessment reports that the health care conditions and outcomes experienced by urban Indians are comparable to AI/AN people on reservations and markedly inferior to non-AI/AN people in urban areas, particularly with respect to substance abuse, chronic disease, infant mortality, suicide, and HIV-related mortality. Urban Indians are also more likely to engage in high-risk behaviors, less likely to receive preventative care, and more likely to have inadequate health insurance.
  7. NCUIH is disappointed in the cut of $2.7 million that is recommended by the Administration for FY18, and we will urge the appropriators to instead provide an increase.


  1. AI/AN people, including urban Indians, are disproportionately dependent on Medicaid. Medicaid expansion has been particularly helpful to AI/AN in allowing them to gain health care, which in turns lightens the financial burden on an already over-stretched IHS.
  2. If per capita caps are to be imposed on federal contributions and Medicaid expansion is to be ended, AI/AN should be excluded from these reforms, consistent with the Trust Responsibility.
  3. In an attempt to mitigate the impact of per capita caps on AI/AN people, AHCA would exempt IHS and Tribal facilities but not UIHPs. The law incorporated by reference in AHCA’s exemption includes only those parts of the I/T/U system whose Medicaid costs are paid for exclusively by the federal government because they have 100% Federal Medical Assistance Percentage (FMAP). The omission of UIHPs in this law is an oversight. If per capita caps are to be imposed on Medicaid, UIHPs should also be exempted for the same rationales that the House excluded IHS and Tribes, particularly the Trust Responsibility and the importance of Medicaid contributions to IHS’ budget.
  4. Even with exemptions for the entire community, the Medicaid caps will inevitably adversely impact AI/AN people because states will likely cut benefits and narrow eligibility for benefits, unless a mechanism is developed to exempt reimbursements for Medicaid services received through the I/T/U system from any state limitations imposed because of caps.

Stretching urban Indian appropriations

NCUIH is thankful that lawmakers appreciate that UIHPs are innovative public- private partnerships that manage to provide high-quality, culturally-competent health care while consuming a tiny fraction of the IHS’ budget, and they want to help UIHPs stretch those few dollars further:

  1. FMAP: According to IHS it would cost only $2.3 million per annum to provide UIHPs with the same 100% FMAP already provided to IHS and Tribal facilities.
  2. UIHPs should also be exempt from per capita caps along with IHS and Tribal facilities. The Trust responsibility is a federal obligation and should be fulfilled consistently from state to state.
  3. IHS-Department of Veterans Affairs (DVA) memorandum of understanding (MoU): This MoU to promote better care for AI/AN veterans has not been implemented for UIHPs. Consequently, IHS and Tribal facilities are fully- reimbursed for care provided to AI/AN veterans, but not UIHPs.
  4. Federal Tort Claims Act (FTCA): IHS and Tribal facilities as well as Community Health Centers are granted medical malpractice liability protection under FTCA with the federal government acting as their primary insurer. However, UIHPs are not covered by this law, even though they share many key characteristics. A single UIHP can pay as much as $250,000 per annum for malpractice insurance, a large sum which might instead be spent on treating patients if UIHPs are also covered by FTCA.