Tag Archive for: Behavioral Health

NCUIH Recommends Noncompetitive Funding Model and Support for Whole Family Substance Abuse Treatment in IHS Behavioral Health Initiatives

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On July 22, 2024, the National Council of Urban Indian Health (NCUIH) submitted comments to the Indian Health Service (IHS) Director, Roselyn Tso, in response to a May 21, 2024, Dear Tribal Leader and Dear Urban Indian Organization Leader letter (DTLL/DULL) and June 20, 2024, Urban Confer on IHS Behavioral Health Initiative Funding. In its comments, NCUIH recommended that IHS consider developing a funding methodology similar to the Special Diabetes Program for Indians (SDPI) National Funding Formula, which was developed to avoid competition for funds and to reduce barriers to access in an effort to ensure equitable distribution of funds for behavioral health grant funding.

Background

President Biden’s December 6, 2023, Executive Order (EO) 14112, “Reforming Federal Funding and Support for Tribal Nations To Better Embrace Our Trust Responsibilities and Promote the Next Era of Tribal Self-Determination,” directs Federal agencies to implement reforms to federal funding and support programs to make them more accessible, flexible, and equitable. In accordance with EO 14112, the IHS Division of Behavioral Health (DBH) is evaluating Agency-wide processes for distributing appropriated funding for behavioral health initiatives. In fiscal year 2024, the IHS administers more than $59 million in behavioral health initiatives funding, including the seven grant programs that address substance abuse, domestic violence, suicide, and youth regional treatment centers aftercare.

Almost every UIO provides behavioral health, mental health, or substance use disorder care, in addition to primary care services, Traditional Healing and Medicine, and social and community services. Further, seven UIOs have intensive inpatient/residential services as part of their behavioral health services. To fund this important work, 18 UIOs utilize the seven behavioral health grant programs that IHS is seeking feedback on to support and save lives, but the need for these programs is felt at all 41 UIOs.

NCUIH’s Recommendations and Requests

In response to the May 21 DTLL/DULL and June 20 Urban Confer, NCUIH made the following recommendations and requests to IHS regarding Behavioral Health Initiative Funding:

  • Ensure noncompetitive program awards across the I/T/U system
  • Support whole family treatment
  • Support for youth residential treatment centers at UIOs
  • Ensure funding reform for these programs does not create additional reporting requirements
  • Continue to engage with UIOs

NCUIH will continue to monitor as IHS conducts the grant funding evaluation process.

Senator Warren and Representative Raskin Re-Introduce NCUIH-Endorsed CARE ACT, Invests $1 Billion a Year to Address Substance Use Crisis in Native Communities

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On May 9, 2024, Senators Elizabeth Warren (D-MA) and Tammy Baldwin (D-WI) as well as Representatives Jamie Rasin (D-MD), Ann Kuster (D-NH), David Trone (D-MD) and Brittany Pettersen (D-CO) re-introduced the Comprehensive Addiction Resources Emergency (CARE) Act (S.4286 / H.R. 8323) to provide resources that combat the substance use epidemic, including in American Indian and Alaska Native communities. It is currently co-sponsored by 16 other Democratic senators and 73 Democratic representatives and supported by over 100 organizations. The bill is modeled after the Ryan White Comprehensive AIDS Resources Emergency Act, that supports federal research and programming that prevents substance use disorder and expands access to evidence-based treatments and recovery support services.

This legislation provides $125 billion in federal funding for Fiscal Years 2025-2035 and specifically nearly $1 billion a year for Tribal governments and organizations. The funding awards grants to fund core medical services, recovery and support services, early intervention and engagement services, harm reduction services, and administrative expenses.

The $1 billion is allocated to:

  • $790 million in grants to Tribal governments for substance use prevention and treatment.
  • $7.5 million for Tribal nations and regional Tribal epidemiology centers.
  • $50 million to Tribal Colleges and Universities as well as Indian-Health Service funded organizations that train Native health professionals.
  • $150 million to Native non-profits and clinics, including urban Indian organizations and Native Hawaiian organizations, specifically to test culturally informed care models.

Resources

Background on Substance Use in Urban Native Communities

NCUIH has long advocated for resources to address the ongoing substance use crisis that disproportionately affects Native people. Between 1999 and 2015, the drug overdose death rates for Native populations increased by more than 500 percent. In 2022, the CDC reported that the American Indian and Alaska Native populations had the highest rate of overdose deaths in the United States. They reported 56.6 deaths per 100,000 persons in 2021. Additionally, a 2020 report from the CDC highlighted that American Indian and Alaska Native people living in rural and urban areas need substance use disorder (SUD) treatment at virtually the same rate.

Next Steps

The bill has been referred to the Senate subcommittee on Health, Education, Labor, and Pensions and awaits consideration.  NCUIH will continue to monitor the bill’s progress

NCUIH Provides Recommendations to Federal Government Regarding Important Native Behavioral Health and Substance Use Disorder Program

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On January 30, 2024, the National Council of Urban Indian Health (NCUIH) submitted written comments to the Substance Abuse and Mental Health Services Administration (SAMHSA) Office of Tribal Affairs in response to SAMHSA’s July 2023 framing paper and October 2023 urban Indian organization (UIO) listening session concerning the development of the funding formula for the Behavioral Health and Substance Use Disorder Resources for Native Americans (BHSUDRNA) Program. NCUIH’s comments make seven key recommendations to SAMSHA when developing the funding methodology for the BHSUDRNA program.

Background

NCUIH, UIOs, Tribes, and Tribal Organizations worked closely with Congress to create a new Behavioral Health program modeled in part after the Special Diabetes Program for Indians (SDPI) to expand access to behavioral health funding for Native communities. Congress authorized this program via the Consolidated Appropriations Act, 2023 (CAA 2023).  The purpose of the Program is to provide services for the prevention of, treatment of, and recovery from mental health and substance use disorders among American Indians, Alaska Natives, and Native Hawaiians. The BHSUDRNA Program will be operated by SAMHSA in consultation with the Indian Health Service. Eligible entities include Urban Indian organizations.

NCUIH’s Recommendations

In its comments, NCUIH recommended that SAMHSA:

  • Ensure noncompetitive Program awards across the IHS/Tribal Organization/UIO (I/T/U) system.
  • Account for administrative duties in the funding formula.
  • Respect Traditional Healing and Indigenous Knowledge in the funding formula.
  • Ensure program measures do not impose additional burdensome reporting requirements.
  • Ensure that all information related to program application is widely available.
  • Seek additional expert feedback from Tribal Advisory Committees and Federal Agencies
  • Continue to engage with and incorporate UIO feedback in the development of the Program.

While Congress authorized $80 million in appropriations for this Program in each of Fiscal Years (FY) 2023-2027, Congress has not yet appropriated the necessary funding for the Program since its authorization. As part of its comments, NCUIH called on the Biden Administration to request that Congress fully fund the Program at the authorized levels.

NCUIH will continue to monitor the development of the funding formula for the BHSUDRNA Program and continue to advocate for Congress to fully fund the Program.

White House 2023 Progress Report for Tribal Nations Highlights Commitment to Supporting Urban Native Communities

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The Biden-Harris Administration released the 2023 Progress Report for Tribal Nations (“Progress Report”) during the December 6-7, 2023, White House Tribal Nations Summit. The Progress Report touches on several areas of concern to urban Indian organizations (UIOs) as discussed in the National Council of Urban Indian Health’s (NCUIH) 2023 Policy Priorities. The Progress Report also highlights work done in partnership with UIOs, such as initiatives addressing Missing and Murdered Indigenous Peoples (MMIP), Native Veteran Health and Homelessness, Mental Health, Health Information Technology (HIT) Modernization, and Reproductive Health Care.

Successes with Urban Native Communities Highlighted MMIP

In January 2023, The Department of Health and Human Services (HHS) submitted the MMIP Prevention, Early Intervention, and Victim and Survivor Services Plan to the White House Domestic Policy Council and to the President. Developed in consultation with the Department of the Interior, Tribal Nations, research and community-based organizations and UIOs, it is 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.

Native Veterans

In support of the Native American Veterans Homelessness Initiative, VA and other federal agencies engaged with UIOs to support and offer resources to AI/AN Veterans experiencing homelessness. The Initiative took the following actions in 2023:

  • VA and Indian Health Service (IHS) developed an informational brochure for Native American veterans experiencing homelessness and distributed these brochures to UIOs, IHS facilities, and external partners across the country.
  • VA and IHS developed and launched an interagency interactive map of UIOs and VA healthcare systems with points of contact information in June 2023.
  • VA developed and implemented training webinars for UIOs to raise awareness of VA homeless programs among Native American veterans and to build or increase effective, responsive, and collaborative relationships between UIOs and VA.
  • VA and various UIOs collaborated on Stand Down events in Seattle, Phoenix, Los Angeles, Albuquerque, and soon Alaska. These one-to-three-day events bring VA staff and volunteers together to provide food, clothing, and health screenings to homeless and at-risk veterans and receive referrals for healthcare, housing solutions, employment, substance use treatment, mental health counseling, and other essential services.

The Veterans Health Administration amended its medical regulations to implement a statute exempting eligible Indian and urban Indian veterans from copayment requirements. This change is based on a requirement within the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020. As of October 2023, 2,674 Native veterans have been approved for the copayment exemption, with copayment cancellations totaling just over $1.5 million.

Mental Health

HHS announced a new $35 million grant opportunity, enabled by the Bipartisan Safer Communities Act, to better support the 988 Suicide and Crisis Lifeline services in Tribal communities. One of the aims of the program is to facilitate collaborations between Tribal, state, and territory health providers, UIOs, law enforcement, and other first responders in a manner that respects Tribal sovereignty.

HIT Modernization

Throughout the process for selecting the new Electronic Health Record (EHR) vendor, IHS coordinated with Tribal and urban Indian organization partners through extensive Tribal engagement via Tribal consultations, listening sessions, urban confers, advisory committee meetings, an Industry Day, and the participation of hundreds of Tribal, urban Indian, and IHS system users in vendor product demonstrations. IHS ultimately awarded a 10-year contract to General Dynamics Information Technology to build, configure, and maintain a new enterprise EHR system utilizing Oracle Cerner technology.

Reproductive Health Care

In response to President Biden’s Executive Order on Strengthening Access to Affordable, High-Quality Contraception and Family Planning Services, IHS added new over-the-counter contraception options to the IHS National Core Formulary, which will expand access to high-quality contraception for patients. IHS encouraged Tribally or UIO operated IHS facilities to make the same options available to patients.

CMS Released Medicaid and CHIP Mental Health and Substance Use Disorder Action Plan and Overview Guide

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On July 25, the Centers for Medicare & Medicaid Services (CMS) released the Medicaid and CHIP Mental Health (MH) and Substance Use Disorder (SUD) Action Plan Overview and Guide, which outlines the agency’s strategies for improving treatment and support for enrollees with these conditions. Areas of focus include improving coverage and integration to increase access to prevention and treatment services, encouraging engagement in care through increased availability of home and community-based services and coverage of non-traditional services and settings, and improving quality of care for MH conditions and SUDs. The areas target issues that impact American Indians and Alaska Natives such as improving coverage of mental health and substance abuse disorder screening and therapies and promoting parity by supporting connection to health care coverage.  

  • Access the Action Plan Overview here. 
  • Access the Action Plan Guide here. 

Background 

The Action Plan is CMS and CHIP’s latest step in addressing MH and SUD. In March 2016, CMS finalized a rule targeting MH and SUD parity. The goal of the rule was to benefit the over 23 million people enrolled in Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs), and CHIP. It required plans to disclose information on MH and SUD benefits upon request- including the criteria for determinations of medical necessity- and required states to disclose the reason for any denial of reimbursement or payment for services with respect to MH and SUD benefits. 

NCUIH’s Advocacy 

NCUIH advocates on behalf of urban Indian organizations (UIOs) and urban American Indians and Alaska Natives to raise awareness of the impacts of MH conditions and SUDs in American Indian and Alaska Native communities. NCUIH outlined the disproportionately high rates of MH conditions and SUDs among American Indians and Alaska Natives in its 2023 Policy Priorities. To address this, NCUIH continues to urge Congress to appropriate $80 million for Behavior Health and Substance Abuse Disorder Resources for American Indians and Alaska Natives, which was authorized in the Fiscal Year 2023 omnibus. NCUIH also advocates for expanding access to traditional healing services at UIOs. NCUIH also recommends Congress remove funding restrictions in grants to allow for traditional healing services at UIOs, that HHS review its existing policies concerning use of federal funding, and that federal agencies engage with UIOs directly to support expansion of traditional healing services.  

NCUIH will continue to advocate on behalf of UIOs and American Indians and Alaska Natives to receive culturally based care to address their MH conditions and SUDs. 

NCUIH Urges Senate and House Appropriations Committees to Provide Full Stable Funding for IHS and Urban Indian Health in FY 2024

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On April 8, 2023, the National Council of Urban Indian Health (NCUIH) sent a letter to Chairman Jeff Merkley (D-OR) and Ranking Member Lisa Murkowski (R-AK) of the Senate Interior Appropriations Committee requesting full funding for the Indian Health Service (IHS) and urban Indian health, advance appropriations for IHS, and resources for Native behavioral health in Fiscal Year (FY) 2024. On March 24, 2023, NCUIH also sent a letter to Chairman Kay Granger (R-TX-12) and Ranking Member Rosa DeLauro (D-CT-3) of the House Interior Appropriations Committee with the same requests.

The letter emphasizes the critical role that urban Indian organizations (UIOs) play in health care delivery to American Indian and Alaska Native (AI/AN) patients and the importance of providing UIOs with the necessary funding to continue to provide quality, culturally competent care to their communities. The requests included in the letter are efforts to achieve parity and uphold the federal trust responsibility for urban Natives.

In the letters, NCUIH requested the following:

  • $51.42 billion for IHS and $973.59 million for Urban Indian Health for FY24, as requested by the Tribal Budget Formulation Workgroup (TBFWG)
  • Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
  • Appropriate $80 million for the Native Behavioral Health Resources Program

These requests come at an important time to protect funding for urban Indian health. Current debt ceiling negotiations by Congress include proposals to cut spending for domestic programs and return funding for federal agencies to FY 2022 levels. These proposals would be detrimental to the success of IHS, Tribal organizations, and UIOs and would roll back historic funding levels that contribute to better health outcomes for Native communities. It is important that members of the House and Senate work to protect the health of all American Indians and Alaska Natives.

Full Letter Text

On behalf of the National Council of Urban Indian Health (NCUIH), the national advocate for health care for the over 70% of American Indians and Alaska Natives (AI/ANs) living off-reservation and the 41 Urban Indian Organizations (UIOs) that help serve this population, we write to respectfully request that Congress honor the federal trust responsibility by ensuring the following asks for Indian Country in Fiscal Year (FY) 2024:

  • $51.42 billion for the Indian Health Service (IHS) and $973.59 million for Urban Indian Health for FY24, as requested by the Tribal Budget Formulation Workgroup (TBFWG)
  • Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
  • Appropriate $80 million for the Native Behavioral Health Resources Program

We applaud the Committee’s longstanding leadership to ensure the trust responsibility for health care is upheld and honored for all AI/AN, especially last year with achieving advance appropriations for IHS.

UIOs Play a Critical Role in Providing Health Care for AI/ANs

UIOs are on the front lines in providing for the health and well-being of AI/ANs living off-reservation, many whom lack access to care that would otherwise be provided through on-reservation health care facilities. UIOs play a critical role in fulfilling the federal government’s responsibility to provide healthcare for AI/ANs and are an integral part of the Indian health system, which is comprised of the IHS, Tribal organizations, and urban Indian organizations (collectively, the I/T/U system). UIOs are critical health care access points to help serve the over 70% of AI/ANs in urban areas. Congress must do more to fully fund the IHS to improve health outcomes for all Native populations.

Need for Full Funding of the Indian Health System including Urban Indian Health

It is the policy of the United States “to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.” This requires that funding for Indian health must be significantly increased if the federal government is to finally fulfill its trust responsibility. At a minimum, funding must be maintained and protected as budget-cutting measures are being considered. UIOs are reporting historic levels of patients, need funding to fulfill the needs of the majority of the AI/AN population. Full funding will empower UIOs to hire more staff, pay appropriate wages, as well as expand vital services, programs, and facilities. Congress must do more to increase funding as the current FY23 funding level of $90.49 million which is only 9.3% of the full FY24 amount requested by Tribes and UIOs to meet current need.

Retain Advance Appropriations for IHS until Mandatory Funding is Enacted and Protect IHS from Sequestration

We applaud this Committee for your work on the historic inclusion of advance appropriations in the FY23 Omnibus.  This is a crucial step towards ensuring long-term, stable funding for IHS. Previously, the I/T/U system was the only major federal health care provider funded through annual appropriations. It is imperative that this Committee retain advance appropriations and ensure that IHS is protected from sequestration.

The GAO cited a lack of consistent funding as a barrier for IHS. The Congressional Research Service stated that advance appropriations would lead to cost savings as continuing resolutions (CRs) “prohibits the agency from making longer-term, potentially cost-saving purchases.” Lapses in federal funding quite literally put lives at risk. During the shutdown at the start of FY 2019, the Indian health system was the only federal healthcare entity that shut down. UIOs are so chronically underfunded that several UIOS had to reduce services, lose staff, or close their doors entirely, forcing them to leave their patients without adequate care. It is imperative that advance appropriations provide certainty to the IHS system and ensure unrelated budget disagreements do not put lives at stake.

Advance appropriations will improve accountability and increase staff recruitment and retention at IHS. When IHS distributes their funding on time, our UIOs can pay their doctors and providers. During a pandemic that has ravaged Indian Country and devasted the workforce, being able to recruit doctors and pay them on time is a top priority.

While advance appropriations are a step in the right direction to avoid disruptions during government shutdowns and continuing resolutions (CRs), mandatory funding is the only way to assure fairness in funding and fulfillment of the trust responsibility. Until authorizers act to move IHS to mandatory funding, we request that Congress continue to provide advance appropriations to the Indian health system to improve certainty and stability.

Cuts from sequestration, the automatic spending cuts that occur through the withdrawal of funding for government programs, force I/T/U providers to make difficult decisions about the scope of healthcare services they can offer to Native patients. For example, the $220 million reduction in IHS’ budget authority for FY 2013 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for AI/ANs. Therefore, we request that you exempt IHS from sequestration and other budget cutting measures as is required by the trust responsibility.

Appropriate $80 Million for the Native Behavioral Health Resources Program

Native people continue to face high rates of behavioral health issues caused by generational trauma and federal policies. Native people experience serious mental illnesses at a rate 1.58 times higher than the national average, and high rates of alcohol and substance abuse. In fact, between 1999 and 2015, the drug overdose death rates for Native populations increased by more than 500%. Native youth also experience the highest rates of suicide and depression, with the Native youth suicide rate being 2.5 times that of the national average.

In response to these chronic health disparities, Congress authorized $80 million to be appropriated for the Native Behavioral Health Resources Program for fiscal years 2023 to 2027. Despite authorizing an appropriation of $80 million for the Program, Congress did not appropriate that sum for FY 23.

We request that the authorized $80 million be appropriated to the Native Behavioral Health Resources Program for FY 24 and each of the remaining authorized years. Until the committee appropriates funding for this program, critical healthcare programs and services cannot operate to their full capability, putting Native lives at-risk. We ask that this essential step is taken to ensure our communities have access to the care they need.

Conclusion

Among the most sacred of the duties encompassed within the federal trust responsibility is the duty to provide for Indian health care. The United State’s failure to fulfill its obligations to provide health care to urban Indians has real and devastating effects on our communities. We urge Congress to act swiftly to redress this problem by appropriating $51.42 billion for the Indian Health Service and $973.59 million for Urban Indian Health in the FY24 Interior, Environment, and Related Agencies Appropriations. NCUIH looks forward to working with you as you craft a budget that upholds the trust responsibility to urban Indians.

Resources

NCUIH Calls for Full Funding and Increased Resources for Urban Indian Health in FY 2024 Written Testimony to House Appropriations Subcommittee

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On March 23, 2023, The National Council of Urban Indian Health (NCUIH) submitted outside written testimony to the House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies regarding Fiscal Year (FY) 2024 funding for Urban Indian Organizations (UIOs). NCUIH advocated in its testimony for full funding for the Indian Health Service (IHS) and urban Indian health and increased resources for Native health programs.

In the testimony, NCUIH requested the following:

  • $51.42 billion for the Indian Health Service and $973.59 million for Urban Indian Health for FY24 (as requested by the Tribal Budget Formulation Workgroup)
  • Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
  • Permanent 100% Federal Medical Assistance Percentage for services provided at UIOs
  • Increase funding for Electronic Health Record Modernization
  • Increase funding to $30 million for Good Health and Wellness in Indian Country (GHWIC)
  • Ensure UIOs are appropriately included in grant programs relating to Indian health
  • Appropriate $80 million for the Native Behavioral Health Resources Program
  • Work with Authorizers to Reauthorize the Special Diabetes Program for Indians

Full Text of Testimony:

My name is Francys Crevier, I am Algonquin and the Chief Executive Officer of the National Council of Urban Indian Health (NCUIH), the national representative of urban Indian organizations receiving grants under Title V of the Indian Health Care Improvement Act (IHCIA) and the American Indians and Alaska Native (AI/ANs) patients they serve. On behalf of NCUIH and these 41 Urban Indian Organizations (UIOs), I would like to thank Chair Aderholt, Ranking Member DeLauro, and Members of the Subcommittee for your leadership to improve health outcomes for urban Indians. We respectfully request the following:

  • $51.42 billion for the Indian Health Service and $973.59 million for Urban Indian Health for FY24 (as requested by the Tribal Budget Formulation Workgroup)
  • Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
  • Permanent 100% Federal Medical Assistance Percentage for services provided at UIOs
  • Increase funding for Electronic Health Record Modernization
  • Ensure UIOs are appropriately included in grant programs relating to Indian health
  • Appropriate $80 million for the Native Behavioral Health Resources Program
  • Work with Authorizers to Reauthorize the Special Diabetes Program for Indians
We want to acknowledge that your leadership was instrumental in providing the greatest investments ever for Indian health and urban Indian Health, especially the inclusion of advance appropriations. It is important that we continue in this direction to build on our successes.
The Beginnings of Urban Indian Organizations

The Declaration of National Indian Health Policy in the Indian Health Care Improvement Act states that: “Congress declares that it is the policy of this Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.” In fulfillment of the National Indian Health Policy, the Indian Health Service funds three health programs to provide health care to AI/ANs: IHS sites, tribally operated health programs, and Urban Indian Organizations (referred to as the I/T/U system).

As a preliminary issue, “urban Indian” refers to any American Indian or Alaska Native (AI/AN) person who is not living on a reservation, either permanently or temporarily. UIOs were created in the 1950s by American Indians and Alaska Natives living in urban areas, with the support of Tribal leaders, to address severe problems with health, education, employment, and housing caused by the federal government’s forced relocation policies. Congress formally incorporated UIOs into the Indian Health System in 1976 with the passage of the Indian Health Care Improvement Act (IHCIA). Today, UIOs continue to play a critical role in fulfilling the federal government’s responsibility to provide health care for AI/ANs and are an integral part of the Indian health system. UIOs serve as a cultural hub for and work to provide high quality, culturally competent care to the over 70% of AI/ANs living in urban settings.

Request: $51.42 billion for Indian Health Service and $973.59 million for urban Indian health

The federal government owes a trust obligation to provide adequate healthcare to AI/ANs. It is the policy of the United States “to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to affect that policy.” This requires that funding for Indian health must be significantly increased if the federal government is to finally fulfill its trust responsibility. At a minimum, funding must be maintained and protected as budget-cutting measures are being considered.

We thus request Congress honor the Tribal Budget Formulation Workgroup (TBFWG) FY24 recommendations of $51.42 billion for IHS and $973.59 million for urban Indian health. That number is much greater than the FY23 enacted amounts of $6.9 billion for IHS and $90.4 million for urban Indian health. The significant difference between the enacted and requested amount underscores the need for Congress to significantly increase funding to IHS to meet the Indian Health System’s level of need. Additionally, IHS has been consistently underfunded in comparison to other major federal health agencies. In 2018, the Government Accountability Office (GAO-19-74R) reported that from 2013 to 2017, IHS annual spending increased by roughly 18% overall and approximately 12% per capita. In comparison, annual spending at the Veterans Health Administration (VHA), which has a similar charge to IHS, increased by 32% overall, with a 25% per capita increase during the same period. In fact, even though the VHA service population is only three times that of IHS, their annual appropriations are roughly thirteen times higher. In other words, it is imperative that Congress fully fund the IHS at the amount requested by the TBFWG to fulfill its trust responsibility and to improve health outcomes for AI/ANs no matter where they live.

The IHS is chronically underfunded, and the Urban Health line item historically is just one percent (1%) of that underfunded budget. UIOs receive direct funding only from the Urban Health line item and do not receive direct funds from other distinct IHS line items. As a result, in FY 2018 U.S. healthcare spending was $11,172 per person, but UIOs received only $672 per AI/AN patient from the IHS budget. Without a significant increase to the urban Indian line item, UIOs will continue to be forced to operate on limited budgets that offer almost no flexibility to expand services or address facilities-related costs. For example, one UIO, Native American Lifelines, is made up of two programs that run in both Boston and Baltimore with an annual budget of just $1.6 million for a service population of over 55,000 people.

Despite this underfunding, UIOs have been excellent stewards of the funds allocated by Congress and are effective at ensuring that increases in appropriations correlate with improved care for their communities. Last Congress, with the help of this committee, the Infrastructure Investment and Jobs Act now allows UIOs to utilize their existing IHS contracts to upgrade their facilities. With funding increases from this Committee and this new allowance, six UIOs opened new facilities in the past year, and an additional 16 UIOs have plans to open new facilities in the next two years. The increased investments in urban Indian health by this committee will continue to result in the expansion of health care services, increased jobs, and improvement of the overall health in our communities.

Request: Maintain Advance Appropriations for IHS Until Mandatory Funding Is Enacted

We applaud Chair Baldwin and this Committee for your work on the historic inclusion of advance appropriations in the FY23 Omnibus. This is a crucial step towards ensuring long-term, stable funding for IHS. Previously, the I/T/U system was the only major federal health care provider funded through annual appropriations. It is imperative that this Committee retain advance appropriations and ensure that IHS is protected from sequestration.

The GAO cited a lack of consistent funding as a barrier for IHS. The Congressional Research Service stated that advance appropriations would lead to cost savings as continuing resolutions (CRs) “prohibits the agency from making longer-term, potentially cost-saving purchases.” Advance appropriations will improve accountability and increase staff recruitment and retention at IHS. When IHS distributes their funding on time, our UIOs can pay their doctors and providers. During a pandemic that has ravaged Indian Country and devasted the workforce, being able to recruit doctors and pay them on time is a top priority.

While advance appropriations are a step in the right direction to avoid disruptions during government shutdowns and continuing resolutions (CRs), mandatory funding is the only way to assure fairness in funding and fulfillment of the trust responsibility. Until authorizers act to move IHS to mandatory funding, we request that Congress continue to provide advance appropriations to the Indian health system to improve certainty and stability.

Cuts from sequestration force I/T/U providers to make difficult decisions about the scope of healthcare services they can offer to Native patients. For example, the $220 million reduction in IHS’ budget authority for FY 2013 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for AI/ANs. Therefore, we request that you exempt IHS from sequestration and other budget cutting measures as is required by the trust responsibility.

Request: Work with Authorizers for Permanent 100% Federal Medical Assistance Percentage (FMAP) for services provided at UIOs

The federal medical assistance percentage (FMAP) refers to the percentage of Medicaid costs covered by the federal government and reimbursed to states. With states already receiving 100% FMAP for services provided at IHS and Tribal facilities, the American Rescue Plan Act (ARPA) temporarily shifted the responsibility of UIO Medicaid cost obligation from state governments to the federal government. This provision finally brought a form of parity to UIOs by setting FMAP for Medicaid services provided at UIOs at 100% for eight fiscal quarters, while offering cost savings to states, and finally creating a sense of consistency in how the federal government honors its obligations to urban Native healthcare. The provision expires this month on March 31, 2023. During this short provision, states have been able to work with UIOs to provide increased funding to help begin construction of a new clinic, youth services center, and establish a new behavioral health unit.

Permanent 100% FMAP will bring some fairness to the I/T/U system and increase available financial resources to UIOs and support them in addressing critical health needs of urban Native patients. Again, we request that the committee work with authorizers for permanent 100% FMAP.

Request: Increase Funding for Electronic Health Record Modernization

We request your support for the Indian Health Service’s (IHS) transition to a new electronic health record (EHR) system for IHS and UIOs. UIOs have expended significant funds for the replacement, upgrade and maintenance of IHS’ Health Information Technology (HIT) systems due to the federal government’s failure to keep pace with HIT development in the wider healthcare industry. This has resulted in UIOs having no choice but to purchase expensive off-the-shelf-replacement systems to ensure that they can continue to provide high-quality and culturally-focused health care to AI/AN patients. As EHR modernization moves from planning to fruition, it is critically important that appropriations continue to increase, and any language included in appropriations must allow funding to be used to reimburse Tribal Organizations and UIOs associated with the cost of EHR modernization. NCUIH requests the committee to support this transition by supporting the President’s budget request of $913 million in FY24 appropriations.

Request: Ensure UIOs are appropriately included in grant programs relating to Indian health

Failure to explicitly include UIOs in legislative programmatic authorizations often effectively prohibits UIOs from accessing the related funding, even if the exclusion was unintentional and UIOs would otherwise be an appropriate addition to program eligibility. UIOs are already severely underfunded and rely on grant funding to support the provision of life-saving services to their patients. Excluding UIOs from grant funding reduces the ability of UIOs to provide and expand service options for their patients. For example, UIOs are left out of statutory language in the nationalization of the Community Health Aide Program (CHAP), which is meant to increase the availability of healthcare workers in Native communities. Because of this legislative oversight, IHS interprets this as UIOs are not eligible to participate in the program, and therefore UIOs cannot utilize the program to ease the burden caused by limited provider availability for the Indian Health System.

Many programs in the Health and Human Services appropriations bills include language for Indian Tribes and Tribal organizations, but not for urban Indian organizations. Urban Indian Organizations are not considered Tribal organizations, which is a common misconception. While UIOs may fall within general terms such as “non-profit organization,” there are times when a general grant to non-profits is not appropriate, but a grant to UIOs would be. For example, if the grant is intended to serve Indian Healthcare facilities, including UIOs in grant funding would be appropriate, while including non-profit organizations generally would not be. Therefore, it is essential that you explicitly include UIOs when they intend UIOs to be included in the program. We request that any addition of UIOs to a program should include a corresponding appropriation increase to ensure that funding for Tribes and Tribal Organizations are not reduced. We emphasize that we acknowledge and respect the government-to-government relationship between Tribes and the United States and understand that there are times when it is not appropriate to add UIOs into legislation directed at Tribes and Tribal Organizations.

Request: Appropriate $80 Million for the Native Behavioral Health Resources Program

Native people continue to face high rates of behavioral health issues caused by generational trauma and federal policies. Native people experience serious mental illnesses at a rate 1.58 times higher than the national average, and high rates of alcohol and substance abuse. In fact, between 1999 and 2015, the drug overdose death rates for Native populations increased by more than 500%. Native youth also experience the highest rates of suicide and depression, with the Native youth suicide rate being 2.5 times that of the national average.

In response to these chronic health disparities, Congress authorized $80 million to be appropriated for the Native Behavioral Health Resources Program for fiscal years 2023 to 2027. Despite authorizing an appropriation of $80 million for the Program, Congress did not appropriate that sum for FY 23.

We request that the authorized $80 million be appropriated to the Native Behavioral Health Resources Program for FY 24 and each of the remaining authorized years. Until the committee appropriates funding for this program, critical healthcare programs and services cannot operate to their full capability, putting Native lives at-risk. We ask that this essential step is taken to ensure our communities have access to the care they need.

Request: Work with Authorizers to Re-authorize the Special Diabetes Program for Indians (SDPI)

SDPI’s integrated approach to diabetes healthcare and prevention programs in Indian country has become a resounding success and is one of the most successful public health programs ever implemented. SDPI has demonstrated success with a 50% reduction in diabetic eye disease rates, drops in diabetic kidney failure, and 50% decline in End Stage Renal Disease. Additionally, the reduction in end stage renal disease between 2006 and 2015 led to an estimated $439.5 million dollars in accumulated savings to the Medicare program, 40% of which, of $174 million, can be attributed to SDPI.

Currently, 31 UIOs are in this program and are at the forefront of diabetes care. Facilities use these funds to offer a wide range of diabetes treatment and prevention services, including but not limited to exercise programs and physical activity, nutrition services, community gardens, culinary education, physical education, health, and wellness fairs, culturally-relevant nutrition assistance, food sovereignty education, group exercise activities, green spaces, and youth and elder-focused activities.

With the program set to expire this year, we request that the committee work with authorizers to permanently reauthorize SDPI at a minimum of $250 million requested in the President’s FY24 budget with automatic annual funding increases tied to the rate of medical inflation, to continue the success of preventing diabetes-related illnesses for all Indian Country.

Conclusion

These requests are essential to ensure that urban Indians are appropriately cared for, in the present and in future generations. The federal government must continue to work towards its trust and treaty obligation to maintain and improve the health of American Indians and Alaska Natives. We urge Congress to take this obligation seriously and provide UIOs with all the resources necessary to protect the lives of the entirety of the Native population, regardless of where they live.

National Native Organizations Call on Administration to Urgently Fund New Behavioral Health Program for Native Communities from Omnibus

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On February 17, 2023, the National Council of Urban Indian Health (NCUIH), the National Indian Health Board (NIHB), Self-Governance Communication and Education Tribal Consortium, and the United South and Eastern Tribes Sovereignty Protection Fund sent a letter to request that the President include funding for the Native Behavioral Health Program authorized in the omnibus. Specifically, the organizations asked for the full authorized level of $80 million for the Native Behavioral Health Resources Program included in the Restoring Hope for Mental Health and Well-Being Act be funded in the President’s Fiscal Year (FY) 2024 Budget Request.

NCUIH particularly applauds Senator Tina Smith for her sponsorship and the co-sponsorship of Senator Cramer, Senator Tester, Senator Lujan, Senator Warren, and Senator Cortez Masto of the Native Behavioral Health Access Improvement Act of 2021, which was the foundation for the behavioral health provisions included in the Restoring Hope for Mental Health and Well-being Act. NCUIH also thanks Ranking Member Frank Pallone and Representative Raul Ruiz for championing this proposal to ensure that American Indians/Alaska Natives (AI/ANs) have greater access to resources necessary to address critical behavioral health needs and bring the federal government closer to fulfilling its trust obligations to AI/AN populations.

In particular, the letter outlines that the Restoring Hope for Mental Health and Well-Being Act includes a Native behavioral health provision that contains:

  • A funding authorization of no less than $125 million annually over a minimum of four fiscal years.
  • A mandate to deliver funding on a non-competitive basis.
  • The opportunity to receive funding through Indian Self-Determination Act contracts or compacts.
  • A requirement that any funding formulas be developed in consultation with Tribal Nations and conference with Urban Indian Health Organizations.
  • A requirement that reporting requirements be developed through a negotiated rulemaking process between the federal government, Tribal Nations, and Urban Indian Health Organizations.

This is in response to the high rates of behavioral health issues caused by centuries of generational trauma resulting from colonization and hostile acts of the United States Government. In fact, as outlined in the letter, Native people experience serious mental illnesses at a rate 1.58 times higher than the national average, and high rates of alcohol and substance abuse. In fact, between 1999 and 2015, the drug overdose death rates for Native populations increased by more than 500%. Native youth also experience the highest rates of suicide and depression, with the Native youth suicide rate being 2.5 times that of the national average.

Letter

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Re: Native Behavioral Health Resources Program

Dear Director Young,

On behalf of the undersigned Tribal partner organizations, we write to urge the inclusion of the full authorized level of $80 million in the President’s Fiscal Year (FY) 2024 Budget Request to fund the Native Behavioral Health Resources Program as included in the Restoring Hope for Mental Health and Well-Being Act. Tribal Nations and our citizens continue to face high rates of behavioral health issues, caused by myriad factors, including centuries of generational trauma resulting from colonization and hostile acts of the United States government. Yet, in violation of federal trust and treaty obligations to provide comprehensive health care to Tribal Nations, we continue to lack substantial and sustained funding to address these challenges for current and future generations. As the collective trauma of living through the COVID-19 public health crisis only exacerbates and intensifies these issues, it is critical that Tribal Nations and the Indian Health System are equipped with the resources necessary to bring healing and recovery to our communities.

Between 1999 and 2015, the drug overdose death rates for American Indian and Alaska Native (AI/AN) populations increased by more than 500%. Addressing the challenges presented by the opioid crisis in Indian Country is further complicated by high rates of alcohol and substance abuse, suicide, and other serious mental health conditions. AI/AN populations experience serious mental illnesses at a rate 1.58 times higher than the national average, and Native youth experience the highest rates of youth suicide and depression in the country. Yet far too many facilities across the Indian Health System are unable to access the quality health care and services necessary to address these behavioral health issues. A survey conducted by the Indian Health Service (IHS) found that Tribal Nations rated the expansion of inpatient and outpatient mental health and substance abuse facilities as our number one priority. Currently, only 39% of IHS facilities provide 24-hour mental health crisis intervention services, and 10% of IHS facilities do not provide any crisis intervention services at all.

To combat the opioid epidemic and the broader behavioral health crisis in Indian Country, Tribal Nations and facilities across the Indian Health System require flexible and substantial funding to create behavioral health programs that are responsive to the unique circumstances facing our communities. Toward that end, along with Congressional partners, we urged at the end of the 117th Congress that the Restoring Hope for Mental Health and Well-Being Act include a Native behavioral health provision that contained the following:

  • A funding authorization of no less than $125 million annually over a minimum of four fiscal years;
  • A mandate to deliver funding on a non-competitive basis;
  • The opportunity to receive funding through Indian Self-Determination Act contracts or compacts;
  • A requirement that any funding formulas be developed in consultation with Tribal Nations and conference with Urban Indian Health Organizations; and
  • A requirement that reporting requirements be developed through a negotiated rulemaking process between the federal government, Tribal Nations, and Urban Indian Health Organizations.

Although only some of our priorities were adopted in the final bill and while centuries of underinvestment in mental and behavioral health across Indian Country will require sustained funding and thoughtful effort on the part of Congress and the Administration to properly address, funding the Native Behavioral Health Resources Program would represent a significant step toward this goal. We urge the Biden Administration to prioritize its trust and treaty obligations to Tribal Nations by supporting Tribal Nation access to federal mental health and substance use disorder programs, including the Native Behavioral Health Resources Program. We thank you for your attention to this matter and look forward to continued collaboration on improve health care throughout Indian Country.

Sincerely,
National Council of Urban Indian Health
National Indian Health Board
Self-Governance Communication and Education Tribal Consortium
United South and Eastern Tribes Sovereignty Protection Fund

Background

In response to these chronic health disparities and the dire need for behavioral health resources for Indian health care providers, the House Energy and Commerce Committee drafted bipartisan legislation creating the Native Behavioral Health Resources Program. This legislation was included in the House-passed Restoring Hope for Mental Health and Well-Being Act (H.R.7666), and ultimately included in the Consolidated Appropriations Act, 2023. This provision authorized to be appropriated $80 million for the Native Behavioral Health Resources Program.

NCUIH to Testify Before House Interior Appropriations

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NCUIH to Testify Before House Interior Appropriations

On Thursday, March 9, 2023 at 9:00 AM, the National Council of Urban Indian Health (NCUIH) Chief Executive Officer, Francys Crevier, JD (Algonquin) will testify in person before the House Interior Appropriations Subcommittee hearing as part of American Indian and Alaska Native Public Witness Days (March 8 and 9, 2023).

In the testimony, NCUIH will advocate for full funding for the Indian Health Service and Urban Indian Health as requested by the Tribal Budget Formulation Workgroup (TBFWG) for Fiscal Year (FY) 2024. Other requests include: maintaining advance appropriations for IHS until mandatory funding is enacted and appropriating at least $80 million for the Native Behavioral Health Resources Program.

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Learn more: https://appropriations.house.gov/events/hearings

NCUIH Releases “2022 Annual Policy Assessment”

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The Policy assessment informs urban Indian organization policy priorities in 2023, identifies traditional healing barriers, and addresses mental and behavioral health needs.

2022 Policy Assessment thumbnailThe National Council of Urban Indian Health (NCUIH) is pleased to announce the release of its 2022 Annual Policy Assessment. NCUIH hosted five focus groups to identify Urban Indian Organization (UIO) policy priorities for 2023, as they relate to the Indian Health Service (IHS) designated facility types (full ambulatory, limited ambulatory, outreach and referral, and outpatient and residential). The focus groups were held on October 18, 21, and 24, 2022. Additional information was also collected from the UIOs via a questionnaire sent out on November 15, 2022.

Together these tools allow NCUIH to work with UIOs to identify policy priorities in 2023 and identify barriers that impact delivery of care to Native patients and their communities.  Of 41 UIOs, 26 attended the focus groups and/or participated in the questionnaire. This is the third year that NCUIH has conducted the assessment via focus groups and follow up questionnaire. This is also the highest response from UIOs NCUIH has seen since following this process.

Read the 2022 Policy Assessment

Overview of Policy Assessment

2022 Policy Assessment chartAfter the height of the COVID-19 pandemic, newfound priorities were identified for 2023, including workforce development and retention, increased funding for traditional healing, and expanded access to care and telehealth services. Existing priorities also remain a key focus across UIOs, especially increasing funding amounts for the urban Indian health line item and IHS, maintaining advance appropriations for IHS, establishing permanent 100% Federal Medical Assistance Percentage (FMAP) for UIOs, reauthorizing the Special Diabetes Program for Indians (SDPI), and increasing behavioral health funding.

 

Key findings from the discussions are as follows:

  • Funding Flexibility is Key to Expanding Services
  • Need for Funding Security Remains a Priority
  • Advance Appropriations Mitigates Funding Insecurities Generated by Government Shutdowns and Continuing Resolutions
  • Facility Funding Directly Impacting UIOs
  • Permanent 100% FMAP Increases Available Financial Resources to UIOs
  • Workforce Concerns Amidst Inflation and Market Changes
  • Traditional Healing Crucial to Advance Comprehensive Native Healthcare
  • Addressing Access and Quality of Native Veteran Care
  • Health Information Technology and Electronic Health Record Modernization
  • New Barriers Limit UIO Distribution of Vaccines
  • HIV, Behavioral Health, and Substance Abuse Report
  • Reauthorizing the Special Diabetes Program for Indians
  • UIOs Find Current NCUIH Services Beneficial

Next Steps

NCUIH will release a comprehensive document of the 2023 Policy Priorities in the coming weeks.

Past Resources: