NCUIH Submits Comments to CMS with Recommendations on Native American Access to Medicaid Services

On July 3, 2023, the National Council of Urban Indian Health (NCUIH) submitted written comments and recommendations to the Centers for Medicare and Medicaid Services (CMS) Administrator, Chiquita Brooks-LaSure, in response to the May 2, 2023, request for comment on the CMS proposed rule regarding ensuring access to Medicaid services (CMS–2442–P).  NCUIH urged CMS to specifically consider how the proposed sections will advance the Nation’s efforts to fulfill its trust responsibility to provide services to maintain and improve the health of American Indians and Alaska Natives (AI/ANs).

NCUIH recommended that CMS take the following actions:

In its comments, NCUIH recommended that CMS ensure AI/AN representation on each state Medicaid Advisory Committee (MAC) and Beneficiary Advisory Group (BAG), ensure the rule does not impose additional burdensome reporting requirements on providers, engage with the Tribal Technical Advisory Committee (TTAG) to consider regulations or guidance to enforce the state consultation and confer requirements, and support 100% Federal Medical Assistance Percentage (FMAP) for Medicaid services provided at urban Indian organizations (UIOs) to ensure AI/AN Medicaid beneficiaries receive appropriate, quality culturally competent care. By extending this funding mechanism to cover all Medicaid services provided at UIOs, CMS can make substantial progress in reducing the existing barriers to healthcare access faced by urban Native populations.

Background on the Proposed Rule Ensuring Access to Medicaid Services (CMS–2442–P):

The proposed rule, Ensuring Access to Medicaid Services, includes both proposed changes to current requirements and newly proposed requirements that would advance CMS’s efforts to improve access to care, quality, and health outcomes, and better promote health equity for Medicaid beneficiaries across fee-for-service (FFS) and managed care delivery systems, including for home and community-based services provided through those delivery systems. These proposed requirements are intended to increase transparency and accountability, standardize data and monitoring, and create opportunities for states to promote active beneficiary engagement in their Medicaid programs.

Background on Medicaid and AI/ANs:

AI/AN people depend upon Medicaid to receive their healthcare coverage and services. In 2020, over 1.8 million AI/ANs were enrolled in Medicaid. According to a NCUIH analysis of American Community Survey (ACS) data, in 2019 Medicaid covered 1.3 million urban AI/ANs, including 30% of urban AI/AN adults under the age of 65. Medicaid and CHIP are important programs for addressing the significant disparities in insurance coverage which exist for AI/AN people.  For example, according to the Urban Institute, AI/AN children were uninsured at a rate of 8.9% in 2019, the highest rate for any ethnic group in the country.  AI/AN parents were uninsured at a rate of 18.7% in 2019, the second highest rate in the country. The Urban Institute reported that in 2019, AI/AN children remained more than twice as likely as white children to be uninsured and AI/AN were more than 2.5 times more likely to be uninsured than with white parents.

Medicaid is also an important source of funding for to support the operation of the Indian Health system, including UIOs who help serve the approximately 70% of AI/AN people who live in urban areas.  Medicaid remains the largest secondary source of funding for UIO clinics. In 2020, 33% of the total population served at UIOs were Medicaid beneficiaries, and 35% of the AI/AN population served at UIOs were Medicaid beneficiaries. As the Kaiser Family Foundation noted in 2017, “Medicaid funds are not subject to annual appropriation limits . . . since Medicaid claims are processed throughout the year, facilities receive Medicaid funding on an ongoing basis for covered services provided to AIANs.”  Because the Medicaid program receives Mandatory appropriations, Medicaid revenue is particularly essential for Indian health providers when IHS funding is reduced or interrupted by budgetary disagreements.

Supreme Court Held Oral Argument on Case Challenging the Indian Child Welfare Act

On November 9, 2022, the Supreme Court of the United States held oral argument in Haaland v. Brackeen, a case challenging the constitutionality of the Indian Child Welfare Act of 1978 (ICWA). The questions presented to the Court in Brackeen are: (1) Whether various provisions of ICWA violate the anticommandeering doctrine of the Tenth Amendment; (2) Whether the individual plaintiffs have Article III standing to challenge ICWA’s placement preferences for “other Indian families,” and for “Indian foster home[s];” (3) Whether the default placement preferences for Indian homes in adoption or foster care cases are rationally related to legitimate governmental interests and therefore consistent with equal protection. The Supreme Court’s decision in Brackeen will have far-reaching implications on all areas of Federal Indian Law and policy and the National Council of Urban Indian Health (NCUIH) continues to advocate for the protection of ICWA to safeguard American Indian/Alaska Native (AI/AN) children and families.

Summary of Oral Argument

Oral argument for Brackeen lasted over three hours and focused heavily on the scope of Congress’s constitutional authority to legislate on behalf of AI/ANs, the equal protection limitations on that power, and whether the requirements imposed on states by the ICWA, particularly the “active efforts” requirement, violates the anticommandeering doctrine. Oral argument began with the parties challenging ICWA, referred to as “plaintiffs.” Solicitor General Judd Stone argued on behalf of the state of Texas, and Matthew McGill, a partner at Gibson, Dunn & Crutcher, argued on behalf of the potential adoptive families. The plaintiffs’ arguments centered on the assertion that ICWA deprives Indian children and non-Indian prospective parents of the “best interest of the child” standard in child welfare proceedings in violation of the Equal Protection Clause. The parties defending ICWA, referred to as “defendants,” argued second. Deputy Solicitor General Edwin Kneeler argued on behalf of the federal defendants and Ian H. Gershengorn, a partner at Jenner & Block, LLC , argued on behalf of the intervening Tribes (the Cherokee Nation, Oneida Nation, Quinault Nation, and Morongo Band of Mission Indians).  The defendant’ arguments centered on the fact that Congress has broad power to legislate in Tribal affairs, and this power is limited only by other constitutional provisions or by the test set by Supreme Court precedent in Morton v. Mancari, 417 U.S. 535 (1974), which requires congressional action to be rationally related to the fulfillment of Congress’ unique obligations to Indians.

Background on Haaland v. Brackeen

Congress enacted the ICWA in 1978 to re-establish Tribal authority over the adoption of AI/AN children. ICWA is a procedural safeguard to “protect the best interests of Indian children and to promote the stability and security of Indian Tribes and families.” 25 U.S.C. § 1902. In Brackeen, Texas, Indiana, Louisiana, and individual plaintiffs (plaintiffs) sued the federal government in the U.S. District Court for the Northern District of Texas, arguing that ICWA and its implanting regulations are unconstitutional because they violate the equal protection and substantive due processes provisions of the Fifth Amendment and violate the anticommandeering doctrine of the Tenth Amendment.  The plaintiffs also argued that ICWA and the implementing regulations violate the nondelegation doctrine and the APA. The District Court ruled in favor of the plaintiffs, finding that the ICWA violates the Constitution’s guarantee of equal protection because it applies to all children eligible for membership in a Tribe, not just enrolled tribal members, and therefore operates as a race-based statute.  The District Court further held that ICWA violates the Tenth Amendment’s prohibition on the federal government issuing direct orders to states and unconstitutionally delegates Congress’s power by giving Tribes the authority to change adoption placement preferences and make states abide by them. On appeal, the Fifth Circuit reversed the District Court’s opinion in most respects. In a fractured ruling, the Fifth Circuit sitting en banc upheld portions of the District Court’s opinion and reversed other portions.

In early September 2021, the United States government, tribal defendants, as well as state and private plaintiffs filed petitions asking the United States Supreme Court to review the Fifth Circuit’s decision. The U.S. Supreme Court agreed to review the Fifth Circuit’s decision in Brackeen v. Haaland on February 28, 2022, and held oral argument on November 9, 2022.

NCUIH Advocacy

On August 19, 2022, NCUIH and five urban Indian organizations (UIOs) (Nebraska Urban Indian Health Coalition, Inc., Sacramento Native American Health Center, Fresno American Indian Health Project, All Nations Health Center, and Oklahoma City Indian Clinic) signed on to the National Indigenous Women’s Resource Center’s (NIWRC) amicus brief to the Supreme Court in support of the constitutionality of ICWA in the  Haaland v. Brackeen case. NCUIH worked directly with NIWRC to engage with UIOs to ensure that the submitted brief was inclusive of urban AI/ANs. On September 7, NCUIH submitted written comments to the Bureau of Indian Affairs (BIA) and the Administration for Children and Families (ACF) on the BIA and ACF’s efforts to promote the consistent application of ICWA) and protect children, families, and Tribes.

NCUIH previously provided an in-depth analysis on the impact of ICWA and will continue to monitor ongoing developments.

Next Steps

The Supreme Court will hand down a decision by the end of the 2022 term on July 1, 2023. Due to the complex nature of the case, a decision is not expected until the Spring. The Supreme Court’s decision in Brackeen will have far-reaching implications on all areas of Federal Indian Law and policy. The recognition that the AI/AN classification is political classification rather than racial is a critical underpinning of not just ICWA, but many laws that relate to housing, healthcare, education, and employment. This political classification goes back to the 19th Century and has been upheld by Courts at multiple levels. Acknowledging the importance of tribal citizenship, AI/ANs are classified by this citizenship, not by their race.  If overturned, the repeal of ICWA would not only upend a law in place for more than 40 years but undercut the heart of tribal sovereignty and the federal government’s trust responsibility to Native communities.

NCUIH Submits Comments to IHS Regarding the Office of Urban Indian Health Programs Strategic Plan and Implementation Plan

On December 15, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments to the Indian Health Service (IHS) regarding additional input and recommendations for revisions to the third draft of the IHS Office of Urban Indian Health Programs (OUIHP) Strategic Plan and the Implementation Plan. The Strategic Plan and the Implementation Plan will be significant in guiding the provision of high-quality and culturally competent health care in fulfillment of the United States’ trust obligation to American Indian/Alaska Native (AI/AN) people. These comments were submitted in response to a November 17, 2022 Dear Urban Leader letter seeking input and recommendations for the final draft of the 2023-2027 IHS OUIHP Strategic Plan and Implementation Plan.


In 2017, IHS developed an OUIHP Strategic Plan 2017-2021, pursuant to the Consolidated Appropriations Act, which described what the Agency hoped to achieve over the next 5 years. IHS is currently finalizing a new OUIHP Strategic Plan for 2023-2027 based on evaluations of the prior Strategic Plan along with participation and feedback received from urban Indian organization (UIO) leaders, IHS staff, and other stakeholders. According to the OUIHP, the new Plan will include goals, objectives, strategies, and performance measures, based on input from UIO Leaders, partners, and external stakeholders.

NCUIH’s Role

NCUIH has submitted three separate comments and recommendations to IHS regarding the Plan. These comments were based on NCUIH’s consultations with UIOs, the IHS Urban Confer held on December 15, 2022, and NCUIH’s subject matter expertise. NCUIH reiterated that input from UIOs is vital for IHS and its operating divisions to effectively gather comprehensive feedback, share critical information, and build mutual trust.


As OUIHP works to finalize the Strategic Plan for 2023-2027, NCUIH made numerous recommendations to strengthen the OUIHP strategic plan.  Among these recommendations were keeping strategic pillars from the prior draft regarding facilitating communication with federal partners on UIO issues and to provide technical assistance to UIOs transitioning from an outreach and referral program to an ambulatory clinic. Further, NCUIH recommended revisions on a strategic pillar to retain strategies regarding receiving 100% Federal Medical Assistance Percentage (FMAP) for UIOs.

NCUIH thanks the OUIHP for the hard work in developing this comprehensive third draft and for conferring with UIOs on additional recommendations. NCUIH also appreciates the opportunity to provide additional comments and recommendations on the OUIHP Strategic Plan Draft 3.  NCUIH strongly believes that the Strategic Plan and the Implementation Plan are important vehicles to articulate leadership priorities, provide direction for program management functions, engage external partners and entities, and measure OUIHP’s progress toward meeting the goals and objectives of IHS. NCUIH looks forward to the final version of the 2023-2027 Strategic Plan and to working with OUIHP to ensure both the Strategic Plan and Implementation Plan are successful.

NCUIH Submits Comments to the Department of Veterans Affairs and IHS on VHA-IHS Memorandum of Understanding Operational Plan

On November 30, 2022, NCUIH submitted comments to the U.S. Department of Veterans Affairs (VA) and the Indian Health Service (IHS) regarding the Veterans Health Administration (VHA) and IHS first-ever Draft Annual Operational Plan for fiscal year (FY) 2022 for the VHA-IHS Memorandum of Understanding (MOU). The MOU establishes a framework for coordination and partnership between VHA and IHS to leverage and share resources and investments in support of each organization’s mutual goals. NCUIH believes that the Draft Annual Operational Plan (Operational Plan) can be a significant step forward in implementing the IHS-VHA MOU and ensuring high quality health care for all American Indian/Alaska Native (AI/AN) veterans and continues to work closely with our colleagues at VA and IHS to ensure that Native veterans receive access to the care they earned through their military service, no matter where they live.


AI/AN veterans have served in the United States military in every armed conflict in the Nation’s history and have traditionally served at a higher rate than any other population in the United States. In return for their service, the United States promised all veterans, including Native veterans, “exceptional health care that improves their health and well-being.” However, of the estimated 86.2 percent of AI/AN veterans that live in urban areas, they generally have higher unemployment, lower education attainment, lower income, higher VA-service connected disability, and generally live in poorer housing conditions than non-Native veterans also living in urban areas.


In its comments, NCUIH stressed the importance of the Operational Plan being a vehicle to articulate leadership priorities, provide direction for program management and distribution of resources, engage internal and external partners, and measure the overall progress toward meeting the MOU’s goals and objectives. NCUIH’s comments emphasized the importance of having OUIHP representation and leadership throughout the plan. As subject matter experts in the health needs of Natives living in urban areas, having representatives who are familiar with UIOs will ensure the needs of urban Native veterans are incorporated into the plan’s actions. Additionally, to improve the collaboration between the VA and IHS, and to ensure that care for AI/AN veterans is not disrupted, NCUIH recommended that the Operational Plan has a strategy in place to achieve seamless referrals between the VA and the I/T/U system. NCUIH further stressed the importance of regular consultation with Tribal Governments, Urban Confers with UIOs, and meetings with the HHS Secretary’s Tribal Advisory Committee on Tribal and Indian Affairs.  Moreover, because VA data currently indicates that Native veterans use Veterans Benefits Administration benefits or services at lower percentages than other veterans, NCUIH recommended that the Operational Plan add an additional objective be added to increase AI/AN veteran use of VA benefits and services.

NCUIH’s work with the VA

NCUIH continues to work on behalf of Native veterans living in urban areas to ensure that they have access to the high-quality, culturally competent care the country owes to them for their military service and as a result of the trust responsibility.

For more information on NCUIH’s efforts please visit:









NCUIH Submits Comments to HRSA to Improve Access to Pediatric Health Care in Urban Native Communities

On August 31, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments to the Health Resources and Services Administration (HRSA) on the Pediatric Mental Health Care Access (PMCHA) Program. In a July 27 Dear Tribal Leader Letter, HRSA explicitly sought feedback from Urban Indian Organizations (UIOs) about how to increase access to and improve pediatric behavioral health care through telehealth and the PMCHA program’s development and implementation. NCUIH’s comments address the essential role of access to pediatric mental health care for American Indian/Alaska Native (AI/AN) communities across the country, including AI/AN communities in urban areas.


According to the Indian Health Service (IHS), Native youth living off-reservation share similar health problems to their AI/AN peers nationwide, which are exacerbated by lack of access to family and traditional cultural environments. Notably, the AI/AN youth suicide rate is 2.5 times that of the national average.

UIOs are actively engaged in overcoming, addressing, and preventing mental and behavioral health issues in urban AI/AN youth. Virtually every UIO offers mental and behavioral health services, which became critically important during the height of the pandemic for families to continue accessing needed health care services to keep their doors open in the wake of reduced in-person visits. Since then, UIOs have continued to provide telehealth services to their patients, especially for mental and behavioral health programs.


NCUIH provided the following recommendations to HRSA regarding pediatric mental health care and telehealth services:

  • Facilitate UIO Participation in the PMHCA Program
    NCUIH urged HRSA to facilitate UIO participation in the PMHCA program. Although UIOs are a critical source of health care for urban AI/AN communities, they are often left underfunded and under resourced because federal grant programs unintentionally exclude UIOs. Accordingly, NCUIH suggested that whenever HRSA is asked to provide technical assistance on the PMHCA program to Congress, it advises Congress of this exclusion and a legislative fix to expand eligibility to UIOs. Any expansion of eligibility should be accompanied by a similar expansion in funding for the PMHCA program to ensure that there is no decrease in funding available for Tribes or Tribal organizations.
  • Continue to Engage with UIOs and Develop an Urban Confer Policy
    NCUIH recommended that HRSA continues to foster its relationship with UIOs through consistent and timely communication to UIOs. We further encouraged HRSA to cultivate meaningful partnerships between other federal agencies and stakeholders to notify UIOs when they are eligible for certain programs. Finally, NCUIH urged HRSA to develop an Urban Confer Policy, which would ensure HRSA’s services are more responsive to the needs and desires of urban AI/AN communities.

We will continue to monitor ongoing implementation of HRSA’s pediatric behavioral and mental health care programs that serve Indian Country.

NCUIH Submits Recommendations to HHS to include Support for Urban Native Communities in its Initiative to Strengthen Primary Health Care

On August 1, 2022, the National Council of Urban Indian Health (NCUIH) submitted written comments to the Department of Health and Human Services (HHS) Office of the Assistant Secretary for Health (OASH) in response to its request for information (RFI) regarding the HHS Initiative to Strengthen Primary Care. NCUIH supports HHS’ efforts to promote health equity and reduce barriers to care for underserved populations, including American Indians/Alaska Natives (AI/ANs). AI/ANs, including those in urban areas, face significant health disparities attributable in part to a lack of access to high-quality, culturally competent care. NCUIH strongly supports the purpose and scope of the Initiative in establishing a federal foundation that supports advancement towards the stated “goal state” of the practice of primary health care.

NCUIH made the following specific recommendations to HHS OASH:
  • Support UIO models for health care delivery already in place at UIOs:
    • NCUIH recommended that HHS address the need for continued and expanded support for UIOs.
    • UIOs are a fundamental and inseverable component of the IHS, Tribal Health Program, and UIO (I/T/U) system. UIOs “are an important support to Native families and individuals seeking to maintain their values and ties with each other and with their culture,” which exist to provide “a wide range of culturally sensitive programs to a diverse clientele.”
  • Address barriers to the delivery of care at UIOs like insufficient funding and resources:
    • Presently, the ability of UIOs to expand upon their current offerings is severely limited by the chronic underfunding of the Indian health system generally, and UIOs in particular. In 2018, the average health care spending was $11,172 per person nationally, yet UIOs only received $672 per AI/AN patient.
    • NCUIH requested that HHS engage with other federal agencies and Congress to advocate for advance appropriations for the IHS. In addition to a lack of funding, UIOs also face significant barriers to providing primary care to AI/ANs in urban areas due to uncertainty over the consistency and timing of federal funding.
    • NCUIH requested that HHS consider supporting UIO recruitment efforts and increasing funding for staff at UIO facilities. UIOs have long faced understaffing issues that reduce the number of patients they can serve and the quality of service at each facility.
  • Establish an Urban Confer Policy
    • NCUIH recommended that HHS establish an Urban Confer policy to seek UIO input to guide HHS actions to strengthen primary health care. An Urban Confer is an established mechanism for dialogue between federal agencies and UIOs. Urban Confers are responses to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that resulted in 70 percent of AI/AN people living outside of Tribal jurisdictions, thus making Urban Confers integral to addressing the care needs of most AI/AN persons.
    • The development of an HHS Urban Confer policy will help coordinate and integrate care between UIOs and HHS, including the relevant agencies and Departments within HHS that have a trust responsibility to provide care to AI/ANs no matter where they live.
    • An urban confer policy will also help HHS fulfill the United States’ national policy, set forth by Congress, “to ensure maximum Indian participation in the direction of health care services so as to render the persons administering such services and the services themselves more responsive to the needs and desires of Indian communities.”
Background on the HHS Initiative to Strengthen Primary Care

Access to high-quality primary health care has been shown to improve health equity and health outcomes, however, the United States’ primary health care foundation is weakening and in need of support: primary health care is under-resourced; the workforce is shrinking; workforce well-being is in peril; and many practices face reimbursement challenges that may result in financial instability. In response to this, OASH launched the Initiative in September 2021 to develop a federal foundation for the provision of primary health care for all that supports improved health outcomes and advanced health equity.  The goals of the Initiative are to:

The first task of the Initiative is to develop an initial HHS plan for strengthening primary health care that will delineate specific actions that HHS agencies and offices may take to achieve the aims, within the current legislation and funding environment. The plan will also include actions that establish an infrastructure in HHS to continue its focus on strengthening primary health, develop subsequent HHS plans that build on the initial plan, and monitor progress and impact. The purpose of OASH’s June 15 RFI was to provide OASH with diverse perspectives, experiences, and knowledge that may inform the development of the initial plan for HHS, as well as future steps for the Initiative.

NCUIH remains committed to advocating for the health rights of urban AI/ANs and continues to respond to requests for information when applicable.

NCUIH Submits Comments to the Indian Health Service on the Creation of an Urban Indian Interagency Workgroup

On September 12, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to the Indian Health Service (IHS) regarding the formation of an Urban Interagency Workgroup with other federal agencies. The agency held an Urban Confer on July 13, in response to a letter sent to President Biden and Vice President Harris from several Senators, requesting the formation of such a workgroup. NCUIH supports the development of an Interagency Workgroup and believes that this would be a key step to increasing support and resources to American Indians/Alaska Natives (AI/ANs) living in urban areas.

NCUIH Recommendations to IHS

NCUIH noted in the comments that Tribes have a unique government-to-government relationship with the federal government and it is essential that any group does not disrupt this. Furthermore, NCUIH supports the federal government in its attempts to better uphold the trust responsibility it has to AI/ANs living in urban areas, which requires more complete involvement of urban Indian organizations (UIOs). However, this does not mean that resources and funding should come at the expense of Tribes. Rather, the government should broaden and deepen the services it provides to all AI/ANs while additionally further meeting the trust responsibility to urban-dwelling AI/ANs.

NCUIH provided the following recommendations to IHS in response to the Urban Confer:

  • Respect Tribal Sovereignty and the government-to-government relationship in the formation of an Interagency Workgroup.
  • Create a committee within the White House Council on Native American Affairs (WHCNAA) focused on how federal agencies can better serve AI/ANs living in urban areas.
    • The White House Council on Native American Affairs (WHCNAA) was established to improve outcomes for AI/AN communities through a stronger relationship between the federal government and Native people.
    • Developing an Interagency Oversight Committee on Urban Indian Affairs within WHCNAA would allow cross-collaboration across all agencies and ensure that all other WHCNAA committees are accurately incorporating urban Indian communities into their work.
  • IHS should provide technical assistance to federal agencies to develop Urban Confer policies.
    • Urban Confer policies or UIO-specific consultations do not supplant or otherwise alter Tribal Consultations and the government-to-government relationship between Tribes and federal agencies. IHS should provide support and assistance to federal agencies as they begin the development of such policies.


The formation of an Urban Indian Interagency Work Group to identify the needs and develop strategies to better serve urban AI/AN populations has been a priority for NCUIH. On February 3, 2022, Senator Van Hollen, along with Senators Alex Padilla (D-CA), Catherine Cortez Masto (D-NV), Tina Smith (D-MN), Dianne Feinstein (D-CA), Elizabeth Warren (D-MA), Ed Markey (D-MA), Mark Kelly (D-AZ), Amy Klobuchar (D-MN), Patty Murray (D-WA), Tammy Baldwin (D-WI), Jacky Rosen (D-NV), Jeff Merkley (D-OR), and Jon Tester (D-MT) sent a letter to the Biden Administration requesting the establishment of this workgroup. NCUIH worked closely with Senator Padilla on this letter and supports the effort to bring better representation for the needs of AI/ANs who do not reside on Tribal land.

The Senate Appropriations Subcommittee directed IHS to continue to explore the formation of this interagency working group in its Fiscal Year 2023 Interior Appropriations bill, noting that “in addition to the Indian Health Service, the working group should consist of the U.S. Department of Health and Human Services, U.S. Department of Housing and Urban Development, U.S. Department of Agriculture, U.S. Department of Justice, U.S. Department of Education, U.S. Department of Veteran Affairs, U.S. Department of Labor, the Small Business Administration, the Economic Development Agency, FEMA, the U.S. Conference of Mayors, and others as identified by UIOs.”

The Work Group would help identify federal funding strategies to better address the needs of urban AI/ANs, advance the development of a wellness-centered framework to inform health services, strengthen support for practice-based traditional healing approaches, improve Urban Confer policies at Health and Human Services and associated agencies, and ensure that Urban Indian Organizations can regularly meet with federal agencies to address relevant topics of concern.

NCUIH will continue to monitor for any further development on the formation of an Urban Interagency Workgroup. NCUIH will also continue to engage with IHS, the White House, and Congress on moving this proposal forward.

NCUIH Submits Comment on Consistent Application of the Indian Child Welfare Act

On September 7, the National Council of Urban Indian Health(NCUIH) submitted written comments to the Bureau of Indian Affairs (BIA) and the Administration for Children and Families (ACF) on the BIA and ACF’s efforts to promote the consistent application of the Indian Child Welfare Act (ICWA) and protect children, families, and Tribes.

In the submitted comments, NCUIH made the following specific comments, requests, and recommendations to ACF and BIA in response to the July 8, 2022 correspondence:

  • Ensure that urban child welfare and judicial systems are aware of and able to implement ICWA appropriately
    • According to the National Indian Child Welfare Association (NICWA), American Indian/Alaska Native(AI/AN) children continue to be overrepresented in the state foster care system at a rate 7 times higher than their non-Native peers. Because more than 70% of AI/AN people live in urban settings, this overrepresentation undoubtedly includes AI/AN children living in urban areas.
    • To properly implement ICWA, state courts must determine whether a child is an “Indian Child” for the purposes of ICWA as a threshold determination in the proceedings. There are states with experience in the application of ICWA and making applicability determinations. However, some state courts and child protective agencies may not be aware of this requirement or may make incorrect assumptions about a child’s “Indian child” status based on physical appearance or distance from their Tribe. This process needs to be standardized across all states to ensure the safety of these children
    • An AI/AN child’s physical location should not affect whether they receive ICWA’s protections. Specifically, NCUIH requests that ACF and BIA provide technical assistance on ICWA to state social service and child welfare agencies and courts located in urban areas.
  • Actively inform urban child welfare and judicial systems about urban Indian organizations (UIOs) as a potential resource for ICWA proceedings
    • NCUIH recommended that, as part of their efforts to strengthen and implement ICWA, ACF and BIA actively inform state child welfare and judicial systems located in urban areas about UIOs as a potential ICWA resource.
    • While UIOs are healthcare organizations, they often provide culturally competent services that state child welfare services and courts can refer parents to in accordance with ICWA’s “active efforts” requirements. For example, various UIOs provide the following services: family support services, parenting classes and groups, gender-based violence programs, and breastfeeding support.
    • Because UIOs are AI/AN organizations, they may be able to provide useful contacts or other information when a state child welfare agency throughout the child welfare process, including during the initial “Indian child” determination phase.
    • The UIO connection may be particularly useful in areas, such as Chicago, where there is an active UIO but no federally recognized Tribes nearby, and urban systems may not know where to start with the ICWA process.


Congress enacted ICWA in 1978 to re-establish tribal authority over the adoption of Native American children (25 U.S.C. § 1903.) The goal of the Act was to strengthen and preserve Native American family structure and culture. Studies conducted in advance of ICWA’s drafting showed that between 25% and 35% of all Native children were being removed from their home by state child welfare and private adoption agencies. Of those, 85% were placed with non-Native families, even when fit and willing relatives were available. ICWA was established as a safeguard that requires:

  1. Recognition of Tribal jurisdiction over decisions for their Indian children;
  2. Establishment of minimum Federal standards for the removal of Indian children from their families;
  3. Establishment of preferences for placement of Indian children with extended family or other Tribal families; and
  4. Institution of protections to ensure that birth parents’ voluntary relinquishments of their children are truly voluntary.

According to NICWA, ICWA “[l]essens the trauma of removal by promoting placement with family and community . . . [p]romotes the best interest of Indian children by keeping them connected to their culture, extended family, and community, which are proven protective factors . . . [and] [p]romotes placement stability by ensuring that voluntary adoptions are truly voluntary.”

Next Steps

NCUIH will continue to advocate for  the appropriate application of ICWA to all welfare proceedings involving AI/AN children, regardless of whether the child is located in an urban or rural community.



USDA Publishes 2022 Tribal Resource Guide

On August 16, 2022, the United States Department of Agriculture (USDA) released the 2022 edition of the USDA Resource Guide for American Indians and Alaska Natives (Resource Guide). The Resource Guide provides information regarding USDA resources and services available to tribal governments, citizens, and organizations. The Resource Guide covers four categories of USDA programs: 1) agriculture, food sovereignty, and traditional foods; 2) Indian Country economic development; 3) conservation and forestry; and 4) research, extension, and outreach. Additionally, the USDA released the Native Youth Resource Guide (Youth Guide). The Youth Guide summarizes USDA scholarship opportunities, internship programs, cultural summer camps for Native youth, afterschool activities, and resources for employment in the federal government.


The USDA is a federal executive department responsible for food, agriculture, natural resources, rural development, nutrition, and related issues within the United States. The USDA plays an important role in the development of tribal nations and self-governance.  Funding from the USDA helps grow new tribal agricultural ventures, promote traditional food ways, and benefit Indigenous health through foods tailored to American Indian/Alaska Native dietary needs. As a federal agency, the USDA helps advance the federal trust responsibility to Native American communities.

The newly published Resource Guides seek to provide transparency to tribal nations. “These guides can introduce our tribal nation partners to the many USDA funding opportunities and resources that can benefit them and their communities,” remarked Secretary of Agriculture, Tom Vilsack. NCUIH recommends tribal nations use the Resource Guides to help facilitate growth within Indian Country.

NCUIH Comments on the IHS Urban Indian Infrastructure Study

On August 23, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments regarding additional funding for the Urban Indian Infrastructure Study (Infrastructure Study) provided by the Consolidated Appropriations Act, 2022. The additional fiscal year (FY22) funding for the Infrastructure Study is approximately $800,696. NCUIH supports the appropriation of the additional funding and it recommended that IHS disseminate the findings of the FY21 Infrastructure Study, already in progress, to UIOs prior to making any decisions regarding the use of the additional funding. NCUIH also requested that the Office of Urban Indian Health Programs (OUIHP) create a timeline of when the Infrastructure Study will be released to UIOs, the contracting process necessary to use additional funding, and the deadline for obligation of the additional funding. Lastly, NCUIH requested that IHS host an additional Urban Confer after the release of updates about the scope and results of the FY21 Infrastructure Study.


In 2021, Congress allocated $1 million in funds for IHS to conduct an Urban Indian Infrastructure study through the Consolidated Appropriations Act, 2021. The purpose of the Infrastructure Study is to further understand the most critical deficiencies facing UIOs. IHS contracted with The Innova Group, a healthcare consultancy entity, to conduct the Infrastructure Study.

On March 15, 2022, Congress provided $800,969 in additional funding to IHS for the Infrastructure Study through the Consolidated Appropriations Act, 2022. As of September 2022, the results from the Infrastructure Study have not been released by IHS and The Innova Group. On June 16, 2022, IHS requested input regarding the additional funding from 2022 and how these funds can be utilized by IHS. On June 23, 2022, UIO Leaders and NCUIH attended an Urban Confer where IHS explained that the Infrastructure Study will be completed by December 31, 2022, with results to be released in January 2023.

NCUIH’s Recommendations to IHS

NCUIH made the following recommendations regarding the Infrastructure Study:

  • Provide UIOs with the findings from the first Infrastructure Study prior to making any decisions regarding use of the additional funds
    • It is crucial that UIOs are aware of the scope, results, and usefulness of the Infrastructure Study before they make any recommendations regarding the use of the further funding.
    • Given the timeline presented during the Urban Confer, there should be an 8-month window in which UIOs and IHS will be able to review the Infrastructure Study results following their release in January 2023 and decide as to the best use of the additional funding
  • OUIHP should provide a timeline of the Planning Process to UIOs
    • NCUIH requested a timeline be released to UIOs delineating when the initial Infrastructure Study will be released, the contracting process necessary to use the additional funding, and the deadline for the obligation of the additional funding.
    • The requested timeline will provide clarity to UIOs. With a clearer picture in mind, the planning process and use of the additional FY22 funds for the Infrastructure Study becomes more cooperative between UIOs and IHS.
  • IHS should host an additional Urban Confer after releasing the results of the Infrastructure Study.
    • NCUIH notes that informed feedback from UIOs creates a scenario where the additional funding can be best used to support the needs of UIOs.

NCUIH continues to advocate for transparency in the process of the Infrastructure Study and greater support to address the critical infrastructure needs at UIOs. NCUIH will continue to keep UIOs informed as more information is made available from IHS.