Tag Archive for: Comments

NCUIH Calls for Improved Data Accuracy, Partnerships with Other Agencies, and Urban Indian Health Inclusion in IHS Strategic Plan

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On June 28, 2024, the National Council of Urban Indian Health (NCUIH) submitted written comments to the Indian Health Service (IHS) Director, Roselyn Tso, in response to IHS’ May 2, 2024, Dear Urban Indian Organization (UIO) Leader Letter (DULL) and May 30, 2024, Urban Confer regarding IHS’ Draft Strategic Plan for Fiscal Years 2024-2028 (Draft Strategic Plan). In its comments, NCUIH requested that IHS include improved data accuracy and partnerships with other key agencies and stakeholders including the Office of Management and Budget in the agency’s Draft Strategic Plan.

Background on IHS Strategic Plan

The Draft Strategic Plan will establish IHS’ direction for the next five years. It is developed based on feedback received from Headquarters Offices and the Strategic Plan Workgroup and builds on the work of Headquarters Offices to determine appropriate measures. IHS is also incorporating input and feedback from other stakeholders including UIOs. The Draft Strategic Plan includes three Strategic Goals which consist of their own Strategic Objectives, Performance Goals, and Measures.

NCUIH’s Requests

In its comments in response to the May 2, 2024, DULL and May 30, 2024, Urban Confer, NCUIH requested that IHS:

NCUIH Requests Inclusive Governance and Equitable Cohort Selection for Urban Indian Organizations in IHS’ Health Information Technology Modernization Efforts

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On March 7, 2024, and June 7, 2024, the National Council of Urban Indian Health (NCUIH) submitted written comments to the Indian Health Service (IHS) Director, Roselyn Tso, regarding the IHS’ January 18, 2024, Dear Tribal Leader and Urban Indian Organization Leader letter (DTLL/DULL) about the February 8, 2024, and May 9, 2024, Tribal Consultation and Urban Confer (TC/UC) sessions regarding Health Information Technology (HIT) Modernization. In its comments, NCUIH requested that HIT Modernization governance be inclusive of urban Indian organizations (UIOs) by ensuring Domain Groups reflect the scope of facility types, and that the cohort selection process is equitable by ensuring that cohort selection equally prioritizes all facility types.

NCUIH’s Requests

The purpose of the February 8 TC/UC session was for IHS to receive feedback from Tribes and UIOs concerning the HIT Modernization Enterprise Collaboration Group (ECG). The ECG will be a user-focused body that will inform system configuration in clinical and administrative areas.  It will review preferred, evidence-based practices and recommendations for operational aspects of the EHR implementation and deployment. IHS stated that one of the purposes of the ECG is to ensure users of the enterprise EHR drive the configuration of the system that they will use for patient care. It will also engage Tribes and UIOs and their users in enterprise EHR management. Within the ECG there will be Domain Groups which will be multi-disciplinary bodies comprised of EHR users from IHS, Tribal health centers and UIOs (I/T/U) and will be forums for clinical and business subject matter experts to make EHR design and configuration recommendations on behalf of the end users the represent.

For the presentation slides from the February 8 TC/UC session, please click here.

In its comments to this urban confer, NCUIH requested IHS:

  • Ensure all UIO facility types are represented in the ECG Domain Groups
  • Encourage consideration of interoperability by the ECG either through existing Domain Groups or a new Domain Group
  • Ensure Tribal and UIO representation on the ECG Executive Committee
  • Clarify expectations, scope, and outcomes for Domain Groups

The purpose of the May 9 TC/UC session was for IHS to receive feedback from Tribes and UIOs concerning HIT Modernization deployment and cohort planning. IHS presented on the proposed timeline for deployment implementation pathways and approach, and the steps Tribes and UIOs can take to prepare for implementation at their individual sites. IHS will begin the HIT Modernization process by first having implementation occur at IHS pilot sites and then begin implementation at cohorts using the lessons learned from pilot sites. The cohorts will be groups of facilities selected for simultaneous system implementation.

For the presentation slides from the May 9 TC/UC session, please click here.

In its comments to this urban confer, NCUIH requested IHS:

  • Clarify the cohort identification process
  • Ensure IHS accounts for challenges related to operational and financial costs
  • Develop training materials for I/T/U facilities to use as a planning base to prepare for transitioning to a new Electronic Health Record (EHR)
  • Ensure IHS address data integration and migration process for a new EHR

NCUIH Advocacy on HIT Modernization

NCUIH has previously submitted several comments to IHS on HIT Modernization:

NCUIH also submitted written testimony  to the House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies regarding the Fiscal year (FY) 2024 funding for UIOs in which NCUIH requested increased funding for EHR Modernization. Specifically, NCUIH requested support for the IHS’ transition to a new EHR system for IHS and UIOs by supporting the President’s budget request of $913 million in FY 2024 appropriations.

NCUIH will continue to closely follow IHS’s progress and policies with HIT Modernization.

Background on IHS HIT Modernization

During the November 8, 2023, Tribal Consultation and Urban Confer on HIT Modernization, IHS announced that it selected General Dynamics Information Technology, Inc. (GDIT) to build, configure, and maintain a new IHS enterprise Electronic Health Record (EHR) system utilizing Oracle Cerner technology. The new EHR will replace the Resource and Patient Management System.

For more information about HIT Modernization implementation, please click here.

NCUIH Requests Enhanced VA Support and Improved Reimbursement Rates for Urban Indian Organizations in Reimbursement Agreement Program

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On May 15, 2024, that National Council of Urban Indian Health (NCUIH) submitted comments to the Department of Veterans Affairs’ (VA), in response to a May 1, 2024, Urban Confer regarding the revised template for the urban Indian organization (UIO)-VA Reimbursement Agreement Program (RAP) (“revised agreement”). In its comments, NCUIH requested that VA support UIO participation in the Program by providing technical assistance to UIOs and improving UIO reimbursement rates under the revised agreement.

Background

The VA Indian Health Service (IHS)/Tribal Health Program (THP)/UIO RAP provides VA reimbursement to IHS, THP, and UIO health facilities for services provided to eligible American Indian and Alaska Native Veterans. The agreements program was first initiated in 2012 for IHS and Tribal health facilities. It was expanded in 2022 to include UIOs. The RAP is part of a larger effort to improve access to care and coordination for American Indian and Alaska Native Veterans under a broader VA-IHS Memorandum of Understanding managed by Veterans Health Administration (VHA).

NCUIH previously submitted comments to VA in February 2022, requesting VA improve VA’s urban confer process and continue to improve VA’s relationship with UIOs.

NCUIH’s Recommendations

In its May 15, 2024, comments, NCUIH recommended that VA:

  • Continue to engage with and provide updates to UIO on the revised agreement through its development.
  • Improve the UIO reimbursement rates under the revised agreement.
  • Ensure changes to the scope of services include services provided at UIOs.
  • Provide technical assistance to UIOs to support UIO participation.

NCUIH will continue to monitor the development of the revised UIO-VA RAP template.

NCUIH Requests that CMS Include UIOs in its Proposed Framework on Reimbursement for Traditional Healing Services

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On March 27, 2024, and April 29, 2024, the National Council of Urban Indian Health (NCUIH) submitted comments to the Centers for Medicare and Medicaid Services (CMS) Director of the State Demonstrations Group, Jacey Cooper, regarding the Proposed Framework for Traditional Health Care Practices in Section 1115 demonstrations (“Proposed Framework”) in response to CMS’s request for feedback. CMS sought advice and input on the scope of coverage of Traditional Health Care Practices that could be provided at Indian Health Service (IHS) and Tribal facilities, recommendations on provider qualifications, and monitoring and evaluation criteria. As part of its responses, NCUIH requested that CMS include urban Indian organizations (UIOs) in the Proposed Framework because UIOs are critical to providing Traditional Healing services to urban American Indian and Alaska Native populations.

Background

During a March 6, 2024, presentation, CMS provided an overview of the Section 1115(a) demonstration process and a high-level overview of the four pending demonstration proposals to cover Traditional Health Care Practices- Arizona, California, New Mexico, and Oregon. CMS discussed the development of a Proposed Framework for potential coverage of Traditional Health Care Practices, consistent with the authorities in the Indian Health Care Improvement Act. The presented Proposed Framework does not include UIOs as eligible facilities. CMS solicited feedback following the March 2024 presentation and an April 3, 2024, webinar on the Proposed Framework.

For more information on Section 1115 Demonstrations, please click here.

Funding is a Barrier for UIOs to Provide Traditional Healing Services to Native People

Inclusion of UIOs in CMS’ Proposed Framework is critical, as UIOs fill an essential gap in care for American Indian and Alaska Native people living off reservations by providing culturally sensitive and community-focused care options, including traditional healing services and programs. Funding continues to be a barrier for UIOs to provide traditional healing services to their Native patients. They have to work to stretch already limited dollars to include these vital services because healthcare funding sources, including Medicaid, do not adequately reimburse for traditional healing services.

NCUIH’s Requests and Recommendations

In its March 27 comments, NCUIH requested that CMS:

  • Include services delivered at UIOs to American Indian and Alaska Native Medicaid beneficiaries in the Proposed Framework.
  • Host Urban Confers or UIO Listening Sessions Consistently Throughout the Development of the Proposed Framework.

In its April 29, comments NCUIH recommended that CMS:

  • Include Traditional Healing services provided at UIOs in the Proposed Framework.
    • Allow Tribes, UIOs, and States the flexibility to develop a solution which serves all American Indian and Alaska Native beneficiaries.
    • Ensure the Proposed Framework reflects the requests of Tribes and UIOs.
    • Ensure the Proposed Framework does not create inequities in care.
  • Respect confidentiality for Traditional Healers and Traditional Healing practices.
  • Engage with UIOs by hosting an Urban Confer and continue to engage with Tribes.

NCUIH will continue to monitor the development of the Proposed Framework and advocate for UIO inclusion.

NCUIH Urges Protection of Indian Health Care Providers’ Ability to Serve Native People Amid HHS Grant Rule Revisions

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On January 18, 2024, the National Council of Urban Indian Health (NCUIH) submitted written comments to the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) Director, Melanie Fontes Rainer, regarding the notice of proposed rulemaking (NPRM) to repromulgate and revise certain regulatory provisions of HHS’ Uniform Administrative Rule Requirements, Cost Principles, and Audit Requirements for HHS Awards (the rule). NCUIH’s comments urge HHS to ensure that the proposed revisions to not inadvertently impact Indian health care providers’ aility to serve Tribal citizens.

Background

The NPRM pertains to the portions of the rule addressing applicability, and statutory and national policy requirements. Among the changes, HHS is proposing to repromulgate a section addressing discrimination and is including a section stating that HHS will follow all applicable Supreme Court decisions in administering its award programs. HHS is also proposing language providing for religious exemptions for certain provisions.

One of the ways in which the United States meets its trust obligation to provide services and resources to improve the health of American Indian and Alaska Native people is through awarding funding to Tribes, Tribal Organizations and urban Indian organizations (UIOs). HHS funding is critical to the success of the Indian Health Service, Tribes, and UIO (I/T/U) system and ensuring the federal government upholds the federal trust responsibility owed to American Indian and Alaska Native people.

NCUIH’s Recommendations

In its comments, NCUIH recommended that OCR:

  • Include language in the proposed rule that clearly states that nothing in the rule will limit ability of Tribes or UIOs to serve American Indian and Alaska Native people exclusively using HHS awards.
  • Ensure OCR and HHS grant staff are properly trained on the unique political status of American Indian and Alaska Native people.

NCUIH will continue to monitor the rulemaking process for HHS’ Uniform Administrative Requirements.

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.

IHS Responds to NCUIH’s Request to Provide Clarity on the Health IT Modernization Implementation During Virtual Summit

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On December 13, 2023, the Indian Health Service (IHS) held the Health Information Technology (HIT) Modernization Virtual Summit. IHS gave Tribal and urban Indian organization (UIO) leaders an update on the HIT Modernization Program and provided a forum to engage with IHS on the Program. The purpose of the Summit was to raise awareness of the new enterprise Electronic Health Record (EHR) solution and to give Tribal and UIO leaders an opportunity to engage in a conversation with IHS on the HIT Modernization Program. In providing updates on the HIT Modernization implementation process, IHS also responded to comments that the National Council of Urban Indian Health recently submitted to the agency regarding HIT Modernization on December 8.

For more information on the Summit, please click here.

NCUIH Requested IHS Provide Clarity on the HIT Modernization Implementation

On December 8, 2023, NCUIH submitted comments and requests to IHS Director, Roselyn Tso, in response to a Tribal Consultation and Urban Confer and request for input on the HIT Modernization Program. In its comments, NCUIH urged IHS to maintain transparency in the HIT Modernization process to ensure that UIOs stay informed on the progress of the complex, multi-year rollout for the new EHR.

In its comments, NCUIH requested that IHS:

  • Clarify the HIT Modernization implementation process. This includes providing clarity on the vendor’s scope of work, the data migration process, and the ways in which IHS will support all facility types.
  • Provide an update to the timeline for HIT Modernization implementation. Specifically, NCUIH seeks clarity on the multi-year rollout cohort identification process.
  • Provide frequent and regular updates to the IHS HIT Modernization webpage.
  • Communicate the status of the Enterprise Collaboration Group (ECG).
IHS Responds to NCUIH’s Request Regarding Focus Groups and the Enterprise Collaboration Group

In NCUIH’s recently submitted comments to IHS regarding HIT Modernization, NCUIH requested clarification on the differences between the Focus Group and the ECG. During the Summit, IHS provided more information on the entities’ role in the HIT Modernization process.

Focus Groups are for every facility regardless of which EHR they are choosing to utilize. The ECG will be comprised of subject matter experts from IHS as well as Tribes and UIOs who provided statements of interest. It will be a chartered entity with many committees that will facilitate structured conversations to help manage the system. The ECG is for entities that will use the new system.

Other Takeaways from the HIT Modernization Program Updates

Timeline

The contract with GDIT is a 10-year indefinite delivery, indefinite quantity (IDIQ) contract. Initial go-live(s) expected to occur late Fiscal Year 2025. IHS requested Tribes and UIO maintain their current HIT system and keep data up to date to support EHR replacement if desired.

Substance Use Disorder Treatment and the New EHR

The EHR will support substance abuse/alcohol abuse treatment centers. IHS stated that it is working to understand how to share patient information with a health information exchange (HIE) partner in compliance with 42 CFR Part 2 (Confidentiality of Substance Use Disorder Patient Records). Because there are limits on how patient information can be shared, IHS is discussing how to share the information effectively under the rules and doing so in the HIE environment.

Background on HIT Modernization

During the November 8, 2023, Tribal Consultation and Urban Confer on HIT Modernization, IHS announced that it selected General Dynamics Information Technology, Inc. (GDIT) to build, configure, and maintain a new IHS enterprise EHR system utilizing Oracle Cerner technology. The new EHR will replace the Resource and Patient Management System.

For more information about HIT Modernization implementation, please click here.

NCUIH Action

NCUIH has submitted several written comments to IHS on HIT Modernization:

NCUIH also submitted written testimony  to the House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies regarding the Fiscal year (FY) 2024 funding for UIOs in which NCUIH requested increased funding for EHR Modernization. Specifically, NCUIH requested support for the IHS’ transition to a new EHR system for IHS and UIOs by supporting the President’s budget request of $913 million in FY 2024 appropriations.

NCUIH will continue to closely follow IHS’s progress and policies with HIT Modernization.

NCUIH Urges Office of Management and Budget to Fully Fund IHS and Fund Critical Indian Health Programs

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On September 29, 2023, the National Council of Urban Indian health (NCUIH) submitted comments to the Office of Management and Budget (OMB) Director, Shalanda Young, regarding the formulation of the President’s Fiscal Year (FY) 2025 Budget. In its comments, NCUIH made seven key recommendations to fully fund and support health services for urban Indian organizations (UIOs) and urban American Indian and Alaska Native (AI/AN) people.

Background

OMB serves as a clearinghouse for budget formulation by developing overarching presidential priorities, coordinating across agencies, and publishing the annual President’s Budget. For more information on OMB, please click here.

NCUIH’s Recommendations

In its comments, NCUIH recommended that the President’s FY2025 budget:

  • Fully fund the Indian Health Service (IHS) and the Urban Indian Health Line Item , as recommended by the Tribal Budget Formulation Workgroup. Full funding for IHS in the President’s FY 2025 Budget will address the following UIO priorities:
    • Infrastructure and facility needs
    • Food security
    • Traditional Healing
    • Health information technology and electronic health record modernization
  • Safeguard IHS and UIO funding by transitioning the IHS budget from discretionary funding to mandatory funding and exempting IHS funding from sequestration.
  • Propose setting the Federal Medical Assistance Percentage (FMAP) at 100% for Medicaid services provided at UIOs.
  • Request inclusion of $80 million for the Native Behavioral Health Resource Program (NBHRP).
  • Propose permanent reauthorization of the Special Diabetes Program for Indians (SDPI) at $250 million, if not reauthorized in the FY 2024 budget.
  • Request a legislative fix permitting the U.S. Public Health Service Commissioned Corps Officers to be detailed to UIOs

NCUIH will continue to monitor the FY 2025 budget formulation process and report developments across federal agencies and in Congress.

NCUIH Advocates for HHS Office of Minority Health to Address AI/AN Needs in Healthy People 2030 Leading Health Indicators Initiative

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On October 31, 2023, the National Council of Urban Indian Health (NCUIH) submitted written comments in response to the Department of Health and Human Services (HHS) Office of Minority Health’s (OMH) September 13, 2023, letter regarding the development of a Notice of Funding Opportunity (NOFO) entitled Healthy People 2030 Leading Health Indicators Initiative (LHII). In its comments, NCUIH urges OMH to consider the health needs of American Indian and Alaska Native people living in urban areas when developing the NOFO, in accordance with Congress’ directive in the Indian Health Care Improvement Act “to raise the health status of Indians and urban Indians to at least the levels set forth in the goals contained within the Healthy People 2010 initiative or successor objectives,” like Healthy People 2030. NCUIH highlighted particular leading health indicators (LHIs) which impact American Indians and Alaska Natives living in urban areas, such as maternal deaths, food insecurity, diabetes, behavioral health, substance use disorders, and drug overdose deaths, and also urged OMH to facilitate partnerships between grantees and UIOs to ensure American Indians and Alaska Natives can be served by the LHII no matter where they reside.

Background

Healthy People 2030 identifies public health priorities to help individuals, organizations, and communities across the United States improve health and well-being. Healthy People 2030, the initiative’s fifth iteration, builds on knowledge gained over the first four decades. The Healthy People 2030 LHII is intended to identify innovative adaptations of evidence based/evidence informed practices that improve health outcomes related to Healthy People 2030 LHIs among racial, ethnic, tribal and other disadvantaged communities.

LHIs are a small subset of high-priority Healthy People 2030 objectives selected to drive action toward improving health and well-being. Most LHIs address important factors that impact major causes of death and disease in the United States, and they help organizations, communities, and states across the nation focus their resources and efforts to improve the health and well-being of all people. Healthy People 2030 includes 23 LHIs that are organized by life stage: Infants, Children and Adolescents, Adults and Older Adults, and All Ages.

Projects funded under the LHII will implement public health improvement models intended to improve health for one to two Healthy People 2030 LHIs in geographic areas targeted by the recipients. OMH also expects the initiative will result in enhanced capacity of public health, community, and government entities to address and reduce health disparities in geographic areas targeted by the recipients.

Next Steps

NCUIH will continue to monitor the development of the Healthy People 2030 Leading Health Indicators Initiative and advocate on the inclusion of issues of importance to American Indians and Alaska Natives living in urban areas and the UIOs that serve them.

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

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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.