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:

• Support health and wellness through sustained partnerships with patients, families/caregivers, and their communities;
• Equitably provide first contact access to all, as well as whole person, comprehensive care over time, using interprofessional teams; and
• Coordinate and integrate care across systems, including other health care providers, public health, and community-based health promotion and social service organizations.

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.

On July 15, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to the Administration, the Department of Health and Human Services (HHS), and the US Department of Agriculture (USDA) on hunger, nutrition, and health. This comment was in response to correspondence from the Administration, HHS, and USDA dated May 27, 2022, which sought input on the development and implementation of the national strategy on hunger, nutrition, and health. NCUIH recommended that the Administration, HHS, and USDA support UIO programs to promote food security, nutrition, and exercise, include urban AI/AN populations in future research efforts and government projects, and establish consistent Urban Confers regarding nutrition, hunger, and health.

Background

AI/AN people face high levels of food insecurity and diseases related to lack of access to healthy foods, including diabetes and heart disease. Furthermore, AI/AN people who live in urban settings are especially likely to experience food insecurity. According to a 2017 report published in the Journal of Hunger & Environmental Nutrition, “[u]rban AI/ANs were more likely to experience food insecurity than rural AI/ANs.” The high rates of food insecurity in urban AI/AN communities are likely a result of “AI/ANs living on reservations… [having] access to tribally provided food and health care resource services that may not be accessible to AI/ANs living in urban areas.”[1]

NCUIH’s Actions

As a result of the high rates of food insecurity in urban AI/AN communities, and in effort to highlight the programs already in place at UIOs that address hunger, nutrition, and physical exercise, NCUIH made the following recommendations to the Administration, HHS and USDA:

• NCUIH recommended that the Administration, HHS, and USDA support UIO programs to promote food security, nutrition, and exercise.
  • Many UIOs operate programs to improve food security and nutrition, such as: food banks, meal services, community gardens, cultural cooking and nutrition classes, community workout groups, facilities, and events, and counseling and classes about diabetes prevention and care. Through their offerings, UIOs incorporate cultural knowledge and traditional practices, address other social needs, and strengthen community bonds.
  • Recognizing that UIOs face chronic underfunding which limits them from expanding their offerings, NCUIH urged the Administration, HHS, and USDA to support the maintenance and expansion of UIO programs related to hunger and nutrition.
• NCUIH requested that the Administration, HHS, and USDA support further research efforts and include urban AI/AN populations in future framing documents and government projects.
  • The inclusion of data about urban AI/AN populations in future research projects about food security and nutrition will contribute to a more comprehensive and reflective understanding of AI/AN experiences and needs.
  • Any and all efforts to include UIOs and urban populations in government research projects should be complementary to the inclusion of Tribal governments and should not supplant or otherwise alter Tribal representation. Research efforts should also respect tribal sovereignty.
• NCUIH requested that HHS and USDA establish consistent Urban Confers with UIOs regarding nutrition, hunger, and health.
  • • Urban Confers are not only integral to addressing the care needs of urban AI/AN persons and fulfilling the government’s trust responsibility, but also sound public policy.
  • Meeting regularly with UIO through Urban Confers will help HHS and the USDA ensure that AI/ANs in urban areas are able to voice their needs and priorities to both agencies.
  • Urban Confer policies or inclusion of UIOs in UIO-specific consultations do not supplant or otherwise alter Tribal Consultation and the government-to-government relationship between Tribes and federal agencies.

NCUIH will continue to closely follow the Administration’s development and implementation of the national strategy on hunger, nutrition, and health. NCUIH will also continue to advocate for the resources needed to reduce health disparities for AI/ANs, regardless of where they live.

[1] Id. at 5-6. See also Castor M.L., Smyser M.S., Taualii M.M., et al., A nationwide population-based study identifying health disparities between American Indians/Alaska Natives and the general populations living in select urban counties. 96 Am. J. Public Health. 1478-84 (2006).

On May 19, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to Health and Human Services (HHS) about Executive Order (EO) 14053— Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People. These comments responded to correspondence, dated April 4, 2022, initiating a Tribal Consultation on the policy directives outlined in EO 14053. NCUIH outlined recommendations for HHS including communication and collaboration with UIOs, engagement with UIOs as critical stakeholders in HHS’ comprehensive plan to address the MMIP Crisis and violent crime, and the establishment of an agency-wide Urban Confer policy.

History of MMIP and EO 14053

According to the National Missing and Unidentified Persons System (NamUs), as of August 1, 2021, data demonstrates that most missing and unidentified cases involving AI/AN persons occur off tribal land. Still, relevant data on violence and crime in urban AI/AN communities is significantly lacking. What data does exist demonstrates a troubling situation for urban AI/AN communities. At least seventy percent (70%) of violent victimization experienced by AI/ANs is committed by persons not of the same race – a substantially higher rate of interracial violence than experienced by white or black victims. Furthermore, a 2019 report from the Minnesota Statistical Analysis Center found that AI/AN persons made up twenty percent (20%) of all victims of sex trafficking in Minnesota in 2017. Additionally, according to the California Consortium of Urban Indian Health’s Red Women Rising initiative, sixty-five percent (65%) of urban Indian women experienced interpersonal violence, forty percent (40%) experienced multiple forms of violence, and forty-eight percent (48%) experienced sexual assault. An October 2021 report by the Government Accountability Office (GAO) on the Missing or Murdered Indigenous Women noted that “tribal organization officials told [GAO] that AI/AN individuals who leave rural villages to move to urban, nontribal areas are at a higher risk of becoming victims to violent crime, including human trafficking, which they stated is a serious concern related to the MMIP crisis.”

NCUIH has consistently advocated for violent crime perpetrated against AI/ANs and the MMIP crisis to be treated as more than solely criminal justice or public safety issues.  Crime and violence are key Social Determinants of Health (SDOH) that both affect the immediate victims and cause negative health impacts throughout AI/AN communities.  Also, according to HHS, “[a]ddressing exposure to crime and violence as a public health issue may help prevent and reduce the harms to individual and community health and well-being.” A 2019 NCUIH survey found that sixty-six percent (66%) of UIOs said the most significant risk factors leading to AI/AN patients missing in their communities are: homelessness, foster system transitioning, domestic violence, substance misuse, and human trafficking, among others.  In turn, the federal government’s trust responsibility to provide “[f]ederal health services to maintain and improve the health of the Indians” requires it to address violent crime against AI/ANs and the MMIP crisis through a holistic and inter-agency approach that supports and improves the health of AI/AN communities and individuals

EO 14053 is a landmark pledge “to strengthen public safety and criminal justice in Indian Country and beyond, to reduce violence against Native American people, and to ensure swift and effective Federal action that responds to the problem of missing or murdered indigenous people.” In EO 14053, the federal government committed to “[c]onsistent engagement, commitment, and collaboration,” with AI/AN people and communities to “drive long-term improvement to public safety for all Native Americans.” EO 14053 specifically directs the federal government to “build on existing strategies to identify solutions directed toward the particular needs of urban Native Americans,” because “approximately 70 percent of American Indian and Alaska Natives live in urban areas and part of this epidemic of violence is against Native American people in urban areas.” In addition, EO 14053 directs the federal government to “work closely with Tribal leaders and community members, Urban Indian Organizations, and other interested parties to support prevention and intervention efforts that will make a meaningful and lasting difference on the ground.”  Pursuant to Section 5 of EO 14053, HHS must “develop 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.”

NCUIH’s Requests to HHS

NCUIH issued the following comments and recommendations regarding the creation of HHS’ comprehensive plan and its implementation of EO 14053:

• NCUIH requests that HHS honor EO 14053 through consistent and clear communication, as well as collaboration, with UIOs.
  • In EO 14053, the federal government committed to “[c]onsistent engagement, commitment, and collaboration,” with AI/AN people and communities to “drive long-term improvement to public safety for all Native Americans.” This includes working with Tribal leaders and UIOs to drive meaningful prevention and intervention efforts.
  • Communication and collaboration with UIOs is not only required by EO 14053, but also sound public policy. Working with UIOs will help HHS make local connections, source, share, and analyze data, better understand the extent and causes of violent crime against AI/ANs and the MMIP epidemic, and evaluate the adequacy of research and data collection efforts at CDC and NIH.
  • NCUIH is ready, willing, and able to assist HHS communicate with UIOs and develop ongoing relationships to support this work.
• NCUIH requests that HHS engage UIOs as critical stakeholders in its comprehensive plan to support prevention efforts that reduce risk factors for the victimization of Native Americans and increase protective factors.
  • NCUIH is appreciative that IHS recently held an Urban Confer on EO 14053 with UIOs. However, NCUIH emphasizes that it is the responsibility of the Secretary, and HHS as a whole, not just IHS, to work with urban AI/AN communities to reduce violent crime and address the MMIP epidemic.
  • UIOs are already engaged in culturally focused, community-based prevention efforts such as projects funded through the Domestic Violence Prevention Program, partnerships to provide services for victims of crime, and direct services for substance abuse disorders, mental health, and behavioral health.
• NCUIH requests that HHS establish an Urban Confer policy to set the necessary policies and procedures for direct and clear communication with UIOs.
  • Urban Confer policies are a response 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. Urban Confers are integral to addressing the care needs of most AI/AN persons and fulfilling the government’s trust responsibility.
  • Developing and implementing an Urban Confer policy for HHS is sound public health policy. Given the gravity of MMIP and violence against AI/ANs, it is imperative that HHS as a whole address these problems holistically and agency-wide, not solely at the IHS level. Urban Confers would enable UIOs to share feedback, recommendations, and testimony on the unique needs of their UIOs.

NCUIH will continue to closely follow HHS’ implementation EO 14053 and advocate for the resources needed to address the MMIP crisis and violent crime against AI/ANs, regardless of where victims live.