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NCUIH Releases New Resource Highlighting Medicaid’s Crucial Role for American Indian and Alaska Native Communities

March 25, 2025/in Policy Blog, Resources/one pagers/by Meredith Raimondi

The National Council of Urban Indian Health (NCUIH) has released a comprehensive overview highlighting the crucial role Medicaid plays in providing health care to American Indian and Alaska Native (AI/AN) communities. This report emphasizes the importance of preserving Medicaid resources and exempting AI/AN beneficiaries from work requirements to fulfill the federal government’s trust responsibility.

Access the Resource

Approximately 2.7 million AI/AN people are enrolled in Medicaid, with 24% of AI/AN adults aged 18-64 and 23% of those over 64 benefiting from the program.
Almost 49% of AI/AN children are enrolled in Medicaid.
Urban Indian Organizations serve as vital health care providers.
- 59% of AI/AN people receiving care at UIOs are Medicaid beneficiaries.
- Eight out of the top ten states with the largest number of AI/AN Medicaid beneficiaries have UIOs providing essential services.

Call to Action

Preserve Medicaid Resources

Cuts to Medicaid would severely impact AI/AN health care access, necessitating state funding gaps and reducing essential services like diabetes programming and cancer screenings.

Exempt AI/AN Beneficiaries from Work Requirements:

Mandatory work requirements would disproportionately affect AI/AN beneficiaries due to unique economic challenges. Exemption is crucial to protect health care access, consistent with the Indian Health Care Improvement Act.

Percentage of American Indian and Alaska Native Population on Medicaid by State and Age Range:

Below is a table of Medicaid data for the AI/AN population, based on the American Community Survey data (2023, 1-year estimate).

State	0-18 % of AI/AN Pop on Medicaid	19 – 64 % of AI/AN Pop on Medicaid	65+ % of AI/AN Pop on Medicaid
Alabama	58.84	14.97	22.11
Alaska	55.85	36.74	33.21
Arizona	48.31	29.57	30.78
Arkansas	47.24	23.11	16.94
California	47.16	26.66	26.25
Colorado	49.51	26.06	27.58
Connecticut	44.46	37.48	19.05
Delaware	56.56	21.19	20.40
District of Columbia	31.99	4.85	24.97
Florida	39.17	13.3	20.23
Georgia	44.67	12.10	16.88
Hawaii	44.49	25.28	20.44
Idaho	29.99	23.67	15.58
Illinois	47.78	19.71	17.96
Indiana	46.63	28.09	23.48
Iowa	54.32	23.95	19.33
Kansas	39.11	14.84	19.97
Kentucky	61.44	32.86	23.60
Louisiana	50.16	28.86	22.90
Maine	62.81	36.51	29.80
Maryland	40.43	17.56	19.58
Massachusetts	51.09	37.18	41.82
Michigan	47.32	29.74	16.24
Minnesota	50.35	32.43	14.18
Mississippi	65.29	14.60	26.81
Missouri	55.78	20.56	19.62
Montana	68.30	42.37	26.44
Nebraska	52.94	25.51	28.72
Nevada	41.06	22.72	19.65
New Hampshire	51.70	24.62	35.66
New Jersey	57.23	19.83	10.63
New Mexico	71.65	43.62	35.09
New York	49.32	30.94	33.53
North Carolina	57.28	21.29	23.66
North Dakota	63.34	37.79	17.69
Ohio	46.73	27.70	27.55
Oklahoma	51.42	21.62	17.18
Oregon	59.71	33.21	25.83
Pennsylvania	50.85	32.67	30.96
Rhode Island	46.77	25.63	16.85
South Carolina	40.89	18.65	18.50
South Dakota	60.30	26.67	30.01
Tennessee	51.66	22.20	22.64
Texas	35.10	9.37	16.87
Utah	29.98	20.95	18.67
Vermont	73.74	33.13	24.74
Virginia	37.40	21.24	13.27
Washington	49.27	27.90	18.98
West Virginia	45.81	32.73	10.62
Wisconsin	53.46	27.34	15.72
Wyoming	52.42	19.57	15.07
All States + DC	48.68	24.22	22.97

NCUIH Calls for Protected Funding of Indian Health Service & Funding for Key Indian Health Programs in Written Testimony to the Senate Committee on Indian Affairs

March 17, 2025/in Policy Blog/by Carrie Kowalyk

On February 26, 2025, the National Council of Urban Indian Health (NCUIH) submitted written testimony to the Senate Committee on Indian Affairs (SCIA) regarding the 119^th Congress Priorities for Indian Country. NCUIH requested in its testimony for protected funding for the Indian Health Service (IHS) and Urban Indian Health as well as increased resources for key health programs.

NCUIH Testimony for SCIA 119^th Congress Priorities for Indian Country

In the testimony, NCUIH requested the following:

Protect Funding for the Indian Health Service and fund Urban Indian Health at $100 million for Fiscal Year (FY) 2026.
Maintain Advance Appropriations for the Indian Health Service, until mandatory funding is achieved, and protect IHS from sequestration.
Ensure Federal Policies Uphold Trust Obligations to American Indian and Alaska Native Communities.
Reauthorize the Special Diabetes Program for Indians at $250 million.
Appropriate $80 million for Behavioral Health and Substance Use Disorder Resources for Native Americans.
Protect Medicaid and Authorize Permanent 100% Federal Medical Assistance Percentage for services provided at urban Indian organizations (UIOs).
Allow U.S. Public Health Service Commissioned Officers detailed directly to UIOs.
Fund the Initiative for Improving Native American Cancer Outcomes at $10 million for FY 2026.

Next Steps:

This testimony will be considered by the Senate Committee on Indian Affairs and used in the development of the Committee’s priorities. NCUIH will continue to advocate for these requests in the 119^th Congress and work closely with SCIA members and their staff.

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), a national representative advocating for the 41 Urban Indian Organizations (UIOs) contracting with the Indian Health Service (IHS) under the Indian Health Care Improvement Act (IHCIA) and the American Indians and Alaska Native patients they serve. On behalf of NCUIH and these 41 UIOs, I would like to thank Chairman Murkowski, Vice Chairman Schatz, and Members of the Committee for your leadership to improve health outcomes for urban Indians and for the opportunity to provide testimony. We respectfully request the following:

Protect Funding for the Indian Health Service and fund Urban Indian Health at $100 million for FY26
Maintain Advance Appropriations for the Indian Health Service, until mandatory funding is achieved, and protect IHS from sequestration.
Ensure Federal Policies Uphold Trust Obligations to American Indian and Alaska Native Communities.
Reauthorize the Special Diabetes Program for Indians at $250 million.
Appropriate $80 million for Behavioral Health and Substance Use Disorder Resources for Native Americans.
Protect Medicaid and Authorize Permanent 100% Federal Medical Assistance Percentage for services provided at UIOs.
Allow U.S. Public Health Service Commissioned Officers detailed directly to UIOs
Fund the Initiative for Improving Native American Cancer Outcomes at $10 million for FY26.

A Brief History on Urban Indian Organizations:

As a preliminary issue, “urban Indian” refers to any American Indian or Alaska Native (AI/AN) person who is living in an urban area, either permanently or temporarily. UIOs were created by urban AI/AN people with the support of Tribes, starting in the 1950s in response to severe problems with health, education, employment, and housing.¹ Congress formally incorporated UIOs into the Indian Health System in 1976 with the passage of the Indian Health Care Improvement Act (IHCIA). Today, over 70% of AI/AN people live in urban areas. UIOs are an integral part of the Indian health system, comprised of the Indian Health Service, Tribes, and UIOs (collectively I/T/U), and provide essential healthcare services, including primary care, behavioral health, and social and community services, to patients from over 500 Tribes in 38 urban areas across the United States. UIOs also work closely with Tribal and law enforcement partners to address the Missing and Murdered Indigenous People’s (MMIP) crisis.

Request: Protect Funding for the Indian Health Service and fund Urban Indian Health at $100 million for FY26

The federal government owes a trust obligation to provide healthcare services to AI/AN people no matter where they live. In fact it is the national 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.”² This requires that funding for Indian health 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.

Without an increase to the urban Indian health line item, UIOs will continue to be forced to operate on limited and inflexible budgets, that limit their ability to fully address the needs of their patients. A lack of federal funding is deeply impactful for UIOs who are on the front lines in working to provide for the health and well-being of American Indians and Alaska Natives living outside of Tribal jurisdictions. While UIOs historically only receive 1% of the IHS budget, they 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.

We thus request Congress honor its trust obligation by appropriating the maximum amount possible for IHS and appropriating at least $100 million for Urban Indian Health, which is in line with the House proposed amount for FY25. As the Tribal Budget Formulation Workgroup (TBFWG) report states, “Only a significant increase to the Urban Indian Health line item will allow UIOs to increase and expand services to address the needs of their American Indian and Alaska Native patients, support the hiring and retention of culturally competent staff, and open new facilities to address the growing demand for UIO services.” Increased investments in Urban Indian Health will continue to result in the expansion of health care services, increased jobs, and improvement of the overall health in urban American Indian and Alaska Native communities.

Request: Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and Protect Against Sequestration

The inclusion of advance appropriations in the FY24 Omnibus and maintaining advance appropriations for FY25, 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 Congress maintain advance appropriations for the IHS in the final spending bill for FY26 and beyond. It is also imperative to protect IHS from sequestration.

Advance appropriations improve accountability and increase staff recruitment and retention at IHS. When IHS distributes their funding on time, our UIOs can consistently pay their doctors and providers.

It is also imperative to shield and protect the IHS from cuts or funding freezes that force Indian health-providers to make difficult decisions about the scope of healthcare services they can offer to American Indian and Alaska Native patients. For example, the sequestration of $220 million in IHS’ budget authority for FY 2013 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for American Indian and Alaska Native patients.³ A recent survey from the National Council of Urban Indian Health, over half of surveyed UIOs report they would be unable to sustain operations beyond six months without federal funding.⁴ UIOs provide essential healthcare services to their patients, including primary care, urgent care, and behavioral health services, and are on the front lines in working to provide for the health and well-being of American Indian and Alaska Native people living in urban areas, many of whom lack access to the health care services that it is the federal government’s trust responsibility to provide. Any reduction or pause in funding would reduce UIOs’ ability to provide these essential services to their patients and communities, delaying care and reducing UIO capacity to take on additional patients.

Therefore, we request that you exempt IHS from sequestration in an amendment to Sec. 255 of the Balanced Budget and Emergency Deficit Control Act. We also request that IHS funding be protected from impoundment and other budget-cutting measures as is required by the trust responsibility.

Finally, while advance appropriations are a step in the right direction to avoid disruptions during government shutdowns and 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.

Request: Ensure Federal Policies Uphold Trust Obligations to American Indian and Alaska Native Communities

We acknowledge and appreciate the recent steps taken by the Departments of Health and Human Services (HHS), Interior, and the Office of Personnel Management (OPM) to clarify that actions should not interfere with the United States’ commitment to fulfilling its trust obligations to American Indian and Alaska Native communities. However, we remain concerned that potential future actions may fail to adequately consider this unique relationship.

Therefore, we respectfully request that the Congress take necessary steps to ensure these directives are implemented in a manner consistent with the unique political status of American Indian and Alaska Native people under U.S. law, as well as the federal government’s legal obligation to uphold its trust responsibilities. Specifically, we request that Congress pass legislative text that explicitly exempts IHS from similar policies being applied across the federal government to safeguard the delivery of critical services to American Indian and Alaska Native people.

Request: Appropriate $80 Million for Behavioral Health and Substance Use Disorder Resources for Native Americans

In response to these chronic health disparities, Congress authorized $80 million to be appropriated for the Behavioral Health and Substance Use Disorder Resources for Native Americans Program for fiscal years 2023 to 2027. Despite authorizing $80 million for the Program, Congress has failed to appropriate funds for this program.

We request that the authorized $80 million be appropriated to the Behavioral Health and Substance Use Disorder Resources for Native Americans Program for FY25 and each of the remaining authorized years. Until Congress appropriates funding for this program, critical healthcare programs and services cannot operate to their full capability, putting American Indian and Alaska Native lives at-risk. This is an essential step to ensure our communities have access to the care they need.

Request: Reauthorize the Special Diabetes Program for Indians at $250 Million

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 State Renal Disease.⁵ 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.⁶

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, group exercise activities, green spaces, and youth and elder-focused activities.

The incredibly successful Special Diabetes Program for Indians (SDPI) has repeatedly been reauthorized in Continuing Resolutions and is now set to expire on March 14, 2025. We request that the committee work with authorizers to permanently reauthorize SDPI at a minimum of $250 million with automatic annual funding increases tied to the rate of medical inflation, to continue the success of preventing diabetes-related illnesses for all of Indian Country.

Request: Protect Medicaid and Authorize Permanent 100% Federal Medical Assistance Percentage for services provided at UIOs.

The Medicaid program plays a vital role in providing essential healthcare services to American Indian and Alaska Native communities, serving as a critical lifeline for those who rely on it. In fact, Medicaid is the largest source of funding for Urban Indian Organizations (UIOs) outside of the Indian Health Service (IHS). In 2021 alone, UIOs received over $137 million in Medicaid reimbursements for services delivered to Medicaid beneficiaries, underscoring the program’s significance in sustaining healthcare access for American Indian and Alaska Native populations.

NCUIH Board Vice President Angel Galvez recently emphasized the profound impact of Medicaid, stating, “The services we provide are services [our patients] can’t afford otherwise… What you’re doing is saving someone’s life.” ⁷ This sentiment highlights the life-saving role Medicaid plays in ensuring that vulnerable populations receive the care they need.

Protecting and strengthening the Medicaid program is essential to maintaining support for UIOs and the 59% of American Indian and Alaska Native patients they serve who depend on Medicaid for their healthcare. Safeguarding this program ensures that UIOs can continue to deliver critical services, ultimately improving health outcomes and quality of life for American Indian and Alaska Native communities.

A top Medicaid legislative priority for UIOs is providing 100% federal medical assistance percentage (FMAP) for services provided at UIOs. The FMAP refers to the percentage of Medicaid costs covered by the federal government and reimbursed to states. States have received 100% FMAP for services provided to IHS/Medicaid beneficiaries at Indian Health Service and Tribal facilities for decades, and UIOs have advocated for parity through legislation since 1999. Extending 100% FMAP to UIOs will require the federal government, not states, to bear the cost of Medicaid services provided to AI/AN people no matter which facet of the Indian health system they utilize, as is required by the trust responsibility.

Ultimately, permanent 100% FMAP will bring fairness to the I/T/U system and increase available financial resources to UIOs and support them in addressing critical health needs of urban American Indian and Alaska Native patients.

Request: Allow U.S. Public Health Service Commissioned Officers detailed directly to UIOs

Due to chronic underfunding, many UIOs continue to grapple with hiring and retaining skilled health service providers. Detailing Public Health Service Commissioned Officers (PHSCOs) to UIOs would help address workforce shortages and increase collaboration across the federal healthcare system.

Section 215 of the Public Health Service Act (PHSA) authorizes the Secretary of Health and Human Services (HHS) to detail officers to federal agencies and state health or mental health authorities. While UIOs have requested that officers be detailed to them to fill many roles related to the functions of the Public Health Service, subsection (c) of Section 215 (42 U.S.C. 215(c)) prevents UIOs from receiving detailed officers because they do not fall within the requirement that non-profits eligible for detailing be educational or research non-profits, or non-profits “engaged in health activities for special studies and dissemination of information”.

With this being said, subsection (b) has been interpreted to allow HHS to detail an officer to a state health authority, which may then designate the UIO as the officer’s duty station. The officer is authorized to perform work at a UIO that is related to the functions of the Service, including health care services and support functions. This process is completely dependent on the availability of a State or local health authority that is capable and willing to enter into such an arrangement. The process can be burdensome and time-consuming for all involved, leaving many State health authorities reluctant to participate.

Amending the law would provide IHS with the discretionary authority to detail officers directly to a UIO to perform work related to the functions of the Service. Therefore, we request full support for this proposal to allow UIOs to continue engaging in critical health care services for urban American Indian and Alaska Native communities.

Request: Fund the Initiative for Improving Native American Cancer Outcomes at $10 million for FY26

Rising cancer rates has become an increasingly alarming issue in Indian Country. In fact, cancer is the leading cause of death among American Indian and Alaska Native women and the second leading cause of death among American Indian and Alaska Native men.⁸ The rising cancer rates has been described by some UIO leaders as the “new diabetes” in Indian Country, with one clinic alone diagnosing 15-20 cases a month.

This is why specific funding for cancer in Indian Country is critical. The FY24 LHHS spending bill appropriated $6 million in few funding to address American Indian and Alaska Native cancer outcomes, by creating the Initiative for Improving Native American Cancer Outcomes, the Initiative will support efforts including research, education, outreach, and clinical access to improve the screening, diagnosis, and treatment of cancers among American Indian and Alaska Native people. The purpose of this Initiative is to ultimately improve screening, diagnosis and treatment of cancer for American Indian and Alaska Native patients.

This initiative will be critical to addressing cancer-related health disparities in Indian Country. We request that the Committee continue to support the appropriation of funds for the Initiative in FY26 and increase funding to $10 million.

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 the I/T/U system with all the resources necessary to protect the lives of the entirety of the American Indian and Alaska Native population, regardless of where they live.

[1] Relocation, National Council for Urban Indian Health, 2018. 2018_0519_Relocation.pdf(Shared)- Adobe cloud storage

[2] 25 U.S.C. § 1601(1)

[3] Contract Support Costs and Sequestration: Fiscal Crisis in Indian Country: Hearings before the Senate Committee on Indian Affairs.(2013) (Testimony of The Honorable Yvette Roubideaux)

[4] Impact of Federal Funding Pauses on Urban Indian Organizations. National Council of Urban Indian Health. 2025. https://ncuih.org/wp-content/uploads/Fed-Funding-Pause_NCUIH-D562_F3.pdf

[5] 2020 SDPI Report to Congress, Indian Health Service, 2020, 2020 SDPI Report to Congress (ihs.gov)

[6] The Special Diabetes Program for Indians: Estimates of Medicare Savings, DHHS ASPE Issue Brief (May 10, 2019). Available at: SDPI_Paper_Final.pdf (hhs.gov)

[7] Catie Edmonson, Medicaid Cuts Pose Budget Conundrum for Valadao and Republicans Nationwide, N.Y. Times, Feb. 21, 2025. https://www.nytimes.com/2025/02/21/us/politics/medicaid-republicans-budget.html?unlocked_article_code=1.zk4.bCdx.cjxuKW_H25do&smid=nytcore-ios-share&referringSource=articleShare

[8] Elizabeth Arias, Kenneth Kochanek, & Farida B Ahmad, Provisional Life Expectancy Estimates for 2021, Vital Statistics Rapid Release, Report 23, August 2022. Vital Statistics Rapid Release, Number 023 (August 2022) (cdc.gov)

35 Organizations Sign NCUIH Letter to Congressional Leadership Requesting 100% FMAP for Urban Indian Organizations

December 17, 2024/in Policy Blog/by Emily Larsen

On December 6, 2024, the National Council of Urban Indian Health (NCUIH) and 35 health care advocates sent a letter to Congressional Leadership requesting the inclusion of 100% Federal Medical Assistance Percentage for Urban Indian Organizations (100% FMAP for UIOs) to be included in the end-of-year public health extenders package. Passing this priority will ensure parity for Urban Indian Organizations and is essential to upholding the federal trust responsibility and ensuring access to culturally competent care for American Indian and Alaska Native people.

NCUIH is grateful for the support of the following organizations:

National Council of Urban Indian Health
National Indian Health Board
National Congress of American Indians
United South and Eastern Tribes, Inc.
Montana Consortium for Urban Indian Health
California Consortium for Urban Indian Health
American Indian Council on Alcoholism, Inc
Native American Health Center
Indian Family Health Clinic
Hunter Health
Urban Indian Center of Salt Lake
American Indian Health and Family Services
The NATIVE Project
Urban Indian Center of Salt Lake
Native Health of Phoenix
Native Directions, Inc.
Indian Health Care Resource Center of Tulsa
Native American Rehabilitation Association of the Northwest, Inc.
Texas Native Health
Rhode Island Indian Council (New York Indian Council)
Oklahoma City Indian Clinic
Tucson Indian Center
Kansas City Indian Center
Nevada Urban Indians, Inc.
Fresno American Indian Health Project
Native American Connections
Native American LifeLines, Inc.
Kansas City Indian Center
UnidosUS
National Association of Rural Health Clinics
National Association of Pediatric Nurse Practitioners
National Health Care for the Homeless Council
American Nurses Association
National Council for Mental Wellbeing
Catholic Health Association of the United States
National Association of Community Health Centers

Full Letter Text

Dear Majority Leader Schumer, Minority Leader McConnell, Speaker Johnson, and Minority Leader Jefferies:

On behalf of the National Council of Urban Indian Health (NCUIH) and the undersigned organizations, we request that you support the inclusion of 100% Federal Medical Assistance Percentage for services provided to Medicaid beneficiaries at Urban Indian Organizations (100% FMAP for UIOs) in the proposed end-of-year health extender legislation. This issue has broad, bipartisan support and is urgently needed to improve the health care for American Indians and Alaska Native people residing in urban areas. There is a bipartisan bill in the House led by Rep. Ruiz and Rep. Bacon and cosponsored by Rep. Davids and Rep. Cole. The bill is a priority for the Native American Caucus, and there is no known opposition to this bill.

The federal government has a trust responsibility to provide “[f]ederal health services to maintain and improve the health of the Indians.” The federal government owes that duty to all American Indians and Alaska Native people, no matter where they live, and Congress has declared it 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.” When Congress first authorized 100% FMAP for the Indian healthcare system in 1976, it did so because it recognized that “Medicaid payments are . . . a much-needed supplement to a health care program which has for too long been insufficient to provide quality health care to” American Indians and Alaska Native people and because “the Federal government has treaty obligations to provide services to Indians, it has not been a State responsibility.” Unfortunately, UIOs were not included in this initial authorization and therefore, services provided at UIOs are not eligible for 100% FMAP. The proposed amendment will ensure that the federal government assumes full financial responsibility for 125 U.S.C. § 1601(1). 225 U.S.C. § 1602(1). 3H.R. 94-1026 (1976). Medicaid services provided at IHS, Tribal, and UIO providers, as is required by the federal trust responsibility.

Native organizations have been advocating for 100% FMAP for UIOs for more than two decades, introducing the first bill on this issue in 1999. Now is the time to secure 100% FMAP for UIOs and ensure comprehensive, culturally competent care is available to all American Indian and Alaska Native people, regardless of where they live. We remain grateful for your leadership and commitment to the Medicaid program and the population it serves. If you have questions or seek any additional information on this issue, please contact Meredith Raimondi, Vice President of Public Policy and Communications, at mraimondi@ncuih.org.

Background on 100% FMAP for UIOs:

In November 2023, Representative Ruiz and Representative Bacon introduced H.R. 6533, the Urban Indian Health Parity Act, which would provide 100% FMAP for UIOs. The bill was cosponsored by Representative Cole (R-OK) and Representative Davids (D-KS).

NCUIH Advocacy

Since 1999, Native organizations have been advocating for 100% FMAP for UIOs and has remained a top priority for UIOs. NCUIH worked to include a temporary authorization of 100% FMAP for UIOs to increase funding support for their UIOs in the 2021 American Rescue Plan Act’s (ARPA). NCUIH also released a report highlighting the importance of 100% FMAP, which includes case studies of two states, Washington and Montana, that successfully utilized the ARPA provision. The report also provides an extensive history of 100% FMAP in the Indian health care system.

IHS Releases New Quarterly Report Highlighting Progress on Urban Indian Health Priorities: 100% FMAP, Collaboration with Other Federal Agencies

July 8, 2024/in Policy Blog/by Alex Sampson

On May 21, 2024, the Indian Health Service’s (IHS) Office of Urban Indian Health Programs (OUIHP) released their 4th Quarterly Report outlining progress on the agency’s 2023 Work Plan to implement the goals from the 2023-2027 OUIHP Strategic Plan for urban Indian organizations (UIOs).

The quarterly report highlights the OUIHP accomplishments as of December 31, 2023, on the five pillars outlined in the Strategic Plan: provide effective, timely and transparent communication; improve OUIHP’s operational oversight and management; leverage partnerships to expand UIO resources; improve data quality; and expand the infrastructure and capacity of UIOs. The accomplishments include providing technical assistance to other federal agencies to engage UIO leaders in an IHS UIO Listening Session, collaborations with the Veterans Health Administration and the White House Council on Native American Affairs Health Committee, and providing technical assistance on 100% Federal Medical Assistance Percentage (100% FMAP) and the assignment of United States Public Health Service Commissioned Officers to UIOs.

View the full list of accomplishments in the quarterly report here.

Background

In June 2023, IHS released their 2023-2027 OUIHP Strategic Plan which describes how OUIHP will achieve its mission and vision through five strategic pillars to support urban Indian organizations:

Provide effective, timely, and transparent communication;
Improve OUIHP’s operational oversight and management;
Leverage partnerships to expand UIO resources;
Improve data quality; and
Expand the infrastructure and capacity of UIOs.

IHS also released its corresponding work plan that outlines critical actions and activities to implement these strategic goals, and includes communications on progress, barriers encountered, and accomplishments. The OUIHP tracks progress for each activity and evaluates progress over time. According to the work plan, progress will be shared with UIOs, partners, and stakeholders quarterly.

NCUIH Blog: IHS Releases Office of Urban Indian Health Strategic Plan, Incorporates NCUIH Suggestions to Improve Data Accuracy and Facilitate Communication Efforts with Federal Partners and UIOs (July 26, 2023).
NCUIH Blog: IHS Progress Report Highlights Accomplishments Regarding FMAP and Native Veteran Homelessness, Among Other Urban Indian Health Priorities (March 8, 2024).

NCUIH’s Role

NCUIH played a critical role in the drafting of the 2023-2027 OUIHP Strategic Plan and Implementation Plan. NCUIH has submitted a total of four comments to OUIHP with recommendations to strengthen the plans, specifically requesting that the agency develop quarterly reports to provide information on OUIHP’s progress towards achieving the goals and objectives described in the Strategic Plan, and making those reports publicly available.

NCUIH Blog: NCUIH Submits Comments to IHS Regarding the Office of Urban Indian Health Programs Strategic Plan and Implementation Plan (January 20, 2023).

American Medical Association Adopts NCUIH-Supported Resolution on IHS Improvements, Includes Key Medicaid Parity Provision for UIOs

November 30, 2023/in Policy Blog/by Chelsea Gutierrez

On November 3, 2023, the National Council of Urban Indian Health (NCUIH) submitted written testimony to the 2023 Interim Meeting of the American Medical Association (AMA) House of Delegates (HOD), held on November 10-14, 2023, regarding the proposed resolution “Federal Medical Assistance Percentage Extension for Urban Indian Organizations” as part of a larger resolution, Resolution 812 (I-23), “Indian Health Service Improvements.” This testimony was read in support of the resolution and resulted in the adoption of the entire resolution by the AMA, with amendments, including the language in support of 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs).

In its testimony, NCUIH emphasized that “Congress must enact legislation to provide permanent 100% FMAP for Medicaid services provided at UIOs to ensure parity across the IHS healthcare system and further fulfill the federal trust obligation to provide healthcare to Native people.” NCUIH also shared examples of how the temporary extension of 100% FMAP in 2021 benefited UIOs in Washington and Montana and emphasized permanent 100% FMAP as a vehicle to provide UIOs with a much-needed source of supplemental income to support the continued provision of comprehensive and culturally competent health care.

The Reference Committee noted that 100% FMAP would “lead to enhanced and directed advocacy of priorities as identified by American Indian/Alaska Native-serving health organizations and other important stakeholders.” After discussion, the Committee recommended the entire resolution be adopted as amended. The House of Delegates adopted the resolution and its new language, which reads as follows:

“RESOLVED, that our American Medical Association supports an increase to the Federal Medical Assistance Percentage (FMAP) to 100% for medical services which are received at or through an Urban Indian Organization that has a grant or contract with the Indian Health Service (IHS) and encourage state and federal governments to reinvest Medicaid savings from 100% FMAP into tribally-driven health improvement programs.”

Adoption of this resolution means that 100% FMAP will now be a priority of the AMA moving forward. Having the support of the largest physician advocacy organization is an additional advocacy tool NCUIH and other organizations can utilize, and it shows Congress the necessity of passing 100% FMAP legislation.

Background on 100% FMAP for UIOs

Federal Medical Assistance Percentage (FMAP) refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. Congress first authorized 100% FMAP for the Indian healthcare system in 1976 because it recognized that “Medicaid payments are . . . a much-needed supplement to a health care program which has for too long been insufficient to provide quality health care to” Native people and because “the Federal government has treaty obligations to provide services to Indians, it has not been a State responsibility.” Unfortunately, UIOs were not included in this initial authorization and therefore, services provided at UIOs were not eligible for 100% FMAP.

In 2021, Congress amended the Social Security Act (SSA) to provide for eight fiscal quarters of 100% FMAP for UIOs. This amendment temporarily eased the financial burden on states by allowing states to be reimbursed by the federal government for the full cost of providing care to Medicaid beneficiaries at UIOs. As a result, some states were able to utilize the provision to increase funding to UIOs. Unfortunately, this provision expired on March 31, 2023, meaning that states once again are responsible for covering a portion of the cost of Medicaid services provided at UIOs.

About the AMA House of Delegates (HOD)

The House of Delegates (HOD) is the legislative and policy-making body of the American Medical Association. State medical associations and national medical specialty societies are represented in the HOD along with AMA sections, national societies such as American Medical Writers Association (AMWA), American Osteopathic Association (AOA) and the National Medical Association (NMA), professional interest medical associations, and the federal services, including the Public Health Service. At HOD Meetings, resolutions are referred to the Reference Committee for open discussion and to allow recommendations for HOD action. If adopted by the HOD, the resolution can become the foundation of a new AMA program, establish or modify policy on an issue, or become a new directive for action. Policies of the AMA House of Delegates are policy statements on health topics and are one of the cornerstones of the AMA as they define what the Association stands for as an organization. They provide the information and guidance that physicians and others seek from the AMA about health care issues.

The AMA Interim Meeting of the House of Delegates takes place in November every year. Materials presented at the 2023 Interim Meeting are generated by AMA delegates/delegations, the AMA Board of Trustees, AMA Councils and AMA Sections. The delegates will next meet in June for the 2024 AMA Annual Meeting in Chicago.

CMS Releases Medicaid Unwinding FAQs Document

July 25, 2023/0 Comments/in Policy Blog/by Alex Sampson

On May 12, 2023, the Centers for Medicare and Medicaid Services (CMS) released a frequently asked questions (FAQs) document regarding changes made to the Medicaid continuous enrollment condition under the Families First Coronavirus Response Act (FFCRA) by the Consolidated Appropriations Act 2023 (CAA, 2023). Key topics addressed in the FAQs include questions relating to the CAA, 2023 returned mail condition for states claiming the increased FMAP available under the FFCRA, reestablishment of premiums in Medicaid and CHIP, renewal requirements for individuals who receive Social Security Income, and Medicaid and CHIP agency capacity to share beneficiary data with enrolled providers to support renewals.

These FAQs clarify other CMS guidance most recently released in the January 5, 2023 CMCS Informational Bulletin and January 26, 2023 State Health Official letter #23-002.

Background

On Thursday, December 29, 2022, Congress enacted the Consolidated Appropriations Act, 2023 (CAA, 2023). CAA, 2023 includes various Medicaid and Children’s Health Insurance Program (CHIP) provisions, including significant changes to the continuous enrollment condition at section 6008(b)(3) of the Families First Coronavirus Response Act (FFCRA) that took effect April 1, 2023. Under this section of the FFCRA, states claiming a temporary 6.2 percentage point increase in the Federal Medical Assistance Percentage (FMAP) have been unable to terminate enrollment for most individuals enrolled in Medicaid as of March 18, 2020, as a condition of receiving the temporary FMAP increase. Currently, states must, over time, return to normal eligibility and enrollment operations. States will have up to 12 months to initiate, and 14 months to complete, a renewal for all individuals enrolled in Medicaid, CHIP, and the Basic Health Program (BHP) following the end of the continuous enrollment condition— this process is commonly referred to as “unwinding”.

Under the Consolidated Appropriations Act 2023 (CAA, 2023) expiration of the continuous enrollment condition and receipt of the temporary FMAP increase will no longer be linked to the end of the Covid-19 public health emergency. The continuous enrollment condition ended on March 31, 2023. Beginning April 1, 2023, the FFCRA’s temporary FMAP increase will be gradually reduced and phased down and will end on December 31, 2023. Additionally, as of April 1, 2023, states have been able to terminate Medicaid enrollment for individuals no longer eligible.

Medicaid Unwinding and UIOs

During this unwinding, 12% of all AI/AN children and 6% of all AI/AN adults nationwide are expected to lose CHIP or Medicaid coverage. Urban Indian Organization (UIO) Medicaid beneficiaries may lose their Medicaid coverage as result of the unwinding. The National Council of Urban Indian Health (NCUIH) is helping to mitigate this. It released a Medicaid unwinding toolkit for UIOs in December 2022. On April 24, 2023, NCUIH, in collaboration with the Asian & Pacific Islander American Health Forum, the Coalition on Human Needs, The Leadership Conference on Civil and Human Rights, the National Association for the Advancement of Colored People, National Urban League, Protect Our Care, UnidosUS and 220 other organizations, sent a letter to the Department of Health and Human Services (HHS) Secretary Xavier Becerra. In it, the coalition of organizations called on the Administration to use the full extent of its authorities to safeguard Medicaid coverage and outlined specific steps the Administration can take to avoid wrongful terminations.

See NCUIH’s COVID-19 Public Health Emergency Medicaid Unwinding Toolkit for more information on Medicaid unwinding, its impact on UIO Medicaid beneficiaries and additional resources: https://ncuih.org/2022/12/05/resource-covid-19-public-health-emergency-medicaid-unwinding-toolkit-released/.

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

April 5, 2023/0 Comments/in Policy Blog/by Jeremy Grabiner

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.

NCUIH Releases “2022 Annual Policy Assessment”

March 6, 2023/0 Comments/in Policy Blog/by Sam Sears

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

The 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

After 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:

NCUIH Advocacy Results in New Guidance from HHS on 100% FMAP for Urban Indian Organizations

February 15, 2023/0 Comments/in Policy Blog/by Rori Collins

On December 27, 2022, the Center for Medicaid Services (CMS) released a State Medicaid Director Letter (SMDL) #22-006: “Additional Guidance on Section 9815 of the American Rescue Plan Act of 2021.” The SMDL provides additional guidance to states on Section 9815 of the America Rescue Plan Act of 2021 (ARPA), which amended Section 1905(b) of the Social Security Act to set the federal medical assistance percentage (FMAP) for Medicaid services provided at Urban Indian Organizations (UIOs) at 100% for eight fiscal quarters, starting on April 1, 2021. The National Council of Urban Indian Health (NCUIH) and UIO advocacy efforts helped secure the inclusion of Section 9815 in the ARPA, and NCUIH has called on the Administration to provide guidance to states to ensure this provision is implemented in the way intended by Congress. ARPA Section 9815’s 100% FMAP UIO extension ends on March 31, 2023, and UIOs have generally have not seen the benefit of the provision that was intended to increase resources for Indian healthcare providers.

Overview of Additional Guidance provided in SMD #22-006:

The guidance reiterates prior guidance issued by CMS, and invites individual State Medicaid Directors to reach out to CMS for additional information or guidance on implementing ARPA Section 9815. Below is a brief overview of the additional guidance relating to UIOs provided by SMD #22-006. The SMD:

Reiterates that CMS interprets ARPA’s 100% FMAP UIO extension to apply to Medicaid services received by all Medicaid beneficiaries through UIOs with a grant or contract with the Indian Health Service (IHS) under title V of the Indian Health Care Improvement Act
Provides that 100% FMAP is available for state expenditures on Medicaid services provided by a non-UIO provider but furnished under a qualifying care coordination agreement with UIOs for the ARPA period.
Reiterates that states have the discretion to set and adjust Medicaid provider payment rates if the state payment rates are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the state plan at least to the extent that such care and services are available to the general population in the geographic area. (42 U.S.C. 1396a(a)(30)(A))
Reiterates that states must comply with the provisions of section 1902(bb) of the Act when setting Medicaid payment rates for Federally Qualified Health Center (FQHC) services that are furnished by FQHCs.
Provides that CMS is available to provide technical assistance to states that believe adjusting their reimbursement rates to UIOs, Centers, or Systems is appropriate.
Encourages states needing technical assistance to contact their CMS state lead, and UIOs, Centers, and Systems needing technical assistance to contact their CMS Native American Contact.

ARPA Section 9815’s UIO 100% FMAP extension expires on March 31, which is less than two months away. NCUIH is continuing policy work to ensure that UIOs can benefit from this Section as was intended by Congress. NCUIH also is continuing efforts to secure permanent 100% FMAP for UIOs.

Senator Warren and Representative Kilmer Introduce NCUIH-Endorsed Bill to Honor Promises to Native People with Key Provisions for Urban Indian Health

December 7, 2022/0 Comments/in Policy Blog/by Carrie Kowalyk

On December 5, 2022, Senator Elizabeth Warren (D-MA) and Representative Derek Kilmer (D-WA-6) introduced the Honoring Promises to Native Nations Act, which will address the underfunding and barriers to sovereignty in Indian Country acknowledged in the 2018 U.S. Commission on Civil Rights report, Broken Promises: Continuing Federal Funding Shortfall for Native Americans. The legislation reaffirms the federal government’s trust obligation to all American Indians and Alaska Natives (AI/ANs) to strengthen federal programs and support Native Communities. This legislation guarantees mandatory, full, and inflation-adjusted funding that can support healthcare, education, housing, and economic development and is cosponsored by national Indian organizations such as the National Council of Urban Indian Health (NCUIH), the National Congress of American Indians, and the National Indian Health Board.

NCUIH worked closely with Senator Warren’s office on this landmark policy platform, which includes permanent 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs) and modifying an existing policy to allow the Secretary of the Department of Health and Human Services (HHS) to better communicate on issues affecting urban Indian health. Additionally, the legislation includes mandatory-adjusted funding for the Indian Health Service (IHS), advance appropriations for IHS, increased long-term funding for Special Diabetes Programs for Indians (SDPI) to $300 million through fiscal year (FY) 2032 (currently expiring in FY 2023 and only funded at $150 million annually), and exempting Indian programs from sequestration.

“For generations, the U.S. government has clearly failed to fulfill its commitments to Tribal Nations. This bill is sweeping in ambition to make good on those commitments and empower Native communities, and it provides a much-needed legislative blueprint to deliver significant, long-term funding for the advancement of Native Americans. I won’t stop fighting to ensure the U.S. government honors its promises,” said Senator Warren.

“Congress and the federal government have a moral and a legal obligation to fulfill the promises made to Indian Country. That’s why I’m proud to introduce this legislation with Senator Warren to help reverse the decades-long pattern of systemic funding shortfalls to Native communities and to strengthen federal programs that support Indian Country. Congress should move swiftly to get this legislation enacted. It is long overdue.” said Representative Kilmer. “

“The health of our people has suffered due to the failure of the government to uphold the trust responsibility of providing health care to all American Indians and Alaska Natives. It is time that we address the needs of Indian Country and enact the recommendations included in the 2018 Broken Promises report, including improving health care for all Native people. The National Council of Urban Indian Health is grateful for the inclusion of Urban Indians in this legislation, especially regarding permanent 100% FMAP for urban Indian organizations and Urban Confer within HHS, both of which have been top priorities for NCUIH. We fully support this bill and believe that this Act is fundamental in honoring the federal government’s trust responsibility to American Indian and Alaska Natives,” – Francys Crevier (Algonquin), CEO, NCUIH.

“On behalf of the nearly 1/4 UIOs in California, CCUIH endorses the Honoring Promises to Native Nations Act because it will increase health access for American Indians no matter where they live.  California is home to the largest population of American Indians, with more than 90% living in an urban area.  Full, mandatory, inflation-adjusted funding for the Indian Health Service; funding for the Special Diabetes Programs for Native Americans; permanent FMAP for Urban Indian Health Programs; and Medicaid coverage of any services provided by Indian health care providers will offer critical funding necessary to address the continued disparities in health experienced by American Indians,” – Virginia Hedrick (Yurok), Executive Director, California Consortium for Urban Indian Health, Inc.

“The American Indian Health Service of Chicago, Inc. is pleased to endorse the Honoring Promises to Native Nations Act, as it will enable the 70% of American Indians and Alaska Natives who live in Urban Areas to continue to receive the same level of care that is received by other federally funded health programs, while slowly moving toward true health equity with the rest of the United States. With hope that Urban Programs will be able to receive an increase in the funding to be able to offer additional services (such as dental, podiatry, imaging, and women’s wellness) to the American Indian and Alaska Native Chicago based population. AIHSC also appreciates the efforts to increase the Special Diabetes Program for Indians, as our percentages of AI/AN who are diagnosed with diabetes increase,” – RoxAnne M LaVallie-Unabia (Turtle Mountain Band of Chippewa Indians), Executive Director, American Indian Health Service of Chicago.

“South Dakota Urban Indian Health enthusiastically supports the Honoring Promises to Native Nations Act. This bill secures funding for essential health services and through the inclusion of Medicaid reimbursements for substance use disorder facilities, recognizes the urgency of addiction for our relatives. For generations, Native Americans have persevered through forced assimilation, forced removal from our ancestral lands, and broken promises from the United States government. Despite these challenges, we remain a thriving group of sovereign nations and peoples across the geographic United States. This bill is a stride toward health equity for the more than 70% of Native Americans who live in urban areas of the United States.” – Michaela Seiber (Sisseton-Wahpeton Dakota), CEO, South Dakota Urban Indian Health.

“Native Health endorses the Honoring Promises to Native Nations Act because it will provide resources to fulfill the Federal Government’s obligation to provide health care to AI/ANs. The bill supports urban Indian organizations through 100% FMAP and SDPI reauthorization. These measures are especially needed by the underserved AI/AN urban community. In the current environment, UIOs are overwhelmed by the rising demand and the rising costs of providing health care,” – Walter Murillo (Choctaw Nation of Oklahoma), CEO, Native Health.

“The Honoring Promises to Native Nations Act is a major step forward in recognizing the trust and treaty obligations to Tribes and American Indian and Alaska Native peoples,” – Jacqueline Mercer, CEO, Native American Rehabilitation Association of the Northwest (NARA).

“Hunter Health endorses the Honoring Promises to Native Nations Act because it will increase access to quality healthcare services and allows Urban Indian Organizations to work with their state to expand services for Native American people living in their community,” – Rachel Mayberry, Chief Advancement Officer, Hunter Health.

“The Indian Health Center of Santa Clara Valley is pleased to endorse Senator Warren’s Honoring Broken Promises Act. This bill addresses priorities for urban Indian organizations such as mandatory funding, 100% FMAP, increased SDPI funding, and urban confer. This bill contributes to health equity for American Indians and Alaska Natives and moves forward with the federal government’s trust and treaty responsibility by improving AI/AN health services,” – Sonya Tetnowski (Makah), CEO, Indian Health Center of Santa Clara Valley.

“Denver Indian Health and Family Services endorses the Honoring Promises to Native Nations Act because it will allow all Urban Indian Organizations (UIOs) to leverage their services and sustain their funding despite many healthcare challenges. (i.e., the pandemic, the opioid crisis, suicide prevention, etc.). It is time the federal government met its trust and treaty obligations to Native peoples, particularly regarding federal spending. Failing to fund Indian Health Service (IHS) fully and UIOs fails to fulfill the federal government’s trust responsibilities. As recipients of less than 1% of the Indian Health Service budget, inadequate funding requires UIOs to depend on every dollar of federal funding and find creative ways to stretch limited resources. The Act will cover a wide range of issues that impact Indian Country; specifically, urban confer for HHS and the VA; 100% FMAP for UIOs; and Special Diabetes for Indians, reauthorized at $300 million for ten years,” – Adrianne Maddux (Hopi Tribe), Executive Director, Denver Indian Health and Family Services.

“The Oklahoma City Indian Clinic (OKCIC) endorses the Honoring Promises to Native Nations Act because it will provide promised and necessary funding for Indian Health Care services. The OKCIC is the largest Urban Indian Health Care Center in the United States, serving 22,000 patients from over 200 Tribes. Many of our patients are chronically ill and require high levels of expensive medical care. To provide that care it is very important that Title II of the Honoring Promises to Native Nations Act, specifically a full, mandatory and inflation-adjusted funding for the Indian Health Service and permanent adequate funding for the Special Diabetes Program for Indians is not only necessary but vital to maintaining the good health of our people,” – Robyn Sunday-Allen (Cherokee), CEO, Oklahoma City Indian Clinic.

Bill Highlights for Urban Indian Organizations

Mandatory Funding and Advance Appropriations for the Indian Health Service

The Indian health system, including IHS, Tribal facilities, and UIOs, is the only major federal provider of health care that is funded through annual appropriations. If IHS were to receive mandatory funding or, at the least, advance appropriations, it would not be subject to the harmful effects of government shutdowns and continuing resolutions (CRs) as its funding for the next year would already be in place. This is needed as lapses in federal funding put lives at risk. Without funding certainty during government shutdowns can cause UIOs to reduce services, close their doors, or force them to leave their patients without adequate care. During the last government shutdown, UIOs reported at least 5 patient deaths and significant disruptions in patient services. Securing stable funding for IHS has been a major priority for Indian Country and NCUIH has taken part in extensive advocacy to ensure the continuation and delivery of health services to all Native people regardless of where they live.

This bill authorizes $50,138,679,000 in mandatory appropriations for FY 2023, $51,416,373,000 for FY 2024, and for FY 2025 and each fiscal year thereafter, “an amount equal to the sum of the amount appropriated for the previous fiscal year, as adjusted annually to reflect the change in the medical care component of the consumer price index for all urban consumers (U.S. city average); and, as applicable, 1.8 percent of the amount appropriated for the previous fiscal year.” The bill also provides advance appropriations for IHS.

Special Diabetes Programs for Indians

The SDPI Demonstration Project includes research-based interventions for diabetes prevention and cardiovascular disease (CVD) risk reduction into AI/AN community-based programs and health care settings. The program has demonstrated success with a 50% reduction in diabetic eye disease rates, drops in diabetic kidney failure, and a 50% decline in End Stage Renal Disease. Many UIOs receive SDPI funding and the program has directly enabled UIOs to provide critical services to their AI/AN patients, in turn significantly reducing the incidence of diabetes and diabetes-related illnesses among urban Indian communities. These successes are impactful, as AI/ANs have the highest diabetes prevalence rates of all racial and ethnic groups in the United States, with AI/AN adults almost three times more likely than non-Hispanic white adults to be diagnosed with diabetes. According to the Centers for Disease Control and Prevention, 13.7% of adults in urban Native communities are diagnosed with diabetes. SDPI is a critical program to address the high rates of diabetes among AI/ANs and requires secure funding to continue its success. NCUIH has long advocated for SPDI to be fully funded. On May 16, 2022, NCUIH submitted comments and recommendations to IHS emphasizing the importance of SDPI in reducing health disparities related to diabetes for AI/AN populations. These comments included increasing SDPI funding with built-in automatic annual medical inflationary increases and that IHS ensures the SDPI remains inclusive of UIOs.

This legislation will reauthorize SDPI at $300,000,000 for each fiscal year beginning in 2023 through 2032.

Permanent 100% Federal Medical Assistance Percentage (FMAP)

FMAP refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. Permanent 100% FMAP for UIOs will further the government’s trust responsibility to AI/ANs by increasing available financial resources to UIOs and support them in addressing critical health needs of AI/AN patients. In March of 2021, Congress enacted the American Rescue Plan Act of 2021 (ARPA) which authorized eight fiscal quarters of 100% FMAP coverage for UIOs. Unfortunately, with only 3 months until the provision expires, most UIOs have not received any increase in financial support because many states have not increased their Medicaid reimbursement rates to UIOs, citing short-term authorization concerns.

There has been strong support for the expansion of 100% FMAP to UIOs across Indian Country and NCUIH has tirelessly advocated to permanently fix this parity issue. The National Congress of American Indians and the National Indian Health Board passed resolutions along with NCUIH in support of extending 100% FMAP to UIOs. Additionally, there has been longstanding bipartisan congressional support, with over 17 pieces of legislation having been introduced since 1999 on this issue. NCUIH recently sent a letter to the House Committee on Energy and Commerce leadership requesting a markup on the Improving Access to Indian Health Services Act (H.R. 1888), which would establish permanent 100% FMAP for services provided to AI/ANs Medicaid beneficiaries at UIOs.

This bill amends the Social Security Act by including UIOs as eligible entities to receive permanent 100% FMAP.

Urban Confer with HHS and UIOs

An Urban Confer is an established mechanism for dialogue between federal agencies and UIOs. Urban confer policies are a response to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that have resulted in 70% of AI/AN people living outside of Tribal jurisdictions, thus making Urban Confer integral to addressing the care needs of a majority of AI/ANs. An urban confer policy that includes all HHS agencies, including the Centers for Medicare & Medicaid Services (CMS), ensures that obstacles relating to programs and benefits that directly affect UIOs are addressed quickly so UIOs are better equipped to provide healthcare to their patients. NCUIH has long advocated for facilitating confer between numerous federal branches within HHS and UIO stakeholders. Currently, only IHS has a legal obligation to confer with UIOs. It is important to note that urban confer policies do not supplant or otherwise impact Tribal consultation and the government-to-government relationship between Tribes and federal agencies.

This bill would require the Secretary of HHS, to the maximum extent practicable, to confer with UIOs in carrying out the health services of the Department.

Office of Management and Budget Office of Native Nations

The bill establishes an Office of Native Nations within the Office of Management (OMB), which coordinates with the rest of OMB and the Executive branch on matters of funding for federal programs and policy affecting AI/ANs and Native Hawaiians. The Administrator, a career position, of the office is responsible for matters such as compiling data on all federal funding for federal programs affecting AI/ANs and Native Hawaiians; ensuring that the budget requests of IHS and the Bureau of Indian Affairs indicate how much funding is needed for programs affecting AI/ANs and Native Hawaiians to be fully funded and how far the federal government is from achieving that full funding; and preparing a crosscutting document each fiscal year containing detailed information, based on data from all federal agencies, on the amount of federal funding that is reaching Indian Tribes, tribal organizations, Native Hawaiian organizations, and UIOs. The bill directs the Administrator to consult with Indian Tribes, collaborate with Native Hawaiian organizations, and confer with UIOs annually to ascertain how the crosscutting document can be modified to make it more useful to Indian Tribes, Native Hawaiian organizations, and UIOs.

On September 12, 2022, after recommendations from NCUIH and Tribal leaders, the Biden administration created a position of a Tribal Policy Advisor within OMB to communicate the needs of Indian Country and AI/ANs. This position was an important first step in ensuring that Native voices are heard during the budget process, and we are grateful that this bill works to further consider the needs of Native programs in federal funding.

Next Steps

Senator Warren and Congressman Kilmer invite comments and feedback on how to refine and improve the legislation in the next Congress. Written input can be submitted at HonoringPromises@warren.senate.gov.

Background

Broken Promises

On December 20, 2018, the Broken Promises report was released and addressed areas where the federal government has failed to fulfill its trust responsibility, including criminal justice and public safety, health care, education, housing, and economic development. Specifically, the report requests advance appropriations for the IHS and funding to implement the Indian Health Care Improvement Act, including job training programs to address chronic shortages of health professionals in Indian Country and a mental health technician training program to address the suicide crisis in Indian Country. The report also recommends direct, long-term funding to Tribes, analogous to the mandatory funding Congress provides to support Medicare, Social Security, and Medicaid, avoiding pass-through of funds via states.

The proposal for this bill was first introduced in August 2019 by Congresswoman Deb Haaland (D- N.M.) and Senator Warren. Lawmakers then took feedback from tribal governments and citizens, tribal organizations, UIOs, experts, and other stakeholders which informed the development of this current legislation.