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

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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.

Partnership for Medicaid Advocates for Key Urban Indian Health Priority in Omnibus Request

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On October 28, 2022, the Partnership for Medicaid (Partnership) sent a letter to House and Senate leadership urging that several Medicaid policy proposals be prioritized as Congress considers an end-of-year health care package. In the letter, they requested that Congress seek to include legislation that would extend 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs) and Native Hawaiian Health Systems for another two years. After advocacy from the National Council for Urban Indian Health (NCUIH), the American Rescue Plan Act (ARPA) authorized 8 fiscal quarters of 100% FMAP to UIOs, which is set to expire in just 3 months.

Full Letter Text

Dear Leader Schumer, Speaker Pelosi, Minority Leader McConnell, and Minority Leader McCarthy:

On behalf of the Partnership for Medicaid (Partnership), thank you for your continued commitment to the Medicaid program. Our member organizations are eager to collaborate with you to build upon efforts to sustain and strengthen Medicaid.

The Partnership – a nonpartisan, nationwide coalition made up of organizations representing clinicians, health care providers, safety net plans, and counties –appreciates initiatives from Congress throughout the COVID-19 pandemic to bolster the Medicaid program and support the health care safety net. Your continued attention has not only allowed the program to meet the needs of millions of Americans during a public health crisis but has also reinforced the importance of investing in Medicaid now to protect and sustain its promise for the future.

As the Congress considers an end-of-year health care package, the Partnership urges lawmakers to prioritize policy proposals to strengthen Medicaid and ensure its stability for underrepresented populations who rely on this critical program. Congress should seek to include legislation that would:

  • building on provisions included in the FY 2022 Continuing Resolution, create a permanent and sustainable Medicaid financing solution for Puerto Rico and other territories;
  • permanently ensure that all pregnant individuals on Medicaid and the Children’s Health Insurance Program (CHIP) keep their health coverage during the critical first year postpartum;
  • provide one year of continuous eligibility for children covered by Medicaid and CHIP;
  • appropriately fund the Medicaid program in a manner that supports states to set competitive rates necessary for garnering equitable access for Medicaid, as undervaluing Medicaid payments—and consequently, the patients Medicaid serves—perpetuates systemic barriers to health and health care and worsens health disparities;
  • invest in and improve access to Medicaid home-and community-based services (HCBS) and mental health services, including for children, while strengthening the direct care workforce;
  • provide Medicaid coverage to eligible, justice-involved individuals 30 days prior to release;
  • extend the 100 percent federal medical assistance percentage (FMAP) for Urban Indian Organizations and Native Hawaiian Health Systems for another two years;
  • make permanent Medicaid’s Money Follows the Person program and the Protection Against Spousal Impoverishment.
  • permanently fund CHIP; and
  • close the Medicaid coverage gap for Americans living in states that have yet to expand Medicaid and still lack access to health insurance

Taken together, these proposed improvements to Medicaid and CHIP represent an opportunity to stabilize and expand access to health care and long-term services and supports for millions of low-income Americans, from older adults, people with disabilities, children, pregnant and postpartum individuals, and their families, and more.

Furthermore, for Medicaid issues legislatively tied to the public health emergency, we urge Congress to proceed with caution when applying imminent, static sunsets to policies stakeholders rely upon to help mitigate COVID-19’s ongoing impact. For example, Congress should create a predictable, evidence-informed wind down of the enhanced FMAP and continuous coverage provisions included in the Families First Coronavirus Response Act that provides sufficient guardrails to protect beneficiaries while also reflecting the trajectory of the COVID-19 pandemic.

We remain grateful for your leadership and commitment to the Medicaid program and the populations it serves. If you have questions or seek any additional information, please contact Jonathan Westin at the Jewish Federations of North America, First Co-Chair of the Partnership for Medicaid at Jonathan.Westin@jewishfederations.org.

Sincerely,

America’s Essential Hospitals
American College of Obstetricians and Gynecologists
American Dental Education
Association American Network of Community Options and Resources (ANCOR)
Associations of Clinicians for the Underserved
Catholic Health Association of the United States
Children’s Hospital Association
Easterseals
Jewish Federations of North America
National Association of Counties
National Association of Pediatric Nurse Practitioners
National Association of Rural Health Clinics (NARHC)
National Council for Mental Wellbeing
National Council of Urban Indian Health
National Health Care for the Homeless Council
National Rural Health Association

About the Partnership for Medicaid

NCUIH is a member of the Partnership for Medicaid, which is a nonpartisan, nationwide coalition of organizations representing clinicians, health care providers, safety-net health plans, and counties. The goal of the coalition is to preserve and improve the Medicaid program. Members of this coalition include:

Background and NCUIH Advocacy on Medicaid

100% FMAP for UIOs

FMAP refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. Permanent authorization or an extension of the 100% FMAP for UIOs provision will further the government’s trust responsibility to American Indians/Alaska Natives (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 ARPA which authorized eight fiscal quarters of 100% FMAP coverage for UIOs. Congress did this in part to increase the financial resources available to UIOs and support the provision of critically needed health services to urban AI/ANs during the COVID-19 pandemic. 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.

NCUIH and Partnership for Medicaid Priority: Medicaid Unwinding

After the COVID-19 Public Health Emergency (PHE), states will resume normal operations, which includes processing eligibility renewals and ending coverage for individuals no longer eligible for Medicaid and Children’s Health Insurance Program (CHIP) in a process known as “unwinding.” The Partnership for Medicaid advocates for protections against the potential loss of coverage for millions of Medicaid beneficiaries at the end of the PHE. NCUIH recently released a Medicaid unwinding toolkit for UIOs as they prepare for changes in Medicaid coverage. This document outlines the impact of Medicaid unwinding on AI/ANs and the steps UIOs can take to assist their patients with their coverage, such as working with their state, Tribes, federal agencies, and their community.

NCUIH Resource: Tribal Nations Summit Briefing Book on Urban Indian Health Issues

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On Novemeber 29, 2022, the National Council of Urban Indian Health (NCUIH) collaborated on the White House Tribal Nations Summit Briefing held by the National Indian Health Board (NIHB) and National Congress of American Indians (NCAI) for Indian Country leaders to prepare for the upcoming White House Tribal Nations Summit. As the organization that advocates for the health and well-being of urban Native Americans, NCUIH prepared a resource that highlights key priorities for urban Indian organizations (UIOs).

View the resource

One of the main priorities for NCUIH is tribal sovereignty. The organization stands in strong support of consultation and the nation-to-nation relationships between Tribes and the United States government. NCUIH also supports the work of the Tribal Budget Formulation Workgroup, which crafts a budget request for Congress and the Administration each year. NCUIH also advocates for the US government to uphold the Declaration of National Indian Health Policy in the Indian Health Care Improvement Act. This policy states that it is the responsibility of the US government to ensure the highest possible health status for Indians and urban Indians and to provide the necessary resources to do so.

UIOs and urban Indians face unique challenges when it comes to access to healthcare. There are 41 UIOs that serve Indian Health Service beneficiaries at over 90 locations, but these organizations receive significantly less funding per patient than other healthcare facilities. On average, the health care spending in the US is $11,172 per person, while tribal and Indian Health Service (IHS) facilities receive only $4,078 per patient from the IHS budget. UIOs receive even less, at just $672 per patient.

Despite these challenges, UIOs serve a significant portion of the Native American population. Over 95% of UIO patients are tribal citizens, and over 70% of Native Americans do not live on federally recognized tribal land. NCUIH is advocating for 100% Federal Medical Assistance Percentage for UIOs to help address these disparities in healthcare access.

NCUIH is also advocating for advance appropriations for IHS— a top priority across Indian Country. The Indian healthcare system, including IHS, Tribal facilities, and UIOs, is the only major federal healthcare provider funded through annual appropriations and is not protected from government shutdowns and continuing resolutions. This policy is needed to save Native lives, as lapses in federal funding puts lives at risk. During the 2019 government shutdown, several UIOs had to reduce services or close their doors entirely, forcing them to leave their patients without adequate care which unfortunately led to fatalities. Advance appropriations is critical to provide certainty to the IHS system and ensure unrelated budget disagreements do not risk lives.

The Full Resource:

Urban Indian Health Issues
White House Tribal Nations Summit Briefing Book

National Council of Urban Indian Health (NCUIH)

  • Tribal sovereignty is a top priority for the National Council of Urban Indian Health (NCUIH). We know all too well that the promises made to American Indians and Alaska Natives are often broken. NCUIH stands in strong support of Consultation and the Nation-to-Nation relationships of Tribes and the United States government.
  • NCUIH strongly supports the work of the Tribal Budget Formulation Workgroup to craft a budget request for Congress and the Administration each year. NCUIH follows the guidance and requests of the Workgroup in its recommendations to Congress.
  • NCUIH advocates for the US government to uphold the Declaration of National Indian Health Policy in the Indian Health Care Improvement Act: “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.”

Urban Indian Organizations and Urban Indians

  • 41 Urban Indian Organizations serve IHS beneficiaries at over 90 locations
  • The average health care spending in the United States is $11,172 per person, however, Tribal and Indian Health Service (IHS) facilities receive only $4,078 per American Indian/Alaska Native (AI/AN) patient from the IHS budget. Urban Indian Organizations (UIOs) receive just $672 per AI/AN patient from the IHS budget.
  • 95% of Urban Indian Organization patients are Tribal citizens
  • Over 70% of AI/AN citizens do not reside on Federally Recognized Tribal Land.

100% Federal Medical Assistance Percentage for Urban Indian Organizations

Background of 100% Federal Medical Assistance Percentage (FMAP) for UIOs:
  • FMAP is the percentage of Medicaid costs covered by the federal government, through reimbursement to state Medicaid programs. As a baseline, FMAP cannot be less than 50% of the cost of services provided.
  • In 1976, Congress passed the Indian Health Care Improvement Act (IHCIA) amended section 1905(b) of the Social Security Act to set the FMAP at 100% for Medicaid services “received through an Indian Health Service (IHS) facility whether operated by the Indian Health Service or by an Indian tribe or tribal organization.”
  • Congress authorized 100% FMAP for IHS facilities so that Medicaid payments could supplement the chronically underfunded IHS annual appropriation and provide IHS with additional financial resources to better fulfill the federal government’s trust responsibility to provide safe and quality healthcare to American Indians/Alaska Natives (AI/ANs).
  • Despite being an integral part of the Indian healthcare system, UIOs were overlooked in the original legislation authorizing 100% FMAP for IHS and Tribal healthcare providers. As a result, the federal government is not paying its fair share for Medicaid-IHS beneficiaries and is skirting the trust responsibility.
What is the issue?
  • In March 2021, Congress authorized 8 fiscal quarters of 100% FMAP coverage for Medicaid services at UIOs for IHS beneficiaries through the American Rescue Plan Act of 2021 (ARPA).
  • Since 2021, the federal government has been covering 100% match for IHS-Medicaid beneficiaries but starting on March, States will have to go back to paying for a portion of services received from IHS-Medicaid beneficiaries at UIOs.
  • Congress needs to hear from Tribes that 100% FMAP provision for UIOs needs to be permanently authorized or at least extended to provide adequate care for tribal citizens living in urban areas.
How Tribes Can Support
  • Create a resolution supporting permanent 100% FMAP for UIOs.
  • Support 100% FMAP in Fiscal Year 2023 Omnibus bill.
  • Contact your Members of Congress before it expires in 4 months to support an extension to the provision in the end-of-year Omnibus.
  • If your Tribe is interested in supporting 100% FMAP for UIOs, please contact policy@ncuih.org
What Needs to be Done Now?
  • Tell the Administration that the federal government must fulfill its trust responsibility for all IHS beneficiaries by making 100% FMAP permanent.
  • The 100% FMAP provision for UIOs is going to expire in four months and the federal government will no longer be honoring its trust responsibility to IHS-Medicaid beneficiaries who receive care at urban Indian organizations.
  • Congress needs to hear from Tribes that 100% FMAP provision for UIOs needs to be permanently authorized or at least extended to provide adequate care for tribal citizens living in urban areas.
What Tribes Can do to Support

If your Tribe is interested in supporting 100% FMAP for UIOs, please contact policy@ncuih.org

Tribal Support
➤     Create a resolution supporting permanent 100% FMAP for UIOs.
Congressional Advocacy
➤     Support 100% FMAP in the Fiscal Year 2023 Omnibus bill.

  • Contact your Members of Congress before it expires in 4 months to support an extension to the ARPA provision in the end-of-year Omnibus.

Tribe and Tribal Organization Support for 100% FMAP for UIOs

Advance Appropriations

Advocacy
  • On January 17, 2019, NCUIH sent a letter to the Vice Chairman of the Senate Committee on Indian Affairs, Tom Udall, in support of IHS advance appropriations legislation.
  • On March 9, 2022, NCUIH joined NIHB and over 70 Tribal nations and national Indian organizations in sending a series of joint letters to Congress requesting advance appropriations for IHS in the Fiscal Year (FY) 2022 omnibus.
  • On June 16, 2022, NIHB and NCAI requested that the Committee support and include IHS advance appropriations in the current FY 2023 appropriations bill in an action alert.
  • On June 24, NCUIH issued a call to action to reach out to Speaker Pelosi for House support of advance appropriations.
  • On June 24 and July 1, 2022, NCUIH sent a letters to Speaker Pelosi and House Minority Leader McCarthy to support advance appropriations for IHS.
  • On June 29, 2022, NCUIH sent letters to the Senate Interior Appropriations Committee and the Senate Committee on Indian Affairs to support advance appropriations for IHS.
  • On June 30 and July 1, 2022, NCUIH sent letters to Senate Majority Leader Schumer and Senate Minority Leader McConnell to support advance appropriations for IHS.
  • On August 19, NCUIH issued a second call to action to reach out to Speaker Nancy Pelosi for House support of advance appropriations.
  • On August 22, 2022, NCUIH launched a website with educational resources on advance appropriations.
  • On October 26, 2022 NCUIH launched an advance appropriations social media campaign and toolkit with the hashtag #AdvanceIndianHealtht.
  • On October 28, 2022, NCUIH released an advance appropriations advocacy toolkit.
  • In November 2022, NCUIH signed-on to NIHB’s intertribal and inter-organization Congressional and White House letters requesting advance appropriations for the FY 2023.

NCUIH Requests Committee Action to Extend Medicaid Provisions Expiring in 2023

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On September 20, 2022, The National Council of Urban Indian Health (NCUIH) sent a letter to Chair Frank Pallone and Ranking Member Cathy McMorris Rodgers on the House Committee on Energy and Commerce requesting a markup on the Improving Access to Indian Health Services Act (H.R. 1888). This bill would establish permanent 100% Federal Medical Assistance Percentage (FMAP) for services provided to American Indian/Alaska Native (AI/AN) Medicaid beneficiaries at urban Indian Organizations (UIOs).  The American Rescue Plan (ARP) authorized 8 fiscal quarters of 100% FMAP to UIOs. However, the ARP provision expires in less than 5 months, and UIOs are not seeing the benefit of this provision. States are generally not increasing their Medicaid reimbursement rates to UIOs, resulting in states seeing the 100% FMAP savings intended to go to UIOs.

Full Letter Text

Dear Chair Pallone and Ranking Member McMorris Rodgers,

On behalf of the National Council of Urban Indian Health (NCUIH), the national advocate for health care for the over 70% of American Indians and Alaska Natives (AI/ANs) living off-reservation and the 41 Urban Indian Organizations (UIOs) that serve these populations, we write to request the markup of H.R. 1888. This bill would permanently establish a 100% federal matching rate, also known as the Federal Medical Assistance Percentage (FMAP), for Medicaid services provided at UIOs.  This bill would also permanently expand Medicaid coverage to include clinical services provided outside of a clinic by an Indian Health Service (IHS) facility, a tribe or tribal organization, or UIO.

Extending FMAP to UIOs

FMAP refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. In 1976, Congress passed the Indian Health Care Improvement Act (IHCIA) which amended the Social Security Act to add Section 1911. Section 1911 authorized reimbursement by Medicaid for services provided to AI/AN Medicaid beneficiaries at Indian Health Service (IHS) and Tribal health care facilities.1 In addition,  ICHIA amended section 1905(b) of the SSA to set the FMAP at 100% for Medicaid services received through an IHS facility, whether operated by IHS or by an Indian Tribe. 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” AI/ANs and because “the Federal government has treaty obligations to provide services to Indians, it has not been a State responsibility.”2 Unfortunately, the IHCIA amendments to the SSA were not inclusive of UIOs, meaning that services provided at UIOs were not eligible for 100% FMAP under IHCIA’s authority.

In March of 2021, Congress enacted the American Rescue Plan Act of 2021 (ARPA). Section 9815 of ARPA authorized eight (8) fiscal quarters of 100% FMAP coverage for Medicaid services at provided UIOs. Congress intended Section 9815 in part to increase the financial resources available to UIOs and support the provision of critically needed health services to urban AI/ANs during the COVID-19 pandemic. However, the ARPA’s 100% FMAP extension to UIOs ends in less than 6 months, and UIOs have generally not seen any increased financial support because of this extension. Unfortunately, states are not increasing their Medicaid reimbursement rates to UIOs, citing the short-term authorization for the UIO 100% FMAP extension as a reason not to increase their reimbursement rates.

On March 23, 2021, the House Committee on Energy and Commerce held a legislative hearing on the Affordable Care Act, which included H.R. 1888. At the hearing, Representative Raul Ruiz emphasized that there is no sound policy reason for excluding UIOs from eligibility for 100% FMAP and advocated for the Committee to pass this critical piece of legislation to address this longstanding issue.  There has been strong support for the expansion of 100% FMAP to UIOs across Indian Country. For example, both the National Congress of American Indians and the National Indian Health Board have passed resolutions in support of extending 100% FMAP to UIOS. Additionally, there has been longstanding bipartisan congressional support for extending 100% FMAP to UIOs, with over 17 pieces of legislation having been introduced since 1999 on this issue.

The federal government has a trust responsibility to provide “[f]ederal health services to maintain and improve the health of the Indians.3 The federal government owes that duty to all AI/ANs, 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.”4 Permanent 100% FMAP for UIOs will further the U.S. government’s trust responsibility to AI/ANs by increasing the available financial resources to UIOs and supporting them in addressing the critical health needs of their AI/AN patients. We request the markup of H.R. 1888 to honor this trust responsibility and progress the health of all AI/AN people, regardless of their location. Thank you for your attention to this urgent matter.

FMAP Background

FMAP refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. In 1976, Congress passed the Indian Health Care Improvement Act (IHCIA) which authorized reimbursement by Medicaid for services provided to AI/AN Medicaid beneficiaries at IHS and Tribal health care facilities. This set FMAP at 100% for Medicaid services received through an Indian Health Service (IHS) facility, whether operated by IHS or by an Indian Tribe.

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 AI/ANs.” However, UIOs were not included in this IHCIA authorization as an oversight, meaning that services provided at UIOs were not eligible for 100% FMAP.

ARPA FMAP Provision and Permanent 100% FMAP for UIOs

In March of 2021, Congress enacted the ARP, which authorized two years of 100% FMAP coverage for Medicaid services provided at UIOs. Congress did this in part to increase the financial resources available to UIOs and support the provision of critically needed health services to urban AI/ANs during the COVID-19 pandemic. However, ARPA’s 100% FMAP extension to UIOs expires in less than 6 months, and states are generally not increasing their Medicaid reimbursement rates to UIOs, citing short-term authorization as a reason not to increase their reimbursement rates. H.R. 1888 would remedy this problem and establish a permanent 100% FMAP rate for services provided at UIOs to ensure they can continue providing critical health services to their AI/AN patients.

This bill would also permanently expand Medicaid coverage to include clinical services provided outside of a clinic by an IHS facility, Tribe, tribal organization, or UIO. This has been a critical priority identified by Indian Country to ensure that services provided through an Indian health care program are eligible for reimbursement at the IHS all-inclusive rate, no matter where that service is provided.

Support for 100% FMAP to UIOs

On March 23, 2021, the House Committee on Energy and Commerce held a legislative hearing on the Affordable Care Act, which included H.R. 1888. At the hearing, Representative Raul Ruiz emphasized that there is no sound policy reason for excluding UIOs from eligibility for 100% FMAP and advocated for the Committee to pass this critical piece of legislation to address this longstanding issue.  Additionally, there has been longstanding bipartisan congressional support for extending 100% FMAP to UIOs, with over 17 pieces of legislation having been introduced since 1999 on this issue.

 There has also been strong support for the expansion of 100% FMAP to UIOs across Indian Country. For example, both 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.

The federal government has a trust responsibility to provide health services to maintain and improve the health of all AI/ANs, no matter where they live.  Congress has also declared it the policy of the United States to ensure the highest possible health status for AI/ANs and to provide all resources necessary to do so. H.R. 1888 is a critical piece of legislation that would further the federal government’s trust responsibility to AI/ANs by increasing the available financial resources to UIOs to better address the critical health needs of their patients and ultimately bolster the entire Indian Health system.

Next Steps

NCUIH will continue to advocate for the markup of H.R. 1888 and provide updates on its movement within Congress.

Urban FMAP Fix Bill Introduced

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FOR IMMEDIATE RELEASE
November 16, 2017

Contact: Francys Crevier
NCUIH Executive Director
FCrevier@NCUIH.org

 

The National Council of Urban Indian Health (NCUIH), which represents 41 urban Indian organizations (UIOs) with Title V contracts across the nation, appreciates the bipartisan legislation to be introduced by Representative Ben Ray Lujan (D-NM-3) and Senator Tom Udall (D-NM) to fix Medicaid for American Indian/Alaska Native (AI/AN) patients who are served by UIOs.

Title V UIOs, which constitute an integral part of the Indian Health Service (IHS), are non-profit corporations which recruit and retain their own staffs in order to provide high-quality, culturally-competent health care to AI/AN people who live off of reservations.

“Medicaid is a vital health care program for AI/AN people,” declared Ms. Ashley Tuomi, NCUIH’s President.  “Congress authorized all three parts of IHS to bill Medicaid for services provided to eligible AI/AN people in order to supplement chronic underfunding of IHS and thus better fulfill the federal government’s Trust Responsibility to provide health care to AI/AN people.”

“In recognition that it would honor the Trust Responsibility to AI/AN and stretch dollars for the Indian health system,” continued Ms. Tuomi, who is also the CEO of American Indian Health & Family Services of Southeast Michigan, in Detroit, MI, “Congress provided that states would be reimbursed by the federal government at a Federal Medical Assistance Percentage (FMAP) of 100.  However, UIOs were not explicitly mentioned in the law, and the Centers for Medicare and Medicaid Services states it lacks the discretion to authorize 100% FMAP for UIOs.”

“That’s why the legislation introduced by Senator Udall and Representative Lujan is so important,” declared Ms. Linda Son-Stone, who is the executive director of First Nations Community Healthsource, in Albuquerque, NM.  “It would simply include UIOs in the FMAP law, so that all three parts of IHS are treated the same with respect to Medicaid reimbursement.  More importantly, it will allow UIOs to provide more high- quality, culturally-competent health care services to urban Indians, who currently experience health care conditions and outcomes that are markedly inferior to their non-Indian counterparts in urban areas.”

“In fact,” continued Ms. Son-Stone, “the two largest UIOs, in Tulsa and Oklahoma City, have been so successful in part because of a legal exception through which their state of Oklahoma already receives 100% FMAP.  We appreciate the strong leadership of Representative Lujan and Senator Udall on this very important issue, which would allow UIO patients in New Mexico and other states to benefit from the same arrangement.”

100% FMAP State Health Official Announcement

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On Friday, February 26, 2016 the Centers for Medicare & Medicaid Services (CMS) released the Dear State Health Official letter regarding 100% FMAP to inform state agencies and health officials about the update in payment policy affecting federal funding for services received by Medicaid-eligible individuals who are AI/ANs through facilities of the Indian Health Service (IHS), whether operated by IHS or Tribes. Through this letter, CMS is re-interpreting its payment policy with respect to services “received through” an IHS/Tribal facility, and is expanding the scope and nature of services that qualify for the matching rate.

This update to the national policy has Tribal implications for IHS and Tribal facilities as well as on Urban Indian Health Programs (UIHPs) that provide services to AI/AN Medicaid beneficiaries. CMS held several Tribal Consultations, participated in an Urban Conferring session between IHS and NCUIH, and solicited comments on the parameters of a reinterpretation of section 1905(b) of the Social Security Act as specified in CMS’ October 2015 Medicaid Services ‘Received Through’ and Indian Health Service/Tribal Facility: A Request for Comment.” They received comments from Tribes, Tribal organizations, urban Indian organizations, States, and other stakeholders in support of the proposed policy change.

The new policy is intended to help states, IHS, Tribes, and UIHPs improve the delivery of health to AI/AN Medicaid beneficiaries by increasing access to care and strengthening continuity of care. The letter outlining the new policy is attached and will be available online on Medicaid.gov here. CMS will be holding an All Tribes’ Call to walk through the policy and provide time for questions and answers.  They will send out a Save the Date notice for the All Tribes’ Call, and information about the All Tribes’ Call will be posted here. We will make sure that notice gets sent out to UIHP Directors.

NCUIH believes that the new policy marks progress for UIHPs at the regulatory level. The CMS announcement coupled with the 100% FMAP for All Indian Health Programs inclusion in the President’s FY2017 budget demonstrates a desire by the government to achieve parity for Urbans within the Indian healthcare system for Medicaid beneficiaries. There are still determinations to be made regarding technical eligibility issues and operationalizing the updated CMS regulation. Consultations with State Medicaid programs and conferring sessions between IHS and NCUIH’s FMAP Work Group will be sought to clarify outstanding issues and to figure out the best way advance the interests of UIHPs within the context of the new FMAP regulation. NCUIH still seeks the help of all UIHPs in reaching out to Members of Congress to request support for the 100% FMAP provision within the President’s budget. Lastly, NCUIH would like to express gratitude to the FMAP Work Group (Donna Keeler – South Dakota, Aren Spark – Seattle, Walter Murillo – Phoenix, and Ashley Tuomi – Detroit) as well as all of the UIHP Directors that have contributed time and effort over recent days, weeks, months, and years towards achieving 100% FMAP inclusion for Urbans. Should you have any questions regarding this announcement, please contact Rudy Soto, NCUIH Policy Analyst, at rsoto@ncuih.org.