Tag Archive for: Letters

Department of Veterans Affairs Announces Revised Urban Indian Organization Reimbursement Agreement Program Template, Broadens Scope of Services

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On July 11, 2024, the Department of Veterans Affairs (VA)published a Dear Facility Leader letter announcing implementation of the revised VA-Urban Indian Organization (UIO) Reimbursement Agreement Program (RAP) template (hereinafter “revised agreement”). VA states that the revised agreement contains several key improvements designed to expand the scope of reimbursements and honors the unique capabilities and traditions of American Indian and Alaska Native Health Programs, including reducing duplicative terms, expanding timely filing to 36 months, and broadening the scope of services. For example, the revised agreement explicitly includes reimbursements for durable medical equipment (DME), prosthetics/orthotics and supplies, and home health services, while no longer explicitly excluding reimbursement for residential treatment. It also now includes dental services under “Reimbursement Rates for Direct Care Services.”

Download the Template

Background

The VA Indian Health Service (IHS)/Tribal Health Program (THP)/UIO RAP provides VA reimbursement to IHS, THP, and UIO health facilities for services provided to eligible American Indian and Alaska Native Veterans. The agreements program was first initiated in 2012 for IHS and Tribal health facilities. It was expanded in 2022 to include UIOs. The RAP is part of a larger effort to improve access to care and coordination for American Indian and Alaska Native Veterans under a broader VA-IHS Memorandum of Understanding managed by Veterans Health Administration (VHA). On May 1, 2024, VA hosted an Urban Confer regarding the revised template for the VA-UIO RAP template.

NCUIH’s Actions

NCUIH submitted comments on May 15, 2024, in response to the May 1, 2024, Urban Confer. In its comments, NCUIH recommended that VA continue to engage with and provide updates to UIOs on the revised agreement through its development; improve the UIO reimbursement rates under the revised agreement; ensure changes to the scope of services include services provided at UIOs; and provide technical assistance to UIOs to support UIO participation. NCUIH also previously submitted comments to VA in February 2022, requesting VA improve VA’s urban confer process and continue to improve VA’s relationship with UIOs.

NCUIH will continue to monitor developments regarding the RAP.

NCUIH Calls for Full, Protected Funding of Indian Health Service & Funding for Key Indian Health Programs in Written Testimony to House and Senate Appropriators

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In May 2024, The National Council of Urban Indian Health (NCUIH) submitted written testimony to the House and Senate Appropriations Subcommittees on Labor, Health and Human Services, Education, and Related Agencies (LHHS), as well as to the  House and Senate Appropriations Subcommittees on Interior, Environment, and Related Agencies regarding Fiscal Year (FY) 2025 funding. NCUIH advocated in its testimony for full funding for the Indian Health Service (IHS) and Urban Indian Health and increased resources for key health programs.

In the testimonies, NCUIH requested the following:

  • Full funding at $53.85 billion for the Indian Health Service (IHS) and $965.3 million for Urban Indian Health for Fiscal Year (FY) 2025 (as requested by the Tribal Budget Formulation Workgroup).
  • Maintain Advance Appropriations for the Indian Health Service, until mandatory funding is authorized and protect IHS from sequestration.
  • Fund the Initiative for Improving Native American Cancer Outcomes at $10 million for FY25.
  • Fund the Good Health and Wellness in Indian Country (GHWIC) Program at $30 Million for FY25.
  • Protect Funding for HIV/AIDS Prevention and Treatment.
  • Reclassify Contract Support Costs and 105 (l) Tribal Lease Payments as Mandatory Appropriations.

Next Steps:

These testimonies will be considered by the House and Senate Appropriations Committee and used in the development of FY25 spending bills. NCUIH will continue to advocate for these requests in FY 2025 and work closely with Appropriators throughout the remainder of the Appropriations process.

Full Text:

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 of the 41 UIOs contracting with the Indian Health Service under the Indian Health Care Improvement Act (IHCIA) and the American Indians and Alaska Native patients they serve. On behalf of NCUIH and the UIOs we serve, I would like to thank Chair Baldwin, Ranking Member Moore Capito, and Members of the Subcommittee for your leadership to improve health outcomes for urban Indians.

We respectfully request the following:

  • $53.85 billion for the Indian Health Service (IHS) and $965.3 million for Urban Indian Health for Fiscal Year (FY) 2025 (as requested by the Tribal Budget Formulation Workgroup).
  • Maintain Advance Appropriations for the Indian Health Service, until mandatory funding is authorized and protect IHS from sequestration.
  • Fund the Initiative for Improving Native American Cancer Outcomes at $10 million for FY25.
  • Fund the Good Health and Wellness in Indian Country (GHWIC) Program at $30 Million for FY25.
  • Protect Funding for HIV/AIDS Prevention and Treatment.

NCUIH Supports Tribal Sovereignty

First, I would like to emphasize that NCUIH respects and supports Tribal sovereignty and the unique government-to-government relationship between our Tribal Nations and the United States. NCUIH works to support those federal laws, policies, and procedures that respect and uplift Tribal sovereignty and the government-to-government relationship. NCUIH does not support any federal law, policy, or procedure that infringes upon, or in any way diminishes, Tribal sovereignty or the government-to-government relationship.

Urban Indian Organizations Play a Critical Role in Providing Health Care for American Indian and Alaska Native People

UIOs were created by urban American Indian and Alaska Native people, with the support of Tribal leaders, starting in the 1950s in response to severe problems with health, education, employment, and housing caused by the federal government’s forced relocation policies[1]. Congress formally incorporated UIOs into the Indian Health System in 1976 with the passage of IHCIA. Today, over 70% of American Indian and Alaska Native 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[2] in 38 urban areas across the United States. There are four different UIO facility types, including full ambulatory, limited ambulatory, outreach and referral, and outpatient and residential alcohol and substance abuse treatment, that offer a wide range of healthcare services.

UIOs are on the front lines in providing for the health and well-being of American Indian and Alaska Native people living in urban areas, many of whom lack access to care that would otherwise be provided through IHS and Tribal facilities. American Indians and Alaska Native people experience major health disparities compared to the general U.S. populations, including, lower life expectancy,[3] and higher rates of infant and maternal mortality. A lack of sufficient federal funding plays a significant role in these continuing devastating health disparities,[4] and Congress must do more to fully fund the Indian health system to improve health outcomes for all American Indian and Alaska Native people.

Request: Fully fund the Indian Health Service at $53.85 billion and Urban Indian Health at $965.3 million for FY25

The United States has a trust responsibility to provide “federal health services to maintain and improve the health” of American Indian and Alaska Native people. This responsibility is codified in IHCIA.[5] Additionally, 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 effect that policy.”[6] To finally fulfill its trust responsibility, we request that Congress fully fund Indian Health at $53.85 billion for the Indian Health Service and $965.3 million for Urban Indian Health. These amounts reflect the recommendations made by the Tribal Budget Formulation Work Group (TBFWG), a workgroup comprised of Tribal leaders representing all twelve IHS service areas and serving all 574 federally recognized Tribes.

According to the TBFWG, fulfillment of the trust responsibility “remain[s] illusory due to chronically underfunded and woefully inadequate annual spending by Congress.”[7] Congress must prioritize increasing funding, as the current FY24 allocation of $6.96 billion for IHS and $90.49 million for Urban Indian Health represents only 12.9% and 9.4% respectively of the total FY24 funding requested by Tribes and UIOs to adequately address current needs.

UIOs are primarily funded through a single line item in the IHS budget, the Urban Indian Health line item, and without a significant increase to this 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. As one UIO leader highlighted, “funding to the Urban Indian Health line item is critical in ensuring that our funding better meets the needs of urban tribal citizens who come to us seeking medical, dental, and behavioral health care. Increased funding means that we can worry less about having to deny or delay care because of budget constraints.” For example, current funding levels pose challenges for UIOs in offering competitive salaries to hire and retain qualified staff who are essential for UIOs to continue to deliver quality care to their patients. Additionally, UIOs need resources to expand their services and programs to address the needs of their communities, including addressing pressing issues such as food insecurity, behavioral health challenges, and rising facilities costs. One UIO reported, “increased funding will allow our UIO to sustain our program capacity, maintain our workforce, address infrastructure needs, and expand health services that are greatly needed within our community.” 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 Native communities.

Request: Retain Advance Appropriations for IHS until Mandatory Funding is Authorized and Protect IHS from Sequestration

Advanced appropriations allowed the I/T/U system to operate normally and without fear of funding lapses during the entire FY24 budget negotiation process. Among other benefits, when IHS distributes their funding on time, our UIOs can pay their doctors and providers without disruption, ensuring continuity of care for UIO patients. Additionally, advanced appropriations allow our UIOs to ensure they can stay open and provide patients with critically needed care, even in the event of a government shut down. We emphasize that advanced appropriations are a crucial step towards ensuring long-term, stable funding for the I/T/U system and, therefore, it is imperative that you include advance appropriations for IHS FY26 in the final FY25 Interior, Environment, and Related Agencies Appropriations Act.

While advance appropriations are a step in the right direction to avoid disruptions during government shutdowns and continuing resolutions, mandatory funding is the only way to assure fairness in funding and fulfillment of the trust responsibility. As the President’s FY25 budget notes, “Mandatory funding is the most appropriate, long-term solution for adequate, stable, and predictable funding for the Indian health system.”[8] We request your support for mandatory funding, and until authorizers act to move IHS to mandatory funding, we request you continue to provide advance appropriations to the Indian health system to improve certainty and stability.

We also request that this Committee protect IHS from sequestration through an amendment to Section 255 of the Balanced Budget and Emergency Deficit Control Act[9]. Sequestration forces Indian Health Care 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 FY13 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for American Indian and Alaska Native patients[10].

Sequestering funds reduces UIOs’ ability to provide essential services to their patients and communities, delaying care and reducing UIO capacity to take on additional patients. One UIO leader emphasized that loss of funding “translates into Tribal citizens lacking access to care that is guaranteed to them through the trust and treaty obligations held by the United States. Cuts mean UIOs can’t provide things like insulin for diabetics, counseling services for survivors of domestic violence, and oral surgery for our relatives.”

Request: Fund the Initiative for Improving Native American Cancer Outcomes at $10 million for FY25

The FY24 LHHS spending bill appropriated $6 million in new funding to address Native American cancer outcomes, by creating the Initiative for Improving Native American Cancer Outcomes.[11] 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 the Initiative is to ultimately improve the screenings, 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. According to the American Cancer Society, the mortality rates for liver, stomach, and kidney cancers in Native American people are twice as high as mortality rates for White people.[12]  We request that the Committee support the Initiative by continuing to appropriate funds for the Initiative in FY25 and increasing funding to $10 million.

Request: Fund the Good Health and Wellness in Indian Country (GHWIC) program at $30 Million for FY25

The GHWIC program provides essential funding support to Tribes, Tribal organizations, and UIOs to improve chronic disease prevention efforts, expand physical activity, and reduce commercial tobacco use. The program is currently funded at $24 million, but additional funding is needed to maintain programmatic success and account for rising costs. NCUIH requests the Committee support the GHWIC program by increasing funding to $30 million for FY25.

Request: Protect Funding for HIV/AIDS Prevention and Treatment

American Indian and Alaska Native people have the highest rate of undiagnosed HIV cases compared to other racial/ethnic groups in the U.S.[13], and according to IHS, as many as 34% of the American Indian and Alaska Native people living with HIV infection do not know it.[14] UIOs are an important resource for urban American Indian and Alaska Native people for HIV/AIDS testing and referral to appropriate care Maintaining UIO programmatic support for HIV/AIDS is critical to safeguarding the health of urban American Indian and Alaska Native populations. Therefore, we request that the Committee protect funding for HIV/AIDS treatment and prevention programs, such as the Minority HIV/AIDS Fund, by maintaining funding for these programs at current levels.

Request: Reclassify Contract Support Costs and 105 (l) Tribal Lease Payments as Mandatory Appropriations

We are also in strong support of the TBFWG’s proposal to reclassify Contract Support Costs (CSC) and Section 105(l) Tribal Lease Payments as mandatory appropriations.  These accounts are already mandatory in nature, and their inclusion in the discretionary budget makes it difficult for other programs to expand under discretionary funding caps.  In 2014, the Appropriations Committees highlighted the challenging nature of these payments, stating, “Typically obligations of this name are addressed through mandatory spending, but in this case since they fall under discretionary spending, they have the potential to impact all other programs funded under the Interior and Environment Appropriations bill, including other equally important tribal programs.”[15]  This proposal will make sure that other IHS programs are not impacted by these costs and can receive true increases to their line items. Reclassifying as mandatory appropriations will have no direct impact on the federal budget and does not conflict with restrictions set forth by the Fiscal Responsibility Act. On July 12, 2023, NCUIH joined the National Indian Health Board and 21 Tribal Nations and Native Partner Organizations in sending a letter to House and Senate leadership in support of this proposal.

Conclusion

The federal government must continue to work to fulfill its trust 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 the resources necessary to protect the lives of the entirety of the American Indian and Alaska Native population, regardless of where they live. The requests outlined herein are an important step towards fulfilling this obligation, and we respectfully request your consideration of each request.

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

[2] Indian Health Service, IHS National Budget Formulation Data Reports for Urban Indian Organizations (2023), https://www.ihs.gov/sites/urban/themes/responsive2017/display_objects/documents/IHS_National_Budget_Formulation_Reports_Calendar_Year_2021.pdf

[3] Elizabeth Arias, et. al., Provisional life expectancy estimates for 2021, Vital Statistics Rapid Release; no 23, National Center for Health Statistics, Centers for Disease Control and Prevention, National Vital Statistics System (Aug. 2022), available at DOI: https://dx.doi.org/10.15620/cdc:118999.

[4] U.S. Comm’n on Civil Rights, Broken Promises: Continuing Federal Funding Shortfall for Native Americans (Dec. 2018), available at: https://www.usccr.gov/files/pubs/2018/12-20-Broken-Promises.pdf; The National Tribal Budget Formulation Workgroup, Advancing Health Equity Through the Federal Trust Responsibility: Full Mandatory Funding for the Indian Health Service and Strengthening Nation-to-Nation Relationships, The National Tribal Budget Formulation Workgroup’s Recommendations on the Indian Health Service Fiscal Year 2024 Budget 17 (May 2022), available at: https://www.nihb.org/docs/09072022/FY%202024%20Tribal%20Budget%20Formulation%20Workgroup%20Recommendations.pdf.

[5] 25 U.S.C. § 1601(1)

[6] 25 USC § 1602.

[7] The National Tribal Budget Formulation Workgroup, Honor Trust and Treaty Obligations: A Tribal Budget Request to Address the Tribal Health

Inequity Crisis, The National Tribal Budget Formulation Workgroup’s Recommendations on the Indian Health Service Fiscal Year 2025 Budget (April 2023), available at: https://www.nihb.org/resources/FY2025%20IHS%20National%20Tribal%20Budget%20Formulation%20Workgroup%20Requests.pdf.

[8] IHS FY25Congressional Justification, https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY-2025-IHS-CJ030824.pdf

[9] P.L. 118–31

[10] 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)

[11] H.R.2882 – 118th Congress (2023-2024): Further Consolidated Appropriations Act, 2024, H.R.2882, 118th Cong. (2024), https://www.congress.gov/bill/118th-congress/house-bill/2882/text.

[12] Siegel RL , Giaquinto AN , Jemal A . Cancer statistics, 2024. CA Cancer J Clin. 2024; 74(1): 12-49. doi:10.3322/caac.21820.

[13] IHS Awards New Cooperative Agreements for Ending the HIV and HCV Epidemics in Indian Country. (2022, September 27). Retrieved January 5, 2023, from https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/HIV-Funding-PressRelease09272022.pdf

[14] Indian Health Service, HIV/AIDS in American Indian and Alaska Native Communities. Retrieved August 8, 2023, from: https://www.ihs.gov/hivaids/hivaian/#:~:text=The%20IHS%20National%20HIV%2FAIDS,Get%20tested%20for%20HIV.

[15] Explanatory statement, DIVISION G- DEPARTMENT OF THE INTERIOR, ENVIRONMENT, AND RELATED AGENCIES APPROPRIATIONS ACT, 2014. https://docs.house.gov/billsthisweek/20140113/113-HR3547-JSOM-G-I.pdf

Coalition of Health Organizations Request Congress Increase Funding for Key IHS Resources to Address Native American Health Needs

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On May 20, 2024, the American Indian/Alaska Native (AI/AN) Health Partners, a coalition of health organizations dedicated to improving health care for American Indians and Alaska Natives, sent letters to House and Senate Interior, Environment, and Related Agencies Subcommittee leadership regarding the fiscal year (FY) 2025 appropriations. In these letters, AI/AN Health Partners urged that House and Senate appropriators address workforce, housing, and equipment needs.

Letter Highlights:

  • $18,000,000 requested for increases in funding for the Indian Health Professions account for FY 2025 to make a meaningful dent in high vacancy rate across the Indian Health System.
  • Requests the Appropriations Committee make Indian Health Service loan repayments and scholarships tax free. This is in line with the National Health Service Corps and other federal loan repayment programs and would enable the Service to fund 218 more providers without increasing the Indian Health Professional account.
  • $11 million requested for new and replacement staff quarters, which is key for the Indian Health Service and Tribes to recruit and retain health care personnel.
  • $42,862,000 requested for medical and diagnostic equipment. The Indian health system manages approximately 90,000 devices consisting of laboratory, medical imaging, patient monitoring, pharmacy, and other biomedical, diagnostic, and patient equipment.
  • $435 million requested to modernize the electronic health records system and ultimately replace IHS’s current medical, health, and billing records systems.

Full Text:

Dear Chairman Simpson and Ranking Member Pingree:

The AI/AN Health Partners is a coalition of health organizations dedicated to improving health care for American Indians and Alaska Natives (AI/ANs). AI/ANs face substantial health disparities, and higher mortality and morbidity rates than the general population. The Indian Health Service (IHS) is critical to how they access health care. However, the IHS must have sufficient resources to meet its mission to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.

Maintaining a consistent and constant level of health care funding for Native Americans is vital to ensuring that the Indian Health Service, tribal, and urban Indian health care (I/T/U) programs can provide uninterrupted care. We thank you for recognizing the importance of the health care needs of Native Americans with your support of advanced appropriations for the IHS for FY 2025.

However, while the advanced appropriations provide stability for services, they do not allow for program growth which is especially important since the IHS estimates the nation’s Native American population will grow by 1.8 percent in 2026.

A long-standing priority for our organizations has been to ensure that the services provided by the I/T/U health care programs be maintained to meet the current and future AI/AN population needs. As you work to finalize FY 2025 appropriations for the IHS, we urge you to include several significant budget increases that we believe will dramatically improve the delivery of health care to AI/ANs.

Health Professions Workforce needs

The Indian Health Professions account provides loan repayment, the Service’s best recruitment tool, for providers who work in Indian Country. It also funds scholarships for Native American health care students. Currently, the IHS lacks sufficient funding to meet its needs. There are over 1,330 vacancies for health care professionals within IHS including: physicians, dentists, nurses, pharmacists, physician assistants, and nurse practitioners. Additionally, the IHS reported in its FY 2025 budget justification that it had 455 loan repayment applications from 85 behavioral health providers, 29 dentists, 52 NPs/PAs and 166 nurses that it could not fund. The inability to fund these applicants is a significant challenge for the recruitment efforts of the Service. For FY 2025, the Administration is requesting $81,252,000 for the Indian Health Professions account. This is a $684,000 increase that will fail to make any meaningful dent in the backlog of loan repayment applicants or the high vacancy rate across the system. It has been estimated that it would take approximately $18,000,000 to close this gap. We therefore request $18,000,000 for the Indian Health Professions account for FY 2025.

Making IHS loan repayment and scholarships tax free

We appreciate that the Committee is under pressure to cut back federal funding for all programs. Therefore, we urge the Committee to authorize, in its FY 2025 Interior Appropriations bill, legislation to provide a tax exemption for the Indian Health Service Health Professions Scholarship and Loan Repayment Programs. The IHS is currently paying more than $9 million in taxes for these programs. If the loan repayment and scholarship programs were made tax-free, it would enable the Service to fund 218 more providers without increasing the Indian Health Professions account. This is in line with the National Health Service Corps and other federal loan repayment programs that all enjoy tax-free status.

Staff quarters                                                                                                  

Decent staff housing is also key for the IHS and tribes to be able to recruit health care personnel. Many of the 2,700 staff quarters in the IHS health delivery system are more than 40 years old and in need of major renovation or total replacement. Additionally, in several locations, the amount of housing units is insufficient. Staff quarters, especially in remote areas, is necessary for attracting and keeping health care providers in Indian Country.

We were pleased to see that, for FY 2025, the Administration has requested $11 million for new and replacement staff quarters. We urge the Committee to fund this request and if possible, to increase it.

Medical and diagnostic equipment

Health care professionals need modern equipment to make accurate clinical diagnoses and prescribe effective medical treatments. The I/T/U health programs manage approximately 90,000 devices consisting of laboratory, medical imaging, patient monitoring, pharmacy, and other biomedical, diagnostic, and patient equipment. However, many of these facilities are using outdated equipment like analog mammography machines. In some cases, they are using equipment that is no longer manufactured. Today’s medical devices/systems have an average life expectancy of approximately six to eight years. The IHS has calculated for several years that to replace the equipment at the end of its six to eight-year life would require approximately $100 million per year. For FY 2025, the Administration has requested $33,874,000. This is an increase of only $1,276,000 over the current funding of $32,598,000 which was the same amount appropriated in FY 2023 and FY 2024. We urge the Committee for FY 2025 to fund the Indian Health Facilities equipment account at the House-approved FY 2024 amount of at least $42,862,000.

Electronic Health Records

Being able to have a modern electronic health record (EHR) system is necessary to enable the IHS and tribal health professionals to provide accurate and vital health care for patients. The IHS uses its EHR for all aspects of patient care, including maintaining patient records, prescriptions, care referrals, and billing insurance providers that reimburse the Service for over $1 billion annually. We urge the Committee to support the Administration’s request of $435 million that provides an additional $213 million to modernize its system and ultimately replace IHS’s current medical, health, and billing records systems.

Thank you for considering our requests. We look forward to working with you to improve health care for American Indians and Alaska Natives.

Sincerely yours,

American Academy of Pediatrics
American Association of Colleges of Nursing
American Association of Colleges of Osteopathic Medicine
American Dental Association
American Dental Education Association
American Medical Association
Association of Diabetes Care & Education Specialists
Commissioned Officers Association of the USPHS
International Certification & Reciprocity Consortium

20 Senators Request Increased Resources and Stable Funding for Urban Indian Health in FY 2025

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On May 14, 2024, 20 Senators requested up to $965.3 million for urban Indian health in Fiscal Year (FY) 2025 and advance appropriations for the Indian Health Service (IHS).

Sen. Tina Smith (D-MN) and 19 other Senators sent a letter to Chairman Jeff Merkley (D-OR) and Ranking Member Lisa Murkowski (R-AK) of the Senate Interior Appropriations Committee requesting up to $965.3 million for urban Indian health as part of the Tribal Formulation Workgroup’s topline request of $53.85 billion for IHS in FY 2025. The letter also requests the Appropriations Committee maintain advance appropriations for IHS for FY26. The letter emphasizes the critical role that Urban Indian Organizations (UIOs) play in the health care delivery to American Indian and Alaska Native patients and the importance of providing UIOs with the necessary funding to continue to provide quality, culturally competent care to their communities. On May 1, 2024, a group of 52 Representatives sent a letter to the House Interior Appropriations Committee with the same requests.

The letter also notes that chronic underfunding of IHS and urban Indian health has contributed to the health disparities among American Indian and Alaska Native people living in urban areas that suffer greater rates of chronic disease, infant mortality, and suicide compared to other populations.

This letter sends a clear and powerful message to Chairman Merkley and Ranking Member Murkowski and the members of the Senate that funding for urban Indian health must be significantly increased to fulfill the federal government’s trust responsibility to provide quality healthcare to all American Indian and Alaska Native people.

NCUIH is grateful for the support of the following Senators:

  1. Tina Smith
  2. Tammy Baldwin
  3. Maria Cantwell
  4. Ben Luján
  5. Edward Markey
  6. Alex Padilla
  7. Jack Rosen
  8. Jon Tester
  9. Chris Van Hollen
  10. Elizabeth Warren
  11. Amy Klobuchar
  12. Catherine Cortez Masto
  13. Laphonza Butler
  14. Kyrsten Sinema
  15. Ron Wyden
  16. Mark Kelly
  17. Kirsten Gillibrand
  18. Richard Blumenthal
  19. Tammy Duckworth
  20. Michael Bennet

Full Letter Text

Dear Chairman Merkley and Ranking Member Murkowski,

We write to thank you for your proven commitment to the Indian health system, including Urban Indian Organizations (UIOs), and to request you continue your support by funding urban Indian health at the highest level possible, up to $965.3 million, and retaining advanced appropriations for the Indian Health Service (IHS) in the Fiscal Year (FY) 2025 Interior, Environment, and Related Agencies Appropriations Act.

These requests reflect the full need for urban Indian health determined by the Tribal Budget Formulation Workgroup, which is comprised of Tribal leaders representing all twelve IHS service areas. The Workgroup recommended this funding amount for urban Indian health as a part of a $53.85 billion topline recommendation for the Indian Health Service.

UIOs are an important part of the IHS, which oversees a three-prong system for the provision of health care: Indian Health Service, Tribal Programs, and Urban Indian Organizations (I/T/U).UIOs 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. They serve patients from over 500 federally recognized Tribal Nations in 38 urban areas across the country. UIOs are not eligible for other federal line items that IHS and Tribal facilities are, like hospitals and health clinics, money, purchase and referred care dollars, or IHS dental services dollars. Therefore, this funding request is essential to providing quality, culturally-competent health care to AI/AN people living in urban areas.

Chronic underfunding of IHS and urban Indian health has contributed to the health disparities among AI/AN people. Additionally, AI/AN people living in urban areas suffer greater rates of chronic disease, infant mortality, and suicide compared to all other populations. Urban Native populations are less likely to receive preventive care and are less likely to have health insurance. Additional funding is critical to addressing this disparity.

In order to fulfill the federal government’s trust responsibility to all AI/AN people to provide quality healthcare, funding for urban Indian health must be significantly increased. It is also imperative that such an increase not be paid for by diminishing funding for already hard-pressed IHS and Tribal providers. The solution to address the unmet needs of urban Native and all AI/AN people is an increase in the overall IHS budget.

Thank you for your continued support of urban Indian health and your consideration of this important request.

NCUIH Urges Congress to Protect the Indian Health Service from Automatic Budget Cuts in FY 2024

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On January 29, 2024, the National Council of Urban Indian Health (NCUIH) sent a letter to Congressional Leadership to request that Congress protect the Indian Health Service (IHS) from sequestration in the fiscal year (FY) 2024 funding bill. Sequestration of funding for IHS would jeopardize the capacity of Urban Indian Organizations (UIOs) to provide culturally appropriate essential services and impact access to care. Any reduction in funding for IHS and UIOs does not uphold the federal trust responsibility to provide health care services to American Indian and Alaska Native people.

Background

On June 3, 2023, the Fiscal Responsibility Act (FRA) passed with the purpose to suspend the debt limit and reinstitute discretionary spending limits in FY 2024 and FY 2025 for both defense and nondefense discretionary spending. To ensure Congress passes appropriations in a timely manner, the FRA includes a provision mandating sequestration if Congress does not meet certain deadlines. Sequestration refers to automatic spending cuts that occur through the withdrawal of funding for certain government programs.

On January 4, 2024, the Congressional Budget Office sent a letter to the House Budget Committee outlining that a Congressional approval of a full-year appropriations deal could result in a potential 9 percent sequestration, if the full-year funding is set at the amounts in the current continuing resolution. If the sequestering of funds occurred, it would significantly impact already underfunded UIOs. Current funding levels pose challenges for UIOs in offering competitive salaries to attract and retain qualified staff who are essential for delivering quality care to their communities. Additionally, UIOs need resources to expand their services and programs, including addressing pressing issues such as food insecurity, behavioral health challenges, and rising facilities costs.

Next Steps

NCUIH will continue to advocate to Congress to protect funding for IHS and UIOs in any FY24 spending bills. Congress must ensure that UIOs have the necessary resources to guarantee that American Indians and Alaska Natives receive the comprehensive and culturally competent healthcare services they deserve.

Full Text of the Letter

RE: Protect the Indian Health Service from Sequestration in the 2024 Funding Bill

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

On behalf of the National Council of Urban Indian Health (NCUIH) and the 41 urban Indian organizations (UIOs) that we represent, we write to respectfully request that the final Fiscal Year (FY) 2024 funding bill include a sequestration exemption for the Indian Health Service (IHS). Per the January 4, 2024 letter from the Congressional Budget Office to the House Budget Committee, approval of a full-year appropriations deal by Congress could result in an estimated 9 percent sequestration, if full-year funding is set at the amounts in the current continuing resolution. Such a reduction in funding would severely impact Indian Health Care Providers, including UIOs, who are on the front lines in working to provide for the health and well-being of American Indians and Alaska Natives in urban areas, many of whom lack access to the health care services that it is the United States trust responsibility to provide.

Sequestration forces Indian health-providers to make difficult decisions about the scope of healthcare services they can offer to 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 AI/AN patients. 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 Natives 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. Sequestering funds 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.

Indian Country is united in its stance that the Indian healthcare system cannot support any reduction in funding. On September 22, 2023, NCUIH joined the National Congress of American Indians (NCAI), National Indian Health Board (NIHB), and five other national Native organizations in a joint press statement opposing any reductions in funding for vital Indian Country programs and reminding Congress that Native lives should never be used as political pawns.

Protecting IHS from sequestration is essential to upholding the federal trust responsibility to American Indian and Alaska Native people, and therefore we urge you to exempt IHS from sequestration in the final funding bill for FY24. As Chair Mike Simpson (R-ID-2) stated at a recent Full Appropriations Committee markup, “We have a moral and a trust responsibility to the Indians of this country, and we need to make sure that we are trying to address that. We still have a long way to go, but we are moving in the right direction.”

For additional information, please contact Meredith Raimondi, Vice President of Public Policy and Communications at the National Council of Urban Indian Health at mraimondi@ncuih.org. Thank you for your time and consideration.

Sincerely,
Francys Crevier, J.D.
Chief Executive Officer

NCUIH Joins NIHB and 21 Tribal Nations and Native Partner Organizations in Advocating for Tribal Sovereignty Payments for FY 2024

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On July 12, 2023, the National Council of Urban Indian Health (NCUIH) joined the National Indian Health Board (NIHB) and 21 Tribal Nations and Native partner organizations in sending a letter to House and Senate leadership regarding the Administration’s proposed fiscal year (FY) 2024 Interior, Environment, and Related Agencies Appropriations Bill. In the letter, they state their support for the President’s FY 2024 proposal to reclassify Contract Support Costs (CSC) and Section 105(l) Tribal Lease Payments as mandatory appropriations and to increase program administration staff. They also urge Congress to include the proposal in their FY 2024 Interior bill.

Read the Full Letter

Full Letter Text:

Dear Chair Murray, Chair Granger, Vice Chair Collins, and Ranking Member DeLauro:

On behalf of the undersigned Tribal partner organizations and the 574+ sovereign federally recognized American Indian and Alaska Native (AI/AN) Tribal nations we serve, we write in strong support of the President’s fiscal year 2024 (FY24) proposal to reclassify Contract Support Costs (CSC) and Section 105(l) Tribal Lease Payments as mandatory appropriations and to increase program administration staff. We respectfully urge you to include the proposal in the FY24 Interior, Environment, and Related Agencies Appropriations Bill (herein “Interior bill”).

The Appropriations Committees recognized as far back as 2014 that the mandatory nature of CSC obligations places the appropriators in an “untenable position.” As they wrote in the Explanatory Statement that year, “[t]ypically obligations of this nature are addressed through mandatory spending, but in this case since they fall under discretionary spending, they have the potential to impact all other . . . equally important tribal programs.” Similarly, appropriators stated in the FY 2021 Explanatory Statement for the Interior bill that 105(l) leases, as confirmed in the Maniilaq cases, appear to create an entitlement to compensation . . . that is typically not funded through discretionary appropriations. Tribal participation in ISDEAA programs has increased rapidly over the past decade, and Congress continues to struggle to meet CSC and Section 105(l) funding obligations through discretionary appropriations. In their Explanatory Statements, the Committees called on the agencies and Congress to find a sustainable solution including mandatory reclassification.

The Fiscal Responsibility Act severely restricted discretionary appropriations for FY24 and FY25. The Act also provided new mandatory appropriations to offset cuts to discretionary appropriations for some agencies, but provided no such relief for the federal government’s treaty and trust obligations to Tribal nations. Agencies estimate that Tribal sovereignty payments will increase by almost $392 million (27%) in FY24. Despite this increase, the House and Senate have proposed cuts to the Interior bill by 35 percent and 3 percent, respectively. Deeper cuts elsewhere in the bill to offset Tribal sovereignty payment increases are, thus, inevitable.

Immediately moving these two accounts to mandatory is good risk management for the United States because the amount is already mandatory in nature and there is a mechanism for controlling costs. If the goal or intent is better fiscal management or maintaining annual control over federal spending, then leaving accounts in the discretionary process with standing to sue that would also generate additional administrative or legal costs if any underpayment or delay were to occur is wasteful and misleading, at best, and intentionally reckless, at worst. Since the amount is already mandatory in nature, there is nothing added to the mandatory budget by moving this authority to the mandatory side of the federal ledger. It does not take away any new money or create any new authority. In fact, it would benefit those with a keen fiscal eye because it would properly classify the authority for scoring purposes. Both CSC and Section 105(l) Lease Agreement accounts are necessarily bound by the parameters of the authorizing law and amounts are determined through sophisticated negotiations and calculations between parties with administrative avenues for recourse prior to suit. This means that the amount is determinable each year and can be determined into the future with reliability and accuracy. Further, it means that costs are controlled and defined by the amount of resources provided for HHS and DOI programs, services, functions, or activities in the Interior bill, along with other quantifiable measures like employee pay costs.

There is a better way to manage and score this authority for the American people and that is by providing such sums as may be necessary for these accounts through mandatory spending. Reallocating base funding from discretionary to mandatory funding has a net zero impact on the Federal budget and would not undermine the Fiscal Responsibility Act. Moreover, as mandatory appropriations in the Interior bill, the Appropriations Committees would retain oversight of the programs. The President’s proposal is sound, reasonable, and fair. Our organizations recognize and appreciate your strong leadership and support over the years for Tribal self-determination. For the sake of continuing to improve the federal government’s commitments to meeting its trust and treaty obligations under your leadership, we urge you to include the President’s Tribal sovereignty payments proposal in the FY24 Interior bill.

Full List of Letter Supporters

The full list of supporting Tribal Nations and Native Partner Organizations is as follows:

Tribal Nations:

Native Partner Organizations:

FY 2024 Appropriations Background & Update

On March 17, 2023, IHS published their FY 2024 Congressional Justification with the full details of the President’s Budget, which included $1.6 billion in proposed mandatory funding for Contract Support Costs, Section 105(l) Leases, and the Special Diabetes Program for Indians.

On May 10, the Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies held a hearing to review the President’s Budget for the Indian Health Service (IHS) for FY 2024. IHS Director Tso discussed the importance of contract support costs and 105(l) leases as tools for tribal self-governance, and Senators Merkley and Murkowski expressed support for their classification as mandatory funding.

The House Appropriations Subcommittee on Interior, Environment, and Related Agencies recently released its FY 2024 Appropriations bill on July 12, rejecting the Administration’s proposal and Tribal requests to make contract support costs and Tribal leases mandatory spending.

NCUIH Urges Senate and House Appropriations Committees to Provide Full Stable Funding for IHS and Urban Indian Health in FY 2024

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On April 8, 2023, the National Council of Urban Indian Health (NCUIH) sent a letter to Chairman Jeff Merkley (D-OR) and Ranking Member Lisa Murkowski (R-AK) of the Senate Interior Appropriations Committee requesting full funding for the Indian Health Service (IHS) and urban Indian health, advance appropriations for IHS, and resources for Native behavioral health in Fiscal Year (FY) 2024. On March 24, 2023, NCUIH also sent a letter to Chairman Kay Granger (R-TX-12) and Ranking Member Rosa DeLauro (D-CT-3) of the House Interior Appropriations Committee with the same requests.

The letter emphasizes the critical role that urban Indian organizations (UIOs) play in health care delivery to American Indian and Alaska Native (AI/AN) patients and the importance of providing UIOs with the necessary funding to continue to provide quality, culturally competent care to their communities. The requests included in the letter are efforts to achieve parity and uphold the federal trust responsibility for urban Natives.

In the letters, NCUIH requested the following:

  • $51.42 billion for IHS and $973.59 million for Urban Indian Health for FY24, as requested by the Tribal Budget Formulation Workgroup (TBFWG)
  • Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
  • Appropriate $80 million for the Native Behavioral Health Resources Program

These requests come at an important time to protect funding for urban Indian health. Current debt ceiling negotiations by Congress include proposals to cut spending for domestic programs and return funding for federal agencies to FY 2022 levels. These proposals would be detrimental to the success of IHS, Tribal organizations, and UIOs and would roll back historic funding levels that contribute to better health outcomes for Native communities. It is important that members of the House and Senate work to protect the health of all American Indians and Alaska Natives.

Full Letter Text

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 help serve this population, we write to respectfully request that Congress honor the federal trust responsibility by ensuring the following asks for Indian Country in Fiscal Year (FY) 2024:

  • $51.42 billion for the Indian Health Service (IHS) and $973.59 million for Urban Indian Health for FY24, as requested by the Tribal Budget Formulation Workgroup (TBFWG)
  • Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
  • Appropriate $80 million for the Native Behavioral Health Resources Program

We applaud the Committee’s longstanding leadership to ensure the trust responsibility for health care is upheld and honored for all AI/AN, especially last year with achieving advance appropriations for IHS.

UIOs Play a Critical Role in Providing Health Care for AI/ANs

UIOs are on the front lines in providing for the health and well-being of AI/ANs living off-reservation, many whom lack access to care that would otherwise be provided through on-reservation health care facilities. UIOs play a critical role in fulfilling the federal government’s responsibility to provide healthcare for AI/ANs and are an integral part of the Indian health system, which is comprised of the IHS, Tribal organizations, and urban Indian organizations (collectively, the I/T/U system). UIOs are critical health care access points to help serve the over 70% of AI/ANs in urban areas. Congress must do more to fully fund the IHS to improve health outcomes for all Native populations.

Need for Full Funding of the Indian Health System including Urban Indian Health

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 effect 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. UIOs are reporting historic levels of patients, need funding to fulfill the needs of the majority of the AI/AN population. Full funding will empower UIOs to hire more staff, pay appropriate wages, as well as expand vital services, programs, and facilities. Congress must do more to increase funding as the current FY23 funding level of $90.49 million which is only 9.3% of the full FY24 amount requested by Tribes and UIOs to meet current need.

Retain Advance Appropriations for IHS until Mandatory Funding is Enacted and Protect IHS from Sequestration

We applaud 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.” Lapses in federal funding quite literally put lives at risk. During the shutdown at the start of FY 2019, the Indian health system was the only federal healthcare entity that shut down. UIOs are so chronically underfunded that several UIOS had to reduce services, lose staff, or close their doors entirely, forcing them to leave their patients without adequate care. It is imperative that advance appropriations provide certainty to the IHS system and ensure unrelated budget disagreements do not put lives at stake.

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, the automatic spending cuts that occur through the withdrawal of funding for government programs, 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.

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.

Conclusion

Among the most sacred of the duties encompassed within the federal trust responsibility is the duty to provide for Indian health care. The United State’s failure to fulfill its obligations to provide health care to urban Indians has real and devastating effects on our communities. We urge Congress to act swiftly to redress this problem by appropriating $51.42 billion for the Indian Health Service and $973.59 million for Urban Indian Health in the FY24 Interior, Environment, and Related Agencies Appropriations. NCUIH looks forward to working with you as you craft a budget that upholds the trust responsibility to urban Indians.

Resources

NCUIH Joins Families USA and 230 other Partner Organizations in Sending a Letter to Congress to Protect Medicaid from Cuts

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On April 20, 2023, Families USA, with 230 national and state partner organizations, including the National Council of Urban Indian Health (NCUIH), sent a letter to Majority Leader Schumer, Minority Leader McConnell, Speaker McCarthy, and Minority Leader Jefferies to protect Medicaid from proposed cuts amid debt limit negotiations. This letter is important to show opposition to any cuts to a critical program for the health of 91 million Americans with Medicaid coverage.

The letter highlights the need to protect Medicaid coverage as it provides healthcare access to populations that the American Healthcare System historically underserves, including 1.8 million  American Indians and Alaska Natives (AI/ANs), communities of color, and vulnerable populations such as seniors and people with disabilities.

Medicaid is critical to fulfilling the United States’ trust responsibility to maintain and improve AI/AN health. Cuts to Medicaid can result in patients at Urban Indian Organizations (UIOs) having inadequate health insurance coverage or gaps in coverage may cause UIO patients to delay or avoid medical care altogether.

Full Letter Text

Dear Majority Leader Schumer, Minority Leader McConnell, Speaker McCarthy, and Minority Leader Jeffries:

As leading national, state, and local organizations dedicated to promoting the health and well-being of America’s families, we are writing to underscore the critical importance of the Medicaid program and to express our united opposition to any proposals to cut Medicaid funding as part of upcoming negotiations over the federal budget, debt limit, or any other legislative priorities. We urge you to protect this vital program from cuts or harmful changes in any budget negotiations or other legislative venue this year.

Our health should not depend on our wealth in this country. Efforts to undermine Medicaid would harm millions of families whose health hangs in the balance when they cannot get the care they need otherwise. Medicaid is a lifeline to 91 million Americans, providing insurance coverage for millions of children, veterans, and people who own and work at small businesses. The program is a critical source of coverage to people who have historically been egregiously underserved by our health care system including people of color, particularly in Black, Latino, Asian American, Native Hawaiian and Pacific Islander, and Indigenous communities, and people living in rural communities. It provides health insurance to 6.9 million seniors and over 10 million people with disabilities, and covers 54 percent of long-term care services and 42 percent of all births in the country. Additionally, more than 60 percent of adults with disabilities qualified for Medicaid without supplemental security income (SSI), largely through Medicaid expansion under the Affordable Care Act (ACA).

The evidence is clear that when people have a reliable source of high-quality health coverage, they can access critical health services, including preventive care and behavioral health services; experience improved health outcomes and better overall health; and are protected against unexpected medical expenses. After the upheavals associated with the COVID-19 epidemic over the past three years, it is clearer than ever how critical Medicaid is to our country’s health and financial well-being.

In recent years, proposals to cut the Medicaid program have been thinly disguised as policies such as “per capita spending caps,” “block grants,” “provider tax reforms,” and bureaucratic “work requirements.” Since the passage of the ACA thirteen years ago, there have been continued attempts to repeal or otherwise undermine Medicaid expansion, which covers 18 million people in 40 states and Washington D.C., many of whom would otherwise go uninsured. No matter how they are framed, the reality of these policy proposals is that they destabilize state budgets and local economies, take health care away from millions of children, older adults, working parents, people with disabilities, and people of color with cascading harmful effects on small businesses, rural communities, health care providers and others.

These ideas are not new: they were resoundingly rejected by people across the country when they were proposed as part of efforts to repeal the ACA in 2017. Unsurprisingly, the American public continues to strongly oppose them – new polling shows that 71 percent of Americans say it is important to prevent Medicaid cuts. Our collective message is as clear today as it was then: cuts to the Medicaid program are unacceptable.

Background

Medicaid: A Critical Source of Coverage for AI/ANs

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

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

National Native Organizations Call on Administration to Urgently Fund New Behavioral Health Program for Native Communities from Omnibus

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On February 17, 2023, the National Council of Urban Indian Health (NCUIH), the National Indian Health Board (NIHB), Self-Governance Communication and Education Tribal Consortium, and the United South and Eastern Tribes Sovereignty Protection Fund sent a letter to request that the President include funding for the Native Behavioral Health Program authorized in the omnibus. Specifically, the organizations asked for the full authorized level of $80 million for the Native Behavioral Health Resources Program included in the Restoring Hope for Mental Health and Well-Being Act be funded in the President’s Fiscal Year (FY) 2024 Budget Request.

NCUIH particularly applauds Senator Tina Smith for her sponsorship and the co-sponsorship of Senator Cramer, Senator Tester, Senator Lujan, Senator Warren, and Senator Cortez Masto of the Native Behavioral Health Access Improvement Act of 2021, which was the foundation for the behavioral health provisions included in the Restoring Hope for Mental Health and Well-being Act. NCUIH also thanks Ranking Member Frank Pallone and Representative Raul Ruiz for championing this proposal to ensure that American Indians/Alaska Natives (AI/ANs) have greater access to resources necessary to address critical behavioral health needs and bring the federal government closer to fulfilling its trust obligations to AI/AN populations.

In particular, the letter outlines that the Restoring Hope for Mental Health and Well-Being Act includes a Native behavioral health provision that contains:

  • A funding authorization of no less than $125 million annually over a minimum of four fiscal years.
  • A mandate to deliver funding on a non-competitive basis.
  • The opportunity to receive funding through Indian Self-Determination Act contracts or compacts.
  • A requirement that any funding formulas be developed in consultation with Tribal Nations and conference with Urban Indian Health Organizations.
  • A requirement that reporting requirements be developed through a negotiated rulemaking process between the federal government, Tribal Nations, and Urban Indian Health Organizations.

This is in response to the high rates of behavioral health issues caused by centuries of generational trauma resulting from colonization and hostile acts of the United States Government. In fact, as outlined in the letter, 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.

Letter

Download Letter

Re: Native Behavioral Health Resources Program

Dear Director Young,

On behalf of the undersigned Tribal partner organizations, we write to urge the inclusion of the full authorized level of $80 million in the President’s Fiscal Year (FY) 2024 Budget Request to fund the Native Behavioral Health Resources Program as included in the Restoring Hope for Mental Health and Well-Being Act. Tribal Nations and our citizens continue to face high rates of behavioral health issues, caused by myriad factors, including centuries of generational trauma resulting from colonization and hostile acts of the United States government. Yet, in violation of federal trust and treaty obligations to provide comprehensive health care to Tribal Nations, we continue to lack substantial and sustained funding to address these challenges for current and future generations. As the collective trauma of living through the COVID-19 public health crisis only exacerbates and intensifies these issues, it is critical that Tribal Nations and the Indian Health System are equipped with the resources necessary to bring healing and recovery to our communities.

Between 1999 and 2015, the drug overdose death rates for American Indian and Alaska Native (AI/AN) populations increased by more than 500%. Addressing the challenges presented by the opioid crisis in Indian Country is further complicated by high rates of alcohol and substance abuse, suicide, and other serious mental health conditions. AI/AN populations experience serious mental illnesses at a rate 1.58 times higher than the national average, and Native youth experience the highest rates of youth suicide and depression in the country. Yet far too many facilities across the Indian Health System are unable to access the quality health care and services necessary to address these behavioral health issues. A survey conducted by the Indian Health Service (IHS) found that Tribal Nations rated the expansion of inpatient and outpatient mental health and substance abuse facilities as our number one priority. Currently, only 39% of IHS facilities provide 24-hour mental health crisis intervention services, and 10% of IHS facilities do not provide any crisis intervention services at all.

To combat the opioid epidemic and the broader behavioral health crisis in Indian Country, Tribal Nations and facilities across the Indian Health System require flexible and substantial funding to create behavioral health programs that are responsive to the unique circumstances facing our communities. Toward that end, along with Congressional partners, we urged at the end of the 117th Congress that the Restoring Hope for Mental Health and Well-Being Act include a Native behavioral health provision that contained the following:

  • A funding authorization of no less than $125 million annually over a minimum of four fiscal years;
  • A mandate to deliver funding on a non-competitive basis;
  • The opportunity to receive funding through Indian Self-Determination Act contracts or compacts;
  • A requirement that any funding formulas be developed in consultation with Tribal Nations and conference with Urban Indian Health Organizations; and
  • A requirement that reporting requirements be developed through a negotiated rulemaking process between the federal government, Tribal Nations, and Urban Indian Health Organizations.

Although only some of our priorities were adopted in the final bill and while centuries of underinvestment in mental and behavioral health across Indian Country will require sustained funding and thoughtful effort on the part of Congress and the Administration to properly address, funding the Native Behavioral Health Resources Program would represent a significant step toward this goal. We urge the Biden Administration to prioritize its trust and treaty obligations to Tribal Nations by supporting Tribal Nation access to federal mental health and substance use disorder programs, including the Native Behavioral Health Resources Program. We thank you for your attention to this matter and look forward to continued collaboration on improve health care throughout Indian Country.

Sincerely,
National Council of Urban Indian Health
National Indian Health Board
Self-Governance Communication and Education Tribal Consortium
United South and Eastern Tribes Sovereignty Protection Fund

Background

In response to these chronic health disparities and the dire need for behavioral health resources for Indian health care providers, the House Energy and Commerce Committee drafted bipartisan legislation creating the Native Behavioral Health Resources Program. This legislation was included in the House-passed Restoring Hope for Mental Health and Well-Being Act (H.R.7666), and ultimately included in the Consolidated Appropriations Act, 2023. This provision authorized to be appropriated $80 million for the Native Behavioral Health Resources Program.

NCUIH Joins NIHB and over 130 Tribal Nations and Other Organizations in Urgent Push for Stable Funding for the Indian Health Service

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As Native American Heritage Month ended, advocates for Native communities joined together during the Tribal Nations Summit in Washington, DC to call for Congress and the White House to enact Advance Appropriations for Indian health now.

On December 12, 2022, the National Council of Urban Indian Health (NCUIH) joined the National Indian Health Board (NIHB) and over 130 groups, including Urban Indian Organizations (UIOs), Tribal Nations, and friends of Indian health in sending letters to the President and Congressional leadership while negotiations on Fiscal Year (FY) 2023 spending are currently underway. The letters request support for the House-passed funding of $8.121 billion for the Indian Health Service (IHS) for FY 2023 and advance appropriations for IHS for FY 2024. The urgency is being felt among advocates as the government is currently funded under a Continuing Resolution through December 16. During the last government shutdown, UIOs reported at least 5 patient deaths and significant disruptions in patient services. Securing stable funding for IHS in the final FY 2023 omnibus has been a major priority for Indian Country to ensure the continuation and delivery of health services to all Native people regardless of where they live.  There is bipartisan support for ensuring advance appropriations and ending budget delays for the Indian Health Service.

This week, allies joined in support of a Day of Action on November 30, 2022 on the last day of Native American Heritage Month and the first day of the White House Tribal Nations Summit.

Photo of Chairman W. Ron Allen

Native Leaders Call on Congress to Act Now on Advance Appropriations

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A Bipartisan Tradition: Supporting Stability for the Indian Health Service Unites a Divided Congress

Currently, 107 current Members of Congress have expressed support for advance appropriations for the Indian Health Service since the first bill was introduced by the late Representative Don Young (R-AK-At Large; H.R. 3229) and Senator Lisa Murkowski (R-AK; S. 1570) in 2013. Closing today, House Native American Caucus Co-Chairs Sharice Davids (D-KS-03) and Tom Cole (R-OK-04) are leading the third bipartisan letter of the year to the House Appropriations Committee calling for advanced appropriations for IHS to be included in the final FY23 Appropriations bill. Members of Congress also joined the Day of Action conversation by expressing their direct support for protecting IHS funding. For example:

  • Longstanding sponsor of the Indian Health Service advance appropriations, Rep. Betty McCollum (D-MN-04) called on her colleagues to vote in support of advance appropriations and stated that “Vital health care services should NOT be interrupted if there’s a government shutdown.”
  • Former Chair of the Senate Committee on Indian Affairs and current Committee Member, Senator John Tester (D-MT) stated, “Our Native communities deserve a stable health care system—yet the Indian Health Service is the only major federal provider without stable funding. I stand with advocates across Indian Country today in pushing for advance appropriations for the IHS.”
  • Champion of the Honoring Promises to Native Nations proposal, Senator Elizabeth Warren (D-MA) said, “IHS is the only major federal provider of health care that faces budget uncertainty. It’s time for Congress to guarantee predictable funding and end this inequity.”
  • Melanie Stansbury (D-NM-01), member of the House Natural Resources Committee, stated that “When budget negotiations falter, Indigenous lives are at stake… I stand with Indigenous communities in support of advance appropriations for the Indian Health Service.”.
  • Staunch advocate for IHS on the Energy and Commerce Committee, Rep. Raul Ruiz (D-CA-36) stated that “Lack of funding shouldn’t be an impediment for our Tribes to receive the lifesaving services they need and deserve.”
Full List of Letter Supporters

The full list of supporting Tribal Nations and organizations is as follows:

Tribal Nations:
  • Absentee Shawnee Tribe of Oklahoma
  • Caddo Nation
  • Chickasaw Nation
  • Citizen Potawatomi Nation
  • Cloverdale Rancheria of Pomo Indians of California
  • Confederated Tribes of the Colville Reservation
  • Cowlitz Tribe
  • Fond du Lac Band of Lake Superior Chippewa
  • Jamestown S’Klallam Tribe
  • Jamul Indian Village of California
  • Keweenaw Bay Indian Community
  • La Posta Band of Mission Indians
  • Lummi Indian Business Council
  • Manchester Point Arena Band of Pomo Indians
  • Match-E-Be-Nash-She-Wish Band of Pottawatomi Indians (Gun Lake Tribe)
  • Mississippi Band of Choctaw Indians
  • Nez Perce Tribe
  • Oneida Nation
  • Pechanga Band of Indians
  • Peoria Tribe of Indians of Oklahoma
  • Poarch Creek Indians
  • Pueblo of Tesuque
  • Pyramid Lake Paiute Tribe
  • Rappahannock Tribe
  • Resighini Rancheria
  • Saint Regis Mohawk Tribe
  • San Carlos Apache Tribe
  • Sault Ste. Marie Tribe of Chippewa Indians
  • Skokomish Tribe
  • Sokaogon Chippewa Community
  • Standing Rock Sioux Tribe
  • Swinomish Indian Tribal Community
  • Tohono O’odham Nation
  • Tsalagiyi Nvdagi Tribe
  • Tunica-Biloxi Tribe of Louisiana
  • Upper Mattaponi Indian Tribe
  • Walker River Paiute Tribe
  • Wampanoag Tribe of Gay Head (Aquinnah)
  • Ysleta del Sur Pueblo
Organizations:
  • ACA Consumer Advocacy
  • AI/AN Health Partners
  • Alaska Native Health Board
  • Alaska Native Tribal Health Consortium
  • Albuquerque Area Indian Health Board, Inc.
  • American Academy of Dermatology Association
  • American Academy of Pediatrics
  • American Indian Health & Services
  • American Indian Health Commission for Washington State
  • American Indian Health Service of Chicago
  • Association on American Indian Affairs
  • Bakersfield American Indian Health Project, Inc.
  • Bristol Bay Area Health Corporation
  • California Consortium for Urban Indian Health
  • California Rural Indian Health Board
  • Canoncito Band of Navajos Health Center
  • Caring Ambassadors Program
  • Choctaw Health Center
  • Coalition of Large Tribes
  • Colorado Consumer Health Initiative
  • Consolidated Tribal Health Project, Inc.
  • Cook Inlet Tribal Council, Inc.
  • Copper River Native Association
  • Council of Athabascan Tribal Governments
  • Every Texan
  • Fallon Tribal Health Center
  • Families USA
  • Family Voices
  • First Focus on Children
  • Fresno American Indian Health Project
  • Great Lakes Area Tribal Health Board
  • Great Plains Tribal Leaders’ Health Board
  • Health Care Voices
  • Hepatitis C Mentor & Support Group, Inc.
  • Hunter Health
  • Indian Health Care Resource Center of Tulsa
  • Indian Health Center of Santa Clara Valley
  • Indigenous Pact
  • Inter Tribal Association of Arizona
  • International Association for Indigenous Aging
  • International Association of Forensic Nurses
  • Justice in Aging
  • Kansas City Indian Center
  • Kids Forward
  • Maniilaq Association
  • Metro New York Health Care for All
  • Michigan League for Public Policy
  • National Association of Pediatric Nurse Practitioners
  • National Council of Urban Indian Health
  • National Indian Health Board
  • National Indigenous Women’s Resource Center
  • National League for Nursing
  • National Native American Boarding School Healing Coalition
  • National Partnership for Women & Families
  • Native American Connections
  • Native American LifeLines, Inc.
  • Native American Rehabilitation Association of the Northwest, Inc.
  • Native Americans for Community Action, Inc.
  • NATIVE Project – Urban Indian Health Program – Spokane, WA
  • Nevada Coalition to End Domestic and Sexual Violence
  • Nisqually Tribal Health & Wellness Center
  • Northwest Harvest
  • Northwest Portland Area Indian Health Board
  • Oklahoma City Indian Clinic
  • Oklahoma Policy Institute
  • Partners In Health
  • R2H Action [Right to Health]
  • Riverside-San Bernardino County Indian Health, Inc.
  • Rocky Mountain Tribal Leaders Council
  • San Francisco AIDS Foundation
  • Sault Tribe Health Division
  • Seattle Indian Health Board
  • Self-Governance Communication & Education Tribal Consortium
  • SF Hep B Free – Bay Area
  • South Dakota Urban Indian Health
  • Southcentral Foundation
  • Southeast Alaska Regional Health Consortium
  • Southern Indian Health Council, Inc.
  • Southern Plains Tribal Health Board
  • Texas Native Health
  • Treatment Action Group
  • Tuba City Regional Health Care Corporation
  • United American Indian Involvement, Inc.
  • United South and Eastern Tribes Sovereignty Protection Fund
  • Universal Health Care Foundation of Connecticut
  • University of California San Francisco School of Medicine HEAL Initiative
  • Urban Inter-Tribal Center of Texas – Urban Indian Health Program – Dallas, TX
  • USAging
  • Wiconi Wakan Health and Healing Center
  • Work for Consolidated Tribal Health Project
Friends of Indian Health:
  • Angela Alvary
  • Ken Artis (Ho-Chunk Nation), Artis Law Office
  • Lana Fox
  • Miranda Carman, LCSW
  • Patricia Powers
  • Yana Blaise
Next Steps

NCUIH continues to advocate for the inclusion of advance appropriations for IHS in the final FY 2023 appropriations package. NCUIH will also provide updates on the status of advance appropriations in Congress during final negotiations.