Tag Archive for: Letters

NCUIH Sends Letter to HHS Requesting Exemption for IHS from Workforce Reduction Initiatives, Protection for IHS Funding

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On March 12, 2025, the National Council of Urban Indian Health (NCUIH) sent a letter to the U.S. Department of Health and Human Services (HHS) Secretary, Robert F. Kennedy, Jr., urgently requesting his immediate intervention to safeguard the Indian Health Service (IHS) workforce and funding. The letter requested that Secretary Kennedy exempt IHS from all current and future workforce reduction initiatives and rescind hiring freezes, and protect IHS funding including shielding IHS from sequestration and impoundment.

Read the full letter here.

Background

The United States Senate confirmed Robert F. Kennedy, Jr. as the Secretary for HHS on February 13, 2025. During his confirmation and remarks at the February HHS Secretary Tribal Advisory Committee (STAC) meeting, Secretary Kennedy emphasized his support for Indian Country, including having a Native person at the Assistant Secretary level in HHS. NCUIH looks forward to working with Secretary Kennedy to improve the health of Indian Country. During the meeting, Secretary Kennedy offered protections to Tribal leaders and the Indian health system, stating, “When they announced $9.6 billion in cuts to my agency—10% of our workforce—the one sub-agency I insisted must be protected was IHS. We safeguarded 1,000 jobs at IHS, and we will continue to do so. As new orders and additional cuts come down, protecting these jobs remains my priority.”

NCUIH Joins Indian Country Coalition in Urging the Department of Health and Human Services Secretary to Uphold Tribal Sovereignty and Protect Funding for Native Programs

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On February 14, 2025, the National Council of Urban Indian Health (NCUIH) joined a coalition of Tribal Organizations and national Native organizations in sending a letter to the U.S. Department of Health and Human Services (HHS) Secretary, Robert F. Kennedy, Jr., to congratulate Secretary Kennedy on his confirmation and request to meet to discuss implementing President Trump’s priorities in a manner that recognizes the sovereign governmental status of Tribal Nations and the United States’ longstanding trust and treaty obligations. The letter also requests that HHS ensure funding to Tribal Nations, Tribal citizens, and Tribal communities is neither paused nor reduced. Additionally, it urges HHS to exempt the Indian Health Service (IHS) and all employees in Tribal offices—or those responsible for delivering services or funding to Tribal Nations, their citizens, or communities—from any workforce reductions.

Read the letter here.

About the Tribal Coalition

NCUIH has joined a coalition with over 20 Tribal organizations to ensure administrative actions account for the government-to-government relationship between Tribes and the United States and the trust and treaty responsibility to Tribal nations and citizens.

The coalition has been active in creating joint messages to share with policy makers, sending letters to key administration officials, and developing advocacy strategies. Access the Tribal Coalition’s online resource hub, where you can find our letters and other advocacy tools.

NCUIH Joins Indian Country Coalition in Urging Office of Personnel Management to Protect Federal Employees Serving Indian Country from Workforce Reductions

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On February 14, 2025, the National Council of Urban Indian Health (NCUIH) joined a coalition of Tribes, Tribal Organizations and other national Native organizations in sending a letter to the Office of Personnel Management (OPM) Acting Director, Charles Ezell, requesting OPM take action to protect Federal employees who serve Indian Country from the planned reductions in force (RIF) as outlined in Executive Order 14210.

Specifically, the Letter asks Acting Director Ezell to exempt from any workforce reductions all employees of the Indian Health Service (IHS), Bureau of Indian Affairs (BIA), Bureau of Indian Education (BIE), and all Tribal offices throughout all Federal agencies, as well as other Federal employees whose role is to deliver services or funding to Tribal Nations or their citizens or communities. The Letter states that exercising RIF exemption authority with respect to these employees is necessary to fulfill the trust and treaty obligations owed to American Indian and Alaska Native people by the United States and to protect the unique political relationship with Tribal Nations and their citizens and communities. Exercising this authority also aligns with past and present federal practices and is necessary to avoid creating unintended life-or-death.

Following this advocacy, a February 17 report confirmed that U.S. Department of Health and Human Services (HHS) Secretary Kennedy rescinded the layoffs of 950 IHS employees. For NCUIH’s blog on the rescinded layoffs, click here.

About the Tribal Coalition

NCUIH has joined a coalition with over 20 Tribal organizations to ensure administrative actions account for the government-to-government relationship between Tribes and the United States and the trust and treaty responsibility to Tribal nations and citizens.

The coalition has been active in creating joint messages to share with policy makers, sending letters to key administration officials, and developing advocacy strategies. Access the Tribal Coalition’s online resource hub, where you can find our letters and other advocacy tools.

NCUIH Joins Indian Country Coalition in Urging Office of Management and Budget Director to Uphold Tribal Sovereignty and Protect Funding for Native Programs

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On February 14, 2025, the National Council of Urban Indian Health (NCUIH) joined a coalition of Tribal Organizations and national Native organizations in sending a letter to the Office of Management and Budget (OMB) Director, Russell Vought, to congratulate Director Vought on his confirmation and request to meet to discuss implementing President Trump’s priorities in a manner that recognizes the sovereign governmental status of Tribal Nations and the United States’ longstanding trust and treaty obligations. The letter also urges OMB to issue a mandate to all federal agencies to ensure that Tribal Nations and Tribal-serving entities are not further impacted by implementation of the President’s Executive Orders and policies, and exempt all Tribal programs across federal agencies from efforts to pause or reduce federal funding.

About the Tribal Coalition

NCUIH has joined a coalition with over 20 Tribal organizations to ensure administrative actions account for the government-to-government relationship between Tribes and the United States and the trust and treaty responsibility to Tribal nations and citizens.

The coalition has been active in creating joint messages to share with policy makers, sending letters to key administration officials, and developing advocacy strategies. Access the Tribal Coalition’s online resource hub, where you can find our letters and other advocacy tools.

NCUIH Joins NIHB in Letter to Congressional Leadership Advocating for Protecting the Indian Health System from Funding Freezes

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On January 31, 2025, the National Council of Urban Indian Health (NCUIH) joined the National Indian Health Board (NIHB) in sending a letter to House and Senate leadership to communicate concerns about the impacts of the Office of Management and Budget’s (OMB) now-rescinded memorandum that implemented a temporary pause in federal funding. In the Letter, NCUIH and NIHB urged Congress to communicate and work with Administration officials on guidance about the unique relationship Tribes have with the United States and include a broad Tribal exemption from any future funding restrictions or pauses.

While the recent OMB memorandum has been rescinded, we will continue to monitor this situation and any potential impacts on Indian Health Service funding.

Read the full letter here.

Background on the OMB Memorandum

In a memorandum dated January 27, 2025, the OMB Acting Director, Matthew Vaeth, instructed the heads of executive departments and agencies to temporary pause agency grant, loan, and other financial assistance programs. The now-rescinded memorandum would have temporarily paused “all activities related to obligation or disbursement of all Federal financial assistance, and other relevant agency activities that may be implicated” by recent executive order (EOs). These EOs concern topics such as financial assistance for foreign aid, nongovernmental organizations, diversity, equity and inclusion (DEI) programs, “woke gender ideology,” and the green new deal. OMB later rescinded the memorandum in a memorandum dated January 29, 2025.

NCUIH will continue to monitor any developments.

NCUIH Joins Indian Country Coalition in Urging Senate Leadership to Honor Trust and Treaty Obligations for Native People in Upcoming Budget Reconciliation

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On February 20, 2025, the National Council of Urban Indian Health (NCUIH) joined a coalition of Tribes, Tribal Organizations and other national Native organizations in sending a letter to Majority Leader Thune (R-SD) and Minority Leader Schumer (D-NY) expressing concerns and highlighting opportunities for Indian Country as Congress considers budget reconciliation legislation.

The letter addresses the proposed cuts to federal spending related to taxation, border security, education, infrastructure laws, Tribal Temporary Assistance Program for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP) and Medicaid. Specifically, any cuts or caps to programs such as TANF, SNAP, and Medicaid would reduce access to critical resources that can have a disproportionate impact on American Indian and Alaska Native people. Work requirements for SNAP and Medicaid would directly impact access to healthy food and healthcare, which does not honor the trust and treaty responsibilities to American Indian and Alaska Native people. The letter reinforces to Senate leadership that the inclusion of long-standing tax priorities and other legislative actions affirms Tribal sovereignty and the unique relationship with the federal government is in fulfillment of trust and treaty obligations to all American Indian and Alaska Native people.

About the Indian Country Coalition

NCUIH has joined a coalition with over 20 Tribal organizations to ensure administrative actions account for the government-to-government relationship between Tribes and the United States and the trust and treaty responsibility to Tribal nations and citizens.

The coalition has been active in creating joint messages to share with policy makers, sending letters to key administration officials, and developing advocacy strategies. Access the Tribal Coalition’s online resource hub, where you can find our letters and other advocacy tools.

Full Letter Text

Dear Majority Leader Thune and Minority Leader Schumer,

On behalf of the undersigned organizations that collectively serve sovereign Tribal Nations and their citizens and communities, we write to express concern and highlight opportunities for Indian Country as Congress considers budget reconciliation legislation. While we recognize that Congress is seeking to address broader issues related to taxation and border security, we remind you that proposed changes to federal spending and programs are likely to have a disproportionate impact on Tribal Nations and our people. In addition, Tribal Nations have long sought changes to the tax code aimed at extending the governmental parity they are due. To that end, we urge that any reconciliation bill protect and advance the interests of Tribal Nations and our people, in fulfillment of trust and treaty obligations.

Unique Legal Status of Tribal Nations. Tribal Nations are and always have been inherently sovereign governments that have strong political relationships with our Tribal citizens and community members. We govern and police our lands, and we provide services aimed at keeping our communities safe and healthy. Tribal Nations also have political, government-to-government relationships with the United States, and we prepaid with our lands and resources for the trust and treaty obligations that the United States owes us in perpetuity. The U.S. Constitution singles out Tribal Nations and Native people as unique, and the U.S. Supreme Court has time and again affirmed the principle that United States actions that deliver on trust and treaty obligations to Tribal Nations, Tribal citizens, and Tribal communities do not run afoul of the U.S. Constitution’s equal protection requirements.

Scope of Trust and Treaty Obligations. The United States fulfills its trust and treaty obligations both through the direct delivery of Tribal programs and services and the provision of federal funding to Tribal Nations to deliver services to our own communities. Any Tribal program or funding delivered to Tribal Nations—including through Urban Indian Organizations and Tribal organizations serving Tribal Nations—is provided in furtherance of the United States’ trust and treaty obligations. The federal employees necessary for the functioning of Tribal programs and the disbursement of Tribal funds are also part of the trust and treaty obligations. These actions are not discretionary; they are legal obligations rooted in treaties, trust obligations, the U.S. Constitution, and long-standing federal statutes.

Concerns with Potential Changes to Federal Programs and Spending. As you consider reconciliation legislation in the Senate, we ask that you work to exempt Indian Country from the harmful impacts of changes to federal spending and policy. Reductions in the scope or funding of the programs that we access are not only violations of trust and treaty obligations, but will have devastating impacts for our people. As the budget reconciliation process continues to unfold, we would like to highlight our deep concern and opposition to the inclusion of any language that reduces services or funding to Indian Country. We call upon you to ensure that exemptions are provided for Tribal Nations, Tribal serving organizations, and Native people within any reconciliation legislation, including, but not limited to, the following changes:

Medicaid is critical method by which the United States seeks to deliver upon trust and treaty obligations to provide health care to Tribal Nations. Medicaid resources are vitally important to supplementing the chronically underfunded Indian Health System (comprised of the IHS, Tribal providers, and Urban Indian Organizations). Reforms, such as cost caps, would shift costs to states for American Indian and Alaska Native (AI/AN) Medicaid beneficiaries who currently have their costs covered by 100% Federal medical assistance percentage (FMAP) when seen at an Indian Health Service (IHS) or Tribal facility. Further, conditioning access to Medicaid with work requirements fails to honor trust and treaty obligations, and are not reflective of on-the ground realities in Indian Country. Specifically, many AI/ANs are employed but face unique barriers that make it difficult to prove this. These include limited mail access, poor broadband, insufficient transportation infrastructure, and language barriers. Additionally, Medicaid resources are a critical consideration for Tribal Nations deciding whether to take over Indian Health Programs under the Indian Self-Determination and Education Assistance Act (ISDEAA). Reducing access to Medicaid resources will disincentivize Tribal Nations from electing to take over programs from the IHS and reduce access to much needed supplemental resources for existing Tribal, IHS, and Urban Indian Organizations. This includes any changes to the FMAP or Medicaid expansion. Both AI/AN people and the Indian Health System must be made exempt from any Medicaid reforms. The last time Congress considered Medicaid reform in 2017, it provided such exemptions, and we ask you to do the same again. In addition, the first Trump Administration approved several section 1115 waivers related to work requirements that exempted AI/ANs, including in Arizona, Indiana, South Carolina, and Utah. We support the letter the National Indian Health Board sent on January 31, 2025, and encourage you to refer to that statement for further information.

Changes to Education Funding Structures. As Congress looks to restructure the core of the American education system and redirect federal funding to the states, it is essential that any block grant funding must explicitly protect Tribal Nations and Tribal education systems as eligible entities with dedicated set-asides in each program, ensuring that Tribal Nations and Tribal education systems do not have to seek federal funding through state governments. We highlight the importance of Title III programs under Higher Education Act (HEA) (20 U.S.C. § 1057), Title VI programs under the Elementary and Secondary Education Act (ESEA) (20 U.S.C. § 7401), Title I programs under ESEA (20 U.S.C. § 6301), and Impact Aid under Title VII of ESEA (20 U.S.C. § 7701), as well as all programs administered through the Office of Indian Education (OIE). As these programs may be relocated to other agencies, we want to ensure the funding and staffing levels necessary to operate these programs move with them. We encourage Congress to look to the Child Care and Development Block Grant (CCDBG) as a model for successful Tribal set-asides and direct Tribal funding. 42 U.S.C. § 618(a)(3)(B) ensures that Tribal Nations and Tribal serving Organizations receive funds directly from the federal government, enabling them to operate their own childcare programs tailored to the needs of their communities without requiring them to seek federal funding through state governments.

Changes to TANF. Nearly half of all federally recognized Tribal Nations are now served by a Tribal Temporary Assistance for Needy Families (TANF) program, which enables them to better meet community needs, deliver services in ways that honor Tribal culture, and take advantage of additional flexibilities. An indiscriminate reduction in TANF funding will jeopardize this vital funding. We urge the exemption of the Tribal TANF Block Grant from any funding reductions.

Changes to SNAP. Similarly, the Supplemental Nutrition Assistance Program (SNAP) is a critical program ensuring millions of low-income families, including AI/ANs, have access to food. As a federal program, it is also a critical mechanism by which the United States meets its trust and treaty obligations to Tribal Nations and communities. Federal programs to combat hunger like SNAP are important to Tribal communities— approximately 25 percent of Native Americans receive some type of federal food assistance, and in some Tribal communities, participation is as high as 80 percent. Our populations must be exempt from any reductions in SNAP benefits, including any reductions related to work requirements.

Repeal of Infrastructure Laws. Under recently enacted federal infrastructure packages, including the Inflation Reduction Act (IRA) and the Infrastructure Investment and Jobs Act, Tribal Nations have access to over $14 billion in direct funding and are eligible for billions more in funding through competitive grants, loans, loan guarantees, tax credits, and contracts. This funding is essential to addressing centuries of unmet infrastructure obligations across Indian Country, and we urge you to ensure it continues to flow to Tribal communities and enterprises.

Inclusion of Tribal Tax Priorities. With bipartisan, bicameral support, the Tribal Tax and Investment Reform Act amends the Internal Revenue Code to bring parity for Tribal governments to access the same financing opportunities and engage in the same economic development and job creation activities available to state governments. Enactment of this legislation will remove persistent barriers to accessing the necessary capital required to support economic development and growth in Tribal communities, including through parity in the issuance of tax-exempt bonds. To that end, we urge the inclusion of all the bill’s provisions in any reconciliation legislation. We further request the addition of language recognizing and protecting the sovereignty of Tribal governments, including our ability to retain the revenue generated within our borders through taxation that does not have to compete with taxes states attempt to collect for activities on our lands.

In recognition of the government-to-government relationship between Tribal Nations and the United States, and the federal trust and treaty obligations owed to us, we ask that you work to protect Indian Country from becoming collateral damage in the budget reconciliation process. We have prepaid for the services and funding delivered to us, much of which could be jeopardized without an exemption from larger policy change or reductions. We stand ready to work with you on the inclusion of our long-standing tax priorities and other legislative action that upholds and recognizes our sovereignty and unique relationship.

Sincerely,
Affiliated Tribes of Northwest Indians
American Indian Higher Education Consortium
Great Plains Tribal Chairman’s Association, Inc.
Indian Gaming Association Midwest Alliance of Sovereign Tribes
National Congress of American Indians
National Council of Urban Indian Health
National Indian Child Welfare Association
National Indian Education Association
National Indian Health Board
Native American Finance Officers Association
Self-Governance Communication & Education Tribal Consortium
United South and Eastern Tribes Sovereignty Protection Fund

NCUIH Joins NIHB, NCAI and Self-Governance Communication and Education Tribal Consortium in Requesting the Indian Health System be Exempt from Federal Hiring Freezes

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On January 31, 2025, the National Council of Urban Indian Health (NCUIH) joined the National Indian Health Board (NIHB), National Congress of American Indians (NCAI), and Self-Governance Communication and Education Tribal Consortium in sending a letter to the U.S. Department of Health and Human Services (HHS) Acting Secretary, Dr. Dorothy Fink, regarding a memorandum issued by President Donald Trump instituting a federal civilian employee hiring freeze. The letter requests an exemption for the Indian Health Service (IHS) from any plans, policies, or incentives that seek to decrease its workforce because IHS is the principal health care provider for American Indian and Alaska Native people and is essential in fulfilling the United States legal and trust obligation to provide health care to American Indian and Alaska Native people. The letter also states that exempting IHS from the federal civilian position hiring freeze is critically necessary to protect public safety.

Read the full letter here.

Background on the Hiring Freeze

On January 20, 2025, President Trump issued a memorandum ordering a hiring freeze for federal civilian positions. The hiring freeze is not inclusive of military personnel. It also does not apply to positions related to immigration enforcement, national security, or public safety. The memorandum states that “nothing in this memorandum shall adversely impact the provision of Social Security, Medicare, or Veterans’ benefits.” The memorandum also instructs the Director of the Office of Management and Budget, in consultation with the Director of the Office of Personnel Management and the Administrator of the United States DOGE Service, to “submit a plan to reduce the size of the Federal Government’s workforce through efficiency improvements and attrition.”

NCUIH will continue to monitor any developments.

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