Tag Archive for: Maternal/Child Health

NCUIH Requests HHS Prioritize Urban Native Communities in Initiatives Aimed at Improving Health Equity

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On March 3, 2023, the National Council of Urban Indian Health (NCUIH) submitted comments to the Health and Human Services (HHS) Office of the Assistant Secretary for Health (OASH) regarding the HHS Initiative to Strengthen Primary Health Care (the Initiative). The Initiative aims to improve health equity and reduce barriers to care for traditionally underserved populations, included American Indians and Alaska Natives (AI/ANs).  As part of the Initiative, OASH has hosted listening sessions with Urban Indian Organizations (UIOs) and tribal leaders to collect input and inform HHS regarding the needs of AI/AN stakeholders and beneficiaries.

Background

Launched in September 2021, the goal of the Initiative is to develop a federal foundation for the provision of primary health care aimed to improve health outcomes and advance health equity for the improved health and wellness of patients, families/caregivers, and communities. Access to high-quality primary health care has been shown to improve health equity and health outcomes, and is essential for addressing key priorities, including mental and substance use disorder prevention and care, prevention and management of chronic conditions, addressing the impact of gender-based violence, and maternal and child health and well-being.

Generally, AI/ANs throughout the country experience the most significant health disparities of any group, when compared to the general population. Further, AI/ANs living in urban areas experience greater rates of chronic disease, maternal and infant mortality, and suicide compared to all other populations and they are less likely to receive preventive care and are less likely to have health insurance.

NCUIH’s Role

NCUIH recent comment and recommendations to OASH regarding the Initiative are based on NCUIH’s consultations with UIOs, and listening session held with UIO leaders on February 2, 2023, and NCUIH’s subject matter expertise. NCUIH reiterated that input from UIOs is vital for OASH effectively gather comprehensive feedback, share critical information, and build mutual trust.

Recommendations

In NCUIH’s comments to OASH regarding the Initiative, NCUIH recommended the following priorities:

  • Develop a better understanding of the health inequities pervasive in Native communities
  • Ensure primary care is culturally competent
  • Improve CMS Programs ability to serve American Indian and Alaska Native beneficiaries
  • Address workforce shortages at UIOs
  • Ensure that notices of funding opportunities are accurate and that UIOs have the technical assistance necessary to apply
  • Facilitate referrals of AI/AN patients in and out of the Indian health system, as well as within it
  • Establish an agency-wide Urban Confer Policy

NCUIH thanks OASH for hosting a UIO listening session and greatly appreciates the opportunity to provide feedback on the Initiative. We are heartened by HHS’ commitment to improving health equity and reducing barriers to care for the AI/AN community. We are especially grateful that OASH demonstrated this commitment by addressing NCUIH’s prior recommendation to host a meeting with UIOs regarding the Initiative.

President Biden Continues to Demonstrate Strong Commitment to Urban Indians, Proposes a 27% Increase for Urban Indian Health for FY 2024

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The FY 2024 budget request includes $115 million for urban Indian health, a 27% increase over the FY 2023 enacted amount, mandatory funding through FY 2033, and an IHS exemption from sequestration.

 On March 17, 2023, the Indian Health Service (IHS) published their Fiscal Year (FY) 2024 Congressional Justification with the full details of the President’s Budget, which includes $115 million for urban Indian health – a 27% increase above the FY 2023 enacted amount of $90.42 million. The President’s proposal included a total $144.3 billion in discretionary funding for the Department of Health and Human Services (HHS) and $9.7 billion in total funding for IHS— which maintains the $5.1 billion in advance appropriations enacted in the FY 2023 omnibus and includes $1.6 billion in proposed mandatory funding for Contract Support Costs, Section 105(l) Leases, and the Special Diabetes Program for Indians.

The budget proposes full mandatory funding for IHS from FY 2025 to FY 2033 to the amount of $288 billion over ten-years, as well as exempting IHS from sequestration. This mandatory formula would culminate in $44 billion for IHS in FY 2033, to account for inflation, staffing increases, long-COVID treatment, and construction costs. This move from discretionary to mandatory funding is essential as noted in the IHS Congressional Justification, “While the progress achieved through the enactment of advance appropriations will have a lasting impact on Indian Country, funding growth beyond what can be accomplished through discretionary spending is needed to fulfill the federal government’s commitments to Indian Country.”

Line Item   FY22 Enacted   FY23 Enacted  FY24 Tribal Request  FY24 President’s  Budget 
Urban Indian Health $73.43 million $90.42 million $973.6 million $115 million
Indian Health Service $6.6 billion $6.9 billion $51.4 billion $9.7 billion
Advance Appropriations ——————— $5.13 billion ——————— ———————
Hospitals and Clinics $2.3 billion  $2.5 billion  $12.2 billion $3.5 billion
Tribal Epidemiology Centers $24.4 million  $34.4 million  ——————– $34.4 million
Electronic Health Record System $145 million  $217.5 million  $491.9 million $913.1 million
Community Health Representatives $63.6 million  $65.2 million $1.2 billion $74.5 million
Mental Health $121.9 million  $127.1 million  $3.4 billion $163.9 million
Cancer Moonshot Initiative ——————— ——————— ——————— $108 million
HIV & Hepatitis ——————— ——————— ——————— $47 million

The National Council of Urban Indian Health (NCUIH) requested full funding for urban Indian health for FY 2024 at $973.59 million and at least $51.42 billion for IHS in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. The marked increase for FY 2024 is due to Tribal leaders’ budget recommendations to address health disparities that have historically been ignored. The Congressional Justification states the importance of addressing these disparities, “The COVID-19 experience in Indian Country illustrates the urgent need for large-scale investments to improve the overall health status of AI/ANs and ensure that the disproportionate impacts experienced during the pandemic are never repeated.”

Overview of Budget

Key Provisions for IHS, Tribal Organizations, and Urban Indian Organizations (UIOs)
  • $9.7 billion for IHS for FY 2024
  • $115 million for urban Indian health for FY 2024
  • $5.1 billion in Advance Appropriations for FY 2024
  • $1.2 billion in mandatory funding for Contract Support Costs
  • $153 million in mandatory funding for Section 105(l) Leases
  • $250 million in mandatory funding for Special Diabetes Program for Indians (SDPI)
Other Budget Highlights
  • Addressing Targeted Public Health Challenges
    • $47 million for HIV and Hepatitis C.
      • UIOs eligible
    • $3 million for improving maternal health.
      • UIOs eligible
    • $9 million for addressing opioid use.
      • UIOs eligible
  • Cancer Moonshot Initiative
    • $108 million
      • Develops a coordinated public health and clinical cancer initiative to implement best practices and prevention strategies to address the incidence of cancer and mortality among AI/ANs.
        • UIOs eligible
  • Division of Telehealth
    • $10 million
      • Manages and oversees a comprehensive telehealth program at IHS that will expand telehealth services, develop governance structures, provide training to users, and integrate with clinical services.
  • Division of Graduate Medical Education
    • $4 million
      • Expands and supports Graduate Medical Education programs to create a pathway for future physicians to address longstanding vacancy issues at IHS.
  • Indian Health Professions
    • $13 million
      • Offers additional IHS Scholarship and Loan Repayment awards, bolstering recruitment and retention efforts through these two high demand programs.
        • UIOs eligible
Legislative Proposal

Once again, the legislative proposal to amend federal law to permit the U.S. Public Health Service Commissioned Officers to be detailed to UIOs was proposed. This amendment to the Public Health Service Act would provide IHS the discretionary authority to detail officers directly to an UIO to perform work related to the functions of HHS.

Currently, there are 1,614 officers of the U.S. Public Health Service assigned to IHS. There are only 5 of these officers who are assigned to States, who have duty stations at UIOs.

The permittance of officers to be detailed directly to UIOs addresses the staff shortage that hinders the capacity of UIOs to improve access to health care for urban Natives. The strengthening of the IHS workforce will contribute to better health outcomes and reduce disparities.

Background and Advocacy

On March 9, 2023, President Biden released his budget request for Fiscal Year 2024, pending the more detailed IHS budget request released on March 17, including the funding recommendation for urban Indian Health.

On March 9, 2023, NCUIH Chief Executive Officer, Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding for UIOs. NCUIH requested funding in accordance with the requests of the TBFWG at funding levels of $973.59 million for urban Indian health and $51.42 billion for IHS, maintain advance appropriations until mandatory funding is achieved, and appropriate $8o million the Native Behavioral Health Resources Program. On March 24, NCUIH sent a letter to House Appropriations leadership, Chair Kay Granger and Raking Member Rosa DeLauro, reiterating these requests

Next Steps

The Appropriations Committees will review the President’s Budget for consideration as they craft their bills for FY 2024. NCUIH will continue to work with the Biden Administration and Congress to push for full funding of urban Indian health in FY 2024.

NCUIH Requests the Administration of Children and Families Host Urban Confer with UIOs Regarding the Tribal Maternal, Infant, and Early Childhood Home Visiting Program

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On January 27, 2023, the National Council of Urban Indian Health submitted comments to the Administration for Children and Families (ACF) in response to their December 20, 2022 request for comment on review of the Tribal Maternal, Infant, and Early Childhood Home Visiting Program (Tribal MIECHV) Guidance for Submitting Reports to the Secretary of the Office of Management and Budget (OMB). The Tribal MIECHV Program provides grants to tribal organizations and urban Indian organizations (UIOs) to develop, implement, and evaluate home visiting programs in American Indian and Alaska Native (AI/AN) communities.

Recommendations

NCUIH made the following recommendations to ACF in response to the request for comments:

  • NCUIH requested that ACF host an Urban Confer with UIO leaders to discuss the Tribal MIECHV program.
  • NCUIH recommended that ACF work with its colleagues at IHS to host and facilitate an Urban Confer on the annual reporting requirements for Tribal MIECHV grantees.
    • Given the substantial increase in the set-aside for the Tribal NCUIH further recommends that ACF consider broadening the scope of this Urban Confer to engage with UIOs on the Tribal MIECHV program generally.
    • This will provide ACF a forum in which to work with UIOs to ensure that they are participating in this program to the greatest extent possible and that urban Native communities are being served as Congress intended.

Background

Under the ACF, the MIECHV Program supports pregnant people and parents with young children who live in communities that face greater risks and barriers to achieving positive maternal and child health outcomes. The Tribal MIECHV program is funded by a six percent set-aside from the larger MIECHV program. The Tribal MIECHV program aims to support the development of happy, healthy, and successful AI/AN children and families through a coordinated home visiting strategy that addresses critical maternal and child health, development, early learning, family support, and child abuse and neglect prevention needs. It also implements high-quality, culturally relevant, evidence-based home visiting programs in AI/AN communities and expands the evidence base around home visiting interventions with Native populations.

Urban Native Maternal and Child Health Disparities

Native people have endured a tragic history of forced removal from their homelands throughout eras of colonization and US expansion. Formally dating back to the 1800s, forced removal included the loss of ancestral homelands,  children taken from their parents and placed into government boarding schools, and policy aimed at integrating Native people into US cities, each resulting in traditional and cultural deprivation. This migration into cities has resulted in urban Indians experiencing more unemployment and homelessness compared to the general population, lower levels of educational achievement, higher rates of morbidity and mortality and a loss of traditional and cultural connection. Urban Indian women have considerably lower rates of prenatal care and higher rates of infant mortality than their reservation counterparts within the same state. While UIOs provide critical health and social services, the safety net available to those living on reservations is often not matched in urban environments. Recognizing the health disparities experienced by urban Indians, MIECHV legislation allows Tribal MIECHV funds to be awarded to UIOs to further support the health and social needs of Native people living in urban areas.

NCUIH’s Role

NCUIH has engaged in extensive policy work, including attending Congressional meetings and joining sign-on letters with coalition partners, in support of reauthorizing the MIECHV program and doubling the Tribal set-aside. NCUIH was pleased that Congress reauthorized the Tribal MIECHV program and increased the funding level. The Tribal MIECHV program helps improve the lives of AI/AN children and families and NCUIH looks forward to more UIOs becoming grantees and working with ACF to support the development of happy, healthy, and successful Native children and families no matter where they live.

NCUIH Recommendations Included in Report on Improving the Health and Safety of American Indian and Alaska Native Mothers and Infants

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On December 7, 2022, the Health and Resources and Services Administration (HRSA) Advisory Committee on Infant and Maternal Mortality (ACIMM) submitted a report to the Health and Human Services (HHS) Secretary Xavier Becerra titled: “Making Amends: Recommended Strategies and Actions to Improve the Health and Safety of American Indian and Alaska Native Mothers and Infants.” The report offers a set of recommended actions that could be among the many steps the Federal government may take, both to reconcile past actions and to step up to the obligations to American Indians and Alaska Natives (AI/AN) that it has abrogated since the founding of our nation. The National Council of Urban Indian Health (NCUIH) played an integral role in the report to ensure the needs of off-reservation AI/AN mothers were included. The report offers an analysis of the historic issues and current conditions facing AI/AN women and infants in the United States, through the lens of poor birth outcomes for AI/AN mothers and babies. It highlights a toxic legacy of genocide and trauma and acknowledges centuries of detrimental policies and programs that have disadvantaged and decimated AI/AN populations.

NCUIH has advocated on the behalf of urban AI/AN maternal and infant health and has worked closely with the ACIMM on AI/AN maternal and infant health issues. On September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, testified before the HRSA ACIMM on urban Indian disparities and policy changes to address these disparities. Raimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.”

Background

ACIMM focused its work on the birth outcomes of AI/AN mothers and infants because AI/AN populations are often overlooked in programmatic and policy discussions and investments even though their birth outcomes are among the worst in the country. Reasons for this oversight are numerous, including small population size, dispersed populations, lack of representation in decision-making spaces, and Tribes being non-state entities. The plight of AI/AN mothers and infants in the United States is a human rights issue that must be urgently addressed.

ACIMM’s report recommended three areas for strategic action framed on the premises of having healthy social and physical environment and access to high-quality care are essential to good birth outcomes; racism and the devaluing of AI/AN women disproportionately affects this population which negatively impact maternal and infant health outcomes and mortality; and AI/AN people have inherently protective practices embedded in their culture that contribute to their ongoing resilience.

  1. Make the health and safety of AI/AN mothers and infants a priority for action.
  2. Improve the living conditions of AI/AN mothers and infants and assure universal access to high quality healthcare.
  3. Address urgent and immediate challenges that disproportionately affect AI/AN women before, during, and after pregnancy.

Infant and Maternal Health Disparities in Native Health

According to the Office of Minority Health (OMH), Native infants have almost twice the infant mortality rate as non-Hispanic whites.  Native infants are also almost three times more likely than non-Hispanic whites to die from accidental deaths before the age of one year. Contributing factors to these disparities include cost, discrimination, and lack of cultural competency during prenatal care. Additional ongoing and historical trauma due to colonization, genocide, forced migration, and cultural erasure also contribute to health inequities, including pregnancy-related deaths and other maternal health conditions. Approximately 41% of AI/AN women cite cost as a barrier to receiving the recommended number of prenatal visits and 23% of AI/ANs report they have faced discrimination in clinical settings due to being an AI/AN. Consequently, AI/AN people are more likely to have underlying chronic health conditions, and they face systemic barriers to care including higher rates of poverty and needing to travel long distances to receive quality health care services.

NCUIH’s work with AI/AN Maternal and Infant Health

The National Council of Urban Indian Health (NCUIH) has engaged in extensive advocacy on behalf of AI/AN mothers and infants and for increased funding and support to the UIOs which provide maternal health, infant health, prenatal, and family planning services to AI/AN mothers and infants.  In March 2022, NCUIH signed onto a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing HRSA’s Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and doubling the Tribal set-aside – which includes UIOs. Additionally, in August, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program. In our comments, we have continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations. NCUIH also released an infographic showcasing data on infant and maternal health disparities in AI/AN communities.

HHS Launches New Maternal Health Resources for American Indian and Alaska Native Communities

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On December 1, 2022, the U.S. Department of Health and Human Services(HHS) Secretary Xavier Becerra attended the White House Tribal Nations Summit where he discussed the Department’s commitment to addressing mental and maternal health in American Indian and Alaska Native (AI/AN) communities. As part of HHS’ commitment, the Centers for Disease Control and Prevention (CDC) and the Office of Minority Health (OMH) launched a new Hear Her campaign segment that works to improve AI/AN maternal health outcomes by raising awareness of life-threatening warning signs during and after pregnancy and improving communication between health care providers and their patients.

Background on Hear Her Campaign

The CDC’s Division of Reproductive Health launched the Hear Her in 2020 as a national campaign that brings attention to pregnancy-related deaths and provide education and encouragement to pregnant and postpartum women (within one year of delivery).  The campaign supports CDC’s efforts to prevent pregnancy-related deaths by sharing potentially life-saving messages about urgent warning signs.

The Hear Her campaign was launched because too many people die from pregnancy-related complications. Alarmingly over 700 women die each year in this country from problems related to pregnancy or delivery complications. Every death is a tragedy, especially when two thirds of pregnancy-related deaths could be prevented. As many as 50,000 women experience severe, unexpected health problems related to pregnancy that may have long-term health consequences. Additionally, there are significant racial and ethnic disparities in pregnancy-related complications and deaths.  The Hear Her campaign centers on the stories of women who have experienced pregnancy-related complications.  Recognizing urgent maternal warning signs and getting an accurate and timely diagnosis can save lives during pregnancy and up to a year after delivery.

AI/AN Infant and Maternal Health Disparities

According to the OMH, Native infants have almost twice the infant mortality rate as non-Hispanic whites.  Native infants are also almost three times more likely than non-Hispanic whites to die from accidental deaths before the age of one year. Contributing factors to these disparities include cost, discrimination, and lack of cultural competency during prenatal care. Additional ongoing and historical trauma due to colonization, genocide, forced migration, and cultural erasure also contribute to health inequities, including pregnancy-related deaths and other maternal health conditions. Approximately 41% of AI/AN women cite cost as a barrier to receiving the recommended number of prenatal visits and 23% of AI/ANs report they have faced discrimination in clinical settings due to being an AI/AN. Consequently, AI/AN people are more likely to have underlying chronic health conditions, and they face systemic barriers to care including higher rates of poverty and needing to travel long distances to receive quality health care services.

Given the maternal health disparities that AI/AN people and communities experience, it is a priority for CDC and OMH to reach tribal communities with resources CDC and OMH have worked to include the voices and perspectives of AI/AN throughout the development of the campaign and will continue to do so over time. As the campaign moves forward into implementation, the focus will be on building capacity for tribes and tribal serving organizations to implement the campaign and improve maternal outcomes.

UIO and NCUIH work in AI/AN Infant and Maternal Health

Urban Indian organizations (UIOs) provide a range of services such as primary care, behavioral health, traditional, and social services— including those for infants, children, and mothers. At least 23 of these clinics provide care for maternal health, infant health, prenatal, and/or family planning. They also provide pediatric services and participate in maternal-child care programs such as WIC and the Health Resources and Services Administration (HRSA) Maternal, Infant, and Early Childhood Home Visiting program (MIECHV).

 

Furthermore, the National Council of Urban Indian Health (NCUIH) has engaged in extensive advocacy on behalf of AI/AN mothers and infants and for increased funding and support to the UIOs which provide maternal health, infant health, prenatal, and family planning services to AI/AN mothers and infants.  In March 2022, NCUIH signed onto a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing HRSA’s Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and doubling the Tribal set-aside – which includes UIOs. Additionally, NCUIH submitted comments to HRSA Advisory Committee on Infant and Maternal Mortality (ACIMM), which advises the Secretary of HHS on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality, and sever maternal morbidity and improving the health status of infants and women before, during, and after pregnancy. Moreover, in August, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program. In our comments, we have continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations. NCUIH also recently released an infographic showcasing data on infant and maternal health disparities in AI/AN communities.

In addition to written advocacy, NCUIH has been invited to present on urban AI/AN maternal and infant health. On September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, testified before the HRSA ACIMM on urban Indian disparities and policy changes to address these disparities. Raimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.”

Maternal, Infant, and Early Childhood Home Visiting Program Reauthorization Included in Final Appropriations Package with Tribal Set-Aside Increase

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On December 29, 2022, the Jackie Walorski Maternal and Child Home Visiting Reauthorization Act of 2022 (H.R. 8876) was included in the final appropriations package, also known as the omnibus, for Fiscal Year (FY) 2023. Notably, the omnibus reauthorized the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and increased funding through FY 2027. The program supports home visit programs, including the Tribal Home Visiting Program (THVP), for expectant and new parents who live in communities that are at risk for poor maternal and child health outcomes. To continue improving the infant and maternal health of American Indian/Alaska Native (AI/AN) communities, the bill provides a notable improvement to the THVP program by (from 3% to 6%) starting in FY 2023. The National Council of Urban Indian Health (NCUIH) has advocated for the reauthorization of MIECHV and increasing funding for the Tribal set-aside and continues to advocate on behalf of AI/AN mothers and infants.

In addition, the bill makes several to the MIECHV program overall, such as:

  • $500,000,000starting grant base in FY23, scheduled funding increases of $50,000,000 through FY 2027.
  • Dedicates a 2% set-aside for workforce support, retention, and case management.
  • Allows set-asides for research, evaluation, and administration (3%) and technical assistance (2%).
  • Creates an “outcomes dashboard” to help Congress and the public track MIECHV’s success in improving family outcomes.
  • Annual report to Congress to better oversee the program and make improvements in the future.

Background

The Tribal Home Visiting Program

Since 2010, a 3% set-aside has been allotted to the THVP, a program administered within MIECHV to specifically support and promote the health and well-being of AI/AN families.

From the MIECHV 2015 Congressional Report, THVP grantees, including urban Indian organizations (UIOs), served 870 families—5 times the number served in FY 2012. Nearly 20,000 home visits were provided to 3,197 adult participants and children between FY 2012 and FY 2014. After 3 years of implementation, 77% of grantees also demonstrated overall improvement in several benchmark areas. These include:

  • 62% improvements in maternal and newborn health
  • 85% increase in the prevention of child injuries, child abuse, neglect, or maltreatment, and reduction of emergency department visits
  • 69% improvement in school readiness and achievement
  • 77% reduction in crime or domestic violence
  • 77% improvement in family economic self-sufficiency
  • 69% improvements in the coordination and referrals for other community resources

Since its inception, the THVP has been an influential program to help improve the development of healthy AI/AN children and families through coordinated, culturally relevant, and evidence-based home-visiting strategies addressing critical maternal and child health needs.

NCUIH Advocacy

NCUIH has engaged in extensive advocacy on behalf of AI/AN mothers and infants for increased funding and support to the UIOs that provide maternal health, infant health, prenatal, and family planning services. On March 9, 2022, NCUIH signed on to a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing the MIECHV program and doubling the Tribal set-aside, which includes UIOs.

NCUIH also submitted comments on March 10, 2022, to the Health Resources and Services Administration (HRSA) Advisory Committee on Infant and Maternal Mortality (ACIMM), which advises the Secretary of Health and Human Services (HHS) on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and severe maternal morbidity, and improving the health status of infants and women before, during, and after pregnancy. On August 31, 2022, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program. In those comments, NCUIH continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations.

On September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, presented before the HRSA ACIMM on urban Indian disparities and policy changes to address these disparities. Raimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.”

Thanks to this NCUIH advocacy, H.R. 8876 included language to double the Tribal set-aside from 3% to 6% in FY 2023, which was ultimately included in the final appropriations package for FY 2023.

AI/AN Maternal Health Disparities

American Indian and Alaska Native (AI/AN) communities throughout the country, including urban AI/AN communities, experience significant maternal and infant health disparities compared to the general population. A report by the National Center for Health Statistics noted that between 2005 and 2014, AI/ANs were the group that did not experience a decline in infant mortality.

Over half of UIOs provide care for maternal health, infant health, prenatal, and/or family planning. A study of Natives in UIO service areas found that while birth rates, in general, were lower in the urban Native population (12.8 and 16.5 per 1,000 population, respectively), premature birth rates for both urban and non-urban AI/AN were higher than those of all other races and ethnicities combined (12.3% of live births among AI/AI in urban areas and 10.9% among the general population in the same area).

Through expanded research efforts, many factors have been directly identified as reasons for AI/AN infant and maternal health disparities. These include:

Final FY2023 Omnibus Bill Includes Advance Appropriations for the Indian Health Service and Several Other Priorities

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The bill includes $6.96 billion for IHS and $90.42 million for urban Indian health.

On December 29, 2022, the Consolidated Appropriations Act, 2023 (H.R. 2617) for fiscal year (FY) 2023, also known as the ‘omnibus,’ was signed into law by President Biden. This follows a third continuing resolution for FY2023 through December 30. The bill passed in the Senate with a 68-29 vote followed by a House passage of a 221-205-1 vote. The 4,155-page omnibus bill authorizes $6.96 billion for the Indian Health Service (IHS) for FY 2023, a $360 million increase above the FY 2022 enacted level; advance appropriations for IHS totaling $5.13 billion for FY 2024; and $90.42 million for urban Indian health for FY 2023. In addition, the final package includes increased funding to expand behavioral health services and programs eligible to urban Indian organizations (UIOs).

The National Council of Urban Indian Health (NCUIH) has long advocated for larger investments in American Indian and Alaska Native (AI/AN) health care and has called on Congress to strengthen its commitment to Indian Country with increased funding in the FY 2023 appropriations. Unfortunately, despite robust NCUIH advocacy, the bill does not include an extension of 100% Federal Medical Assistance Percentage (FMAP) for UIOs or an Urban Confer policy with the Department of Health and Human Services (HHS). NCUIH will continue to advocate for these priorities in future legislation.

The Tribal Budget Formulation Workgroup (TBFWG), a national workgroup that identifies annual Tribal funding priorities, requested full funding for IHS at $49.9 billion and $949.9 million for urban Indian health. While the bill provides a key Indian Country request for advance appropriations for IHS, unfortunately, the final amount still falls short of fully funding IHS so that the agency can properly provide health care services for all AI/ANs.

To read NCUIH’s joint press release with the National Indian Health Board (NIHB) and the National Congress of American Indians (NCAI) on the inclusion of IHS advance appropriations in the omnibus, click here.

Bill Text:
Overview of IHS and Urban Indian Health Requests
Line Item FY22 Enacted FY23 TBFWG Request FY23
President’s
Budget		 FY23
House Passed		 FY23 Senate Proposed FY23 Omnibus
Urban Indian Health $73.43 million $949.9 million $112.5 million $200 million $80.4 million $90.4 million
Indian Health Service $6.6 billion $49.8 billion $9.3 billion – Mandatory funding* $8.1 billion $7.38 billion $6.9 billion
Advanced Appropriations ——————- ———————- ————— —————- $5.6 billion $5.1 billion
Hospitals and Clinics $2.3 billion $8.66 billion $3.4 billion $2.8 billion $2.8 billion $2.5 billion
TECs $24.4 million $24.4 million $24.8 million $34.4 million $34.4 million $34.4 million
EHRs $145 million $451 million $284.5 million $284.5 million $217.5 million $217.5 million
CHRs $63.6 million $1.4 billion $68.8 million $65.2 million $67 million $65.2 million
Direct Operations $95 million $98.4 million $115.4 million $135.4 million $103.8 million $103.8 million
Mental Health $121.9 million $3.9 billion $199.1 million $130 million $127.1 million $127.1 million
BIA MMIW $24.9 million ——————– ————— $25.1 million $25.1 million $25.1 million
Key Provisions for IHS, Tribal Organizations, and UIOs
  • $6.9 billion for IHS for FY 2023
  • $90.4 million for urban Indian health for FY 2023
  • $5.1 billion for Advance Appropriations for FY 202
  • $24 million for the Good Health and Wellness in Indian Country Program
  • $15.6 million to make payments under the National Health Service Corps Loan Repayment program
  • $80 million authorized to be appropriated through FY2023-FY2027 for Native Behavioral Health Access Grants
  • Reauthorizes and establishes scheduled funding increases for the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and doubles the Tribal set-aside from 3% to 6% for the Tribal Home Visiting Program
  • Fully funds Contract Support Costs and Payments for Tribal Leases
Analysis

Urban Indian Health

  • $90,419,000 for urban Indian health for FY 2023

Indian Health Service

  • $5,129,458,000 in advance appropriations for IHS for FY 2024
  • $6,958,223,000 in agency funding for IHS in FY 2023
    • Indian Health Services – $4,890,282,000
  • Hospitals and Health Clinics – $2,503,025,000
  • Tribal Epidemiology Centers (TECs) – $34,400,000
  • Electronic Health Records (EHRs) – $217, 564,000
  • Community Health Representative (CHRs) – $65,212,000
  • Mental health – $127,171,000
  • Direct Operations – $103,805,000
  • Indian Health Care Improvement Fund – $74,138,000
  • Indefinite appropriation to fully fund Contract Support Costs at $969,000,000 for FY 2023
  • Indefinite appropriation to fully fund payments for 105(l) leases at $111,000,000 for FY 2023
  • Funds Indian Health Facilities at $958,553,000

Health and Human Services (HHS)
Health Resources and Services Administration (HRSA)

  • Native Hawaiian Health Care
    • $27,000,000
  • National Health Service Corps (NHSC)
    • $15,600,000 to Indian Health Service facilities, Tribally Operated Health Programs, and Urban Indian Health Programs to make payments under the NHSC loan repayment program.
  • Center of Excellence for Eating Disorders – Screening and Referrals
    • $1,000,000 through FY 2027
      • Funding for training and technical assistance to primary and behavioral health providers and non-clinical community support workers to identify treatment and provide ongoing support to individuals with eating disorders

Centers for Disease Control and Prevention (CDC)

  • Good Health and Wellness in Indian Country (GHWIC)
    • $24,000,000
  • Minority HIV/AIDS Prevention and Treatment Program
  •  $5,000,000 Tribal set-aside under the Minority HIV/AIDS Prevention and Treatment Program

Important Behavioral and Mental Health Provisions (Restoring Hope For Mental Health And Wellbeing)

  • Medication-Assisted Treatment for Prescription Drug and Opioid Addiction
    • $14,500,000
  • Peer-Supported Mental Health Services
    • $13,000,000 for each of fiscal years 2023 through 2027
      • A new grant program with direct UIO eligibility
  • Infant and Early Childhood Mental Health Promotion, Intervention and Treatment
    • $50,000,000 for fiscal years 2023 through 2027
  • Behavioral Health and Substance Use Disorder Resources for Native Americans
    • $80,000,000
    • Ensures HHS consult with Indian Tribes and Tribal organizations, confer with UIOs, and engage with Native Hawaiian health organization regarding the administration of funding
  • Mental and Behavioral Health Education and Training Grants
    • $31,700,000 for each fiscal year 2023-2027
      • The training demonstration has I/T/U eligible entities
  • State Opioid Response (SOR) Grants
    • $55,000,000
    • UIOs not eligible
  • Tribal Behavioral Health grant (formally known as Native Connections)
  • Reauthorized for fiscal years 2023 through 2027

Bureau of Indian Affairs (BIA)

  • Missing and Murdered Indigenous Women (MMIW)
    • $24,898,000 for Law Enforcement Special Initiatives, of which an additional $5,000,000 is to continue addressing the MMIW effort
  • Mental Health and Suicide Prevention Outreach to Minority Veterans and American Indian and Alaska Native Veterans
    • that each VA medical center has a full-time minority veteran coordinator who must receive training in the delivery of culturally appropriate mental health and suicide prevention services to AI/AN veterans
  • Tribal Home Visiting Program and Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV)
    • Reauthorizes and establishes scheduled funding increases for the MIECHV and doubles the set-aside from 3% to 6% for the Tribal Home Visiting Program
    • $500,000,000 starting grant base in FY23, scheduled funding increases of $50,000,000 through FY 2027
  • Native Boarding School Initiative
    • $19,409,000 is for Assistant Secretary support, which maintains funding to implement the PROGRESS Act, the Diversity and Inclusion program for BIA and OST, and the Native boarding school initiative
  • Violence Against Women Act (VAWA) – $25,000,000
    • $500,000 is for a national clearinghouse that provides training and technical assistance on issues relating to sexual assault of AI/AN women
    • $11,000,000 is to assist tribal exercising special Tribal criminal jurisdiction
    • $3,000,000 is for an initiative to support cross-designation of Tribal prosecutors as Tribal Special Assistant United States Attorneys
Topic Section Funding Language
Urban Indian Health Urban Indian Health $90,419,000 Pg. 69
“The agreement includes $90,419,000 for the Urban Indian health program, which includes the reallocation of former NIAAA funds.”
Indian Health Service (IHS) Advanced Appropriations $5,129,458,000 Pg.67
‘The agreement provides advance appropriations for the Indian Services and Indian Health Facilities accounts totaling $5,129,458,000 for fiscal year 2024.”
IHS Funding $6,958,233,000 Pg.67:  
“The bill provides a total of $6,958,223,000 for the Indian Health Service (IHS )”
Indian Health Services $4,890,282,000 Pg.67:  
“The bill provides a total of $6,958,223,000 for the Indian Health Service (IHS ), of which $4,890,282,000 is for the Services account”
Hospitals and Clinics $2,503,025,000 Pg.68
“The agreement provides $2,503,025,000 for Hospitals and Health Clinics, which includes an additional $10,000,000 for Tribal epidemiology centers, $2,000,000 for village built clinics, and an additional $1,000,000 to improve maternal health. This amount also includes requested reallocation of prior year staffing funds for the Phoenix Indian Medical Center, Cherokee Nation, and United Keetoowah Band. The agreement maintains funding at fiscal year 2022 enacted levels for the Alzheimer’s program and Produce Prescription Pilot program. The agreement also continues funding at the fiscal year 2022 enacted levels for the domestic violence prevention program, accreditation emergencies as discussed in the House report, health information technology, healthy lifestyles in youth project, and the National Indian Health Board cooperative agreement.”
TECs $34,433,361 Pg. 68
“The agreement provides $2,503,025,000 for Hospitals and Health Clinics, which includes an additional $10,000,000 for Tribal epidemiology centers, $2,000,000 for village built clinics, and an additional $1,000,000 to improve maternal health.”
EHRs $217,564,000 Pg. 69
“The agreement provides $217,564,000 for Electronic Health Records (EHR), which includes an increase for uses as requested.”
CHRs $65,212,000 Pg. 274: See Chart for Language
Mental Health $127,171,000 Pg. 69
“The bill provides $127,171,000 for Mental Health, which continues funding at fiscal year 2022 enacted levels for the behavioral health integration initiative, for suicide prevention, and for the Tele-behavioral Health Center of Excellence and includes the requested reallocation of staffing funds”
Direct Operations $103,805,000 Pg. 70
“The bill provides $103,805,000 for direct operations, which includes an increase of $5,000,000 for quality and oversight, for uses as requested, and an increase of $1,000,000 for management and operations.”
Indian Health Care Improvement Fund $74,138,000 Pg. 274: See Chart for Language
Contract Support Costs $969,000,000 Pg. 70:
“The bill continues language from fiscal year 2022 providing an indefinite appropriation to fully fund contract support costs, which are estimated to be $969,000,000 in fiscal year 2023.”
105(l) leases $111,000,000 Pg. 74:
“The bill continues language from fiscal year 2022 providing an indefinite appropriation to fully fund payments for Tribal leases, which are estimated to be $111,000,000 in fiscal year 2023.”
Indian Health Facilities $958,553,000 Pg. 70
“The bill provides $958,553,000 for Indian Health Facilities.
Costs for accreditation emergencies and supplementing activities funded under the heading ‘‘Indian Health Facilities’’ $58,000,000 Pg.878:
“That of the funds provided, $58,000,000 shall be for costs related to or resulting from accreditation emergencies, including supplementing activities funded under the heading ‘‘Indian Health Facilities,’’ of which up to $4,000,000 may be used to supplement amounts otherwise available for Purchased/
Referred Care”
Health and Human Services (HHS) HRSA—
Hawaiian Health Care Program		 $27,000,000 Pg.10
The agreement includes no less than $27,000,000 for the Native Hawaiian Health Care Program, of which not less than $10,000,000 shall be provided to Papa Ola Lokahi for administrative purposes authorized under 42 U.S.C. 11706, including to expand research and surveillance related to the health status of Native Hawaiians and strengthen the capacity of the Native Hawaiian Health Care Systems.”
HRSA—
NHSC Loan Repayment Program		 $15,600,000 Pg. 991:
“That, within the amount made available in the previous provison, $15,600,000 shall remain available until expended for the purposes of making payments under the NHSC Loan Repayment Program under section 338B of the PHS Act to individuals participating in such program who provide primary health services in Indian Health Service facilities, Tribally-Operated 638 Health Programs, and Urban Indian Health Programs (as those terms are defined by the Secretary), notwithstanding the assignment priorities and limitations under section 333(b) of such Act”
CDC—
Good Health and Wellness in Indian Country		 $24,000,000 Pg. 33: See Chart for Language
CDC—
Minority HIV/AIDS Prevention and Treatment Program		 $5,000,000 Pg.130
Tribal Set-aside.-The agreement includes an increase of $2,000,000 for a Tribal set-aside within the Minority HIV/AIDS Prevention and Treatment program.
Important Behavioral and Mental Health Provisions (Restoring Hope For Mental Health And Wellbeing) Medication-Assisted Treatment for Prescription Drug and Opioid Addiction $14,500,000 Pg. 104
“The agreement directs SAMHSA to ensure that these grants include as an allowable use the support of medication-assisted treatment and other clinically appropriate services to achieve and maintain abstinence from all opioids, including programs that offer low-barrier or same day treatment options. Within the amount provided, the agreement includes $14,500,000 for grants to Indian Tribes and Tribal Organizations.”
Peer-Supported Mental Health Services $13,000,000
for FY23-FY27		 Pg. 3067
“There is authorized to be appropriated to carry out this section $13,000,000 for each of fiscal years 2023 through 2027.’’
Infant and Early Childhood Mental Health Promotion, Intervention and Treatment $50,000,000
for FY23-FY27		 Pg. 3177
“in subsection (g) (as redesignated by paragraph (1)), by striking ‘‘$20,000,000 for the period of fiscal years 2018 through 2022’’ and inserting ‘‘$50,000,000 for the period of fiscal years 2023 through 2027’’.
Behavioral Health and Substance Use Disorder Resources for Native Americans $80,000,000
for FY23-FY27		 Pg. 3072
“There are authorized to be appropriated to carry out this section, $80,000,000 for each of fiscal years 2023 through 2027.’’
Mental and Behavioral Health Education and Training Grants $31,700,000
for FY23-FY27		 Pg. 3171
‘‘$10,000,000 for each of fiscal years 2018 through 2022’’  and $31,700,000 for each of fiscal years 2023 through 2027”
State Opioid Response (SOR) Grants $55,000,000 Pg. 1016:
“That of such amount $55,000,000 shall be made available to Indian Tribes or tribal organizations”
Tribal Behavioral Health grant (formally known as Native Connections) Reauthorized Pg. 3044:
“PRIORITY MENTAL HEALTH NEEDS OF REGIONAL AND NATIONAL SIGNIFICANCE.—Section 520A of the Public Health Service Act (42 U.S.C. 290bb–32) is
amended […](2) in subsection (f), by striking ‘‘$394,550,000 for each of fiscal years 2018 through 2022’’ and inserting ‘‘$599,036,000 for each of fiscal years 2023 through 2027’’.”
Bureau of Indian Affairs (BIA) and Bureau of Indian Education at the Department of the Interior (DOI) for Law Enforcement Special Initiatives – MMIW Effort $25,094,000 Pg.37
“The agreement includes $25,094,000 for Law Enforcement Special Initiatives, which continues funding at enacted levels for the MMIW Tribal Public Safety initiative, Tiwahe recidivism initiative, equipment to collect and preserve evidence at crime scenes, and victim witness specialists.”
Native Boarding School Initiative $19,409,000 Pg.37
“The bill includes $263,766,000 for Executive Direction and Administrative Services, of which: $19,409,000 is for Assistant Secretary support, which maintains funding to implement the PROGRESS Act, the Diversity and Inclusion program for BIA and OST, and the Native boarding school initiative.”
Mental Health and Suicide Prevention Outreach to Minority Veterans and American Indian and Alaska Native Veterans N/A Pg.2652
“Not later than 180 days after the date of the enactment of this Act, the Secretary, in consultation December 19, 2022 with the Director of the Office of Mental Health and Suicide Prevention, shall ensure that the suicide prevention coordinator and minority veteran coordinator of each medical center of the Department have developed and disseminated to the director of the medical center a written plan for conducting mental health and suicide prevention outreach to all tribes and urban Indian health organizations within the catchment area of the medical center.”
Tribal Home Visiting Program and Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) $500,000,000 starting grant base in FY23, scheduled funding increases of $50,000,000 through FY 2027.

Doubles the set-aside from 3% to 6% for the Tribal Home Visiting Program

 Page 3883:
“(B) in subparagraph (A)— (i) by striking ‘‘3’’ and inserting ‘‘6’’; (ii) by inserting ‘‘and administering’’ before ‘‘grants’’;”
Violence Against Women Act (VAWA) National clearinghouse that provides training and technical assistance on issues relating to sexual assault of AI/AN women $500,000 Pg. 178
“$500,000 is for a national clearinghouse that provides training and technical assistance on issues relating to sexual assault of American Indian and Alaska Native women.”
Assist tribal exercising special Tribal criminal jurisdiction $11,000,0000 Pg. 178
‘$11,000,000 is for programs to assist Tribal Governments in exercising special Tribal criminal jurisdiction, as authorized by section 204 of the Indian Civil Rights Act.”
Initiative to support cross-designation of Tribal prosecutors as Tribal Special Assistant United States Attorneys $3,000,0000 Pg. 179
‘$3,000,000 is for an initiative to support cross-designation of tribal prosecutors as Tribal Special Assistant United States Attorneys.”

NCUIH Contact: Lycia Maddocks (Ft. Yuma Quechan), Director of Congressional Relations, lmaddocks@ncuih.org

Health Resources and Services Administration Seeking Nominations for Membership to Serve on the Advisory Committee on Infant and Maternal Mortality

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On November 22, 2022, the Health and Resources and Services Administration (HRSA) issued a notice seeking nominations of qualified candidates for consideration to serve as members of the Advisory Committee on Infant and Maternal Mortality (ACIMM). ACIMM advises the Secretary of Health and Human Services (HHS) (Secretary) on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and severe maternal morbidity, and improving the health status of infants of women before, during, or after pregnancy. Written nominations for membership on the ACIMM must be received on or before January 23, 2022, and nomination packages must be submitted electronically as email attachments to Vanessa Lee, MPH, the ACIMM’s Designated Federal Official, at: SACIM@hrsa.gov. NCUIH strongly encourages UIO staff working in the areas of infant and maternal health to submit nomination materials.

Background

The ACIMM was established in 1991 and advises the Secretary on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and severe maternal morbidity, and improving the health status of infants and women before, during, and after pregnancy. The ACIMM provides advice on how to coordinate federal, state, local, tribal, and territorial governmental efforts designed to improve infant mortality, related adverse birth outcomes, and maternal health, as well as influence similar efforts in the private and voluntary sectors. The ACIMM provides guidance and recommendations on the policies, programs, and resources required to address the disparities and inequities in infant mortality, related adverse birth outcomes and maternal health outcomes, including maternal mortality and severe maternal morbidity. With its focus on underlying causes of the disparities and inequities seen in birth outcomes for women and infants, the ACIMM advises the Secretary on the health, social, economic, and environmental factors contributing to the inequities and proposes structural, policy, and/or systems level changes. The ACIMM meets approximately four times per year, or at the discretion of the Designated Federal Officer in consultation with the Chair.

Nomination Eligibility and Information

HRSA is requesting nominations for voting members to serve as Special Government Employees (SGEs) on the ACIMM to fill open positions. The Secretary appoints ACIMM members with the expertise needed to fulfill the duties of the Advisory Committee. Nominees sought are medical, technical, or scientific professionals with special expertise in the field of maternal and child health, in particular, infant and/or maternal mortality and related health disparities; members of the public having special expertise about or concern with infant and/or maternal mortality; and/or representatives from such public health constituencies, consumers, and medical professional societies. Interested applicants may self-nominate or be nominated by another individual or organization.

Individuals selected for appointment to the Committee will be invited to serve for up to 4 years. Members appointed as SGEs receive a stipend and reimbursement for per diem and travel expenses incurred for attending ACIMM meetings and/or conducting other business on behalf of the ACIMM, as authorized by 5 U.S.C. 5703 for persons employed intermittently in government service

Nomination Package Materials

The following information must be included in the package of materials submitted for each individual nominated for consideration:

  1. A statement that includes the name and affiliation of the nominee and a clear statement regarding the basis for the nomination, including the area(s) of expertise and/or experience that may qualify a nominee for service on the ACIMM, as described above;
  2. confirmation the nominee is willing to serve as a member of the ACIMM;
  3. the nominee’s contact information (please include home address, work address, daytime telephone number, and an email address); and
  4. A current copy of the nominee’s curriculum vitae or resume. Nomination packages may be submitted directly by the individual being nominated or by the person/organization recommending the candidate.

Individuals who are selected to be considered for appointment will be required to provide detailed information regarding their financial holdings, consultancies, and research grants or contracts. Disclosure of this information is required in order for HRSA ethics officials to determine whether there is a potential conflict of interest between the SGE’s public duties as a member of the ACIMM and their private interests, including an appearance of a loss of impartiality as defined by federal laws and regulations, and to identify any required remedial action needed to address the potential conflict.

AI/AN Infant and Maternal Health

AI/AN communities throughout the country, including urban AI/AN communities, experience significant maternal and infant health disparities compared to the general population. According to HHS’ Office of Minority Health (OMH), AI/AN infants have almost twice the infant mortality rate as non-Hispanic whites.  Native infants are also almost three times more likely than non-Hispanic whites to die from accidental deaths before the age of one year. Contributing factors to these disparities include cost, discrimination, and lack of cultural competency during prenatal care. Additional ongoing and historical trauma due to colonization, genocide, forced migration, and cultural erasure also contribute to health inequities, including pregnancy-related deaths and other maternal health conditions. Approximately 41% of AI/AN women cite cost as a barrier to receiving the recommended number of prenatal visits and 23% of AI/ANs report they have faced discrimination in clinical settings due to being an AI/AN. Consequently, AI/AN people are more likely to have underlying chronic health conditions, and they face systemic barriers to care including higher rates of poverty and needing to travel long distances to receive quality health care services.

Recognizing the infant and maternal health disparities that AI/AN people and communities experience, the HHS Secretary Xavier Becerra attended the White House Tribal Nations Summit on December 1, 2022, where he discussed the Department’s commitment to addressing mental and maternal health in AI/AN communities. As part of HHS’ commitment, the Centers for Disease Control and Prevention (CDC) and the Office of Minority Health (OMH) launched a new Hear Her campaign segment that works to improve AI/AN maternal health outcomes by raising awareness of life-threatening warning signs during and after pregnancy and improving communication between health care providers and their patients.  Given HHS’ current focus on addressing Native infant and maternal health, it is highly recommended that UIO staff submit applications to the ACIMM to ensure that the voice of urban Native communities continues to be heard in this work.

UIO and NCUIH work in AI/AN Infant and Maternal Mortality

UIOs provide a range of services such as primary care, behavioral health, and traditional, and social services— including those for infants, children, and mothers. Several UIOs provide care for maternal health, infant health, prenatal, and/or family planning. They also provide pediatric services and participate in maternal-child care programs such as WIC and the Health Resources and Services Administration (HRSA) Maternal, Infant, and Early Childhood Home Visiting program (MIECHV).

NCUIH has engaged in extensive policy work on behalf of AI/AN mothers and infants and for increased funding and support to the UIOs which provide maternal health, infant health, prenatal, and family planning services to AI/AN mothers and infants. On March 9, 2022, NCUIH signed on to a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing HRSA’s  MIECHV and doubling the Tribal set-aside— which includes UIOs.

Also, in March, NCUIH submitted comments to the ACIMM, and on September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, testified before the ACIMM on urban Indian disparities and policy changes to address these disparities.  Raimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.” Raimondi provided the following recommendations to the Advisory Committee:

  • Reauthorize MIECHV at a higher amount and double the Tribal set-aside from 3% to 6%.
  • ACIMM and other stakeholders should collaborate with UIOs to gather critical and accurate information on urban AI/AN populations.
  • Advise the HHS Secretary to lead the establishment of an urban confer policy across all HHS agencies.
  • Include a Tribal and UIO health provider representative on the ACIMM and create an ACIMM subcommittee dedicated to addressing AI/AN infant and maternal health disparities.

In August, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program. In our comments, we have continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations.

Furthermore, NCUIH recently released an infographic showcasing data on infant and maternal health disparities in American Indian/Alaska Native (AI/AN) communities.

 

Resource: Data on Infant and Maternal Health Disparities in Native Communities

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The National Council of Urban Indian Health (NCUIH) recently released an infographic showcasing data on infant and maternal health disparities in American Indian/Alaska Native (AI/AN) communities. Unfortunately, AI/AN communities throughout the country, including urban AI/AN communities, experience significant maternal and infant health disparities compared to the general population.

View the resource

AI/AN Infant and Maternal Health Disparities

A report by the National Center for Health Statistics noted that between 2005 and 2014, American Indian/Alaska Native was the only racial or ethnic group that did not experience a decline in infant mortality.[1]

AI/AN Infant and Maternal Health Disparities

Urban AI/AN Infant and Maternal Health Disparities

Over half of urban Indian organizations (UIOs) provide care for maternal health, infant health, prenatal, and/or family planning. A study of Natives in UIO service areas found that while birth rates, in general, were lower in the urban Native population (12.8 and 16.5 per 1,000 population, respectively), premature birth rates for both urban and non-urban AI/AN were higher than those of all other races and ethnicities combined (12.3% of live births among AI/AI in urban areas and 10.9% among the general population in the same area).[2]

AI/AN Infant and Maternal Health Disparities

Contributing Factors to AI/AN Infant and Maternal Health Disparities

AI/AN Infant and Maternal Health Disparities

  • Cost, discrimination, and lack of cultural competency are all contributing factors to the stark infant and maternal health disparities among AI/ANs.
  • 41% of AI/AN women cite cost as a barrier to receiving the recommended number of prenatal visits.[3]
    • AI/AN women are 3-4x more likely to begin prenatal care in the third trimester.[4]
  • 21% of AI/AN women ages 15-44 are uninsured, compared to 8% of white women.[5]
  • 23% of AI/ANs report they have faced discrimination in clinical settings due to being an AI/AN.[6]
    • 15% report avoiding medical care for themselves or family members due to fear of discrimination.[7]
  • Access to culturally appropriate care can be difficult for AI/ANs living in urban areas, as most IHS clinics and hospitals, as well as Tribal healthcare facilities, are located on reservations.[8]

UIO and NCUIH work in AI/AN Infant and Maternal Mortality

UIOs provide a range of services such as primary care, behavioral health, traditional, and social services— including those for infants, children, and mothers. At least 23 of these clinics provide care for maternal health, infant health, prenatal, and/or family planning. They also provide pediatric services and participate in maternal-child care programs such as WIC and the Health Resources and Services Administration (HRSA) Maternal, Infant, and Early Childhood Home Visiting program (MIECHV).

NCUIH has engaged in extensive advocacy on behalf of AI/AN mothers and infants and for increased funding and support to the UIOs which provide maternal health, infant health, prenatal, and family planning services to AI/AN mothers and infants. On March 9, 2022,  NCUIH signed on to a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing HRSA’s Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and doubling the Tribal set-aside— which includes UIOs.

Also, in March, NCUIH submitted comments to the HRSA Advisory Committee on Infant and Maternal Mortality (ACIMM), which advises the Secretary of Health and Human Services (HHS) on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and severe maternal morbidity, and improving the health status of infants and women before, during, and after pregnancy. In August, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program in August. In our comments, we have continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations.

On September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, testified before the HRSA ACIMM on urban Indian disparities and policy changes to address these disparities. Photo of Meredith Raimondi, NCUIH’s Vice President of Public PolicyRaimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.” Raimondi provided the following recommendations to the Advisory Committee:

  • Reauthorize MIECHV at a higher amount and double the Tribal set-aside from 3% to 6%.
  • ACIMM and other stakeholders should collaborate with UIOs to gather critical and accurate information on urban AI/AN populations.
  • Advise the HHS Secretary to lead the establishment of an urban confer policy across all HHS agencies.
  • Include a Tribal and UIO health provider representative on the ACIMM and create an ACIMM subcommittee dedicated to addressing AI/AN infant and maternal health disparities.

 

 

[1] Mathews TJ, Driscoll AK, Trends in infant mortality in the United States, 2005–2014, (2017) available at: https://www.cdc.gov/nchs/data/databriefs/db279.pdf

[2]Castor ML, Smyser MS, Taualii MM, Park AN, Lawson SA, Forquera RA. “A nationwide population-based study identifying health disparities between American Indians/ Alaska Natives and the general populations living in select urban counties.” Am J Public Health, 2006;96(5)

[3] National Partnership for Women and Families, American Indian and Alaska Native Women’s Maternal Health: Addressing the Crisis, (2019), https://www. nationalpartnership.org/our-work/resources/health-care/maternity/american-indian-and-alaska.pdf

[4] Urban Indian Health Institute, Community Health Profile: National Aggregate of Urban Indian Health Program Service Areas, (2016), http://www.uihi.org/wp-content/ uploads/2017/08/UIHI_CHP_2016_Electronic_20170825.pdf

[5] National Partnership for Women and Families, American Indian and Alaska Native Women Face Pervasive disparities in Access to Health Insurance, (2019), https:// www.nationalpartnership.org/our-work/resources/health-care/AIAN-health-insurance-coverage.pdf

[6] Harvard T.H. Chan School of Public Health, Poll finds more than one-third of Native Americans report slurs, violence, harassment, and being discriminated against in the workplace (2017), https://www.hsph.harvard.edu/news/press-releases/poll-native-americans-discrimination/

[7] Id.

[8] See Mental Health America, Native and Indigenous Communities and Mental Health – Prevalence, https://www.mhanational.org/issues/native-and-indigenouscommunities-and-mental-health (last accessed Aug. 20, 2022).

Health Equity and Accountability Act (HEAA) Includes Key Provisions for Urban Indian Health

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On June 23, Senator Cory Booker (D-NJ), Senator Raphael Warnock (D-GA), and Representative Robin Kelly (D-IL-02) reintroduced the Health Equity and Accountability Act of 2022 (HEAA) (S. 4486/H.R. 7585). The bill aims to address racial and ethnic health disparities by creating a more equitable health care system through systemic changes. After much advocacy from the National Council of Urban Indian Health (NCUIH), the bill included critical provisions for urban Indian health, such as 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs), urban Indian inclusion in the Community Health Aide Program (CHAP), and the first-ever legislative text establishing an urban confer policy with the Department of Veteran Affairs (VA).

Bill Highlights for Urban Indian Health

100% FMAP for Services at UIOs

Congress authorized 100% FMAP for Indian Health Service (IHS) and Tribal health facilities in the Indian Health Care Improvement Act (IHCIA) in order to supplement chronic underfunding of IHS and thus better fulfill the federal government’s trust responsibility to provide safe and quality healthcare to American Indians/Alaska Natives (AI/ANs). UIOs were not included in the IHCIA amendments as an oversight, and therefore services provided at a UIO were not eligible for 100% FMAP. For decades, urban Indian leaders and NCUIH advocated how critical this provision would be in enhancing the ability of UIOs to provide services for IHS-Medicaid beneficiaries. In 2021, NCUIH was successful in securing two years of 100% FMAP in the American Rescue Plan Act (ARPA) and has continued to advocate for an indefinite extension. This bill includes the permanent authorization for UIOs to receive 100% FMAP, bringing them into parity with other providers in the Indian healthcare system.

Conferring with Urban Indian Organizations

This bill includes legislation for both a confer policy with HHS, as well as the first-ever legislative text establishing an urban confer policy with the VA. An urban confer is an established mechanism for dialogue between federal agencies and UIOs. Urban confer policies are a response to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that have resulted in 70% of AI/AN people living outside of Tribal jurisdictions, thus making urban confer integral to address the care needs of most AI/AN persons. Currently, only IHS has a legal obligation to confer with UIOs.

NCUIH was successful in passing urban confer for the Department of Health and Human Services (HHS) (H.R. 5221) in the House and has introduced a companion bill in the Senate (S. 4323). This type of policy would ensure the many branches and divisions within HHS and all agencies under its purview establish a formal confer process to dialogue with UIOs on policies that impact them and their AI/AN patients living in urban centers. A clear communication pathway between federal health agencies and UIOs is imperative, especially during the ongoing COVID-19 pandemic that has disproportionately impacted AI/ANs. Missed opportunities for awareness and information provided to UIOs regarding AI/AN healthcare can be easily avoided through a confer process. For example, key information regarding vaccine distribution for the initial COVID-19 vaccine rollout in December of 2020 was poorly communicated to UIOs and created unnecessary hardships. HHS addressed initial communications only to Tribes and did not direct it to the UIO component of the IHS system. When HHS was asked about whether UIOs needed to similarly decide between an IHS or state vaccine allocation, it was unclear for weeks as to whether they were expected to make such a decision. Eventually, HHS asked UIOs to decide between receiving their vaccine distribution from either their state jurisdiction or IHS on the same day as the initial deadline (which thankfully HHS subsequently extended for several days). Some UIOs were informed of the deadline by their Area office with no formal national communication. Consequently, UIOs were prevented from providing input, resulting in many clinics experiencing serious delays in vaccine distribution. For example, Native American LifeLines, the Baltimore UIO, did not receive vaccines until just 5 days before the general public was eligible. This had dire consequences, as the pandemic took the lives of AI/ANs at the highest rates of any population. Ultimately, this flawed process could have been easily avoided with an urban confer policy.

NCUIH has also been advocating for the creation of an urban confer with the VA. AI/ANs have a long history of distinguished service to this country. Per capita, AI/ANs serve at a higher rate in the Armed Forces than any other group of Americans and have served in all the nation’s wars since the Revolutionary War. In fact, AI/ANs served in several wars before they were even recognized as U.S. citizens. According to a VA report, 140,507 Veterans identify themselves as AI/AN, and a higher percentage of AI/AN Veterans served in the Pre-9/11 period (17.7%) compared to Veterans of all other races (14.0%). The report also showed significant disparities between AI/AN veterans and other Veterans including that AI/AN Veterans had lower personal incomes than Veterans of other races, the percentage of AI/AN Veterans who were unemployed was higher than the percentage of Veterans of other races who were unemployed, AI/AN Veterans were more likely to lack health insurance than Veterans of other races, and AI/AN Veterans were more likely to have a service-connected disability than Veterans of other races. As the VA continues to work more closely with UIOs to increase access to health care services for AI/AN Veterans and address these disparities, it is imperative that a formal confer process is established for the VA.

The HEAA addresses these key parity issue and provides a forum for important feedback from AI/AN stakeholders to HHS and the VA.

Inclusion of UIOs in the National Community Health Aide Program (CHAP)

The legislation includes UIOs as eligible entities for CHAP. This inclusion will increase the availability of health workers in AI/AN communities. Currently, IHS asserts that UIOs are excluded simply because they are not explicitly included in the statutory language of the nationalization of CHAP. Securing UIO inclusion in CHAP is a policy priority for NCUIH in 2022.

Commissions and Committees

HEAA adds UIOs to commissions and committees relating to various health equity provisions. Urban Indian health representatives were added as members of the Commission on Ensuring Data for Health Equity” to provide clear and robust guidance to improve the collection, analysis, and use of demographic data in responding to future public health emergencies.

Commission/Committee Description Urban Indian Inclusion
Commission on Ensuring Data for Health Equity Urban Indian health representatives were added as members of the Commission to provide clear and robust guidance to improve the collection, analysis, and use of demographic data in responding to future public health emergencies.
CREATING MODEL PROGRAMS FOR THE CARE OF INCARCERATED INDIVIDUALS IN THE PRENATAL AND POSTPARTUM PERIODS:

“The Attorney General, acting through the Director of the Bureau of Prisons (in this subsection referred to as the “Director”), shall establish, in not fewer than 6 Bureau of Prisons facilities, programs to optimize maternal health outcomes for pregnant and postpartum individuals incarcerated in such facilities.”

 The Grant allows for the establishment of partnerships with local public entities, including urban Indian organizations, to establish or expand pretrial diversion programs as an alternative to incarceration for pregnant and postpartum individuals.

 

Appropriations: $10,000,000 for each of fiscal years 2023 through 2027.
GRANTS TO PROMOTE REPRESENTATIVE COMMUNITY ENGAGEMENT IN MATERNAL MORTALITY REVIEW COMMITTEES:

The Secretary may, using funds made available to assist an applicable maternal mortality review committee of a State, Indian tribe, tribal organization, or Urban Indian organization

 Appropriations: $10,000,000 for each of fiscal years 2023 through 2027.

 

Tribal Set-Aside: Of the amount made available under the preceding sentence for a fiscal year, not less than $1,500,000 shall be reserved for grants awarded under subsection (d)(9) to Indian tribes, tribal organizations, or Urban Indian organizations.

Next Steps

HEAA has been referred to the Senate Finance Committee and the House Subcommittee on Health, where it awaits consideration.

Resources

Additional Bill Funding for Urban Indian Organizations

HEAA also includes other appropriations for UIOs discussed in greater detail below:

Grant Description Grant Amount
EXPANDING CAPACITY FOR MATERNAL HEALTH OUTCOMES:

 The Secretary shall award grants to eligible entities to evaluate, develop, and expand the use of technology-enabled collaborative learning and capacity-building models and improve maternal health outcomes.

UIOs are included as eligible entities.

 Appropriations: $6,000,000 for each of fiscal years 2023 through 2027.
GRANT PROGRAM TO PROTECT VULNERABLE MOTHERS AND BABIES FROM CLIMATE CHANGE RISKS:

The Secretary of HHS shall establish a grant program to protect vulnerable individuals from risks associated with climate change.

 Appropriations: $100,000,000 for fiscal years 2023 through 2026.
HOUSING FOR MOMS GRANT PROGRAM:

 The Secretary of Housing and Urban Development shall establish a Housing for Moms grant program under this subsection to make grants to eligible entities to increase access to safe, stable, affordable, and adequate housing for pregnant and postpartum individuals and their families.

UIOs included as eligible entities.

 Appropriations: $10,000,000 for fiscal year 2022, which shall remain available until expended.
GRANT PROGRAM FOR HEALTHY FOOD AND CLEAN WATER FOR PREGNANT AND POSTPARTUM INDIVIDUALS:

An eligible entity shall use grant funds awarded under this paragraph to deliver healthy food, infant formula, clean water, or diapers to pregnant and postpartum individuals located in areas that are food deserts, as determined by the Secretary using data from the Food Access Research Atlas of the Department of Agriculture.

 Appropriations: $5,000,000 to carry out this paragraph for fiscal years 2022 through 2024.
MATERNAL MENTAL HEALTH EQUITY GRANT PROGRAM:

SAMHSA will establish a program to award grants to eligible entities to address maternal mental health conditions and substance use disorders with respect to pregnant and postpartum individuals, with a focus on racial and ethnic minority groups.

 Appropriations: $25,000,000 for each of fiscal years 2023 through 2026.
Grants For Innovative Approaches:

HRSA in collaboration with other agencies, including IHS, will award grants to eligible entities for developing and implementing innovative approaches to improve maternal and child health outcomes of victims of domestic violence, dating violence, sexual assault, stalking, human trafficking, sex trafficking, child sexual abuse, or forced marriage.

 Appropriations: $25,000,000 for the period of fiscal years 2023 through 2025.
TELEHEALTH AND RURAL ACCESS PILOT PROJECTS:

The Secretary of Veterans Affairs, in cooperation with the Secretary of Defense and the Secretary of Health and Human Services (referred to in this subsection collectively as the “Secretaries”) shall establish 4-year telehealth pilot projects for the purpose of analyzing the clinical outcomes and cost-effectiveness associated with telehealth services in a variety of geographic areas that contain high proportions of medically underserved populations, including African Americans, Latinos or Hispanics, American Indians or Alaska Natives, and those in rural areas.

 Appropriations: There is authorized to be appropriated to carry out this section for the period of fiscal years 2023 through 2027 an amount equal to the amount of savings for the Federal Government projected to be achieved over such period by implementation of this section.