Tag Archive for: SDPI

55 Senators Request Protection and Prioritization of Special Diabetes Program for Indians Funding

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On November 12, 2024, 55 Senators sent a letter to Senate Leadership requesting the vital Special Diabetes Program (SDP) and Special Diabetes Program for Indians (SDPI) be reauthorized before funding expires on December 31, 2024.

Senator Collins (R-ME) and Senator Shaheen (D-NH) led the letter that calls for a renewal of SDPI at $160 million or more per year. It also emphasizes that while Congress has reauthorized the program every year since 1997, it was flat funded until the 2024 reauthorization, highlighting the importance of reauthorizing the program at $160 million or more per year.

SDPI provides culturally informed care, funds life-saving efforts to fight diabetes at Indian Health Service facilities (including 31 Urban Indian Organizations) and is critical to improving long-term health outcomes in Indian Country. The highly successful, bipartisan program is a proven success, and reauthorization should be a top priority for Congress.

NCUIH is grateful for the support of the following Senators:

  • Susan Collins (R-ME)
  • Jeanne Shaheen (D-NH)
  • Steve Daines (R-MT)
  • Shelley Moore Capito (R-WV)
  • Joni Ernst (R-IA)
  • Amy Klobuchar (D-MN)
  • Maria Cantwell (D-WA)
  • James Risch (R-ID)
  • Catherine Cortez Masto (D-NV)
  • Dan Sullivan (R-AK)
  • Debbie Stabenow (D-MI)
  • Raphael Warnock (D-GA)
  • Mazie Hirono (D-HI)
  • Tammy Duckworth (D-WI)
  • Jack Reed (D-RI)
  • Cynthia Lummis (R-WY)
  • Kevin Cramer (R-ND)
  • Christopher Coons (D-DE)
  • Mike Crapo (R-ID)
  • Richard Blumenthal (D-CT)
  • Elizabeth Warren (D-MA)
  • Thomas Carper (D-DE)
  • Ben Ray Lujan (D-NM)
  • Peter Welch (D-RI)
  • Tina Smith (D-MN)
  • Mark Kelly (D-AZ)
  • Robert Casey Jr. (D-PA)
  • Kyrsten Sinema (D-AZ)
  • Alex Padilla (D-CA)
  • Tammy Baldwin (D-WI)
  • Angus King (I-ME)
  • Thom Tillis (R-NC)
  • Sheldon Whitehouse (D-RI)
  • Jerry Moran (D-KS)
  • Jeffrey Merkley (D-OR)
  • Cory Booker (D-NJ)
  • Gary Peters (D-MI)
  • Mark Warner (D-VA)
  • Lisa Murkowski (R-AK)
  • Ron Wyden (D-OR)
  • Charles Grassley (R-IA)
  • Deb Fischer (R-NE)
  • Markwayne Mullin (R-OK)
  • Jacky Rosen (D-NV)
  • Michael Rounds (R-SD)
  • John Hoeven (R-ND)
  • Michael Bennet (D-CO)
  • Chris Van Hollen (D-CT)
  • Margaret Wood Hassan (D-NH)
  • Edward Markey (D-MA)
  • Brian Schatz (D-HI)
  • Patty Murray (D-WA)
  • John Boozman (R-AR)
  • Todd Young (R-IN)
  • Roger Wicker (R-MS)

 

Full Letter Text

Dear Leader Schumer and Leader McConnell:

We write today to thank you for your longstanding support of the Special Diabetes Program (SDP) and to ask for your commitment to reauthorize this vital program prior to the funding cliff on December 31, 2024. As part of the March 8 funding package, you helped deliver the first funding increase for the SDP in 20 years, and we look forward to working with you to continue that momentum before the end of the year.

For 27 years, the Special Diabetes Program – comprised of the Special Statutory Funding Program for Type 1 Diabetes Research and the Special Diabetes Program for Indians (SDPI) – has delivered meaningful resources and research breakthroughs for the 38.4 million Americans with diabetes and 97.6 million with prediabetes. It is essential that we continue to invest in the research necessary to develop a cure for diabetes, as well as support the programs that help prevent and treat the disease and its complications.

Diabetes is one of our country’s most costly diseases in both human and economic terms, affecting people of all ages and races, and in every region of our country. It is a leading cause of kidney disease, blindness in working-age adults, lower-limb amputations, heart disease, and stroke. Approximately one in four health care dollars and one in three Medicare dollars are spent treating people with diabetes. Diabetes costs our nation $412.9 billion in 2022. Medical expenditures for individuals diagnosed with diabetes are roughly 2.6 times higher than expenditures for those without the disease.

Although the costs and prevalence of diabetes continue to increase, research funded by the SDP is leading directly to the development of new insights and therapies that are improving the lives of those with diabetes and accelerating progress toward curing and preventing the disease. This progress was highlighted at a bipartisan Senate Appropriations Committee hearing in July 2024, titled “Accelerating Breakthroughs: How the Special Diabetes Program Is Creating Hope for those Living with Type 1 Diabetes.”

In particular, in recent years, federal funding from the SDP has contributed to landmark research that culminated in the first early, preventive treatment that can delay clinical diagnosis of Type 1 diabetes in those at high risk of developing the disease. SDP-funded research is also advancing knowledge of how insulin-producing beta cells are lost with Type 1 diabetes and how they can be protected or replaced in people, which is helping scientists accelerate new cell replacement therapies.

The SDP has also allowed researchers to continue to make progress in other areas, such as:

  • Environmental Factors Influencing T1D: Researchers are conducting a groundbreaking 15-year study to determine what environmental factors influence the onset of T1D. They believe that by identifying specific triggering factors, new strategies can be developed to prevent the initial onset of the disease.
  • Artificial Pancreas (AP) Systems: SDP-funded research laid early groundwork for developing AP systems, which have shown the ability to reduce costly and burdensome complications and improve the quality of life for those with the disease. SDP funds led to the first fully automated insulin-dosing system being made available to patients in 2017, some five to seven years earlier than expected. Positive results from clinical trials since then have led to another FDA-approved AP system and next-generation AP devices that have outperformed first-generation devices in adolescents and young adults. According to one study, the use of AP systems in adults could save Medicare roughly $1 billion over 25 years.
  • Therapies to Delay T1D Onset: The SDP enabled the creation of TrialNet, the largest clinical network for T1D, which conducted the clinical trials that supported the 2022 FDA approval of the first disease-modifying therapy for T1D, which can delay onset by nearly three years. Other therapies to delay and ultimately prevent onset are in the research pipeline.
  • Eye Therapies: SDP-funded research discovered that combining a drug with laser therapy can reverse vision loss in people living with diabetes. The SDP also filled a critical research gap by funding a head-to-head comparison of three drugs for the treatment of diabetic eye disease. In the SDP era, diabetic eye disease rates have decreased by more than 50 percent for American Indian and Alaskan Natives, resulting in a reduction of vision loss and blindness.
  • Diabetes Prevention in the American Indian and Alaskan Native (AI/AN) Community: SDPI has been one of the most successful programs ever created to reduce the incidence and complications due to Type 2 diabetes. Communities with SDPI-funded programs have seen substantial growth in diabetes prevention resources, and, for the first time, from 2013 to 2017, diabetes incidence in the AI/AN population decreased each year. In addition, the average blood sugar level, as measured by the hemoglobin A1C test, decreased from 9.0 percent in 1996 to 8.1 percent in 2014 in the American Indian and Alaskan Native population, resulting in reduced risk of eye, kidney, and nerve complications.

These are only a few of the many groundbreaking discoveries made possible by the Special Diabetes Program. New technology, therapies, and data sets are improving the lives of the more than 133 million Americans living with or at risk of developing diabetes, while also greatly reducing the long-term health care expenditures related to its complications. Long-term, sustained investment in this program would provide the stability researchers need to continue large-scale trials, conduct outreach and education, and determine where best to allocate resources – all of which play an important role in helping to better treat, prevent, and ultimately cure diabetes.

We thank you again for your support for renewing the Special Diabetes Program through December 2024 at $160 million per year, per component. While Congress has reauthorized the SDP with bipartisan support on a regular basis since the program’s inception in 1997, prior to this action, funding had remained flat since fiscal year 2004. During this time, the cost of research has increased, as has the size of the Indian Health Service population and the cost of medical care. We greatly appreciate your recognition of these considerations.

As we face yet another expiration of this program at the end of this year, we look forward to working with you to ensure that the SDP can continue to support Americans living with or at risk of developing diabetes.

President Biden Proposes a 15% Increase for Indian Health Service, 5% Increase for Urban Indian Health for FY 2025

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The FY 2025 budget request includes $95 million for urban Indian health, a 5% increase over the FY 2024 enacted amount, mandatory funding through FY 2033, and an IHS exemption from sequestration.

On March 11, 2024, the Indian Health Service (IHS) published their Fiscal Year (FY) 2025 Congressional Justification with the full details of the President’s Budget, which includes $95 million for Urban Indian Health – a 5% increase above the FY 2024 enacted amount of $90.4 million. The President’s proposal included a total $130.7 billion in discretionary funding for the Department of Health and Human Services (HHS) and $8 billion in funding for IHS, a 15% increase above the FY 2024 enacted amount of $6.96 billion. The budget request also includes $260 million in proposed mandatory funding for the Special Diabetes Program for Indians (SDPI), bringing the total IHS funding to 8.2 billion. The proposal maintains the IHS budget should be moved to mandatory funding and includes $979 million in indefinite discretionary appropriation for Contract Support Costs and $349 million for Section 105(l) Leases.

Budget Caps and Debt Limit Impacts

The President’s budget reflected a discretionary spending request that was in line with caps set under the 2023 debt limit deal. This means that while there was a decrease in the President’s overall budget request in comparison to FY 2024 request, the Indian Health Service and the Urban Indian Line Item still received an increase over the FY2024 enacted amount.

Mandatory Funding and Advance Appropriations

The budget transitions IHS funding from advance appropriations to full mandatory funding for IHS from FY 2026 to FY 2034 to the amount of $288.9 billion over ten-years, as well as exempting IHS from sequestration. On January 29, 2024, the National Council of Urban Indian Health (NCUIH) sent a letter to Congressional Leadership to request that Congress protect the Indian Health Service (IHS) from sequestration in the fiscal year 2024 funding bill. This mandatory formula would culminate in $42 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, “Mandatory funding is the most appropriate, long-term solution for adequate, stable, and predictable funding for the Indian health system.”

NCUIH Efforts to Support Tribal Request for FY 2025

The National Council of Urban Indian Health (NCUIH) requested full funding for urban Indian health for FY 2025 at $965.3 million and at least $53.85 billion for IHS in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. The marked increase for FY 2025 is due to Tribal leaders’ budget recommendations to address health disparities that have historically been ignored.

NCUIH Supports President’s Legislative Proposals

The President’s Budget includes potential legislative solutions to address workforce challenges in Indian Country. These proposals include meeting the IHS loan repayment/scholarship service obligation on a half-time basis and providing tax exemptions for IHS professions scholarship and repayment programs. NCUIH has endorsed the IHS Workforce Parity Act (S. 3022) which expands healthcare provider access to IHS scholarship and loan repayment programs, including scholarships for half-time clinical practice. The President’s budget also proposes that U.S. Public Health Service Commissioned Officers be permitted to be detailed directly with UIOs. On May 24, 2022, the National Council of Urban Indian Health (NCUIH) sent a letter to the Chairs of the House and Senate Appropriations Committees, expressing NCUIH’s support for detailing Public Health Service Commission Officers (PHSCOs) to Urban Indian Organizations (UIOs).

Next Steps

The Appropriations Committees will review the President’s Budget for consideration as they craft their bills for FY 2025. NCUIH will submit testimony and send letters to House and Senate Appropriators to request full funding for FY2025.  NCUIH will continue to work with the Biden Administration and Congress to push for full funding of urban Indian health in FY 2025.

Line Item   FY23 Enacted   FY24 Enacted  FY25 Tribal Request  FY25 President’s  Budget 
Urban Indian Health $90.42 million $90.4 million $973.6 million $94.99 million
Indian Health Service $6.96 billion $ 6.96 billion $51.4 billion $8.2 billion
Advance Appropriations $5.13 billion $5.19 billion ——————— ———————
Hospitals and Clinics $2.5 billion  $2.55 billion  $12.2 billion $2.93 Billion
Tribal Epidemiology Centers $34.4 million  $34.4

 million

  ——————– $34.4 million
Electronic Health Record System $218 million  $190.57 million  $491.9 million $435.1 million
Community Health Representatives $65.21 million  $65.2

million

 $1.2 billion $69.63 million
Mental Health $127.1 million  $129.77 million  $3.4 billion $138.75 million
IHS Cancer Moonshot Initiative —————- —————- ——————— 108 million
HIV & Hepatitis $5 million $5 Million ——————— $15 million

Overview of Budget

Key Provisions for IHS, Tribal Organizations, and Urban Indian Organizations (UIOs)

  • $8.1 billion for IHS for FY 2025
  • $95 million for urban Indian health for FY 2025
  • $979 million in indefinite discretionary funding for Contract Support Costs
  • $349 million in indefinite discretionary funding for Section 105(l) Leases
  • $260 million in mandatory funding up to 2026 for SDPI

Other Budget Highlights

  • Addressing Targeted Public Health Challenges
    • $15 million for HIV and Hepatitis C.
      • UIOs eligible
    • $21 million for addressing opioid use.
      • UIOs eligible
    • Urban Indian Health Program – Alcohol and Substance Abuse Title V Grants
      • $3.4 million
        • Allocates funds to the Office of National Drug Control Policy (ONDCP) budget to give resources to UIOs to provide high quality, culturally relevant prevention, early intervention, outpatient and residential substance abuse treatment services, and recovery support to address the unmet needs of the Urban Indian communities they serve.
  • IHS Cancer Moonshot Initiative
    • $108 billion
      • 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
  • Indian Health Professions
    • $81.25 million
      • Offers additional IHS Scholarship and Loan Repayment awards, bolstering recruitment and retention efforts through these two high demand programs.
        • UIOs eligible

Legislative Proposals

  • U.S. Public Health Service Commissioned Officers to be Detailed to Urban Indian Organizations to Cooperate in or Conduct Work Related Functions of the Department of Health and Human Services

  • Sequestration Exemption for Indian Health Program
    • Proposal Description
      • Amends current law to exempt IHS from future sequestration cuts.
      • The services provided by the IHS are no less critical. Budget reductions of any kind have implications for the services IHS, Tribes, and Urban Indian organizations provide to American Indian and Alaska Native patients and communities.
    • NCUIH Action
      • January 29, 2024 Letter Requesting Exemption
  • Meet Loan Repayment/Scholarship Service Obligations on a Half-Time Basis
    • Proposal Description
      • Permit both Indian Health Service (IHS) scholarship and loan repayment recipients to fulfill service obligations through half-time clinical practice, under authority similar to that now available to the National Health Service Corps (NHSC) Loan Repayment Program (LRP) and Scholarship Program.
      • Permitting IHS scholarship and loan repayment health professional employees to fulfill their service obligations through half-time clinical practice for double the amount of time and to offer half the loan repayment award amount in exchange for a two-year service obligation could increase the number of providers interested in serving in the Indian health system.
    • NCUIH Action
      • NCUIH has endorsed the IHS Workforce Parity Act ( S. 3022) which expands healthcare provider access to IHS scholarship and loan repayment programs, including scholarships for half-time clinical practice.
  • Provide Tax Exemption for Indian Health Service Health Professions Scholarship and Loan Repayment Programs
    • The Indian Health Service (IHS) seeks tax treatment similar to that provided to recipients of scholarships and loan repayment from the National Health Service Corps (NHSC). The IHS seeks to allow scholarship funds for qualified tuition and related expenses received under the Indian Health Service Health Professions Scholarships to be excluded from gross income under section 117(c)(2) of the Internal Revenue Code of 1986 (IRC) and to allow participants in the IHS Loan Repayment Program to exclude from gross income, payments made by the IHS Loan Repayment Program under section 108(f)(4) of the IRC. With the above exemptions, the IHS programs would also be exempt from any Federal Employment Tax (FICA), making the IHS programs comparable to the current NHSC status.
    • NCUIH Action:
      • NCUIH has endorsed the IHS Workforce Parity Act (S. 3022) which expands healthcare provider access to IHS scholarship and loan repayment programs, including scholarships for half-time clinical practice.

House Passes Bipartisan Bill that Includes the Reauthorization of the Special Diabetes Program for Indians at $170 Million

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On December 11, 2023, the House passed the Lower Costs, More Transparency Act (H.R. 5378) with a vote of 320-71. The bill has now been received in the Senate. The original sponsor, Rep. Cathy McMorris Rodger (R-WA-05) introduced this bipartisan legislation on September 8, 2023, which would extend funding for the Special Diabetes Program and the Special Diabetes Program for Indians (SDPI) through 2025, including $124.4 million for the rest of fiscal year (FY) 2024 and $170 million in FY 2025 for each program, plus $42.8 million for the remainder of calendar year 2025 for each program. The bill’s reauthorization of SDPI would allow for urban Indian organizations (UIOs) to continue to use grant funding to offer a wide range of diabetes treatment and prevention services, including but not limited to exercise programs and physical activity, nutrition services, community gardens, culinary education, physical education, health and wellness fairs, culturally relevant nutrition assistance, food sovereignty education, group exercise activities, green spaces, and youth and elder-focused activities. Under the FY 2024 Continuing Resolution (CR), SDPI is set to expire January 19, 2024, making this legislation even more crucial to avoid lapses in critical diabetes research and care funding.

Specifically, the bill increases transparency to the health care system and extends important public health legislation by:

  1. A 13 percent increase in funding for both the Special Diabetes Program (SDP) and the Special Diabetes Program for Indians (SDPI), to $170 million each year for fiscal years 2024 and 2025
  2. Codifying the Hospital Price Transparency rule and the Transparency in Coverage rule, which requires hospitals to make public all standard charges for all items and services, and requires insurers to make public their negotiated in-network provider rates for all items and services
  3. Extending these price transparency requirements to other providers and services, including labs, imaging providers, and ambulatory surgical centers
  4. A 10 percent increase in mandatory funding for Community Health Centers (CHCs)
  5. A 13 percent increase in funding for the National Health Service Corps (NHSC)
  6. A seven-year reauthorization for the Teaching Health Centers Graduate Medical Education (THCGME) program
  7. Lowering health care costs and reducing seniors’ cost-sharing by ensuring that Medicare beneficiaries are not paying more for drug administration if a drug is administered in a hospital outpatient department instead of a physician’s office
  8. Prohibiting the use of “spread pricing,” or markups charged by PBMs, for prescription drugs in Medicaid, and including provisions to help ensure that Medicaid payments to pharmacies are adequate and accurate
  9. Increasing access to affordable generic drugs by requiring the Food and Drug Administration to provide more information to generic drug manufacturers during the development process, speeding their path to market and increasing competition.

 This bill is endorsed by The Alliance to Fight for Health Care, Better Solutions for Healthcare, Families USA, The Leukemia & Lymphoma Society, the National Association of Community Health Centers, the American Association of Teaching Health Centers, the American Association of Colleges of Osteopathic Medicine, the American Academy of Family Physicians, Advocates for Community Health, AARP, American Benefits Council, Small Business Majority, the National Alliance of Healthcare Purchaser Coalitions, the Purchaser Business Group on Health (PBGH), The ERISA Industry Committee, EmployersRx, Consumers First, Consumers for Fair Hospital Pricing, and United States of Care, and more.

Need for a Crucial Investment in SDPI

SDPI is set to expire on January 19, 2024, with first funding deadline for the current FY 2024 Continuing Resolution. SDPI’s integrated approach to diabetes healthcare and prevention programs in Indian country has become a resounding success and is one of the most successful public health programs ever implemented. SDPI has demonstrated success with a 50% reduction in diabetic eye disease rates, drops in diabetic kidney failure, and 50% decline in End Stage Renal Disease.  Additionally, the reduction in end stage renal disease between 2006 and 2015 led to an estimated $439.5 million dollars in accumulated savings to the Medicare program, 40% of which, of $174 million, can be attributed to SDPI.

Currently, 31 UIOs are in this program and are at the forefront of diabetes care. Facilities use these funds to offer a wide range of diabetes treatment and prevention services, including but not limited to exercise programs and physical activity, nutrition services, community gardens, culinary education, physical education, health and wellness fairs, culturally relevant nutrition assistance, food sovereignty education, group exercise activities, green spaces, and youth and elder-focused activities.

SDPI has been funded at $150 million since 2004, despite significant inflation and increases in healthcare expenditures over the past twenty years. With the program set to expire in January 2024, the permanent reauthorization of SDPI at a minimum of $170 million requested in the President’s FY 2024 budget with automatic annual funding increases tied to the rate of medical inflation is essential to continue the success of preventing diabetes-related illnesses for all of Indian Country.

NCUIH Advocacy

The National Council of Urban Indian Health (NCUIH) has long supported the permanent reauthorization of SDPI and will continue to advocate for the UIOs’ requested amount of $250,000,000. On September 12, 2023, the National Indian Health Board (NIHB), the NCUIH, and 15 other Tribal partners sent a letter to House and Senate leadership requesting the reauthorization of the SDPI and brought for consideration for a floor vote by the time the program expired, on September 30, 2023. On September 14, 2023, NCUIH also released an action alert regarding SDPI to assist Indian Health Advocates in contacting congress about the potential lapse in SDPI funding.

Next Steps

This bill has been received in the Senate. NCUIH will continue to monitor the bill’s progress.

Tribal Leaders Diabetes Committee Meeting Highlights Portland Urban Indian Organization’s Exemplary Programming

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On December 5-6, 2023, the National Council of Urban Indian Health (NCUIH) represented urban Indian organizations (UIOs) as a technical advisor at the Indian Health Service (IHS) Tribal Leaders Diabetes Committee (TLDC) meeting in Portland, Oregon. During the two-day meeting, committee members discussed the status and future of the Special Diabetes Program for Indians (SDPI), received Portland Area diabetes programming updates and legislative updates, and had a discussion with IHS Deputy Director Benjamin Smith. The SDPI status updates from IHS were crucial as the current continuing resolution (CR) legislation has authorized the program for an additional $25.89 million, for a total of $46 million through January 19, 2024.

TLDC is planning on hosting the next in-person meeting on March 5-6 in Reno, Nevada. Details are forthcoming.

NARA NW, Portland UIO, Recognized for Exemplary Diabetes Programing

Native American Rehabilitation Association of the Northwest, Inc. (NARA)

During the TLDC meeting, the Native American Rehabilitation Association of the Northwest, Inc. (NARA), a Portland area urban Indian organization (UIO), was recognized for its work on diabetes treatment and prevention. NARA gave a presentation on its Saturday Diabetes Clinics, which started in 1999 and has since emerged as a highly successful program. NARA’s Saturday Diabetes Clinics are a multidisciplinary “one-stop-shop” for diabetes care offered once a month. Because this clinic is offered on the weekends, NARA has been able to increase involvement and attendance in the program with an average of 14-16 patients attending each session.

The monthly clinic offers comprehensive diabetes care, presenting a holistic approach to managing the disease. The process involved various healthcare professionals and services, beginning with a pharmacist and medical assistants to facilitate annual labs and vaccines. Patients also consult with an ophthalmologist, podiatrist, medical provider for a thorough review of the disease management and medication use, and a dietitian for personalized coaching lasting 20-30 minutes. Additionally, behavioral health support is provided, recognizing the often co-occurring challenges of diabetes and depression. The clinic integrates a cancer screening indicator and hosts a semi-annual eye exam clinic offered by the local university. Furthermore, dental services are offered, contributing to the overall well-being of the patients. The innovative and comprehensive nature of NARA NW’s Saturday Diabetes Clinics garnered enthusiastic support from TLDC members, who expressed their excitement and interest in replicating the model within their own Tribes.

Special Diabetes Program for Indians Updates and Planning

The current CR legislation has granted authorization for SDPI, allocating $46 million for the fiscal year (FY) 2024 until January 19, 2023. However, the full authorization for SDPI in 2024 remains pending, awaiting further legislative action. In response to the evolving funding landscape, the IHS has made decisions to optimize available resources. A portion of the one-time, unobligated SDPI funding, combined with the allocated $46 million from the FY2024 CR, will be utilized to fund all grant recipients for the first six months of the 2024 grant year, extending until June 20, 2024. The total available funds for this initiative amount to $69.5 million.

IHS has also initiated the implementation of another program, SDPI-2. This new grant program aims to extend SDPI funding to Tribes and UIOs that do not currently have an SDPI grant. Funded using unobligated and prior-year SDPI grant funding, SDPI-2 is structured as a four-year grant program. The application review process for SDPI-2 officially started on December 4, 2023 with the anticipated date for grant awards set for January 13, 2024. IHS noted that 9 applications were selected with one applicant being a UIO.

Members of TLDC discussed the potential funding outcomes for SDPI. These options included the reauthorization of SDPI with an allocation exceeding $150 million for one or more years, reauthorization at $150 million for one or more years, a scenario where SDPI is reauthorized with $147 million (reflecting a 2% reduction due to sequestration) for one or more years, and the possibility that SDPI may not be reauthorized at all.

Background on TLDC

The IHS Director established the TLDC in 1998. The TLDC makes recommendations to the IHS Director on broad-based policy and advocacy priorities for diabetes and related chronic conditions as well as recommends a process for the distribution of SDPI funds.

The TLDC consists of the following members:

  • One elected or duly-appointed Tribal Leader from each of the 12 IHS Areas serves as the primary representative.
  • Each Area also designates an alternate member to serve when the primary member is unavailable to do so.
    • TLDC elects one of its members to serve as the Tribal Co-Chair
  • One federal representative, who serves as the Federal Co-Chair
    • One technical advisor from each of the following American Indian/Alaska Native organizations serves in an advisory (non-voting) capacity to the TLDC: Direct Service Tribes Advisory Committee, National Congress of American Indians, National Council of Urban Indian Health, National Indian Health Board, and Tribal Self-Governance Advisory Committee.

NCUIH Joins NIHB and 15 Tribal Partners in Letter to Congress Requesting Immediate Reauthorization of SDPI

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On September 12, 2023, the National Indian Health Board (NIHB), the National Council of Urban Indian Health (NCUIH), and 15 Tribal partner organizations sent a letter to House and Senate leadership requesting the reauthorization of the Special Diabetes Program for Indians (SDPI) be brought for consideration for a floor vote by September 30, 2023. The letter emphasizes that SDPI serves 780,000 American Indians and Alaska Natives across 302 programs in 35 states and is scheduled to expire on September 30, 2023.

SDPI provides culturally informed care, funds life-saving efforts to fight diabetes at Indian Health Services facilities (including 31 UIOs), and is critical to improving long-term health outcomes in Indian Country. The highly successful, bipartisan program is a proven success, and reauthorization should be a top priority for Congress.

Read the Full Letter

Full Letter Text

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

On behalf of the undersigned Tribal partner organizations and the 574+ sovereign federally recognized American Indian and Alaska Native (AI/AN) Tribal nations we serve, we write today to thank you for your longstanding support of the Special Diabetes Program for Indians (SDPI) and ask for your commitment to reauthorize this vital program before it expires at the end of this month. Please bring the SDPI forward for consideration for a floor vote by September 30, 2023.

The Special Diabetes Program for Indians serves 780,000 American Indians and Alaska Natives across 302 programs in 35 states.1 SDPI focuses on a culturally informed and community-directed approach to treat and prevent Type 2 diabetes in Tribal communities. American Indians and Alaska Natives disproportionately suffer from Type 2 diabetes, but thanks to the success of SDPI, that statistic is improving.

As part of the Balanced Budget Act of 1997, Congress established the SDPI program to address the growing epidemic of diabetes in AI/AN communities. At a rate approximately twice the national average, AI/ANs have the highest prevalence of diabetes. Further, AI/ANs are 1.8 times more likely to die from diabetes. In some Tribal communities, over 50 percent of adults have been diagnosed with Type 2 diabetes. However, from 2013 to 2017, diabetes incidence in AI/ANs decreased each year for the first time, thanks to the success of the SDPI program. American Indians and Alaska Natives are the only racial/ethnic group that has seen a decrease in prevalence.2 SDPI has also resulted in significant savings in Medicare due to a reduction in End Stage Renal Disease (ESRD). Between 1996 and 2013, incidence rates of ESRD in AI/AN individuals with diabetes declined by 54 percent. This reduction alone is estimated to have saved $520 million between 2006-2015.3

SPDI is bipartisan and widely supported in Congress but has yet to be reauthorized. Earlier this year, the Congressional Diabetes Caucus led bipartisan sign-on letters requesting support to reauthorize SDPI. The letters received 60 Senate signers and 240 House signers. And while these letters may show how bipartisan this program is, they do not reauthorize the most effective federally funded program.

More recently, legislation was passed out of committee in both the House (H.R. 3561) and Senate (S. 1855) that would reauthorize the SDPI program at $170 million per year for two years but awaits consideration by the full House and Senate. Failure to reauthorize SDPI will create unnecessary program uncertainty and impact the continuity of care for the patients who depend on this highly effective program. Despite the lack of funding, the Special Diabetes Program for Indians continues to prove how successful and widely bipartisan it is.

Unless the Speaker of the House and the Senate Majority Leader bring legislation to the floor for a vote, the program will expire on September 30, 2023, resulting in diminished type 2 diabetes care for thousands of AI/ANs. This program is highly successful, bipartisan, and has proven to be a worthwhile financial investment of taxpayer dollars.

The future of this successful program is in the hands of Congress. Passing legislation to reauthorize the SDPI program must be a top priority in September. The undersigned organizations urge House and Senate leadership to schedule the legislation for a floor vote and reauthorize the Special Diabetes Program for Indians by September 30, 2023.

Sincerely,
Alaska Native Health Board
Albuquerque Area Indian Health Board, Inc.
American Indian Higher Education Consortium
California Rural Indian Health Board
Great Plains Tribal Leaders’ Health Board
Inter Tribal Association of Arizona
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
Northwest Portland Area Indian Health Board
Rocky Mountain Tribal Leaders Council
Self-Governance Communication and Education Tribal Consortium
Southern Plains Tribal Health Board
United South and Eastern Tribes Sovereignty Protection Fund
National Indian Health Board

Background

In March 2023, the House Diabetes Caucus Leaders and Senate Diabetes Caucus Leaders sent a letter to House and Senate leadership advocating for the reauthorization of SDPI and outlining the program’s positive impacts on reducing diabetes in AI/AN communities. The House Diabetes Caucus letter closed with 238 signatures, and the Senate Diabetes Caucus letter closed with 60 signatures.

SDPI includes research-based interventions for diabetes prevention and cardiovascular disease (CVD) risk reduction AI/AN community-based programs and healthcare settings. AI/ANs have the highest diabetes prevalence rates of all racial and ethnic groups in the United States. AI/AN adults are almost three times more likely than non-Hispanic white adults to be diagnosed with diabetes. The program has demonstrated success with a 50% reduction in diabetic eye disease rates, drops in diabetic kidney failure, and a 50% decline in End Stage Renal Disease. SDPI is, therefore, a critical program to address the disparate high rates of diabetes among AI/ANs.

The 31 UIOs currently receiving SDPI funding have used these funds to purchase blood sugar monitoring devices, medication, wound care, endocrinology, and retinal imaging services. Other projects include a robust preventative education and support system and a Garden Project to teach classes about creating and maintaining a healthy diet.

Senate Committee Passes Bipartisan Bill to Reauthorize the Special Diabetes Program for Indians, Marking First Increase in Nearly Two Decades

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On June 15, 2023, the Senate Health, Education, Labor, and Pensions Committee passed the bipartisan Special Diabetes Program Reauthorization of 2023 (S.1855), introduced by Sen. Susan Collins (R-ME) and Sen. Jeanne Shaheen (D-NH). The bill would reauthorize the Special Diabetes Program for Type 1 Diabetes and the Special Diabetes Program for Indians (SDPI) at $170 million for fiscal years (FY) 24-25 for each program. This is the first time the program has seen an increase in funding, as the program has been funded at $150 million annually since 2004, and is set to expire in September 2023. The bill passed out of the committee with a 20-1 vote.

On May 17, 2023, the House Subcommittee on Health passed the bipartisan Special Diabetes Program for Indians Reauthorization Act (H.R. 2547), introduced by Representative Tom Cole (R-OK-04) and Representative Raul Ruiz (D-CA-25). Similar to S. 1855, the bill would reauthorize the program for fiscal years 2024 and 2025 at $170 million per year. The bill will now be moved to the full Energy and Commerce Committee.

SDPI’s integrated approach to diabetes healthcare and prevention programs in Indian Country has become a resounding success and is one of the most successful public health programs ever implemented. Currently, 31 urban Indian organizations (UIOs) receive SDPI funding that enables UIOs to provide critical services that reduce the incidence of diabetes-related illness among urban Indian communities. The program is currently set to end in September 2023, and it remains critical that Congress reauthorizes SDPI to ensure there is no lapse in funding.

Bipartisan Letters from the Diabetes Caucus

In March 2023, The House Diabetes Caucus Leaders Rep. Diana DeGette (D-CO-1) and Rep. Gus Bilirakis (R-FL-12) sent a letter to Speaker McCarthy and Minority Leader Jeffries, and Senate Diabetes Caucus Leaders Sen. Susan Collins (R-ME) and Sen. Jeanne Shaheen (D-NH) sent a letter to Majority Leader Schumer and Minority Leader McConnell regarding the reauthorization of the Special Diabetes Program (SDP) comprised of Special Statutory Funding Program for Type 1 Diabetes Research and SDPI. The House Diabetes Caucuses letter closed with 238 signatures and the Senate Diabetes Caucus letter closed with 60 signatures.

The letter outlines that the programs fund research that led to new therapies improving the lives of those with diabetes and notes that “SDPI has been one of the most successful programs ever created to reduce the incidence and complications due to Type 2 diabetes.  Communities with SDPI-funded programs have seen substantial growth in diabetes prevention resources, and, for the first time, from 2013 to 2017, diabetes incidence in the AI/AN population decreased each year.” This funding invests in necessary research to develop a cure for diabetes as well as support programs, like SDPI, that help prevent and treat the disease and its complications.

The letter notes developments from the SDP and SDPI include:

  • Type 1 (T1D) Prevention Research
  • Artificial Pancreas (AP) System Research Led to the First Fully Automated Insulin-Dosing System Available to Patients
  • Kidney Disease Research on Reduction in End-Stage Renal Disease
  • Eye Therapy Research on Diabetic Eye Disease
  • Glucose Control Research for the American Indian/Alaska Native (AI/AN) Population that Reduced the Risk of Eye, Kidney, and Nerve Complications
  • Diabetes Prevention in the AI/AN Community that Leads to a Reduction in the Incidence and Complications due to Type 2 Diabetes

Background on SDPI and American Indians/Alaska Natives

SDPI includes research-based interventions for diabetes prevention and cardiovascular disease (CVD) risk reduction AI/AN community-based programs and healthcare settings. AI/ANs have the highest diabetes prevalence rates of all racial and ethnic groups in the United States, with AI/AN adults almost three times more likely than non-Hispanic white adults to be diagnosed with diabetes. The program has demonstrated success with a 50% reduction in diabetic eye disease rates, drops in diabetic kidney failure, and a 50% decline in End Stage Renal Disease. SDPI is therefore a critical program to address the disparate high rates of diabetes among AI/ANs.

The 31 UIOs currently receiving SDPI funding have used these funds to purchase blood sugar monitoring devices, medication, wound care, endocrinology, and retinal imaging services. Other projects include: a robust preventative education and support system and a Garden Project to teach classes about creating and maintaining a healthy diet.

NCUIH Action

The National Council of Urban Indian Health (NCUIH) has long supported SDPI and after conducting focus groups for the 2022 Policy Assessment, UIOs have requested an increase in SDPI funding from current FY23 levels of $150,000,000 to $250,000,000. NCUIH will continue to advocate for the UIOs’ requested amount of $250,000,000.

Resources

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

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On March 23, 2023, The National Council of Urban Indian Health (NCUIH) submitted outside written testimony to the House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies regarding Fiscal Year (FY) 2024 funding for Urban Indian Organizations (UIOs). NCUIH advocated in its testimony for full funding for the Indian Health Service (IHS) and urban Indian health and increased resources for Native health programs.

In the testimony, NCUIH requested the following:

  • $51.42 billion for the Indian Health Service and $973.59 million for Urban Indian Health for FY24 (as requested by the Tribal Budget Formulation Workgroup)
  • Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
  • Permanent 100% Federal Medical Assistance Percentage for services provided at UIOs
  • Increase funding for Electronic Health Record Modernization
  • Increase funding to $30 million for Good Health and Wellness in Indian Country (GHWIC)
  • Ensure UIOs are appropriately included in grant programs relating to Indian health
  • Appropriate $80 million for the Native Behavioral Health Resources Program
  • Work with Authorizers to Reauthorize the Special Diabetes Program for Indians

Full Text of Testimony:

My name is Francys Crevier, I am Algonquin and the Chief Executive Officer of the National Council of Urban Indian Health (NCUIH), the national representative of urban Indian organizations receiving grants under Title V of the Indian Health Care Improvement Act (IHCIA) and the American Indians and Alaska Native (AI/ANs) patients they serve. On behalf of NCUIH and these 41 Urban Indian Organizations (UIOs), I would like to thank Chair Aderholt, Ranking Member DeLauro, and Members of the Subcommittee for your leadership to improve health outcomes for urban Indians. We respectfully request the following:

  • $51.42 billion for the Indian Health Service and $973.59 million for Urban Indian Health for FY24 (as requested by the Tribal Budget Formulation Workgroup)
  • Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
  • Permanent 100% Federal Medical Assistance Percentage for services provided at UIOs
  • Increase funding for Electronic Health Record Modernization
  • Ensure UIOs are appropriately included in grant programs relating to Indian health
  • Appropriate $80 million for the Native Behavioral Health Resources Program
  • Work with Authorizers to Reauthorize the Special Diabetes Program for Indians
We want to acknowledge that your leadership was instrumental in providing the greatest investments ever for Indian health and urban Indian Health, especially the inclusion of advance appropriations. It is important that we continue in this direction to build on our successes.
The Beginnings of Urban Indian Organizations

The Declaration of National Indian Health Policy in the Indian Health Care Improvement Act states that: “Congress declares that it is the policy of this Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.” In fulfillment of the National Indian Health Policy, the Indian Health Service funds three health programs to provide health care to AI/ANs: IHS sites, tribally operated health programs, and Urban Indian Organizations (referred to as the I/T/U system).

As a preliminary issue, “urban Indian” refers to any American Indian or Alaska Native (AI/AN) person who is not living on a reservation, either permanently or temporarily. UIOs were created in the 1950s by American Indians and Alaska Natives living in urban areas, with the support of Tribal leaders, to address severe problems with health, education, employment, and housing caused by the federal government’s forced relocation policies. Congress formally incorporated UIOs into the Indian Health System in 1976 with the passage of the Indian Health Care Improvement Act (IHCIA). Today, UIOs continue to play a critical role in fulfilling the federal government’s responsibility to provide health care for AI/ANs and are an integral part of the Indian health system. UIOs serve as a cultural hub for and work to provide high quality, culturally competent care to the over 70% of AI/ANs living in urban settings.

Request: $51.42 billion for Indian Health Service and $973.59 million for urban Indian health

The federal government owes a trust obligation to provide adequate healthcare to AI/ANs. It is the policy of the United States “to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to affect that policy.” This requires that funding for Indian health must be significantly increased if the federal government is to finally fulfill its trust responsibility. At a minimum, funding must be maintained and protected as budget-cutting measures are being considered.

We thus request Congress honor the Tribal Budget Formulation Workgroup (TBFWG) FY24 recommendations of $51.42 billion for IHS and $973.59 million for urban Indian health. That number is much greater than the FY23 enacted amounts of $6.9 billion for IHS and $90.4 million for urban Indian health. The significant difference between the enacted and requested amount underscores the need for Congress to significantly increase funding to IHS to meet the Indian Health System’s level of need. Additionally, IHS has been consistently underfunded in comparison to other major federal health agencies. In 2018, the Government Accountability Office (GAO-19-74R) reported that from 2013 to 2017, IHS annual spending increased by roughly 18% overall and approximately 12% per capita. In comparison, annual spending at the Veterans Health Administration (VHA), which has a similar charge to IHS, increased by 32% overall, with a 25% per capita increase during the same period. In fact, even though the VHA service population is only three times that of IHS, their annual appropriations are roughly thirteen times higher. In other words, it is imperative that Congress fully fund the IHS at the amount requested by the TBFWG to fulfill its trust responsibility and to improve health outcomes for AI/ANs no matter where they live.

The IHS is chronically underfunded, and the Urban Health line item historically is just one percent (1%) of that underfunded budget. UIOs receive direct funding only from the Urban Health line item and do not receive direct funds from other distinct IHS line items. As a result, in FY 2018 U.S. healthcare spending was $11,172 per person, but UIOs received only $672 per AI/AN patient from the IHS budget. Without a significant increase to the urban Indian line item, UIOs will continue to be forced to operate on limited budgets that offer almost no flexibility to expand services or address facilities-related costs. For example, one UIO, Native American Lifelines, is made up of two programs that run in both Boston and Baltimore with an annual budget of just $1.6 million for a service population of over 55,000 people.

Despite this underfunding, UIOs have been excellent stewards of the funds allocated by Congress and are effective at ensuring that increases in appropriations correlate with improved care for their communities. Last Congress, with the help of this committee, the Infrastructure Investment and Jobs Act now allows UIOs to utilize their existing IHS contracts to upgrade their facilities. With funding increases from this Committee and this new allowance, six UIOs opened new facilities in the past year, and an additional 16 UIOs have plans to open new facilities in the next two years. The increased investments in urban Indian health by this committee will continue to result in the expansion of health care services, increased jobs, and improvement of the overall health in our communities.

Request: Maintain Advance Appropriations for IHS Until Mandatory Funding Is Enacted

We applaud Chair Baldwin and this Committee for your work on the historic inclusion of advance appropriations in the FY23 Omnibus. This is a crucial step towards ensuring long-term, stable funding for IHS. Previously, the I/T/U system was the only major federal health care provider funded through annual appropriations. It is imperative that this Committee retain advance appropriations and ensure that IHS is protected from sequestration.

The GAO cited a lack of consistent funding as a barrier for IHS. The Congressional Research Service stated that advance appropriations would lead to cost savings as continuing resolutions (CRs) “prohibits the agency from making longer-term, potentially cost-saving purchases.” Advance appropriations will improve accountability and increase staff recruitment and retention at IHS. When IHS distributes their funding on time, our UIOs can pay their doctors and providers. During a pandemic that has ravaged Indian Country and devasted the workforce, being able to recruit doctors and pay them on time is a top priority.

While advance appropriations are a step in the right direction to avoid disruptions during government shutdowns and continuing resolutions (CRs), mandatory funding is the only way to assure fairness in funding and fulfillment of the trust responsibility. Until authorizers act to move IHS to mandatory funding, we request that Congress continue to provide advance appropriations to the Indian health system to improve certainty and stability.

Cuts from sequestration force I/T/U providers to make difficult decisions about the scope of healthcare services they can offer to Native patients. For example, the $220 million reduction in IHS’ budget authority for FY 2013 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for AI/ANs. Therefore, we request that you exempt IHS from sequestration and other budget cutting measures as is required by the trust responsibility.

Request: Work with Authorizers for Permanent 100% Federal Medical Assistance Percentage (FMAP) for services provided at UIOs

The federal medical assistance percentage (FMAP) refers to the percentage of Medicaid costs covered by the federal government and reimbursed to states. With states already receiving 100% FMAP for services provided at IHS and Tribal facilities, the American Rescue Plan Act (ARPA) temporarily shifted the responsibility of UIO Medicaid cost obligation from state governments to the federal government. This provision finally brought a form of parity to UIOs by setting FMAP for Medicaid services provided at UIOs at 100% for eight fiscal quarters, while offering cost savings to states, and finally creating a sense of consistency in how the federal government honors its obligations to urban Native healthcare. The provision expires this month on March 31, 2023. During this short provision, states have been able to work with UIOs to provide increased funding to help begin construction of a new clinic, youth services center, and establish a new behavioral health unit.

Permanent 100% FMAP will bring some fairness to the I/T/U system and increase available financial resources to UIOs and support them in addressing critical health needs of urban Native patients. Again, we request that the committee work with authorizers for permanent 100% FMAP.

Request: Increase Funding for Electronic Health Record Modernization

We request your support for the Indian Health Service’s (IHS) transition to a new electronic health record (EHR) system for IHS and UIOs. UIOs have expended significant funds for the replacement, upgrade and maintenance of IHS’ Health Information Technology (HIT) systems due to the federal government’s failure to keep pace with HIT development in the wider healthcare industry. This has resulted in UIOs having no choice but to purchase expensive off-the-shelf-replacement systems to ensure that they can continue to provide high-quality and culturally-focused health care to AI/AN patients. As EHR modernization moves from planning to fruition, it is critically important that appropriations continue to increase, and any language included in appropriations must allow funding to be used to reimburse Tribal Organizations and UIOs associated with the cost of EHR modernization. NCUIH requests the committee to support this transition by supporting the President’s budget request of $913 million in FY24 appropriations.

Request: Ensure UIOs are appropriately included in grant programs relating to Indian health

Failure to explicitly include UIOs in legislative programmatic authorizations often effectively prohibits UIOs from accessing the related funding, even if the exclusion was unintentional and UIOs would otherwise be an appropriate addition to program eligibility. UIOs are already severely underfunded and rely on grant funding to support the provision of life-saving services to their patients. Excluding UIOs from grant funding reduces the ability of UIOs to provide and expand service options for their patients. For example, UIOs are left out of statutory language in the nationalization of the Community Health Aide Program (CHAP), which is meant to increase the availability of healthcare workers in Native communities. Because of this legislative oversight, IHS interprets this as UIOs are not eligible to participate in the program, and therefore UIOs cannot utilize the program to ease the burden caused by limited provider availability for the Indian Health System.

Many programs in the Health and Human Services appropriations bills include language for Indian Tribes and Tribal organizations, but not for urban Indian organizations. Urban Indian Organizations are not considered Tribal organizations, which is a common misconception. While UIOs may fall within general terms such as “non-profit organization,” there are times when a general grant to non-profits is not appropriate, but a grant to UIOs would be. For example, if the grant is intended to serve Indian Healthcare facilities, including UIOs in grant funding would be appropriate, while including non-profit organizations generally would not be. Therefore, it is essential that you explicitly include UIOs when they intend UIOs to be included in the program. We request that any addition of UIOs to a program should include a corresponding appropriation increase to ensure that funding for Tribes and Tribal Organizations are not reduced. We emphasize that we acknowledge and respect the government-to-government relationship between Tribes and the United States and understand that there are times when it is not appropriate to add UIOs into legislation directed at Tribes and Tribal Organizations.

Request: Appropriate $80 Million for the Native Behavioral Health Resources Program

Native people continue to face high rates of behavioral health issues caused by generational trauma and federal policies. Native people experience serious mental illnesses at a rate 1.58 times higher than the national average, and high rates of alcohol and substance abuse. In fact, between 1999 and 2015, the drug overdose death rates for Native populations increased by more than 500%. Native youth also experience the highest rates of suicide and depression, with the Native youth suicide rate being 2.5 times that of the national average.

In response to these chronic health disparities, Congress authorized $80 million to be appropriated for the Native Behavioral Health Resources Program for fiscal years 2023 to 2027. Despite authorizing an appropriation of $80 million for the Program, Congress did not appropriate that sum for FY 23.

We request that the authorized $80 million be appropriated to the Native Behavioral Health Resources Program for FY 24 and each of the remaining authorized years. Until the committee appropriates funding for this program, critical healthcare programs and services cannot operate to their full capability, putting Native lives at-risk. We ask that this essential step is taken to ensure our communities have access to the care they need.

Request: Work with Authorizers to Re-authorize the Special Diabetes Program for Indians (SDPI)

SDPI’s integrated approach to diabetes healthcare and prevention programs in Indian country has become a resounding success and is one of the most successful public health programs ever implemented. SDPI has demonstrated success with a 50% reduction in diabetic eye disease rates, drops in diabetic kidney failure, and 50% decline in End Stage Renal Disease. Additionally, the reduction in end stage renal disease between 2006 and 2015 led to an estimated $439.5 million dollars in accumulated savings to the Medicare program, 40% of which, of $174 million, can be attributed to SDPI.

Currently, 31 UIOs are in this program and are at the forefront of diabetes care. Facilities use these funds to offer a wide range of diabetes treatment and prevention services, including but not limited to exercise programs and physical activity, nutrition services, community gardens, culinary education, physical education, health, and wellness fairs, culturally-relevant nutrition assistance, food sovereignty education, group exercise activities, green spaces, and youth and elder-focused activities.

With the program set to expire this year, we request that the committee work with authorizers to permanently reauthorize SDPI at a minimum of $250 million requested in the President’s FY24 budget with automatic annual funding increases tied to the rate of medical inflation, to continue the success of preventing diabetes-related illnesses for all Indian Country.

Conclusion

These requests are essential to ensure that urban Indians are appropriately cared for, in the present and in future generations. The federal government must continue to work towards its trust and treaty obligation to maintain and improve the health of American Indians and Alaska Natives. We urge Congress to take this obligation seriously and provide UIOs with all the resources necessary to protect the lives of the entirety of the Native population, regardless of where they live.

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 Releases “2022 Annual Policy Assessment”

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

2022 Policy Assessment thumbnailThe National Council of Urban Indian Health (NCUIH) is pleased to announce the release of its 2022 Annual Policy Assessment. NCUIH hosted five focus groups to identify Urban Indian Organization (UIO) policy priorities for 2023, as they relate to the Indian Health Service (IHS) designated facility types (full ambulatory, limited ambulatory, outreach and referral, and outpatient and residential). The focus groups were held on October 18, 21, and 24, 2022. Additional information was also collected from the UIOs via a questionnaire sent out on November 15, 2022.

Together these tools allow NCUIH to work with UIOs to identify policy priorities in 2023 and identify barriers that impact delivery of care to Native patients and their communities.  Of 41 UIOs, 26 attended the focus groups and/or participated in the questionnaire. This is the third year that NCUIH has conducted the assessment via focus groups and follow up questionnaire. This is also the highest response from UIOs NCUIH has seen since following this process.

Read the 2022 Policy Assessment

Overview of Policy Assessment

2022 Policy Assessment chartAfter the height of the COVID-19 pandemic, newfound priorities were identified for 2023, including workforce development and retention, increased funding for traditional healing, and expanded access to care and telehealth services. Existing priorities also remain a key focus across UIOs, especially increasing funding amounts for the urban Indian health line item and IHS, maintaining advance appropriations for IHS, establishing permanent 100% Federal Medical Assistance Percentage (FMAP) for UIOs, reauthorizing the Special Diabetes Program for Indians (SDPI), and increasing behavioral health funding.

 

Key findings from the discussions are as follows:

  • Funding Flexibility is Key to Expanding Services
  • Need for Funding Security Remains a Priority
  • Advance Appropriations Mitigates Funding Insecurities Generated by Government Shutdowns and Continuing Resolutions
  • Facility Funding Directly Impacting UIOs
  • Permanent 100% FMAP Increases Available Financial Resources to UIOs
  • Workforce Concerns Amidst Inflation and Market Changes
  • Traditional Healing Crucial to Advance Comprehensive Native Healthcare
  • Addressing Access and Quality of Native Veteran Care
  • Health Information Technology and Electronic Health Record Modernization
  • New Barriers Limit UIO Distribution of Vaccines
  • HIV, Behavioral Health, and Substance Abuse Report
  • Reauthorizing the Special Diabetes Program for Indians
  • UIOs Find Current NCUIH Services Beneficial

Next Steps

NCUIH will release a comprehensive document of the 2023 Policy Priorities in the coming weeks.

Past Resources:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bill Highlights for Urban Indian Organizations

Mandatory Funding and Advance Appropriations for the Indian Health Service

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

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

Special Diabetes Programs for Indians

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

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

Permanent 100% Federal Medical Assistance Percentage (FMAP)

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

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

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

 Urban Confer with HHS and UIOs

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

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

 Office of Management and Budget Office of Native Nations

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

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

Next Steps

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

Background

Broken Promises

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

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