Tag Archive for: Testimony

American Medical Association Adopts NCUIH-Supported Resolution on IHS Improvements, Includes Key Medicaid Parity Provision for UIOs

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On November 3, 2023, the National Council of Urban Indian Health (NCUIH) submitted written testimony to the 2023 Interim Meeting of the American Medical Association (AMA) House of Delegates (HOD), held on November 10-14, 2023, regarding the proposed resolution “Federal Medical Assistance Percentage Extension for Urban Indian Organizations” as part of  a larger resolution, Resolution 812 (I-23), “Indian Health Service Improvements.” This testimony was read in support of the resolution and resulted in the adoption of the entire resolution by the AMA, with amendments, including the language in support of 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs).

In its testimony, NCUIH emphasized that “Congress must enact legislation to provide permanent 100% FMAP for Medicaid services provided at UIOs to ensure parity across the IHS healthcare system and further fulfill the federal trust obligation to provide healthcare to Native people.” NCUIH also shared examples of how the temporary extension of 100% FMAP in 2021 benefited UIOs in Washington and Montana and emphasized permanent 100% FMAP as a vehicle to provide UIOs with a much-needed source of supplemental income to support the continued provision of comprehensive and culturally competent health care.

The Reference Committee noted that 100% FMAP would “lead to enhanced and directed advocacy of priorities as identified by American Indian/Alaska Native-serving health organizations and other important stakeholders.” After discussion, the Committee recommended the entire resolution be adopted as amended. The House of Delegates adopted the resolution and its new language, which reads as follows:

“RESOLVED, that our American Medical Association supports an increase to the Federal Medical Assistance Percentage (FMAP) to 100% for medical services which are received at or through an Urban Indian Organization that has a grant or contract with the Indian Health Service (IHS) and encourage state and federal governments to reinvest Medicaid savings from 100% FMAP into tribally-driven health improvement programs.”

Adoption of this resolution means that 100% FMAP will now be a priority of the AMA moving forward. Having the support of the largest physician advocacy organization is an additional advocacy tool NCUIH and other organizations can utilize, and it shows Congress the necessity of passing 100% FMAP legislation.

Background on 100% FMAP for UIOs

Federal Medical Assistance Percentage (FMAP) refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. Congress first authorized 100% FMAP for the Indian healthcare system in 1976 because it recognized that “Medicaid payments are . . . a much-needed supplement to a health care program which has for too long been insufficient to provide quality health care to” Native people and because “the Federal government has treaty obligations to provide services to Indians, it has not been a State responsibility.” Unfortunately, UIOs were not included in this initial authorization and therefore, services provided at UIOs were not eligible for 100% FMAP.

In 2021, Congress amended the Social Security Act (SSA) to provide for eight fiscal quarters of 100% FMAP for UIOs. This amendment temporarily eased the financial burden on states by allowing states to be reimbursed by the federal government for the full cost of providing care to Medicaid beneficiaries at UIOs. As a result, some states were able to utilize the provision to increase funding to UIOs. Unfortunately, this provision expired on March 31, 2023, meaning that states once again are responsible for covering a portion of the cost of Medicaid services provided at UIOs.

About the AMA House of Delegates (HOD)

The House of Delegates (HOD) is the legislative and policy-making body of the American Medical Association. State medical associations and national medical specialty societies are represented in the HOD along with AMA sections, national societies such as American Medical Writers Association (AMWA), American Osteopathic Association (AOA) and the National Medical Association (NMA), professional interest medical associations, and the federal services, including the Public Health Service. At HOD Meetings, resolutions are referred to the Reference Committee for open discussion and to allow recommendations for HOD action. If adopted by the HOD, the resolution can become the foundation of a new AMA program, establish or modify policy on an issue, or become a new directive for action. Policies of the AMA House of Delegates are policy statements on health topics and are one of the cornerstones of the AMA as they define what the Association stands for as an organization. They provide the information and guidance that physicians and others seek from the AMA about health care issues.

The AMA Interim Meeting of the House of Delegates takes place in November every year. Materials presented at the 2023 Interim Meeting are generated by AMA delegates/delegations, the AMA Board of Trustees, AMA Councils and AMA Sections. The delegates will next meet in June for the 2024 AMA Annual Meeting in Chicago.

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.

NCUIH to Testify Before House Interior Appropriations

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NCUIH to Testify Before House Interior Appropriations

On Thursday, March 9, 2023 at 9:00 AM, the National Council of Urban Indian Health (NCUIH) Chief Executive Officer, Francys Crevier, JD (Algonquin) will testify in person before the House Interior Appropriations Subcommittee hearing as part of American Indian and Alaska Native Public Witness Days (March 8 and 9, 2023).

In the testimony, NCUIH will advocate for full funding for the Indian Health Service and Urban Indian Health as requested by the Tribal Budget Formulation Workgroup (TBFWG) for Fiscal Year (FY) 2024. Other requests include: maintaining advance appropriations for IHS until mandatory funding is enacted and appropriating at least $80 million for the Native Behavioral Health Resources Program.

Tune in!

Livestream

 

Learn more: https://appropriations.house.gov/events/hearings

NCUIH Bill Helps Urban Indian Organization Purchase New Building for Women’s Health and Pediatric Services

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In October 2022, the Oklahoma City Indian Clinic (OKCIC), one of the 41 Urban Indian Organizations (UIOs) serving the more than 70% of American Indian and Alaska Native (AI/AN) individuals living in urban areas, announced their purchase of a new clinic building in Oklahoma City, Oklahoma. “This building is larger than our other locations” says Oklahoma City Indian Clinic’s Chief Operating Officer Lysa Ross. “The extra space will give us more opportunities to expand services and continue providing excellent health care to American Indians.” In 2021, The National Council of Urban Indian Health (NCUIH) worked tirelessly to include the Padilla-Moran-Lankford Urban Indian Health amendment to the bipartisan infrastructure package which allows UIOs to use existing Indian Health Service (IHS) funding for facilities improvement and renovations.

The clinic plans to renovate the nearly 65,000 square foot structure, with six-stories, to hold primarily women’s health and pediatric services. Their pediatric department offers several specialty clinics, including an asthma and a foster care clinic. Well-child visits, same-day visits, physical examinations, immunizations, and vision and hearing checks will also be procedures provided in the new building. The women’s health department at Oklahoma City Indian Clinic offers birth control, preventative health and wellness services and prenatal care, including delivery options.

The new building is still undergoing renovations, but OKCIC plans to see patients at this new location in 2023.

Background

NCUIH has worked on a bipartisan basis for legislation that that would expand the use of existing IHS resources under Section 509 of the Indian Health Care Improvement Act (IHCIA) (25 U.S.C. § 1659) to increase the funding authority for renovating, constructing, and expanding UIOs. In August 2021, NCUIH successfully advocated for the Padilla-Moran-Lankford Urban Indian Health Amendment to be included in the bipartisan infrastructure package, which allows UIOs to use existing IHS funding for infrastructure projects.

Prior to the passage of the bipartisan infrastructure package with this amendment, IHS did not have funding allocated specifically for use toward UIO facilities, maintenance, sanitation or medical equipment, nor could UIOs use their contract funds to make such purchases or payments. At the height of the pandemic, while the whole IHS system transitioned to telehealth, negative pressurizing rooms and other facility renovations that were needed to safely continue to see patients, restrictions within the relevant statutory text would not allow UIOs to spend their funds to make similar such transition. Section 509 of the Indian Health Care Improvement Act (IHCIA), where the technical fix this amendment provided exists, only allowed IHS to provide UIOs with funding for minor renovations and to assist UIOs in meeting or maintaining compliance with The Joint Commission (TJC) accreditation standards.

Prior to the passage of the Padilla-Moran-Lankford amendment, in May, Congressmen Ruben Gallego (D-AZ) and Don Bacon (R-NE) introduced the Urban Indian health Facilities Provider Act (H.R. 3496) in the House of Representative, expanding the use of existing IHS resources under Section 509 to increase the funding authority for renovating, constructing, and expanding UIOs. An identical bill was introduced at the same time in the Senate (S. 1797) by Senators Alex Padilla (D-CA) and James Lankford (R-OK), with initial co-sponsors including Senators Moran (R-KS), Feinstein (D-CA) and Smith (D-MN) who is on the Senate Committee on Indian Affairs.

NCUIH also testified in support of the Urban Indian health Facilities Provider Act before both the House Natural Resources Subcommittee for Indigenous Peoples of the United States (SCIP) and the Senate Committee on Indian Affairs (SCIA) in May of 2021. Sonya Tetnowski (Makah Tribe), Chief Executive Officer of the Indian Health Center of Santa Clara Valley and the NCUIH President-Elect at the time of the hearing, testified before SCIP, and Robyn Sunday-Allen (Cherokee), Chief Executive Officer of the Oklahoma City Indian Clinic and NCUIH Vice President, testified before SCIA.

NCUIH Submits Written Testimony to Senate Interior Appropriations with FY23 Budget Requests for Urban Indian Health

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The National Council of Urban Indian Health (NCUIH) CEO, Francys Crevier (Algonquin), submitted public witness written testimony to the Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding Fiscal Year (FY) 2023 funding for Urban Indian Organizations (UIOs) in response to the Subcommittee Hearing, “A Review of the Fiscal Year 2023 President’s Budget for the Indian Health Service,” held on May 11, 2022. NCUIH advocated in its testimony for additional resources for the Indian Health Service and urban Indian Health.

Full Text of Testimony

In the testimony, NCUIH requested the following:

  • $49.8 billion for the Indian Health Service (IHS) and $949.9 million for Urban Indian Health for FY23 (as requested by the Tribal Budget Formulation Workgroup)
  • Advance appropriations for IHS until mandatory funding is enacted

These requests are essential to ensure that urban Indians are properly cared for and move us closer to fulfilling the federal government’s trust responsibility to American Indians/Alaska Natives (AI/ANs).

Background:

On March 28, 2022, President Biden released his discretionary budget request for FY23. This request includes $127.3 billion for the Department of Health and Human Services (HHS), $9.1 billion in mandatory funding for IHS— an increase of $2.5 billion above the 2022 enacted level, and $112.5 million for Urban Indian Health— an increase of $39.1 billion above the 2022 enacted level.

NCUIH previously submitted testimony to the House Appropriations Subcommittee on Interior regarding UIO funding for FY23 and reiterated that “The federal government owes a trust responsibility to tribes and AI/ANs that is not restricted to the borders of reservations. Funding for Indian health must be significantly increased if the federal government is, to finally, and faithfully, fulfill its trust responsibility.”

On May 27, 2022, 12 Senators echoed these requests in a letter to Chairman Jeff Merkley and Ranking Member Lisa Murkowski of the Senate Interior Appropriations Committee. The letter emphasizes that increasing funding “is essential to providing quality, culturally-competent health care to AI/AN people living in urban areas.” Earlier, on April 26, 2022, 28 Representatives sent a letter to the House Interior Appropriations Committee with similar requests.

NEXT STEPS:

The testimony will be read and considered by the Subcommittee as the appropriations process goes forward for Fiscal Year 2023. The Senate markup schedule is yet to be released.

The House Interior Subcommittee markup for its FY 2023 appropriations bill will be held on June 21, 2022, and the Full Committee markup will be held on June 29, 2022. Further details on the timing and location of each markup are to be determined.

NCUIH Submits Written Testimony to Senate Appropriations Subcommittee with FY 2023 Budget Requests for Urban Indian Health

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On May 10, 2022, The National Council of Urban Indian Health (NCUIH) submitted outside written testimony to the Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies regarding Fiscal Year (FY) 2023 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:

  • Fully fund IHS at $49.8 billion and Urban Indian Health at $949.9 million for FY23 (as requested by the Tribal Budget Formulation Workgroup)
  • Advance appropriations for IHS until mandatory funding is enacted
  • Increase funding for Electronic Health Record Modernization
  • Increase funding to $30 million for Good Health and Wellness in Indian Country (GHWIC)
  • Permanently reauthorize Native Connections (Tribal Behavioral Health Grant)
  • Include urban Indians in language for all health programs
  • Include UIOs in critical opioid grants

Full Text of Testimony:

National Council of Urban Indian Health – Testimony for Senate LHHS on FY2023 Health and Human Services Appropriations Bill

My name is Francys Crevier, I am Algonquin and the Chief Executive Officer of the National Council of Urban Indian Health (NCUIH). On behalf of NCUIH, the national advocate for health care for the over 70% of American Indians and Alaska Natives (AI/ANs) living off-reservation and the 41 Urban Indian Organizations (UIOs) that serve these populations, I would like to thank Chairwoman Murray, Ranking Member Blunt, and Members of the Subcommittee for the opportunity to submit public witness testimony regarding Fiscal Year (FY) 2023 appropriations. We respectfully request the following:

  • Fully fund the Indian Health Service (IHS) at $49.8 billion and Urban Indian Health at $949.9 million for FY23 (as requested by the Tribal Budget Formulation Workgroup)
  • Advance appropriations for IHS until mandatory funding is enacted
  • Increase funding for Electronic Health Record Modernization
  • Increase funding to $30 million for Good Health and Wellness in Indian Country (GHWIC)
  • Permanently reauthorize Native Connections (Tribal Behavioral Health Grant)
  • Include urban Indians in language for all health programs
  • Include UIOs in critical opioid grants
Fully fund the Indian Health Service at $49.8 billion and Urban Indian Health at $949.9 million for FY23 (as requested by the Tribal Budget Formulation Workgroup)

While your leadership was instrumental in providing the greatest investments ever for Indian health and urban Indian health, it is important that we continue in this direction to build on our successes. The average health care spending is around $12,000 per person, however, Tribal and IHS facilities receive only around $4,000 per patient.  UIOs receive just $672 per IHS patient – that is only 6 percent of the per capita amount of the national average. That’s what our organizations must work with to provide health care for urban Indian patients.

The federal trust obligation to provide health care to Natives is not optional, and we thus request Congress honor the Tribal Budget Formulation Workgroup (TBFWG) FY23 recommendations of $49.8 billion for IHS and $949.9 million for urban Indian health. That number is much greater than the FY21 enacted amount of $63.7 million, which truly demonstrates how far we have to go to reach the level of need for urban Indian health. At an IHS Area Report meeting where Tribal leaders presented their budget requests, one Oklahoma Tribal leader stated that “There are inadequate levels of funding to address the rising urban Indian population.” Congress must do more to fully fund the IHS in order to improve health outcomes for all Native populations at the amount requested.

In 2018 the Government Accountability Office (GAO-19-74R) reported that from 2013 to 2017, IHS annual spending increased by roughly 18% overall, and roughly 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. Similarly, spending under Medicare and Medicaid increased by 22% and 31% respectively. In fact, even though the VHA service population is only three times that of IHS, their annual appropriations are roughly thirteen times higher.

Currently, the entire Eastern seaboard is without any full-ambulatory UIOs due to lack of funding. The IHS has deemed the two remaining UIOs on the East Coast to be outreach and referral only, with a combined less than two-million-dollar budget. Unfortunately, the pandemic has shown that two outreach and referral UIOs to serve all urban Indians on the entire East Coast of the country is a failure to uphold the federal trust obligation. It is evident the UIO line item is insufficient to allow IHS to authorize our East Coast UIOs to open fully operational clinics. Native American Lifelines is actually two programs run in both Boston and Baltimore with an annual budget for both cities of $1.6 million.  During the height of the pandemic, that meant Native people living in urban areas on the East Coast had to go back to reservations to get their vaccine to take advantage of the IHS authority that would give them the vaccine early and hopefully not become a mortality statistic.

The federal government owes a trust responsibility to tribes and AI/ANs that is not restricted to the borders of reservations. Funding for Indian health must be significantly increased if the federal government is, to finally, and faithfully, fulfill its trust responsibility.

Advance Appropriations for IHS Until Mandatory Funding Is Enacted

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, automatic sequestration cuts, and continuing resolutions (CRs). When IHS is funded through a CR, the IHS can only expend funds for the duration of a CR, which prohibits longer term purchases, disrupts the contracts that allow UIOs to provide health care, and quite literally puts lives at risk. Because UIOs must rely on every dollar of limited federal funding they receive to provide critical patient services, any disruption has significant and immediate consequences.

NCUIH supports the President’s proposal in the FY 2023 Budget to fund the IHS through mandatory appropriations and to exempt IHS from proposed law sequestration.   The ten years of appropriated mandatory funding in the FY 2023 Budget will ensure predictability that will allow the I/T/U system to engage in long-term and strategic planning. The lack of consistent and clear funding creates significant barriers on the already underfunded IHS system. Until authorizers act to move IHS to mandatory funding, we request that Congress provide advance appropriations to the Indian health system to improve certainty and stability.

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. As EHR modernization moves from planning to fruition, it is vitally important that appropriations continue to increase as appropriate to provide for its success. NCUIH Requests the committee to support this transition with $355.8 million in FY23 appropriations. NCUIH is also supportive of the inclusion of report language suggested by members of Congress in a letter to the House appropriations committee.[1]

CDC: Good Health and Wellness in Indian Country – $30 Million Good Health and Wellness in Indian Country (GHWIC)

The GHWIC program is CDC’s single largest investment in Indian Country. The program funds a total of 27 Tribes, Tribal organizations, and UIOs to improve chronic disease prevention efforts, expand physical activity, and reduce commercial tobacco use. The FY 2023 President’s Budget proposes maintaining at current levels of $22 million. NCUIH requests the Committee support the GHWIC program by increasing funding to $30 million for FY2023.

SAMHSA: Tribal Behavioral Health Grant (Native Connections) – $23.2 Million

The Tribal Behavioral Health Grant (known as Native Connections) is a five-year grant program that helps American Indian and Alaska Native communities identify and address the behavioral health needs of Native youth. The program supports grantees in reducing suicidal behavior and substance use among Native youth up to age 24, easing the impacts of substance use, mental illness, and trauma in tribal communities, and supporting youth as they transition into adulthood.

As of June 2021, SAMHSA had awarded 242 five-year grants to eligible AI/AN entities including UIOs. The program is up for reauthorization in 2022 and the FY23 President’s budget has a request of $23.2 million for the program, an increase of $2.5 million from the FY 2022 Annualized Continuing Resolution. NCUIH requests the committee support addressing the behavioral health needs of our Native communities by reauthorizing this critical program.

Include Urban Indians in Language for All Health Programs

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). Unfortunately, this system has been hampered by decades of chronic underfunding. Additionally, while the majority of the Native population resides in urban areas, only 1% of the entire Indian health budget is provided for urban Indian health.

When urban Indians are not specifically mentioned in programmatic language they are most often excluded from participating in such programs. 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. Therefore, UIOs must be explicitly included to receive funding. UIOs also do not have access to other IHS line items like IHS and Tribal facilities and do not receive hospitals and health clinics money, purchase and referred care dollars, or IHS dental services dollars, and are not eligible for the IHS facilities fund.

As one advocate stated, “The language everywhere has to include the word ‘urban’ – urban Indian or urban Native. They have to say it, they have to write it and then it’ll reach a critical mass, eventually. Because they don’t get it, you know. We’re just invisible.”[2]

Include UIOs in Critical Opioid Grants

UIOs have repeatedly been left out of funding designed to help AI/AN communities address the opioid crisis. To address the opioid overdose epidemic in Indian Country by increasing access to culturally appropriate and evidence-based treatment, Congress provided funding for Tribal Opioid Response grants. NCUIH has long advocated for UIOs to be added to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) State Opioid Response (SOR) grants given the extent of the impact of the opioid epidemic on all AI/ANs regardless of residence. Since FY 2018, Congress has enacted set asides in opioid response grants to help Native communities address this crisis. However, it was only available for Tribes and Tribal organizations, meaning UIOs working against the same problem are left without the resources necessary to reach the highest health status for all AI/ANs as required of the federal government. This is a failure of equity. Without the necessary funding to address health crises in Indian Country, urban AI/AN people will again be left out of the equation.

Last Spring, Congress introduced the State Opioid Response Grant Authorization Act of 2021 (H.R. 2379), which included a 5 percent set-aside of the funds made available for each fiscal year for Indian Tribes, Tribal organizations, and UIOs to address substance abuse disorders through public health-related activities such as implementing prevention activities, establishing or improving prescription drug monitoring programs, training for health care practitioners, supporting access to health care services, recovery support services, and other activities related to addressing substance use disorders. NCUIH worked closely with Congressional leaders to ensure the inclusion of urban Indians in the funding set-aside outlined in this bill, which eventually passed the House on October 20, 2021. Despite this effort, UIOs were removed from the SOR Grant reauthorization, which saw a $5 million increase (9 percent increase from FY 2021), included in the recently passed FY 2022 Omnibus (H.R. 2471). The final language in the Omnibus only listed “Indian Tribes or Tribal organizations” as eligible and did not use the language from H.R. 2379. When UIOs are not explicitly stated as eligible entities, we are excluded from critical resources and grants, which is a violation of the trust obligation.

We were disappointed to yet again be left out of this key resource as our communities are plagued by the opioid crisis. Inclusion in this program could have enabled UIOs to expand services or workforce or to help address the catastrophic impacts of the opioid epidemic in Indian Country.  We urge you to work to ensure funding designated to help AI/AN communities have the proper language to prevent UIOs from lacking access to these critical funds.

Conclusion

These requests are essential to ensure that urban Indians are properly cared for, both during this crisis and in the critical times following. It is the obligation of the United States government to provide these resources for AI/AN people residing in urban areas. This obligation does not disappear in the midst of a pandemic, instead it should be strengthened, as the need in Indian Country is greater than ever. 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 AI/AN population, regardless of where they live.

[1] https://files.constantcontact.com/a3c45cb9201/562eb81b-dee4-48b8-8519-69bcbebb0ff2.pdf?rdr=true
[2] https://www.usatoday.com/story/news/politics/2022/03/07/opioids-native-americans-funding/9380063002/?gnt-cfr=1