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NCUIH 2025 Policy Priorities Released

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NCUIH 2025 Policy Priorities

The National Council of Urban Indian Health (NCUIH) is pleased to announce the release of its 2025 Policy Priorities document, which outlines a summary of urban Indian organization (UIO) priorities for the Executive and Legislative branches of the government for 2025. These priorities were informed by NCUIH’s 2024 Policy Assessment.

NCUIH hosted five focus groups to identify UIO policy priorities for 2025, as they relate to Indian Health Service (IHS)- designated facility types (full ambulatory, limited ambulatory, outreach and referral, and outpatient and residential). NCUIH worked with UIOs to identify policy priorities in 2025 under eight themes:

  • Funding for Native Health Initiatives
  • Elevating Native Voices and Fostering Dialogue
  • Strengthening Health Outcomes: Addressing Social Determinants of Health
  • Honoring Promises to Native Veterans
  • Revitalizing Native Health: Embracing Traditional Healing and Behavioral Wellness
  • “Not One More’: Healing Generational Trauma and Protecting Native Lives
  • Addressing Workforce Recruitment and Retention Challenges
  • Improving the Indian Health Service
Read the 2025 Policy Priorities

2025 Policy Priorities:

FUNDING FOR NATIVE HEALTH INITIATIVES
Increasing Funding for Indian Health Service (IHS) and Urban Indian Health
  • Appropriate the Maximum Amount Possible for IHS and Fund Urban Indian Health at $100 million.
  • Support Participation and Continued Inclusion of Urban Indian Organizations in the IHS Budget Formulation Process.
Protecting Funding for Native Health from Political Disagreements
  • Maintain Advance Appropriations for IHS to Insulate the Indian Health System from Government Shutdowns
  • and to Protect Patient Lives.
  • Transition IHS from Discretionary to Mandatory Appropriations.
  • Transition Contract Support Costs and 105 (l) Leases to Mandatory Appropriations.
Meeting the Trust Obligation for IHS-Medicaid Beneficiaries Receiving at Urban Indian Organizations (UIOs)
  • Pass the Urban Indian Health Parity Act to Ensure Permanent Full (100%) Federal Medical Assistance
  • Percentage (FMAP) for Services Provided at UIOs (100% FMAP for UIOs).
  • Ensure that All American Indian and Alaska Native People are Exempt from Medicaid Work Requirements.
  • Allow for Audio-Only Telehealth Services for Medicare Beneficiaries at UIOs through the Telehealth for Tribal Communities Act.
Transforming Health Care Resources in Indian Country and Beyond
  • Decrease Competition and Reduce Barriers to Access to Ensure Equitable Distribution of Grant Funding.
ELEVATING NATIVE VOICES AND FOSTERING DIALOUGE
Inclusion of Urban Native Communities in Resource Allocation
  • Ensure Critical Resource and Funding Opportunities are Inclusive of Urban Native Communities and the Urban Indian Organizations that Help Serve Them.
STRENGTHENING HEALTH OUTCOMES: ADDRESSING SOCIAL DETERMINANTS OF HEALTH
Improving Native Maternal and Infant Health
  • Strengthen the Ability of the Advisory Committee on Infant and Maternal Mortality to Address Native Maternal and Infant Health.
  • Improve Funding Access for Urban Indian Organizations to expand Housing Services.
Improving Food Security for Urban American Indian and Alaska Native People
  • Increase Access to U.S. Department of Agriculture (USDA) Resources and Funding Opportunities for Urban American Indian and Alaska Native Communities and the Urban Indian Organizations that Serve Them.
  • Increase Urban Indian Organization Access to Fresh and Traditional Foods Through Increased Funding for the IHS Produce Prescription Pilot Program.
  • Permanently Reauthorize and Increase Funding for the Special Diabetes Program for Indians (SDPI) at a Minimum of $250 Million Annually
Including Urban American Indian and Alaska Native People in Preparing and Protecting Their Communities
  • Increase Emergency Preparedness through the Passage of the CDC Tribal Public Health Security and Preparedness Act.
HONORING THE PROMISES TO NATIVE VETERANS
Improving American Indian and Alaska Native Veteran Health Outcomes
  • Engage with Urban Indian Organizations to Successfully Implement the Interagency Initiative to Address Homelessness for Urban American Indians and Alaska Native Veterans.
REVITALIZING NATIVE HEALTH: EMBRACING TRADITIONAL HEALING AND BEHAVIORAL WELLNESS
Improving Behavioral Health for All American Indian and Alaska Native People
  • Increase Funding for Behavioral Health and Substance Use Disorder Resources for American Indian and Alaska Native People.
  • Respond to the Significant Increase in Overdose Deaths in Indian Country.
  • Pass the Comprehensive Addiction Resources Emergency (CARE) Act.
Improving Health Outcomes Through Traditional Healing and Culturally Based Practices
  • Improve Funding Access for Urban Indian Organizations to Expand Traditional Healing and Culturally Based Practices.
“NOT ONE MORE”: HEALING GENERATIONAL TRAUMA AND PROTECTING NATIVE LIVES
Healing from Federal Boarding Schools
  • Support Federal Initiatives to Allow the Indian Health Service to Support Healing from Boarding School Policies.
Ending the Epidemic of Missing or Murdered Indigenous Peoples (MMIP)
  • Pass the Bridging Agency Data Gaps and Ensuring Safety (BADGES) for Native Communities Act.
  • Honor Executive Order 14053: Improving Public Safety and Criminal Justice for Native Americans and
  • Addressing the Crisis of Missing or Murdered Indigenous People by Including Urban Indian Organizations in Prevention and Intervention Efforts.
ADDRESSING WORKFORCE RECRUITMENT AND RETENTION CHALLENGES
Improving the Indian Health Workforce
  • Include Urban Indian Organizations in the national Community Health Aide Program (CHAP).
  • Improve the Indian Health Workforce through the Placement of Residents at Urban Indian Organizations through the Department of Veterans Affairs Pilot Program on Graduate Medical Education and Residency Program (PPGMER).
  • Enable Urban Indian Organizations to Fill Critical Workforce Needs through University Partnerships by Passing the Medical Student Education Authorization Act.
  • Extend Federal Health Benefits to Urban Indian Organizations.
  • Improve Recruitment and Retention of Physicians at Urban Indian Organizations by Reintroducing the IHS Workforce Parity Act.
  • Increase Tax Fairness for Loan Repayment for Urban Indian Organization Staff by Reintroducing the Indian Health Service Health Professions Tax Fairness Act.
  • Permit U.S. Public Health Service Commissioned Officers to be Detailed to Urban Indian Organizations.
  • Improve Community Health Worker Coverage at Urban Indian Organizations through the Introduction of the Community Health Workers Access Act.
Accurately Account for Provider Shortages
  • Engage with the Health Resources and Services Administration (HRSA) so that Urban Indian Organizations receive Health Professional Shortage Area (HPSA) Scores that Accurately Reflect the Level of Provider Shortage for Urban Indian Organization Service Areas.
IMPROVING THE INDIAN HEALTH SERVICE
Bridging the Gap: Enhancing Patient Care by Advancing Health Information Technology
  • Improve Health Information Technology, Including Electronic Health Records Systems.
Elevate the Health Care Needs of American Indian and Alaska Native People Within the Federal Government
  • Pass the Stronger Engagement for Indian Health Needs Act to elevate the IHS Director to Assistant Secretary for Indian Health.

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

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

Download the Template

Background

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

NCUIH’s Actions

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

NCUIH will continue to monitor developments regarding the RAP.

VA Exempts Over 5,000 Native Veterans from Copayments, Reimburses $3 Million: VA Secretary McDonough Highlights Progress at NCUIH Conference

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On April 17, 2024, the Department of Veterans Affairs (VA) announced that more than 4,000 Native Veterans have been approved for the VA’s copayment exemption and has exempted and/or reimbursed over 168,000 copayments totaling more than $3 million for Native Veterans. During NCUIH’s Annual Conference on April 30, 2024, VA Secretary Denis McDonough highlighted these new numbers and noted an update – that over 6000 Native Veterans have applied and over 5000 had been approved.

Background

American Indians and Alaska Natives serve in the military at some of the highest rates in the country, and many Native veterans receive healthcare from the Veterans Health Administration (VHA), alongside IHS, Tribal, and urban Indian organization (UIO) facilities. Unfortunately, American Indian and Alaska Native Veterans generally face a higher rate of mental health disorders compared to White veterans.

On April 4, 2023, VA published a final rule in the Federal Register establishing the waiver process for Veterans to submit documentation to have their VA copays waived. This rule implements Section 3002 of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020 Public Law 116-315, signed into law on January 5, 2021, which prohibits collection of a health care copayment by the Secretary of Veterans Affairs from an American Indian and Alaska Native Veteran who meets the definitions of “Indian” or “urban Indian” under the Indian Health Care Improvement Act (IHCIA).

The copayment exemption is a crucial step in honoring the federal government’s trust responsibility to “maintain and improve the health of the Indians” and NCUIH has been a strong advocate for this policy. NCUIH continues to stress that Native Veterans are entitled to this copayment exemption due to the federal government’s responsibility to provide and support services for Native Veterans, fulfilling the trust responsibility for healthcare provisions for all American Indians and Alaska Natives. We remain committed to engaging with the VA on issues affecting American Indian and Alaska Native Veterans in urban areas.

See NCUIH resources on the VA Copayment Exemption for Native Veterans:

IHS Releases New Quarterly Report Highlighting Progress on Urban Indian Health Priorities: 100% FMAP, Collaboration with Other Federal Agencies

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On May 21, 2024, the Indian Health Service’s (IHS) Office of Urban Indian Health Programs (OUIHP) released their 4th Quarterly Report outlining progress on the agency’s 2023 Work Plan to implement the goals from the 2023-2027 OUIHP Strategic Plan for urban Indian organizations (UIOs).

The quarterly report highlights the OUIHP accomplishments as of December 31, 2023, on the five pillars outlined in the Strategic Plan: provide effective, timely and transparent communication; improve OUIHP’s operational oversight and management; leverage partnerships to expand UIO resources; improve data quality; and expand the infrastructure and capacity of UIOs. The accomplishments include providing technical assistance to other federal agencies to engage UIO leaders in an IHS UIO Listening Session, collaborations with the Veterans Health Administration and the White House Council on Native American Affairs Health Committee, and providing technical assistance on 100% Federal Medical Assistance Percentage (100% FMAP) and the assignment of United States Public Health Service Commissioned Officers to UIOs.

View the full list of accomplishments in the quarterly report here.

Background

In June 2023, IHS released their 2023-2027 OUIHP Strategic Plan which describes how OUIHP will achieve its mission and vision through five strategic pillars to support urban Indian organizations:

  • Provide effective, timely, and transparent communication;
  • Improve OUIHP’s operational oversight and management;
  • Leverage partnerships to expand UIO resources;
  • Improve data quality; and
  • Expand the infrastructure and capacity of UIOs.

IHS also released its corresponding work plan that outlines critical actions and activities to implement these strategic goals, and includes communications on progress, barriers encountered, and accomplishments. The OUIHP tracks progress for each activity and evaluates progress over time. According to the work plan, progress will be shared with UIOs, partners, and stakeholders quarterly.

NCUIH’s Role

NCUIH played a critical role in the drafting of the 2023-2027 OUIHP Strategic Plan and Implementation Plan. NCUIH has submitted a total of four comments to OUIHP with recommendations to strengthen the plans, specifically requesting that the agency develop quarterly reports to provide information on OUIHP’s progress towards achieving the goals and objectives described in the Strategic Plan, and making those reports publicly available.

NCUIH Requests Enhanced VA Support and Improved Reimbursement Rates for Urban Indian Organizations in Reimbursement Agreement Program

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On May 15, 2024, that National Council of Urban Indian Health (NCUIH) submitted comments to the Department of Veterans Affairs’ (VA), in response to a May 1, 2024, Urban Confer regarding the revised template for the urban Indian organization (UIO)-VA Reimbursement Agreement Program (RAP) (“revised agreement”). In its comments, NCUIH requested that VA support UIO participation in the Program by providing technical assistance to UIOs and improving UIO reimbursement rates under the revised agreement.

Background

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

NCUIH previously submitted comments to VA in February 2022, requesting VA improve VA’s urban confer process and continue to improve VA’s relationship with UIOs.

NCUIH’s Recommendations

In its May 15, 2024, comments, NCUIH recommended that VA:

  • Continue to engage with and provide updates to UIO on the revised agreement through its development.
  • Improve the UIO reimbursement rates under the revised agreement.
  • Ensure changes to the scope of services include services provided at UIOs.
  • Provide technical assistance to UIOs to support UIO participation.

NCUIH will continue to monitor the development of the revised UIO-VA RAP template.

Veterans Affairs Publishes Final Rule Confirming UIO Eligibility for Placement of Graduate Medical Students

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On November 13, 2023, the Department of Veterans Affairs (VA) adopted as final, with changes, a proposed rule amending its medical regulations to establish a new pilot program on graduate medical education and residency (PPGMER), as required by the VA MISSION Act of 2018. The PPGMER is designed to help expand health care access for Veterans in rural, tribal, and underserved areas across the country. It will do so by funding physician residents’ clinical rotations in non-VA health care facilities, prioritizing facilities operated by Indian Tribes or tribal organizations, and the Indian Health Service. No fewer than 100 residents will be placed in these facilities as well as facilities located in communities that the VA Secretary has designated as underserved. The proposed rule provides a framework to establish additional medical residency positions at certain covered facilities. In issuing the final rule, VA stated that § 17.245(f) of the rule already allows VA to consider UIOs as covered facilities for the purposes of PPGMER. Placement of residents at UIOs would be in addition to those residents at IHS and Tribal facilities.

Please click here for the news release announcing the PPGMER.

 

For more information about the PPGMER, contact Andrea Bennett, Office of Academic Affiliations, Veterans Health Administration, Department of Veterans Affairs, at (202) 368–0324 or VAMission403Help@va.gov.

Next Steps

VA will issue a request for proposals (RFP) in Summer 2024 to solicit the interest of graduate medical education (GME) sponsoring institutions and interested health care facilities to partner in establishing resident rotations beginning in July 2025. The Office of Academic Affiliations will hold information sessions for relevant stakeholders about the RFP process prior to its release. UIOs are urged to follow the development of this program closely for its potential to relieve workforce shortages through the placement of medical residents.

We will continue to monitor ongoing implementation of the VA PPGMER and provide updates on how the program impacts urban Indian communities.

Veterans Save $2.5 Million Thanks to Department of Veteran Affairs Copay Exemption Championed by NCUIH and Native Partner Organizations

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On February 13, 2024, the Department of Veterans Affairs (VA) announced that it has exempted or reimbursed more than 143,000 copayments totaling approximately $2.5 million for more than 3,800 eligible American Indian and Alaska Native Veterans.

This comes less than a year after the VA implemented a final rule, championed by the National Council of Urban Indian Health (NCUIH), that exempts eligible American Indian and Alaska Native Veterans to make copayments for health care and urgent care received through VA ― making VA health care more accessible and affordable. Under this policy, VA also reimburses for copayments paid on or after January 5, 2022.

Learn more about copayment exemptions for Native American and Alaska Native Veterans and VA benefits and programs for American Indian and Alaska Native Veterans.

Background

The copayment exemption is a significant step to upholding the federal government’s trust responsibility to “maintain and improve the health of the Indians.” American Indians and Alaska Natives serve in the military at one of the highest rates of any group in the United States and many Native veterans receive healthcare from the Veterans Health Administration, an agency within VA, in addition to utilizing IHS, Tribal, and UIO facilities. Unfortunately, American Indian and Alaska Native Veterans generally have a higher prevalence of mental health disorders compared with White veterans, and among all veterans, the prevalence of suicidal ideation is highest for those reporting a diagnosis of depression, anxiety, or post-traumatic stress disorder. Further, an estimated 86.2 percent of American Indian and Alaska Native Veterans that live in urban areas generally have higher unemployment, lower education attainment, lower income, higher VA-service connected disability, and generally live in poorer housing conditions than non-Native Veterans also living in urban areas.

On April 4, 2023, VA published a final rule in the Federal Register establishing the waiver process for Veterans to submit documentation to have their VA copays waived. This rule implements Section 3002 of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020 Public Law 116-315, signed into law on January 5, 2021, which prohibits collection of a health care copayment by the Secretary of Veterans Affairs from an American Indian and Alaska Native Veteran who meets the definitions of “Indian” or “urban Indian” under the Indian Health Care Improvement Act (IHCIA).

NCUIH’s Role

NCUIH has championed this copayment exemption and continues to advocate for Native Veterans living in urban areas to ensure that they have access to the high-quality, culturally competent care that the country owes to them for their service because of the federal trust responsibility. In February 2023, NCUIH submitted comments to the VA in response to the then proposed rule on the copayment exemption for American Indian and Alaska Native Veterans, stressing our support for this long overdue federal action and the need throughout Indian Country. Because the proposed rule only required VA to cover the first three urgent care visits in a calendar year, NCUIH and partnering Native organizations strongly urged the VA to cover all urgent care visits needed by Indian or urban Indian Veterans, which the VA adopted in the final rule. Moreover, NCUIH stressed that Native Veterans are entitled to the copayment exemption because of the federal government’s responsibility to provide and support services for Native Veterans in fulfilment of the trust responsibility for health care provisions for all American Indians and Alaska Native people.

NCUIH is encouraged to see the impact this rule has made in Indian Country and we will continue to engage with the VA on issues related to American Indian and Alaska Native Veterans living in urban areas.

White House 2023 Progress Report for Tribal Nations Highlights Commitment to Supporting Urban Native Communities

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The Biden-Harris Administration released the 2023 Progress Report for Tribal Nations (“Progress Report”) during the December 6-7, 2023, White House Tribal Nations Summit. The Progress Report touches on several areas of concern to urban Indian organizations (UIOs) as discussed in the National Council of Urban Indian Health’s (NCUIH) 2023 Policy Priorities. The Progress Report also highlights work done in partnership with UIOs, such as initiatives addressing Missing and Murdered Indigenous Peoples (MMIP), Native Veteran Health and Homelessness, Mental Health, Health Information Technology (HIT) Modernization, and Reproductive Health Care.

Successes with Urban Native Communities Highlighted MMIP

In January 2023, The Department of Health and Human Services (HHS) submitted the MMIP Prevention, Early Intervention, and Victim and Survivor Services Plan to the White House Domestic Policy Council and to the President. Developed in consultation with the Department of the Interior, Tribal Nations, research and community-based organizations and UIOs, it is a comprehensive plan to support prevention efforts that reduce risk factors for victimization of Native Americans and increase protective factors, including by enhancing the delivery of services for Native American victims and survivors as well as their families and advocates.

Native Veterans

In support of the Native American Veterans Homelessness Initiative, VA and other federal agencies engaged with UIOs to support and offer resources to AI/AN Veterans experiencing homelessness. The Initiative took the following actions in 2023:

  • VA and Indian Health Service (IHS) developed an informational brochure for Native American veterans experiencing homelessness and distributed these brochures to UIOs, IHS facilities, and external partners across the country.
  • VA and IHS developed and launched an interagency interactive map of UIOs and VA healthcare systems with points of contact information in June 2023.
  • VA developed and implemented training webinars for UIOs to raise awareness of VA homeless programs among Native American veterans and to build or increase effective, responsive, and collaborative relationships between UIOs and VA.
  • VA and various UIOs collaborated on Stand Down events in Seattle, Phoenix, Los Angeles, Albuquerque, and soon Alaska. These one-to-three-day events bring VA staff and volunteers together to provide food, clothing, and health screenings to homeless and at-risk veterans and receive referrals for healthcare, housing solutions, employment, substance use treatment, mental health counseling, and other essential services.

The Veterans Health Administration amended its medical regulations to implement a statute exempting eligible Indian and urban Indian veterans from copayment requirements. This change is based on a requirement within the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020. As of October 2023, 2,674 Native veterans have been approved for the copayment exemption, with copayment cancellations totaling just over $1.5 million.

Mental Health

HHS announced a new $35 million grant opportunity, enabled by the Bipartisan Safer Communities Act, to better support the 988 Suicide and Crisis Lifeline services in Tribal communities. One of the aims of the program is to facilitate collaborations between Tribal, state, and territory health providers, UIOs, law enforcement, and other first responders in a manner that respects Tribal sovereignty.

HIT Modernization

Throughout the process for selecting the new Electronic Health Record (EHR) vendor, IHS coordinated with Tribal and urban Indian organization partners through extensive Tribal engagement via Tribal consultations, listening sessions, urban confers, advisory committee meetings, an Industry Day, and the participation of hundreds of Tribal, urban Indian, and IHS system users in vendor product demonstrations. IHS ultimately awarded a 10-year contract to General Dynamics Information Technology to build, configure, and maintain a new enterprise EHR system utilizing Oracle Cerner technology.

Reproductive Health Care

In response to President Biden’s Executive Order on Strengthening Access to Affordable, High-Quality Contraception and Family Planning Services, IHS added new over-the-counter contraception options to the IHS National Core Formulary, which will expand access to high-quality contraception for patients. IHS encouraged Tribally or UIO operated IHS facilities to make the same options available to patients.

VA Responds to Advisory Committee on Tribal and Indian Affairs’ Recommendations to Improve Native Veteran Health

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The Department of Veterans Affairs (VA) released its consolidated responses to VA’s Advisory Committee of Tribal and Indian Affairs’ (ACTIA) November 2022 recommendations to VA Secretary Dennis McDonough regarding improvements to VA’s programs and services to better serve Native American veterans. These recommendations were finalized during the November 8-11, 2022, ACTIA Meeting and included several recommendations to improve the delivery of health services to Native veterans living in urban areas. These included suggestions regarding interagency collaboration under the Veteran Health Administration-Indian Health Service (VHA-IHS) memorandum of understanding (MOU), development of a VA Urban Confer policy, use of traditional healing practice for American Indian and Alaska Native (AI/AN) veterans, data on urban veteran behavioral health, and urban veteran homelessness. VA’s responding is a crucial step toward achieving the goal of supporting AI/AN veterans as whole people and meeting their needs.

Background on the ACTIA

The Committee was established in accordance with section 7002 of Public Law 116- 315 (H.R.7105 – Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020). Pursuant to Public Law 116-315, the Committee provides advice and guidance to the Secretary of Veterans Affairs on all matters relating to Indian Tribes, tribal organizations, Native Hawaiian organizations, and Native American Veterans. The Committee serves in an advisory capacity and, at least once a year, the Committee must submit recommendations to the Secretary of Veterans Affairs and relevant Congressional committees concerning legislative or administrative action to improve programs and services of the Department to better serve Native American Veterans.

Alongside partners from throughout Indian Country, the National Council of Urban Indian Health (NCUIH) played a critical role in getting this legislation passed in 2020. In a December 4, 2020 letter NCUIH signed with other National Native organizations regarding the ACTIA, NCUIH emphasized the importance of establishing the ACTIA to improve programs and services for Native veterans.

NCUIH subsequently nominated NCUIH’s Board President, Ms. Sonya Tetnowski, to the ACTIA, where she serves as the Chair of the Health Subcommittee. Ms. Tetnowski is the CEO of the Indian Health Care Center of Santa Clara Valley and is an Army veteran.

Recommendations and Responses

The ACTIA submitted eleven recommendations to VA to improve the care of AI/AN veterans. NCUIH is highlighting VA’s response to five of those recommendations below. To read the full response, click here.

Recommendation 1C: Interagency Collaboration Under VHA-IHS MOU

VA Office of Tribal Government Relations (OTGR), Veterans Health Administration (VHA) Office of Tribal Health (OTH) and the Office of Rural Health concur in principle with the ACTIA recommendation to require annual partnership between Veterans Integrated Services Network Directors and at least one Indian Health Service (IHS), Tribal, Urban or Native Hawaiian Health program to meet a specific goal or objective as described in the current Veterans Health Administration (VHA) – IHS Memorandum of Understanding (VHA-IHS MOU). ACTIA recommended that this be implemented in FY 2023. OTGR, VHA OTH, and the Office of Rural Health recommend that Network Directors submit an annual report to the Executive Committee of the VHA/IHS MOU Interagency Workgroup documenting compliance with this recommendation. The VHA-IHS MOU Interagency Workgroup will then provide an annual summary report of these efforts to VA’s ACTIA.

Recommendation 1D: Urban Confer Policy

The ACTIA recommended that  VA develop an Urban Confer Policy in order to partner with UIOs more effectively in their provisions of health services of Native Veterans in urban areas.  The ACTIA stated that this recommendation should be implemented by December 2023.

VA will research the processes and authorities used by other federal agencies to create the urban confer policy that ACTIA recommended.

Recommendation 3A: Behavioral Health/Suicide Prevention

The ACTIA recommended that VA provide information on its efforts to collect data on:

(1) Veteran suicides that occur on tribal lands which can be included in the VA/IHS MOU operational plan; and

(2) AI/AN Veteran suicides that occur in urban areas.

The ACTIA stated that data concerning urban city in which Native Veteran suicides occur needs greater specificity to address issues such as how VA defines rural and urban. The ACTIA recommended VA begin collecting data by October 2023, publish its first report by October 2024, then annually publish the results at the beginning of each fiscal year thereafter in October of each calendar year.

VA stated that it supports the goals of this recommendation and requested the opportunity to discuss and coordinate regarding avenues for enhancing available data sources to broaden accurate and reliable reporting on suicides among AI/AN Veterans. VA stated that it is not aware of resources needed to identify whether Veteran suicide deaths occur on tribal lands and that Veteran suicide deaths are identified from joint VA/Department of Defense searches of the Centers for Disease Control and Prevention’s National Death Index (NDI). VA OTGR and VHA OTH will provide a plan of action by the end of the second quarter of FY 2024.

Recommendation 3B: Cultural Healers/Natural Helpers

As part of the ACTIA recommendations regarding cultural healers/natural helpers, the ACTIA recommended VA, incorporating input gathered in tribal consultation and urban confer, amend VA policy and relevant VHA Directives to champion and/or allow the use of traditional healing as a legitimate and evidence-based practice that promotes the wellbeing of American Indian, Alaska Native and Native Hawaiian Veterans. It stated that VA should complete this recommendation by October 2024.

VA responded by stating that VHA looks forward to supporting evidence-based traditional healing in alignment with VHA’s Whole Health System of Care. VA also stated that VHA suggested changes to language in this recommendation.

Recommendation 3C: Homelessness as a Health Disparity

The ACTIA recommended that VHA Homeless Programs Office (HPO) amend its Strategic Plan to target a 5% increase in Stand Downs located on tribal lands, rural communities, Native Hawaiian communities and in urban areas with a high population of AI/ANs.

It also recommended that VA should:

  • Create objectives in the operations plans of each region to ensure the target increase percentage in Stand Downs can be met.
  • Provide quarterly updates with information on progress made or a justification for why the goal was not reached.
  • Gather information on the number of American Indians, Alaska Natives and Native Hawaiians that attend each event, including their tribal affiliation.
  • Complete this recommendation by October 2025.

VA staff will ensure that messaging is provided to the Bureau of Indian Affairs when an event is planned, apply for VA specific purpose funding for local Stand Down events and work collaboratively with local providers to gather information on the number of American Indians, Alaska Natives and Native Hawaiians that attend each event, including their tribal affiliation.

VA stated that it is committed to increasing the number of Stand Downs in targeted areas with high populations of AI/AN. Starting in FY 2023, VA will begin sharing stand down data with the ACTIA.

VHA HUD-VA Supportive Housing agrees with the replacement of BIA with “IHS, Urban Indian Organizations and Tribal Health Programs.”

VHA Homeless Program Office (HPO) will:

  • encourage UIOs, IHS, and where appropriate, tribes to participate in existing stand down development and implementation.
  • collaborate with and support UIOs, IHS and tribes interested in developing Stand Downs.
  • provide an educational and outreach tool (VHA stand down presentation) it has developed to assist UIOs and IHS in developing tribal specific stand downs.

VHA HPO would recommend that Tribes who are interested in tribal specific Stand Downs request the assistance of VA OTGR.

For information on Stand Down events, please click here.

Next Steps

The National Council of Urban Indian Health (NCUIH) welcomes the VA’s response to the ACTIA’s recommendations. The ACTIA recommendations provide tangible programmatic changes that VA can make to better serve Native veterans. NCUIH looks forward to continuing to work with the ACTIA and VA to advance these changes and ensure that Native veterans have access to the benefits and services that the earned through their military services.

House Passes NCUIH-Endorsed Bipartisan Bill that Improves Home and Community-Based Services for Native Veterans, Includes Collaboration with Tribal Programs and Urban Indian Organizations

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On December 5, 2023, the House passed the National Council of Urban Indian Health (NCUIH)-endorsed legislation, the Elizabeth Dole Home-and Community-Based Services for Veterans and Caregivers Act of 2023 (H.R. 542) with a vote of 414-5. The bill has now been received in the Senate. The original sponsor, Rep. Julia Brownley (D-CA-26) reintroduced this bipartisan legislation on January 26, 2023, which would direct the Department of Veterans Affairs (VA) to expand options for long-term home and community services. The bill also directs the VA to collaborate with the Director of the Indian Health Service (IHS) and representatives from tribal health programs and Urban Indian Organizations (UIOs) to ensure the availability of home-and community-based services for Native American veterans, including Native American veterans receiving health care and medical services under multiple health care systems. The bill currently has 63 Democrat and 13 Republican co-sponsors.

Specifically, the bill expands existing Home and Community Based Services (HCBS):

  1. The Veteran Directed Care Program, which provides veterans a flexible budget to hire friends, family, and neighbors to help with activities of daily living, such as bathing, or instrumental activities of daily living, such as making meals.
    1. The bill directs the VA Secretary to ensure the availability of the program for eligible veterans who are Native American veterans receiving care and services furnished by the Indian Health Service, a tribal health program, an Urban Indian organization, or (in the case of a Native Hawaiian veteran) a Native Hawaiian health care system, to the extent practicable.
  2. The Homemaker and Home Health Aide Program, which allows VA to contract with a community partner that employs home health aides to care for veterans in their homes, providing skilled services, case management, help with daily living, or to ease caregiver burnout.
  3. The Home-Based Primary Care Program, which allows for a VA physician to supervise a health care team that provides care in the veteran’s home for a veteran who has difficulty traveling or is isolated.
  4. The Skilled Home Health Care Program, which allows for VA to contract with a community health agency to provide in-home care for veterans who have higher levels of need like wound care, speech therapy, or skilled nursing.

“Every veteran should have the right to a peaceful and dignified life after their service to our country, and every veteran should have the right to stay in their home and receive the care they need, the care they have earned, and the care they deserve.” – Congresswoman Julia Brownley (D-CA)

Background on Native Veterans

Native Veteran Disparities 

Native veterans have served in the United States military in every armed conflict in the Nation’s history and have traditionally served at a higher rate than any other population in the United States. Unfortunately, Native veterans suffer significant disparities when they transition to civilian life. For example, Native veterans are more likely to be uninsured and have a service-connected disability than other veterans. Native veterans suffer these disparities no matter where they live. Native veterans living in urban areas experience the same poor physical and mental health outcomes as Native veterans in rural areas. In addition, urban Native veterans generally have lower incomes, higher unemployment, lower education attainment, higher VA-service connected disability, and generally live in poorer housing conditions than non-Native urban veterans.

Urban Indian Organizations Provide Culturally Competent Care for Native Veterans

UIOs are essential partners in serving Native veterans and are vital to improve care and access to services for Native veterans because of their deep ties to the Native community in urban areas. UIOs currently serve seven of the ten urban areas with the largest Native veteran populations, including the following areas: Phoenix, Arizona; Los Angeles, California; Seattle, Washington; Dallas, Texas; Oklahoma City, Oklahoma; New York City, New York; and Chicago, Illinois.

UIOs are uniquely positioned to assist the VA in improving culturally competent healthcare access for Native people. As such, this partnership has the potential to improve the quality of care and well-being to Native veterans in urban areas, but it is also consistent with the United States’ trust responsibility to provide services and resources to improve the health of all Native people.

Next Steps

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