House Passes Budget Reconciliation Which Includes Long Needed Infrastructure Funds for Urban Indian Health

The Build Back Better Act maintained $100 million for UIO facilities and extension of key Medicaid parity provision for UIOs.

On November 19, 2021, the House passed President Biden’s Build Back Better (BBB) Act with a 220-213 vote. The BBB Act, allocates $2.347 billion to the Indian Health Service (IHS), $100 million for Urban Indian Health facilities, and extension of an additional eight fiscal quarters of 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs) beginning April 1, 2021. As Congress negotiated the Reconciliation bill from $3.5 trillion to $1.75 trillion, funding for Indian Country was significantly reduced from the original reconciliation instruction allocation of $20.5 billion. Earlier this week, the President signed into law the bipartisan infrastructure bill which allows UIOs to use existing resources to fund infrastructure projects.

“Adequate funding for Indian Country is crucial now more than ever, especially as the COVID-19 pandemic has, and continues to be, the deadliest for American Indian and Alaska Native communities. We are grateful for our House champions who ensured that urban Indian health was a priority. We cannot build back better without Indian Country and encourage the Senate to retain these critical provisions.” said Francys Crevier (Algonquin), CEO of NCUIH.

Background and Advocacy

UIOs, which are a fundamental, inseverable component of the Indian Health Service/Tribal Health Program/UIO (I/T/U) system, face chronic underfunding. The National Council of Urban Indian Health (NCUIH) has long advocated for adequate funding for ALL three parts of the I/T/U system to better serve the American Indian/Alaska Native (AI/AN) population.

NCUIH initially advocated for $21 billion for IHS in the budget reconciliation package. The draft reconciliation bill released on September 27 included $100 million for UIO facilities. Since 1988, $13.3 billion in facilities funding has been allocated to IHS, however UIOs are not eligible for the IHS Facilities or Sanitation line items. The allocation of $100 million for UIO facilities in BBB is historic and long overdue.

NCUIH and UIO advocacy to Congressional leadership helped retain provisions in the BBB Act affecting UIOs that were at risk of cuts during Congress’ negotiations to reduce the cost of the budget reconciliation bill. However, the overall stark decrease in the funding commitment for Indian Country is disappointing for AI/ANs and does not uphold the trust and treaty obligations of the federal government. This past week, NCUIH sent a letter to Speaker Pelosi’s office urging the passage of the BBB Act with support for Indian Country.

• NCUIH letter to Speaker Pelosi urging passage of BBB Act (November 16, 20201)
• NCUIH Policy Alert: House Draft of Build Back Better Includes Long Needed Infrastructure Funds for Urban Indian Health
• NCUIH letter to Speaker Pelosi and Majority Leader Schumer urging Congress to retain $20.5 billion for Indian Country and $42 million for UIOs in Build Back Better plan (October 25, 2021)
• NCUIH letter to Congressional leadership requesting $21 billion for Indian health infrastructure in the budget reconciliation package (August 1, 2021)
• Joint letter led by the National Congress of American Indians (NCAI) and signed by NCUIH requesting $21 billion for Indian health infrastructure among countless other Tribal priorities (April 13, 2021)

Next Steps

The Reconciliation bill will now be sent to the Senate for consideration. NCUIH will also be requesting that the Senate retain the $100 million for UIO facilities and extension of 100% FMAP.

Image courtesy NCUIH

Budget Reconciliation Bill Highlights

Committee on Natural Resources

Indian Health Service

• “MAINTENANCE AND IMPROVEMENT.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $945,000,000, to remain available until September 30, 2031, for maintenance and improvement of facilities operated by the Indian Health Service pursuant to a self-determination contract (as defined in subsection (j) of section 4 of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304(j))) or a self-governance compact entered into pursuant to subsection (a) of section 404 of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5364(a)).”
   
• “MENTAL HEALTH AND SUBSTANCE USE DISORDERS.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $123,716,000, to remain available until September 30, 2031, for mental health and substance use prevention and treatment services, including facility renovation, construction, or expansion relating to mental health and substance use prevention and treatment services.
   
• “PRIORITY HEALTH CARE FACILITIES.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $1,000,000,000, to remain available until September 30, 2031, for projects identified through the health care facility priority system established and maintained pursuant to subparagraph (A) of paragraph (1) of subsection (c) of section 301 of the Indian Health Care Improvement Act (25 U.S.C. 1631(c)(1)(A)).”
   
• “SMALL AMBULATORY.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $40,000,000, to remain available until September 30, 2031, for small ambulatory construction.”
   
• “URBAN INDIAN ORGANIZATIONS.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $100,000,000, to remain available until September 30, 2031, for, notwithstanding the restrictions described in section 509 of the Indian Health Care Improvement Act (25 U.S.C. 1659), the renovation, construction, expansion, equipping, and improvement of facilities owned or leased by an Urban Indian organization (as defined in item (29) of section 4 of that Act (25 U.S.C. 1603(29))).”
   
• “EPIDEMIOLOGY CENTERS.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $25,000,000, to remain available until September 30, 2031, for the epidemiology centers established under paragraphs (1) through (2) of subsection (a) of section 214 of the Indian Health Care Improvement Act (25 U.S.C. 1621m(a)(1)–(2)).”
   
• “ENVIRONMENTAL HEALTH AND FACILITIES SUPPORT ACTIVITIES.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $113,284,000, to remain available until September 30, 2031, for environmental health and facilities support activities of the Indian Health Service.”

Committee on Education and Labor

Grants to Support the Direct Care Workforce

• “GRANTS AUTHORIZED.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $1,000,000,000, to remain available until September 30, 2031, for awarding, on a competitive basis, grants to eligible entities to carry out the activities described in subsection (c) with respect to direct support workers.
   
  • Urban Indian Organizations are listed as eligible entities for this grant to “provide competitive wages, benefits, and other supportive services, including transportation, child care, dependent care, workplace accommodations, and workplace health and safety protections, to the direct support workers served by the grant”

Committee on Energy and Commerce

Extension of 100 Percent Federal Medical Assistance Percentage for Urban Indian Health Organizations and Native Hawaiian Health Care Systems

• “The third sentence of section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) is amended— (1) by striking ‘‘for the 8 fiscal year quarters beginning with the first fiscal year quarter beginning after the date of the enactment of the American Rescue Plan Act of 2021’’ and inserting ‘‘for the period of the 16 fiscal year quarters that begins on April 1, 2021’’; and (2) by striking ‘‘such 8 fiscal year quarters’’ and inserting ‘‘such period of 16 fiscal year quarters.”

Funding for Palliative Care and Hospice Education and Training

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $25,000,000, to remain available until expended, to support the establishment or operation of programs that— (1) support training of health professionals in palliative and hospice care (including through traineeships or fellowships); and (2) foster patient and family engagement, integration of palliative and hospice care with primary care and other appropriate specialties, and collaboration with community partners to address gaps in health care for individuals in need of palliative or hospice care.”
  • UIOs are mentioned as eligible applicants for funding

Funding for Local Entities Addressing Social Determinants of Maternal Health

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $100,000,000, to remain available until expended, for carrying out a program to award grants or contracts to community-based organizations, Indian Tribes and Tribal organizations, Urban Indian organizations, Native Hawaiian organizations, or other nonprofit organizations working with a community-based organization, or consortia of any such entities, operating in areas with high rates of adverse maternal health outcomes or with significant racial or ethnic disparities in maternal health outcomes.”

Funding to Grow and Diversify the Doula Workforce

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $50,000,000, to remain available until expended, for carrying out a program to award grants or contracts to health professions schools, academic health centers, State or local governments, territories, Indian Tribes and Tribal organizations, Urban Indian organizations, Native Hawaiian organizations, or other appropriate public or private nonprofit entities (or consortia of any such entities, including entities promoting multidisciplinary approaches), to establish or expand programs to grow and diversify the doula workforce, including through improving the capacity and supply of health care providers.”

Funding to Grow and Diversify the Maternal Mental Health and Substance Use Disorder Treatment Workforce

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $75,000,000, to remain available until expended, for carrying out a program to award grants or contracts to health professions schools, academic health centers, State or local governments, territories, Indian  Tribes and Tribal organizations, Urban Indian organizations, Native Hawaiian organizations, or other appropriate public or private nonprofit entities (or consortia of any such entities, including entities promoting multidisciplinary approaches), to establish or expand programs to grow and diversify the maternal mental health and substance use disorder treatment workforce, including through improving the capacity and supply of health care providers.”

Funding for Maternal Mental Health Equity Grant Programs

• IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $100,000,000, to remain available until expended, for carrying out a program to award grants or contracts to community-based organizations, Indian Tribes and Tribal organizations, Urban Indian organizations, Native Hawaiian organizations, health care providers, accredited medical schools, accredited schools of nursing, teaching hospitals, accredited midwifery programs, physician assistant education programs, residency or fellowship programs, or other nonprofit organizations, schools, or programs determined appropriate by the Secretary, or consortia of any such entities, to address maternal mental health conditions and substance use disorders with respect to pregnant, lactating, and postpartum individuals in areas with high rates of adverse maternal health outcomes or with significant racial or ethnic disparities in maternal health outcomes.”

Funding for Expanding the Use of Technology-Enabled Collaborative Learning and Capacity Building Models for Pregnant and Postpartum Individuals

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $30,000,000, to remain available until expended, for carrying out a program to award grants or contracts to community-based organizations, Indian Tribes and Tribal organizations, Urban Indian organizations, health care providers, accredited medical schools, accredited schools of nursing, teaching hospitals, accredited midwifery programs, physician assistant education 15 programs, residency or fellowship programs, or other 16 schools or programs determined appropriate by the Secretary, or consortia of any such entities, that are operating in health professional shortage areas designated under section 332 of the Public Health Service Act (42 U.S.C. 254e) with high rates of adverse maternal health outcomes or significant racial and ethnic disparities in maternal health outcomes, to evaluate, develop, and expand the use of technology-enabled collaborative learning and capacity building models (as defined in section 330N of the Public Health Service Act (42 U.S.C. 254c–20)).”

Funding for Promoting Equity in Maternal Health Outcomes Through Digital Tools

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $30,000,000, to remain available until expended, for carrying out a program to award grants or contracts to community-based organizations, Indian Tribes and Tribal organizations, Urban Indian organizations, health care providers, accredited medical schools, accredited schools of nursing, teaching hospitals, accredited midwifery programs, physician assistant education programs, residency or fellowship programs, or other schools or programs determined appropriate by the Secretary, or consortia of any such entities, that are operating in health professional shortage areas designated under section 332 of the Public Health Service Act (42 U.S.C. 254e) with high rates of adverse maternal health outcomes or significant racial and ethnic disparities in maternal health outcomes to reduce racial and ethnic disparities in maternal health outcomes by increasing access to digital tools related to maternal health care.”

Funding for Community Violence and Trauma Interventions

• “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary, for fiscal year 2022, out of any money in the Treasury not otherwise appropriated $2,500,000,000, to remain available until expended, for the purposes described in subsection (b):
   
  • (b) USE OF FUNDING.—The Secretary, acting through the Director of the Centers for Disease Control and Prevention, and in consultation with the Assistant  Secretary for Mental Health and Substance Use, the Administrator of the Health Resources and Services Admin1istration, the Deputy Assistant Secretary for Minority Health, and the Assistant Secretary for the Administration for Children and Families, shall use amounts appropriated by subsection (a) to support public health-based interventions to reduce community violence and trauma, taking into consideration the needs of communities with high rates of, and prevalence of risk factors associated with, violence-related injuries and deaths, by—
    • (1) awarding competitive grants or contracts to local governmental entities, States, territories, Indian Tribes and Tribal organizations, Urban Indian organizations, hospitals and community health centers, nonprofit community-based organizations, culturally specific organizations, victim services providers, or other entities as determined by the Secretary (or consortia of such entities) to support evidence-informed, culturally competent, and developmentally appropriate strategies to reduce community violence, including outreach and conflict mediation, hospital-based violence intervention, violence interruption, and services for victims and individuals and communities at risk for experiencing violence, such as trauma-informed mental health care and counseling, social-emotional learning and school-based mental health services, workforce development services, and other services that prevent or mitigate the impact of trauma, build appropriate skills, or promote resilience”