Joint Letter to the House of Representatives in re Preservation of the Indian Healthcare Improvement Act and other Affordable Care Act Provisions Serving American Indians and Alaska Natives

December 20, 2016

The Honorable Paul Ryan
Speaker of the House
U.S. House of Representatives
H-232 The Capitol Washington, DC 20515

The Honorable Mitch McConnell
Majority Leader
U.S. Senate
S-230 The Capitol Washington, DC 20510

Re: Preservation of the Indian Healthcare Improvement Act and other Affordable Care Act provisions serving American Indians and Alaska Natives

Dear Speaker Ryan and Majority Leader McConnell:

On behalf of the undersigned Tribes and Tribal organizations and the 567 Tribes we serve, we write today to ask you to support the retention of the Indian Healthcare Improvement Act (IHCIA) in any efforts to repeal or replace the Patient Protection and Affordable Care Act (ACA) (P.L. 111- 148). The IHCIA is unrelated to the overall ACA, and revoking IHCIA would have catastrophic consequences for the Indian health system and American Indians and Alaska Natives (AI/ANs) nationwide. Provisions included in the IHCIA were a result of years of negotiations, meetings and strategy sessions between Tribes and Congress resulting in legislation that was not only impactful, but bipartisan.

First enacted in 1976, the Indian Healthcare Improvement Act is the legislative embodiment of the federal trust and treaty responsibilities to American Indian and Alaska Native people for healthcare. IHCIA was permanently enacted in 2010 as part of the ACA (Section 10221) in an effort to pass this long-stalled legislation. It serves as the backbone legislation for the Indian
Health Service (IHS)/Tribal/ and Urban Indian (collectively known as the I/T/U) health system which provides healthcare services for AI/ANs in fulfillment of the federal government’s trust responsibility for health that is derived from statutes, treaties, and executive orders.

IHCIA states 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”* and reaffirms a system for the federal government to do so. The law provides the foundational authority for the Indian Health Service to be reimbursed by Medicare, Medicaid and third party insurers, to make grants to Indian Tribes and Tribal organizations, and to run programs designed to address specific, critical health concerns for AI/ANs such as substance abuse, diabetes and suicide.

Six years later, IHCIA has provided significant progress in the I/T/U system. IHCIA updates and modernizes health delivery services, such as cancer screenings, home and community based services, hospice care, and long-term care for the elderly and disabled. It establishes a continuum of care through integrated behavioral health programs (both prevention and treatment) to address alcohol/substance abuse problems and the social service and mental health needs of Indian people. Additionally, it provides many essential cost-saving provisions for IHS and Tribes, such as the authority for I/T/U health providers to be licensed in any state and practice at an I/T/U facility and the ability for Tribes to access the Federal Employee Health Benefits (FEHB) system. The law also authorizes IHS and Tribes to enter into arrangements with the Department of Veterans Affairs and Department of Defense to share medical facilities and services which increases government efficiency and ensures that American Indian and Alaska Native Veterans (who serve at a higher percentage than any other group) are taken care of. IHCIA allows I/T/U providers to be eligible for participation in any federal healthcare program and for reimbursement from 3rd party payers which is critical to bring in additional resources into the I/T/U system.

Other provisions also exist within the ACA, separate from IHCIA that we strongly believe must be preserved to ensure that the Indian health delivery system remain viable. These provisions are also unrelated to the overall healthcare reform legislation. They are as follows:

Repealing these provisions and the IHCIA now would have disastrous consequences for the Indian health system. I/T/Us would lose critical 3rd party revenue, legal authorities, and life-saving programs. As you consider a path forward on healthcare reform, we urge you to ensure that this law is preserved so the Indian health system can continue to operate under a framework appropriate for 21st century healthcare delivery and honors the United States’ trust responsibility to provide healthcare to American Indians and Alaska Natives.

Thank you for your attention to this important matter. We look forward to working with you on these critical efforts in the 115th Congress and beyond. Should you have any questions about this, please contact the National Indian Health Board’s Executive Director Stacy A. Bohlen at (202) 507-4070 or


Lester Secatero
National Indian Health Board

Jacqueline Pata Executive Director
National Congress of American Indians

Sarah Kastelic
Executive Director
National Indian Child Welfare Association

Ahniwake Rose
Executive Director
National Indian Education Association

Ashley Tuomi
National Council on Urban Indian Health

W. Ron Allen
Board Chairman
Self-Governance Communication & Education Tribal Consortium

Nicholas Barton
Direct Service Tribes Advisory Committee

Mark LeBeau
Executive Director
California Rural Indian Health Board

Jerilyn Church
Chief Executive Officer
Great Plains Tribal Chairmen’s Health Board

Phyllis Davis
Great Lakes Area Tribal Health Board

Nancy Martine-Alonzo
Executive Director
Albuquerque Area Indian Health Board

Jennifer LittleSun
Executive Director
Southern Plains Tribal Health Board

Robert Valencia
Tribal Chairman
Pascua Yaqui Tribe

Chief Kirk Francis
United South and Eastern Tribes Sovereignty Protection Fund

Lincoln Bean, Sr.
Alaska Native Health Board

Andy Joseph
Jr. Chairman
Northwest Portland Area Indian Health Board

Chairman Greg Walden, Incoming Chairman, House Energy and Commerce Committee Chairman Kevin Brady, House Ways and Means Committee
Chairman Rob Bishop, House Natural Resources Committee Chairman Orrin Hatch, Senate Finance Committee
Chairman Lamar Alexander, Senate Health Labor and Pensions Committee Chairman John Barrasso, Senate Committee on Indian Affairs
NIHB Board of Directors

*25 U.S.C. § 1602.