Letter to VA in re: Priorities for Serving American Indian and Alaska Native Veterans

Submitted via email: tribalgovernmentconsultation@va.gov

October 7, 2016

Mr. James Albino
Deputy Assistant Secretary
U.S. Department of Veterans Affairs
Office of Intergovernmental Affairs (075F)
810 Vermont Avenue, NW, Suite 915G
Washington, DC 20420

RE: Priorities for Serving American Indian and Alaska Native Veterans

Dear Mr. Albino:

On behalf of National Council of Urban Indian Health (NCUIH), I write to submit comments in response to Mr. Albino’s letter dated May 19, 2016 requesting Tribal priorities for Native veterans. NCUIH fully supports increasing access to healthcare for our Native veterans. It is important to note that an overwhelming majority of American Indians/Alaska Natives live in urban settings and are currently neglected by the federal government. We hope to work with the VA to change this tragedy.

The National Council of Urban Indian Health was founded 18 years ago to represent the interests of Urban Indian Health Programs (UIHPs) before Congress and Federal agencies, and to influence policies impacting the health conditions experienced by urban American Indians and Alaska Natives (AI/AN).The National Council of Urban Indian Health is a 501(c)(3), membership-based organization devoted to support the development of quality, accessible, and culturally sensitive health care programs for AI/AN living in urban communities. NCUIH fulfills its mission by serving as a resource center providing advocacy, education, training, and leadership for urban Indian health care providers. NCUIH strives for healthy American Indians and Alaska Natives living in urban settings, which comprise over 70% of the AI/AN population, supported by quality, accessible health care centers and governed by leaders in the Indian community. NCUIH represents urban Indian Health Programs receiving grants under Title V of IHCIA and the American Indian and Alaska Natives they serve.

AI/ANs serve in the U.S. military at higher rates than any other race, yet they are underrepresented among veterans who access the services and benefits they have earned. NCUIH recommends the following priorities for serving AI/AN veterans: (1) creation of a VA Tribal and Urban technical advisory health care committee; (2) improve access to medical care; (3) VA and the Indian health system working together; (4) VA support of traditional healing providers and treatments; (5) suicide prevention; and (6) treatment for PTSD and mental health.

Creation of a VA, Tribal and Urban Technical Advisory Health Care Committee

The VA has a special responsibility to engage in Tribal consultation and support the government-to-government relationships with federally recognized Tribes as well as a fiduciary responsibility to AI/AN in urban settings. NCUIH requests that the VA include UIHPs and build strong relationships with them and Tribal governments in order to increase the number of AI/AN veterans who access VA programs, benefits, and services. The VA, IHS, and Tribal partners have achieved significant successes through joint workgroups on increasing care coordination, health care services, and reimbursement for training and cultural competency for eligible Veterans. While those partnerships are successful, there are still many urban Indian veterans not be served.
NCUIH recommends creating a committee with both Tribal and urban Indian representatives to ensure that the VA is serving all veterans in Indian Country.
It is also vital that the VA engages Tribal and Urban representatives in meaningful consultations. Tribal and urban communities are knowledgeable about providing care to their AI/AN veteran communities. Implementation of VA’s Tribal Consultation Policy requires Tribal consultation to occur before the VA takes action or makes decisions that may significantly affect Tribal resources, rights, or lands.

Improve Access to Medical Care

Many AI/AN Veterans experience various challenges in receiving VA health care benefits in remote environments and even in urban settings. IHS/Tribal/Urban Health Programs provide exceptional culturally competent medical care closer to home. NCUIH supports efforts to promote and expand upon putting AI/AN Veterans in control of how, when, and where they wish to be served quality health care services. NCUIH recommends that the VA work with UIHPs to provide additional outreach and advocacy resources to ensure that AI/AN Veterans are aware of various health care benefits available in their community.

Access to care for our veterans is an important priority for UIHPs, and while the VA has challenges with long wait times, UIHPs do not. When asked at the National Indian Health Board conference why the VA hasn’t worked with the UIHPs to fulfill the federal government’s trust responsibility, the VA stated that there are VA offices in urban settings and working with UIHPs wasn’t necessary. If the solution to helping AI/AN veterans was only to have a VA office nearby, then the problem would not exist. UIHPs can access AI/AN veterans in a way that the VA cannot: cultural competency and better wait times. These veterans may not go to the VA, but they do go to our UIHPs to receive health services as well as other services and community events. Their friends and families go to UIHPs, and many tribal members prefer UIHPs as well. UIHPs gladly provide veterans with services but are very limited in funding as they have less than 1% of the IHS budget. NCUIH proposes that in order to improve access, the VA must work with UIHPs as well as allow UIHPs to host a tribal office to process VA benefits. NCUIH would be happy to work with the VA to make this a reality and truly serve our Native veterans.

To provide an example of how UIHPs are instrumental in saving both Native and non- Native veterans, the VA in Phoenix is walking distance to Native Health, a UIHP. The Office of the Inspector General released a report this Tuesday that stated 215 deceased patients were awaiting specialist consultations on the date of their death. Native Health provides primary care, dental and behavioral services, and could have provided care to Native veterans which would allow the VA to focus on specialty services. Many of these deaths could have been prevented if the VA partnered with UIHPs. NCUIH highly recommends that the VA expedite MOUs with UIHPs in order to provide more efficient care.

VA and the Indian Health System Working Together

One of the VA’s goals is to connect veterans with health care services through raising awareness of available health services and working to remove barriers to care. NCUIH strongly supports the full inclusion of the Indian health system, I/T/Us, as key partners in the VA’s community care network. The 2010 VA, IHS, and THP memorandum of understanding (MOU) defined many ways VA and IHS can collaborate innovatively together. VA must include UIHPs in future MOUs as well as continue to maintain and strengthen current MOU agreements between VA, IHS, and Tribal health programs.
NCUIH also recommends expediting the MOU process as it currently takes upwards of four years in some cases to finalize.

VA Support of Traditional Healing Providers and Treatments

Some VA medical centers have added traditional healer treatments, such as sweat lodges for AI/AN Veterans. While those are helpful, and many AI/AN veterans may prefer to utilize holistic healing and spirituality treatments to recover from trauma, these treatments are not done often and only allow male veterans. Examples of traditional healing treatments include the use of herbal remedies, purification ceremonies, empowering rituals, sweat lodges, and dream interpretations. NCUIH recommends that the VA include other traditional treatment approaches for consideration of how the patient’s culture may impact what and how they experience the trauma as well as allow women to participate.

Suicide Prevention

Upon returning to civilian life, AI/AN Veterans may suffer from depression, anxiety, and posttraumatic stress disorder (PTSD). The VA is using telemental health care to reach Native Veterans with PTSD and other mental health care needs. Suicide prevention initiatives are dependent upon VA partnerships with Tribal/Indian Health Service employees, traditional/cultural spiritual leaders, Tribal leaders, local AI/AN veterans, veteran centers, and community members. NCUIH recommends that the expansion of telemental health services are crucial to prevent AI/AN veterans from attempting or committing suicide. UIHPs can also help provide culturally relevant treatment for AI/AN veterans that the VA may lack.

Treatment for PTSD and Mental Health

Historically, there has been distrust among AI/AN Veterans when it comes to mental health, especially from older generations, which tend to underutilize mental health services. Research shows that the overall findings seem to be that most ethnic minority Veteran groups have a higher rate of PTSD than White Veterans. In 2002, a study compared rates of PTSD by ethnicity among male Vietnam Veterans and found a higher prevalence of both 1-month and lifetime PTSD among American Indians compared to White Veterans. Barriers to treating AI/AN Veterans include distance, poverty, a lack of cultural competence, mental health symptoms, historical trauma, limited number of
Native providers, and the sole focus on evidence-based practices. NCUIH recommends that the VA utilize innovative culturally-based approaches to treatment, such as acculturation assessments to allow for culturally competent providers to assess the cultural identity of a patient. When approaching PTSD treatment for AI/AN Veterans, it is important to consider practice-based evidence as well as cultural remedies of AI/AN patients.


NCUIH hopes to work with the VA in the near future to get our Native veterans the healthcare they are entitled to. We thank you for this opportunity to provide our comments and recommendations and look forward to further engagement. Please contact Francys Crevier, Policy Analyst and Congressional Relations Liaison at FCrevier@ncuih.org, if there are any additional questions or comments on the issues addressed in these comments.


Ashley Tuomi President
National Council of Urban Indian Health