Urban Indian Organizations : A Critical Community Resource Worth Investing In

MBPC Staff | June 2023 | Presented by the Montana Budget & Policy Center

Everyone should be able to live a healthy life, but an ongoing history of violent and discriminatory government policies continues to impact the health and well-being of Indigenous people today. These impacts range from poverty rates to Indigenous Montanans having a median lifespan that is a full generation shorter than white Montanans. Indigenous people disproportionately experience lower outcomes across a range of indicators; however, urban Indian people who live away from reservation communities often fare worse. This reality is situated in its own history of government policies that aimed to relocate Indigenous people to cities from their tribal homelands and assimilate them into non-Indian society.

In the wake of these policies, Urban Indian Organizations (UIOs) emerged to provide urban Indian people with health and social services. UIOs continue to be a critical resource for the communities they serve, including non-Indian people, and they do so on limited budgets. Despite the vast majority (more than 70 percent) of Indigenous people living in urban areas nationally and the federal government’s trust responsibility to provide health services to Indigenous people, UIO funding accounts for just 1 percent of the Indian Health Service (IHS) budget. This shortfall requires UIOs to supplement their budgets with other funding sources.

While the federal government has a clear role to play, the Montana Legislature has an opportunity to help ensure UIOs have the resources they need to serve Montanans. Two steps the Legislature can take in 2023 include:

• maintaining Medicaid expansion; and
• funding Urban Indian Organizations (UIOs)

Urban Indian Organizations: A Summary

What are UIOs?

There are 41 UIOs nationwide, five of which are in Montana (Billings, Butte, Great Falls, Helena, and Missoula).^[i] Collectively, these nonprofit organizations provide a wide range of health and social services (see below graphic) to their communities. UIOs vary in the area they serve, size, the services they offer, and their budgets. While there is diversity among these organizations, they all commit to providing culturally appropriate services for Indigenous people who may not have access to IHS or tribal health facilities. UIOs largely fall into one of three service levels:^[ii]

• Outreach and referral. Outreach and referral programs do not offer medical or dental services. Instead, they coordinate access to services through outside providers. Some outreach and referral programs provide mental health, substance use, health education, and traditional medicine services.
• Limited ambulatory. Limited ambulatory programs provide medical services for less than 40 hours per week. They do not have onsite dental care, pharmacies, or radiology services. The Butte and Great Falls UIOs fall under this service level.^[iii]
• Full ambulatory/comprehensive. Full ambulatory care UIOs represent the most common service level and serve the majority (nearly 90 percent) of urban Indian people. These UIOs provide medical services for at least 40 hours per week, offer comprehensive services, and sometimes have pharmacies, labs, radiology, and dental care. The Billings, Helena, and Missoula UIOs fall under this service level.^[iii]

 

Who UIOs Serve

Urban Indian Organizations (UIOs) provide health and social services to many people. Of the 5.8 million Indigenous people in the United States, about 71 percent live in urban areas.^[iv],[v] (In Montana, the share of Indigenous people living in urban communities is about 40 percent.^[vi]) While UIOs are committed to serving urban Indian people, they ultimately serve a broader community. Across all UIOs, 60 percent of the population they serve is non-Indian.^[vii]

UIOs help serve people who are largely underserved. For example, one-third of people UIOs serve are on Medicaid.7 Across all UIO service areas, or the area that a UIO serves, Indigenous people younger than 65 are three times more likely than their white counterparts to not have health insurance (19.7 percent vs. 6 percent).8 The trend holds true for children, with 12.6 percent of Indigenous kids and 3.4 percent of white kids not having health insurance coverage. Across all UIO service areas, Indigenous people older than 16 are more than twice as likely as white people to experience unemployment (11.2 percent vs. 4.9 percent). In all UIO service areas, Indigenous people are more likely to live in poverty, regardless of age and family status. Indigenous people overall are nearly three times as likely as white people to live in poverty (24.5 percent vs. 8.9 percent). Indigenous kids specifically are more than three times as likely as white kids to live in poverty (30.5 percent vs. 9.3 percent).

Research shows a relationship between social disadvantage and poorer health outcomes.^[viii] Unequal access to education, greater unemployment, higher poverty rates, and housing issues create inequities between urban Indian and white populations.

Funding: An Unmet Need

Federal health care policy toward American Indian and Alaska Native people focuses largely on Indigenous people living on reservations. While the health care needs of Indigenous people living in reservation communities is significant, the majority (more than 70 percent) of Indigenous people live in urban communities. Despite this and the federal government’s trust responsibility to provide health services to Indigenous people, UIO funding accounts for just 1 percent of the Indian Health Service (IHS) budget.^[ix] The Indian Health Service acknowledges that the ability of UIOs to provide health care services depends on the IHS ensuring UIOs have the necessary funding to do so. Moreover, while UIOs serve a large share of non-Indian people, by law, UIOs can only use IHS funds to serve Indigenous people. Given inadequate IHS funding and the fact that UIOs must use non-IHS funds to serve non-Indian people, UIOs also rely on partnerships with other federal agencies, states, local governments, insurers, foundations, nonprofit organizations, and tribal nations that may operate health care programs that partner with or receive referrals from UIOs.

 

Opportunities for the State to Advance Indigenous Health

While the federal government has a clear role to play, the Montana Legislature has an opportunity to help ensure UIOs have the resources they need to serve Montanans, particularly Indigenous Montanans. Given the fact that the median lifespan of American Indians and Alaska Natives in Montana is about 19 years shorter than that of white Montanans, the state must do more to advance health equity.^[x] Two steps the Legislature can take in 2023 include:

• Maintain Medicaid expansion. Medicaid expansion allows to people to access care. Given the large share of Medicaid enrollees that UIOs serve, maintaining this critical program is necessary for ensuring people can continue to access care.
• Allocate a share of state funding to UIOs. A potential source of funding is recreational cannabis tax revenue.