On January 21, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments to the Indian Health Service (IHS) regarding funding opportunities in the American Rescue Plan Act (ARPA) and the Build Back Better Act (BBBA). The comments were submitted in response to a November 22, 2021 (updated on December 20), IHS Dear Urban Indian Organization Leader letter (DULL) that outlined an additional $210 million allocated for Public Health Workforce Activities from the ARPA. The DULL also outlined $2.35 billion in proposed funding in the BBBA.
ARPA and BBBA’s IHS Program Impact
In response to the COVID-19 pandemic, President Biden signed the ARPA into law in March 2021. This COVID-19 relief bill included $84 million for urban Indian health and two years of 100% Federal Medical Assistance Coverage for urban Indian Organizations (UIOs). In November 2021, the Administration announced additional directed funding to support COVID-19 response and recovery efforts in the hardest-hit and high-risk communities and populations, including additional funding of $210 million allocated to the IHS. The newly allocated funding includes $92 million to provide nurses in Bureau of Indian Educations schools; $67 million to enhance public health capacity for IHS and Tribal Nations; $45 million for additional IHS loan repayment awards; and $6 million for core surveillance and epidemiology work for American Indian and Alaska Native populations.
The BBBA proposes $1.75 trillion in government spending with an emphasis on social and climate goals. While the BBBA is currently stalled in Congress, the proposed funding includes $2.35 billion in additional resources for several IHS programs. The $2.35 billion includes $1 billion to address the 1993 Health Care Facilities Construction Priority List; $945 million for Maintenance and Improvement projects; $124 million for behavioral health services, including necessary facilities improvements; $113 million for Facilities and Environmental Health Support activities; $100 million for Urban Indian Organization construction; $40 million for the Small Ambulatory Program; and $25 million for Tribal Epidemiology Centers.
On December 15, 2021, NCUIH held a prep call with UIOs to discuss the additional ARPA and BBBA funding. This call allowed UIOs to share concerns, recommendations, and specific requests for the upcoming Urban Confer with IHS. NCUIH and UIOs then attended the IHS Urban Confer to voice support for and stress the importance of the additional funding.
In its submitted comments, NCUIH applauded the allocation of a further $210 million to support pandemic recovery in AI/AN communities. The additional ARPA funding will be used to protect children in BIE schools, recruit and retain highly skilled health care professionals, enhance public health capacity, and support epidemiology work for AI/AN populations. NCUIH noted that at both the December 9, 2021 All Tribal and Urban Indian Organization Leaders meeting and the subsequent December 15, 2021 Urban Confer that the IHS committing to making $47 million of the $67 million allocated to enhance public health capacity and build emergency preparedness available to Tribes, Tribal organizations, and UIOs. NCUIH reiterated to IHS that it must follow through on this plan and make this funding available to UIOs in addition to Tribes and Tribal organizations, as the funding is crucial to ensuring that all AI/AN communities can continue to battle the on-going COVID-19 pandemic and also build capacity to prepare for future emergencies.
NCUIH also requested that in addition to allocating the additional ARPA funds, IHS promptly disburse previously allocated ARPA funds which many UIOs have still not received. To date, many UIOs have yet to receive all previously allocated ARPA assistance funds — funds critical to addressing adequate COVID-19 response and recovery. As new funds are prepared for distribution, IHS must not lose sight of already allocated ARPA funds that are delayed and have yet to be received by all UIOs.
NCUIH also supported and applauded the historic levels of funding for AI/AN health in the BBBA. However, it urged IHS to take notice of the fact that the level of funding for Indian Country currently proposed in the BBBA is significantly below the $20.5 billion announced in the original reconciliation instruction and the fact that the $2.35 billion in additional funding for several IHS programs does not come close to the $48 billion needed to fully fund IHS.
NCUIH noted with concern that UIOs continue to be excluded from the vast majority of federal funding allocated for AI/AN health. Of the $2.35 billion in proposed funding, UIOs are ineligible for almost $2.1 billion. Full and inclusive funding of IHS is imperative to ensure Tribes and UIOs have the resources required to serve our communities.
NCUIH expressed its strong support for the $100 million proposed in the BBBA for UIO facilities. This funding will assist UIOs in addressing critical needs that they face in their mission to improve health outcomes for AI/ANs. NCUIH estimates that ninety percent (90%) of UIOs need facility upgrades to improve health care services. Current estimates place the total cost of these needed upgrades at $200 million. This includes $172 million in shovel ready projects at UIOs. The allocation of $100 million for UIO facilities in BBBA is historic and long overdue to uphold the trust and treaty responsibilities of the federal government to all AI/ANs. NCUIH requested that if the BBBA is passed, IHS identify out of the $100 million what it intends to use for administrative functions, so that NCUIH and UIOs can fully assess the total amount of funding available.
Finally, NCUIH backed the allocation of $124 million to behavioral health services and necessary facilities in the BBBA. NCUIH noted that pursuant to the reported text of the BBBA, UIOs are fully eligible to receive funds from this allocation, as there are no restrictions on entities to whom the IHS may disburse this money. NCUIH urged IHS to maintain this broad eligibility in any implementing regulations if the BBBA is passed. NCUIH has long advocated before Congress to fund and preserve behavioral health initiatives for UIOs under the Indian health care system, as AI/AN populations are at a much higher risk for behavioral health issues than the general population. NCUIH is especially encouraged by the ability to use this funding for facility renovation, construction, or expansion. This funding will enhance opportunities for UIO residential programs who have had to reduce the number of patients they admit due to COVID-19 guidelines, in a pandemic that has exacerbated behavioral health needs.
NCUIH will continue to closely monitor the status of the additional allocated ARPA funds. NCUIH also continues to track the progress of the BBBA and advocate against any further cuts to Indian Country’s allocation in the bill.