FY 2024 Spending Bill Signed into Law, Includes Modest Increase for the Indian Health Service and Maintains Advance Appropriations

The bill includes $6.96 billion for IHS and flat funding for Urban Indian Health.

On March 09, 2024, the Consolidated Appropriations Act, 2024 (H.R. 4366), also known as a ‘minibus,’ was signed into law by President Biden, finalizing appropriations for six spending accounts for fiscal year (FY) 2024. This follows a fourth continuing resolution (CR) for FY 2024 that extended partial government funding through March 8 and March 22. The bill, which passed in the House with a 339-85 vote, followed by final passage in the Senate with a 75-22 vote, is the first package of final Appropriations bills for FY 2024 and included Interior appropriations.

The minibus authorizes $6.96 billion for the Indian Health Service (IHS) for FY 2024, which is $3.6 million above the comparable FY 2023 level; $90.42 million for urban Indian health for FY 2024, which is equal to the FY 2023 enacted level; and advance appropriations for IHS totaling $5.19 billion for FY 2025.
In addition, the final package includes an authorization of $130 million for the Special Diabetes Program for Indians (SDPI) for the period of March 9 through December 31, 2024, bringing the total funding to $158 million for Calendar Year (CY) 2024 (includes SDPI funding allocated in FY 2024 CRs).

Despite cuts in funding for other programs in the Interior appropriations bill, such as a 10% cut to the Environmental Protection Agency (EPA), the Indian Health Service was thankfully able at a minimum maintain current funding levels. In addition, advance appropriations for FY 2025 were protected with a modest increase of $61.43 million, which will ensure that all AI/AN people will have continuous access to care, even in the event of a government shutdown. Finally, the reauthorization of the extremely successful SDPI will allow UIOs and other grantees to continue to use grant funding to offer a wide range of diabetes treatment and prevention services.

The National Council of Urban Indian Health (NCUIH) has long advocated for larger investments in American Indian and Alaska Native (AI/AN) health care and has called on Congress to strengthen its commitment to Indian Country with increased funding in the FY 2024 appropriations. The Tribal Budget Formulation Workgroup, a national workgroup that identifies annual Tribal funding priorities, requested full funding for IHS at $51.42 billion and $973.59 million for Urban Indian Health. Unfortunately, the final legislative text falls short of fully funding IHS so that the agency can properly provide health care services for all AI/AN people.

Bill Text:

Overview of IHS and Urban Indian Health Requests:

Table

Line Item	FY 2023 Enacted	FY 2024 TBFWG Request	FY 2024 President’s Budget Request	FY 2024 House Passed	FY 2024 Senate Passed	FY 2024 Enacted
Urban Indian Health	$90.4 million	$973.59 million	$115.15 million	$115.15 million	$92.42 million	$90.4 million
Indian Health Service	$6.9 billion	$50.9 billion	$9.7 billion	$7.078 billion	$7.26 billion	$6.96 billion
Advance Appropriations	$5.1 billion	$9.1 billion	$5.13 billion	$5.88 billion	$5.23 billion	$5.19 billion
Hospitals and Clinics	$2.5 billion	$12.338 billion	$3.553 billion	$2.66 billion	$2.58 billion	$2.551 billion
TECs	$34.4 million	_______	$34.4 million	$35 million	_______	$34.4 million
CHRs	$65.2 million	$1.247 billion	$74.56 million	___________	_________	$65.2 million
Direct Operations	$103.8 million	$101.9 million	$118.5 million	$101.73 million	$103.8 million	$103.8 million
Mental Health	$127.1 million	$3.46 billion	$163.99 million	$130.86 million	$130.16 million	$129.77 million
BIA MMIW	$25.1 million	_________	__________	$15.56 million	$26.09 million	$25.1 million
EHRs	$217.5 million	$491.97 million	$319.03 million	________	$217.56 million	$190.57 million
Produce Prescription Program	$3 million	_______	_________	$6 million	$3 million	$3 million

Key Provisions for IHS, Tribal Organizations, and UIOs:

$6.96 billion for IHS for FY 2024, $3.6 million above the FY 2023 level.
$90.419 million for Urban Indian Health for FY 2024, the same amount as the FY 2023 level.
$5.19 billion for advance appropriations for FY 2025, $61.43 million above the FY 2024 advance.
Fully funds Contract Support Costs and Payments for Tribal Leases
Total SDPI funding for CY 2024: $158 million

Funding Mechanism	Dates	Authorization Total	Daily Rate	2024 Calendar Year (Daily rate x funding period)*
CR 1	10/1/2023 – 11/17/2023	$19,726,027	$419,702	_______
CR 2	11/18/2023 – 1/19/2024	$25,890,411	$410,958	$8,219,178
CR 3	1/20/2024-3/8/2024	$20,136,986	$428,447	$20,136,986
Minibus	3/9/2024 – 12/31/2024	$130,000,000	$437,710	$130,000,000
Total	10/1/2023 – 12/31/2024	$195,753,424	________	$158,356,164

*Calendar year funding calculated by multiplying the daily rate with the number of days in 2024 for that funding period.

Analysis:

Urban Indian Health

$90,419,000 for Urban Indian Health for FY 2024

Indian Health Service

$5,190,883,000 in advance appropriations for IHS for FY 2025
$6.962 billion in agency funding for IHS for FY 2024
- Indian Health Services Account – $4,948,731,000
Hospitals and Health Clinics – $2,550,514,000
Tribal Epidemiology Centers (TECs) – $34,400,000
Electronic Health Records (EHRs) – $190,564,000, a $27 million decrease from FY 2023 enacted levels
Community Health Representative (CHRs) – $65,212,000
Mental health – $129,756,000
Produce Prescription Pilot Program – $3,000,000
Direct Operations – $103,805,000
Indian Health Care Improvement Fund – $74,138,000
Funds Indian Health Facilities at $813,183,000
Indefinite appropriation to fully fund contract support costs, which are estimated to be $1,051,000,000 in FY 2024
Indefinite appropriation to fully fund payments for Tribal leases, which are estimated to be $149,000,000 in FY 2024

Bureau of Indian Affairs (BIA)

$1,898,550,000 for Operation of Indian Programs
Missing and Murdered Indigenous Women (MMIW)
- $24,898,000 for Law Enforcement Special Initiatives, of which an additional $5,000,000 is to continue addressing the MMIW effort.
Native Boarding School Initiative
- $260,634,000 for Executive Direction and Administrative Services, including maintaining FY 2023 levels for the Native Boarding School Initiative.
Violence Against Women Act (VAWA)
- $3,000,000 is for an initiative to support cross-designation of Tribal prosecutors as Tribal Special Assistant United States Attorneys

Topic	Section	Funding	Language
Urban Indian Health	Urban Indian Health	$90,419,000	Pg. 52 “The agreement provides $90,419,000 for the Urban Indian health Program.”
Indian Health Service	Advance Appropriations	$5,190,883,000	Pg. 51 “The agreement provides advance appropriations for the Indian Health Services and Indian Health Facilities accounts totaling $5,190,883,000 for fiscal year 2025. Advanced appropriations are not provided for the Electronic Health Record System, Indian Health Care Improvement Fund, Contract Support Costs, Payments for Tribal Leases, Sanitation Facilities Construction, and Health Care Facilities Construction. Additional details, instructions, and requirements follow in the table at the end of this division”
	Staffing for New Facilities	$56,061,000	Pg. 51 “The agreement includes $56,061,000 for staffing newly opened health facilities, which is the full amount required in fiscal year 2024 based upon updated estimates provided to the Committees. Funds for staffing of new facilities are limited to facilities funded through the Health Care Facilities Construction Priority System or the Joint Venture Construction Program that have opened in fiscal year 2023 or will open in fiscal year 2024. None of these funds may be allocated to a facility until such facility has achieved beneficial occupancy status. As initial estimates included as part of the annual budget request are refined, IHS is expected to communicate updated cost estimates to the Committees.”