House Advances Interior Bill with a 23% Increase for the Indian Health Service and Maintained Advance Appropriations for IHS

The House Appropriations Full Committee passed an Interior bill that includes $8.56 billion for IHS and $99.99 million for Urban Indian Health.

On July 9, 2024, the House Appropriations Full Committee passed the Fiscal Year (FY) 2025 appropriations bill for Interior, Environment, and Related Agencies, which was previously approved by the House Subcommittee on June 28, 2024. The bill authorizes $8.56 billion for the Indian Health Service (IHS)— an increase of $1.6 billion from FY24 and $361.64 million above the President’s request. The bill also provides $99.99 million for Urban Indian health, which is $9.5 million above the FY24 enacted amount and $5 million above the President’s budget request.  The Committee report included language that affirmed the trust responsibility for all Native people including those who reside in urban areas.

Other key provisions include: maintaining advance appropriations for IHS for FY26 with an increase to $5.98 billion from $5.19 billion in FY25, $8 million for generators at IHS/Tribal Health Programs/Urban Indian Organizations (UIOs), $7 million, a $4 million increase, for the Produce Prescription Pilot Program for Tribes and UIOs to increase access to produce and other traditional foods, as well as $44.43 million, a $10 million increase, for Tribal Epidemiology Centers (TECs).

NCUIH recently worked closely with Representatives Gallego and Grijalva on leading a Congressional letter signed by 52 House members to the House Committee on Appropriations for FY 2025. The letter has bipartisan support and calls for support for Urban Indian Health based on the TBFWG’s recommendation and to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. NCUIH also joined the National Indian Health Board, National Congress of American Indians, and 25 other organizations on a letter urging Congressional Appropriations leaders to transition Contract Support Cost and 105(l) leases to mandatory appropriations.

Next Steps

The House is scheduled to vote on the Interior, Environment, and Related Agencies spending bill the week of July 22. The legislation is not expected to become law in its current form. House leadership will need to work with Senate Leadership to negotiate a final bill text for passage in both chambers. The Senate Appropriations Committee is tentatively scheduled to mark up the Senate Interior bill the week of July 22.

FY24 funding is set to end on September 30, 2024. If Congress cannot come to a funding agreement by that deadline, they will need to pass a Continuing Resolution to keep the funding levels at the FY24 level until they can reach an agreement. Should political disagreements lead to a government shutdown, UIOs and parts of IHS will be protected by Advance Appropriations.

Bi-Partisan Support for IHS Funding and Advance Appropriations in Bill Hearing

Throughout the appropriations process, there has been clear bipartisan support for the Indian Health Service:

“I refuse to balance the budget on the backs of tribes. I am proud this bill makes strong investments to further the federal government’s trust and treaty commitments to the Tribes.” – Chairman Mike Simpson (R-ID-2)

“The measure [Interior Bill] before us today impacts vast aspects of American Life. It also advances the federal commitment to honor our trust and treaty responsibilities to American Indian and Alaska Native communities. Essential resources are delivered at the total funding level at $38.4 billion,” said Appropriations Chairman Tom Cole (R-OK-4), “Delivering on our trust and treaty commitments are of critical importance to my home state of Oklahoma and to all people of Indian Country.”

“I want to show my pride and appreciation for the continued nonpartisan trust and treaty responsibility that’s the hallmark of this Interior bill. Chairman Cole I want to thank you for raising interior allocation to allow us to meet the increased responsibilities for contract support costs,” said Rep. Betty McCollum (D-MN-4), and she also acknowledged the inclusion of advance appropriations for IHS, “Chairman Simpson I appreciate you once again prioritizing funding for life, health and safety issues for Indian Country, including advance appropriations for the Indian Health Service for a third year in a row.”

Committee leadership also signified their support of the transition of Contract Support Costs to mandatory funding:

Ranking Member Pingree (D-ME-1) shared, “I want to acknowledge and thank Chairman Cole for adjusting the Interior Allocation to accommodate the $739 million increase required by the result of the Supreme Court decision on contract support costs. These costs will continue to rise, and I hope we can work together to make these funds mandatory.”

Appropriations Ranking Member Rosa De Lauro (D-CT-3), shared her support for funding contract support costs, “It is my hope that we can work together to see the funding needed to address rising contract support costs is made mandatory.”

Bill Highlights

LINE ITEM FY24 ENACTED FY25 TBFWG REQUEST FY25 PRESIDENT’S BUDGET FY25 HOUSE PROPOSED
URBAN INDIAN HEALTH $90,419,000 $965,254,000 $94,990,000 $99,992,000
INDIAN HEALTH SERVICE $6,961,914,000 $53,852,801,000 $8,200,000,00 $8,561,647,000
ADVANCE APPROPRIATIONS $5,190,000,000 ————————- $5,129,458,000 $5,975,150,000
PRODUCE PRESCRIPTION PILOT PROGRAM $3,000,000 ————————- —————————- $7,000,000
TRIBAL EPIDEMIOLOGY CENTERS $34,433,000 $34,433,000 $44,433,000
CONTRACT SUPPORT COSTS $1,051,000,000 Move to Mandatory $ 979,000,000 $2,036,000,000
105 (L) LEASES $149,000,000 $261,000,000 $349,000,000 $400,000,000
ALCOHOL AND SUBSTANCE ABUSE $266,636,000 $4,859,237,000 $291,389,000 $282,380,000
GENERATORS AT I/T/US $3,000,000 ————————- —————————- $8,000,000
MATERNAL HEALTH $2,000,000 ————————- —————————- $3,000,000
DENTAL HEALTH $252,561,000 $3,174,342,000 $276,085,000 $283,080,000
Indian Health Service: $8.56 billion
  • Bill Report, Pg.93: The recommendation includes $5,274,783,000 that is available for obligation in fiscal year 2025 for the Indian Health Services Account, $326,052,000 above the fiscal year 2024 enacted level. This includes $4,684,029,000 provided as a fiscal year 2025 advance and $590,754,000 recommended in this bill and available in this fiscal year. These funds are available for two years unless otherwise specified.
Urban Indian Health: $99.99 million
  • Bill Report, pg. 95: The Committee recognizes the Federal trust responsibility to provide health care services to American Indian and Alaska Native citizens and acknowledges that approximately seventy-one percent live in urban areas. The recommendation includes $99,992,000, $9,573,000 above the fiscal year 2024 enacted level and $5,000,000 above the President’s budget request, for Urban Indian Health programs.
Contract Support Costs – $2.036 billion and Tribal 105(l) leases – $400 million
  • Bill Report, pg. 96: The Committee recommends an indefinite appropriation estimated to be $2,036,000,000 for contract support costs incurred by the agency as required by law. It does not include the Administration’s request for Administrative Costs. The bill continues language making available such sums as are necessary to meet the Federal government’s full legal obligation and prohibiting the transfer of funds to any other account for any other purpose. In addition, the bill includes language specifying carryover funds may be applied to subsequent years’ contract support costs.
    • In a recent Supreme Court opinion, Becerra v. San Carlos Apache, found that self-determination contracts between Tribes and IHS require spending and collection of third-party revenue, therefore, by doing so and incurring administrative costs, IHS is then required to reimburse for those contract support costs.
  • Bill Report, pg. 96: The Committee recommends an indefinite appropriation estimated to be $400,000,000 for Payments for Tribal Leases incurred by the agency as required by law. It does not include the Administration’s request for Administrative Costs. The bill includes language making available such sums as necessary to meet the Federal government’s full legal obligation and prohibits the transfer of funds to any other account for any other purpose.
Hospitals and Health Clinics: $2.84 billion
  • Bill Report, pg. 93: The recommendation includes $2,845,868,000 for Hospitals and Health Clinics, $295,354,000 above the fiscal year 2024 enacted level.
Direct Operations: $105.96 million
  • No report language
Indian Health Care Improvement Fund: $75.47 million
  • Bill Report, pg. 96: The Committee does not accept the IHS’s proposal to move the Indian Health Care Improvement Fund within the Hospitals and Health Clinics funding. The recommendation provides $75,472,000 for the Indian Health Care Improvement Fund, which is $1,334,000 above the fiscal year 2024 enacted level.
Purchased and Referred Care: $1.04 billion
  • Bill Report, pg. 94: The recommendation includes $1,048,804,000, $52,049,000 above the fiscal year 2024 enacted level, for Purchase and Referred Care (PRC).
Public Health Nursing: $120.95 million
  • No report language.
Immunization AK: $2.3 million
  • No report language.
Indian Health Professions: $89.25 million
  • Bill Report, pg. 95: The recommendation includes $89,252,000 for Indian Health Professions programs, $8,684,000 above the fiscal year 2024 enacted level and $8,000,000 above the President’s budget request. The Committee continues to support Indian Health Professions programs and expects IHS to allocate the increase provided across all programs, including the Scholarship Program, Loan Repayment Program, Indians into Medicine Program (INMED), American Indians into Nursing (RAIN) Program, and the American Indians into Psychology Programs.
Tribal Management: $2.98 million
  • No report language.
Self-Governance: $6.18 million
  • No report language.
Maintenance and Improvement: $174.35 million
  • No report language.
Sanitation Facilities Construction: $127.96 million
  • Bill Report, pg. 97: The Committee continues advance appropriations for programs advanced in fiscal year 2024 and expands advance appropriations to the Indian Health Facilities Sanitation Facilities Construction and Health Care Facilities Construction accounts.
Health Care Facilities Construction: $185.7 million
  • Bill Report, pg. 97: The recommendation includes $185,702,000 for Health Care Facilities Construction, $3,023,000 above the fiscal year 2024 enacted level. The recommendation includes $14,000,000, for Staff Quarters, $3,000,000 above the fiscal year 2024 enacted level, for staff housing across the IHS health care delivery system to support the recruitment and retention of quality healthcare professionals across Indian country.
Facility and Environmental Health Support: $323.96 million
  • No report language.
Dental Health: $238 million
  • Bill Report, pg. 94: The recommendation includes $283,085,000 for Dental Health services, $30,524,000 above the fiscal year 2024 enacted level and $7,000,000 above the President’s budget request.
    • Also includes $8,000,000 to expand Dental Support Centers to all 12 service areas and $6,500,000 to install a electronic Dental Records System.
Equipment – Generators:  $8 million
  • Bill Report, pg. 97: To increase the resilience of these facilities, the recommendation includes $8,000,000 to purchase generators, $5,000,000 above the fiscal year 2024 enacted level, including for IHS, Tribal Health Programs, and Urban Indian Organizations located in areas impacted by de-energization events.
Bureau of Indian Affairs, Missing and Murdered Indigenous Women Initiative: $30 million
  • Bill Report, pg. 47: Within the increase provided, the recommendation includes an additional $13,500,000 for the Missing and Murdered Indigenous Women Initiative. A total of $30,000,000 is provided to address the crisis of missing and murdered indigenous women, including resources for criminal investigators, software platforms, and evidence recovery equipment. The Committee directs BIA to work with Tribal and Federal law enforcement agencies to facilitate sharing law enforcement and public records data and other technological tools to assist those agencies in finding missing individuals.
Community Health Representatives: $69.62 million
  • No report language.
Mental Health: $140.74 million
  • Bill Report, pg. 94: The recommendation includes $140,746,000 for Mental Health/Social Services, $10,981,000 above the fiscal year 2024 enacted level.
Alcohol and Substance Abuse: $282.38 million
  • Bill Report, pg. 94: The recommendation includes $282,389,000, $15,753,000 above the fiscal year 2024 enacted level, for Alcohol and Substance Abuse programs.
Produce Prescription Pilot Program: $7 million
  • Bill Report, pg. 93: The recommendation includes $7,000,000, $4,000,000 above the fiscal year 2024 enacted level, for IHS to expand, in coordination with Tribes and Urban Indian Organizations (UIOs), the Produce Prescription Pilot to implement a produce prescription model to increase access to produce and other traditional foods among its service population. The Committee encourages IHS to provide a briefing to the Committee not later than 90 days following the enactment of this Act on the distribution of funds and implementation efforts
Tribal Epidemiology Centers: $44.43 million
  • Bill Report, pg. 93: The Committee recognizes the importance of Tribal Epidemiology Centers (TEC) which conduct epidemiology and public health functions critical to the delivery of health care services for Tribal and urban Indian communities. The recommendation includes $44,433,000 for TECs, $10,000,000 above the fiscal year 2024 enacted level.
Maternal Health: $3 million
  • Bill Report, pg. 93: The recommendation includes $3,000,000, $1,000,000 above the fiscal year 2024 enacted level, for Improving Maternal Health.
Alzheimer’s Disease: $6 million
  • Bill Report pg. 93: The recommendation includes $6,000,000, $500,000 above the fiscal year 2024 enacted level, to continue Alzheimer’s and related dementia activities. These funds will enable awardees to continue to implement locally developed models of culturally appropriate screening, diagnostics, and management of people living with Alzheimer’s and other related dementia. This funding also supports the Dementia ECHO program, designed to support clinicians and caregivers to strengthen their knowledge and care around dementia for Tribal patients.
Background and Advocacy

On March 9, 2024, President Biden released his budget request for FY25 which included $8.2 billion for IHS and proposed mandatory funding for IHS from FY 2026 to FY 2034 to the amount of $288.9 billion over-ten years as well as exempting IHS from sequestration. This mandatory formula would culminate in $42 billion for IHS in FY 2033, to account for inflation, staffing increases, long-COVID treatment, and construction costs. On March 11, 2024, IHS published their FY 2024 Congressional Justification with the full details of the President’s Budget, which includes $95 million for urban Indian health – a 5% increase above the FY 2024 enacted amount of $90.42 million.

NCUIH also requested full funding for urban Indian health for FY 2025 at $963.5 million for urban Indian Health in FY25 in accordance with the Tribal Budget Formulation Workgroup recommendations. NCUIH requested that advance appropriations be maintained for the Indian Health Service (IHS) until mandatory funding is achieved. This budget recommendation is the result of Tribal leaders, over several decades, providing budget recommendations to phase in funding increases over 10-12 years to address growing health disparities that have largely been ignored.

On May 8, 2024, NCUIH Board Member and Executive Director of Helena Indian Alliance – Leo Pocha Clinic, Todd Wilson (Crow), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2025 funding. NCUIH requested full funding for IHS at $53.8 billion and $ 965.3 million for Urban Indian Health for FY 2025 as requested by the Tribal Budget Formulation Workgroup (TBFWG), maintain advance appropriations for IHS, and protecting IHS from sequestration.

NCUIH recently worked closely with Representatives Gallego and Grijalva on leading a Congressional letter signed by 52 House members to the House Committee on Appropriations for FY 2025. The letter has bipartisan support and calls for support for Urban Indian Health based on the TBFWG’s recommendation and to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. On May 14, 2024, a group of 20 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests.