Tag Archive for: Advance Appropriations

Senate Interior Appropriations Bill Passes out of Committee with a 22% Increase for the Indian Health Service and Maintained Advance Appropriations for IHS

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The bill includes $8.5 billion for IHS, $1.5 billion more than the amount enacted for Fiscal Year 2024.

On July 25, 2024, the Senate Appropriations Committee completed the markup of the Fiscal Year (FY) 25 Interior, Environment, and Related Agencies bill. The bill passed out of Committee with a vote of 28-1 and will advance to the Senate floor for initial passage. The bill authorizes $8.5 billion for IHS— an increase of $1.5 billion from FY24 and $500 million above the President’s request. The FY25 budget also includes $94.57 million for Urban Indian health, which is $4.17 million above the FY24 enacted levels, but $5.42 million under the House recommended amount and $419,000 under President Biden’s Request. Advance appropriations for IHS was maintained for FY26 and received an increase to $5.45 billion from $5.19 billion for FY25. Other key provisions include: $3 million to improve maternal health and $2.5 million for the Produce Prescription Pilot Program for Tribes and urban Indian organizations (UIOs) to increase access to produce and other traditional foods. A more detailed analysis follows below.

The National Council of Urban Indian Health (NCUIH) recently worked closely with Sen. Smith (D-MN) on leading a Senate Dear Colleague letter signed by 20 Senators to the Senate Interior Appropriations Committee. The letter has bipartisan support and calls for support for Urban Indian Health based on the Tribal Budget Formulation Workgroup (TBFWG) recommendations and to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending.

Proposed Amendment Regarding Contract Support Costs and 105 (l) Leases Withdrawn

During the hearing, the Chairman of the Senate Interior Appropriations Committee, Jeff Merkley (D-OR), offered an amendment that would reclassify tribal sovereignty payments as mandatory by FY26, making these payments subject to the appropriations process. Merkley said the payments are required by law and will “affect the Interior budget for a long time to come.” However, Merkley said the proposal did not have enough votes to pass and withdrew the amendment.

NCUIH 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, and will continue to advocate for this proposal.

Next Steps

The bill will now advance to the Senate floor for a vote. The legislation is not expected to become law in its current form. House and Senate leadership will work together to negotiate a final bill text for passage in both chambers.

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.

Background and Advocacy

On July 24, 2024, the House of Representatives passed the FY25 Interior Appropriations bill with $8.56 billion for IHS, an increase in FY26 advance appropriations for IHS to $5.97 billion, and $99.99 million for urban Indian health.

Full Funding, Maintain Advance Appropriations, and Mandatory Funding as Priorities

The marked increase for FY25 is a 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.

In addition to the Senate Dear Colleague letter calling for support for Urban Indian Health based on the TBFWG’s recommendation and to maintain advance appropriations for IHS, NCUIH worked with Representatives Gallego and Grijalva in leading a Congressional letter to the House Committee on Appropriations for FY 2025 with the same requests. On May 8, 2024, Helena Indian Alliance – Leo Pocha Clinic Executive Director 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 $53.82 billion and Urban Indian Health for FY 2024 as requested by the TBFWG, maintain advance appropriations for IHS, and support of mandatory funding for IHS.

Bill Highlights

Line Item FY24 Enacted FY25 TBFWG Request FY25
President’s
Budget		 FY25 House Proposed FY25 Senate Proposed
Urban Indian Health $90,419,000 $965,419,000 $94,990,000 $99,992,000 $94,573,000
Indian Health Service $6,961,914,000 $53,852,801,000 $8,000,000,000 $8,561,647,000 $8,500,000,000
Advance Appropriations $5,190,00,00 Request is to expand advance appropriations to include all IHS accounts $5,129,458,000 $5,975,150,000 $5,450,000,000
Produce Prescription Pilot Program $2,500,000 ————————– ———————– $7,000,000 $2,500,000
Tribal Epidemiology Centers $34,433,000 ————————– $34,433,000 $44,433,000 $44,433,000
Contract Support Costs $1,052,000,000 Move to Mandatory $979,000,000 $2,036,000,000 $2,036,000,000
105 (l) Leases $149,000,000 $261,000,000 $349,000,000 $400,000,000 $400,000,000
Alcohol and Substance Abuse $266,636,000 $4,859,237,000 $291,389,000 $282,380,000 $273,138,000
Generators at I/T/Us $3,000,000 ————————— ———————– $8,000,000 Not in bill report.
Maternal Health $2,000,000 ————————— ———————– $3,000,000 $3,000,000
Dental Health $252,561,000 $3,174,342,000 $276,085,000 $283,080,000 $267,189,000

Commitment to Urban Indian Health, UIOs, and Establishment of a UIO Interagency Workgroup

The bill also includes direction for IHS to establish a UIO Interagency Workgroup. The bill report reads, “The Committee is committed to improving the health and well-being of AI/AN living in urban Indian communities. Despite the excellent efforts of Urban Indian Organizations, AI/AN populations continue to be left out of many Federal initiatives. Therefore, the Committee reminds the IHS of the directive to explore the formation of an interagency working group to identify existing Federal funding supporting Urban Indian Organizations [UIOs] and determine where increases are needed, or what programs should be amended to allow for greater access by UIOs; to develop a Federal funding strategy to build out and coordinate the infrastructure necessary to pilot and scale innovative programs that address the needs and aspirations of urban AI/ANs in a holistic manner; develop a wellness centered framework to inform health services; and meet quarterly with UIOs to address other relevant issues. In addition to the Indian Health Service, the working group should consist of the U.S. Department of Health and Human Services, U.S. Department of Housing and Urban Development, U.S. Department of Agriculture, U.S. Department of Justice, U.S. Department of Education, U.S. Department of Veteran Affairs, U.S. Department of Labor, the Small Business Administration, the Economicevelopment Agency, FEMA, the U.S. Conference of Mayors, and others as identified by UIOs.”

NCUIH has advocated for the creation of the UIO Interagency Workgroup as a key step to increasing support and resources to American Indians and Alaska Natives (AI/ANs) living in urban areas. On September 12, 2022, NCUIH submitted comments and recommendations to IHS regarding the formation of an Urban Interagency Workgroup with other federal agencies. The agency held an Urban Confer on July 13, 2022, in response to a letter sent to President Biden and Vice President Harris from several Senators, requesting the formation of such a workgroup. NCUIH will continue to work with House and Senate appropriators to ensure this language is included in the final appropriations bill.

Indian Health Service: $8.5 billion

  • Bill Report, Pg. 121: “The Committee recommends $5,211,808,000 in total resources for fiscal year 2025 for Indian Health Services, an increase of $263,077,000 to the enacted level. The Committee recommendation also provides $4,933,790,000 in advance appropriations for the Services account for fiscal year 2026, equal to the fiscal year 2025 Committee recommendation with the exception of funding provided for Electronic Health Records and the Indian Healthcare Improvement Fund, which is provided only an annual appropriation. The following direction relates to the total fiscal year 2025 funding recommendation. All programs, projects, and activities are maintained at fiscal year 2024 enacted levels unless otherwise stated. The bill provides $119,037,000 for pay costs within current services, as requested.”

Urban Indian Health: $94.57 million

  • Bill Report, pg. 124: “The recommendation includes $94,573,000 for the Urban Indian Health program, an increase of $4,154,000 to the enacted level.”

Contract Support Costs $2.03 billion and Tribal 105(l) leases $400 million

  • Bill Report, pg. 125: “The Committee has continued language from fiscal year 2021 establishing an indefinite appropriation for contract support costs estimated to be $2,036,000,000 in fiscal year 2025. By retaining an indefinite appropriation for this account, additional funds may be provided by the Agency if its budget estimate proves to be lower than necessary to meet the legal obligation to pay the full amount due to Tribes. The Committee believes that fully funding these costs will ensure Tribes have the resources they need to deliver program services efficiently and effectively”
  • Bill Report, pg. 126: “The recommendation includes an indefinite appropriation of an estimated $400,000,000 for the compensation of operating costs associated with facilities leased or owned by Tribes and Tribal organizations for carrying out health programs under ISDEAA contracts and compacts as required by 25 U.S.C. 5324(l).”

Dental Health: $267.18 million

  • Bill Report pg. 123, “The recommendation includes $267,189,000 for dental health, an increase of $14,628,000 to the enacted level. The Service is encouraged to coordinate with the Bureau of Indian Education [BIE] to integrate preventive dental care at schools within the BIE system.

Equipment: $32 million

  • Bill Report, pg. 127: “The recommendation includes $32,598,000 for medical equipment upgrades and replacement, equal to the enacted level.”

Electronic Health Records: $203.88 million

  • Bill Report, pg. 123: “The Committee is aware there is a need for a new electronic health record system to improve the overall interoperability, efficiency, and security of the Service’s information technology system and provides $203,880,000 for this effort, equal to the enacted level. Further, the Committee understands many Tribes recently upgraded computer systems for the new Department of Veterans Affairs [VA] system, and it is important these systems are compatible. It is the Committee’s expectation that the Service will be able to use the compiled information gathered during this recent effort with VA to inform both the Service and the Committee on which Tribes use their own system and the estimated costs. Finally, the Committee notes that the Electronic Health Records is excluded from the advance appropriation for fiscal year 2026 as specified in bill language.”

Mental Health: $135.28 million

  • Bill Report, pg. 123: “The recommendation includes $135,287,000 for mental health programs, an increase of $5,522,000 to the enacted level. The bill maintains fiscal year 2024 funding for the behavioral health integration initiative to better integrate treatment programs for mental health and substance abuse problems and for the suicide prevention initiative.”

Alcohol and Substance Abuse: $273.18 million

  • Bill Report, pg. 123: “The recommendation includes $273,138,000 for alcohol and substance abuse programs, an increase of $6,502,000 to the enacted level. The bill also provides $11,000,000 for opioid abuse.”

Produce Prescription Pilot Program: $2.5 million

  • Bill Report, pg. 122: “The bill maintains funding at fiscal year 2024 enacted levels for the Alzheimer’s program and Produce Prescription Pilot program.”

Improving Maternal Health: $3 million

  • Bill Report, pg. 122: “The Committee remains concerned with the maternal mortality crisis in the United States, which is even more acute in Native American communities. American Indian and Alaska Native women are two times more likely to die of pregnancy-related causes than White women, and 93 percent of pregnancy-related deaths among American Indian and Alaska Native women are preventable. The Committee recommendation supports funding for maternal health initiatives and provides an additional $1,000,000 for these efforts as noted above. The Committee reminds the IHS of the directive to brief the Committee within 90 days of enactment of this act on its plans for such funds. Further, the Committee directs IHS to coordinate with the Centers for Disease Control and Prevention, Health Resources and Services Administration, and Centers for Medicare and Medicaid Services to further enhance its maternal health initiatives, which should include improved data collection to facilitate an agency-wide effort to improve outcomes for American Indian and Alaska Native women.”

Alzheimer’s Disease: $5.5 million

  • Bill Report pg. 122: “The bill maintains funding at fiscal year 2024 enacted levels for the Alzheimer’s program and Produce Prescription Pilot program.”

Purchased and Referred Care: $1 billion

  • Bill Report pg. 124: “The recommendation includes $1,005,356,000 for purchased/referred care, an increase of $8,601,000 above the enacted level. The Committee directs IHS to examine the policies for the Purchased/Referred Care Program and work to better facilitate reimbursement of authorized travel to be used for more than one medical procedure or visit during the time that a patient is scheduled for such healthcare treatment.”

Senators Underscore the Importance of Urban Indian Health Funding and Safeguarding IHS Funding in FY 2025

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On May 23, 2024, the Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies held a hearing with the Indian Health Service (IHS) entitled “To examine proposed budget estimates and justification for fiscal year (FY) 2025 for Indian Country.” At the hearing Chairman Jeff Merkley (D-OR) and Ranking Member Lisa Murkowski (R-AK) welcomed testimony from Roslyn Tso, Director of the Indian Health Service, Jillian E. Curtis, CFO of the Indian Health Service, and Bryan Newland, Assistant Secretary for Indian Affairs at the Department of the Interior. The hearing focused on the President’s FY25 budget and legislative proposals and their potential impact on Indian Country.

Congress Underscores Importance of UIO Funding to Provide Health Care

Many committee members expressed the importance of a budget that fulfills the trust responsibility to provide healthcare to American Indian and Alaska Native people. Sen. Van Hollen, Chris (D-MD) focused his questioning to IHS about the needs of urban Indian organizations (UIOs). Senator Van Hollen expressed concerns that it is critical to mention UIOs, given that UIOs “ensure access to comprehensive, culturally relevant healthcare.” He noted that, “The Indian Health Service spends about 1% on the urban Indian health programs.” Going further Sen. Van Hollen posed the question to Director Tso asking, “What are the limitations today to urban Indian health organizations being able to provide care they need to, and what are some specific proposals to the administration budget that might address that issue?” In response, Director Tso explained that ensuring that reimbursement is similar to the rest of the IHS/Tribal/UIO (I/T/U) system is necessary. She suggested that initiatives such as granting UIOs a 100% Federal Medical Assistance Percentage would be instrumental.

Senator Merkley Emphasizes the Need to Safeguard IHS Funding from Sequestration

Chairman Merkley also noted that IHS needs the same funding protections as the Veterans Health Administration (VHA), “It [the President’s budget] also proposes to make IHS funding exempt from sequestration, which the VA has already gained under the Fiscal Responsibility Act. Well, IHS was forgotten, … we should adopt a number of the VA reforms to afford the same dignity to Native Americans and Alaska Natives.” He also expressed his frustration with the proposed cuts to the Electronic Health Records (EHR) line item, given that the IHS’ EHR is over 40 years old.

Senator Tester (D-MT) noted his concerns regarding the President’s IHS budget proposal being $53 billion short of the estimation determined by Tribes and the current 30% vacancy rate at IHS, “How do you fulfill trust responsibilities with those kinds of numbers?… We put you guys [IHS] in a lose-lose position – we need more doctors, we need more nurses, the works.”

NCUIH is thankful for advocates within Senate who recognize that funding is critical to provide safe, quality, and equitable healthcare for all American Indian and Alaska Native people. NCUIH will continue to advocate for full, mandatory funding for IHS and Urban Indian Health.

House FY 2025 Bill Proposes 23% Increase for the Indian Health Service, Maintains Advance Appropriations

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On June 27, 2024, the House Appropriations Subcommittee on Interior, Environment, and Related Agencies released the draft bill text for the fiscal year (FY) 2025 budget. The bill provides $38.478 billion for Interior, Environment, and Related Agencies, which is $72 million below the FY24 levels and $4.407 billion below the Biden Administration’s request. Despite the overall reduction, the bill proposes $8.56 billion for the Indian Health Service (IHS) which is $1.6 billion (+23%) above the FY24 enacted levels and $360 million (+4.4%) above the Biden Administration’s request. Additionally, the bill provides $5.98 billion in advance appropriations for FY26. Appropriations Committee Chairman Cole (R-OK) emphasized that this bill “safeguards the sacred oath this nation made to protect Native American communities.” 

Next Steps 

The House Appropriations Subcommittee on Interior, Environment, and Related Agencies will hold a markup meeting on June 28, 2024. Once the Subcommittee approves the bill, it will proceed to the full Appropriations Committee for markup on July 9, 2024. During this full Committee markup, a detailed bill report will be provided, outlining the specific amounts for line items within the IHS budget, including the urban Indian health line item. NCUIH will offer a detailed analysis of the budget once the bill report is released. 

20 Senators Request Increased Resources and Stable Funding for Urban Indian Health in FY 2025

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On May 14, 2024, 20 Senators requested up to $965.3 million for urban Indian health in Fiscal Year (FY) 2025 and advance appropriations for the Indian Health Service (IHS).

Sen. Tina Smith (D-MN) and 19 other Senators sent a letter to Chairman Jeff Merkley (D-OR) and Ranking Member Lisa Murkowski (R-AK) of the Senate Interior Appropriations Committee requesting up to $965.3 million for urban Indian health as part of the Tribal Formulation Workgroup’s topline request of $53.85 billion for IHS in FY 2025. The letter also requests the Appropriations Committee maintain advance appropriations for IHS for FY26. The letter emphasizes the critical role that Urban Indian Organizations (UIOs) play in the health care delivery to American Indian and Alaska Native patients and the importance of providing UIOs with the necessary funding to continue to provide quality, culturally competent care to their communities. On May 1, 2024, a group of 52 Representatives sent a letter to the House Interior Appropriations Committee with the same requests.

The letter also notes that chronic underfunding of IHS and urban Indian health has contributed to the health disparities among American Indian and Alaska Native people living in urban areas that suffer greater rates of chronic disease, infant mortality, and suicide compared to other populations.

This letter sends a clear and powerful message to Chairman Merkley and Ranking Member Murkowski and the members of the Senate that funding for urban Indian health must be significantly increased to fulfill the federal government’s trust responsibility to provide quality healthcare to all American Indian and Alaska Native people.

NCUIH is grateful for the support of the following Senators:

  1. Tina Smith
  2. Tammy Baldwin
  3. Maria Cantwell
  4. Ben Luján
  5. Edward Markey
  6. Alex Padilla
  7. Jack Rosen
  8. Jon Tester
  9. Chris Van Hollen
  10. Elizabeth Warren
  11. Amy Klobuchar
  12. Catherine Cortez Masto
  13. Laphonza Butler
  14. Kyrsten Sinema
  15. Ron Wyden
  16. Mark Kelly
  17. Kirsten Gillibrand
  18. Richard Blumenthal
  19. Tammy Duckworth
  20. Michael Bennet

Full Letter Text

Dear Chairman Merkley and Ranking Member Murkowski,

We write to thank you for your proven commitment to the Indian health system, including Urban Indian Organizations (UIOs), and to request you continue your support by funding urban Indian health at the highest level possible, up to $965.3 million, and retaining advanced appropriations for the Indian Health Service (IHS) in the Fiscal Year (FY) 2025 Interior, Environment, and Related Agencies Appropriations Act.

These requests reflect the full need for urban Indian health determined by the Tribal Budget Formulation Workgroup, which is comprised of Tribal leaders representing all twelve IHS service areas. The Workgroup recommended this funding amount for urban Indian health as a part of a $53.85 billion topline recommendation for the Indian Health Service.

UIOs are an important part of the IHS, which oversees a three-prong system for the provision of health care: Indian Health Service, Tribal Programs, and Urban Indian Organizations (I/T/U).UIOs are on the front lines in working to provide for the health and well-being of American Indians and Alaska Natives living outside of Tribal jurisdictions. They serve patients from over 500 federally recognized Tribal Nations in 38 urban areas across the country. UIOs are not eligible for other federal line items that IHS and Tribal facilities are, like hospitals and health clinics, money, purchase and referred care dollars, or IHS dental services dollars. Therefore, this funding request is essential to providing quality, culturally-competent health care to AI/AN people living in urban areas.

Chronic underfunding of IHS and urban Indian health has contributed to the health disparities among AI/AN people. Additionally, AI/AN people living in urban areas suffer greater rates of chronic disease, infant mortality, and suicide compared to all other populations. Urban Native populations are less likely to receive preventive care and are less likely to have health insurance. Additional funding is critical to addressing this disparity.

In order to fulfill the federal government’s trust responsibility to all AI/AN people to provide quality healthcare, funding for urban Indian health must be significantly increased. It is also imperative that such an increase not be paid for by diminishing funding for already hard-pressed IHS and Tribal providers. The solution to address the unmet needs of urban Native and all AI/AN people is an increase in the overall IHS budget.

Thank you for your continued support of urban Indian health and your consideration of this important request.

President Biden Proposes a 15% Increase for Indian Health Service, 5% Increase for Urban Indian Health for FY 2025

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The FY 2025 budget request includes $95 million for urban Indian health, a 5% increase over the FY 2024 enacted amount, mandatory funding through FY 2033, and an IHS exemption from sequestration.

On March 11, 2024, the Indian Health Service (IHS) published their Fiscal Year (FY) 2025 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 $90.4 million. The President’s proposal included a total $130.7 billion in discretionary funding for the Department of Health and Human Services (HHS) and $8 billion in funding for IHS, a 15% increase above the FY 2024 enacted amount of $6.96 billion. The budget request also includes $260 million in proposed mandatory funding for the Special Diabetes Program for Indians (SDPI), bringing the total IHS funding to 8.2 billion. The proposal maintains the IHS budget should be moved to mandatory funding and includes $979 million in indefinite discretionary appropriation for Contract Support Costs and $349 million for Section 105(l) Leases.

Budget Caps and Debt Limit Impacts

The President’s budget reflected a discretionary spending request that was in line with caps set under the 2023 debt limit deal. This means that while there was a decrease in the President’s overall budget request in comparison to FY 2024 request, the Indian Health Service and the Urban Indian Line Item still received an increase over the FY2024 enacted amount.

Mandatory Funding and Advance Appropriations

The budget transitions IHS funding from advance appropriations to full 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. On January 29, 2024, the National Council of Urban Indian Health (NCUIH) sent a letter to Congressional Leadership to request that Congress protect the Indian Health Service (IHS) from sequestration in the fiscal year 2024 funding bill. 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. This move from discretionary to mandatory funding is essential as noted in the IHS Congressional Justification, “Mandatory funding is the most appropriate, long-term solution for adequate, stable, and predictable funding for the Indian health system.”

NCUIH Efforts to Support Tribal Request for FY 2025

The National Council of Urban Indian Health (NCUIH) requested full funding for urban Indian health for FY 2025 at $965.3 million and at least $53.85 billion for IHS in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. The marked increase for FY 2025 is due to Tribal leaders’ budget recommendations to address health disparities that have historically been ignored.

NCUIH Supports President’s Legislative Proposals

The President’s Budget includes potential legislative solutions to address workforce challenges in Indian Country. These proposals include meeting the IHS loan repayment/scholarship service obligation on a half-time basis and providing tax exemptions for IHS professions scholarship and repayment programs. NCUIH has endorsed the IHS Workforce Parity Act (S. 3022) which expands healthcare provider access to IHS scholarship and loan repayment programs, including scholarships for half-time clinical practice. The President’s budget also proposes that U.S. Public Health Service Commissioned Officers be permitted to be detailed directly with UIOs. On May 24, 2022, the National Council of Urban Indian Health (NCUIH) sent a letter to the Chairs of the House and Senate Appropriations Committees, expressing NCUIH’s support for detailing Public Health Service Commission Officers (PHSCOs) to Urban Indian Organizations (UIOs).

Next Steps

The Appropriations Committees will review the President’s Budget for consideration as they craft their bills for FY 2025. NCUIH will submit testimony and send letters to House and Senate Appropriators to request full funding for FY2025.  NCUIH will continue to work with the Biden Administration and Congress to push for full funding of urban Indian health in FY 2025.

Line Item   FY23 Enacted   FY24 Enacted  FY25 Tribal Request  FY25 President’s  Budget 
Urban Indian Health $90.42 million $90.4 million $973.6 million $94.99 million
Indian Health Service $6.96 billion $ 6.96 billion $51.4 billion $8.2 billion
Advance Appropriations $5.13 billion $5.19 billion ——————— ———————
Hospitals and Clinics $2.5 billion  $2.55 billion  $12.2 billion $2.93 Billion
Tribal Epidemiology Centers $34.4 million  $34.4

 million

  ——————– $34.4 million
Electronic Health Record System $218 million  $190.57 million  $491.9 million $435.1 million
Community Health Representatives $65.21 million  $65.2

million

 $1.2 billion $69.63 million
Mental Health $127.1 million  $129.77 million  $3.4 billion $138.75 million
IHS Cancer Moonshot Initiative —————- —————- ——————— 108 million
HIV & Hepatitis $5 million $5 Million ——————— $15 million

Overview of Budget

Key Provisions for IHS, Tribal Organizations, and Urban Indian Organizations (UIOs)

  • $8.1 billion for IHS for FY 2025
  • $95 million for urban Indian health for FY 2025
  • $979 million in indefinite discretionary funding for Contract Support Costs
  • $349 million in indefinite discretionary funding for Section 105(l) Leases
  • $260 million in mandatory funding up to 2026 for SDPI

Other Budget Highlights

  • Addressing Targeted Public Health Challenges
    • $15 million for HIV and Hepatitis C.
      • UIOs eligible
    • $21 million for addressing opioid use.
      • UIOs eligible
    • Urban Indian Health Program – Alcohol and Substance Abuse Title V Grants
      • $3.4 million
        • Allocates funds to the Office of National Drug Control Policy (ONDCP) budget to give resources to UIOs to provide high quality, culturally relevant prevention, early intervention, outpatient and residential substance abuse treatment services, and recovery support to address the unmet needs of the Urban Indian communities they serve.
  • IHS Cancer Moonshot Initiative
    • $108 billion
      • Develops a coordinated public health and clinical cancer initiative to implement best practices and prevention strategies to address the incidence of cancer and mortality among AI/ANs.
        • UIOs eligible
  • Indian Health Professions
    • $81.25 million
      • Offers additional IHS Scholarship and Loan Repayment awards, bolstering recruitment and retention efforts through these two high demand programs.
        • UIOs eligible

Legislative Proposals

  • U.S. Public Health Service Commissioned Officers to be Detailed to Urban Indian Organizations to Cooperate in or Conduct Work Related Functions of the Department of Health and Human Services

  • Sequestration Exemption for Indian Health Program
    • Proposal Description
      • Amends current law to exempt IHS from future sequestration cuts.
      • The services provided by the IHS are no less critical. Budget reductions of any kind have implications for the services IHS, Tribes, and Urban Indian organizations provide to American Indian and Alaska Native patients and communities.
    • NCUIH Action
      • January 29, 2024 Letter Requesting Exemption
  • Meet Loan Repayment/Scholarship Service Obligations on a Half-Time Basis
    • Proposal Description
      • Permit both Indian Health Service (IHS) scholarship and loan repayment recipients to fulfill service obligations through half-time clinical practice, under authority similar to that now available to the National Health Service Corps (NHSC) Loan Repayment Program (LRP) and Scholarship Program.
      • Permitting IHS scholarship and loan repayment health professional employees to fulfill their service obligations through half-time clinical practice for double the amount of time and to offer half the loan repayment award amount in exchange for a two-year service obligation could increase the number of providers interested in serving in the Indian health system.
    • NCUIH Action
      • NCUIH has endorsed the IHS Workforce Parity Act ( S. 3022) which expands healthcare provider access to IHS scholarship and loan repayment programs, including scholarships for half-time clinical practice.
  • Provide Tax Exemption for Indian Health Service Health Professions Scholarship and Loan Repayment Programs
    • The Indian Health Service (IHS) seeks tax treatment similar to that provided to recipients of scholarships and loan repayment from the National Health Service Corps (NHSC). The IHS seeks to allow scholarship funds for qualified tuition and related expenses received under the Indian Health Service Health Professions Scholarships to be excluded from gross income under section 117(c)(2) of the Internal Revenue Code of 1986 (IRC) and to allow participants in the IHS Loan Repayment Program to exclude from gross income, payments made by the IHS Loan Repayment Program under section 108(f)(4) of the IRC. With the above exemptions, the IHS programs would also be exempt from any Federal Employment Tax (FICA), making the IHS programs comparable to the current NHSC status.
    • NCUIH Action:
      • NCUIH has endorsed the IHS Workforce Parity Act (S. 3022) which expands healthcare provider access to IHS scholarship and loan repayment programs, including scholarships for half-time clinical practice.

Policy Alert: FY23 Funding Extended, Averting a Government Shutdown

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On November 15, 2023, a full government shutdown was averted when Congress passed a two-tiered Continuing Resolution (CR) serving as a stopgap spending measure. The CR was signed into law by President Biden on November 16, 2023.

What is included:

The CR includes two funding deadlines for the twelve appropriations accounts, January 19 and February 2. Last year, Congress authorized $5.13 billion in advanced appropriations for IHS, insulating the majority of IHS programs from the worst effects of a government shutdown. The CR re-authorized the Special Diabetes Program for Indians (SDPI) until January 19th at $25.89 million, and funds IHS accounts not receiving advanced appropriations at FY23 levels through February 2nd. President Biden requested $250 million for IHS in emergency supplemental funding in response to the current opioid epidemic. Congress has not included this funding in this CR.

Moving Forward:

Congress will continue to negotiate a final spending bill during this time and NCUIH will monitor for updates.

FY 2024 Appropriations Update: IHS to Maintain Continuity of Operations with Advance Appropriations

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On October 1, 2023, Indian Health Service (IHS) Director, Roselyn Tso, sent a Dear Tribal Leader and Urban Indian Organization Leader letter sharing critical information regarding the current status of fiscal year (FY) 2024 appropriations for the IHS. This letter is in response to the recently enacted “Continuing Appropriations Act, 2024 and Other Extensions Act” (the continuing resolution) which funds the Federal Government through November 17, 2023. The letter notes that because IHS received its first ever advance appropriations in the Consolidated Appropriations Act, 2023 (Public Law 117-328), which provides $5.1 billion in FY 2024 for nearly all programs in the IHS Services and Facilities accounts, the IHS has authorization and funding to continue operations and the provision of direct health care services. The FY 2024 advance appropriations and carryover funds from previously appropriated funds, including COVID supplemental funds, are not limited to the pro-rata percentage applied by the continuing resolution, and the IHS has access to this full funding amount as of October 1.

In the coming days, the IHS will begin distributing FY 2024 advance appropriations to IHS programs, Tribal Health Programs, and Urban Indian Organizations (UIOs). You can find additional information on IHS advance appropriations at the link that follows: IHS Blog: IHS Provides an Update on Advance Appropriations Implementation.

Payment Processes

HHS financial systems will re-open after October 1, 2023, for FY 2024 activities. All of the timelines and requirements to receive a payment remain the same. For example, funds will be paid out according to performance periods. If your UIO contract performance period is October – September, the earliest you could receive a payment for FY 2024 is October 2023. If your performance period is November – October, the earliest you could receive a payment for FY 2024 is November. Additionally, UIOs must have a signed Federal Acquisition Regulation (FAR) contract in place to receive a FY 2024 payment.

Activities that did not receive FY 2024 advance appropriations include the following:

  • Electronic Health Record Modernization
  • Indian Health Care Improvement Fund
  • Health Care Facilities Construction
  • Sanitation Facilities Construction
  • Contract Support Costs
  • Section 105(l) Leases (Payments for Tribal Leases)

Background on IHS Advance Appropriations

The FY 2023 Consolidated Appropriations Act (Public Law 117-328) included a total of $5.1 billion in FY 2024 advance appropriations for IHS, including the urban Indian health line item. The full year funding level will be available for programs on Oct. 1, 2023, regardless of whether Congress enacts a continuing resolution or full year bill. Advance appropriations provide long overdue funding stability and predictability for the IHS. Congress will determine a final appropriations level for the IHS in the FY 2024 appropriations process and has the ability to significantly increase the IHS budget, in-line with the recommendations of the National Tribal Budget Formulation Workgroup, through additional discretionary appropriations.

NCUIH Advocacy

After tireless advocacy from the National Council of Urban Indian Health (NCUIH) and our partners across Indian Country, Congress included advance appropriations for IHS in the FY 2023 final spending bill to provide stable funding for FY 2024. The current advanced appropriation expires in FY 2025, and NCUIH is continuing its advocacy to secure advanced appropriations for IHS for future years. NCUIH endorsed the bipartisan, bicameral Indian Program Advance Appropriations Act (H.R.4832/S.2424) which was reintroduced by Sen. Lujan (D-NM), Sen. Mullin (R-OK), Rep. McCollum (D-MN-04), and Rep. Cole (R-OK-04) on July 24, 2023. This bill would authorize advance appropriations for several accounts under the Bureau of Indian Affairs and Bureau of Indian Education within the Department of Interior and IHS within the Department of Health and Human Services.

On March 9, 2023, NCUIH CEO Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding and requested that advance appropriations for IHS be maintained. NCUIH also worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations for FY 2024, urging to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. On April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests. Due to this advocacy, advance appropriations for IHS was maintained for FY 2025 in both the House and Senate Interior Appropriations proposed FY 2024 spending bills.

IHS Hosts Listening Session on Advance Appropriations, Provides Updates to Tribes and UIOs on Goals, Implementation Timelines, and Payment Processes

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On August 17, 2023, the Indian Health Service (IHS) hosted a listening session for Tribal and urban Indian organization (UIO) leaders to share information and solicit input on advance appropriations implementation. During the listening session, IHS shared that they are currently on track in terms of advance appropriations implementation. In September, IHS plans to start apportionment review and processing and in October, IHS will start distributing funds across the Indian Health, Tribal, and UIO (I/T/U) system. During this process, IHS is seeking input from Tribal and UIO Leaders on advance appropriations implementation regarding the following questions:

  • What additional information would be helpful to you?
  • Are there any considerations you think IHS is missing?
  • What is the best way to collect information about the impact of advance appropriations and success stories?

The IHS will host an identical listening session on Wednesday, September 6, 2023, from 3:00-4:30 p.m., Eastern Time. Click here to join the listening session.

Payment Processes

HHS financial systems will re-open after October 1, 2023, for Fiscal Year (FY) 2024 activities. All of the timelines and requirements to receive a payment remain the same. For example, funds will be paid out according to performance periods. If your UIO contract performance period is October – September, the earliest you could receive a payment for FY2024 is October 2023. If your performance period is November – October, the earliest you could receive a payment for FY2024 is November. Additionally, UIOs must have a signed Federal Acquisition Regulation (FAR) contract in place to receive a FY2024 payment.

Activities that did not receive FY 2024 advance appropriations include the following:

  • Electronic Health Record Modernization
  • Indian Health Care Improvement Fund
  • Health Care Facilities Construction
  • Sanitation Facilities Construction
  • Contract Support Costs
  • Section 105(l) Leases (Payments for Tribal Leases)

Background on IHS Advance Appropriations

The FY 2023 Consolidated Appropriations Act (Public Law 117-328) included a total of $5.1 billion in FY 2024 advance appropriations for the Indian Health Service, including the urban Indian health line item. The full year funding level will be available for programs on Oct. 1, 2023, regardless of whether Congress enacts a continuing resolution or full year bill. Advance appropriations provide long overdue funding stability and predictability for the IHS. Congress will determine a final appropriations level for the IHS in the FY 2024 appropriations process and has the ability to significantly increase the IHS budget, in-line with the recommendations of the National Tribal Budget Formulation Workgroup, through additional discretionary appropriations.

NCUIH Advocacy

After tireless advocacy from the National Council of Urban Indian Health (NCUIH) and our partners across Indian Country, Congress included advance appropriations for IHS in the FY 2023 final spending bill to provide stable funding for FY 2024. The current advanced appropriation expires in FY 2025, and NCUIH is continuing its advocacy to secure advanced appropriations for IHS for future years. NCUIH endorsed the bipartisan, bicameral Indian Program Advance Appropriations Act (H.R.4832/S.2424) which was reintroduced by Sen. Lujan (D-NM), Sen. Mullin (R-OK), Rep. McCollum (D-MN-04), and Rep. Cole (R-OK-04) on July 24, 2023. This bill would authorize advance appropriations for several accounts under the Bureau of Indian Affairs and Bureau of Indian Education within the Department of Interior and IHS within the Department of Health and Human Services.

On March 9, 2023, NCUIH CEO Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding and requested that advance appropriations for IHS be maintained. NCUIH also worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations for FY 2024, urging to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. On April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests. Due to this advocacy, advance appropriations for IHS was maintained for FY 2025 in both the House and Senate Interior Appropriations proposed FY 2024 spending bills.

IHS Initiates Listening Sessions for Tribal and Urban Indian Organization Leaders on Advance Appropriations Implementation

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On August 8, 2023, the Indian Health Service (IHS) sent a Dear Tribal Leader and Urban Indian Organization (UIO) Leader letter inviting Tribal and UIO leaders to participate in Agency-sponsored Listening Sessions to share information and solicit input on advance appropriations implementation. IHS will host two (2) identical Listening Sessions for Tribes and UIOs on August 17, 2023, and September 6, 2023. During the Listening Sessions, IHS will share additional information on implementation plans and strategies for advance appropriations, and seek Tribal and UIO input. The information discussed in these sessions will be used to prepare public-facing Frequently Asked Questions and other helpful materials.

Since advance appropriations was included in the final FY 2023 spending bill, the National Council of Urban Indian Health (NCUIH) has consistently requested that IHS host a Tribal Consultation and Urban Confer to ensure Tribes and UIOs are briefed on the implementation process and prepared for fund distribution. NCUIH recently met with IHS Director Roselyn Tso and emphasized the importance of hosting an Urban Confer before October 1, 2023. We look forward to continuing to engage with IHS to ensure successful implementation of advance appropriations for the whole IHS, Tribal, and UIO system.

The Advance Appropriations Implementation Listening Sessions will be on Thursday, August 17, 2023, 12:00-1:30 p.m., ET and Wednesday, September 6, 2023, 3:00-4:30 p.m., ET.

    • Click here to join the Thursday, August 17 Listening Session
    • Click here to join the Wednesday, September 6 Listening Session

Background on IHS Advance Appropriations

The FY 2023 Consolidated Appropriations Act (Public Law 117-328) included a total of $5.1 billion in FY 2024 advance appropriations for the Indian Health Service, including the urban Indian health line item. The full year funding level will be available for programs on Oct. 1, 2023, regardless of whether Congress enacts a continuing resolution or full year bill. Advance appropriations provide long overdue funding stability and predictability for the IHS. Congress will determine a final appropriations level for the IHS in the FY 2024 appropriations process and has the ability to significantly increase the IHS budget, in-line with the recommendations of the National Tribal Budget Formulation Workgroup, through additional discretionary appropriations.

NCUIH Advocacy

After tireless advocacy from the National Council of Urban Indian Health (NCUIH) and our partners across Indian Country, Congress included advance appropriations for IHS in the FY 2023 final spending bill to provide stable funding for FY 2024. The current advanced appropriation expires in FY 2025, and NCUIH is continuing its advocacy to secure advanced appropriations for IHS for future years. NCUIH endorsed the bipartisan, bicameral Indian Program Advance Appropriations Act (H.R.4832/S.2424) which was reintroduced by Sen. Lujan (D-NM), Sen. Mullin (R-OK), Rep. McCollum (D-MN-04), and Rep. Cole (R-OK-04) on July 24, 2023. This bill would authorize advance appropriations for several accounts under the Bureau of Indian Affairs and Bureau of Indian Education within the Department of Interior and IHS within the Department of Health and Human Services.

NCUIH has been advocating that advance appropriations be maintained for IHS until mandatory funding is achieved. On March 9, 2023, NCUIH CEO Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding and requested that advance appropriations for IHS be maintained. NCUIH also worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations for FY 2024, urging to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. On April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests. Due to this advocacy, advance appropriations for IHS was maintained for FY 2025 in both the House and Senate Interior Appropriations proposed FY 2024 spending bills.

IHS Outlines Strategic Goals including Rapid Disbursement of Funds, for FY 2024 Advance Appropriations Implementation

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On July 19, 2023, the Indian Health Service (IHS) sent a Dear Tribal Leader and Urban Indian Organization Leader letter providing an update on the status of implementing the Fiscal Year (FY) 2024 advance appropriations provided to the IHS. To ensure the successful implementation of advance appropriations, the IHS has identified three strategic goals. Goal 1 aims to distribute FY 2024 advance appropriations for IHS, Tribal, and Urban Indian health programs as close as possible on or after October 1, 2023. Goal 2 aims to ensure regular engagement with Tribal Leaders, Urban Indian Organization (UIO) Leaders, and Congress so that all relevant stakeholders have a clear understanding of the Agency’s progress. Goal 3 aims to demonstrate the impact of advance appropriations to demonstrate the positive impacts.

IHS Strategic Goals for Advance Appropriations

The IHS’s first goal in implementing advance appropriations is to distribute the funds as soon as possible after October 1, 2023. To date, to achieve this goal, the IHS has taken the following steps:

  • Updating existing budget execution systems and internal timelines to allow funds to be distributed as quickly as possible. The IHS has confirmed that all financial systems will support the rapid distribution of funds.
  • Ensuring apportionments, which authorize the expenditure of funds, are prepared and approved timely by the IHS for submission to the Department of Health and Human Services (HHS) and Office of Management and Budget (OMB);
  • Partnering with all IHS Headquarters and Area Office staff involved in payments to Tribal Organizations and UIOs to ensure an effective process; and
  • Upon the enactment of a full year bill, the IHS will distribute any additional funds enacted by Congress as soon as possible after the passage of the bill.

The IHS’s second goal in implementing advance appropriations is to ensure regular outreach and engagement with Tribal Leaders, UIO Leaders, and Congress, so that all relevant stakeholders have a clear understanding of the Agency’s progress. To achieve this goal, the IHS is:

  • Making useful information about advance appropriations implementation available on the IHS Web site; 􀁸 Briefing Tribal Leaders and Urban Indian Organization Leaders on implementation progress during scheduled meetings and/or engagements. Conducting listening sessions, or Tribal Consultation and Urban Confer; and
  • Providing updates to Congress on the IHS’s progress toward implementation.

The IHS’s third goal in implementing advance appropriations is to demonstrate the positive impacts of advance appropriations, including:

  • Partnering with health programs operated by the IHS, Tribes, and UIOs to identify metrics for success, including success stories. The IHS is developing a plan to engage IHS, Tribal, and Urban Indian health programs on an ongoing basis to seek your input on how advance appropriations have improved your ability to provide high-quality health care services.
  • The IHS will complete an evaluation to assess the implementation, impact, and customer service satisfaction regarding the execution of advance appropriations.

Background on IHS Advance Appropriations

In FY 2023, the IHS received the first ever advance appropriation for the FY 2024 Budget. The FY 2023 Consolidated Appropriations Act (Public Law 117-328) included a total of $5.1 billion in FY 2024 advance appropriations for the Indian Health Service, which includes funding at the same level as FY 2023 enacted for nearly all IHS programs. The full year funding level will be available for these programs on Oct. 1, 2023, regardless of whether Congress enacts a continuing resolution or full year bill. Advance appropriations provide long overdue funding stability and predictability for the IHS.

NCUIH Advocacy

After tireless advocacy from the National Council of Urban Indian Health (NCUIH) and across Indian Country, advance appropriations for IHS was included in the FY 2023 final spending bill to provide stable funding for FY 2024. The current advanced appropriation expires in FY 2025, and NCUIH is continuing its advocacy to secure funding for IHS for future years. NCUIH endorsed the bipartisan, bicameral Indian Program Advance Appropriations Act (H.R.4832/S.2424) which was reintroduced by Sen. Lujan (D-NM), Sen. Mullin (R-OK), Rep. McCollum (D-MN-04), and Rep. Cole (R-OK-04) on July 24, 2023. This bill would authorize advance appropriations for several accounts under the Bureau of Indian Affairs and Bureau of Indian Education within the Department of Interior and IHS within the Department of Health and Human Services.

For FY 2024, NCUIH has been advocating that advance appropriations be maintained for IHS until mandatory funding is achieved. On March 9, 2023, NCUIH CEO Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding and requested that advance appropriations for IHS be maintained. NCUIH also worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations for FY 2024, urging to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. On April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests. Due to this advocacy, advance appropriations for IHS was maintained for FY 2025 in both the House and Senate Interior Appropriations proposed FY 2024 spending bills.

Next Steps

NCUIH continues to engage with IHS to ensure the successful implementation of advance appropriations for the whole IHS, Tribal organization, and UIO system. NCUIH encourages IHS to host an Urban Confer before October 1, 2023, to ensure UIOs are briefed on the implementation process and are prepared for fund distribution.