Tag Archive for: Advance Appropriations

Policy Alert: FY23 Funding Extended, Averting a Government Shutdown

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

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

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

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

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.

NCUIH Endorses Bipartisan, Bicameral Bill To Secure Advance Appropriations For Critical Indian Country Programs

On July 24, 2023, Senators Lujan (D-NM) and Mullin (R-OK) and Representatives McCollum (D-MN-04) and Cole (R-OK-04) reintroduced the bipartisan, bicameral Indian Program Advance Appropriations Act (H.R.4832/S.2424). The 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 the Indian Health Service (IHS) within the Department of Health and Human Services. The bill would specifically provide advance appropriations for IHS, Contract Support Costs, Payments for Tribal Leases, Indian Health Facilities, Operation of Indian Programs, Operation of Indian Education, and several other critical Indian Services accounts.  The bill is sponsored by twenty-three Democrats and four Republicans. The bill has been endorsed by the National Congress of American Indians, the National Indian Health Board, and the National Council of Urban Indian Health (NCUIH).

“The National Council of Urban Indian Health is pleased to endorse the Indian Programs Advance Appropriations Act from Senators Lujan, Mullin and Congresswoman McCollum and Congressman Cole. This legislation is simple and essential. It would enable Congress to appropriate funding for the Indian Health Service, the Bureau of Indian Affairs, and the Bureau of Indian Education one year in advance- ensuring timely and sustained funding for essential programs and services that are vital to the well-being and prosperity of Native communities. The Act demonstrates a commitment to transparency and accountability, ultimately empowering our communities to thrive. I urge Congress to swiftly pass this bill, a significant step forward in supporting Native American health and education initiatives.” – Francys Crevier (Algonquin), CEO, NCUIH.

Next Steps

The bill was referred to the Senate Committee on Indian Affairs and the House Natural Resources Committee. The bill has been added to the NCUIH bill tracker and can be found here.

Background

After tireless advocacy across Indian Country, advance appropriations for IHS were included in the fiscal year (FY) 2023 final spending bill to provide stable funding for FY 2024. On July 19, 2023, the House Appropriations Committee released their FY 2024 Interior, Environment, and Related Agencies Appropriations Bill – maintaining advance appropriations for FY 2023 at $5.878 billion. Despite the victory in the final FY23 spending bill for IHS, other critical Indian country programs were not included in advance appropriations. It is paramount that all critical programs receive advance appropriations to ensure all American Indians and Alaska Natives have continuous access to the essential services many rely on.

Senate Interior Appropriations Bill Passes out of Committee with Advance Appropriations and a Modest Increase for the Indian Health Service

The bill includes $7.27 billion for IHS, $2.6 billion less than the amount requested by the President.

On July 27, 2023, the Senate Appropriations Committee completed the markup of the Fiscal Year (FY) 24 Interior, Environment, and Related Agencies bill. The bill passed out of committee with a vote of 28-0 and will advance to the Senate floor for initial passage. The bill authorizes $7.27 billion for IHS— an increase of $218.6 million from FY23 but $2.68 billion below the President’s request. The FY24 budget also includes $92.4 million for Urban Indian health, which is $2 million above the FY23 enacted levels but $22.7 million under the House recommended amount and President Biden’s Request. Advance appropriations for IHS was maintained for FY25 and received an increase to $5.22 billion from $5.12 billion for FY24. Other key provisions include: $8 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.

During the Full Appropriations Committee hearing, Chair of the Committee, Senator Patty Murray (D-WA) expressed the importance of protecting the Indian Health Service, “This bill plays a critical role in making sure we keep our promises to Tribes and deliver on key federal investments by sustaining funding for the Indian Health Service and providing new resources to support Tribal families, protect Tribal treaty rights, and more.” 


Line Item
FY23 Enacted FY24 TBFWG Request FY24
President’s
Budget
FY24 House Proposed FY24 Senate Proposed
Urban Indian Health $90,419,000 $973,590,000 $115,150,000 $115,150,000 $92,419,000
Indian Health Service $6,958,223,000 $50,996,276,000 $9,700,000,000 $7,078,223,000 $7,275,531,000
Advance Appropriations $5,129,458,00 Request is to expand advance appropriations to include all IHS accounts $5,129,458,00 $5,878,223,000 $5,228,112,000

Establishment of a UIO Interagency Workgroup

The bill also includes direction for IHS to establish a UIO Interagency Workgroup. The bill report reads, “Despite the excellent efforts of Urban Indian Organizations, AI/AN populations continue to be left out of many Federal initiatives. Therefore, the Committee directs the Indian Health Service to continue 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, where funding is lacking, 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 Economic Development Agency, FEMA, the U.S. Conference of Mayors, and others as identified by UIOs.”

The National Council of Urban Indian Health (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.

Background and Advocacy

On March 9, 2023, President Biden released his budget request for FY24 which included $9.7 billion for IHS and proposed mandatory funding for IHS from FY 2025 to FY 2033 to the amount of $288 billion over-ten years as well as exempting IHS from sequestration. This mandatory formula would culminate in $44 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, “While the progress achieved through the enactment of advance appropriations will have a lasting impact on Indian Country, funding growth beyond what can be accomplished through discretionary spending is needed to fulfill the federal government’s commitments to Indian Country.” On March 17, 2023, IHS published their Fiscal Year (FY) 2024 Congressional Justification with the full details of the President’s Budget, which includes $115 million for urban Indian health – a 27% increase above the FY 2023 enacted amount of $90.42 million.

On July 18, 2023, the House of Representatives Appropriations Committee advanced the FY24 Interior Appropriations bill with $7.079 billion for IHS, an increase in FY25 advance appropriations for IHS to $5.8 billion, and $115.15 million for urban Indian health.

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

NCUIH requested full funding for urban Indian health for FY 2024 at $973.59 million for urban Indian Health in FY24 in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. NCUIH also requested that advance appropriations be maintained for the Indian Health Service (IHS) until mandatory funding is achieved. The marked increase for FY24 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.

On April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee. 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. Representatives Gallego and Grijalva also led a Congressional letter to the House Committee on Appropriations for FY 2024 with the same requests.

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. NCUIH requested full funding for IHS at $51.41 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

Indian Health Service: $7.27 billion

  • Bill Report, Pg. 119, “The Committee recommendation provides $7,275,531,000 for IHS for fiscal year 2024 discretionary funding, an increase of $248,042,000 to the enacted level and a decrease of $2,194,123,000 to the requested level.”

Urban Indian Health: $92.4 million

  • Bill Report, pg. 123, “The recommendation includes $92,419,000 for the Urban Indian Health program, $2,000,000 above the enacted level.”

Contract Support Costs $1 billion and Tribal 105(l) leases $149 million

  • Bill Report, pg. 124, “The Committee has continued language from fiscal year 2021 establishing an indefinite appropriation for contract support costs estimated to be $1,051,000,000 in fiscal year 2024.
  • Bill Report, pg. 124, “The recommendation includes an indefinite appropriation of an estimated $149,000,000 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).”
  • The Biden Administration included Contract Support Costs and Tribal 105(l) leases as mandatory costs. The Committee did not recommend the line items to be mandatory costs.
    • NCUIH along with 22 other Tribes and Native organizations advocated for these tribal sovereignty payments as mandatory in a letter to Congressional appropriators.

Dental Health: $254.7 million

  • Bill Report pg. 122, “The recommendation includes $254,729,000 for dental health, an increase of $6,631,000 above 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: $32.59 million

  • Bill Report, pg. 125, “The recommendation includes $32,598,000 for medical equipment upgrades and replacement, equal to the enacted level.”

Electronic Health Records: $217.6 million

  • Bill Report, pg. 88, “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 $217,564,000 for this effort, equal to the enacted level”

Mental Health: $130.2 million

  • Bill Report, pg. 122, “The recommendation includes $130,155,000 for mental health programs, an increase of $2,984,000 above the enacted level.”

Alcohol and Substance Abuse: $266.8 million

  • Bill Report, pg. 122, “The recommendation includes $266,843,000 for alcohol and substance abuse programs, an increase of $403,000 above the enacted level. The bill also provides $11,000,000 for opioid abuse, described below.”

Produce Prescription Pilot Program: $2.5 million

  • Bill Report, pg. 120, “The bill maintains funding at fiscal year 2023 enacted levels for the Alzheimer’s program and Produce Prescription Pilot program.”

Maternal Health: $8 million

  • Bill Report, pg. 120, “The Committee recommendation supports funding for maternal health initiatives and provides an additional $1,000,000 for these efforts as noted above.”

Alzheimer’s Disease: $5.5 million

  • Bill Report pg. 120, “The bill maintains funding at fiscal year 2023 enacted levels for the Alzheimer’s program and Produce Prescription Pilot program.”

Purchased and Referred Care: $997.8 million

  • Bill Report pg. 123, “—The recommendation includes $997,755,000 for purchased/referred care, an increase of $1,000,000 above the enacted level.”

In a Divided Fiscal Climate, House Advances Interior Bill with Advance Appropriations and a Modest Increase for Indian Health Service

The bill advanced to the Full Committee on Wednesday and includes $7.078 billion for IHS, $2.6 billion less than the amount requested by the President.

On July 18, 2023, the House Appropriations Subcommittee on Interior, Environment, and Related Agencies released the Committee Bill Report for the fiscal year (FY) 2024 budget with $115,156,000 for Urban Indian health. The bill appropriates $25.4 billion for Interior, Environment, and Related Agencies, which is $13.4 billion below the fiscal 2023 levels and $21.3 billion below the Biden Administration’s request.  However, the bill rescinds $9.37 billion in funding for programs established in  the Inflation Reduction Act, resulting in the final program level of $34.79 billion. Despite the sizeable cut to the Interior, Environment, and Related Agencies bill and reducing funding for nearly every account to below FY23 enacted levels, the Indian Health Service (IHS) received a 2.2% increase.

The report and bill were approved by the House Subcommittee on Interior on July 13, 2023 and approved with amendments by the full House Appropriations Committee on July 19, 2023. The bill authorizes $7.078 billion for IHS— an increase of $149 million from FY23 but $2.6 billion below the President’s request. Advance appropriations for IHS was maintained for FY25 and received an increase to $5.8 billion from $4.9 billion in FY24. Other key provisions include: $3 million for generators at IHS/Tribal Health Programs/Urban Indian Organizations (UIOs), $6 million for the Produce Prescription Pilot Program for Tribes and UIOs to increase access to produce and other traditional foods, as well as $35 million for Tribal Epidemiology Centers (TECs). A more detailed analysis follows below.

“While the proposed funding for Indian health by the House falls short of the full funding amount requested by the Tribal Budget Formulation Workgroup, NCUIH is grateful for the Committee’s commitment to securing funding for IHS with advance appropriations in Fiscal Year 2025 at the Fiscal Year 2024 enacted amount. We thank Chair Mike Simpson and Ranking Member Chellie Pingree for their continued efforts to ensure that Native lives are not at-risk because of funding disputes.”Francys Crevier (Algonquin), CEO, National Council of Urban Indian Health (NCUIH).

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

On July 19, 2023, the House Appropriations Committee completed the markup of the FY24 Interior, Environment, and Related Agencies bill.  The bill was passed out of committee 33 to 27 and referred to the House Floor.  The Majority Leadership will now work to schedule the bill for a vote on the House floor. They will also work with Senate Leadership to negotiate a final bill text for passage in both chambers. The Senate Appropriations Committee has scheduled a markup for the Senate FY24 Interior, Environment, and Related Agencies bill for July 27, 2023, at 10:30a.m.

During the Full Appropriations Committee markup, Representative Mike Simpson (R-ID-2) expressed his commitment to providing stable funding for IHS, “I am pleased that the bill provides a fiscal year 2025 advance appropriation for the Indian Health Service and it’s very important that we do that. I made a commitment from the start of this that we were not going to balance this budget on the backs of our Indian brothers and sisters, and we kept that commitment in this bill. It is a bipartisan commitment. We have a moral and a trust responsibility to the Indians of this country, and we need to make sure that we are trying to address that. We still have a long way to go, but we are moving in the right direction.”

“This is an extraordinarily good bill from a Native American standpoint. I was quite shocked; I go through these bills very carefully cause that’s a passionate area of interest. I want to thank all four current chairmen and the 3 former chairmen for working together. Chairman Simpson started us on this course of trying to begin to address many, many years of neglect and broken treaty responsibilities. The members on both sides of the aisle have been enormously helpful with this… in particular I want to thank the Chairman for keeping in advance appropriations for the Indian Health Service which is absolutely critical. There was a situation where whenever we had a government shutdown or differences, we shut down healthcare systems on reservations. It is the only healthcare system we have that gets almost all of its money from discretionary dollars. That was extraordinary,” – Representative Tom Cole (R-OK-4).

 “…I think we made great, great, strides and I am so excited about our opportunity with the Indian Health Service, which we know is in desperate need for federal assistance to get it in the place where people can continue to get their healthcare,” – Representative Rosa DeLauro (D-CT-3).

Line Item FY23 Enacted FY24 TBFWG Request FY24 President’s Budget FY24 House Proposed
Urban Indian Health $90,419,000 $973,590,000 $115,150,000 $115,150,000
Indian Health Service $6,958,223,000 $50,996,276 $9,700,000,000 $7,078,223,000
Advance Appropriations $5,129,458,00 $9,100,000,000 $5,129,458,00 $5,878,223,000

 

Background and Advocacy

On March 9, 2023, President Biden released his budget request for FY24 which included $9.7 billion for IHS and proposed mandatory funding for IHS from FY 2025 to FY 2033 to the amount of $288 billion over-ten years as well as exempting IHS from sequestration. This mandatory formula would culminate in $44 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, “While the progress achieved through the enactment of advance appropriations will have a lasting impact on Indian Country, funding growth beyond what can be accomplished through discretionary spending is needed to fulfill the federal government’s commitments to Indian Country.” On March 17, 2023, IHS published their Fiscal Year (FY) 2024 Congressional Justification with the full details of the President’s Budget, which includes $115 million for urban Indian health – a 27% increase above the FY 2023 enacted amount of $90.42 million.

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

NCUIH requested full funding for urban Indian health for FY 2024 at $973.59 million for urban Indian Health in FY24 in accordance with the Tribal Budget Formulation Workgroup recommendations. NCUIH also requested that advance appropriations be maintained for the Indian Health Service (IHS) until mandatory funding is achieved. The marked increase for FY24 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.

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. NCUIH requested full funding for IHS at $51.41 billion and Urban Indian Health for FY 2024 as requested by the Tribal Budget Formulation Workgroup (TBFWG), maintain advance appropriations for IHS, and support of mandatory funding for IHS.

NCUIH recently worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations for FY 2024. 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 April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests.

Bill Highlights

Indian Health Service: $7.078 billion

  • Bill Report, Pg.2 : “The bill provides $2,582,452,000 for the Bureau of Indian Affairs (BIA), $1,399,504,000 for the Bureau of Indian Education (BIE), and $7,078,223,000 for the Indian Health Service (IHS) in funding available in fiscal year 2024.”

Urban Indian Health: $115 million

  • Bill Report, pg. 90: “The bill includes $115,156,000 for this program, which will help to expand access to urban Indian program care services.”

Mandatory Funding: Contract Support Costs and Tribal 105(l) leases

  • Bill Report, pg. 44: ” The Committee recommends an indefinite appropriation estimated to be $342,000,000 for contract support costs incurred by Indian Affairs as required by law and does not include the Administration’s mandatory proposal”
  • Bill Report, pg. 44 :” The Committee recommends an indefinite appropriation estimated to be $64,000,000 for Payments for Tribal Leases incurred by Indian Affairs as required by law and does not include the Administration’s mandatory proposal”
  • The Biden Administration included Contract Support Costs and Tribal 105(l) leases as mandatory costs. The Committee outlined in the bill report, “It does not include the Administration’s proposal to make these costs mandatory.”
    • NCUIH along with 22 other Tribes and Native organizations advocated for these tribal sovereignty payments as mandatory in a letter to Congressional appropriators.

Dental Health: $288 million

  • Bill Report pg. 88: “The recommendation includes $288,230,000 for the Dental Health program, including $8,844,000 for staffing at new facilities and $31,288,000 to expand access to dental care.”

Equipment: $42 million

  • Bill Report, pg. 91: “The recommendation continues $500,000 for TRANSAM and provides an increase of $10,264,000 above the fiscal year 2023 level for additional medical equipment at Federally and Tribally-operated healthcare facilities.”
  • Bill Report , pg. 91: “The recommendation directs IHS to continue to use at least $3,000,000 to purchase generators for IHS, Tribal Health Programs, and Urban Indian Organizations in areas impacted by de-energization events.”

Electronic Health Records:

  • Bill Report, pg. 88: “The bill reduces funding for the Electronic Record Health System below the 2023 level to fund the required new staffing increases and other patient care initiatives. The Committee recognizes the importance of this project but is concerned about the overall cost and schedule of the project. The bill continues language prohibiting IHS from obligating or expending funds to select or implement a new IT infrastructure system unless IHS notifies the Committee at least 90 days before such funds are obligated or expended.”

Mental Health: $130 million

  • Bill Report, pg. 89: “The Committee provides $130,864,000 for Mental Health, including $3,693,000 for staffing at new IHS facilities.”

Alcohol and Substance Abuse: $276 million

  • Bill Report, pg. 87: “The Committee provides $267,194,000 for this program, including $754,000 for staffing at new IHS facilities.”

Produce Prescription Pilot Program: $6 million

  • Bill Report,pg. 89: “The recommendation includes $6,000,000 for IHS to maintain, in coordination with Tribes and Urban Indian Organizations (UIOs), the pilot program to implement a produce prescription model to increase access to produce and other traditional foods among its service population.”

Tribal Epidemiology Centers: $35 million

  • Bill Report, pg. 89: “The Committee recognizes the importance of TECs which conduct epidemiology and public health functions critical to the delivery of health care services for Tribal and urban Indian communities. The recommendation includes $35,000,000 for TECs.”

Maternal Health: $10 million

  • Bill Report, pg. 89: “The recommendation includes $3,000,000 above the fiscal year 2023 level to improve maternal health. The Committee directs IHS to provide a briefing within 180 days of enactment of this Act on the use of funds including hiring and staff training.”

Alzheimer’s Disease: $6 million

  • Bill Report pg. 87: “The recommendation includes $6,000,000 to continue Alzheimer’s and related dementia activities.”

Senators Reiterate Trust Responsibility and Highlight Necessity of Mandatory Funding in IHS FY 2024 Appropriations Hearing

On May 10, 2023, the Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies held a hearing, chaired by Senator Merkley, to review the President’s Budget for Fiscal Year (FY) 2024 for the Indian Health Service (IHS). Testimony was provided by Roselyn Tso, IHS Director and Bryan Newland, Assistance Secretary for Indian Affairs within the Department of the Interior. Topics addressed include the proposal to shift from discretionary to mandatory spending, which Director Tso highlighted as the most appropriate long-term solution to the historical underfunding of IHS. The National Council of Urban Indian Health continues to advocate for full funding for IHS and Urban Indian Health and maintain advance appropriations until mandatory funding is enacted in FY 24.

Updates from IHS and Director Tso

Director Roselyn Tso was questioned directly by Senators on various initiatives and programs. The biggest issue raised by Senator Merkley was the proposal to shift contract support costs and 105(l) leases to mandatory funding. Senator Murkowski expanded on this and inquired about any statutory language or legal definition of what these costs are, which would be helpful for Congress when working to reclassify them. Director Tso discussed the importance of contract support costs and 105(l) leases as tools for tribal self-governance.

Senator Murkowski reiterated her support for advanced appropriations but wanted an update as to any authorizing language regarding this legislative proposal to shift to mandatory funding. Jillian Curtis (Director of the Office of Finance and Accounting at IHS) informed that they will work with the Office of Management and Budget (OMB) on a tribal consultation which took place in June, with the goal that it will inform a better legislative package.

Other updates include:

  • Senator Merkley raised the issues of vacancy rates and employee retention, specifically the nurse preceptorship program, which was highlighted as an important goal of IHS. Their request is 1 million dollars to provide training development and support to replenish the workforce they have lost with older generations, as well as integrate recent graduates. IHS is also requesting the elimination of the tax related to loan repayment.
  • Senator Merkley also inquired about the Community Health Aide Program (CHAP) Expansion to the lower 48 states and how this proposed expansion would be implemented. IHS is moving forward with Portland Area expansion and have plans for the Billings Area as well. They are planning to work closely with the Alaska program to uplift the program nationally.
  • Director Roselyn Tso’s Full Testimony

Senator Merkley Emphasized the Importance of a Funding Increase to Eliminate the Health Care Gap

Through his remarks, Senator Merkley pointed to IHS receiving a $2.5 billion increase as a solution to the health care disparities faced within the American Indian and Alaska Native community. He also mentioned how advanced appropriations were a significant achievement for FY 23, and that they would like to build off of this. Within the IHS budget proposal for FY 24, there is a mandatory reclassification proposal for contract support costs and 105(l) leases, which he supports, because reclassifying funds as mandatory would promote and allow for tribal self-governance.

Senator Murkowski Reflected on the Importance of Upholding the Trust Responsibility as a Bipartisan Priority

Senator Murkowski opened her remarks by stating, “this subcommittee has always worked together to fund essential programs that serve our Tribes and Native communities…I think we have made upholding the federal government’s trust responsibility a bipartisan priority. It needs to continue to be so.”  She then highlighted how FY 24 increases almost every budget line, but she noted her disappointment that the budget proposal doesn’t focus on successful implementation of advanced appropriations, but instead proposes mandatory funding for IHS beginning in 2025 without any accompanying legislative text. She also listed her important IHS priorities that have remained unchanged:

  • Funding for VBCs (Village Built Clinics);
  • Facilities construction accounts;
  • Programs that support Alaska Dental Health Therapy;
  • Community Aide Health Programs;
  • Contract Support Costs; and
  • 105(l) lease payments

She emphasized that due to ongoing questions surrounding costs for these programs and initiatives, it has spurred additional court cases and created budget uncertainty. IHS currently has an unobligated balance that needs to be addressed, so the Senator urged IHS to be open and transparent during their conversations so that the best services possible are provided.

Senator Murray Remarked on the Importance of Committing to Federal Investments  

Senator Murray discussed the importance of these programs and how we cannot let partisan infighting negatively impact them. She emphasized this point by discussing the Default on America Act and its impact on IHS, by cutting funding by nearly a billion dollars and taking care away from 2.5 million people. The work being done in the Subcommittee is an opportunity to demonstrate a commitment to tribal communities, so any support needs to be reflected through funding. She reiterated this by stating, “it is important we are holding this hearing today to make sure our nation meets its obligations to our Tribes—honoring their sovereignty and providing the federal investments that we have promised.”

House Passes Final Debt-Limit Deal with Advance Appropriations Authority for IHS

On May 31, 2023, after weeks of negotiations between President Biden and Congress, the House of Representatives passed by a margin of 314 to 117, The Fiscal Responsibility Act (H.R. 3746), which will suspend the debt ceiling through January 1, 2025.

The legislation includes spending caps on the total amount for non-defense discretionary funding for two years.

  • The Indian Health Service (IHS) falls under non-defense discretionary funding, however, how the caps impact the actual IHS budget has yet to be determined.

The bill also includes “claw backs” of some unobligated COVID-19 funding, however, the American Rescue Plan funding for the Indian Health Service (IHS) is protected from these rescissions.

The legislation included the budgetary authority to extend advance appropriations for IHS for FY25 and FY26 but limits the advance appropriation amount for each year to the FY 2024 appropriated amount.

Lastly, the deal includes expanding certain work requirements for federal nutrition and cash assistance programs but does not include new work requirements for Medicaid.

House of Representatives Passes Final Debt-Limit Deal with Advance Appropriations Authority for IHS

President Biden and Speaker McCarthy

Spending Caps for Non-Defense Discretionary Spending, including the Indian Health Service 

  • This legislation “caps” (limits) non-defense spending from FY23 through FY24 and only increases by 1% in FY25. The FY24 cap for non-defense discretionary spending is $704 billion, with $121 billion for veteran’s medical care and the rest of the $538 billion would be allocated to other areas, such as IHS.

Go deeper: The agreement authorized increased spending for Veterans’ healthcare but does not include a similar specific authorization for Indian Health Service.

By the numbers: IHS was funded at $6.9 billion in FY23 and Congressional appropriators still retain authority on how the capped spending will be appropriated across federal programs.

What’s it all mean? At this point, it is unclear how the IHS budget for FY24 will be impacted.

“Claw Backs” on COVID-19 Relief Funds

What’s a “claw back”? The agreement includes “claw backs” which rescinds unobligated balances (funds that have been appropriated for a program or other purpose but have not been spent) from some COVID-19 funding.

The bottom line: IHS funds from the American Rescue Plan Act are protected however, it remains unclear what remaining other COVID-19 unobligated balances exist for IHS and whether they would be protected.

  • For urban Indian organizations (UIOs), COVID-19 funds that the UIO has received will not be clawed back.
  • Certain other COVID-19 funds that have not been obligated are potentially subject to claw backs.

Yes, but: At this time, IHS has not issued guidance about the effects on non-ARPA IHS COVID-19 unobligated funds that may be clawed back.

Advance Appropriations for the Indian Health Service: The bill authorizes advance appropriations for IHS for FY25 and FY26.

What’s next: It is still up to Appropriations Committees to appropriate that advance appropriation, but this sets up and enables them to do so. The funding must stay at the FY24 spending level.

Work Requirements for Federal Programs 

The big picture: The bill adds some increased work requirements to qualify for the Supplemental Nutrition Assistance Program (SNAP).

  • The bill raises the age requirement to 51 years of age in FY23, 53 in FY24, and 55 in FY25.
  • However, the bill adds an exemption to work requirements for homeless individuals, veterans, and persons who are under 24 and were in a state foster care system until age 18 or any higher age as required by the state.
  • The bill does not include explicit work requirement exemptions for American Indian and Alaska Native recipients.
  • These amendments sunset on October 1, 2030.

What about Medicaid work requirements? Notably, the bill does not enact stricter work requirements for Medicaid, as in the House’s original debt limit legislation.

  • On May 8, 20223, NCUIH signed on to a Partnership for Medicaid letter to Congressional Leadership expressing concern about work requirements as a mandatory condition for Medicaid eligibility in the debt ceiling bill.
  • With over 1.8 million American Indians and Alaska Natives enrolled in Medicaid, NCUIH has worked diligently to ensure beneficiaries do not needlessly lose coverage.

How did we get here? The Fiscal Responsibility Act (H.R. 3746) comes after weeks of negotiation between President Biden and House Republicans after the House of Representatives previously passed the Limit, Save, Grow Act of 2023 (H.R. 2811) to lift the US debt limit for a year.

  • That legislation included several measures, including reverting federal spending to FY22 levels, limiting spending increases to 1% a year for the next 10 years, rescinding any unspent Covid-19 funds, and enacting stricter work requirements for social programs such as Medicaid.
  • The legislation was dead on arrival in the Democratic-led Senate as President Biden had indicated that he would veto the legislation.
  • In response to this legislation, NCUIH released a statement calling on Congressional leaders to safeguard Indian health funding from proposed cuts.

Looking Forward: This legislation will now be considered in the Senate, hoping to pass it by Friday, June 2. NCUIH will continue to advocate for the protection of the Indian Health Service.

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