Advance Appropriations Archives - Page 2 of 7

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

August 4, 2023/0 Comments/in Policy Blog/by Emily Larsen

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

August 3, 2023/0 Comments/in Policy Blog/by Jeremy Grabiner

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

July 26, 2023/0 Comments/in Policy Blog/by Jeremy Grabiner

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

July 5, 2023/0 Comments/in Policy Blog/by Chelsea Gutierrez

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.

Watch the full hearing.

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.”

Murray’s Full Remarks

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

June 6, 2023/0 Comments/in Policy Blog/by NCUIH

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

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.

Resources

Full Bill Text – H.R. 3746
NCUIH Statement – Proposed Legislation to Lift US Debt Limit Threatens Native Health Care

NCUIH Urges Senate and House Appropriations Committees to Provide Full Stable Funding for IHS and Urban Indian Health in FY 2024

May 2, 2023/0 Comments/in Policy Blog/by Jeremy Grabiner

On April 8, 2023, the National Council of Urban Indian Health (NCUIH) sent a letter to Chairman Jeff Merkley (D-OR) and Ranking Member Lisa Murkowski (R-AK) of the Senate Interior Appropriations Committee requesting full funding for the Indian Health Service (IHS) and urban Indian health, advance appropriations for IHS, and resources for Native behavioral health in Fiscal Year (FY) 2024. On March 24, 2023, NCUIH also sent a letter to Chairman Kay Granger (R-TX-12) and Ranking Member Rosa DeLauro (D-CT-3) of the House Interior Appropriations Committee with the same requests.

The letter emphasizes the critical role that urban Indian organizations (UIOs) play in health care delivery to American Indian and Alaska Native (AI/AN) patients and the importance of providing UIOs with the necessary funding to continue to provide quality, culturally competent care to their communities. The requests included in the letter are efforts to achieve parity and uphold the federal trust responsibility for urban Natives.

In the letters, NCUIH requested the following:

$51.42 billion for IHS and $973.59 million for Urban Indian Health for FY24, as requested by the Tribal Budget Formulation Workgroup (TBFWG)
Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
Appropriate $80 million for the Native Behavioral Health Resources Program

These requests come at an important time to protect funding for urban Indian health. Current debt ceiling negotiations by Congress include proposals to cut spending for domestic programs and return funding for federal agencies to FY 2022 levels. These proposals would be detrimental to the success of IHS, Tribal organizations, and UIOs and would roll back historic funding levels that contribute to better health outcomes for Native communities. It is important that members of the House and Senate work to protect the health of all American Indians and Alaska Natives.

Full Letter Text

On behalf of the National Council of Urban Indian Health (NCUIH), the national advocate for health care for the over 70% of American Indians and Alaska Natives (AI/ANs) living off-reservation and the 41 Urban Indian Organizations (UIOs) that help serve this population, we write to respectfully request that Congress honor the federal trust responsibility by ensuring the following asks for Indian Country in Fiscal Year (FY) 2024:

$51.42 billion for the Indian Health Service (IHS) and $973.59 million for Urban Indian Health for FY24, as requested by the Tribal Budget Formulation Workgroup (TBFWG)
Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
Appropriate $80 million for the Native Behavioral Health Resources Program

We applaud the Committee’s longstanding leadership to ensure the trust responsibility for health care is upheld and honored for all AI/AN, especially last year with achieving advance appropriations for IHS.

UIOs Play a Critical Role in Providing Health Care for AI/ANs

UIOs are on the front lines in providing for the health and well-being of AI/ANs living off-reservation, many whom lack access to care that would otherwise be provided through on-reservation health care facilities. UIOs play a critical role in fulfilling the federal government’s responsibility to provide healthcare for AI/ANs and are an integral part of the Indian health system, which is comprised of the IHS, Tribal organizations, and urban Indian organizations (collectively, the I/T/U system). UIOs are critical health care access points to help serve the over 70% of AI/ANs in urban areas. Congress must do more to fully fund the IHS to improve health outcomes for all Native populations.

Need for Full Funding of the Indian Health System including Urban Indian Health

It is the policy of the United States “to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.” This requires that funding for Indian health must be significantly increased if the federal government is to finally fulfill its trust responsibility. At a minimum, funding must be maintained and protected as budget-cutting measures are being considered. UIOs are reporting historic levels of patients, need funding to fulfill the needs of the majority of the AI/AN population. Full funding will empower UIOs to hire more staff, pay appropriate wages, as well as expand vital services, programs, and facilities. Congress must do more to increase funding as the current FY23 funding level of $90.49 million which is only 9.3% of the full FY24 amount requested by Tribes and UIOs to meet current need.

Retain Advance Appropriations for IHS until Mandatory Funding is Enacted and Protect IHS from Sequestration

We applaud this Committee for your work on the historic inclusion of advance appropriations in the FY23 Omnibus. This is a crucial step towards ensuring long-term, stable funding for IHS. Previously, the I/T/U system was the only major federal health care provider funded through annual appropriations. It is imperative that this Committee retain advance appropriations and ensure that IHS is protected from sequestration.

The GAO cited a lack of consistent funding as a barrier for IHS. The Congressional Research Service stated that advance appropriations would lead to cost savings as continuing resolutions (CRs) “prohibits the agency from making longer-term, potentially cost-saving purchases.” Lapses in federal funding quite literally put lives at risk. During the shutdown at the start of FY 2019, the Indian health system was the only federal healthcare entity that shut down. UIOs are so chronically underfunded that several UIOS had to reduce services, lose staff, or close their doors entirely, forcing them to leave their patients without adequate care. It is imperative that advance appropriations provide certainty to the IHS system and ensure unrelated budget disagreements do not put lives at stake.

Advance appropriations will improve accountability and increase staff recruitment and retention at IHS. When IHS distributes their funding on time, our UIOs can pay their doctors and providers. During a pandemic that has ravaged Indian Country and devasted the workforce, being able to recruit doctors and pay them on time is a top priority.

While advance appropriations are a step in the right direction to avoid disruptions during government shutdowns and continuing resolutions (CRs), mandatory funding is the only way to assure fairness in funding and fulfillment of the trust responsibility. Until authorizers act to move IHS to mandatory funding, we request that Congress continue to provide advance appropriations to the Indian health system to improve certainty and stability.

Cuts from sequestration, the automatic spending cuts that occur through the withdrawal of funding for government programs, force I/T/U providers to make difficult decisions about the scope of healthcare services they can offer to Native patients. For example, the $220 million reduction in IHS’ budget authority for FY 2013 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for AI/ANs. Therefore, we request that you exempt IHS from sequestration and other budget cutting measures as is required by the trust responsibility.

Appropriate $80 Million for the Native Behavioral Health Resources Program

Native people continue to face high rates of behavioral health issues caused by generational trauma and federal policies. Native people experience serious mental illnesses at a rate 1.58 times higher than the national average, and high rates of alcohol and substance abuse. In fact, between 1999 and 2015, the drug overdose death rates for Native populations increased by more than 500%. Native youth also experience the highest rates of suicide and depression, with the Native youth suicide rate being 2.5 times that of the national average.

In response to these chronic health disparities, Congress authorized $80 million to be appropriated for the Native Behavioral Health Resources Program for fiscal years 2023 to 2027. Despite authorizing an appropriation of $80 million for the Program, Congress did not appropriate that sum for FY 23.

We request that the authorized $80 million be appropriated to the Native Behavioral Health Resources Program for FY 24 and each of the remaining authorized years. Until the committee appropriates funding for this program, critical healthcare programs and services cannot operate to their full capability, putting Native lives at-risk. We ask that this essential step is taken to ensure our communities have access to the care they need.

Conclusion

Among the most sacred of the duties encompassed within the federal trust responsibility is the duty to provide for Indian health care. The United State’s failure to fulfill its obligations to provide health care to urban Indians has real and devastating effects on our communities. We urge Congress to act swiftly to redress this problem by appropriating $51.42 billion for the Indian Health Service and $973.59 million for Urban Indian Health in the FY24 Interior, Environment, and Related Agencies Appropriations. NCUIH looks forward to working with you as you craft a budget that upholds the trust responsibility to urban Indians.

Resources

Bipartisan Group of Thirty-Eight Congressional Leaders Request Increased Resources for Urban Indian Health and Support Mandatory Funding for Indian Health in FY24

April 10, 2023/0 Comments/in Policy Blog/by Jeremy Grabiner

On March 24, 2023, 38 Congressional leaders requested up to $973.59 million for urban Indian health in FY24 and maintaining advance appropriations for the Indian Health Service (IHS) until mandatory funding is achieved.

Representatives Gallego and Grijalva again led a letter to Chairman Simpson and Ranking Member Pingree of the House Interior Appropriations Committee requesting up to $973.59 million for urban Indian health in FY24 and maintaining advance appropriations for IHS until authorizers move IHS to mandatory funding. The letter includes the Tribal Budget Formulation Workgroup (TBFWG)’s findings stating the need for full funding for the urban Indian line item, “Due to historically low funding levels for urban Indian health, UIOs are chronically underfunded. Full funding of UIOs will directly benefit urban Indians that rely on UIOs to access culturally-competent care.”

The National Council of Urban Indian Health (NCUIH) has made continuous efforts to address the health disparities for Natives living in urban areas. Following the pandemic, Native life expectancy has decreased by almost 7 years, coupled with the highest rates of diabetes, infant mortality, and suicide. Despite these staggering statistics, Congress funds the IHS at around 10% of need.

The 38 Congressional leaders stated their support for the Appropriations Committee’s work on the historic inclusion of advance appropriations in the FY23 omnibus. Previously, IHS was the only federal health care provider funded through annual appropriations. Without advance appropriations, IHS is subject to the negative impacts of government shutdowns and continuing resolutions that can lead to serious disruptions in UIO’s ability to provide critical patient services. The inclusion of advance appropriations is a crucial step toward ensuring long-term stable funding for IHS. The letter also emphasizes that the urban Indian line item must be protected from sequestration and any budget-cutting measures being considered in Congress.

This letter sends a powerful and straightforward message to Chairman Simpson and Ranking Member Pingree, and members of Congress that in order to fulfill the federal government’s trust responsibility to all Natives to provide safe and quality healthcare, funding for urban Indian health must be significantly increased and protected.

NCUIH is grateful for the support of the following Representatives:

Don Bacon
Nanette Barragán
Earl Blumenauer
Shontel Brown
Salud Carabjal
Greg Casar
Sharice Davids
Diana DeGette
Ruben Gallego
Steven Horsford
Jared Huffman
Pramila Jayapal
Dusty Johnson
William Keating
Ro Khanna
Teresa Leger Fernandez
Mike Levin
Zoe Lofgren
Doris Matsui
Gwen Moore
Eleanor Holmes Norton
Ilhan Omar
Mary Peltola
Brittany Pettersen
Deborah Ross
Adam Schiff
Kim Schrier
Terri Sewell
Adam Smith
Melanie Stansbury
Greg Stanton
Jill Tokuda
Gabe Vasquez
Jasmine Crockett
Chris Pappas
Raul Ruiz
Jesus “Chuy” Garcia
Raul Grijalva

Full Letter Text

Dear Chairman Simpson and Ranking Member Pingree,

We write to thank you for your proven commitment to urban Indian health and Urban Indian Organizations (UIOs) and to request you continue your support by funding urban Indian health at the highest level possible, up to $973.59 million, and retaining advance appropriations for IHS in the FY 2024 Interior, Environment, and Related Agencies Appropriations Act.

UIOs provide health care for the over 70% of American Indians and Alaska Natives (AI/ANs) living off-reservation and are an important part of the Indian health system, which oversees a three-prong system for the provision of health care: the Indian Health Service, Tribal Programs, and UIOs (I/T/U). UIOs receive direct funding only from the Urban Health line item and do not receive direct funds from other distinct IHS line items, including the Hospital and Health Clinics, Indian Health Care Improvement Fund, Health Education, Indian Health Professions, or any of the line items under the IHS Facilities account.

Our FY24 request for $973.59 million for urban Indian health reflects the recommendation made by the Tribal Budget Formulation Workgroup (TBFWG), which is comprised of sovereign Tribal leaders representing all twelve IHS service areas. For FY23, the House passed $200 million for urban Indian health, reflecting the minimum investment we must make in urban Indian health. The marked increase between the FY23 and FY24 request is a result of Tribal leaders’ decision, over several decades, to provide budget recommendations based on a plan to phase in full funding for IHS and UIOs over 10-12 years to address growing health disparities that have largely been ignored. In FY24, Tribal leaders are unified in their request to fully fund UIO need at $973.59 million.

In its report, the TBFWG states that, “Due to historically low funding levels for urban Indian health, UIOs are chronically underfunded. Full funding of UIOs will directly benefit urban Indians that rely on UIOs to access culturally-competent care.” If urban Indian health funding continues to be funded at its current pace, it will continue to contribute to the severe health disparities. Due to this fact, we respectfully request the highest possible funding for Urban Indian Health up to TBFWG’s recommendation of $973.59 million, and no less than the FY23 House passed level of $200 million.

Underfunding not only impacts day-to-day operations of the 41 UIOs, it has resulted in entire sections of the United States lacking in culturally focused healthcare for AI/ANs living in urban areas. Currently, the entire Eastern seaboard, with an estimated urban Indian population of over 2 million, lacks full-ambulatory UIOs due to insufficient funding. The IHS has deemed the two remaining UIOs on the East Coast to be outreach and referral providers only. Two outreach and referral UIOs to serve all urban Indian patients on the entire East Coast of the country is undeniably inadequate to uphold the federal trust obligation to provide healthcare to AI/ANs. Without a significant increase to the urban Indian line item, UIOs will continue to be forced to operate on limited budgets that offer almost no flexibility to expand services or address facilities-related costs.

We applaud this Committee for your work on the historic inclusion of advance appropriations in the FY23 Omnibus. This is a crucial step towards ensuring long-term, stable funding for IHS. Previously, the I/T/U system was the only major federal health care provider funded through annual appropriations. It is imperative that this Committee retain advance appropriations and ensure that IHS is protected from sequestration.

Cuts from sequestration force I/T/U providers to make difficult decisions about the scope of healthcare services they can offer to Native patients. For example, the $220 million reduction in IHS’ budget authority for FY 2013 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for AI/ANs. At a minimum, funding must be maintained and protected as budget-cutting measures are being considered.

We thank you for your consideration of our request to provide as high a funding level as possible for urban Indian health and the 41 Title V UIOs up to $973.59 million, and to retain advance appropriations for IHS in the FY 2024 Interior, Environment, and Related Agencies Appropriations Act.

NCUIH Calls for Full Funding and Increased Resources for Urban Indian Health in FY 2024 Written Testimony to House Appropriations Subcommittee

April 5, 2023/0 Comments/in Policy Blog/by Jeremy Grabiner

On March 23, 2023, The National Council of Urban Indian Health (NCUIH) submitted outside written testimony to the House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies regarding Fiscal Year (FY) 2024 funding for Urban Indian Organizations (UIOs). NCUIH advocated in its testimony for full funding for the Indian Health Service (IHS) and urban Indian health and increased resources for Native health programs.

In the testimony, NCUIH requested the following:

$51.42 billion for the Indian Health Service and $973.59 million for Urban Indian Health for FY24 (as requested by the Tribal Budget Formulation Workgroup)
Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
Permanent 100% Federal Medical Assistance Percentage for services provided at UIOs
Increase funding for Electronic Health Record Modernization
Increase funding to $30 million for Good Health and Wellness in Indian Country (GHWIC)
Ensure UIOs are appropriately included in grant programs relating to Indian health
Appropriate $80 million for the Native Behavioral Health Resources Program
Work with Authorizers to Reauthorize the Special Diabetes Program for Indians

Full Text of Testimony:

My name is Francys Crevier, I am Algonquin and the Chief Executive Officer of the National Council of Urban Indian Health (NCUIH), the national representative of urban Indian organizations receiving grants under Title V of the Indian Health Care Improvement Act (IHCIA) and the American Indians and Alaska Native (AI/ANs) patients they serve. On behalf of NCUIH and these 41 Urban Indian Organizations (UIOs), I would like to thank Chair Aderholt, Ranking Member DeLauro, and Members of the Subcommittee for your leadership to improve health outcomes for urban Indians. We respectfully request the following:

$51.42 billion for the Indian Health Service and $973.59 million for Urban Indian Health for FY24 (as requested by the Tribal Budget Formulation Workgroup)
Maintain Advance Appropriations for the Indian Health Service until Mandatory Funding is Enacted and protect IHS from sequestration
Permanent 100% Federal Medical Assistance Percentage for services provided at UIOs
Increase funding for Electronic Health Record Modernization
Ensure UIOs are appropriately included in grant programs relating to Indian health
Appropriate $80 million for the Native Behavioral Health Resources Program
Work with Authorizers to Reauthorize the Special Diabetes Program for Indians

We want to acknowledge that your leadership was instrumental in providing the greatest investments ever for Indian health and urban Indian Health, especially the inclusion of advance appropriations. It is important that we continue in this direction to build on our successes.

The Beginnings of Urban Indian Organizations

The Declaration of National Indian Health Policy in the Indian Health Care Improvement Act states that: “Congress declares that it is the policy of this Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.” In fulfillment of the National Indian Health Policy, the Indian Health Service funds three health programs to provide health care to AI/ANs: IHS sites, tribally operated health programs, and Urban Indian Organizations (referred to as the I/T/U system).

As a preliminary issue, “urban Indian” refers to any American Indian or Alaska Native (AI/AN) person who is not living on a reservation, either permanently or temporarily. UIOs were created in the 1950s by American Indians and Alaska Natives living in urban areas, with the support of Tribal leaders, to address severe problems with health, education, employment, and housing caused by the federal government’s forced relocation policies. Congress formally incorporated UIOs into the Indian Health System in 1976 with the passage of the Indian Health Care Improvement Act (IHCIA). Today, UIOs continue to play a critical role in fulfilling the federal government’s responsibility to provide health care for AI/ANs and are an integral part of the Indian health system. UIOs serve as a cultural hub for and work to provide high quality, culturally competent care to the over 70% of AI/ANs living in urban settings.

Request: $51.42 billion for Indian Health Service and $973.59 million for urban Indian health

The federal government owes a trust obligation to provide adequate healthcare to AI/ANs. It is the policy of the United States “to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to affect that policy.” This requires that funding for Indian health must be significantly increased if the federal government is to finally fulfill its trust responsibility. At a minimum, funding must be maintained and protected as budget-cutting measures are being considered.

We thus request Congress honor the Tribal Budget Formulation Workgroup (TBFWG) FY24 recommendations of $51.42 billion for IHS and $973.59 million for urban Indian health. That number is much greater than the FY23 enacted amounts of $6.9 billion for IHS and $90.4 million for urban Indian health. The significant difference between the enacted and requested amount underscores the need for Congress to significantly increase funding to IHS to meet the Indian Health System’s level of need. Additionally, IHS has been consistently underfunded in comparison to other major federal health agencies. In 2018, the Government Accountability Office (GAO-19-74R) reported that from 2013 to 2017, IHS annual spending increased by roughly 18% overall and approximately 12% per capita. In comparison, annual spending at the Veterans Health Administration (VHA), which has a similar charge to IHS, increased by 32% overall, with a 25% per capita increase during the same period. In fact, even though the VHA service population is only three times that of IHS, their annual appropriations are roughly thirteen times higher. In other words, it is imperative that Congress fully fund the IHS at the amount requested by the TBFWG to fulfill its trust responsibility and to improve health outcomes for AI/ANs no matter where they live.

The IHS is chronically underfunded, and the Urban Health line item historically is just one percent (1%) of that underfunded budget. UIOs receive direct funding only from the Urban Health line item and do not receive direct funds from other distinct IHS line items. As a result, in FY 2018 U.S. healthcare spending was $11,172 per person, but UIOs received only $672 per AI/AN patient from the IHS budget. Without a significant increase to the urban Indian line item, UIOs will continue to be forced to operate on limited budgets that offer almost no flexibility to expand services or address facilities-related costs. For example, one UIO, Native American Lifelines, is made up of two programs that run in both Boston and Baltimore with an annual budget of just $1.6 million for a service population of over 55,000 people.

Despite this underfunding, UIOs have been excellent stewards of the funds allocated by Congress and are effective at ensuring that increases in appropriations correlate with improved care for their communities. Last Congress, with the help of this committee, the Infrastructure Investment and Jobs Act now allows UIOs to utilize their existing IHS contracts to upgrade their facilities. With funding increases from this Committee and this new allowance, six UIOs opened new facilities in the past year, and an additional 16 UIOs have plans to open new facilities in the next two years. The increased investments in urban Indian health by this committee will continue to result in the expansion of health care services, increased jobs, and improvement of the overall health in our communities.

Request: Maintain Advance Appropriations for IHS Until Mandatory Funding Is Enacted

We applaud Chair Baldwin and this Committee for your work on the historic inclusion of advance appropriations in the FY23 Omnibus. This is a crucial step towards ensuring long-term, stable funding for IHS. Previously, the I/T/U system was the only major federal health care provider funded through annual appropriations. It is imperative that this Committee retain advance appropriations and ensure that IHS is protected from sequestration.

The GAO cited a lack of consistent funding as a barrier for IHS. The Congressional Research Service stated that advance appropriations would lead to cost savings as continuing resolutions (CRs) “prohibits the agency from making longer-term, potentially cost-saving purchases.” Advance appropriations will improve accountability and increase staff recruitment and retention at IHS. When IHS distributes their funding on time, our UIOs can pay their doctors and providers. During a pandemic that has ravaged Indian Country and devasted the workforce, being able to recruit doctors and pay them on time is a top priority.

While advance appropriations are a step in the right direction to avoid disruptions during government shutdowns and continuing resolutions (CRs), mandatory funding is the only way to assure fairness in funding and fulfillment of the trust responsibility. Until authorizers act to move IHS to mandatory funding, we request that Congress continue to provide advance appropriations to the Indian health system to improve certainty and stability.

Cuts from sequestration force I/T/U providers to make difficult decisions about the scope of healthcare services they can offer to Native patients. For example, the $220 million reduction in IHS’ budget authority for FY 2013 resulted in an estimated reduction of 3,000 inpatient admissions and 804,000 outpatient visits for AI/ANs. Therefore, we request that you exempt IHS from sequestration and other budget cutting measures as is required by the trust responsibility.

Request: Work with Authorizers for Permanent 100% Federal Medical Assistance Percentage (FMAP) for services provided at UIOs

The federal medical assistance percentage (FMAP) refers to the percentage of Medicaid costs covered by the federal government and reimbursed to states. With states already receiving 100% FMAP for services provided at IHS and Tribal facilities, the American Rescue Plan Act (ARPA) temporarily shifted the responsibility of UIO Medicaid cost obligation from state governments to the federal government. This provision finally brought a form of parity to UIOs by setting FMAP for Medicaid services provided at UIOs at 100% for eight fiscal quarters, while offering cost savings to states, and finally creating a sense of consistency in how the federal government honors its obligations to urban Native healthcare. The provision expires this month on March 31, 2023. During this short provision, states have been able to work with UIOs to provide increased funding to help begin construction of a new clinic, youth services center, and establish a new behavioral health unit.

Permanent 100% FMAP will bring some fairness to the I/T/U system and increase available financial resources to UIOs and support them in addressing critical health needs of urban Native patients. Again, we request that the committee work with authorizers for permanent 100% FMAP.

Request: Increase Funding for Electronic Health Record Modernization

We request your support for the Indian Health Service’s (IHS) transition to a new electronic health record (EHR) system for IHS and UIOs. UIOs have expended significant funds for the replacement, upgrade and maintenance of IHS’ Health Information Technology (HIT) systems due to the federal government’s failure to keep pace with HIT development in the wider healthcare industry. This has resulted in UIOs having no choice but to purchase expensive off-the-shelf-replacement systems to ensure that they can continue to provide high-quality and culturally-focused health care to AI/AN patients. As EHR modernization moves from planning to fruition, it is critically important that appropriations continue to increase, and any language included in appropriations must allow funding to be used to reimburse Tribal Organizations and UIOs associated with the cost of EHR modernization. NCUIH requests the committee to support this transition by supporting the President’s budget request of $913 million in FY24 appropriations.

Request: Ensure UIOs are appropriately included in grant programs relating to Indian health

Failure to explicitly include UIOs in legislative programmatic authorizations often effectively prohibits UIOs from accessing the related funding, even if the exclusion was unintentional and UIOs would otherwise be an appropriate addition to program eligibility. UIOs are already severely underfunded and rely on grant funding to support the provision of life-saving services to their patients. Excluding UIOs from grant funding reduces the ability of UIOs to provide and expand service options for their patients. For example, UIOs are left out of statutory language in the nationalization of the Community Health Aide Program (CHAP), which is meant to increase the availability of healthcare workers in Native communities. Because of this legislative oversight, IHS interprets this as UIOs are not eligible to participate in the program, and therefore UIOs cannot utilize the program to ease the burden caused by limited provider availability for the Indian Health System.

Many programs in the Health and Human Services appropriations bills include language for Indian Tribes and Tribal organizations, but not for urban Indian organizations. Urban Indian Organizations are not considered Tribal organizations, which is a common misconception. While UIOs may fall within general terms such as “non-profit organization,” there are times when a general grant to non-profits is not appropriate, but a grant to UIOs would be. For example, if the grant is intended to serve Indian Healthcare facilities, including UIOs in grant funding would be appropriate, while including non-profit organizations generally would not be. Therefore, it is essential that you explicitly include UIOs when they intend UIOs to be included in the program. We request that any addition of UIOs to a program should include a corresponding appropriation increase to ensure that funding for Tribes and Tribal Organizations are not reduced. We emphasize that we acknowledge and respect the government-to-government relationship between Tribes and the United States and understand that there are times when it is not appropriate to add UIOs into legislation directed at Tribes and Tribal Organizations.

Request: Appropriate $80 Million for the Native Behavioral Health Resources Program

Native people continue to face high rates of behavioral health issues caused by generational trauma and federal policies. Native people experience serious mental illnesses at a rate 1.58 times higher than the national average, and high rates of alcohol and substance abuse. In fact, between 1999 and 2015, the drug overdose death rates for Native populations increased by more than 500%. Native youth also experience the highest rates of suicide and depression, with the Native youth suicide rate being 2.5 times that of the national average.

In response to these chronic health disparities, Congress authorized $80 million to be appropriated for the Native Behavioral Health Resources Program for fiscal years 2023 to 2027. Despite authorizing an appropriation of $80 million for the Program, Congress did not appropriate that sum for FY 23.

We request that the authorized $80 million be appropriated to the Native Behavioral Health Resources Program for FY 24 and each of the remaining authorized years. Until the committee appropriates funding for this program, critical healthcare programs and services cannot operate to their full capability, putting Native lives at-risk. We ask that this essential step is taken to ensure our communities have access to the care they need.

Request: Work with Authorizers to Re-authorize the Special Diabetes Program for Indians (SDPI)

SDPI’s integrated approach to diabetes healthcare and prevention programs in Indian country has become a resounding success and is one of the most successful public health programs ever implemented. SDPI has demonstrated success with a 50% reduction in diabetic eye disease rates, drops in diabetic kidney failure, and 50% decline in End Stage Renal Disease. Additionally, the reduction in end stage renal disease between 2006 and 2015 led to an estimated $439.5 million dollars in accumulated savings to the Medicare program, 40% of which, of $174 million, can be attributed to SDPI.

Currently, 31 UIOs are in this program and are at the forefront of diabetes care. Facilities use these funds to offer a wide range of diabetes treatment and prevention services, including but not limited to exercise programs and physical activity, nutrition services, community gardens, culinary education, physical education, health, and wellness fairs, culturally-relevant nutrition assistance, food sovereignty education, group exercise activities, green spaces, and youth and elder-focused activities.

With the program set to expire this year, we request that the committee work with authorizers to permanently reauthorize SDPI at a minimum of $250 million requested in the President’s FY24 budget with automatic annual funding increases tied to the rate of medical inflation, to continue the success of preventing diabetes-related illnesses for all Indian Country.

Conclusion

These requests are essential to ensure that urban Indians are appropriately cared for, in the present and in future generations. The federal government must continue to work towards its trust and treaty obligation to maintain and improve the health of American Indians and Alaska Natives. We urge Congress to take this obligation seriously and provide UIOs with all the resources necessary to protect the lives of the entirety of the Native population, regardless of where they live.

President Biden Continues to Demonstrate Strong Commitment to Urban Indians, Proposes a 27% Increase for Urban Indian Health for FY 2024

April 3, 2023/0 Comments/in Policy Blog/by Jeremy Grabiner

The FY 2024 budget request includes $115 million for urban Indian health, a 27% increase over the FY 2023 enacted amount, mandatory funding through FY 2033, and an IHS exemption from sequestration.

On March 17, 2023, the Indian Health Service (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. The President’s proposal included a total $144.3 billion in discretionary funding for the Department of Health and Human Services (HHS) and $9.7 billion in total funding for IHS— which maintains the $5.1 billion in advance appropriations enacted in the FY 2023 omnibus and includes $1.6 billion in proposed mandatory funding for Contract Support Costs, Section 105(l) Leases, and the Special Diabetes Program for Indians.

The budget proposes full 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.”

Line Item	FY22 Enacted	FY23 Enacted	FY24 Tribal Request	FY24 President’s Budget
Urban Indian Health	$73.43 million	$90.42 million	$973.6 million	$115 million
Indian Health Service	$6.6 billion	$6.9 billion	$51.4 billion	$9.7 billion
Advance Appropriations	———————	$5.13 billion	———————	———————
Hospitals and Clinics	$2.3 billion	$2.5 billion	$12.2 billion	$3.5 billion
Tribal Epidemiology Centers	$24.4 million	$34.4 million	——————–	$34.4 million
Electronic Health Record System	$145 million	$217.5 million	$491.9 million	$913.1 million
Community Health Representatives	$63.6 million	$65.2 million	$1.2 billion	$74.5 million
Mental Health	$121.9 million	$127.1 million	$3.4 billion	$163.9 million
Cancer Moonshot Initiative	———————	———————	———————	$108 million
HIV & Hepatitis	———————	———————	———————	$47 million

The National Council of Urban Indian Health (NCUIH) requested full funding for urban Indian health for FY 2024 at $973.59 million and at least $51.42 billion for IHS in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. The marked increase for FY 2024 is due to Tribal leaders’ budget recommendations to address health disparities that have historically been ignored. The Congressional Justification states the importance of addressing these disparities, “The COVID-19 experience in Indian Country illustrates the urgent need for large-scale investments to improve the overall health status of AI/ANs and ensure that the disproportionate impacts experienced during the pandemic are never repeated.”

Overview of Budget

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

$9.7 billion for IHS for FY 2024
$115 million for urban Indian health for FY 2024
$5.1 billion in Advance Appropriations for FY 2024
$1.2 billion in mandatory funding for Contract Support Costs
$153 million in mandatory funding for Section 105(l) Leases
$250 million in mandatory funding for Special Diabetes Program for Indians (SDPI)

Other Budget Highlights

Addressing Targeted Public Health Challenges
- $47 million for HIV and Hepatitis C.
  - UIOs eligible
- $3 million for improving maternal health.
  - UIOs eligible
- $9 million for addressing opioid use.
  - UIOs eligible
Cancer Moonshot Initiative
- $108 million
  - 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
Division of Telehealth
- $10 million
  - Manages and oversees a comprehensive telehealth program at IHS that will expand telehealth services, develop governance structures, provide training to users, and integrate with clinical services.
Division of Graduate Medical Education
- $4 million
  - Expands and supports Graduate Medical Education programs to create a pathway for future physicians to address longstanding vacancy issues at IHS.
Indian Health Professions
- $13 million
  - Offers additional IHS Scholarship and Loan Repayment awards, bolstering recruitment and retention efforts through these two high demand programs.
    - UIOs eligible

Legislative Proposal

Once again, the legislative proposal to amend federal law to permit the U.S. Public Health Service Commissioned Officers to be detailed to UIOs was proposed. This amendment to the Public Health Service Act would provide IHS the discretionary authority to detail officers directly to an UIO to perform work related to the functions of HHS.

Currently, there are 1,614 officers of the U.S. Public Health Service assigned to IHS. There are only 5 of these officers who are assigned to States, who have duty stations at UIOs.

The permittance of officers to be detailed directly to UIOs addresses the staff shortage that hinders the capacity of UIOs to improve access to health care for urban Natives. The strengthening of the IHS workforce will contribute to better health outcomes and reduce disparities.

Background and Advocacy

On March 9, 2023, President Biden released his budget request for Fiscal Year 2024, pending the more detailed IHS budget request released on March 17, including the funding recommendation for urban Indian Health.

On March 9, 2023, NCUIH Chief Executive Officer, 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 for UIOs. NCUIH requested funding in accordance with the requests of the TBFWG at funding levels of $973.59 million for urban Indian health and $51.42 billion for IHS, maintain advance appropriations until mandatory funding is achieved, and appropriate $8o million the Native Behavioral Health Resources Program. On March 24, NCUIH sent a letter to House Appropriations leadership, Chair Kay Granger and Raking Member Rosa DeLauro, reiterating these requests

Next Steps

The Appropriations Committees will review the President’s Budget for consideration as they craft their bills for FY 2024. NCUIH will continue to work with the Biden Administration and Congress to push for full funding of urban Indian health in FY 2024.

NCUIH to Testify Before House Interior Appropriations

March 7, 2023/0 Comments/in Policy Blog/by Mary Jomia

On Thursday, March 9, 2023 at 9:00 AM, the National Council of Urban Indian Health (NCUIH) Chief Executive Officer, Francys Crevier, JD (Algonquin) will testify in person before the House Interior Appropriations Subcommittee hearing as part of American Indian and Alaska Native Public Witness Days (March 8 and 9, 2023).

In the testimony, NCUIH will advocate for full funding for the Indian Health Service and Urban Indian Health as requested by the Tribal Budget Formulation Workgroup (TBFWG) for Fiscal Year (FY) 2024. Other requests include: maintaining advance appropriations for IHS until mandatory funding is enacted and appropriating at least $80 million for the Native Behavioral Health Resources Program.

Tune in!

Livestream

Learn more: https://appropriations.house.gov/events/hearings

Tag Archive for: Advance Appropriations

Next Steps

Background

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

Establishment of a UIO Interagency Workgroup

Background and Advocacy

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

Bill Highlights

Indian Health Service: $7.27 billion

Urban Indian Health: $92.4 million

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

Dental Health: $254.7 million

Equipment: $32.59 million

Electronic Health Records: $217.6 million

Mental Health: $130.2 million

Alcohol and Substance Abuse: $266.8 million

Produce Prescription Pilot Program: $2.5 million

Maternal Health: $8 million

Alzheimer’s Disease: $5.5 million

Purchased and Referred Care: $997.8 million

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.

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

Background and Advocacy

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

Bill Highlights

Indian Health Service: $7.078 billion

Urban Indian Health: $115 million

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

Dental Health: $288 million

Equipment: $42 million

Electronic Health Records:

Mental Health: $130 million

Alcohol and Substance Abuse: $276 million

Produce Prescription Pilot Program: $6 million

Tribal Epidemiology Centers: $35 million

Maternal Health: $10 million

Alzheimer’s Disease: $6 million

Updates from IHS and Director Tso

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

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

Senator Murray Remarked on the Importance of Committing to Federal Investments

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

Full Letter Text

UIOs Play a Critical Role in Providing Health Care for AI/ANs

Need for Full Funding of the Indian Health System including Urban Indian Health

Retain Advance Appropriations for IHS until Mandatory Funding is Enacted and Protect IHS from Sequestration

Appropriate $80 Million for the Native Behavioral Health Resources Program

Conclusion

Resources

Full Letter Text

In the testimony, NCUIH requested the following:

Full Text of Testimony:

We want to acknowledge that your leadership was instrumental in providing the greatest investments ever for Indian health and urban Indian Health, especially the inclusion of advance appropriations. It is important that we continue in this direction to build on our successes.

The Beginnings of Urban Indian Organizations

Request: $51.42 billion for Indian Health Service and $973.59 million for urban Indian health

Request: Maintain Advance Appropriations for IHS Until Mandatory Funding Is Enacted

Request: Work with Authorizers for Permanent 100% Federal Medical Assistance Percentage (FMAP) for services provided at UIOs

Request: Increase Funding for Electronic Health Record Modernization

Request: Ensure UIOs are appropriately included in grant programs relating to Indian health

Request: Appropriate $80 Million for the Native Behavioral Health Resources Program

Request: Work with Authorizers to Re-authorize the Special Diabetes Program for Indians (SDPI)

Conclusion

The FY 2024 budget request includes $115 million for urban Indian health, a 27% increase over the FY 2023 enacted amount, mandatory funding through FY 2033, and an IHS exemption from sequestration.

Overview of Budget

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

Other Budget Highlights

Legislative Proposal

Background and Advocacy

Next Steps