Tag Archive for: Advance Appropriations

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

/0 Comments/in /by

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.

Resources 

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

/0 Comments/in /by

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

/0 Comments/in /by

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:

  1. Don Bacon
  2. Nanette Barragán
  3. Earl Blumenauer
  4. Shontel Brown
  5. Salud Carabjal
  6. Greg Casar
  7. Sharice Davids
  8. Diana DeGette
  9. Ruben Gallego
  10. Steven Horsford
  11. Jared Huffman
  12. Pramila Jayapal
  13. Dusty Johnson
  14. William Keating
  15. Ro Khanna
  16. Teresa Leger Fernandez
  17. Mike Levin
  18. Zoe Lofgren
  19. Doris Matsui
  20. Gwen Moore
  21. Eleanor Holmes Norton
  22. Ilhan Omar
  23. Mary Peltola
  24. Brittany Pettersen
  25. Deborah Ross
  26. Adam Schiff
  27. Kim Schrier
  28. Terri Sewell
  29. Adam Smith
  30. Melanie Stansbury
  31. Greg Stanton
  32. Jill Tokuda
  33. Gabe Vasquez
  34. Jasmine Crockett
  35. Chris Pappas
  36. Raul Ruiz
  37. Jesus “Chuy” Garcia
  38. 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

/0 Comments/in /by

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

/0 Comments/in /by
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

/0 Comments/in /by

NCUIH to Testify Before House Interior Appropriations

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

NCUIH Releases “2022 Annual Policy Assessment”

/0 Comments/in /by

The Policy assessment informs urban Indian organization policy priorities in 2023, identifies traditional healing barriers, and addresses mental and behavioral health needs.

2022 Policy Assessment thumbnailThe National Council of Urban Indian Health (NCUIH) is pleased to announce the release of its 2022 Annual Policy Assessment. NCUIH hosted five focus groups to identify Urban Indian Organization (UIO) policy priorities for 2023, as they relate to the Indian Health Service (IHS) designated facility types (full ambulatory, limited ambulatory, outreach and referral, and outpatient and residential). The focus groups were held on October 18, 21, and 24, 2022. Additional information was also collected from the UIOs via a questionnaire sent out on November 15, 2022.

Together these tools allow NCUIH to work with UIOs to identify policy priorities in 2023 and identify barriers that impact delivery of care to Native patients and their communities.  Of 41 UIOs, 26 attended the focus groups and/or participated in the questionnaire. This is the third year that NCUIH has conducted the assessment via focus groups and follow up questionnaire. This is also the highest response from UIOs NCUIH has seen since following this process.

Read the 2022 Policy Assessment

Overview of Policy Assessment

2022 Policy Assessment chartAfter the height of the COVID-19 pandemic, newfound priorities were identified for 2023, including workforce development and retention, increased funding for traditional healing, and expanded access to care and telehealth services. Existing priorities also remain a key focus across UIOs, especially increasing funding amounts for the urban Indian health line item and IHS, maintaining advance appropriations for IHS, establishing permanent 100% Federal Medical Assistance Percentage (FMAP) for UIOs, reauthorizing the Special Diabetes Program for Indians (SDPI), and increasing behavioral health funding.

 

Key findings from the discussions are as follows:

  • Funding Flexibility is Key to Expanding Services
  • Need for Funding Security Remains a Priority
  • Advance Appropriations Mitigates Funding Insecurities Generated by Government Shutdowns and Continuing Resolutions
  • Facility Funding Directly Impacting UIOs
  • Permanent 100% FMAP Increases Available Financial Resources to UIOs
  • Workforce Concerns Amidst Inflation and Market Changes
  • Traditional Healing Crucial to Advance Comprehensive Native Healthcare
  • Addressing Access and Quality of Native Veteran Care
  • Health Information Technology and Electronic Health Record Modernization
  • New Barriers Limit UIO Distribution of Vaccines
  • HIV, Behavioral Health, and Substance Abuse Report
  • Reauthorizing the Special Diabetes Program for Indians
  • UIOs Find Current NCUIH Services Beneficial

Next Steps

NCUIH will release a comprehensive document of the 2023 Policy Priorities in the coming weeks.

Past Resources:

Final FY2023 Omnibus Bill Includes Advance Appropriations for the Indian Health Service and Several Other Priorities

/0 Comments/in /by
The bill includes $6.96 billion for IHS and $90.42 million for urban Indian health.

On December 29, 2022, the Consolidated Appropriations Act, 2023 (H.R. 2617) for fiscal year (FY) 2023, also known as the ‘omnibus,’ was signed into law by President Biden. This follows a third continuing resolution for FY2023 through December 30. The bill passed in the Senate with a 68-29 vote followed by a House passage of a 221-205-1 vote. The 4,155-page omnibus bill authorizes $6.96 billion for the Indian Health Service (IHS) for FY 2023, a $360 million increase above the FY 2022 enacted level; advance appropriations for IHS totaling $5.13 billion for FY 2024; and $90.42 million for urban Indian health for FY 2023. In addition, the final package includes increased funding to expand behavioral health services and programs eligible to urban Indian organizations (UIOs).

The National Council of Urban Indian Health (NCUIH) has long advocated for larger investments in American Indian and Alaska Native (AI/AN) health care and has called on Congress to strengthen its commitment to Indian Country with increased funding in the FY 2023 appropriations. Unfortunately, despite robust NCUIH advocacy, the bill does not include an extension of 100% Federal Medical Assistance Percentage (FMAP) for UIOs or an Urban Confer policy with the Department of Health and Human Services (HHS). NCUIH will continue to advocate for these priorities in future legislation.

The Tribal Budget Formulation Workgroup (TBFWG), a national workgroup that identifies annual Tribal funding priorities, requested full funding for IHS at $49.9 billion and $949.9 million for urban Indian health. While the bill provides a key Indian Country request for advance appropriations for IHS, unfortunately, the final amount still falls short of fully funding IHS so that the agency can properly provide health care services for all AI/ANs.

To read NCUIH’s joint press release with the National Indian Health Board (NIHB) and the National Congress of American Indians (NCAI) on the inclusion of IHS advance appropriations in the omnibus, click here.

Bill Text:
Overview of IHS and Urban Indian Health Requests
Line Item FY22 Enacted FY23 TBFWG Request FY23
President’s
Budget		 FY23
House Passed		 FY23 Senate Proposed FY23 Omnibus
Urban Indian Health $73.43 million $949.9 million $112.5 million $200 million $80.4 million $90.4 million
Indian Health Service $6.6 billion $49.8 billion $9.3 billion – Mandatory funding* $8.1 billion $7.38 billion $6.9 billion
Advanced Appropriations ——————- ———————- ————— —————- $5.6 billion $5.1 billion
Hospitals and Clinics $2.3 billion $8.66 billion $3.4 billion $2.8 billion $2.8 billion $2.5 billion
TECs $24.4 million $24.4 million $24.8 million $34.4 million $34.4 million $34.4 million
EHRs $145 million $451 million $284.5 million $284.5 million $217.5 million $217.5 million
CHRs $63.6 million $1.4 billion $68.8 million $65.2 million $67 million $65.2 million
Direct Operations $95 million $98.4 million $115.4 million $135.4 million $103.8 million $103.8 million
Mental Health $121.9 million $3.9 billion $199.1 million $130 million $127.1 million $127.1 million
BIA MMIW $24.9 million ——————– ————— $25.1 million $25.1 million $25.1 million
Key Provisions for IHS, Tribal Organizations, and UIOs
  • $6.9 billion for IHS for FY 2023
  • $90.4 million for urban Indian health for FY 2023
  • $5.1 billion for Advance Appropriations for FY 202
  • $24 million for the Good Health and Wellness in Indian Country Program
  • $15.6 million to make payments under the National Health Service Corps Loan Repayment program
  • $80 million authorized to be appropriated through FY2023-FY2027 for Native Behavioral Health Access Grants
  • Reauthorizes and establishes scheduled funding increases for the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and doubles the Tribal set-aside from 3% to 6% for the Tribal Home Visiting Program
  • Fully funds Contract Support Costs and Payments for Tribal Leases
Analysis

Urban Indian Health

  • $90,419,000 for urban Indian health for FY 2023

Indian Health Service

  • $5,129,458,000 in advance appropriations for IHS for FY 2024
  • $6,958,223,000 in agency funding for IHS in FY 2023
    • Indian Health Services – $4,890,282,000
  • Hospitals and Health Clinics – $2,503,025,000
  • Tribal Epidemiology Centers (TECs) – $34,400,000
  • Electronic Health Records (EHRs) – $217, 564,000
  • Community Health Representative (CHRs) – $65,212,000
  • Mental health – $127,171,000
  • Direct Operations – $103,805,000
  • Indian Health Care Improvement Fund – $74,138,000
  • Indefinite appropriation to fully fund Contract Support Costs at $969,000,000 for FY 2023
  • Indefinite appropriation to fully fund payments for 105(l) leases at $111,000,000 for FY 2023
  • Funds Indian Health Facilities at $958,553,000

Health and Human Services (HHS)
Health Resources and Services Administration (HRSA)

  • Native Hawaiian Health Care
    • $27,000,000
  • National Health Service Corps (NHSC)
    • $15,600,000 to Indian Health Service facilities, Tribally Operated Health Programs, and Urban Indian Health Programs to make payments under the NHSC loan repayment program.
  • Center of Excellence for Eating Disorders – Screening and Referrals
    • $1,000,000 through FY 2027
      • Funding for training and technical assistance to primary and behavioral health providers and non-clinical community support workers to identify treatment and provide ongoing support to individuals with eating disorders

Centers for Disease Control and Prevention (CDC)

  • Good Health and Wellness in Indian Country (GHWIC)
    • $24,000,000
  • Minority HIV/AIDS Prevention and Treatment Program
  •  $5,000,000 Tribal set-aside under the Minority HIV/AIDS Prevention and Treatment Program

Important Behavioral and Mental Health Provisions (Restoring Hope For Mental Health And Wellbeing)

  • Medication-Assisted Treatment for Prescription Drug and Opioid Addiction
    • $14,500,000
  • Peer-Supported Mental Health Services
    • $13,000,000 for each of fiscal years 2023 through 2027
      • A new grant program with direct UIO eligibility
  • Infant and Early Childhood Mental Health Promotion, Intervention and Treatment
    • $50,000,000 for fiscal years 2023 through 2027
  • Behavioral Health and Substance Use Disorder Resources for Native Americans
    • $80,000,000
    • Ensures HHS consult with Indian Tribes and Tribal organizations, confer with UIOs, and engage with Native Hawaiian health organization regarding the administration of funding
  • Mental and Behavioral Health Education and Training Grants
    • $31,700,000 for each fiscal year 2023-2027
      • The training demonstration has I/T/U eligible entities
  • State Opioid Response (SOR) Grants
    • $55,000,000
    • UIOs not eligible
  • Tribal Behavioral Health grant (formally known as Native Connections)
  • Reauthorized for fiscal years 2023 through 2027

Bureau of Indian Affairs (BIA)

  • Missing and Murdered Indigenous Women (MMIW)
    • $24,898,000 for Law Enforcement Special Initiatives, of which an additional $5,000,000 is to continue addressing the MMIW effort
  • Mental Health and Suicide Prevention Outreach to Minority Veterans and American Indian and Alaska Native Veterans
    • that each VA medical center has a full-time minority veteran coordinator who must receive training in the delivery of culturally appropriate mental health and suicide prevention services to AI/AN veterans
  • Tribal Home Visiting Program and Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV)
    • Reauthorizes and establishes scheduled funding increases for the MIECHV and doubles the set-aside from 3% to 6% for the Tribal Home Visiting Program
    • $500,000,000 starting grant base in FY23, scheduled funding increases of $50,000,000 through FY 2027
  • Native Boarding School Initiative
    • $19,409,000 is for Assistant Secretary support, which maintains funding to implement the PROGRESS Act, the Diversity and Inclusion program for BIA and OST, and the Native boarding school initiative
  • Violence Against Women Act (VAWA) – $25,000,000
    • $500,000 is for a national clearinghouse that provides training and technical assistance on issues relating to sexual assault of AI/AN women
    • $11,000,000 is to assist tribal exercising special Tribal criminal jurisdiction
    • $3,000,000 is for an initiative to support cross-designation of Tribal prosecutors as Tribal Special Assistant United States Attorneys
Topic Section Funding Language
Urban Indian Health Urban Indian Health $90,419,000 Pg. 69
“The agreement includes $90,419,000 for the Urban Indian health program, which includes the reallocation of former NIAAA funds.”
Indian Health Service (IHS) Advanced Appropriations $5,129,458,000 Pg.67
‘The agreement provides advance appropriations for the Indian Services and Indian Health Facilities accounts totaling $5,129,458,000 for fiscal year 2024.”
IHS Funding $6,958,233,000 Pg.67:  
“The bill provides a total of $6,958,223,000 for the Indian Health Service (IHS )”
Indian Health Services $4,890,282,000 Pg.67:  
“The bill provides a total of $6,958,223,000 for the Indian Health Service (IHS ), of which $4,890,282,000 is for the Services account”
Hospitals and Clinics $2,503,025,000 Pg.68
“The agreement provides $2,503,025,000 for Hospitals and Health Clinics, which includes an additional $10,000,000 for Tribal epidemiology centers, $2,000,000 for village built clinics, and an additional $1,000,000 to improve maternal health. This amount also includes requested reallocation of prior year staffing funds for the Phoenix Indian Medical Center, Cherokee Nation, and United Keetoowah Band. The agreement maintains funding at fiscal year 2022 enacted levels for the Alzheimer’s program and Produce Prescription Pilot program. The agreement also continues funding at the fiscal year 2022 enacted levels for the domestic violence prevention program, accreditation emergencies as discussed in the House report, health information technology, healthy lifestyles in youth project, and the National Indian Health Board cooperative agreement.”
TECs $34,433,361 Pg. 68
“The agreement provides $2,503,025,000 for Hospitals and Health Clinics, which includes an additional $10,000,000 for Tribal epidemiology centers, $2,000,000 for village built clinics, and an additional $1,000,000 to improve maternal health.”
EHRs $217,564,000 Pg. 69
“The agreement provides $217,564,000 for Electronic Health Records (EHR), which includes an increase for uses as requested.”
CHRs $65,212,000 Pg. 274: See Chart for Language
Mental Health $127,171,000 Pg. 69
“The bill provides $127,171,000 for Mental Health, which continues funding at fiscal year 2022 enacted levels for the behavioral health integration initiative, for suicide prevention, and for the Tele-behavioral Health Center of Excellence and includes the requested reallocation of staffing funds”
Direct Operations $103,805,000 Pg. 70
“The bill provides $103,805,000 for direct operations, which includes an increase of $5,000,000 for quality and oversight, for uses as requested, and an increase of $1,000,000 for management and operations.”
Indian Health Care Improvement Fund $74,138,000 Pg. 274: See Chart for Language
Contract Support Costs $969,000,000 Pg. 70:
“The bill continues language from fiscal year 2022 providing an indefinite appropriation to fully fund contract support costs, which are estimated to be $969,000,000 in fiscal year 2023.”
105(l) leases $111,000,000 Pg. 74:
“The bill continues language from fiscal year 2022 providing an indefinite appropriation to fully fund payments for Tribal leases, which are estimated to be $111,000,000 in fiscal year 2023.”
Indian Health Facilities $958,553,000 Pg. 70
“The bill provides $958,553,000 for Indian Health Facilities.
Costs for accreditation emergencies and supplementing activities funded under the heading ‘‘Indian Health Facilities’’ $58,000,000 Pg.878:
“That of the funds provided, $58,000,000 shall be for costs related to or resulting from accreditation emergencies, including supplementing activities funded under the heading ‘‘Indian Health Facilities,’’ of which up to $4,000,000 may be used to supplement amounts otherwise available for Purchased/
Referred Care”
Health and Human Services (HHS) HRSA—
Hawaiian Health Care Program		 $27,000,000 Pg.10
The agreement includes no less than $27,000,000 for the Native Hawaiian Health Care Program, of which not less than $10,000,000 shall be provided to Papa Ola Lokahi for administrative purposes authorized under 42 U.S.C. 11706, including to expand research and surveillance related to the health status of Native Hawaiians and strengthen the capacity of the Native Hawaiian Health Care Systems.”
HRSA—
NHSC Loan Repayment Program		 $15,600,000 Pg. 991:
“That, within the amount made available in the previous provison, $15,600,000 shall remain available until expended for the purposes of making payments under the NHSC Loan Repayment Program under section 338B of the PHS Act to individuals participating in such program who provide primary health services in Indian Health Service facilities, Tribally-Operated 638 Health Programs, and Urban Indian Health Programs (as those terms are defined by the Secretary), notwithstanding the assignment priorities and limitations under section 333(b) of such Act”
CDC—
Good Health and Wellness in Indian Country		 $24,000,000 Pg. 33: See Chart for Language
CDC—
Minority HIV/AIDS Prevention and Treatment Program		 $5,000,000 Pg.130
Tribal Set-aside.-The agreement includes an increase of $2,000,000 for a Tribal set-aside within the Minority HIV/AIDS Prevention and Treatment program.
Important Behavioral and Mental Health Provisions (Restoring Hope For Mental Health And Wellbeing) Medication-Assisted Treatment for Prescription Drug and Opioid Addiction $14,500,000 Pg. 104
“The agreement directs SAMHSA to ensure that these grants include as an allowable use the support of medication-assisted treatment and other clinically appropriate services to achieve and maintain abstinence from all opioids, including programs that offer low-barrier or same day treatment options. Within the amount provided, the agreement includes $14,500,000 for grants to Indian Tribes and Tribal Organizations.”
Peer-Supported Mental Health Services $13,000,000
for FY23-FY27		 Pg. 3067
“There is authorized to be appropriated to carry out this section $13,000,000 for each of fiscal years 2023 through 2027.’’
Infant and Early Childhood Mental Health Promotion, Intervention and Treatment $50,000,000
for FY23-FY27		 Pg. 3177
“in subsection (g) (as redesignated by paragraph (1)), by striking ‘‘$20,000,000 for the period of fiscal years 2018 through 2022’’ and inserting ‘‘$50,000,000 for the period of fiscal years 2023 through 2027’’.
Behavioral Health and Substance Use Disorder Resources for Native Americans $80,000,000
for FY23-FY27		 Pg. 3072
“There are authorized to be appropriated to carry out this section, $80,000,000 for each of fiscal years 2023 through 2027.’’
Mental and Behavioral Health Education and Training Grants $31,700,000
for FY23-FY27		 Pg. 3171
‘‘$10,000,000 for each of fiscal years 2018 through 2022’’  and $31,700,000 for each of fiscal years 2023 through 2027”
State Opioid Response (SOR) Grants $55,000,000 Pg. 1016:
“That of such amount $55,000,000 shall be made available to Indian Tribes or tribal organizations”
Tribal Behavioral Health grant (formally known as Native Connections) Reauthorized Pg. 3044:
“PRIORITY MENTAL HEALTH NEEDS OF REGIONAL AND NATIONAL SIGNIFICANCE.—Section 520A of the Public Health Service Act (42 U.S.C. 290bb–32) is
amended […](2) in subsection (f), by striking ‘‘$394,550,000 for each of fiscal years 2018 through 2022’’ and inserting ‘‘$599,036,000 for each of fiscal years 2023 through 2027’’.”
Bureau of Indian Affairs (BIA) and Bureau of Indian Education at the Department of the Interior (DOI) for Law Enforcement Special Initiatives – MMIW Effort $25,094,000 Pg.37
“The agreement includes $25,094,000 for Law Enforcement Special Initiatives, which continues funding at enacted levels for the MMIW Tribal Public Safety initiative, Tiwahe recidivism initiative, equipment to collect and preserve evidence at crime scenes, and victim witness specialists.”
Native Boarding School Initiative $19,409,000 Pg.37
“The bill includes $263,766,000 for Executive Direction and Administrative Services, of which: $19,409,000 is for Assistant Secretary support, which maintains funding to implement the PROGRESS Act, the Diversity and Inclusion program for BIA and OST, and the Native boarding school initiative.”
Mental Health and Suicide Prevention Outreach to Minority Veterans and American Indian and Alaska Native Veterans N/A Pg.2652
“Not later than 180 days after the date of the enactment of this Act, the Secretary, in consultation December 19, 2022 with the Director of the Office of Mental Health and Suicide Prevention, shall ensure that the suicide prevention coordinator and minority veteran coordinator of each medical center of the Department have developed and disseminated to the director of the medical center a written plan for conducting mental health and suicide prevention outreach to all tribes and urban Indian health organizations within the catchment area of the medical center.”
Tribal Home Visiting Program and Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) $500,000,000 starting grant base in FY23, scheduled funding increases of $50,000,000 through FY 2027.

Doubles the set-aside from 3% to 6% for the Tribal Home Visiting Program

 Page 3883:
“(B) in subparagraph (A)— (i) by striking ‘‘3’’ and inserting ‘‘6’’; (ii) by inserting ‘‘and administering’’ before ‘‘grants’’;”
Violence Against Women Act (VAWA) National clearinghouse that provides training and technical assistance on issues relating to sexual assault of AI/AN women $500,000 Pg. 178
“$500,000 is for a national clearinghouse that provides training and technical assistance on issues relating to sexual assault of American Indian and Alaska Native women.”
Assist tribal exercising special Tribal criminal jurisdiction $11,000,0000 Pg. 178
‘$11,000,000 is for programs to assist Tribal Governments in exercising special Tribal criminal jurisdiction, as authorized by section 204 of the Indian Civil Rights Act.”
Initiative to support cross-designation of Tribal prosecutors as Tribal Special Assistant United States Attorneys $3,000,0000 Pg. 179
‘$3,000,000 is for an initiative to support cross-designation of tribal prosecutors as Tribal Special Assistant United States Attorneys.”

NCUIH Contact: Lycia Maddocks (Ft. Yuma Quechan), Director of Congressional Relations, lmaddocks@ncuih.org

NCUIH, NIHB, and NCAI Celebrate Historic Inclusion of Advance Appropriations for the Indian Health Service

/0 Comments/in /by

FOR IMMEDIATE RELEASE

Washington, DC | Friday, December 23, 2022 – Today, Congress enacted a Fiscal Year (FY) 2023 omnibus spending package, including a historic provision providing advance appropriations for the Indian Health Service (IHS). Prior to this change, IHS was the only federal healthcare provider without basic certainty of funding from one year to the next.

The Indian health system serves approximately 2.5 million patients at IHS, Tribal facilities, and urban Indian organizations, and was created to meet the U.S. trust responsibility to raise the physical, mental, social, and spiritual health of all Native people to the highest standard. Unfortunately, Indian healthcare remains chronically underfunded – a U.S. policy exacerbated by disruptions in the discretionary appropriations process.

With advance appropriations, American Indians and Alaska Natives will no longer be uniquely at risk of death or serious harm during delays in an FY 2024 funding agreement. Inclusion of IHS advance appropriations in the spending bill means that IHS services will be protected from the harmful effects of disruptions in federal funding for FY 2024 because Congress has agreed to an amount this year that becomes available immediately on October 1, 2023.

“We applaud Congress and the White House for listening to Native communities and doing what is right. For far too long, the federal government has allowed political disputes over budgets to jeopardize the lives of American Indian and Alaska Native people. Every single time there is a stopgap budget, the funding for urban Indian health clinics is deferred and reduced. This compromises the delivery of health care. We look forward to working with our leaders to help the United States make good on its responsibility to provide health care for the people who gave up the land we are on today.” 

  • Sonya Tetnowski (Makah), President of the National Council of Urban Indian Health  

“Including advance appropriations for Indian health in the omnibus is a historic moment for Indian Country over a decade in the making. While Indian health remains chronically underfunded, this provision will help ensure that the Indian Health Service can provide stable, uninterrupted care to our people even when there is a government shutdown. We are confident that we can build on this win and continue our work toward full and mandatory funding for the Indian Health Service, fulfilling the promises this country made to our people over two centuries ago.” 

  • William Smith (Valdez Native Tribe), President of the National Indian Health Board  

“The National Congress of American Indians (NCAI) in partnership with our invaluable allies at the National Indian Health Board (NIHB) and the National Council of Urban Indian Health (NCUIH) have fought for years to get advanced appropriations for the Indian Health Service (IHS) and commends Congress for taking this critically important step for Indian Country. This historic decision comes not a moment too soon as Indian Country continues to be plagued by an ongoing health crisis that affects all of our communities. This week’s action represents a meaningful step taken by the United States towards fulfilling its trust and treaty responsibilities to Tribal Nations and we are grateful for it as we continue to call on the United States to make good on all of its promises made to our ancestors so that our communities may continue to thrive.” 

  • Fawn Sharp (Quinault Indian Nation), President of the National Congress of American Indians 

This success would not have been possible without all the advocacy from Tribes, Tribal organizations, and Urban Indian Organizations. As part of this effort, the National Indian Health Board, the National Congress of American Indians, and the National Council of Urban Indian Health have been part of a broad coalition of advocates and champions for IHS advance appropriations. Our organizations would like to thank the coalition for its dedication and leadership during this endeavor.

We would like to also provide special thanks to Leader Schumer, Speaker Pelosi, and the Biden-Harris administration for championing this historic change, as well as House and Senate appropriators, the Senate Committee on Indian Affairs, the House Committee on Natural Resources, the House Native American Caucus, and all of Indian Country’s champions throughout Congress. Finally, we would like to thank Office of Management and Budget Director Shalanda Young, Department of Health and Human Services (HHS) Secretary Becerra, IHS Director Roselyn Tso, and all the OMB and HHS staff who worked tirelessly to realize this moment.

Together, we made history.

###

About The National Council of Urban Indian Health (https://ncuih.org/)
The National Council of Urban Indian Health (NCUIH) is the national non-profit organization devoted to the support and development of quality, accessible, and culturally competent health and public health services for American Indians and Alaska Natives (AI/ANs) living in urban areas. NCUIH is the only national representative of the 41 Title V Urban Indian Organizations (UIOs) under the Indian Health Service (IHS) in the Indian Health Care Improvement Act (IHCIA). NCUIH strives to improve the health of the over 70% of the AI/AN population that lives in urban areas, supported by quality, accessible health care centers. 
Media Contact: Meredith Raimondi, Vice President of Public Policy, MRaimondi@ncuih.org 

About the National Indian Health Board (https://www.nihb.org/)
Established by the Tribes to advocate as the united voice of federally recognized American Indian and Alaska Native Tribes, NIHB seeks to reinforce Tribal sovereignty, strengthen Tribal health systems, secure resources, and build capacity to achieve the highest level of health and well-being for our People. 
Media Contact: Janee Andrews, Communications Manager, JAndrews@nihb.org

About the National Congress of American Indians (https://www.ncai.org/)
Founded in 1944, the National Congress of American Indians is the oldest, largest and most representative American Indian and Alaska Native organization in the country. NCAI advocates on behalf of tribal governments and communities, promoting strong tribal-federal government-to-government policies, and promoting a better understanding among the general public regarding American Indian and Alaska Native governments, people and rights. For more information, visit www.ncai.org.
Media Contact: Yawna Allen, yallen@ncai.org

What’s Happening: Advance Appropriations for the Indian Health Service

/0 Comments/in /by
  • Advance Appropriations for the Indian Health Service is the most impactful policy that Congress can do for Native communities this year.
  • We can’t let our momentum fade during this critical time.
  • Now is the time to keep the pressure on Congress.

1 Big Thing: Congress has reached a deal on the omnibus

The Latest: Congressional leaders agreed to a government funding framework for a year-end omnibus spending package. (Top appropriators clinch deal on government funding framework)

What’s next: This week, Congress is finalizing the details of the framework, and it’s important that Congress hear from you about why stable funding for the Indian Health Service (IHS) should be on the must-have list.

Last week: The Native American Caucus sent a bipartisan letter from nearly 30 Members of Congress to leadership to request advance appropriations for IHS in the end-of-year package.

This week: The National Indian Health Board sent an updated letter with nearly 140 groups, including Tribes, Urban Indian Organizations, and other supporters to Congress and the White House reiterating the need for stable funding for IHS this year:

  • “Each day without full funding, with only temporary or no funding from the Continuing Resolutions or government shutdowns, is a step backward for Indian health care systems. Health care service delivery, administrative functions, and other operations are significantly impeded, delayed, or disrupted during periods of Continuing Resolutions or government shutdowns to the detriment of the American Indian and Alaska Native patients.”

What can you do?

It’s time to take action: We urge you to contact your Member of Congress and request that they support including advance appropriations for IHS in the FY 2023 final spending package. You can use the text below as a template to call and/or email your Members of Congress.

  • Step 1: Find your Representative here and your Senators here.
  • Step 2: Use the call script and copy the email below.
  • Step 3: Call and email. Use the call script to call your Members of Congress. Next, copy and paste the email into the form on their contact page and send.
Call Script

“(Introduce yourself). It is time that the federal government protect healthcare funding for Native Americans as it does for other health programs. Please let leadership know that advance appropriations for the Indian Health Service must be in the final spending package. Not another Native life should be lost due to budget uncertainty. Can I count on your support?”

Email to Your Representative and Senators

Dear [Member of Congress],

As an Indian health advocate, I respectfully request you ensure the inclusion of advance appropriations for the Indian Health Service (IHS) in the upcoming Fiscal Year (FY) 2023 final spending package.

The Indian health system, including IHS, Tribal facilities, and urban Indian organizations (UIOs), is the only major federal health care provider funded through annual appropriations. If IHS were to receive advance appropriations, it would not be subject to government shutdowns, automatic sequestration cuts, and continuing resolutions as its funding for the next year would already be in place. We need this to protect Native lives!

Please do what’s right for American Indians and Alaska Natives by ensuring that advance appropriations for IHS can finally be made a reality this year.

Thank you for your leadership.

Sincerely,
[contact information]

Do more! Visit our social media toolkit and

Thank you for your advocacy. Your outreach on this is invaluable to providing greater access to health care for all American Indians and Alaska Natives.

Why does the Indian Health Service need advance appropriations?

The Indian health system, including IHS, Tribal facilities, and urban Indian organizations (UIOs), is the only major federal healthcare provider funded through annual appropriations.

  • Short-term budgets cause delayed funding to Indian Health Care Providers that can impact service delivery for patients and families. This is unacceptable.
  • If IHS were to receive advance appropriations, it would ensure continuity of care for American Indians and Alaska Natives.

Over 50% of Native Veterans use the Indian health system for care. VA health funding is protected, but Congress doesn’t protect Native health care. This is unacceptable for our heroes.

Native communities have experienced deaths due to government shutdowns in the past. Five deaths during the last government shutdown is too many.

By the numbers: According to a recent CDC study, Native Americans experienced the biggest drop in life expectancy of any population in the past two years— decreasing by 6.6 years between 2019-2021!

The bottom line: The lives of Native people should not be subject to politics. We need this to protect Native people and preserve access to health care.

Resources

Native Lives Can’t Wait

Photo of Chairman W. Ron Allen

During the White House Tribal Nations Summit, Native leaders gathered to call on Congress to take action now:

Watch Video

Congressional leaders support stabilizing health care delivery for the Indian Health Service.

Senator Dianne Feinstein Tweet

The White House supports advance appropriations. Secretary Becerra said:

It’s an imperative to be able to provide health care regardless of what the political climate is in Washington, DC. So our job is to continue to push the President’s agenda of having mandatory funding for Indian country. And if we can’t get Congress to go all the way to mandatory funding, at least give us advanced appropriations. So that this way Indian country has a way to foresee what’s coming for the next year.

Let’s keep going and make advance appropriations for the Indian Health Service a reality this year.