Tag Archive for: Advance Appropriations

Native American Health Coalition Sends Letters to Congress Requesting Advance Appropriations for the Indian Health Service

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On October 20, 2022, the American Indian/Alaska Native (AI/AN) Health Partners sent letters to House and Senate Interior, Environment, and Related Agencies Subcommittee leadership regarding the fiscal year (FY) 2023 appropriations. In those letters, AI/AN Health Partners urged that the Senate requested advance appropriations amount of $5.577 billion be included in the final FY 2023 IHS appropriation package, among other Indian health provisions.

Letter Highlights

The AI/AN Health Partners stated that since IHS has been chronically underfunded, it often does not have sufficient resources to accomplish its duty of raising the physical, mental, social, and spiritual health of all Native people to the highest standard.

They continue by explaining how the need for advance appropriations was highlighted in a Government Accountability Office (GAO) report from September 2018. In that report, IHS officials and Tribal representatives explained how budget uncertainty resulting from continuing resolutions (CRs) and government shutdowns has a variety of negative effects on the Indian Health system. This includes the lack of access to vital health resources, challenges recruiting and retaining employees (resulting in staffing shortages), and the inability to fund planned pay increases (such as cost-of-living adjustments).

The coalition also noted that the Senate bill provided for advance appropriations, whereas the House bill did not. The letters conclude by requesting the full inclusion of the Senate-provided funding for advance appropriations in the final FY 2023 appropriations package.

Full Letter Text

The full text of the AI/AN Health Partners letter to Senate appropriators can be found below:

Dear Chairman Merkley and Ranking Member Murkowski:

The AI/AN Health Partners is a coalition of health organizations dedicated to improving health care for American Indians and Alaska Natives (AI/ANs).  AI/ANs face substantial health disparities, and higher mortality and morbidity rates than the general population. The Indian Health Service (IHS) is critical to how they access health care.  However, the IHS must have sufficient resources to meet its mission to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.

A long-standing priority for our organizations has been to increase the professional workforces in facilities run by the IHS and tribal organizations.  As you work to finalize fiscal year 2023 appropriations for the IHS, we urge you to include several significant budget increases that we believe will dramatically improve the delivery of health care to AI/ANs.

The Health Professions account provides loan repayment, the Service’s best recruitment tool, for providers who work in Indian Country.  It also funds scholarships for Native American health care students.  Currently, the IHS lacks sufficient funding to meet its needs.  The Service has over 1,398 vacancies for health care professionals. In fiscal year 2021, a total of 1,658 health care professionals received loan repayment. However, the IHS had 341 requests for loan repayment that could not be fulfilled.  At the same time, the Service had over 500 new scholarship applicants but was only able to fund 255 new awards. For fiscal year 2023, we urge you to support the House Interior Appropriations bill amount of $93,568,000 for the Indian Health Professions account to help the IHS to close its vacancy gap.

Medical and diagnostic equipment

Health care professionals need modern equipment to make accurate clinical diagnoses and prescribe effective medical treatments.  The IHS and tribal health programs manage approximately 90,000 devices consisting of laboratory, medical imaging, patient monitoring, pharmacy, and other biomedical, diagnostic, and patient equipment.  However, many of these facilities are using outdated equipment like analog mammography machines.  In some cases, they are using equipment that is no longer manufactured.  Today’s medical devices/systems have an average life expectancy of approximately six to eight years.  The IHS calculates that to replace the equipment at the end of its six to eight-year life would require approximately $100 million per year.  We urge you to support the fiscal year 2023 House-approved amount of $118,511,000 for health care facilities equipment.

Staff Quarters

Decent staff housing is essential for the IHS and tribes to be able to recruit health care personnel.  Many of the 2,700 staff quarters across the IHS health delivery system are more than 40 years old and in need of major renovation or total replacement.  Additionally, in a number of locations the amount of housing units is insufficient.  Decent staff quarters, especially in remote areas, is essential for attracting and keeping health care providers in Indian Country.    In a March 23, 2021, hearing before the House Natural Resources Subcommittee for Indigenous Peoples of the United States, the Honorable Rodney Cawston, Chairman, Colville Business Council Confederated Tribes of the Colville Reservation Nespelem, WA spoke about how the lack of housing affected tribes’ ability to attract health care workers  “Included in the housing needs on a reservation to recruit working professionals, especially medical professionals to rural communities like Washington state it’s always difficult because we don’t always have the available housing for working professionals.”

For fiscal year 2023, the House Appropriations Committee set aside $40,000,000 in the Health Care Facilities line item specifically for staff quarters at existing facilities.   We strongly urge you to support this directive.   The Senate Interior Subcommittee included report language seeking a report on the situation, but that will delay needed funding for at least two years.

Electronic Health Record

Being able to have a modern electronic health record (EHR) system, is essential to enable the IHS and tribal health professionals to provide accurate and vital health care for patients.  The IHS uses its EHR for all aspects of patient care, including maintaining patient records, prescriptions, care referrals, and billing insurance providers that reimburse the Service for over $1 billion annually.  A new EHR system will allow the IHS and tribes to communicate with other entities that AI/AN patients seek care from like the Veterans Affairs, Department of Defense, and tribal and urban Indian health programs.  We urge you to support a fiscal year 2023 appropriation of $284,500,000 for an electronic health record system.   This is the same amount that the House approved, and the Administration requested.

Advanced appropriations

Our organizations were pleased that for fiscal year 2023, the Senate Interior Subcommittee provided $5,577,077,000 for advanced appropriations for the Indian Health Service.  The need for the advanced appropriations was addressed in a September 2018 GAO report, “INDIAN HEALTH SERVICE Considerations Related to Providing Advance Appropriation Authority.”  IHS officials, tribal representatives, and other stakeholders told the GAO how budget uncertainty resulting from continuing resolutions (CRs) and government shutdowns can have a variety of effects on the provision of IHS funded health care services for AI/ANs.    Regarding recruitment and retention of health care providers, GAO reported that IHS officials and tribal representatives said that funding uncertainties can exacerbate challenges to staffing health care facilities:

“…when recruiting health care providers, IHS officials said CRs and potential government shutdowns create doubt about the stability of employment at IHS amongst potential candidates, which may result in reduced numbers of candidates or withdrawals from candidates during the pre-employment process.  IHS officials said that many providers in rural and remote locations are the sole source of income for their families, and the potential for delays in pay resulting from a government shutdown can serve as a disincentive for employees considering public service in critical shortage areas that do not offer adequate spo

usal employment opportunities. Tribal representatives said CRs create challenges for tribes in funding planned pay increases— such as cost-of-living adjustments— for health care staff at their facilities, and they may, as a result, defer increases.”

The House Appropriations Committee did not include funding for advanced appropriations in its fiscal year 2023 bill for the Indian Health Service.  We urge you to maintain the Senate advanced appropriations amount of $5,577,077,000  in the final Fiscal year 2023 IHS appropriation.

Thank you for considering our requests.  We look forward to working with you to improve health care for American Indians and Alaska Natives.

About the AI/AN Health Partners

The AI/AN Health Partners is a coalition of health organizations dedicated to improving health care for AI/ANs. Members of this coalition, all of whom signed the letters to the House and Senate appropriators, include:

  • The Academy of Nutrition and Dietetics
  • The American Academy of Dermatology Association
  • The American Academy of Pediatrics
  • The American Association of Colleges of Nursing
  • The American Association of Colleges of Osteopathic Medicine
  • The American College of Obstetricians and Gynecologists
  • The American Dental Association
  • The American Dental Education Association
  • The American Psychological Association
  • The Association of American Medical Colleges
  • The Commissioned Officers Association of the USPHS
  • The National Kidney Foundation

Background and NCUIH Advocacy

AI/ANs face substantial health disparities compared to the general population. In the Fiscal Year (FY) 2023 Performance Budget Submission to Congress, the Indian Health Service (IHS) highlights these disparities, noting that the “Indian health system is chronically underfunded compared to other healthcare systems in the United States”.

The National Council of Urban Indian Health’s (NCUIH) analysis revealed that the US spends $11,172 in healthcare costs per person. In contrast, Tribal and IHS facilities receive $4,078 per IHS eligible patient, while Urban Indian Organizations (UIOs), which support the over 70% of AI/ANs living off-reservation, receive just $672 per AI/AN patient from the IHS budget. This low per-patient spending makes it difficult for UIOs to address growing patient needs.

NCUIH has been a staunch advocate for adequate funding of IHS, especially advance appropriations. NCUIH’s 2022 Policy Priorities includes securing advance appropriations as a top policy priority to improve AI/AN health and improve funding certainty for IHS. Advance appropriations has been a priority for Indian Country for years and has broad support from Native health advocates. Over the past 10 years, there have been six resolutions in support of advance appropriations from NCUIH, the United South and Eastern Tribes (USET), the Inter-Tribal Council of the Five Civilized Tribes (ITC), the National Indian Health Board (NIHB), the National Congress of American Indians (NCAI), and the American Bar Association.

On January 17, 2019, NCUIH sent a letter to the Vice Chairman of the Senate Committee on Indian Affairs (SCIA), Tom Udall, in support of IHS advance appropriations legislation. On March 9, 2022, NCUIH joined NIHB and over 70 Tribal nations and national Indian organizations in sending a series of joint letters to Congress requesting advance appropriations for IHS in the FY 2022 omnibus. NCUIH also sent letters to Speaker Pelosi, House Minority Leader McCarthy, Senate Majority Leader Schumer, Senate Minority Leader McConnell, the Senate Interior Appropriations Committee, and the Senate Committee on Indian Affairs in support advance appropriations for IHS. Most recently, NCUIH also passed a resolution on August 22, 2022 in support of advance appropriations.

NCUIH Additional Resources on Advance Appropriations

NCUIH has a variety of additional resources including:

Next Steps

NCUIH continues to advocate for the inclusion of advance appropriations for IHS in the final appropriations package. NCUIH will also provide updates on the status of advance appropriations in Congress during final negotiations.

Action Alert: Save Native Lives – Contact Congress Today to Take Action

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Contact Congress │ Social Media Campaign │ Advance Appropriations One-Pager │ Find Out if Your Member of Congress Supports Advance Appropriations


Dear Indian Health Advocates,

The National Council of Urban Indian Health is advocating tirelessly to Congress to ensure advance appropriations for the Indian Health Service (IHS).

We need your help again contacting Congress to support securing advance appropriations and mandatory funding for IHS. 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 ensure continuity of care for American Indians and Alaska Natives and complement President Biden’s budget request to honor commitments to Tribal nations and communities. In fact, Native communities have experienced deaths due to government shutdowns in the past and according to a recent study, Native Americans experienced the biggest drop in life expectancy— decreasing by 6.6 years between 2019-2021. The lives of Native people should not be subject to politics. We need this to protect Native people and preserve access to health care.

We urge you to contact your Member of Congress and request that they support including advance appropriations for IHS in the Fiscal Year (FY) 2023 final spending package. You can use the text below as a template to call and/or email your Members of Congress.

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

Sincerely,

The National Council of Urban Indian Health

STEPS TO CONTACT CONGRESS

  • Step 1:Copy the email below.
  • Step 2: Find your Representative here and your Senator here.
  • Step 3:Paste the email into the form on your Member of Congress’ contact page and send. Please contact Meredith Raimondi (policy@ncuih.org) with questions.
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 until mandatory funding for the agency can be achieved.

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 and continuing resolutions as its funding for the next year would already be in place. We need this to protect Native lives!

I respectfully ask that you honor the federal trust obligation to American Indians and Alaska Natives by ensuring advance appropriations for IHS can finally be made a reality this year.

Thank you for your leadership and your commitment to upholding the United States trust responsibility.

Sincerely,

[contact information]

POST ON SOCIAL MEDIA

Use this graphic to call on your Member of Congress to take action!

Advance Indian Health  Native Lives Can't Wait_Advance Appropriations Now

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Senators Request Congressional Leadership Support Advance Appropriations to Stabilize the Indian Health Service

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On September 30, 2022, six members of the Senate Committee on Indian Affairs (SCIA) sent a letter to House leadership, Senate leadership, and the Appropriations Committee requesting advance appropriations for the Indian Health Service (IHS) in the final upcoming appropriations bill. This letter comes as a continued effort by the National Council of Urban Indian Health (NCUIH) and Indian Country to secure advance appropriations for IHS and ensure stable and predictable funding for healthcare services provided to American Indians/Alaska Natives (AI/ANs). Due to this robust advocacy, the Senate FY 2023 funding bill provides $5.577 billion of advance appropriations for IHS for FY 2024, however, the House bill failed to include advance appropriations.

Senators Brian Schatz (D-HI), Maria Cantwell (D-WA), John Tester (D-MT), Catherine Cortez Masto (D-NV), Tina Smith (D-MN), and Ben Ray Lujan (D-NM) urged Congressional leadership to include advance appropriations for IHS for FY 2024 in the final FY 2023 omnibus bill to protect IHS from temporary lapses in appropriations and continuing resolutions (CRs). The Senators emphasized that during the 2019 government shutdown, “IHS was the only federal health care entity forced to operate without appropriations, causing some Urban Indian Organizations to close their doors completely. This funding disruption resulted in some health providers being unable to provide patients with critical care and medication.” A CR was recently enacted on September 30 to avoid a government shutdown while Congress continues negotiations on the final FY 2023 appropriations bill, extending current funding levels for all normal government programs until December 16, 2022. Urban Indian organizations (UIOs) must continue to operate on less than the FY 2022 funding levels for FY 2023 despite rising costs of healthcare. On July 28, 2022, former Acting Director of IHS, Liz Fowler, stated in her testimony before the House Natural Resources Subcommittee for Indigenous Peoples, “While the IHS has received an exception apportionment to provide the full-year recurring base amounts to Tribal Health Programs operating their own programs through ISDEAA Title I contracts and Title V compacts since FY 2020, this option is not available during government shutdowns, and it is not available at all to IHS-operated health programs, or Urban Indian Organizations. As a result, Direct Service tribes, and American Indians and Alaska Natives served by Urban Indian Organizations are disproportionately affected by disruptions in federal appropriations.”

Full Text of Letter:

Dear Senate and House Leadership,

As members of the Senate Committee on Indian Affairs, we write to urge including advance appropriations for the Indian Health Service (IHS) for fiscal year 2024 (FY24) in the final fiscal year 2023 (FY23) appropriations bill. Providing advance appropriations will ensure that the federal government continues to uphold its trust and treaty obligations to 2.7 million American Indians and Alaska Natives who receive healthcare services at more than 600 IHS hospitals, clinics, and health stations throughout the nation.[1]

The Indian Health Care Improvement Act, along with the Snyder Act of 1921, provides the foundational basis for providing healthcare to American Indians and Alaska Natives through IHS, in partial fulfillment of the United States’ trust and treaty obligations. Yet, unlike the Veterans Health Administration (VHA) at the Department of Veteran’s Affairs, which receives the majority of its funding through advance appropriations, IHS is funded through annual appropriations.[2] We were therefore pleased to see $5.577 billion in advance appropriations included in the Senate-released draft Interior and Environment subcommittee appropriations bill.

Advance appropriations, particularly during temporary lapses in appropriations and continuing resolutions, would provide continued budget certainty and enable long term planning to maintain orderly and continuous operations of critical health programs for Native American communities. Budgetary uncertainty risks interruption of health services and reduction in quality of care. During the partial government shutdown in 2019, for example, IHS was the only federal health care entity forced to operate without appropriations, causing some Urban Indian Organizations to close their doors completely. This funding disruption resulted in some health providers being unable to provide patients with critical care and medication.[3] Additional, and preventable, funding uncertainty impacts include risk of downgraded credit ratings on commercial loans secured by Tribes and Urban Indian Organizations; challenges related to recruitment and retention of healthcare providers; increased administrative burden and costs, such as employee furloughs and terminations; and other negative financial effects on Tribes.[4]

It is critical that advance appropriations are included in the FY23 omnibus appropriations bill. Given the impacts of uncertain funding, the lack of parity with VHA, and the unique trust relationship between the United States and American Indians and Alaska Natives, future year funding is necessary. We look forward to working with you to pass this critical legislation.

Thank you for your consideration of our request.

Background on Advance Appropriations for IHS

Advance appropriations are appropriations that become available one year or more after the year for which the appropriations act is passed. The Indian healthcare system, which includes IHS facilities, Tribal facilities, and UIOs, is the only major federal healthcare provider funded through annual appropriations. Funding through annual appropriations leads to funding uncertainty because the availability and amount of the appropriation is subject to the annual budget negotiation process. If IHS were to receive advance appropriations, it would not be subject to government shutdowns, automatic sequestration cuts, and CRs as its funding for the next year would already be in place. Congress recently enacted a CR, which passed the House by a vote of 230-201 and Senate by a vote of 75-25, to keep the government funded until December 16. UIOs must continue to operate on FY 2022 funding levels for FY2023 despite rising costs of healthcare.

Lapses in federal funding risk AI/AN lives. Every year, on average, Congress passes five continuing resolutions to keep the government open while Congress reaches a budget agreement, and there were long government shutdowns in 1996, 2013, and 2019. During the FY 2019 shutdown, several UIOs did not have adequate funding to maintain normal operations and were required to reduce services, lose staff, or close their doors entirely, putting the health and well-being of their patients at risk. In a UIO shutdown survey, five out of thirteen UIOs indicated that they could only maintain normal operations for 30 days without federal funding. One UIO suffered seven opioid overdoses, five of which were fatal.

Resources on Advance Appropriations for IHS:

NCUIH and Indian Country Advocacy

NCUIH, along with three other national Native organizations, the National Indian Health Board (NIHB), National Congress of American Indians (NCAI), United South and Easter Tribes (USET), have been advocating on behalf of advance appropriations for almost a decade and have passed resolutions supporting advance appropriations for IHS.

On January 17, 2019, NCUIH sent a letter to the Vice Chairman of the Senate Committee on Indian Affairs (SCIA), Tom Udall, in support of IHS advance appropriations legislation. On March 9, 2022, NCUIH joined NIHB and over seventy Tribal nations and national Indian organizations in sending a series of joint letters to Congress requesting advance appropriations for IHS in the FY 2022 omnibus. On June 16, 2022, NIHB and NCAI published a legislative action alert requesting that SCIA support and include IHS advance appropriations in the current FY 2023 appropriations bill. Most recently, NCUIH sent letters to Speaker Pelosi, House Minority Leader McCarthy, Senate Majority Leader Schumer, Senate Minority Leader McConnell, Senate Interior Appropriations Committee,  and SCIA to support advance appropriations for IHS.

Federal and Congressional Support

There has also been strong long-standing support from Congress on this issue. Before the recent SCIA letter to Congressional leadership urging advance appropriations for IHS in the final FY 2023 appropriations bill, the Native American Caucus also sent a letter to House Appropriations Committee Chair DeLauro and Ranking Member Granger requesting that advance appropriations for IHS for FY 2023 be included in the final FY 2022 appropriations bill on January 12, 2022. On June 3, the Native American Caucus sent another letter encouraging the Committee to work towards shifting IHS from discretionary to mandatory funding and requesting that, while this shift is underway, the Committee include advanced appropriations for IHS  in the final FY 2023 Appropriations bill.

On April 25, 2022, a bipartisan group of 28 Representatives requested up to $949.9 million for urban Indian health in FY 2023 and advance appropriations for IHS until such time that authorizers move IHS to mandatory spending, and 12 Senators sent a letter with the same requests. Last year, for the first time ever, the Senate Appropriations Committee included an additional $6.58 billion in advance appropriations to IHS for FY 2023 in its FY 2022 Interior, Environment, and Related Agencies bill.

Back in 2014, SCIA held its first hearing on advance appropriation bill Indian Health Service Advance Appropriations Act of 2013 (S. 1570). In a 2019 House Natural Resources Subcommittee for Indigenous Peoples (SCIP) hearing on advance appropriations bills H.R. 1128 and H.R. 1135, former IHS Principal Deputy Director, Rear Admiral Michael Weahkee, reaffirmed Indian Country’s repeated request for advance appropriations stating that “[t]hrough the IHS’s robust annual Tribal Budget Consultation process, Tribal and Urban Indian Organization leaders have repeatedly and strongly recommended advance appropriations for the IHS as an essential means for ensuring continued access to critical health care services. The Department continues to hear directly from tribes advocating support for legislative language that would provide the authority of advance appropriations for the IHS. The issues that Tribes have identified present real challenges in Indian Country and we are eager to work with Congress on a variety of solutions.” More recently on July 28, 2022, IHS Acting Deputy Director Elizabeth Fowler reaffirmed IHS’s support for advance appropriations during a SCIP hearing on the Indian Health Service Advance Appropriations Act (H.R. 5549) stating that  “[IHS] remain[s] firmly committed to improving quality, safety, and access to health care for American Indians and Alaskan Natives. Mandatory funding and advanced appropriations are necessary and critical steps toward that goal… [I] urge the House to act on advanced appropriations through the appropriations process with or without the authorizing legislation that is the subject of this hearing.”

The U.S. Commission on Civil Rights report from 2018, “Broken Promises: Continuing Federal Funding Shortfall for Native Americans” serves as another benchmark of support by including advance appropriations for IHS as a key recommendation to the federal government to ensure greater funding stability for IHS.

History of Advance Appropriations Bills

Legislation on this effort has been introduced in 11 bills since 2013:​

  •  10/2013 – Indian Health Service Advance Appropriations Act of 2013 (3229/S. 1570) ​
    • Sponsor: Rep. Don Young/Sen. Lisa Murkowski ​
  •  1/2015 – Indian Health Service Advance Appropriations Act of 2015 (395)    ​
    • Sponsor: Rep. Don Young ​
  • 1/2017 – Indian Health Service Advance Appropriations Act of 2017 (235) ​
    •  Sponsor: Rep. Don Young ​
  •  2/2019 – Indian Programs Advance Appropriations Act (1128/S. 229) ​
    • Sponsor: Rep. Betty McCollum/Sen. Tom Udall ​
  • 2/2019 – Indian Health Service Advance Appropriations Act of 2019 (1135/S. 2541) ​
    • Sponsor: Rep. Don Young/Sen. Lisa Murkowski​
  •  10/2021 – Indian Health Service Advance Appropriations Act (5549) ​
    • Sponsor: Rep. Don Young ​
  • 10/2021 – Indian Programs Advance Appropriations Act of 2021 (5567/S. 2985) ​
    • Sponsor: Rep. Betty McCollum/Sen. Ben Ray Lujan​

Next Steps

Congress will have until December 16, 2022 to pass a longer-term spending package for FY 2023. In the meantime, NCUIH will continue to advocate for advance appropriations in the final FY 2023 omnibus.

 

[1] Hybrid SCIP Legis. Hearing – July 28, 2022 Before the Subcomm. on Indigenous Peoples, 117th Cong. 2 (2022) (statement of Elizabeth Fowler, Acting Dir., Indian Health Serv.).

[2] ELAYNE HEISLER & KATE MCCLANAHAN, CONG. RESEARCH SERV., R46265, ADVANCE APPROPRIATIONS FOR THE INDIAN HEALTH SERVICE: ISSUES AND OPTIONS FOR CONGRESS (2020).

[3] Hybrid SCIP Legis. Hearing – July 28, 2022 Before the Subcomm. on Indigenous Peoples, 117th Cong. 2 (2022) (statement of Maureen Rosette, Chief Operating Officer, NATIVE Project).

[4] GAO-18-652 (Sept. 2018), INDIAN HEALTH SERVICE: CONSIDERATIONS RELATED TO PROVIDING ADVANCE APPROPRIATIONS AUTHORITY, available at https://www.gao.gov/assets/700/694625.pdf.

NCUIH Board Approves Resolution on Advance Appropriations

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On August 22, 2022, the National Council of Urban Indian Health (NCUIH) Board of Directors approved a resolution in support of advance appropriations for the Indian Health Service (IHS). Attaining advance appropriations has been a long-standing priority for NCUIH and Indian Country to ensure stable and predictable funding for IHS and American Indian/Alaska Native (AI/AN) healthcare.

Full Text of Resolution:

WHEREAS the National Council of Urban Indian Health (NCUIH) is the national representative of forty-one (41) urban Indian organizations (UIOs) receiving grants under Title V of the Indian Health Care Improvement Act (IHCIA) and the American Indians and Alaska Natives (AI/ANs) they serve;

WHEREAS NCUIH was established in 1998 to support the development of quality, accessible, and culturally sensitive health care programs for AI/ANs living in urban communities;

WHEREAS the United States has a unique and special relationship with AI/ANs as established through the U.S. Constitution, Treaties with Indian Tribes, U.S. Supreme Court decisions and Federal legislation;

WHEREAS this special relationship includes a trust responsibility to AI/AN citizens as established through Treaties with Indian Tribes, U.S. Supreme Court decisions, and Federal legislation;

WHEREAS the trust relationship requires the United States to provide federal health services to maintain and improve the health of AI/ANs, no matter where they live;

WHEREAS it is the declared policy of the United States, as provided in the ICHIA, “to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy;”

WHEREAS the Indian Health Service (IHS) is chronically underfunded by the federal government, and UIOs historically receive only one percent of appropriated funds for IHS;

WHEREAS the Indian health system, including IHS, Tribal, and UIO (I/T/U) facilities, is the only major federal provider of health care that is funded through annual appropriations;

WHEREAS according to the Congressional Research Service, since FY1997, IHS has only once, in FY2006, received full-year appropriations by the start of the fiscal year;

WHEREAS if IHS were to receive advance appropriations, it would not be subject to government shutdowns, automatic sequestration cuts, and continuing resolutions (CRs) as its funding for the next year would already be in place;

WHEREAS during the thirty-five (35) day government shutdown at the start of FY 2019, the Indian healthcare system was the only federal healthcare entity that was required to continue operations without appropriated funds;

WHEREAS during the FY 2019 shutdown, several UIOs did not have adequate funding to maintain normal operations, and were required to reduce services, lose staff, or close their doors entirely, putting the health and wellbeing of their patients at risk;

WHEREAS in a UIO shutdown survey, five (5) out of thirteen (13) UIOs indicated that they could only maintain normal operations for 30 days without federal funding;

WHEREAS advanced appropriations would uphold the trust responsibility by protecting the Indian healthcare system from future government shutdowns and not counting against spending caps; and

WHEREAS advanced appropriations are imperative to provide certainty to the Indian health system and ensure unrelated budget disagreements do not put AI/AN lives at stake.

NOW THEREFORE BE IT RESOLVED, that NCUIH requests that Congress amend the Indian Health Care Improvement Act to authorize Advanced Appropriation for IHS, including Tribal facilities and UIOs; and

BE IT FURTHER RESOLVED, that this resolution shall be the policy of NCUIH until it is withdrawn or modified by subsequent resolution.

CERTIFICATION

The foregoing resolution was adopted by NCUIH on August 22nd, 2022 with a quorum present.

 

Background on Advance Appropriations for IHS

Advance appropriations are appropriations that become available one year or more after the year for which the appropriations act is passed. The Indian healthcare system, which includes IHS facilities, Tribal facilities, and urban Indian organizations (UIOs), is the only major federal healthcare provider funded through annual appropriations. Funding through annual appropriations leads to funding uncertainty because the availability and amount of the appropriation is subject to the annual budget negotiation process. If IHS were to receive advance appropriations, it would not be subject to government shutdowns, automatic sequestration cuts, and continuing resolutions (CRs) as its funding for the next year would already be in place.

Lapses in federal funding risk American Indian and Alaska Native lives. Every year, on average, Congress passes five continuing resolutions to keep the government open while Congress reaches a budget agreement, and there were long government shutdowns in 1996, 2013, and 2019. During the Fiscal Year (FY) 2019 shutdown, several UIOs did not have adequate funding to maintain normal operations and were required to reduce services, lose staff, or close their doors entirely, putting the health and well-being of their patients at risk. In a UIO shutdown survey, five out of thirteen UIOs indicated that they could only maintain normal operations for 30 days without federal funding. One UIO suffered seven opioid overdoses, five of which were fatal. Presently, it is unlikely that Congress will reach a budget agreement before the September 30 deadline. If Congress does not reach a budget agreement, Congress will need to pass a continuing resolution to avoid a government shutdown.

NCUIH Resources on Advance Appropriations for IHS:

NCUIH and Indian Country Advocacy

NCUIH, along with three other national Native organizations the National Indian Health Board (NIHB), National Congress of American Indians (NCAI), United South and Easter Tribes (USET), have been advocating on behalf of advance appropriations for almost a decade. NIHB, NCAI, and USET have all passed resolutions in support of advance appropriations. However, these resolutions don’t explicitly mention UIOs or urban Indians. NCUIH’s resolution provides context for why advance appropriations are essential for UIOs and urban Indian populations and explicitly includes UIOs in the request for advance appropriations.

On January 17, 2019, NCUIH sent a letter to the Vice Chairman of the Senate Committee on Indian Affairs (SCIA), Tom Udall, in support of IHS advance appropriations legislation. On March 9, 2022, NCUIH joined NIHB and over seventy Tribal nations and national Indian organizations in sending a series of joint letters to Congress requesting advance appropriations for IHS in the FY 2022 omnibus. On June 16, 2022, NIHB and NCAI published a legislative action alert requesting that SCIA support and include IHS advance appropriations in the current FY 2023 appropriations bill. Most recently, NCUIH sent letters to Speaker Pelosi, House Minority Leader McCarthy , Senate Majority Leader Schumer, Senate Minority Leader McConnell, Senate Interior Appropriations Committee,  and SCIA to support advance appropriations for IHS.

Federal and Congressional Support

There has also been strong long-standing support from Congress on this issue. On January 12, 2022, the Native American Caucus sent a letter to House Appropriations Committee Chair DeLauro and Ranking Member Granger requesting that advance appropriations for IHS for FY 2023 be included in the final FY 2022 appropriations bill. On June 3 the Native American Caucus sent another letter encouraging the Committee to work towards shifting IHS from discretionary to mandatory funding and requesting that, while this shift is underway, the Committee include advanced appropriations for IHS  in the final FY 2023 Appropriations bill.

On April 25, 2022, a bipartisan group of 28 Representatives requested up to $949.9 million for urban Indian health in FY 2023 and advance appropriations for IHS until such time that authorizers move IHS to mandatory spending, and 12 Senators sent a letter with the same requests. Last year, for the first time ever, the Senate Appropriations Committee included an additional $6.58 billion in advance appropriations to IHS for FY 2023 in its FY 2022 Interior, Environment, and Related Agencies bill.

Back in 2014, SCIA held its first hearing on advance appropriation bill Indian Health Service Advance Appropriations Act of 2013 (S. 1570). In a 2019 House Natural Resources Subcommittee for Indigenous Peoples (SCIP) hearing on advance appropriations bills H.R. 1128 and H.R. 1135, former IHS Principal Deputy Director, Rear Admiral Michael Weahkee, reaffirmed Indian Country’s repeated request for advance appropriations stating that  “[t]hrough the IHS’s robust annual Tribal Budget Consultation process, Tribal and Urban Indian Organization leaders have repeatedly and strongly recommended advance appropriations for the IHS as an essential means for ensuring continued access to critical health care services. The Department continues to hear directly from tribes advocating support for legislative language that would provide the authority of advance appropriations for the IHS. The issues that Tribes have identified present real challenges in Indian Country and we are eager to work with Congress on a variety of solutions.” More recently on July 28, 2022  IHS Acting Deputy Director Elizabeth Fowler reaffirmed IHS’s support for advance appropriations during a SCIP hearing on the Indian Health Service Advance Appropriations Act (H.R. 5549) stating that  “[IHS] remain[s] firmly committed to improving quality, safety, and access to health care for American Indians and Alaskan Natives. Mandatory funding and advanced appropriations are necessary and critical steps toward that goal… [I] urge the House to act on advanced appropriations through the appropriations process with or without the authorizing legislation that is the subject of this hearing.”
The U.S. Commission on Civil Rights report from 2018, “Broken Promises: Continuing Federal Funding Shortfall for Native Americans” serves as another benchmark of support by including advance appropriations for IHS as a key recommendation to the federal government to ensure greater funding stability for IHS.

History of Advance Appropriations Bills

Legislation on this effort has been introduced in 11 bills since 2013:​

  •  10/2013 – Indian Health Service Advance Appropriations Act of 2013 (R. 3229/S. 1570) ​
  • Sponsor: Rep. Don Young/Sen. Lisa Murkowski ​
  •  1/2015 – Indian Health Service Advance Appropriations Act of 2015 (R. 395)    ​
  • Sponsor: Rep. Don Young ​
  • 1/2017 – Indian Health Service Advance Appropriations Act of 2017 (R. 235) ​
  •  Sponsor: Rep. Don Young ​
  •  2/2019 – Indian Programs Advance Appropriations Act (R. 1128/S. 229) ​
  • Sponsor: Rep. Betty McCollum/Sen. Tom Udall ​
  • 2/2019 – Indian Health Service Advance Appropriations Act of 2019 (R. 1135/S. 2541) ​
  • Sponsor: Rep. Don Young/Sen. Lisa Murkowski​
  •  10/2021 – Indian Health Service Advance Appropriations Act (R. 5549) ​
  •  Sponsor: Rep. Don Young ​
  • 10/2021 – Indian Programs Advance Appropriations Act of 2021 (R. 5567/S. 2985) ​
  • Sponsor: Rep. Betty McCollum/Sen. Ben Ray Lujan​
    • 7/28/2022- Subcommittee for Indigenous Peoples (SCIP) held a hearing on the Indian Health Service Advance Appropriations Act (R.5549)​
  • Sponsor: Rep. Don Young
Next Steps

NCUIH will continue to advocate for Advance Appropriations for the 2022-23 Fiscal Year.

Action Alert: Save Native Lives – Contact Speaker Pelosi Today to Take Action

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Dear Urban Indian Health Advocates,

The National Council of Urban Indian Health is advocating tirelessly to Congress to ensure advance appropriations for the Indian Health Service.

We need your help again contacting Congress to support securing Advance Appropriations and mandatory funding for the Indian Health Service (IHS). 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 ensure continuity of care for Native Americans and complement President Biden’s budget request to honor commitments to tribal nations and communities. In fact, there have been Native deaths due to government shutdowns in the past, and the lives of Native people should not be subject to politics. We need this to protect Native people and preserve access to health care.

We encourage you to contact Speaker Pelosi and request that she support including advance appropriations for IHS in the Fiscal Year (FY) 2023 final spending package. You can use the text below as a template to call and/or email Speaker Pelosi.

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

Sincerely,

The National Council of Urban Indian Health

STEPS TO CONTACT CONGRESS

  • Step 1: Copy the email below.
  • Step 2: Find Speaker Pelosi’s contact here.
  • Step 3: Paste the email into the form and send. Please contact Meredith Raimondi (policy@ncuih.org) with questions.

Email to Speaker Pelosi

Dear Speaker Pelosi,

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 until mandatory funding for the agency can be achieved.

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!

“I respectfully ask that you honor the federal trust obligation to American Indians/Alaska Natives and ensure advance appropriations for IHS can finally be made a reality this year.

Thank you for your leadership and your commitment to upholding the United States trust responsibility.

Sincerely,
[contact information]

POST ON SOCIAL MEDIA

Facebook

Post your support on your Facebook.

  • Example post:
    • The Indian health system, including IHS, Tribal facilities, and urban Indian organizations, is the only major federal health care provider funded through annual appropriations. If IHS were to receive mandatory funding, or at the least, advance appropriations, it would not be subject to government shutdowns and continuing resolutions. You can make a difference! Call Speaker Pelosi to support advance appropriations in the FY23 funding bills.

TWITTER

From your Twitter account, tweet to Speaker Pelosi.

  • Example tweet:
    • Dear @ SpeakerPelosi, please support advance appropriations for IHS in FY23 #IndianHealth #urbanIndianhealth @ncuih_official.

House Passes Fiscal Year 2023 Appropriations Minibus with $200 million for Urban Indian Health

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On July 21, 2022, the House passed H.R. 8294, a package of six fiscal year (FY) 2023 federal funding bills, by a 220 to 207 vote. Included within the package is the FY 2023 Interior, Environment, and Related Agencies Appropriations bill, which includes $8.1 billion for the Indian Health Service (IHS) and $200 million for urban Indian health, but fails to include advance appropriations for IHS.

Background

On June 28, 2022, the House Appropriations Subcommittee on Interior, Environment, and Related Agencies released the Committee Bill Report for the FY 2023 budget with $200 million for urban Indian health. The report and bill were considered by the full House Appropriations Committee on June 29, 2022, after being approved by the House Subcommittee on Interior on June 21, 2022. The bill authorizes $8.1 billion for IHS— an increase of $1.5 billion from FY22 but $1 billion below the President’s budget request. Despite robust advocacy from Tribes and Urban Indian Organizations (UIOs), the bill does not include advance appropriations for IHS. Other key provisions include $17 million for generators for IHS/Tribal Health Programs/UIOs and $3 million for a Produce Prescription Pilot Program for Tribes and UIOs to increase access to produce and other traditional foods. A more detailed analysis follows below.

The President’s budget proposed to shift IHS from discretionary funding to mandatory funding in FY 2023. In the meantime, Native health advocates requested Advance Appropriations until mandatory funding is implemented. To much disappointment, the House bill does not provide (or even mention) advance appropriations for IHS. Advance appropriations is a long-standing priority for Indian Country and advocates have been requesting Congress to provide stable funding for IHS, especially considering the COVID-19 pandemic which has had tremendous, adverse impacts on American Indians and Alaska Natives. In the past month alone, NCUIH sent a letter to request Speaker Pelosi and Minority Leader McCarthy to allow for advance appropriations, and NCAI and NIHB also sent an action alert to request the Appropriations Committee include advance appropriations. Previously, NCUIH, along with 28 Representatives and 12 Senators requested advanced appropriations for IHS until such time that authorizers move IHS to mandatory spending.

Status of Senate Interior Appropriations Bill

The Senate has yet to release their appropriations bills, and it is unlikely they will pass their bills before the current September 30 deadline. Congress will need to rely on a Continuing Resolution to avoid a government shutdown.

Bill Highlights

Indian Health Service: $8.1 billion

  • $8.1 billion for the Indian Health Service, an increase of $1.5 billion above the FY 2022 enacted level.

Urban Indian Health: $200 million

  • Bill Report: “The recommendation includes $200,000,000 for Urban Indian Health, $126,576,000 above the enacted level and $200,000,000 above the budget request. This amount includes $31,000 transferred from the Alcohol and Substance Abuse Program as part of the for NIAAA program. The Committee expects the Service to continue including current services estimates for Urban Indian health in annual budget requests.”

Mandatory Funding:

  • Bill Report: “For fiscal year 2023, the Administration proposed reclassifying IHS accounts as mandatory and did not submit a discretionary budget proposal. However, IHS did not provide implementation language and at the time of writing this report, the authorizing committees have not enacted the President’s proposal. Because the authorizing committees have not acted, the Committee is providing discretionary funds for IHS for fiscal year 2023 to ensure health care for Native Americans is not negatively impacted.”
  • Note: There is no mention of advance appropriations for IHS in this bill.

Equipment: $118.5 million

  • Bill Report: “The recommendation includes $118,511,000 for Equipment, $88,047,000 above the enacted level and $118,511,000 above the budget request. The bill continues $500,000 for TRANSAM.
  • The report further states: “The Committee is aware that the increasing severity and frequency of extreme weather events has motivated certain jurisdictions to adopt de-energization protocols to reduce the risks of catastrophic wildfires. While these protocols are useful in limiting loss of life in affected communities, they can also have dire consequences for Tribal Health Programs located in impacted areas. To increase the resilience of these facilities, the recommendation includes an additional $17,000,000 to purchase generators for IHS, Tribal Health Programs, and Urban Indian Organizations located in areas impacted by de-energization events. In procuring backup generators, the Indian Health Service is directed to determine the most cost-effective method, which may include leasing. In determining the most cost-effective procurement method, the Service shall account for life-cycle maintenance costs associated with direct ownership and clinics’ capabilities to maintain these generators.”

Electronic Health Records: $284.5 million

  • Bill Report: “To improve the current IT infrastructure system to support deployment of a new modern electronic health records (EHR) solution, the recommendation includes $284,500,000 for Electronic Health Records, $139,481,000 above the enacted level and $284,500,000 above the budget request.
  • The report further states: “The Committee urges IHS to continue moving forward with modernizing its aging EHR system by replacing it with a solution that is interoperable with the new EHR at the Department of Veterans Affairs and with systems purchased by Tribes and UIOs. Modernization should include robust Tribal consultation and planning to ensure that Tribes and UIOs are enabled to take full advantage of resulting modern health information technology and are not unduly burdened during this process.”

Mental Health: $130 million

  • Bill Report: “The recommendation includes $129,960,000 for Mental Health, $8,014,000 above the enacted level and $129,960,000 above the budget request.”

Alcohol and Substance Abuse: $264 million

  • Bill Report: “The Committee provides $264,032,000 for Alcohol and Substance Abuse, $5,689,000 above the enacted level and $264,032,000 above the budget request. This amount transfers $31,000 to Urban Indians from the former National Institute on Alcohol Abuse and Alcoholism (NIAAA). Funding for Substance Abuse and Suicide Prevention grants is continued at fiscal year 2022 enacted levels.”

Community Health Aide Program (CHAP): $25 million

  • Bill Report: “[…] an additional $20,000,000 is provided to expand the Community Health Aide Program to the lower 48 states with direction for IHS to report within 90 days of enactment of this Act on how funds will be distributed”

Tribal Epidemiology Centers: $34,433,361

  • Bill Report: “[…] an additional $10,000,000 is for Tribal Epidemiology Centers”

Hepatitis C, HIV/AIDS and STDs Initiative: $52 million

  • Bill Report: “[…] an additional $47,000,000 is for the Hepatitis C, HIV/AIDS and STDs initiative.”

Maternal Health: $10 million

  • Bill Report: “The recommendation also includes an additional $4,000,000 to improve maternal health with continued direction to report to the Committee within 180 days of enactment of this Act on use of funds, updates on staff hiring, status of related standards, and the amount of training provided with these funds.”

Alzheimer’s Disease: $5.5 million

  • Bill Report: “The recommendation maintains $5,500,000 to continue Alzheimer’s and related dementia activities at IHS. These funds will further efforts on Alzheimer’s awareness campaigns tailored for the AI/AN perspective to increase recognition of early signs of Alzheimer’s and other dementias; quarterly, competency-based training curriculum, either in-person or virtually, for primary care practitioners to ensure a core competency on assessing, diagnosing, and managing individuals with Alzheimer’s and other dementias; pilot programs to increase early detection and accurate diagnosis, including evidence based caregiver services within Indian Country, inclusive of urban Indian organizations (UIO); and an annual report to the Committee with data elements including the prevalence of Alzheimer’s incidence in the preceding year, and access to services within 90 days of the end of each fiscal year. The Committee continues direction to develop a plan, in consultation with Indian Tribes and urban confer with UIOs, to assist those with Alzheimer’s, the additional services required, and the costs associated with increasing Alzheimer’s patients and submit this information to Congress within 270 days of enactment of this Act.”

Produce Prescription Pilot Program:

  • Bill Report: “The Committee continues $3,000,000 for IHS to create, in coordination with Tribes and UIOs, a pilot program to implement a produce prescription model to increase access to produce and other traditional foods among its service population. Within 60 days of enactment of this Act, the Committee expects IHS to explain how the funds are to be distributed and the metrics to be used to measure success of the pilot, which shall include engagement metrics, and may include appropriate health outcomes metrics, if feasible.”

Headache Disorders Centers of Excellence:

  • Bill Report: “The Committee recognizes that over 560,000 people under IHS care are living with migraine or severe headache disorders and that AI/AN communities have the highest prevalence of both disabling headache disorders and concussion/mild traumatic brain injuries, among any racial or ethnic group in the United States. The Committee is concerned that AI/AN patients with chronic migraine, post-traumatic headache, and other disabling headache disorders often do not receive necessary specialty care. The IHS is encouraged to consider the feasibility of IHS Headache Centers of Excellence and if feasible, developing a budget proposal to establish IHS Headache Centers of Excellence to provide direct care, telehealth, and consultation patient services, as well as education and training.”

Senate Proposes $80.4 million for Urban Indian Health, Includes $5.6 billion in Advance Appropriations for IHS for FY 2023

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The bill will not receive committee markups and includes $7.38 billion for IHS, $1.72 billion less than the amount requested by the President.

WASHINGTON, D.C. (July 29, 2022): The Senate Appropriations Subcommittee has released its fiscal year (FY) 2023 Interior, Environment, and Related Agencies bill with $80.4 million for urban Indian health— $7 million above the current enacted level, and $32 million below the President’s request. The bill also authorizes $7.38 billion for the Indian Health Service (IHS), an increase of $762 million from FY 2022, but $1.72 billion below the President’s request. Thanks to the robust advocacy efforts from NCUIH, Urban Indian Organizations (UIOs) and Tribes alike, the bill text provides $5.577 billion of advance appropriations for IHS for FY 2024. The bill will not receive any committee markups. Other key provisions include $9 million to improve maternal health, increased funding for mental health programs, and expanded funding for community health representatives. A more detailed analysis follows below.

The Committee is not going to conduct markups and it is expected that there will be a continuing resolution when FY22 funding expires on September 30, 2022. NCUIH will continue to advocate for full funding for IHS and urban Indian health with Advance Appropriations for FY23 as negotiations proceed later in the year.

“NCUIH is grateful for the Committee’s inclusion of $80 million for urban Indian health for Fiscal Year 2023, but disappointed to see the reduced request from last year given all the growing costs of inflation. While the proposed amount would not fully fund the Indian Health Service, we are grateful for the inclusion of critical advance appropriations.  We thank all members of the Committee for their efforts to provide resources for Native healthcare and achieve advance appropriations. The Indian Health Service has worked with inadequate and unstable funding for too long, and we hope that the federal government can finally fulfill its trust responsibility to Natives and provide the care we need” – Francys Crevier (Algonquin), CEO, NCUIH.

Advance appropriations is a long-standing priority for Indian Country. Advocates have continuously requested that Congress provide stable funding for IHS, especially considering the impact of the COVID-19 pandemic, which disproportionately affected American Indians and Alaska Natives (AI/ANs) who lost their lives at the highest rates of any population. The President’s budget proposed to shift IHS from discretionary funding to mandatory funding in FY 2023. During this time, Native health advocates requested advance appropriations. During the last few months alone, NCUIH sent letters to request Senate and House leadership to allow for advance appropriations, and the National Congress of American Indians (NCAI) and the National Indian Health Board (NIHB) sent an action alert to request advance appropriations by the House Appropriations Committee. In addition, NCUIH, along with 28 Representatives and 12 Senators, requested advanced appropriations for IHS until such time that authorizers move IHS to mandatory spending.

Line Item FY22 Enacted   FY23 TBFWG Request FY23
President’s
Budget		 FY23
House Proposed		 FY23 Senate Proposed
Urban Indian Health $73,424,000   $949,900,000 $112,514,000 $200,000,000 $80,424,000
Indian Health Service $6,630,986,000   $49,800,000,000 $9,100,000,000 $8,100,000,000 $7,380,000,000
House Appropriations Status

The House passed H.R. 8294 as part of six-bill package on July 21, 2022. The bill included $200 million for urban Indian health, but fails to include advance appropriations for IHS.

Background and Advocacy

On March 28, 2022, President Biden released his budget request for FY 2023 which included, for the first time ever, $9.1 billion in mandatory funding for IHS for the first year with increased yearly funding over the next ten years, and $112.5 million for Urban Indian Health— a 53.2% increase above the FY 2022 enacted amount of $73.4 million.

Full Funding, Advance Appropriations, and Mandatory Funding a Priority

NCUIH requested $49.8 billion for the Indian Health Service and $949.9 million for Urban Indian Health for FY 2023 (as requested by the Tribal Budget Formulation Workgroup (TBFWG) recommendations), Advance appropriations for IHS, and support of mandatory funding for IHS (including UIOs).The considerable increase for FY 2023 is a result of Tribal leaders providing budgetary recommendations for gradual funding increases over the last 10-12 years to address growing health disparities that have gone largely ignored by the federal government. ), advance appropriations for IHS, and support of mandatory funding for IHS (including UIOs).The considerable increase for FY 2023 is a result of Tribal leaders providing budgetary recommendations for gradual funding increases over the last 10-12 years to address growing health disparities that have gone largely ignored by the federal government.

On April 5, 2022, NCUIH President and CEO of the Indian Health Center of Santa Clara Valley, Sonya Tetnowski (Makah Tribe), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2023 funding for UIOs. Most recently, on July 28, 2022, NCUIH testified before the House Subcommittee for Indigenous Peoples in the United States in support of authorizing advance appropriations authority to IHS. In her testimony, Maureen Rosette, NCUIH Board member and Chief Operations Officer of NATIVE Project, emphasized how advance appropriations would no longer subject IHS and Tribal health facilities, especially UIOs, to government shutdowns, automatic sequestration cuts, and continuing resolutions.

NCUIH also worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations in support of increasing the urban Indian health line item for FY 2023. The letter had bipartisan support and called for the highest possible funding for Urban Indian Health up to the TBFWG’s recommendation of $949.9 million and advanced appropriations for IHS until such time that authorizers move IHS to mandatory spending.

Senate Bill Highlights

Indian Health Service: $7.38 billion
  • Bill Report: “For fiscal year 2023, the Administration proposed mandatory funding for all IHS accounts, however at this time no such change has been enacted into law. Therefore, the Committee recommendation provides $7,380,063,000 for IHS for fiscal year 2023 discretionary funding, an increase of $749,077,000 to the enacted level and a decrease of $1,528,937,000 to the requested level of mandatory funding.”
Urban Indian Health: $80.424 million
  • Bill Report: “The recommendation includes $80,424,000 for the Urban Indian Health program, $7,000,000 above the enacted level and $32,089,000 below the budget request.”
  • UIO Interagency workgroup: “The Committee is committed to improving the health and wellbeing of American Indians and Alaska Natives [AI/AN] living in urban Indian communities. Despite the excellent efforts of Urban Indian Organizations, AI/AN populations continue to be left out of many Federal initiatives. Therefore, the Committee 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.”
Advance Appropriations for IHS: $5.577 billion
  • Bill Report: “The Committee recommendation provides advance appropriations for the Indian Health Services and Indian Health Facilities accounts totaling $5,577,077,000 for fiscal year 2024. That amount is equal to the fiscal year 2023 recommendation for those accounts with the exception of funding provided for Electronic Health Records, Sanitation Facilities Construction, and Health Care Facilities Construction which are provided only an annual appropriation in recognition of the project-based nature of those accounts. Overall, the vast majority of Indian Health Service funding, and all such funding supporting the provision of health services to Native Americans such as patient care and medical equipment, is provided an advance appropriation. The Committee recognizes that budget uncertainty due to temporary lapses of appropriations and continuing resolutions have an effect on the orderly operations of critical healthcare programs for Native American communities. Existing challenges related to recruitment and retention of healthcare providers, administrative burden and costs, and financial effects on Tribes were identified areas of concern in a Government Accountability Office [GAO] study (GAO–18–652). This budgetary change will enable IHS to continue to provide health services without interruption or uncertainty, improving the quality of care and providing peace of mind for patients and medical providers.”
Improving Maternal Health: $9 million
  • Bill Report: “$9,000,000 has been included for the maternal health initiative, as estimated in the mandatory proposal. Pregnancy-related deaths have increased generally in the United States with pregnancy-related deaths among Native American women more than twice the non-Hispanic white women rate. The Committee continues to direct IHS to submit a report to the Committee within 180 days of enactment of this act on use of funds, updates on staff hiring, status of related standards, and the amount training provided with these funds.”
Dental Therapy Education Program: $2 million
  • Bill Report: “Within the funds provided, $2,000,000 is to be used for the dental health therapy education program that currently trains students in Alaska, Washington, Idaho, and Oregon. The Committee also directs the Service to continue the cooperative agreement with the National Indian Health Board from within existing funds.”
Dental Health: $260.326 million
  • Bill Report: “The recommendation includes $260,326,000 for dental health, an increase of $24,538,000 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.”
Electronic Health Records: $190 million
  • Bill Report: “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 $190,000,000 for this effort. Further, the Committee understands many Tribes recently upgraded computer systems for the new Department of Veterans Affairs [VA] system, and it is important these systems are compatible. It is the Committee’s expectation that the Service will be able to use the compiled information gathered during this recent effort with VA to inform both the Service and the Committee on which Tribes use their own system and the estimated costs. Finally, the Committee notes that the Electronic Health Records is excluded from the advance appropriation for fiscal year 2024 as specified in the bill.”
Produce Prescription Pilot Program
  • Bill Report: “The recommendation maintains fiscal year 2022 funding to implement a produce prescription program to increase access to produce and other traditional foods in accordance with the explanatory statement accompanying the Consolidated Appropriations Act, 2022, Public Law 117–103.”
Mental Health: $127 million
  • Bill Report: “The recommendation includes $127,088,000 for mental health programs, an increase of $5,142,000 above the enacted level. The bill maintains $6,946,000 for the behavioral health integration initiative to better integrate treatment programs for mental health and substance abuse problems and $3,600,000 for the suicide prevention initiative.”
Alcohol and Substance Abuse: $270.49 million
  • Bill Report: “The recommendation includes $270,490,000 for alcohol and substance abuse programs, an increase of $12,147,000 above the enacted level.”
Opioid Grants: $13 million
  • Bill Report: “To better combat the opioid epidemic, the recommendation includes $13,000,000 to continue a Special Behavioral Health Pilot Program, as authorized by Public Law 116–6. The Director of IHS, in coordination with the Assistant Secretary for Mental Health and Substance Abuse, shall award grants for providing services, provide technical assistance to grantees under this section, and evaluate performance of the program.”
Community Health Representatives: $67 million; CHAP Expansion: $5 million
  • Bill Report: “The recommendation includes $67,000,000 for the community health representatives program, an increase of $3,321,000 above the enacted level. The Committee recommendation includes $5,000,000 for the Community Health Aide Program [CHAP] expansion with instruction that this expansion should not divert funding from the existing CHAP program which shall continue at current levels.”
Headache Centers of Excellence
  • Bill Report: “The Committee recognizes that over 560,000 people under IHS care are living with migraine or severe headache disorders and that American Indian and Alaskan Native [AI/AN] communities have the highest prevalence of both disabling headache disorders and concussion/mild traumatic brain injuries among any racial or ethnic group in the United States. The Committee is concerned that AI/AN patients with these and other disabling headache disorders often do not receive necessary specialty care. There are currently no IHS-affiliated physicians certified with training in the specialty field of Headache, and there is an insufficient number of IHS neurologists overall. The Committee encourages IHS to consider the feasibility of establishing Headache Centers of Excellence in future fiscal years.”

House Releases FY 2023 Appropriations Bill with $200 Million for Urban Indian Health, Fails to Include Advance Appropriations

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The bill is to be considered by Full Committee this week and includes $8.1 billion for IHS, $1 billion less than the amount requested by the President.

Today, June 28, 2022, the House Appropriations Subcommittee on Interior, Environment, and Related Agencies released the Committee Bill Report for the fiscal year (FY) 2023 budget with $200 million for urban Indian health. The report and bill will be considered by the full House Appropriations Committee tomorrow morning and was approved by the House Subcommittee on Interior on June 21, 2022. The bill authorizes $8.1 billion for the Indian Health Service (IHS)— an increase of $1.5 billion from FY22 but $1 billion below the President’s request. Despite robust advocacy from Tribes and Urban Indian Organizations (UIOs), the bill does not include advance appropriations. Other key provisions include $17 million for generators for IHS/Tribal Health Programs/UIOs and $3 million for a Produce Prescription Pilot Program for Tribes and UIOs to increase access to produce and other traditional foods. A more detailed analysis follows below.

“NCUIH is grateful for the Committee’s inclusion of $200 million for urban Indian health for Fiscal Year 2023, but disappointed to see the reduced request from last year given all of the effects of COVID-19 and the growing costs of inflation. Unfortunately, the proposed amount would not fully fund the Indian Health Service and does not include critical advance appropriations. We especially thank Congresswoman McCollum and Ranking Member Joyce for their continued efforts to provide resources for Native healthcare and achieve advance appropriations. Too many Native lives have been lost during times of funding instability and we have had enough. We hope that House leaders will hear the calls of Indian Country to prioritize equity and provide stable funding for our health in accordance with the trust responsibility.” – Francys Crevier (Algonquin), CEO, NCUIH.

The President’s budget proposed to shift IHS from discretionary funding to mandatory funding in FY 2023. In the meantime, Native health advocates requested Advance Appropriations. To much disappointment, the House bill does not provide (or even mention) advance appropriations for IHS. Advance appropriations is a long-standing priority for Indian Country and advocates have been requesting Congress to provide stable funding for IHS especially considering the COVID-19 pandemic which has had tremendous, adverse impacts for American Indians and Alaska Natives. In the past month alone, NCUIH sent a letter to request Speaker Pelosi to allow for advance appropriations and NCAI and NIHB sent an action alert to request the Appropriations Committee include advance appropriations. Previously, NCUIH, along with 28 Representatives and 12 Senators requested advanced appropriations for IHS until such time that authorizers move IHS to mandatory spending.

Line Item FY22 Enacted FY23 TBFWG Request FY23
President’s
Budget		 FY23 House Proposed
Urban Indian Health $73,424,000 $949,900,000 $112,514,000 $200,000,000
Indian Health Service $6,630,986,000 $49,800,000,000 $9,100,000,000 $8,100,000,000

Background and Advocacy

On March 28, 2022, President Biden released his budget request for Fiscal Year FY 2023 which included, for the first time ever, $9.3 billion in mandatory funding for IHS for the first year with increased funding each year over ten years. On April 25, 2022, the Indian Health Service (IHS) published their FY 2023 Congressional Justification with the full details of the President’s Budget, which included $112.5 million for Urban Indian Health— a 53.2% increase above the FY 2022 enacted amount of $73.4 million.

Full Funding, Advance Appropriations, and Mandatory Funding a Priority

NCUIH requested full funding for urban Indian health for FY 2023 at $949.9 million and at least $49.8 billion for IHS in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. The marked increase for FY23 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 5, 2022, NCUIH President-Elect and CEO of the Indian Health Center of Santa Clara Valley, Sonya Tetnowski (Makah Tribe), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2023 funding for UIOs. NCUIH requested $49.8 billion for the Indian Health Service and $949.9 million for Urban Indian Health for FY 2023 as requested by the TBFWG, Advance appropriations for IHS, and support of mandatory funding for IHS including UIOs.

NCUIH recently worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations in support of increasing the urban Indian health line item for FY 2023. The letter has bipartisan support and calls for the highest possible funding for Urban Indian Health up to the TBFWG’s recommendation of $949.9 million and advanced appropriations for IHS until such time that authorizers move IHS to mandatory spending. On May 27, 2022, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests.

During last week’s House Interior Subcommittee markup on the FY2023 funding bill, Rep. Chellie Pingree said of mandatory funding: “This shift requires legislative action by the authorizing committee, the House Committee on Natural Resources. In the absence of that legislation, I have included discretionary funding in this bill to ensure that there is no risk of a disruption in healthcare while that process is underway.”

Bill Highlights

Indian Health Service: $8.1 billion

  • $8.1 billion for the Indian Health Service, an increase of $1.5 billion above the FY 2022 enacted level.

Urban Indian Health: $200 million

  • Bill Report: “The recommendation includes $200,000,000 for Urban Indian Health, $126,576,000 above the enacted level and $200,000,000 above the budget request. This amount includes $31,000 transferred from the Alcohol and Substance Abuse Program as part of the for NIAAA program. The Committee expects the Service to continue including current services estimates for Urban Indian health in annual budget requests.”

Mandatory Funding:

  • Bill Report: “For fiscal year 2023, the Administration proposed reclassifying IHS accounts as mandatory and did not submit a discretionary budget proposal. However, IHS did not provide implementation language and at the time of writing this report, the authorizing committees have not enacted the President’s proposal. Because the authorizing committees have not acted, the Committee is providing discretionary funds for IHS for fiscal year 2023 to ensure health care for Native Americans is not negatively impacted.”
  • Note: There is no mention of advance appropriations for IHS in this bill.

Equipment: $118.5 million

  • Bill Report: “The recommendation includes $118,511,000 for Equipment, $88,047,000 above the enacted level and $118,511,000 above the budget request. The bill continues $500,000 for TRANSAM.
  • The report further states: “The Committee is aware that the increasing severity and frequency of extreme weather events has motivated certain jurisdictions to adopt de-energization protocols to reduce the risks of catastrophic wildfires. While these protocols are useful in limiting loss of life in affected communities, they can also have dire consequences for Tribal Health Programs located in impacted areas. To increase the resilience of these facilities, the recommendation includes an additional $17,000,000 to purchase generators for IHS, Tribal Health Programs, and Urban Indian Organizations located in areas impacted by de-energization events. In procuring backup generators, the Indian Health Service is directed to determine the most cost-effective method, which may include leasing. In determining the most cost-effective procurement method, the Service shall account for life-cycle maintenance costs associated with direct ownership and clinics’ capabilities to maintain these generators.”

Electronic Health Records: $284.5 million

  • Bill Report: “To improve the current IT infrastructure system to support deployment of a new modern electronic health records (EHR) solution, the recommendation includes $284,500,000 for Electronic Health Records, $139,481,000 above the enacted level and $284,500,000 above the budget request.
  • The report further states: “The Committee urges IHS to continue moving forward with modernizing its aging EHR system by replacing it with a solution that is interoperable with the new EHR at the Department of Veterans Affairs and with systems purchased by Tribes and UIOs. Modernization should include robust Tribal consultation and planning to ensure that Tribes and UIOs are enabled to take full advantage of resulting modern health information technology and are not unduly burdened during this process.”

Mental Health: $130 million

  • Bill Report: “The recommendation includes $129,960,000 for Mental Health, $8,014,000 above the enacted level and $129,960,000 above the budget request.”

Alcohol and Substance Abuse: $264 million

  • Bill Report: “The Committee provides $264,032,000 for Alcohol and Substance Abuse, $5,689,000 above the enacted level and $264,032,000 above the budget request. This amount transfers $31,000 to Urban Indians from the former National Institute on Alcohol Abuse and Alcoholism (NIAAA). Funding for Substance Abuse and Suicide Prevention grants is continued at fiscal year 2022 enacted levels.”

Community Health Aide Program (CHAP): $25 million

  • Bill Report: “[…] an additional $20,000,000 is provided to expand the Community Health Aide Program to the lower 48 states with direction for IHS to report within 90 days of enactment of this Act on how funds will be distributed”

Tribal Epidemiology Centers: $34,433,361

  • Bill Report: “[…] an additional $10,000,000 is for Tribal Epidemiology Centers”

Hepatitis C, HIV/AIDS and STDs Initiative: $52 million

  • Bill Report: “[…] an additional $47,000,000 is for the Hepatitis C, HIV/AIDS and STDs initiative.”

Maternal Health: $10 million

  • Bill Report: “The recommendation also includes an additional $4,000,000 to improve maternal health with continued direction to report to the Committee within 180 days of enactment of this Act on use of funds, updates on staff hiring, status of related standards, and the amount of training provided with these funds.”

Alzheimer’s Disease: $5.5 million

  • Bill Report: “The recommendation maintains $5,500,000 to continue Alzheimer’s and related dementia activities at IHS. These funds will further efforts on Alzheimer’s awareness campaigns tailored for the AI/AN perspective to increase recognition of early signs of Alzheimer’s and other dementias; quarterly, competency-based training curriculum, either in-person or virtually, for primary care practitioners to ensure a core competency on assessing, diagnosing, and managing individuals with Alzheimer’s and other dementias; pilot programs to increase early detection and accurate diagnosis, including evidence based caregiver services within Indian Country, inclusive of urban Indian organizations (UIO); and an annual report to the Committee with data elements including the prevalence of Alzheimer’s incidence in the preceding year, and access to services within 90 days of the end of each fiscal year. The Committee continues direction to develop a plan, in consultation with Indian Tribes and urban confer with UIOs, to assist those with Alzheimer’s, the additional services required, and the costs associated with increasing Alzheimer’s patients and submit this information to Congress within 270 days of enactment of this Act.”

Produce Prescription Pilot Program:

  • Bill Report: “The Committee continues $3,000,000 for IHS to create, in coordination with Tribes and UIOs, a pilot program to implement a produce prescription model to increase access to produce and other traditional foods among its service population. Within 60 days of enactment of this Act, the Committee expects IHS to explain how the funds are to be distributed and the metrics to be used to measure success of the pilot, which shall include engagement metrics, and may include appropriate health outcomes metrics, if feasible.”

Headache Disorders Centers of Excellence:

  • Bill Report: “The Committee recognizes that over 560,000 people under IHS care are living with migraine or severe headache disorders and that AI/AN communities have the highest prevalence of both disabling headache disorders and concussion/mild traumatic brain injuries, among any racial or ethnic group in the United States. The Committee is concerned that AI/AN patients with chronic migraine, post-traumatic headache, and other disabling headache disorders often do not receive necessary specialty care. The IHS is encouraged to consider the feasibility of IHS Headache Centers of Excellence and if feasible, developing a budget proposal to establish IHS Headache Centers of Excellence to provide direct care, telehealth, and consultation patient services, as well as education and training.”

NCUIH Submits Written Testimony to Senate Interior Appropriations with FY23 Budget Requests for Urban Indian Health

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The National Council of Urban Indian Health (NCUIH) CEO, Francys Crevier (Algonquin), submitted public witness written testimony to the Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding Fiscal Year (FY) 2023 funding for Urban Indian Organizations (UIOs) in response to the Subcommittee Hearing, “A Review of the Fiscal Year 2023 President’s Budget for the Indian Health Service,” held on May 11, 2022. NCUIH advocated in its testimony for additional resources for the Indian Health Service and urban Indian Health.

Full Text of Testimony

In the testimony, NCUIH requested the following:

  • $49.8 billion for the Indian Health Service (IHS) and $949.9 million for Urban Indian Health for FY23 (as requested by the Tribal Budget Formulation Workgroup)
  • Advance appropriations for IHS until mandatory funding is enacted

These requests are essential to ensure that urban Indians are properly cared for and move us closer to fulfilling the federal government’s trust responsibility to American Indians/Alaska Natives (AI/ANs).

Background:

On March 28, 2022, President Biden released his discretionary budget request for FY23. This request includes $127.3 billion for the Department of Health and Human Services (HHS), $9.1 billion in mandatory funding for IHS— an increase of $2.5 billion above the 2022 enacted level, and $112.5 million for Urban Indian Health— an increase of $39.1 billion above the 2022 enacted level.

NCUIH previously submitted testimony to the House Appropriations Subcommittee on Interior regarding UIO funding for FY23 and reiterated that “The federal government owes a trust responsibility to tribes and AI/ANs that is not restricted to the borders of reservations. Funding for Indian health must be significantly increased if the federal government is, to finally, and faithfully, fulfill its trust responsibility.”

On May 27, 2022, 12 Senators echoed these requests in a letter to Chairman Jeff Merkley and Ranking Member Lisa Murkowski of the Senate Interior Appropriations Committee. The letter emphasizes that increasing funding “is essential to providing quality, culturally-competent health care to AI/AN people living in urban areas.” Earlier, on April 26, 2022, 28 Representatives sent a letter to the House Interior Appropriations Committee with similar requests.

NEXT STEPS:

The testimony will be read and considered by the Subcommittee as the appropriations process goes forward for Fiscal Year 2023. The Senate markup schedule is yet to be released.

The House Interior Subcommittee markup for its FY 2023 appropriations bill will be held on June 21, 2022, and the Full Committee markup will be held on June 29, 2022. Further details on the timing and location of each markup are to be determined.

12 Senators Request Increased Resources for Urban Indian Health and Support Mandatory Funding for Indian Health in FY23

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On May 27, 2022, 12 Senators requested up to $949.9 million for urban Indian health in FY23 and advanced appropriations for the Indian Health Service (IHS) until such time that authorizers move IHS to mandatory spending.

Senator Tina Smith (D-MN) and 11 other Senators requested up to $949.9 million for urban Indian health in FY23 and advanced appropriations for IHS until such time that authorizers move IHS to mandatory in a letter to Chair Merkley and Ranking Member Lisa Murkowski of the Senate Interior Appropriations Committee. The letter emphasizes that increasing funding “is essential to providing quality, culturally-competent health care to AI/AN people living in urban areas.” On April 26, 2022, a group of 28 Representatives sent a letter to the House Interior Appropriations Committee with the same requests.

This letter comes as a continued effort by the National Council of Urban Indian Health (NCUIH) to address acute health disparities for American Indians/Alaska Natives (AI/ANs) living in urban areas, who suffer greater rates of chronic disease, infant mortality and suicide compared to all other populations that have only been exacerbated by COVID-19. Congress has acknowledged these significant health care disparities in Indian Country, but continuously underfunds IHS at around $4,000 per patient, and urban Indian organizations (UIOs) at less than $700 per patient even though AI/ANs living in urban areas comprise over two-thirds of the total AI/AN population.

The senators also stated their support for the President’s proposal of mandatory funding. The Indian health system is currently not shielded from the negative impacts of government shutdowns, continuing resolutions, and automatic sequestration cuts. Already underfunded, these disruptions can have serious consequences to UIOs’ ability to provide critical patient services.

This Appropriations letter sends a powerful and straightforward message to Chair Merkley and Ranking Member Lisa Murkowski, and members of the Senate that in order to fulfill the federal government’s trust responsibility to all AI/ANs to provide safe and quality healthcare, funding for urban Indian health must be significantly increased.

NCUIH is grateful for the support of the following Senators:

  1. Tina Smith
  2. Dianne Feinstein
  3. Tammy Baldwin
  4. Chris Van Hollen
  5. Amy Klobuchar
  6. Catherine Cortez Masto
  7. Maria Cantwell
  8. Alex Padilla
  9. Ben Ray Lujan
  10. Jacky Rosen
  11. Elizabeth Warren
  12. Bernard Sanders

Full Letter Text

Dear Chairman Merkley and Ranking Member Murkowski,

We write to thank you for your proven commitment to urban Indian health and the 41 Urban Indian Organizations (UIOs) and to request you continue your support by appropriating $949.9 million for urban Indian health, supporting the President’s proposal for mandatory funding for the Indian Health Service (IHS), and securing advance appropriations for IHS in the Fiscal Year (FY) 2023 Interior, Environment, and Related Agencies Appropriations Act.

UIOs operate 77 facilities across the nation in 22 states, serving the approximately two thirds of American Indian and Alaska Native (AI/AN) people who live in urban areas. UIOs are an important part of the IHS, which oversees a three-prong system for the provision of health care: Indian Health Service, Tribal Programs, and Urban Indian Organizations (I/T/U). UIOs are not eligible for other federal line items that IHS and Tribal facilities are, like hospitals and health clinics money, purchase and referred care dollars, or IHS dental services dollars. Therefore, this funding request is essential to providing quality, culturally-competent health care to AI/AN people living in urban areas.

Our request for $949.9 million for urban Indian health reflects the recommendation made by the Tribal Budget Formulation Workgroup (TBFWG), a group of Tribal leaders representing all twelve IHS service areas. The significantly increased request for FY23 reflects the full funding needed for urban Indian health. Tribal leaders are unified in this request for full funding.

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

Yet, despite the historical acknowledgement from Congress of the significant health care disparities in Indian Country, IHS is underfunded at around $4,000 per patient, and UIOs receive less than $700 per patient.

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

As a result of the COVID-19 pandemic, UIOs are reporting historic numbers of new patients. Should funding return to pre-pandemic levels, UIOs would not have the staff or resources to continue to meet the community need. A budget increase would allow UIOs, as well as IHS and Tribal facilities, to hire more staff, pay appropriate wages, and expand vital services, programs, and facilities.

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