Tag Archive for: Advance Appropriations

Biden FY23 Budget Request Includes $9.1 Billion in Mandatory Funding for IHS

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On March 28, 2022, President Biden released his Fiscal Year (FY) 2023 Budget. The budget includes $9.1 billion in mandatory funding for the Indian Health Service (IHS) for the first year, an increase of $2.9 billion above FY 2021, and $40.7 billion less than requested by the Tribal Budget Formulation Workgroup (TBFWG). The budget proposes increased funding for IHS each year over ten years, building to $36.7 billion in FY 2032, to keep pace with population growth, inflation, and healthcare costs. Funding for Contract Support Costs and 105(l) leases also shifted from discretionary to mandatory funding in the FY 2023 budget. The President’s budget does not include advance appropriations for IHS, which was requested in the FY 2022 budget. Note: The urban Indian health amount has not yet been released and detailed agency requests are expected to be available in the coming days.

Mandatory Funding for IHS

The Budget Brief stated, “The Administration is committed to implementing long-term solutions to address chronic under-funding of IHS and finally delivering on the nation’s promises to Indian Country.” Further, it states, “Implementing this change to the IHS budget will make meaningful progress toward redressing health inequities and ensuring that the disproportionate impacts of the COVID-19 pandemic on AI/AN communities are never repeated.” About the budget for IHS, President Biden stated it, “makes high-impact investments that will expand access to healthcare services, modernize aging facilities and information technology infrastructure, and address urgent health issues, including HIV and Hepatitis C, maternal mortality, and opioid use. It also includes funding to improve healthcare quality, enhance operational capacity, fully fund operational costs for Tribal health programs to support tribal self-determination, and recruit and retain healthcare providers.”

Advancing health equity by providing high quality care in Indian country is a priority for Biden. The budget book states, “Historical trauma and chronic underinvestment significantly contributed to the perpetuation of health disparities in Indian Country. These stark inequities illustrate the urgent need for investments to improve the health status and quality of life of AI/ANs. In FY 2023, the budget includes $6.3 billion in the Services account, an increase of $1.6 billion above FY 2022 enacted. These increases will expand access to programs that provide essential health services and community-based disease prevention and promotion in tribal communities. This funding will support additional direct patient care services across the IHS system, including inpatient, outpatient, ambulatory care, dental care, and medical support services, such as laboratory, pharmacy, nutrition, behavioral health services, and physical therapy.”

Chart from the Budget Book with Projected Funding for IHS

From President Biden’s Strengthening America’s Public Health Infrastructure section in the Budget, it states the following, “Guarantees Adequate and Stable Funding for the Indian Health Service (IHS). The Budget significantly increases IHS’s funding over time, and shifts it from discretionary to mandatory funding. For the first year of the proposal, the Budget includes $9.1 billion in mandatory funding, an increase of $2.9 billion above 2021. After that, IHS funding would automatically grow to keep pace with healthcare costs and population growth and gradually close longstanding service and facility shortfalls. Providing IHS stable and predictable funding would improve access to high quality healthcare, rectify historical underfunding of the Indian Health system, eliminate existing facilities backlogs, address health inequities, and modernize IHS’ electronic health record system. This proposal has been informed by consultations with tribal nations on the issue of IHS funding and will be refined based on ongoing consultation.”

Tribal Consultation Included as a Priority

According to the Budget, Tribal Consultation and Reconvening the White House Council on Native American Affairs was also included as priority. In his first days in office, the President issued a memorandum making it a priority of his Administration to make respect for Tribal sovereignty and self-governance, commitment to fulfilling Federal trust and treaty responsibilities to Tribal Nations, and regular, meaningful, and robust consultation with Tribal Nations cornerstones of Federal Indian policy. Since then, the Administration has been regularly meeting with Tribal Nations on a range of Administration priorities, from implementing the Bipartisan Infrastructure Law to drafting the President’s Budget.

Background and Next Steps

The Appropriations Committees will review the President’s Budget for consideration as they craft their bills for FY23. NCUIH has requested $949.9 million for FY23 for urban Indian health with at least $49.8 billion for the Indian Health Service in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. NCUIH will continue to work with the Biden Administration and Congress to push for full funding of urban Indian health in FY 2023.

Overview of Budget Request

The budget request includes the following for American Indians/Alaska Natives:

Department of Health and Human Services (HHS)

  • The Budget requests $127.3 billion in discretionary funding for HHS, a $26.9 billion or 26.8 percent increase from the 2021 enacted level.

Indian Health Service

  • $9.1 billion in mandatory funding for the Indian Health Service (IHS) for the first year, an increase of $2.9 billion above FY 2021 and $40.7 billion less than requested by the TBFWG.
  • Ending HIV and Hepatitis C in Indian Country ($52 million): Provides $47 million above FY 2022 enacted to enhance access to HIV testing, promote linkages to care, provide treatment, and reduce the spread of HIV 37 Indian Health Service Indian Health Service through the prescribing of pre-exposure prophylaxis (PrEP). Funds will also support enhanced surveillance and data infrastructure to better track HIV, Hepatitis C, and sexually transmitted diseases through Tribal Epidemiology Centers.
  • Addressing Opioid Use ($20 million): Provides $9 million above FY 2022 enacted to enhance existing activities to provide prevention, treatment, and recovery services to address the impact of opioid use in AI/AN communities. This includes activities to increase knowledge and use of culturally appropriate interventions and encourage the use of medication-assisted treatment.

Maternal Health and Health Equity

  • The United States has the highest maternal mortality rate among developed nations, and rates are disproportionately high for Black and American Indian and Alaska Native women. The Budget includes $470 million to: reduce maternal mortality and morbidity rates; expand maternal health initiatives in rural communities; implement implicit bias training for healthcare providers; create pregnancy medical home demonstration projects; and address the highest rates of perinatal health disparities, including by supporting the perinatal health workforce. The Budget also extends and increases funding for the Maternal, Infant, and Early Childhood Home Visiting program, which serves approximately 71,000 families at risk for poor maternal and child health outcomes each year, and is proven to reduce disparities in infant mortality. To address the lack of data on health disparities and further improve access to care, the Budget strengthens collection and evaluation of health equity data. Recognizing that maternal mental health conditions are the most common complications of pregnancy and childbirth, the Budget continues to support the maternal mental health hotline and the screening and treatment for maternal mental depression and related behavioral disorders.
  • Improving Maternal Health ($10 million): Provides $4 million above FY 2022 enacted to improve maternal health in AI/AN communities. Funding supports preventive, perinatal, and postpartum care; addresses the needs of pregnant women with opioid or substance use disorder; and advances the quality of services provided to improve health outcomes and reduce maternal morbidity.

Department of the Interior (DOI)

  • The Budget requests $17.5 billion in discretionary funding for DOI, a $2.8 billion or 19.3 percent

increase from the 2021 enacted level.

    • $4.5 billion for the DOIs Tribal programs, a $1.1 billion increase above the 2021 enacted level.
    • $632 million in Tribal Public Safety and Justice funding at DOI, which collaborates closely with the Department of Justice, including on continued efforts to address the crisis of Missing and Murdered Indigenous Persons.

Bureau of Indian Affairs (BIA)

  • The Budget proposes to reclassify Contract Support Costs and Indian Self-Determination and Education Assistance Act of 1975 Section 105(l) leases as mandatory spending.
  • Contract Support Costs: Contract Support Costs are the necessary and reasonable costs associated with administering the contracts and compacts through which tribes assume direct responsibility for IHS programs and services. These are costs for activities the tribe must carry out to ensure compliance with the contract but are normally not carried out by IHS in its direct operation of the program. The budget proposes to fully fund Contract Support Costs at an estimated $1.1 billion through an indefinite mandatory appropriation to support these costs in FY 2023. The indefinite mandatory appropriation grows with inflation and is maintained across the 10-year budget window to ensure Contract Support Costs continue to be fully funded each year.
  • Tribal Leases: The Indian Self-Determination and Education Assistance Act requires compensation for reasonable operating costs associated with facilities leased or owned by tribes and tribal organizations to carry out health programs under the Act. In FY 2023, the budget proposes to fully fund section 105(l) leases, or tribal leases, at an estimated $150 million through an indefinite mandatory appropriation. The indefinite mandatory appropriation grows with inflation and is maintained across the 10-year budget window to ensure section 105(l) leases continue to be fully funded each year.

Bureau of Indian Education (BIE)

  • $156 million increase to support construction work at seven Bureau of Indian Education schools, providing quality facilities for culturally appropriate education with high academic standards.
  • $7 million for the Federal Boarding School Initiative.

NCUIH Joins NIHB and 70 Organizations Calling on Congress to include $8 Billion for IHS in FY 2022 and Advance Appropriations

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On March 9, 2022, the National Council of Urban Indian Health (NCUIH) joined the National Indian Health Board (NIHB), and over 70 Tribal nations, Tribal and national Indian organizations, and friends of Indian health in sending a series of joint letters to Congress amid their final negotiations of an omnibus appropriations bill for Fiscal Year (FY) 2022. The recommendations for reauthorization outlined in the letter include:

  • No less than the House-passed level of $8.114 billion for the Indian Health Service (IHS) in the final Appropriations bill for FY 2022
  • Advance Appropriations for the Indian Health Service (IHS)

The House-passed funding level would be an increase of $1.88 billion over the FY 2021 enacted level. The Senate Appropriations Committee FY 2022 funding bill included $6.6 billion in Advance Appropriations for IHS FY 2023.

Letters to Congress:

 

Background and Advocacy

NCUIH has long advocated for larger investments in AI/AN health care and has called on Congress to strengthen their commitment to Indian Country with increased funding in the FY 2022 appropriations:

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

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The National Council of Urban Indian Health (NCUIH) submitted written testimony for Tribal Public Witnesses to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding Fiscal Year (FY) 2023 funding for Urban Indian Organizations (UIOs). On January 28, 2022, the Subcommittee Chair and Ranking Member requested information from “Indian Country on issues and needs” that is used to develop the annual appropriations bill.

NCUIH advocated in its testimony for additional resources for the Indian Health Service and urban Indian Health.

In the testimony, NCUIH requested the following:

  • $48 billion for the Indian Health Service and $950 million for Urban Indian Health for FY23 (as requested by the Tribal Budget Formulation Workgroup)
  • Advance appropriations for IHS
  • UIOs be insulated from unrelated budgetary disputes through a spend faster anomaly so that critical funding is not halted

NCUIH reiterated, “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.”

NEXT STEPS:

The testimony will be read and considered by the subcommittee as the appropriations process goes forward for FY23. The Subcommittee has not yet announced dates for the hearings on the FY 23 budget.

Omnibus Bill Released with VAWA and Strides for Urban Indian Health

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The bill includes $73.4 million for urban Indian health and $6.6 billion for IHS

On March 9, 2022, the House Appropriations Committee released a draft of the Consolidated Appropriations Act, 2022 (H.R. 2471) for Fiscal Year (FY) 2022 (also known as the “Omnibus”) consisting of $1.5 trillion in discretionary spending and $15.6 billion to manage the COVID-19 pandemic. This bill comes after Congress passed three Continuing Resolutions maintaining the FY 2021 budget, with the most recent CR set to expire on March 11, 2022. The 2741-page omnibus bill authorizes $6.6 billion for the Indian Health Service (IHS) for FY 2022, a 6.3% increase above the FY 2021 enacted level; $73.4 million for urban Indian health for FY 2022, a 17.13% increase above the FY 2021 enacted level and the highest increase in the past 10 years; 2022 Violence Against Women Act (VAWA) Reauthorization with Tribal and urban Indian provisions; and COVID-19 supplementals to manage the pandemic domestically and abroad.

The Tribal Budget Formulation Workgroup (TBFWG) requested $12.8 billion for the Indian Health Service and the House included $8.1 billion in its passed legislation, however, the amount enacted would be the highest increase of any account for the Department of Interior and Related Agencies, which demonstrates a strong bipartisan commitment from Congress to improving health outcomes for American Indians and Alaska Natives. Unfortunately, though, the final amount still falls well short of fully funding the Indian Health Service to properly provide health care services for all American Indians and Alaska Natives in the United States to meet the trust responsibility. Additionally, the bill does not include Advance Appropriations despite robust advocacy from Tribes and Urban Indian Organizations.

Current Status and Next Steps

Funding for the federal government expires on March 11. Congress will likely approve the current continuing resolution through March 15. It is expected that the Omnibus will be approved by Congress and signed into law by the President. As of 2:45 p.m. ET today, the COVID-19 supplemental funding has been removed and Speaker Pelosi says the House will move forward to vote on the Omnibus without the COVID funding. The National Council of Urban Indian Health (NCUIH) will continue to monitor developments and provide more in-depth analysis as legislation continues to move forward.

Overview of IHS and Urban Indian Health Requests

Line Item FY21 Enacted FY22 TBFWG Request FY22
President’s
Budget		 FY22 House
 Passed		 FY22 Senate
Proposed		 FY22 Draft Omnibus
 Urban Indian
Health		  $62,684,000  $200,548,000  $100,000,000  $200,500,000  $92,684,000 $73,424,000
Indian Health Service $6,236,279,000 $12,759,004,000 $8,471,279,000 $8,100,000,000 $7,616,250,000 $6,630,986,000
Advance Appropriations – – – – $6,586,250,000 (FY23) –
Missing and Murdered Indigenous Women – – – – $24,900,000 –

Summary

In summary, the package includes the following NCUIH priorities for Urban Indian health:

  • $73.4 million for urban Indian health for FY 2022
  • Inclusion of UIOs in the 2022 VAWA reauthorization
  • $30 million annually from FY23-FY27 for grants for Creating Hope Through Outreach, Options, Services, and Education for Children and Youth (CHOOSE Children & Youth) grants to enhance the safety of youth and children who are victims of, or exposed to, domestic violence, dating violence, sexual assault, stalking, or sex trafficking and prevent future violence.
    • UIOs added as eligible entities.
  • $10 million annually for a new 3-year program (FY23-FY27) to award grants for the clinical training of sexual assault forensic examiners to administer medical forensic examinations and treatments to survivors of sexual assault. Of the $10 million, there is a set aside of 15 percent for purposes of making grants to entities that are affiliated with Indian Tribes or Tribal organizations or Urban Indian organizations.
    • UIOs included as eligible entities.
  • $5 million for a new 5-year demonstration grants (FY23-FY27) established for comprehensive clinical training of health care providers to provide generalist forensic services and trauma-informed care to survivors of interpersonal violence of all ages. Of the $5 million, there is a set-aside of 10 percent for purposes of making grants to support training and curricula that addresses the unique needs of Indian Tribes, Tribal organizations, Urban Indian organizations, and Native Hawaiian organizations.
    • UIOs included as eligible entities.
  • Title VIII “Safety for Indian Women” includes the following purposes:
    • to empower Tribal governments and Native American communities, including urban Indian communities and Native Hawaiian communities, with the resources and information necessary to effectively respond to cases of domestic violence, dating violence, stalking, sex trafficking, sexual violence, and missing and murdered Native Americans; and
    • to increase the collection of data related to missing and murdered Native Americans and the sharing of information among Federal, State, Tribal, and local officials responsible for responding to and investigating crimes impacting Indian Tribes and Native American communities, including urban Indian communities and Native Hawaiian communities, especially crimes relating to cases of missing and murdered Native Americans.

In summary, the bill provides the following for IHS, tribal organizations, and Urban Indian Organizations (UIOs):

  • $6.6 billion for the Indian Health Service for fiscal year 2022
  • $4.7 billion for the IHS health services account
  • Fully funds Contract Support Costs and Payments for Tribal Leases
  • $940 million for health facilities construction
  • $12 million from Substance Abuse and Mental Health Services Administration (SAMHSA) to Indian Tribes, Tribal Organizations, or consortia for Medication-Assisted Treatment for Prescription Drug and Opioid Addiction
  • Increase to SAMHSA State Opioid Response (SOR) Grants for tribes and tribal organizations
    • UIO are not included
  • $22.5 million for the Good Health and Wellness in Indian Country program
  • $15.6 million to make payments under the National Health Service Corps loan repayment program

Background and Advocacy

The National Council of Urban Indian Health (NCUIH) has long advocated for larger investments in AI/AN health care and has called on Congress to strengthen their commitment to Indian Country with increased funding in the FY 2022 appropriations:

Most recently, NCUIH joined the National Indian Health Board (NIHB) and 70 organizations in a letter to several Members of Congress and Congressional Committees urging for Advance Appropriations and no less than the House-passed level of $8.114 billion for IHS in the final Appropriations bill for FY 2022:

VAWA

NCUIH has been tirelessly advocating for an expansion of resources for all AI/ANs, including those who reside off-reservation, in the VAWA reauthorization. Since the passing of the House bill on VAWA (H.R. 1620) early last year which excluded support for off-reservation AI/ANs, NCUIH successfully advocated for urban Indian communities to be added in the Senate draft bill released on December 8, 2021. NCUIH, UIOs, and stakeholders supporting Indian health provided written comments to Senate Committee on Indian Affairs (SCIA) leadership to retain the provisions to assist all AI/ANs in the final VAWA reauthorization bill.

Tribal Leaders Highlight Need for Increased Urban Indian Health Funding in Fiscal Year 2024 Area Reports

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On January 26-27, 2022, the Indian Health Service (IHS) held their Area Report Presentations Webinar for Fiscal Year (FY) 2024 where Tribal leaders from 12 IHS Areas and leaders from three Native organizations, including the National Council of Urban Indian Health (NCUIH), presented on their budget requests. Many Tribal leaders spoke about the need to increase urban Indian health funding and establish designated funding for urban Indian health facilities and infrastructure.  Many Areas also highlighted mental health and substance abuse needs, Health IT modernization, and permanent authorization of the Special Diabetes Program for Indians (SDPI). As part of the trust responsibility to provide health care to all American Indians and Alaska Natives, Tribal Leaders present their funding needs each year to the Secretary of HHS and the Director of the Office of Management and Budget. The recommendations are formed through the Tribal Budget Formulation Work Group and serve as a framework for the Administration in setting budget amounts for their annual requests to Congress. This process ensures the federal government has the resources to provide health care to all American Indians and Alaska Natives in fulfillment of the trust responsibility.

 

Tribal Leaders Highlight the Need for Increased Urban Indian Health Funding

Urban Indian health was a priority in the Area report presentations. IHS Oklahoma Area Representative and President of the Wichita and Affiliated Tribes, Terri Parton, advocated for $509.963 million in funding for urban Indian health, citing that “Although 78% of AI/ANs reside in urban areas, the IHS funding allocation for urban Indian health only reflects close to 1% of the total annual IHS budget,” and “There are inadequate levels of funding to address the rising urban Indian population.”

 

Several Areas featured the work of UIOs in their presentations and advocated for increased allocation of funding and resources for urban Indian health.

  • IHS Phoenix Area recommended a $18.86 billion funding increase for Health Care Facilities Construction with $2 billion for urban Indian health facility renovation. The Phoenix Area Representative also highlighted that the urban Indian health program increase of $92.6 million identified in the FY 2023 budget recommendations remains a top concern in FY 2024, and recommended increased funding for Tribal and Urban Community Health Representative services.
  • IHS Bemidji Area stressed that UIOs are underfunded and rely heavily on grants which can be unstable and recommended $477 million for urban Indian health in FY 2024.
  • IHS Portland Area recommended approximately $1.8 billion in funding for the FY 2024 urban Indian health line item.
  • IHS Tucson Area listed urban Indian facilities renovations in their top health priorities and Wavalene Saunders, Vice Chairwoman of the Tohono O’odham Nation, highlighted Tucson Indian Center’s collaboration with the Pascua Yaqui Tribe and Tohono O’odham Nation to address COVID-19 vaccine and testing efforts.
  • The IHS Billings Area Representatives highlighted two Billings UIO success stories. Lane Spotted Elk, Councilman of Northern Cheyenne Tribal Council, highlighted the Billings Urban Indian Health and Wellness Center’s student mental health and suicide prevention efforts though collaboration with schools. The Indian Family Health Clinic’s food pantry efforts was also highlighted for receiving 5000 pounds of donated food and providing food boxes to patients, primarily seniors, during the pandemic.

 

NCUIH supports the average of the 12 IHS Areas recommendation of $1 billion for urban Indian health funding for FY 2024.

 

Meredith Raimondi, NCUIH’s Interim Vice President of Public Policy, presented the following urban Indian organization (UIO) funding priorities for FY 2024 during the Area Report Webinar:

  1. Urban Indian health funding amount of approximately $1 billion, which reflects the average of the Area budget formulation recommendations.
  2. Availability of funds for UIOs to spend on facilities and infrastructure needs (these funds would be exclusive to UIOs and would not impact the IHS facilities accounts).
  3. Behavioral health funding for UIOs.
  4. SDPI reauthorization and increase to at least $200 million.
  5. Community Health Representatives fund of $3 million for UIOs.

In addition to budget priorities, Raimondi highlighted several “hot topics” for urban Indian health:

  1. Safeguard IHS funding through advance appropriations and exception apportionment across the entire IHS/ Tribal/UIO system.
  2. Permanent increase in Medicaid dollars for Indian health through the permanent extension of 100% Federal Medical Assistance Percentage (FMAP) to UIOs and increased reimbursement rates.
    1. The American Rescue Plan Act authorized a temporary two-year extension of 100% FMAP to UIOs beginning April 1, 2021, however, UIOs have not received a single dollar of increased funding.
  3. Urban confer: establish a mechanism for dialogue and input between the Department of Health and Human Services agencies overseeing UIO programs and UIOs.

 

Next Steps

IHS will hold their FY 2024 National Tribal Budget Formulation Work Group on February 10-11, 2022. NCUIH will continue to advocate for $1 billion in funding for urban Indian health and increased resources for UIOs.

Policy Blast: Tribal Nations Summit Highlights Funding Needs for Indian Health including Urban Indian Health

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Administration leaders discussed new initiatives to address the needs of Indian Country, a memorandum of understanding to support Native languages, advance appropriations for IHS, and additional funding for urban Indian health

 

Last week, the White House convened for the 2021 Tribal Nations Summit for the first time since the Obama Administration. During the summit, remarks encompassed an array of topics all linking back to the health, wellness, and progression of Indian Country. This year’s summit brought together officials and leaders from the Federal government and federally recognized Tribes, to discuss ways to invest and continue to strengthen the Nation-to-Nation relationship.

 

  • During the live broadcast President Biden announced five new initiatives:
  1. Development of 17 departments and agencies to protect Tribal treaty rights in the work of the Federal government;
  2. Increase Tribal participation in management and stewardship of Federal lands;
  3. Institute the Biden Administration as the first to work to achieve comprehensive Tribal ecological knowledge into the Federal governments scientific approach in the fight of climate change;
  4. Take action to protect the greater Chaco landscape in northwestern New Mexico further protecting the area from new oil and gas leasing;
  5. Lastly, signed executive order “Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People”. This order has a heavy emphasis on policy and directs the departments of Justice, Interior, Homeland Security, and Health and Human Services to create and implement strategies that improve safety; additionally, addressing the ongoing crisis of missing or murdered Indigenous people. Strategies identified in the order call for support on enforcement strategies with prevention and response to violence; improved data collection, analysis, and information sharing; early intervention and victim survivor services; and increased consultation and engagement with Indigenous communities.

During the summit, acknowledgement was paid to the profound impact of COVID-19 to Indian country and the devastating consequences. Highlighting the lack of infrastructure, gaps in efficient health insurance access, high rates of unemployment, lack of foundational preschool education for children, and several other critical measures. Janet Yellen, U.S. Secretary of the Treasury, addressed that the goal is not to return Indian country to its pre-covid economic situation, that was already not efficient, but to truly “build back better.” Several mentions were made to the direct promotion of Urban Indian Organization (UIO) capacity and the health status of their patients. Secretary Xavier Becerra, U.S. Department of Health and Human Services, noted that “as of this week, IHS has administered over 1.78 million doses of the COVID-19 vaccine in Indian Country, through Tribal and urban Indian programs”. American Indians and Alaska Natives have an over three times higher infection rate than non-Hispanic whites, are four times more likely to be hospitalized, and have higher rates of mortality at younger ages, yet modeled with resilience in testing and prevention planning, Indian Country now leads the nation for having the highest vaccination rate!

 

First Lady Jill Biden announced a new memorandum of agreement on Native language, bringing governments together to promote and support the instruction and preservation of Native American languages. This investment will bring millions of dollars to enable the revitalization of many languages that are in danger of being forgotten due to the loss of elders during this pandemic. Such loss urges the need for protection of language and tradition more than ever.

Susan Rice, Director of the Domestic Policy Council, covered President Biden’s request for $29 billion for Indian Programs in the next year budget, indicating a 14% increase over last year’s request. Including for the first time, advance appropriations for Indian Health Service (IHS).

As the summit came to a close, IHS announced $9.34 million in funding, enhancing opportunities to support Tribal self-governance and urban Indian health. The Urban Indian Health Programs 4-in-1 Grant Program is for $8.5 million and aims to enhance capacity when developing programs that achieve the highest possible health status for urban Indians. Funding will be used to support four health program objectives:

  • Health promotion and disease prevention services
  • Immunization services
  • Alcohol and substance abuse related services
  • Behavioral health services

There are a total of 33 awards expected to be afforded, lasting the span of 5-years. Applications are due by February 8, 2022. Individual award amounts for the first year will be between $160,000 and $650,000. New applicants can apply for funding up to $200,000. This funding is only open to UIOs that are currently administering a contract or receiving a grant.

 

 

Background

The progress report, published in partnership with the Tribal Nations Summit, was released in advance of last week’s Summit and included the need to meet the obligations to urban Indians. In the report, it addressed that over 70 percent of AI/ANs live off reservation in an urban area. The report reinforces the Biden Administration’s commitment to elevating the voice of urban Indians, including UIOs, in Tribal listening sessions with topics pertinent to health, education, funding, housing, voting, and more, as well as addresses Urban Indian Health Organizations inclusion in 100 percent Federal Medical Assistance Percentages (FMAP).

OMB Urges Passage of Appropriations Bills as a Priority for Indian Health

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On November 12, 2021, The Office of Management and Budget (OMB) released a fact sheet urging Congress to pass their appropriations bills for 2022. The fact sheet includes 17 top priorities around pandemic response and other public health initiatives, national security and American leadership, education, and core citizen services. Of the 17, inclusion of Indian Health Service (IHS) funding and addressing American Indians and Alaska Natives health disparities was in the top 3 priorities:

 

  • Address health disparities among American Indians and Alaska Natives. The President’s Budget and the House and Senate appropriations bills provide funding for thousands more inpatient admissions and millions more outpatient visits at Indian Health Service (IHS) facilities, compared to continuing 2021 funding levels, and would allow IHS to fill hundreds of open medical and other staff positions.

 

Appropriation Bills Status

 

The House fiscal year (FY) 2022 Interior, Environment, and Related Agencies bill (H.R. 4372), which includes $200.5 million for urban Indian health and $8.1 billion for IHS, was part of a seven-bill package the House passed on July 29.

 

The Senate Appropriations Committee released its FY 2022 Interior, Environment, and Related Agencies bill, which includes $92.7 million for urban Indian health, $7.61 billion for IHS, an additional $6.58 billion in advance appropriations to IHS for FY23, and a facilities fix to allow urban Indian organizations to use existing IHS funding for facilities improvement and renovations. However, the Senate has yet to pass their appropriations bill.

NCUIH Endorses Bills Providing Advance Appropriations for IHS

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On October 12, 2021, Representatives Betty McCollum (D-MN-04) and Don Young (R-AK-1) introduced a pair of bipartisan bills that would amend the Indian Health Care Improvement Act (IHCIA) to provide advance appropriations to the Indian Health Service (IHS).

 

The Indian Programs Advance Appropriations Act of 2021 (H.R. 5567), introduced by Rep. McCollum, authorizes advance appropriations authority for certain accounts of the Bureau of Indian Affairs, Bureau of Indian Education, and IHS. The Indian Health Service Advance Appropriations Act (H.R. 5549), introduced by Rep. Young, authorizes advance appropriations authority for IHS.

 

NCUIH has long advocated for advance appropriations for IHS to insulate Indian health care providers from shutdowns and allow for long-term planning. A companion Senate bill, Indian Programs Advance Appropriations Act of 2021 (S. 2985), was introduced by Senators Ben Ray Luján (D-NM) and Martin Heinrich (D-NM) on October 7.

 

NCUIH welcomes the Members of Congress’ legislation to provide budget stability for IHS and strengthen the federal government’s commitment to uphold its trust and treaty responsibilities to American Indians and Alaska Natives.

SENATE RELEASES FY22 FUNDING BILLS WITH HISTORIC INCREASE FOR URBAN INDIAN HEALTH, INDIAN HEALTH SERVICE, ADVANCE APPROPRIATIONS, MMIW AND UIO FACILITY FIX

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The Senate bill includes a $30 million increase above the FY21 enacted level for urban Indian health.

On October 11, 2021, the Senate Appropriations Committee released its fiscal year (FY) 2022 Interior, Environment, and Related Agencies bill, with $92.7 million for urban Indian health. The bill would authorize $7.61 billion for the Indian Health Service (IHS) for FY22, an increase of $1.38 billion above the FY21 enacted level and $593 million below the President’s request. Other key provisions include an additional $6.58 billion in advance appropriations to IHS for FY23 and a facilities fix to allow Urban Indian Organizations (UIOs) to use existing IHS funding for facilities improvement and renovations.

“After decades of being ignored and forgotten, we applaud the Senate Appropriations Committee for the robust legislation proposed to improve outcomes for Indian Country. We are especially encouraged to see the commitment to ensure equitable consideration for all Native communities. We are grateful for all Members of Congress who supported the request for full funding for Indian health, including urban Indian health, especially Senators Schatz, Feinstein, Murkowski, Tester, Moran, Merkley, Hoeven, Van Hollen, Heinrich, and Murray,” said NCUIH CEO Francys Crevier.  

Background 

The National Council of Urban Indian Health (NCUIH) and the Tribal Budget Formulation Workgroup (TBFWG) requested $12.759 billion for the Indian Health Service (IHS) with an urban Indian health line item of $200.5 million for FY 2022. Additionally, 28 Congressional leaders requested $200.5 million for urban Indian health in FY 2022 from the House Appropriations Committee.  

House Appropriations Status 

The House bill (HR 4372) included $200.5 million for urban Indian health and was advanced by subcommittee June 28, and $8.1 billion for the Indian Health Service. The measure was part of a seven-bill package the House passed on July 29.  

Senate Bill Highlights 

Appropriations Chairman Patrick Leahy stated in the bill summary, “The bill makes an unprecedented investment to fulfill the federal government’s treaty and trust responsibilities to Native Americans by providing $18.1 billion for tribal programs and – for the first time – securing advanced appropriations for the Indian Health Service (IHS). The advance appropriation for IHS for fiscal year 2023 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.”  

Indian Health Service 

  • $7,616,250,000 for IHS for fiscal year 2022, an increase of $1,379,971,000 to the enacted level and a decrease of $593,029,000 to the request 

Urban Indian Health 

  • $92,684,000 for the Urban Indian Health program, $30,000,000 above the enacted level and $7,316,000 below the budget request. 

Facilities Fix for Urban Indian Health 

  • “SEC. 435. The Secretary of Health and Human Services may authorize an urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603) that is awarded a grant or contract under title V of that Act (25 U.S.C. 1651 et seq.) to use funds provided in such grant or contract for minor renovations to facilities or construction or expansion of facilities, including leased facilities, to assist the urban Indian organization in meeting or maintaining standards issued by Federal or State governments or by accreditation organizations.” 

Advance Appropriations for IHS 

  • $6,586,250,000 in advance appropriations for fiscal year 2023, equal to the fiscal year 2022 Committee recommendation in accordance with the Concurrent Resolution on the Budget for Fiscal Year 2022
       
  • “The Committee recommendation also provides, for the first time, advanced appropriations for Indian Health Services and Indian Health Facilities. The bill includes $6,586,250,000 in advance appropriations for fiscal year 2023, equal to the fiscal year 2022 Committee recommendation in accordance with the Concurrent Resolution on the Budget for Fiscal Year 2022. 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).” 

Contract Support Costs and 105(l) Leases 

  • “The Committee strongly supports revising the budgetary classification for Contract Support Costs and Payments for Tribal Leases with the goal of including the language needed to codify such a change in the final appropriations Act for fiscal year 2022.” 


Bureau of Indian Affairs – Missing and Murdered Indigenous Women 

  • Missing and Murdered Indigenous Women: $24.9 million  
  • “The Committee is concerned about the crisis of missing, trafficked, and murdered indigenous women that has plagued Native communities. Native American women face high rates of violence and the lack of data on the number of women and girls who go missing or murdered further complicates the Nation’s ability to address this crisis. The Committee recommendation includes both funding and directives under the Bureau of Indian Affairs and the Indian Health Service in order to improve the Federal response to this epidemic.”
      
  • Note: It is unclear at this time if UIOs would be eligible for the funding resources provided to IHS under this provision. 

Bureau of Indian Education – Native Boarding School Initiative 

  • Native Boarding School Initiative: $7 million 

“In June 2021, the Department announced an investigation into the Federal government’s past oversight of Native boarding schools. The past policies of forcing children into these schools tore families apart and led to a loss of culture and identity for generations of Native American youth. The Committee applauds the efforts of the Department to reexamine this era and looks forward to the findings. The bill provides $7,000,000 for these efforts.” 

   

Next Steps 

Congress is likely to pass another continuing resolution before the current spending expires on December 3, 2021. If Democrats quickly begin “top-line” budget negotiations, it’s possible they could pass an omnibus funding package in the Senate.  

NCUIH FY22 IHS URBAN INDIAN HEALTH BUDGET ANALYSIS

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NCUIH FY22 IHS Urban Indian Health Budget Analysis

The President’s request includes nearly 60% increase for urban Indian health and endorses the NCUIH UIO facilities fix.

WASHINGTON, DC (June 16, 2021) – Recently, on May 28, 2021, President Biden released the detailed annual budget proposal for Fiscal Year (FY) 2022. The proposal includes a total of $131.7 billion for the Department of Health and Human Services (HHS), which represents a nearly 23.5% increase to current enacted budget for FY21. The request includes $8.5 billion for the Indian Health Service (IHS), a $2.2 billion increase from FY21 and $100 million for urban Indian health, a nearly 60% increase. The request also endorses NCUIH’s priority fix for allowing urban Indian organizations to use existing IHS funding for facilities improvement and renovations.

The Tribal Budget Formulation Workgroup (TBFWG) requested the Administration to fund IHS at $12.759 billion with an urban Indian health line item of $200.5 million for FY22. These suggested increases were formulated to counteract failed Indian healthcare policies and to fulfill the federal trust obligations to all AI/ANs in the administration of healthcare to American Indian/Alaska Native (AI/AN) populations.

The Budget includes the following legislative proposals:

  • Exempt the IHS from discretionary sequester
  • Authorize Urban Indian Organizations to use their resources for facilities activities
  • Provide the IHS full discretionary use of Title 38 hiring authorities

The additional $2.2 billion requested for IHS will go towards promoting health equity for American Indians/Alaska Natives (AI/ANs) and include Urban Indian Organization (UIO) confer to evaluate options, including mandatory funding, to provide adequate, stable, and predictable funding for IHS in the future. The proposal also includes an advanced appropriation for IHS in FY23 to ensure a more predictable funding stream. NCUIH has long advocated for advanced appropriations for IHS to begin closing the funding disparities that have long hindered Indian Health Care Providers.

NCUIH looks forward to working with the Administration and Congress to fully fund IHS and the urban Indian Health line item. Congress will consider the President’s request as it begins to draft appropriations bills for FY 2022. The House Appropriations Committee will markup its bill on June 28, 2021.

Please find below a summary of some of the proposed funding amounts that would impact urban Indian health.

URBAN INDIAN LINE ITEM

  • The spending proposal recommends a funding level for the urban Indian Health line item at $100 million. This is an approximately $38 million increase from the FY 2021 enacted amount of $62 million, but it is approximately $100.5 million below the TBFWG FY22 recommendation of $200.5 million.

IHS

The President’s Budget for fiscal year 2022 includes a total discretionary budget authority of $8.5 billion, which is $2.2 billion or 36 percent above the enacted FY 2021 funding level.

This includes four accounts:

  • Services: $5.7 billion
  • Facilities: $1.5 billion
  • Contract Support Costs: $1.1 billion .
    • Remains an indefinite discretionary appropriation for fully funding CSC
  • Payments for Tribal Leases: $150 million
    • Remains an indefinite discretionary appropriation for fully funding the cost of section 105(l) leases
  • Contract Support Costs and Payments for Tribal Leases are proposed to shift to mandatory funding in FY 2023.

SERVICES AND FACILITIES

Funding Increases (Services & Facilities)

  • $207 million to fully fund Current Services
    • Offsets increasing costs due to pay, inflation, and population growth
  • $125 million for staffing and operating costs of newly-constructed healthcare facilities

Funding Increases (Hospitals and Health Clinics)

  • $190 million for a general program increase
  • $22 million for the Hepatitis C and HIV Initiative ($27 million total)
  • $20 million for the National Community Health Aide Program ($25 million total)
  • $27 million to offset the rising cost of HHS-wide assessments for information technology, human resources, financial management, and other activities

FACILITIES MAINTENANCE AND IMPROVEMENT

  • The President’s FY22 requested discretionary budget for Facilities Maintenance and Improvement is $222,924,000. This is a $53,952,0000 increase over the FY21 Enacted amount but remains $256,050,000 below the TBFWG requested of $478,974,000.Advanced Appropriations
  • Under advance appropriations, the IHS would request funding in two phases, comparable to the Veteran’s Health Administration. The first phase would address the amount necessary to maintain the current level of services and fully fund known costs, like staffing of new facilities. This amount that would be included for FY 2023 in the FY 2022 President’s Budget and appropriation.  In the second phase, the FY 2023 President’s Budget would address policy proposals that reflect input from Tribal and Urban Indian Organization leaders, as well as the Administration’s goals. While advance appropriations would provide the IHS funding for both FY 2022 and FY 2023, the funding for FY 2023 would not “score” against the discretionary funding caps until it became available in FY 2023.

SPECIAL DIABETES PROGRAM FOR INDIANS (SDPI)

  • Diabetes and its complications are major contributors to death and disability in nearly every Tribal community. AI/AN adults have the highest age-adjusted rate of diagnosed diabetes (14.7 percent) among all racial and ethnic groups in the United States, more than twice the rate of the non-Hispanic white population (7.5 percent).[1] In some AI/AN communities, more than half of adults 45 to 74 years of age have diagnosed diabetes, with prevalence rates reaching as high as 60 percent.[2]
  • The President’s budget also includes continued funding for the SDPI at $147 million. This is $3 million less than the enacted FY21 amount and $13 million less than FY22 TBFWG request. The Consolidated Appropriations Act, 2021 (P.L. 116-260) authorized SDPI until September 30, 2023. FY 2022 would be the 25th year of the SDPI.

105(I) LEASES

  • The FY 2022 budget adds $49 million for 105(l) leases for a total of $150 million. The TBFWG request of $337 million in FY 2022 for section 105(l) line item was to ensure that growing 105(l) lease costs are fully paid without impacting increases to other critical IHS line items. NCUIH opposes IHS action to unilaterally restrict ISDEAA authorities in the absence of Tribal consultation.

INDIAN HEALTH PROFESSIONS

  • The need for qualified mental health providers; in particular, the TBWFG voiced the difficulty in recruiting and retaining fulltime professionals to work and adapt to Native settings. Knowing of the need to grow Indian health professionals to fill this need, the TBWFG requested a nominal increase to $82,634,000. The President’s FY22 recommendation increases IHP to $92,853,000 million.  This is $25,539,000 above the FY21 enacted level and $10,219,000 million above the Tribal Budget Formulation Workgroup recommendation.

FACILITIES MAINTENANCE AND IMPROVEMENT

  • Current misinterpretations have halted the overall improvements and construction of  UIO facilities.  NCUIH continues to advocate for a substantial infrastructure investment within the UIO health system. Allowing the continued deterioration of critical health facilities goes against the mission of the Indian Health Service and Urban Indian Organizations to provide quality healthcare to all American Indians and Alaska Natives.We hope that once this facilities restriction is lifted that an amendment can be made to the Indian Health Improvement Act to add a line item for UIOs to use funding for facilities.
  • The President’s FY22 requested discretionary budget for Facilities Maintenance and Improvement is $222,924,000. This is a $53,952,0000 increase over the FY21 Enacted amount but remains $256,050,000 below the TBFWG requested of $478,974,000. “Facilities Renovation for Urban Indian Organizations to the extent Authorized for Other Government Contractors SEC. 433. The Secretary of Health and Human Services may authorize an urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603)) Provides authority for IHS to make funds available to IHS-funded Urban Indian Organizations for minor renovations to facilities or construction or expansion of facilities, including leased facilities, to the extent authorized for other government contractor”.[3]

CENTERS FOR DISEASE CONTROL AND PREVENTION AND NATIONAL INSTITUTES OF HEALTH

  • The budget request would increase discretionary funding for the Centers for Disease Control and Prevention to $8.7 billion. This is a funding increase of $1.6 billion that would significantly affect the HHS core mission of preventing and controlling emerging public health issues.

Read the Full Analysis

[1] Centers for Disease Control and Prevention (CDC). National Diabetes Statistics Report 2020: Estimates of Diabetes and Its Burden in the United States. Atlanta, GA: U.S. Department of Health and Human Services; 2020. Available at: https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

[2] Lee ET, Howard BV, Savage PJ, et al. Diabetes and impaired glucose tolerance in three American Indian populations aged 45-74 years: the Strong Heart Study. Diabetes Care. 1995;18:599-610