On July 12, 2023, the National Council of Urban Indian Health (NCUIH) joined the National Indian Health Board (NIHB) and 21 Tribal Nations and Native partner organizations in sending a letter to House and Senate leadership regarding the Administration’s proposed fiscal year (FY) 2024 Interior, Environment, and Related Agencies Appropriations Bill. In the letter, they state their support for the President’s FY 2024 proposal to reclassify Contract Support Costs (CSC) and Section 105(l) Tribal Lease Payments as mandatory appropriations and to increase program administration staff. They also urge Congress to include the proposal in their FY 2024 Interior bill.

Full Letter Text:

Dear Chair Murray, Chair Granger, Vice Chair Collins, and Ranking Member DeLauro:

On behalf of the undersigned Tribal partner organizations and the 574+ sovereign federally recognized American Indian and Alaska Native (AI/AN) Tribal nations we serve, we write in strong support of the President’s fiscal year 2024 (FY24) proposal to reclassify Contract Support Costs (CSC) and Section 105(l) Tribal Lease Payments as mandatory appropriations and to increase program administration staff. We respectfully urge you to include the proposal in the FY24 Interior, Environment, and Related Agencies Appropriations Bill (herein “Interior bill”).

The Appropriations Committees recognized as far back as 2014 that the mandatory nature of CSC obligations places the appropriators in an “untenable position.” As they wrote in the Explanatory Statement that year, “[t]ypically obligations of this nature are addressed through mandatory spending, but in this case since they fall under discretionary spending, they have the potential to impact all other . . . equally important tribal programs.” Similarly, appropriators stated in the FY 2021 Explanatory Statement for the Interior bill that 105(l) leases, as confirmed in the Maniilaq cases, appear to create an entitlement to compensation . . . that is typically not funded through discretionary appropriations. Tribal participation in ISDEAA programs has increased rapidly over the past decade, and Congress continues to struggle to meet CSC and Section 105(l) funding obligations through discretionary appropriations. In their Explanatory Statements, the Committees called on the agencies and Congress to find a sustainable solution including mandatory reclassification.

The Fiscal Responsibility Act severely restricted discretionary appropriations for FY24 and FY25. The Act also provided new mandatory appropriations to offset cuts to discretionary appropriations for some agencies, but provided no such relief for the federal government’s treaty and trust obligations to Tribal nations. Agencies estimate that Tribal sovereignty payments will increase by almost $392 million (27%) in FY24. Despite this increase, the House and Senate have proposed cuts to the Interior bill by 35 percent and 3 percent, respectively. Deeper cuts elsewhere in the bill to offset Tribal sovereignty payment increases are, thus, inevitable.

Immediately moving these two accounts to mandatory is good risk management for the United States because the amount is already mandatory in nature and there is a mechanism for controlling costs. If the goal or intent is better fiscal management or maintaining annual control over federal spending, then leaving accounts in the discretionary process with standing to sue that would also generate additional administrative or legal costs if any underpayment or delay were to occur is wasteful and misleading, at best, and intentionally reckless, at worst. Since the amount is already mandatory in nature, there is nothing added to the mandatory budget by moving this authority to the mandatory side of the federal ledger. It does not take away any new money or create any new authority. In fact, it would benefit those with a keen fiscal eye because it would properly classify the authority for scoring purposes. Both CSC and Section 105(l) Lease Agreement accounts are necessarily bound by the parameters of the authorizing law and amounts are determined through sophisticated negotiations and calculations between parties with administrative avenues for recourse prior to suit. This means that the amount is determinable each year and can be determined into the future with reliability and accuracy. Further, it means that costs are controlled and defined by the amount of resources provided for HHS and DOI programs, services, functions, or activities in the Interior bill, along with other quantifiable measures like employee pay costs.

There is a better way to manage and score this authority for the American people and that is by providing such sums as may be necessary for these accounts through mandatory spending. Reallocating base funding from discretionary to mandatory funding has a net zero impact on the Federal budget and would not undermine the Fiscal Responsibility Act. Moreover, as mandatory appropriations in the Interior bill, the Appropriations Committees would retain oversight of the programs. The President’s proposal is sound, reasonable, and fair. Our organizations recognize and appreciate your strong leadership and support over the years for Tribal self-determination. For the sake of continuing to improve the federal government’s commitments to meeting its trust and treaty obligations under your leadership, we urge you to include the President’s Tribal sovereignty payments proposal in the FY24 Interior bill.

Full List of Letter Supporters

The full list of supporting Tribal Nations and Native Partner Organizations is as follows:

Tribal Nations:

• Makah Tribe
• Suquamish Tribe

Native Partner Organizations:

• Affiliated Tribes of Northwest Indians
• Alaska Native Health Board
• Albuquerque Area Indian Health Board
• American Indian Higher Education Consortium
• California Rural Indian Health Board
• California Tribal Chairpersons’ Association
• Great Lakes Inter-Tribal Council
• Intertribal Association of Arizona
• Midwest Alliance of Sovereign Tribes
• National American Indian Housing Council
• National Association of Tribal Historic Preservation Officers
• National Congress of American Indians
• National Council of Urban Indian Health
• National Indian Education Association
• National Indian Health Board
• Native American Finance Officers Association
• Northwest Portland Area Indian Health Board
• Rocky Mountain Tribal Leaders Council
• Self-Governance Communication and Education Tribal Consortium
• Southern Plains Tribal Health Board
• United South and Eastern Tribes Sovereignty Protection Fund

FY 2024 Appropriations Background & Update

On March 17, 2023, IHS published their FY 2024 Congressional Justification with the full details of the President’s Budget, which included $1.6 billion in proposed mandatory funding for Contract Support Costs, Section 105(l) Leases, and the Special Diabetes Program for Indians.

On May 10, the Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies held a hearing to review the President’s Budget for the Indian Health Service (IHS) for FY 2024. IHS Director Tso discussed the importance of contract support costs and 105(l) leases as tools for tribal self-governance, and Senators Merkley and Murkowski expressed support for their classification as mandatory funding.

The House Appropriations Subcommittee on Interior, Environment, and Related Agencies recently released its FY 2024 Appropriations bill on July 12, rejecting the Administration’s proposal and Tribal requests to make contract support costs and Tribal leases mandatory spending.

On April 20, 2023, Families USA, with 230 national and state partner organizations, including the National Council of Urban Indian Health (NCUIH), sent a letter to Majority Leader Schumer, Minority Leader McConnell, Speaker McCarthy, and Minority Leader Jefferies to protect Medicaid from proposed cuts amid debt limit negotiations. This letter is important to show opposition to any cuts to a critical program for the health of 91 million Americans with Medicaid coverage.

The letter highlights the need to protect Medicaid coverage as it provides healthcare access to populations that the American Healthcare System historically underserves, including 1.8 million  American Indians and Alaska Natives (AI/ANs), communities of color, and vulnerable populations such as seniors and people with disabilities.

Medicaid is critical to fulfilling the United States’ trust responsibility to maintain and improve AI/AN health. Cuts to Medicaid can result in patients at Urban Indian Organizations (UIOs) having inadequate health insurance coverage or gaps in coverage may cause UIO patients to delay or avoid medical care altogether.

Full Letter Text

Dear Majority Leader Schumer, Minority Leader McConnell, Speaker McCarthy, and Minority Leader Jeffries:

As leading national, state, and local organizations dedicated to promoting the health and well-being of America’s families, we are writing to underscore the critical importance of the Medicaid program and to express our united opposition to any proposals to cut Medicaid funding as part of upcoming negotiations over the federal budget, debt limit, or any other legislative priorities. We urge you to protect this vital program from cuts or harmful changes in any budget negotiations or other legislative venue this year.

Our health should not depend on our wealth in this country. Efforts to undermine Medicaid would harm millions of families whose health hangs in the balance when they cannot get the care they need otherwise. Medicaid is a lifeline to 91 million Americans, providing insurance coverage for millions of children, veterans, and people who own and work at small businesses. The program is a critical source of coverage to people who have historically been egregiously underserved by our health care system including people of color, particularly in Black, Latino, Asian American, Native Hawaiian and Pacific Islander, and Indigenous communities, and people living in rural communities. It provides health insurance to 6.9 million seniors and over 10 million people with disabilities, and covers 54 percent of long-term care services and 42 percent of all births in the country. Additionally, more than 60 percent of adults with disabilities qualified for Medicaid without supplemental security income (SSI), largely through Medicaid expansion under the Affordable Care Act (ACA).

The evidence is clear that when people have a reliable source of high-quality health coverage, they can access critical health services, including preventive care and behavioral health services; experience improved health outcomes and better overall health; and are protected against unexpected medical expenses. After the upheavals associated with the COVID-19 epidemic over the past three years, it is clearer than ever how critical Medicaid is to our country’s health and financial well-being.

In recent years, proposals to cut the Medicaid program have been thinly disguised as policies such as “per capita spending caps,” “block grants,” “provider tax reforms,” and bureaucratic “work requirements.” Since the passage of the ACA thirteen years ago, there have been continued attempts to repeal or otherwise undermine Medicaid expansion, which covers 18 million people in 40 states and Washington D.C., many of whom would otherwise go uninsured. No matter how they are framed, the reality of these policy proposals is that they destabilize state budgets and local economies, take health care away from millions of children, older adults, working parents, people with disabilities, and people of color with cascading harmful effects on small businesses, rural communities, health care providers and others.

These ideas are not new: they were resoundingly rejected by people across the country when they were proposed as part of efforts to repeal the ACA in 2017. Unsurprisingly, the American public continues to strongly oppose them – new polling shows that 71 percent of Americans say it is important to prevent Medicaid cuts. Our collective message is as clear today as it was then: cuts to the Medicaid program are unacceptable.

Background

Medicaid: A Critical Source of Coverage for AI/ANs

AI/AN people depend upon Medicaid to receive their healthcare coverage and services. In 2020, over 1.8 million AI/ANs were enrolled in Medicaid. According to a NCUIH analysis of American Community Survey (ACS) data, in 2019 Medicaid covered 1.3 million urban AI/ANs, including 30% of urban AI/AN adults under the age of 65. Medicaid and CHIP are important programs for addressing the significant disparities in insurance coverage which exist for AI/AN people.  For example, according to the Urban Institute, AI/AN children were uninsured at a rate of 8.9% in 2019, the highest rate for any ethnic group in the country.  AI/AN parents were uninsured at a rate of 18.7% in 2019, the second highest rate in the country. The Urban Institute reported that in 2019, AI/AN children remained more than twice as likely as white children to be uninsured and AI/AN were more than 2.5 times more likely to be uninsured than with white parents.

Medicaid is also an important source of funding for to support the operation of the Indian Health system, including UIOs  who help serve the approximately 70% of AI/AN people who live in urban areas.  Medicaid remains the largest secondary source of funding for UIO clinics. In 2020, 33% of the total population served at UIOs were Medicaid beneficiaries, and 35% of the AI/AN population served at UIOs were Medicaid beneficiaries. As the Kaiser Family Foundation noted in 2017, “Medicaid funds are not subject to annual appropriation limits . . . since Medicaid claims are processed throughout the year, facilities receive Medicaid funding on an ongoing basis for covered services provided to AIANs.”  Because the Medicaid program receives Mandatory appropriations, Medicaid revenue is particularly essential for Indian health providers when IHS funding is reduced or interrupted by budgetary disagreements.

On May 24, 2022, the National Council of Urban Indian Health (NCUIH) sent a letter to the Chairs of the House and Senate Appropriations Committees, Representative Chellie Pingree (D-ME-1), and Senator Jeff Merkley (D-OR), and to the Ranking Members Representative David Joyce (R-OH-14) and Senator Lisa Murkowski (R-AK), expressing NCUIH’s support for detailing Public Health Service Commission Officers (PHSCOs) to Urban Indian Organizations (UIOs). Detailing officers to UIOs would assist UIO personnel in providing skilled, culturally competent healthcare, help address workforce shortages, and increase collaboration across the federal healthcare system.

Amending the law would provide the Indian Health Service (IHS) with the discretionary authority to detail PHSCOs directly to a UIO to perform work related to the functions of the Service. Such authority would be comparable to the existing authority to detail Officers to Indian Self Determination and Education Assistance Act (ISDEAA) contractors and compactors for the purpose of carrying out the provisions of their ISDEAA contracts (section 7 of the Act of August 5, 1954 (42 U.S.C. § 2004b). The bill would support the 41 UIOs that serve the 70% of American Indians and Alaska Natives that live outside of reservations. Currently, UIOs only get 1% of IHS funding, so to fully staff UIOs, Public Health Service Commissioned Officers need to be deployed.

The Biden Administration and IHS support this deployment of PHSCOs to UIOs by including the provision in their Fiscal Year 2023 budget. NCUIH urges Chair Pingree and Merkley and Ranking Members Joyce and Murkowski to support this provision in the 2023 budget, and if not feasible, to support this provision in the next budget or in a stand-alone bill.

• NCUIH Letter of Support to House Approps on IHS CJ Proposal for PHSCO for UIOs
• NCUIH Letter of Support to Senate Approps on IHS CJ Proposal for PHSCO for UIOs

Background

Section 215 of the Public Health Service Act (PHSA) authorizes the Secretary of Health and Human Services (HHS) to detail officers to federal agencies and state health or mental health authorities. While UIOs have requested that officers be detailed to them to fill many roles related to the functions of the Public Health Service, subsection (c) of Section 215 (42 U.S.C. 215(c)) prevents UIOs from receiving detailed officers because they do not fall within the requirement that non-profits eligible for detailing be educational or research non-profits, or non-profits engaged in health activities for special studies and dissemination of information.” UIOs do not qualify under the current statutory language. Changing this language would allow IHS to detail officers to UIOs to perform work related to the functions of the Indian Health Service.