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.

• Bill Report with Urban Indian Health Line Item
• Senate interior Appropriations Bill
• Bill Summary

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.

• IHS FY 2023 Congressional Justification
• President’s FY 2023 Budget
• NCUIH Analysis of President’s FY 2023 Budget

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.”

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.

• Bill Report with Urban Indian Health Line Item
• Draft House Interior Appropriations Bill
• Bill Summary

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.

• IHS FY 2023 Congressional Justification
• President’s FY 2023 Budget
• NCUIH Analysis of President’s FY 2023 Budget

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.”

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.

• President’s FY 2023 Budget
• OMB FACT SHEET: President Biden’s FY 2023 Budget Honors Commitments to Tribal Nations and Tribal Communities
• HHS FY 2023 Budget in Brief

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.