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Indian Health Services FY 24 Budget
Breakdown and Analysis
The IHS budget is essentially flat funded in FY 2024 following the passage of an FY 2024 Supplemental Appropriation and an FY 2025 Advance Appropriation in the minibus passed by Congress on March 8, 2024. The topline number for the IHS accounts in FY 2024 is $6,961,914,000, which is $3.7 million more than FY 2023, a 0.05% increase. The budget increase does not keep up with inflation which was 3.1% for all items in 2023 per the U.S. Bureau of Labor Statistics Consumer Price Index.[1]
Within the larger Interior, Environment, and Related Agencies Appropriation (Interior-Environment Budget/H.R. 4366, Division E), most agencies and offices were held at the FY 2023 level or were funded below the FY 2023 level. The IHS budget was one of only a handful of agencies/programs which received an overall increase within the Interior-Environment Budget, even when their subaccounts were mixed. The Interior-Environment Budget was $1.5 billion below the FY 2023 enacted level. The budget is a product of a strained fiscal environment in a divided Congress where steep cuts were requested in the House of Representatives, and the Fiscal Responsibility Act of 2023 (FRA/P.L. 118-5) set non-defense discretionary caps 9% below FY 2023 levels.
IHS Accounts
IHS accounts reflect a continued story of dramatically increasing Contract Support Costs (CSC) and 105(l) Lease Payments which make increases in other subaccounts more difficult. The CSC account hit $1 billion for the first time in FY 2024, marking an 8.4% increase over FY 2023 levels, while 105(l) leases saw a 34.23% increase over FY 2023 levels. Growth of these accounts is expected to continue. The bill did not include language to move CSC and 105(l) Lease Payments to mandatory appropriations as has long been requested by Tribal leaders and the Biden Administration. While CSC and 105(l) Leases took most of the budget increases, the Services account saw some modest gains in Hospitals & Health Clinics at 1.9%, Dental Services at 1.8%, and Mental Health at 2.04%. IHS Facilities subaccounts saw the greatest losses, sinking $145.4 million, or 15.17%. The Sanitation Facilities Construction (SFC) line item saw the greatest loss as a percentage of funding, losing $72.5 million, or 36.97%; followed by Health Care Facilities Construction (HCFC) which saw the largest overall loss, losing $78.2 million, or 29.98%. The IHS Electronic Health Record (EHR) System saw a decrease of $27 million, 12.41%. IHS Services and Facilities sustained a total budget decrease of $116.3 million, 1.98% below FY 2023 levels. For additional details, see the table at the end of this analysis.
Advance Appropriations
The IHS was provided advance appropriation for FY 2025 at $5.19 billion. The advance appropriation continues to exclude the EHR line item, Indian Health Care Improvement Fund, SFC, HCFC, CSC, and 105(l) Lease Payments. The FY 2025 advance appropriation carries forward the funding levels of FY 2024. Advance appropriated accounts for FY 2025 (at FY 2024 levels) show an increase of $61.4 million above FY 2023 levels for those same accounts, or a 1.2% increase for advance appropriated accounts. Overall, given inflationary impacts, these accounts are flat funded, and in most cases losing purchasing power.
Joint Explanatory Statement and Congressionally Directed Spending
The Joint Explanatory Statement, which fully incorporates the House and Senate Committee Reports by reference, largely continues directive language from recent years’ appropriations legislation. The Senate Report calls for an additional $5 million to support Community Health Aide Program Expansion and additional $1 million for maternal health with a directive for IHS to work with CDC, HRSA, and CMS on enhanced initiatives and data collection. The House report calls out the IHS’ recent failures to respond to Congressional requests and directs $101 million for Direct Operations including a report to Congress within 30 days on how to improve agency responsiveness. The House report also criticizes the agency’s Service Units and the failures to adequately process referrals, payments, and general barriers to access care. IHS is directed to respond within 90 days on efforts to improve PRC operations.
Both the House and the Senate Reports call out the dire need for staff housing and direct the agency to complete an assessment on the resource needs for staff housing to present to Congress. The Reports also both emphasize the ongoing behavioral health crisis in Indian Country and direct the IHS to open up opioid funding for polysubstance treatment and to continue culturally centered behavioral health programming. All Congressionally Directed Spending earmarked in the IHS budget is for water and sanitation projects. There are 7 projects across 3 Service Areas totaling $17 million.
Rescission
The minibus package also includes two rescissions of IHS funding. Section 447 of Division E rescinds $350 million from section 11001 of the American Rescue Plan Act (P.L. 117-2). This is in addition to a previous set of rescissions under the FRA totaling $419 million for Tribal program transferred to IHS.[2]
Section 448 of Division E further rescinds $90 millions from IHS annual appropriations in FY 2023 and prior years unless those funds were designated emergencies by Congress under the authority of a concurrent resolution on the budget or under the Balanced Budget and Emergency Deficit Control Act of 1985. The impact of this rescission is not immediately clear.
You can read the full appropriations bill here. (IHS starts on page 591)
You can read the Joint Explanatory Statement here. (IHS starts on page 50)
A summary of the whole appropriations package can be found here.
Special Diabetes Program for Indians Reauthorization and Other Health Care Extensions
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