House Appropriations Committee Releases FY 2021 Report with Line Item Totals for IHS Budget

Each IHS Line Item Received At Least Slight Increase Over FY 2020 Levels

July 9, 2020

House Interior Appropriations Subcommittee Releases FY 2021 Committee Report Outlining Line Item Funding Totals for IHS

As NIHB reported earlier this week , the House Appropriations Subcommittee for Interior, Environment, and Related Agencies released its Fiscal Year (FY) 2021 spending bill, proposing to fund Indian Health Service (IHS) at just under $6.5 billion, an increase of $445 million overall above the FY 2020 enacted budget.

In addition to this amount,  the House bill would provide a  separate  $1.5 billion specifically as emergency infrastructure funding to construct and renovate IHS Facilities  . As outlined in the bill text, use of the $1.5 billion in emergency IHS Facilities funds would first require the agency to submit a comprehensive spending plan to Congress for approval. This plan would need to identify the cost of each project, and identify each specific project by Tribe. The bill outlines a few more stipulations on use of emergency infrastructure funds as well. These are itemized below.

  • $1.25 billion would be for construction and related costs for facilities on the IHS Health Facilities Construction Priority System list, and for small ambulatory facilities;
  • $50 million may be used for staff quarters;
  • $50 million is earmarked for equipment; and,
  • $200 million would be to reduce the Backlog of Essential Maintenance, Alternation, and Repair (BEMAR)

As such, it does not appear that the emergency $1.5 billion for IHS Facilities can be used for newly-authorized facilities under the Indian Health Care Improvement Act such as long-term care facilities, or residential treatment centers.

Importantly,  the House bill proposes an indefinite appropriation for 105(l) lease contracts  - a longstanding Tribal priority that was also included in the President's FY 2021 Budget request for IHS. Congress would provide "such sums as may be necessary" to fulfill this obligation, similar to Contract Support Costs.

For FY 2021, the House bill proposes $101 million for 105(l) lease costs, matching the request in the President's Budget but $37 million below the recommendation put forth by the Tribes through the National Tribal Budget Formulation Workgroup. The House bill authorizes an indefinite appropriation for 105(l) lease costs for two years - through September 30, 2022.  This is intended to give IHS more flexibility to obligate funds for 105(l) lease agreements across two years as opposed to one, which is important in the event of a Tribe submitting a request closer to the end of the fiscal year.

Report Language & Line Item Totals
Earlier this morning, the Interior Appropriations Subcommittee released the FY 2021 Interior Report . The purpose of a Committee report is to provide further context and direction behind the funding levels proposed in the bill text, and to demarcate program-specific funding totals across every line item in the agency budget. The FY 2021 House Interior Report includes new language discussing the impact of COVID-19 on AI/AN communities, stating:

The coronavirus pandemic is causing severe challenges to health care delivery in Indian country. Antiquated buildings, poor water infrastructure, and numerous vacancies contribute to the spread of the virus and hinder the ability to fully respond. In addition, Native Americans are postponing preventive health care and routine procedures as evidenced by reduced third party collections. This along with increased mental health and alcohol use will likely cause further issues in the future. 

Further, the Report also documents concerns expressed by Direct Service Tribes (DSTs) that IHS has historically not engaged in sufficient and meaningful consultation with DSTs on how the agency allocates third party collections from payers like Medicare, Medicaid, and private insurance. Moreover, Report language directs IHS to "...consult with direct service Tribes about eligible uses of third party collections."

As documented in the Report, the House bill rejects the proposal in the President's Budget to consolidate funding for Community Health Representatives (CHRs), the Community Health Aide Program (CHAP), and Health Education into a single new line item . Instead, it proposes a slight bump to CHRs to $63 million overall; an increase of $10 million for CHAP to $15 million overall; and a slight increase for Health Education to $20.8 million overall.

The Report also earmarks funds for new programs to address specific priority areas and underlying health conditions. This includes

  • $5 million to address Alzheimer's Disease and related cognitive health conditions with funds going towards a new Alzheimer's Disease education campaign, training curriculum for primary care practitioners, and to launch five pilot projects for early disease detection and diagnosis;
  • $5 million to address HIV and Hepatitis C (HCV) in response to the President's Ending the HIV Epidemic: A Plan for America and Eliminating Hepatitis C in Indian Country initiative;
  • $5 million to address maternal health priorities, with language encouraging IHS to launch a pilot project to evaluate maternal mortality risk factors and provide support to breastfeeding mothers.
  • $2.5 million to expand Dental Support Centers (DSCs) across all twelve IHS Service Areas;
  • $2.5 million for implementation of Electronic Dental Records;
  • $5 million under the IHS Facilities Account to expand energy-efficient green infrastructure

The House bill also proposes $61 million for continued efforts to improve and modernize the IHS Electronic Health Record (EHR) system, which equals an increase of $53 million above the FY 2020 enacted level . Statutory language maintains the requirement that IHS notify Congress at least 90 days prior to obligating the funds. Report language also discusses the importance of interoperability with Tribal and urban Indian EHR systems, and with the VA system as noted below:

Transitioning to a new EHR system is one of the largest undertakings IHS has entered into in many years. Robust Tribal consultation and adequate agency planning are essential to ensuring the success of this transition. The Committee expects the new EHR will be interoperable with the Veterans Affairs Administration’s (VA) new EHR system and directs IHS to report to the Committee within 90 days of enactment of this Act on any additional costs required to ensure interoperability with the new VA system and provide a summary of Tribal consultation sessions that have, or will, take place.

The new electronic health record system should also be interoperable with the electronic health systems of Tribal and UIOs that have chosen to purchase and implement their own systems. The Committee encourages IHS to estimate the costs and needs of health IT infrastructure across IHS, Tribal, and urban Indian electronic health record systems required to ensure interoperability with any new EHR system.

Finally, the Committee notes that the Bureau of Indian Education and Tribal colleges and universities are also expanding broadband and infrastructure technology investments in Indian Country. The Committee directs IHS to coordinate its EHR modernization effort with the Bureau of Indian Education and Tribal colleges and universities, where feasible, to achieve investment savings, reduce delays, and avoid duplication of effort

For a copy of bill text, click here
For a copy of the Committee Report, click here
FY 2020 IHS Enacted Budget

IHS.............................. $6.04 billion

Hospitals & Clinics.......... $2.32 billion
Mental Health.............. $108.9 million
Alcohol & Subs. Abuse....... $245 million
Purchased/Ref Care....... $964 million
Facilities..................... $911 million
Community Health Reps... $62.8 million
Urban Indian Health.......... $57 million
FY 2021 House IHS Budget

IHS.............................. $6.49 billion

Hospitals & Clinics.......... $2.36 billion
Mental Health.............. $132.7 million
Alcohol & Subs. Abuse....... $259 million
Purchased/Ref Care....... $1.01 billion
Facilities..................... $934 million
Community Health Reps... $63 million
Urban Indian Health.......... $66 million
Funding for Important Indian Health Programs Outside IHS
NIHB continues to strongly advocate for important Indian health programs funded under the Labor-HHS budget by agencies such as CDC and the Substance Abuse and Mental Health Services Administration (SAMHSA). Under CDC, the spending package increases funding for the successful Good Health and Wellness in Indian Country Program (GHWIC) to $23 million for FY 2021. In addition, the LHHS bill proposes a new baseline $150 million Tribal set-aside in CDC funding for public health infrastructure and program development.

The bill also maintains the $15 million set-aside for placements of National Health Service Corps (NHSC) officers at IHS, Tribal and urban Indian facilities , and the $50 million Tribal set-aside under SAMHSA for the Tribal Opioid Response grants.

The LHHS Committee Report is set to be released later this week, and will outline totals for important Tribal programs like the AI/AN Suicide Prevention Initiative under SAMHSA, and the SAMHSA Tribal Behavioral Health Grants.

Next Steps
The full House Appropriations Committee is set to markup the Interior bill tomorrow, Friday July 10 at 9:00 AM Eastern and will be livecasted HERE . The Interior Subcommittee had marked up and favorably referred the bill to full committee earlier this week.

Although the Senate had initially planned on beginning appropriations markups before the July 4th holiday, that timeline slipped due to unrelated negotiations on bills to address police brutality and the ongoing COVID-19 pandemic. The Senate is now on recess until Monday July 20. As soon as the Senate returns, efforts will rapidly resume on another COVID-19 relief package before both chambers depart for the month-long August recess, further delaying bicameral action on FY 2021 appropriations likely into September.

With the delayed appropriations timeline and focus on the November election as that date draws closer, the likelihood of yet another continuing resolution cannot be ruled out.

For any questions on FY 2021 appropriations, please contact NIHB Director of Congressional Relations, Shervin Aazami, at

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