President Releases FY 2021 Budget Request

Includes some increases to IHS line items; major cuts to IHS also proposed
FOR IMMEDIATE RELEASE

February 10, 2020

President Releases FY 2021 Budget Request

Today, the Trump Administration released the President's Fiscal Year (FY) 2021 Budget Request . The release of the President's Budget officially kicks off the FY 2021 appropriations cycle, which continues in earnest tomorrow with the American Indian and Alaska Native Public Witness Hearings on the FY 2021 budget before the House Appropriations Subcommittee on Interior, Environment, and Related Agencies. As NIHB reported last week , Chairwoman and Great Plains Area Representative, Victoria Kitcheyan, will be testifying on behalf of NIHB. To access NIHB's testimony, click here .

Background
By law, each year the President is required to release a proposed budget request to Congress. The President's Budget includes recommended funding levels for every federal program and agency that is funded under discretionary (annual) appropriations, and can recommend policy changes to mandatory programs and the tax code. While the President's Budget does not carry the force of law, it provides insight into the Administration's legislative and budget priorities for the next fiscal year.

NIHB's analysis of the FY 2021 budget request for IHS is available under the header below. NIHB is also in the process of examining the congressional justifications of other agencies within the Department of Health and Human Services including budget proposals from the Centers for Disease Control and Prevention (CDC), the Substance Abuse and Mental Health Services Administration (SAMHSA) and others.

NIHB's preliminary analysis of the CDC budget found that for the third year in a row, the President has proposed to zero out the Good Health and Wellness in Indian Country (GHWIC) program . Funded at $21 million in FY 2020, GHWIC is the single largest source of dedicated funding for public health in Indian Country. Tribes and NIHB will fight hard to make sure the program is maintained and increased for FY 2021. NIHB will conduct and share an in-depth analysis of the CDC and SAMHSA budgets in coming days.

President's FY 2021 Request for Indian Health Service
Earlier today, the Indian Health Service (IHS) released its FY 2021 congressional justification , which outlines the agency's funding requests for each line item in the IHS budget and also includes specific legislative policy proposals. Some of these legislative requests are highlighted below.

Establishing an indefinite appropriation for 105(l) lease payments
This has been a long-standing priority of Tribal Nations and NIHB to ensure that IHS has dedicated and sufficient funding to cover 105(l) lease obligations.

  • Section 105(l) of the Indian Self-Determination and Education Assistance Act (ISDEAA) requires IHS to enter into a lease agreement with Tribes or Tribal organizations that have elected to take control over their health facilities through self-governance contracts and compacts.
  • In 2019 alone, IHS received 205 proposals for 105(l) lease contracts from Tribes totaling over $100 million - an exponential growth compared to the only 37 proposals received in FY 2017. Because of the high volume of requests in 2019, IHS was forced to reprogram over $70 million last year from other priorities to pay for 105(l) lease obligations.
  • Under current law, IHS is required to pay for 105(l) lease contracts through the IHS Services Account. With more and more Tribes electing to enter into 105(l) lease agreements, a legislative solution is necessary to ensure continued viability. Establishing an indefinite appropriation for 105(l) leases similar to Contract Support Costs will ensure continued agency viability in meeting its statutory obligations under ISDEAA.

Elevate the IHS Director to Assistant Secretary of Indian Health
  • According to IHS's FY 2021 congressional justification, elevating the position of IHS Director to Assistant Secretary of Indian Health would provide the Director with greater authority and leverage to collaborate with sister agencies across the Department of Health and Human Services.
  • It would also strengthen IHS's statutory framework, and increase access to vital health resources across the Department for American Indians and Alaska Natives served by IHS, Tribal, and urban Indian programs and facilities.

Extend Medicare Telehealth Services for IHS and Tribal Facilities
  • Medicare currently reimburses for some telehealth services provided through IHS and Tribal facilities; however, there are restrictions in receiving reimbursement under the Physician Fee Schedule (PFS) when these services are delivered across state lines.
  • Although current law exempts IHS and Tribal employees from in-state licensure requirements, including for telehealth practitioners, what is lacking is a mechanism for Medicare reimbursement for those telehealth services delivered across state lines.
  • Authorizing Medicare reimbursement for telehealth services delivered across state lines would better accommodate the unique structure of the Indian health system and increase revenue sources for IHS and Tribal facilities.

Waiver of Indian Preference
  • In their FY 2021 congressional justification, IHS is requesting that Congress amend federal law to allow the agency to waive Indian Preference Laws in order to have greater flexibility to address chronic and pervasive health provider shortages.
  • Specifically, the agency asks that Congress allow the Secretary of Health and Human Services to waive Indian Preference without having to first receive a written waiver approval from all Tribes and Tribal organizations served by that IHS facility. It is extremely unlikely that Congress will honor this request.

Funding Requests for Indian Health Service
The FY 2021 IHS congressional justification outlines the agency's funding requests for each line item in the IHS budget. Overall, the agency is requesting $6.232 billion in discretionary funds for FY 2021 , an increase of roughly $190 million above the FY 2020 enacted discretionary budget of $6.04 billion. This includes a request for an indefinite appropriation for 105(l) leases , which are estimated to reach $101 million in FY 2021. Importantly, IHS also requests $125 million for the newly established Electronic Health Record line item , which is an increase of $117 million above the FY 2020 enacted level.

While these requests reflect ongoing Tribal priorities, the budget request also outlines drastic cuts to crucial IHS line items and programs. For instance, while the agency requests that Congress maintain the Special Diabetes Program for Indians (SDPI) as a mandatory program at $150 million for FY 2021, the Administration is proposing a highly troubling 10-year phase out of SDPI funding . The proposal to phase out SDPI is not included in the IHS congressional justification; instead, it is outlined in the summary tables document included as a supplement to the President's Budget. The summary tables document can be found here with information about SDPI on page 117 of the document. While it is extremely unlikely that Congress will honor this request, it is very concerning given SDPI's current reauthorization status. SDPI is only reauthorized through May 22 of this year, and Tribes and NIHB are fighting hard to secure the bipartisan and bicameral 5-year SDPI renewal negotiated by lawmakers last December .

The budget request also proposes to combine funding for Community Health Representatives ($62.8 million in FY 2020), Health Education ($20.56 million in FY 2020), and nationalization of the Community Health Aide Program ($5 million in FY 2020) into a new "Community Health" line item funded at $44.1 million overall . By combining all three line items into one at a level of $44 million, this would equal an estimated $44 million reduction to all three programs overall.

Drastic cuts are also proposed for various line items under the IHS Facilities budget, including a $134 million proposed reduction to Health Care Facilities Construction , among other proposed cuts. The average age of IHS hospitals are four times that of America's hospitals overall. Cutting funding for Facilities funding jeopardizes necessary efforts to update and modernize IHS hospitals, clinics, and health centers.

A more detailed list and comparison of several line item totals for IHS are provided below.
FY 2020 IHS Enacted

Hospitals & Clinics.......... $2.32 billion
Mental Health.............. $108.9 million
Alcohol & Subs. Abuse....... $245 million
Purchased/Ref Care....... $964.8 million
Facilities..................... $911 million
Community Health Reps... $62.8 million
Urban Indian Health.......... $57 million
Equipment...................... $28 million
FY 2021 Pres Bud

Hospitals & Clinics.......... $2.43 billion
Mental Health.............. $128.2 million
Alcohol & Subs. Abuse....... $235 million
Purchased/Ref Care....... $964.7 million
Facilities..................... $769 million
Community Health Reps... ZEROED OUT
Urban Indian Health.......... $49 million
Equipment..................... $23 million
Next Steps
With the President's Budget released, Congress is now able to move forward with drafting bills for all twelve discretionary budgets. While the House has begun scheduling hearings on the FY 2021 budget, the Senate has not yet announced any appropriations hearings.

However, the Senate Appropriations Committee has published information on the Committee website for submitting testimony on FY 2021 appropriations.

The Senate Appropriations Subcommittee on Interior is accepting public testimony through Friday, March 20, 2020 . Instructions can be found here .

The Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies is accepting public testimony through Friday, May 22, 2020 . Instructions can be found here .

For any questions on FY 2021 appropriations, please contact NIHB Director of Congressional Relations, Shervin Aazami, at saazami@nihb.org



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