President Trump Releases FY 2019 Budget Request:
Major Cuts to Domestic Spending and Social Safety Net, Investments in Opioid Treatment and Prevention
February 13, 2018
On Monday, February 12, 2018 President Trump released his fiscal year (FY) 2019 Budget Request to Congress.  This is the proposal that the Administration provides the Congress as they will develop the FY 2019 appropriation including funds for the Indian Health Service and other health programs serving Indian Country.  It will be up to Congress to make any final spending decisions about appropriations for  FY 2019,   which will begin on October 1, 2018. 
Currently, full details of the President's Budget have not been released.  However, there are other documents available that contain an overall picture of the FY 2019 President's Budget. To access the 160-page budget summary document   click here.  To access the "Budget in Brief" for the Department of Health and Human Services (HHS) click here.
The Indian Health Service (IHS) would receive an 8% increase over the current FY 2018 budget, but the proposal still cuts or eliminates several important programs at IHS ( more on IHS below).   Overall, the president's budget request eliminates $3.6 trillion from domestic spending programs including for Medicare, Medicaid, public health and social safety net programs. Many of these programs are at HHS which, as a whole, would take a 21% cut in the President's budget.  For example, the proposed budget would eliminate the Low Income Home Energy Assistance Program (LIHEAP) which is currently funded at $3.4 billion.  It would also eliminate the Agency for Healthcare Research and Quality ($324 million) because the Administration claims that the functions of the agency are already being done by the National Institutes of Health (NIH).  Click here to see an infographic of the cuts to HHS in the FY 2019 Budget Request.
The budget would also make major changes and cuts to the Supplemental Nutrition Assistance Program (SNAP) which would cut 22% of the program and $213.5 billion over the next decade.  The proposal also would redesign SNAP by using a portion of benefits to buy and deliver a package of commodities to SNAP households, noting that it would utilize the government's buying power to obtain common foods at lower costs. Approximately 25% of AI/AN households current utilize SNAP, but in some Tribal communities over 50% of households are recipients of the program.
It is important to note that this is just the first step in the annual appropriations process. It will be up to Congress to decide the actual FY 2019 federal appropriations. Last year, Congress proposed increases for the Indian Health Service despite the Trump Administration proposing a $300 million cut.
IHSIndian Health Service:
The FY 2019 Budget Request would include $5.4 billion for the Indian Health Service which is $413 million (8%) above the FY 2018 Continuing Resolution. For FY 2019, the Tribal Budget Formulation Workgroup (TBFWG) which meets annually and is comprised of Tribal leader representatives from each of the 12 IHS service areas, recommended $6.4 billion in FY 2019. The budget requests an increase for clinical services including an increase of $268 million for Hospitals and Clinics for a total funding amount of $2.1 billion (TBFWG recommended $2.4 billion for Hospitals and Clinics); increase of $32 million for purchased/referred care (PRC) for total funding of $955 million (TBFWG recommended $1.2 billion for PRC); and increase of $340 million for Mental Health, and Alcohol and Substance Abuse Programs, which is $30 million above current spending levels.
Opioids:  The budget proposes $10 billion in new resources to combat the opioid epidemic.  Under the proposal, IHS would receive $150 million "to provide multi-year competitive grants based on need for opioid abuse prevention, treatment, and recovery support in Indian Country."  ( See more on opioid funding below).
Despite these increases, the President's Budget also proposes cuts to other areas of the IHS budget.  For example, the budget would eliminate the Community Health Representatives program (currently funded at $60 million) and the health education program (currently funded at $19 million).  The President's budget would also cut health facilities construction by $38 million which is currently funded at $117 million. TBFWG recommended $244 million for this line item. Other cuts include elimination of Tribal management grants (currently funded at $2 million). According to the HHS Budget In Brief, these cuts are made "to prioritize direct health care services and staffing and operating costs for new and replacement facilities." 
Special Diabetes Program for Indians (SDPI): The budget request makes mention of SDPI and includes information on the remarkable successes of the program.  However, the budget proposes to move SDPI from "mandatory funding" which Congress must authorize from time to time (Recently, this has been every two years) in order for the program's funding to continue, to "discretionary spending" which would allow Congress to control the funding going to SDPI as part of the annual appropriations process. The documents available at the time of this writing do not mention the rationale for this change.
Health Information Technology :  Importantly, the President's budget requests $1.2 billion for the Veterans Health Administration (VHA) to replace its Electronic Health Record (EHR) but according to documents currently available, does not significantly prioritize the replacement of the Resource Patient Management System (RPMS) at IHS despite numerous requests by the Tribes. RPMS is based off of the system VHA currently uses, so failure to replace the IHS system in tandem with the VHA system could have major consequences for the maintenance and improvement of IHS' EHR.  (1) 
OpioidOpioid Funding:
After declaring the opioid crisis a Public Health Emergency last fall, the FY 2019 President's budget proposes a $10 billion investment to treat the epidemic at HHS. The budget document includes a $45 million set-aside for AI/AN Tribes and Tribal organizations to reduce the epidemic within Indian Country. Most of the funding would go to HHS; however, new funding requests were also included for the Drug Enforcement Agency, Department of Justice, along with new guidance for the Centers for Medicare and Medicaid (CMS) and the Department of Veterans Affairs.

Specific funding requests included:
  • $5 billion for the Department of Health and Human Service (HHS) over a five year period, with $1 billion outlined for FY2019 to expand access to effective preventative, treatment and recovery based resources.
  • $625 million to state governments for opioid response initiatives.
  • $50 million to improve first-responder access to life saving opioid reversing drugs such as Naloxone.
  • $100 million for opioid surveillance and other prevention activities, including efforts to bolster statewide Prescription Drug Monitoring Programs (PDMPs).
  • $20 million to expand drug courts, which receive broad support and usage among Tribes through Tribal Healing to Wellness Courts.
  • $10 million to expand treatment services for pregnant and/or post-partum women.
  • $10 million to the Food and Drug Administration (FDA) to expand regulatory science activities that can address opioid misuse and dependence.
  • $65 million to support coalition-building among high-risk rural communities to expand access to treatment and recovery services.
  • $100 million to the National Institutes of Health to expand public-private partnerships to develop new treatments for addiction, new overdose-reversing drugs, and to expand non-opioid treatment modalities.
  • $126 million for the Centers for Disease Control and Prevention (CDC) to improve national surveillance activities, including statewide PDMPs.
The Administration requested $45 million in supplemental grants to address prevention, treatment and recovery needs within AI/AN communities. This amounts to a roughly 7% set-aside for Tribal communities to address the opioid epidemic.

The Budget also included funds to the Department of Justice, Drug Enforcement Agency, and other federal agencies to bolster drug enforcement and interdiction, expand drug courts and recovery services, reduce incarceration, and expand residential substance use treatment.
Centers for Disease Control and Prevention (CDC):
The President's budget request proposes to cut $900 million from the CDC, about 12% of the agency's budget.  The proposal includes $175 million in new funding as part of a broader allocation of $10 billion throughout HHS to fight the opioid crisis.
Chronic Disease Prevention and Health Promotion programs would be reduced by $138 million. The budget would also would cut the Public Health Preparedness and Response fund by $595 million and cut $44 million from immunization and respiratory disease programs.  The proposal also would shift the CDC's National Institute for Occupational Safety and Health into the NIH.
Several programs would receive a bump in funding, including a $326 million increase for vaccines for children and an $8 million increase for HIV/AIDS, viral hepatitis, Sexually Transmitted Infections and Tuberculosis prevention programs
Medicare and Affordable Care Act Program Reforms:
Despite the fact that Congressional leaders have noted that repealing and replacing the Affordable Care Act (ACA) is highly unlikely this year, the FY 2019 budget request proposes to make major changes to programs authorized under the ACA. For example, in the proposal, Medicaid spending would be replaced with a block grant to states leading to the elimination of the ACA's Medicaid expansion and drastic cuts in Medicaid over the next decade. NIHB and Tribes sent letters opposing this strategy to Congress throughout 2017 because Medicaid is one of the key ways that the federal government fulfills its trust responsibility to AI/ANs. The budget would also eliminate subsidies for the ACA's health insurance marketplace, which again, helps contribute to the federal government's trust responsibility obligations. 
In addition, the FY 2019 request would cut Medicare by reducing payments to certain provider types including those in skilled nursing facilities, home health agencies, inpatient rehabilitation and long-term care hospitals. It would also consolidate spending on the federal Graduate Medical Education Program.
NIHB will share more details about the President's FY 2019 Budget's Request as more details become available in the next few days or weeks. Please contact NIHB's Director of Congressional Relations, Caitrin Shuy, at (202) 507-4085 or with any questions.

(1)  It is important to note that the Administration has proposed a one-time investment for Health IT of $200 million for FY 2018 following the budget agreement that was passed by Congress last week.
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