Yesterday, the House of Representatives passed the “Limit, Save, Grow Act of 2023” (H.R. 2811) which is the House Republicans’ proposal to raise the federal debt ceiling and reduce federal spending.  According to House Speaker Kevin McCarthy, the plan would reduce federal spending by $4.5 trillion over 10 years.  The bill is the first offer from House Republicans as they negotiate with the Democratically-controlled Senate and President Biden to raise the debt ceiling, which is expected to be exceeded in the coming months.  

According to economists, the House proposal could cause increased borrowing costs for the United States, reduced consumer and business confidence, and decreased economic growth. A default on the United States’ debt obligations could lead to a downgrade in the U.S. credit rating, which would ripple throughout the global financial markets, and harm working Americans’ take home pay and retirement. Compared to a clean debt ceiling scenario, economists predict by the end of 2024 the implications of the bill would reduce economic growth by 0.65% and employment by 780,000 jobs. 

The Centers for Disease Control and Prevention (CDC) now reports that life expectancy for AI/ANs has declined by nearly 7 years, and that our average life expectancy is now only 65 years—equivalent to the nationwide average in 1944. The United States owes a treaty and trust obligation to provide health benefits to AI/ANs; benefits that were prepaid in full by our ancestors. With a life expectancy 10.9 years less than the national average, this legislation would make many cuts that will uniquely harm the health of American Indians and Alaska Natives (AI/ANs). We detail some of the most serious concerns below.

Rescissions in COVID-19 Supplemental Funding. The bill would rescind unspent COVID-19 relief supplemental appropriations, which provided more than $51 billion in funding for programs serving AI/ANs, including $9 billion in funding to the Indian Health Service (IHS). This total includes funds appropriated through the American Rescue Plan Act (ARPA), which supplied $6 billion in funds to the Indian Health Service for a variety of direct patient care needs as well as urgent facility concerns. Tribal nations are federally-recognized governments with jurisdiction over, and accountability for, millions of people who live, enter, and do business and activities on Tribal lands. This means that rescission of unobligated funds from other federal agencies will negatively impact Tribes and our communities, such as resulting in increased cost burdens in sectors like healthcare. Due to a reduction in resources, social determinates of health, like elder nutrition or public health and education, will be greatly impacted.

Supplemental appropriations enacted during the pandemic were historic investments for Indian Country, and thanks to Congress’ swift action, lives were saved. Regardless, the IHS is so disproportionately underfunded by Congress that a historic investment in response to a global pandemic still provided less resources than the estimate of annual obligations for IHS services. Our communities are still responding to the COVID-19 pandemic in both the impacts of the disease itself and impacts to behavioral health. Even with this critical funding AI/AN communities were some of the most impacted areas of COVID-19. Lack of access to real-time data; limited public health infrastructure; and ongoing challenges accessing quality health services continue to challenge IHS, Tribal, and Urban health providers today. These funds are needed now more than ever. Clawing back critical funds from the IHS will do very little to solve the nation’s debt crisis, but such a reduction in resources will lead to further rationing of health care for AI/ANs.

Work requirements for Lifeline Programs. The bill would also implement work requirements for many social programs – like Medicaid, the Supplemental Nutrition Assistance Program (SNAP), and Temporary Assistance for Needy Families (TANF) – that are critical lifelines in Tribal communities.  Mandatory Medicaid work requirements will not work for Indian Country. For example, the IHS system relies on Medicaid, as it is a critical source of revenue to support health services when IHS appropriations fall short. However, work requirements will not incentivize work for AI/ANs since they have a right to access the Indian Health Service. This is the fulfillment of the federal government’s trust obligation to our people. Instead, more pressure will be placed on the already limited IHS services budget.

Furthermore, requesting AI/ANs to meet work requirements by demonstrating they are seeking employment through State employment programs will fundamentally not work. Tribes have their own employment programs and tribal citizens should not be required to participate in duplicative state programs in order to access the same federal program. Some of the most financially disadvantaged regions of this nation are in Indian Country. With already limited access to jobs, worker training programs, and other resources, it is not reasonable to place a barrier to program access for AI/ANs. These social programs keep healthy meals on the table, and vital support to communities without other options. Work requirements will not create financial independence but will put critical benefits out of reach for many. You can read more about how work requirements are detrimental to Tribal communities here. 

Caps on Discretionary Spending and Sequestration. This legislation, if enacted, would have serious negative consequences for Indian health. For example, it would reduce federal discretionary spending to the FY 2022 level. The majority of IHS funding is currently appropriated through discretionary spending. IHS funding has increased about 5% since FY 2022. This means, that the Indian health system would have less funding and a loss in purchasing power due to inflation and population growth that will exacerbate health disparities experienced by AI/ANs. Under these caps, much needed funding increases accounting for population growth, medical inflation, and program growth would be highly unlikely. The IHS Tribal Budget Formulation Workgroup recommends $49 billion for IHS in FY 2024, or roughly seven times the amount enacted by Congress for FY 2023. Imagine your family living on only one day’s worth of groceries per week for generations - this proposal seeks to provide even less. Such a reduction in resources will further ration already starved resources for Indian Healthcare. A 5% cut to the current IHS budget would devastate the health of AI/ANs. 

Conclusion. In December 2018, the U.S. Commission on Civil Rights’ Broken Promises report found that for decades now, Tribal nations face an ongoing health crisis that is a direct result of the United States’ chronic underfunding of Indian health care, which contributes to vast health disparities between Native Americans and other U.S. population groups. The Limit, Save, Grow Act would do nothing to restore the funding promised to Tribal nations, but instead would further reduce funding to the already starved Indian health system and place unnecessary barriers for AI/ANs to access much needed lifeline services. 

NIHB will continue to monitor debt ceiling negotiations in the coming weeks and months. We will be sharing our concerns with allies and leaders in Congress and urge them to protect the health of American Indians and Alaska Natives.