The National Indian Health Board is a dedicated advocate in Congress on behalf of all Tribal Governments and American Indians/Alaska Natives. Each weekly issue contains a listing of current events on Capitol Hill, information on passed and upcoming legislation, Indian health policy analysis, and action items. To view all of our legislative resources, please visit www.nihb.org/legislative/washington_report.php.
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In This Week's Washington Report
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Indian Health Service Releases FY 2023 Congressional Justification
On April 25, 2022, the Indian Health Service (IHS) published its Fiscal Year (FY) 2023 Congressional Justification (CJ) with the full details of the President’s budget. The President’s proposal included a total of $127.3 billion in discretionary funding for the Department of Health and Human Services (HHS) and, for the first time ever, $9.3 billion in mandatory funding for IHS for the first year. The budget proposes increased funding for IHS each year over ten years, building to $36.7 billion in FY 2032, to keep pace with population growth, inflation, and healthcare costs. For FY 2023, the National Tribal Budget Formulation Workgroup determined the monetary level to achieve full funding was approximately $49.8 billion.
Mandatory Funding
On March 28, 2022, the President released his FY 2023 Budget Request and proposed shifting the Indian health care funding from discretionary to mandatory funding. This proposal is a significant change in response to Tribal leaders’ priorities and voice but will take a massive effort to achieve.
Why is This Important to Tribal Nations? Mandatory funding for Indian health care has been the subject of debate for many years among the Tribal nations. Very early on, it had been a subject for consideration within the reauthorization of the Indian Health Care Improvement Act (IHCIA). While it was not in the IHCIA, Tribal leaders have continued to debate and press for its passage.
Each year, the discretionary IHS funding is subject to limitations in Appropriations Subcommittee allocation caps, so unless the overall total government spending and Subcommittee caps are significantly increased, the IHS funding may not be increased. Moreover, it is often subject to Continuing Resolutions or, in more extreme cases, government shutdowns. In these cases, the Indian health system is denied the full year of funding and cannot appropriately administer the necessary health care services.
Tribal leaders have advocated for budget stability for many years. Advance appropriations were the first step toward the ultimate goal of mandatory funding for Indian health care services. By moving the funding to mandatory, the Indian health care system would be protected to a significant degree from the political effects often involved in discretionary funding.
Much work is needed to achieve mandatory funding for IHS. Advance appropriations are still needed, in the interim, until mandatory funding is achieved. The National Indian Health Board (NIHB) will continue to engage on these issues and urge Tribal leaders to join in these efforts.
Facilities
The Indian Health Service (IHS) system is comprised of 46 hospitals (24 IHS operated, 22 Tribal) and 556 health centers, health stations, village clinics, and school health centers (85 IHS operated, 471 Tribal). At these facilities there were an estimated 40,494 inpatient admissions and 13.752 million outpatient visits in 2018. On average, IHS hospitals are 40 years of age, which is almost four times older than other U.S. hospitals, which have an average age of 10.6 years. A 40-year- old facility is about 26 percent more expensive to maintain than a 10-year-old facility.
In total, the 10-year budget includes over $248 billion for the IHS. Targeted investments include the Health Care Facilities Construction 1993 Priority List: Funds the remaining projects on the IHS 1993 Health Care Facilities Construction Priority List over five years, from FY 2024 to FY 2028, which include Phoenix Indian Medical Center, Phoenix, AZ; Whiteriver Hospital, Whiteriver, AZ; Gallup Indian Medical Center, Gallup, NM; Albuquerque West Health Center, Albuquerque, NM; Albuquerque Central Health Center, Albuquerque, NM; and Sells Health Center, Sells, AZ.
105(l) / CSC
The budget includes a mandatory indefinite appropriation for Contract Support Costs and Section 105(l) lease agreements with estimated funding levels of $1.1 billion for Contract Support Costs (+$262 million above the FY 2022 Enacted level) and $150 million for Section 105(l) Lease Agreements (same as the FY 2022 Enacted level).
The Tribal Budget Formulation Workgroup has recommended that Congress reclassify CSC and 105(l) lease costs as mandatory instead of the current indefinite discretionary appropriation, which requires all such costs be funded and shrinks the available amount of funding available for direct care services.
Special Diabetes Program for Indians
The budget includes $147 million for the Special Diabetes Program for Indians (SDPI), which reflects current law (P.L. 116-260) and includes a mandatory sequester of two percent. An important note is that the CJ also proposes that all IHS programs should be exempt from sequestration in the future through legislative means. Exempting the IHS budget from sequestration ensures funding for direct health care services to AI/ANs is not reduced, consistent with the treatment of other critical programs such as veterans’ benefits and nutrition assistance programs.
For any questions, please reach out to Erin Morris, Congressional Relations Manager, emorris@nihb.org
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Senate Committee on Indian Affairs to Hold Oversight Hearing
Today, Wednesday May 4th, the Indian Affairs Committee will hold an oversight hearing titled "Setting New Foundations: Implementing the Infrastructure Investment and Jobs Act for Native Communities". Acting Director of the Indian Health Service (IHS) Ms. Elizabeth Fowler will be a witness to the hearing. Other witnesses are to be determined.
- $700 million each year for FY 2022 to FY 2026, to remain available until expended.
- Up to $2.2 billion for projects that exceed economical unit cost and available until expended.
- No more than 3 percent for salaries, expenses, and administration.
- 0.5 percent for the Office of Inspector General to provide oversight of the program.
- No funds available for IHS salaries, expenses or administration are available to Tribes under Indian Self-Determination and Education Assistance Act.
This hearing will take place at 2:30 PM ET and can be viewed on the Committee's website here.
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Representative DeLauro represents Connecticut's third congressional district. She is up for re-election in this November's elections. As Chairwoman of the House Committee on Appropriations, DeLauro is the second woman to lead this committee.
Typically, the Chairman of a respective committee does not sponsor legislation outside of the Committee's jurisdiction. In the 117th Congress, DeLauro did not sponsor tribal health-related legislation because she leads the Committee on Appropriations which funds multiple agencies such as the Indian Health Service. However, the in 115th Congress, DeLauro sponsored H.R 4485 the Savanna's Act which would have reformed law enforcement and justice protocols appropriate to address missing and murdered Native women.
Funding for fiscal year 2022, Chairman DeLauro introduced H.R 2471 the Consolidated Appropriations Act which funded the Indian Health Service at $6.6 billion - an increase of approximately $395 million over FY 2021 enacted levels.
The National Indian Health Board (NIHB) has advocated to the Chairman DeLauro and Interior Subcommittee to increase Tribal health funding. On March 3, 2022 the National Indian Health Board along with 72 Tribes, Organizations, and friends of Indian health joined to urge Congress to include advance appropriations and request no less than the House of Representatives passed-level of $8.114 billion for FY22 funding for Indian health care. Requesting a legislative fix for Tribal contract support costs, NIHB wrote to Chairwoman DeLauro and Interior Subcommittee on February 4, 2022 to restore the status quo for contract support costs (CSC) administration for Indian health care systems.
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Senator Murphy is currently serving his second term in the U.S Senate. Murphy serves as Mashantucket Pequot Tribal Nation's's and Mohegan Tribe's congressional Senator – the two federally recognized Tribes in the state of Connecticut. His top issue areas are stricter gun control and regulations, foreign affairs and policy, mental health and substance abuse.
Committees
Tribal Healthcare Legislation
Senator Murphy cosponsored Comprehensive Addiction Resources Emergency Act of 2021, S. 3418, introduced by Senator Elizabeth Warren (D-MA). This bill provides emergency assistance to States, territories, Tribal nations, and local areas affected by substance use disorder, including the use of opioids and stimulants. Specifically, the Department of Health and Human Services must establish a program for purchasing and distributing opioid overdose reversal drugs for states and Indian tribes.
He also cosponsored Senator Brian Schatz's (D-HI) bill S. 1512 Creating Opportunities Now for Effective Care Technologies (CONNECT) for Health Act of 2021. This bill would expand coverage of tele-health services under Medicare, including removing “originating site” restrictions for expanding tele-health coverage in Native health facilities and providing greater flexibility for patients visiting Native health facilities.
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Tribal Health Data Improvement Act of 2021
On April 27, 2021, Senator Tina Smith (D-MN) introduced S.1397 the Tribal Health Data Improvement Act of 2021. This bill will be featured in the legislative hearing held by the Senate Committee on Indian Affairs on Wednesday, March 23, 2022. On June 24, 2021, Representative Markwayne Mullin (R-OK-2) introduced the House companion bill H.R. 3841. Representative Tom O’Halleran (D-AZ-1) co-sponsored the bill.
Both bills are intended to improve Tribal access to important public health data and information – a key priority for Tribal nations and the National Indian Health Board (NIHB) that is reflected throughout the NIHB Legislative and Policy Agenda and in Resolution No. 21-05. Data helps Tribal health officials determine trends in health care improvements or disparities, where the health care services are having positive impacts, or where resources are most needed. Without data, Congress, Tribal leaders, and health department officials may lack the information necessary to make informed decisions on resources and priorities.
That Report found the number of American Indian and Alaska Native (AI/AN) people with Medicaid coverage increased from 1,458,746 in 2012 to 1,793,339 in 2018. This increase of 334,593 AI/AN enrollees is a 23 percent increase over 2012. In 2018, 34 percent of all AI/AN people had Medicaid coverage compared to 30 percent in 2012. This information can be useful in assisting Congress, the Administration, Tribal leaders, and health officials when evaluating the effectiveness of and need for improved enrollment programs.
The NIHB Legislative and Policy Agenda also stressed the need for data and data access improvement for important initiatives such as (1) a study to determine strategies for mandatory funding for Indian health care, (2) approaches to best capture and incorporate American Indian and Alaska Native data accurately and respectfully for the national HIV/AIDS strategy plan, and (3) for behavioral health activities.
Most notably, the NIHB Legislative and Policy Agenda recommended that the Centers for Disease Control and Prevention work with states, Indian Health Service, and other stakeholders to ensure that complete and accurate data is captured and shared with Tribes to effectively respond and recover from COVID-19 and other similar public health emergencies. This legislation is an important step in achieving this priority.
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Representatives Urge House Appropriations Committee to Support New Electronic Health Record System
To fully fund the Indian Health Service, the National Tribal Budget Formulation Workgroup recommends funding of $355.8 million for the modernization of electronic health record (EHR) for fiscal year 2023. Likewise, The President's budget request for FY2023 proposes the modernization of Indian Health Service's EHR. Representatives Markwayne Mullin (R-OK-2), Raul Ruiz (D-AZ-36), Raul Grijalva (D-AZ), Tom O'Halleran (D-AZ-1), Gwen Moore (D-WI-4), Sharice Davids (D-KS-3), Jared Huffman (D-CA-2), and Zoe Lofgren (D-CA-3) shared their support for this request. On April 29th, in response to these two recommendations, the Members of Congress wrote to the Appropriations leadership and Appropriations Subcommittee on Interior leadership to request an increase of FY2023 appropriations. Highlighting factors to consider when transitioning to a modern EHR, the Members asked the Committee to include its previous report language in its FY2023 appropriations explanatory statement. To read the letter and previous Appropriations report language, see here.
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Register for the National Tribal Public Health Summit 2022
Do not miss Dr. Anthony Fauci, Abby Roque, Olympic Silver Medalist, First Indigenous Woman on the USA Olympics Hockey Team, and Dr. Jill Jim of the Navajo Nation Department of Health will speak the National Tribal Public Health Summit (TPHS) 2022! Register now for t he National Indian Health Board's (NIHB) invites you to register for the virtual premiere Indian public health event that attracts over 700 Tribal public health professionals, elected leaders, advocates, researchers, and community-based service providers.
This year’s summit theme is Tribal Health is Public Health and will feature dynamic national speakers, interactive workshops and roundtable discussions, a welcome reception, a fitness event, as well as the presentation of the Native Public Health Innovation Awards.
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