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Following the Money: Indian Health Care

Funding in the Interior and Environment Appropriations Bill

August 21, 2017

There are two big stories about health care in Indian country and for urban Indians. One has to do with the adequacy of staffing and facilities for the Indian Health Service (IHS). The other has to do with protecting continued funding of federal programs including the IHS and Medicaid, Medicare, and veterans programs along with access to affordable and effective health insurance.

IHS Facilities. The Indian Health Service provides health care to about 2.2 million American Indians and Alaska Natives, including direct services in 28 hospitals, 61 health centers, three school health centers, and 34 health stations. In addition, tribes and tribal organizations have contractual arrangements with the IHS to operate 17 hospitals, 249 health centers, six school health centers and 70 health stations. These include 164 Alaska Native village clinics. (Source: IHS.gov)

In the last several years, congressional committees have expressed frustration over the management of certain IHS facilities. While many members of Congress have acknowledged a long-term pattern of underfunding IHS facilities and services, other members have continued to ask “why are there problems?” Recently, the focus has been on hospitals and clinics in the Great Plains region. See background stories from March and July of 2016.

The Senate Committee on Indian Affairs held a legislative hearing on June 13 on S. 1250, the “Restoring Accountability in IHS Act of 2017,” introduced by Senators Barrasso, Hoeven, and Thune. An identical bill, H.R. 2662, was introduced by Representative Noem in the House. The bills address transparency, management, quality standards, and staff recruiting in the IHS. Because the bills include a lot of detailed standards affecting care, records, personnel, and reporting, Senators Udall and one of the witnesses (Councilor Kitcheyan, the Winnebago tribal treasurer) urged that tribes be consulted on the specifics in the legislation, adding that the tribes may be able to offer “creative solutions.”

Now it’s funding season. The President proposed deep cuts in nearly every line of the Indian Health Service budget. We wrote with our interfaith partners to the House and Senate Interior and Environment Appropriations Subcommittees, which handle the funding for the Indian Health Service:

“Hearings in your committee and in the authorizing committees have opened the window on a distressing scene. The Indian Health Service has struggled for many years and is now near collapse in at least one region. You’ve heard the needs: updated (repaired/replaced) facilities, 21st century medical equipment and communications capacities, ability to provide housing for medical professionals, transportation for patients, and full staffing for clinics.

The evidence of this need shows up in the medical charts of Native people, who are far more familiar than they want to be with diabetes (even in children), heart disease, and other long-term preventable illnesses. Yet, progress is also evident. Tribes that have been able to take leadership in establishing health and wellness centers – with the federal government as an active partner – have begun to change the health picture in their communities. Diabetes prevention, through the Special Diabetes Program for Indians, has begun to save lives and limbs and hundreds of thousands of dollars.

... We urge you to keep the federal government at the table as a partner in the improvement of Indian health. Health care was, after all, among the fundamental promises made in exchange for millions of acres of land taken during westward expansion on this continent.”

Apparently, the Committee members were thinking along the same lines. According to the House Committee report (excerpts here), IHS programs are expected to continue operating at the levels allocated in FY2017 (with adjustments allowing for increased costs), except those that were allocated specific increases.

For Indian Health Services, the bill includes an overall increase of $173 million compared to funds approved for FY 2017. Of the increase, about $23.5 million is allocated to cover the rising cost of just continuing current services. Other increases over FY2017 include $6.2 million additional for Indian Health Facilities, and a $3.3 million increase for dental health. The Committee also again allocated $29 million to respond to “accreditation emergencies,” such as the loss of Medicare and Medicaid accreditation in some of the Great Plains facilities.

The bulk of the increase was the restoration of $130 million for the “Indian Health Care Improvement Fund,” which is supposed to support changes and new programs adopted in 2010 as part of the Indian Health Care Improvement Act. These changes focus on reducing health care disparities across the IHS system, by prioritizing diabetes treatment and prevention, behavioral health, and health professions.

Beyond the dollars, the Committee’s report requires the Indian Health Service to buckle down on several high priority repairs to its services and facilities. The IHS is encouraged to consult and communicate with tribes about changes that affect them, to investigate the feasibility of referrals to other federal health facilities that might serve distant populations, and to coordinate with the Bureau of Indian Education about introducing dental health in BIE schools. The Committee was clear that it expects to see analyses of the locations of IHS facilities and services relative to the populations it serves, an accounting of the impact of changes in health care financing over the last 10 years on IHS facilities and services, and future budget proposals that reflect, at a minimum, a continuation of current programs with adjustments for increased costs.

Senator Murkowski looks with disbelief at a witness from the IHS

Sen. Murkowski in Senate Hearing with IHS congress.gov

In a frustrating Senate Subcommittee hearing on the President’s Indian Health budget on July 12, members were adamant that Indian health care funding needed to be increased, not cut. Leading senators, including the chair, Senator Murkowski of Alaska, and Senator Tester of Montana were outraged that the appointed director of IHS would not or could not answer direct questions about the needs of his agency.

Senator Murkowski pointed to the proposed 6 percent cut in IHS funds from current (FY 2017) levels for the agency, and concluded that the budget request would not “meet the needs for health care in Indian country.” IHS is supposed to serve 2.2 million Native people, she noted, with a 30 percent vacancy rate for doctors.

Senator Tester urged the IHS director to answer a direct question as to whether the budget proposal would help or hinder his ability to fill staff vacancies. The answer was neither yes nor no. The Subcommittee continued its inquiry with questions about the IHS facilities budget, which faces a proposed 18-percent cut, while the agency struggles with a backlog in maintenance that would cost more than $500 million to meet. The Senate Subcommittee is continuing to work on its draft bill, but it seems unlikely at this point that it will include the President’s proposed decreases in IHS funding.

Continued access to Medicaid and private insurance. As the debate on a “repeal and replace” health care financing bill steamed toward passage in the Senate, an inspiring number of Senators lined up on July 26th and 27th to offer amendments that would protect Indian access to health care. On this bi-partisan honor roll are Senators Udall, Murkowski, Daines, Heitkamp, Franken, Graham, Sullivan, and Hoeven. Earlier, on July 18, Senators Udall, Heitkamp, and Franken convened a round table with tribal leaders about health care in Indian country, and then took to the floor of the Senate to tell about what they heard from those leaders, and what they knew from the work of the Senate Committee on Indian Affairs. See excerpts of the soliloquy from the Congressional Record here.

The repeal bill eventually failed to pass, and so the amendments were not needed. But it is heartening to see that these senators from both major parties were prepared to speak out and to step up with amendments that would make a big difference in Indian country.

Decisions about Medicaid cuts are not likely to come up until the fall, when Congress entertains a tax cut for wealthy taxpayers, balanced by cuts in “entitlements” such as the Medicaid program. As one tribal leader pointed out, however, providing health care in Indian country is not a matter of “entitlement,” but an obligation of the U.S. government.