Congress announces long-awaited advance funds for Indian Health Service, but ongoing underfunding is problematic
Native nations in the Pacific Northwest and across Turtle Island applauded a historic decision to provide $5.13 billion in advance appropriations funding in 2023 for Indian Health Service.
The funding will provide a critical element of budgetary stability for the chronically underfunded agency. The lack of stable funding historically wreaked havoc on the agency's ability to recruit and retain staff, including in the Portland branch where 100% of dentist positions were vacant in 2021.
Trust and treaty obligations require the U.S. government to provide health care for Native Americans. Indian Health Service, or IHS, provides health care to the citizens of 574 federally recognized tribes.
The 2023 Consolidated Appropriations Act allocates advance IHS funding for the first time, though Native advocates and Native health clinics pushed for advance funding for years. In addition to the advance appropriations — which are only accessible to cover an unforeseen funding lapse — Congress allocated $6.96 billion in annual funds for the agency, representing a 5.45% total increase compared to 2022 funding levels.
Before Congress approved the Consolidated Appropriations Act in December 2022, most funding for IHS came via annual appropriations — funding allocated strictly on a year-by-year basis. This funding structure meant political squabbles causing government shutdowns severely limited IHS' ability to provide care.
Until this year, IHS was the only federally funded health care agency receiving annual appropriations funding instead of advance appropriations. Advance appropriations provide a bridge if there is a gap in yearly federal budgets or a government shutdown.
Although the move provides new funding stability for IHS, helping to maintain its current funding levels, it does not address ongoing underfunding of the agency.
IHS funding issues: Historic, widespread and local
IHS plays a critical role in health care service for Indian Country, though it hasn’t received the funding to match its importance despite nominal yearly increases.
Congress created IHS in 1955. Today, it provides health care to roughly 2.6 million Native Americans throughout Turtle Island, primarily in Alaska and the West.
IHS divides its clinics into 12 branches. The Portland Area Indian Health Service provides health care services to approximately 305,000 Native Americans in Oregon, Washington and Idaho.
The Portland branch has six health facilities in five tribal communities and one clinic at Chemawa Indian School. IHS also supports health clinics individual tribes operate.
Although most IHS clinics and services are centered around reservations, roughly 70% of Native American people live in urban areas, so an additional network of urban health care centers provides services to Native people living in urban areas.
In the Portland service area, several urban Indian health clinics, like the Native American Rehabilitation Association of the Northwest, or NARA, also receive IHS dollars.
Still, Portland area IHS clinics feel the effects of funding woes.
In fiscal year 2021, the latest year for which data is available, Portland area IHS clinics had some of the worst staffing vacancy rates of any IHS service area.
In the Portland area, a troubling 100% of IHS dentist positions were vacant in fiscal year 2021, compared to a 19% vacancy rate IHS-wide. A further 50% of medical officers and 50% of nursing positions were vacant the same year, compared to the IHS-wide average of 26% and 29%, respectively.
Experts say low, unreliable funding makes staff recruitment and retention a major issue for IHS clinics. Low staff levels mean clinics can't always offer a complete suite of services and must often make referrals.
Despite its issues, IHS remains a critical service for the millions of tribal citizens it serves, like Damian White Lightning, a citizen of the Standing Rock Sioux Tribe and recent University of Oregon graduate.
White Lightning said he and his family use IHS and find it helpful, but that additional funding for IHS would be an improvement overall.
“Being told that IHS can only do some dental, vision or other physical aid is kind of irritating; having to go multiple places possibly for one issue,” White Lightning said. “Bringing in more staff would be helpful too, as I know the one we go to only takes so many people at a time cause there’s only two or three qualified people taking everyone, causing a longer wait.”
IHS is not a health insurance provider but a health care service provider, like the Veterans Health Administration, meaning recipients of the agency’s services are not billed individually for the services they receive.
White Lightning said this is a significant benefit he sees when using IHS.
“Having IHS makes getting checked up much easier as I don’t necessarily have to worry about the funds side of it, like worrying about paying a bill or having to spend time worrying about a payment plan like normal hospitals or clinics do,” White Lightning said.
While advance appropriations provide a critical piece of the solution to IHS’s budgetary difficulties — and the 2023 fiscal year budget increases funding by $360 million — a July 2022 report from the Office of the Assistant Secretary for Planning and Evaluation found 2022 IHS funding was $6.98 billion, or 51.4%, below the necessary amount.
It's a matter of debate just how underfunded IHS is, as recommendations vary substantially between tribal and federal estimates.
Native health experts on the Tribal Budget Formulation Workgroup providing annual guidance to the federal government recommended funding IHS for $51.4 billion in 2023, a 675.45% increase above the 2022 budget.
Native health disparities
Native Americans have long endured worse health outcomes than other racial groups — including a life expectancy roughly seven years shorter than average in the United States — which experts say is partly due to inadequate access to comprehensive health care.
“Lower life expectancy and the disproportionate disease burden exist perhaps because of inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences,” IHS says on its website. “These are broad quality of life issues rooted in economic adversity and poor social conditions.”
According to the Centers for Disease Control, Native Americans report a higher prevalence of many health issues and a higher rate of poor health status when compared to white people while simultaneously reporting a lower rate of having a personal doctor or health care provider.
The federal government distributes a brochure for IHS patients repeatedly reminding readers IHS may not provide sufficient health care and urges individuals to buy supplemental health insurance, placing the blame squarely on funding.
“Even though health care is a treaty right, you should still get insurance,” the brochure reads. “IHS has to work within yearly budgets approved by Congress and does not receive enough funds to meet all the health needs of American Indians and Alaska Natives.”
The brochure goes on to say the current IHS budget meets only “about half” of the needs of the patients it serves.
Perpetually underfunded
Not only do Native Americans using IHS face uncertainty in their ability to access health care but the level of per capita spending for IHS is also far less than other federally funded health care systems.
According to an analysis by the U.S. Government Accountability Office, per capita spending for IHS was $4,078 in 2017, less than one-third of per capita spending for Medicare, which was $13,185.
Per capita spending for Medicaid and the Veterans Health Administration was more than double IHS.
Health care spending for federal prisoners was also more than twice as much as IHS per capita.
Although these programs differ in size and programs offered, Native health advocates agree IHS is underfunded — and the poor health outcomes of those who receive IHS services reflect that analysis.
Effects of funding lapses
Before the Dec. 22, 2022 announcement of Congress’ 2023 fiscal year omnibus spending package, Native Americans were in a uniquely precarious position whenever federal spending lapsed.
As the only federal health care program without stable funding, government shutdowns impacted IHS’s ability to provide year-round care and even clinics’ ability to stay open.
The historic 35-day-long 2018-2019 government shutdown was disastrous for IHS clinics. As politicians quibbled about spending, funding for the health care agency began to run out. Tribal health clinic workers were furloughed, and tribal citizens could not get adequate health care until the government shutdown ended.
The National Council of Urban Indian Health, or NCUIH, a nonprofit supporting and developing comprehensive, culturally sensitive health and public health services for Native Americans and Alaska Natives living in urban areas, found the effects of government shutdowns are nearly immediate and can be fatal for patients.
At least five Urban Indian Organization patients died during the 2018-2019 government shutdown, and at least seven suffered a drug overdose. Within a few weeks, 25% of urban clinics had to shut down, and nearly 40% could only maintain operations for 30 days without additional funding.
Advocates say mandatory funding for IHS is critical to saving patients’ lives, and that without a massive spending increase for IHS — which is still yet to come — the health disparities between Natives and other groups will be practically impossible to overcome.
New funding information
The first official proposal for advance appropriations came from U.S. Sen. Jeff Merkley, D-OR, in 2021 in his fiscal year 2022 Senate Interior, Environment and Related Agencies appropriations bill.
Though advance appropriations were not included in the 2022 fiscal year budget, Merkley made the proposal again for the 2023 budget — this time with success.
Last July, the Biden Administration commissioned a report from the Office of the Assistant Secretary for Planning and Evaluation on how increased funding would impact the IHS. The report found both advance appropriations and a significant increase in the agency’s budget are needed to improve outcomes for IHS recipients.
Native advocates, community leaders and Indian health care providers called on Congress to include the badly-needed funding in the 2023 budget, urging the federal government to fulfill its obligations to provide adequate health care services to Native Americans and Alaska Natives.
Before the funding announcement, the NCUIH urged the public to contact Congress and encourage the inclusion of advance appropriations for IHS, calling it “the most impactful policy that Congress can do for Native communities this year.”
NCUIH pointed out over 50% of Native veterans use IHS, describing the lack of guaranteed funding as “unacceptable for our heroes.”
“The lives of Native people should not be subject to politics,” the NCUIH said in a policy update. “We need this to protect Native people and preserve access to health care.”
The funding push didn’t stop with private organizations. On Dec. 6, 2022, the House Native American Caucus sent a letter to the House Committee on Appropriations with 29 signatures from members of Congress urging the Committee to include a shift to mandatory funding for IHS in the spending bill.
“Never has funding for the Indian Health Service come close to meeting the actual level of need, which can only lead one to deduce that the federal government has historically placed less value on Indian health than that of other populations."
— Nickolaus Lewis "Juts-kadim"
Chairman, Northwest Portland Area Indian Health Board
The bipartisan group of lawmakers included three Democratic U.S. Congressmen from Oregon — Rep. Peter Defazio, Rep. Earl Blumenauer and the outgoing Rep. Kurt Schrader.
On Dec. 20, 2022, Merkley announced the inclusion of his proposal for advance appropriations into the final version of the 2023 fiscal spending bill. Three days later, Congress passed the $1.7 trillion dollar spending package, including advance appropriations for IHS through fiscal year 2024.
The guaranteed funding is especially important with the sharply divided makeup of the federal government — with Republicans holding a slight majority in the House of Representatives, a government shutdown is possible this fall.
A chorus of tribal governments, Indian health clinics and Native advocacy groups cheered the historic funding announcement.
Nickolaus Lewis "Juts-kadim" is a citizen of Lummi Nation, councilman for Lummi Nation and chairman of the Northwest Portland Area Indian Health Board, a nonprofit advocating to improve the quality of life and health care of Native American and Alaska Natives on behalf of the 43 federally recognized tribes in Oregon, Washington and Idaho. The group has years of experience advocating for improved services and funding for IHS.
Lewis called the funding announcement a significant step forward but highlighted the ongoing failures of the federal government to meet the health needs of Native Americans.
“It's about time,” Lewis said in a statement. “Never has funding for the Indian Health Service come close to meeting the actual level of need, which can only lead one to deduce that the federal government has historically placed less value on Indian health than that of other populations.
“Advance appropriations will resolve some of the challenges presented by annual discretionary funding like the instability caused by continuing resolutions and lapses in appropriations, but will not address the issue of funding adequacy.”
Leaders of other tribal advocacy groups, like William Smith (Valdez Native Tribe), president of the National Indian Health Board, echoed similar sentiments.
“Including advance appropriations for Indian health in the omnibus is a historic moment for Indian Country over a decade in the making,” Smith said of advocacy efforts. “While Indian health remains chronically underfunded, this provision will help ensure that the Indian Health Service can provide stable, uninterrupted care to our people even when there is a government shutdown.”
Several Northwestern tribal officials echoed the importance of the advance appropriations announcement in their own individual statements of approval.
Cheryle A. Kennedy, chairwoman of the Confederated Tribes of Grand Ronde, cheered the funding announcement in a Dec. 23, 2022 statement.
“It's taken years of prayer, effort, and unity to get to this rightful place for Tribal Nations,” Kennedy said. “Thank you to our brothers and sisters who helped in the battle; now we can rejoice together. It's a great day."
Officials from other Northwestern Native nations, including the Confederated Tribes of Colville, Makah Tribe and Jamestown S’klallam Tribe, applauded the announcement, saying it would help save lives.
Merkley, who officially proposed the funding, also recognized the significance of the decision to provide advance appropriations for IHS. Merkley chairs the Senate Interior Appropriations Subcommittee and oversees billions of dollars in funding for Indian Country.
“This is a big deal and a historic win for Indian tribes in Oregon and beyond,” Merkley told Street Roots. “Health care for Tribal communities should never shut down because the government fails to pass a budget — health challenges and emergencies do not wait on Congress. One of my top priorities when I sit down to write our annual appropriations bill is to ensure Congress is upholding its trust and treaty responsibilities to Indian Tribes through the federal budget process.
“This guarantee will give health care providers peace of mind, help with recruitment and retention, and, most importantly, help ensure health care for IHS patients never stops.”
The advance appropriations will provide budgetary certainty for two fiscal years, a major change in how IHS functions, according to Merkley’s office.
Congress will need to include advance appropriations in its next fiscal budget to maintain this new budgetary stability.
Advocates say this advance funding is only part of the solution.
A major overhaul of the IHS budget is needed to begin to bridge the gap in health outcomes between Native Americans, Alaska Natives and other racial groups.
“We are confident that we can build on this win and continue our work toward full and mandatory funding for the Indian Health Service, fulfilling the promises this country made to our people over two centuries ago,” Smith of the National Indian Health Board said.
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