Biden's $9.1B mandatory IHS funding request falls far short of what's needed, say tribal officials

Not a golden nugget, they say, but a Band-Aid.

WASHINGTON — White House officials appear to be slowly realizing that one of the major tenets they were selling as “historic” in President Joe Biden’s fiscal year 2023 budget proposal offers yet another bone of contention for tribal advocates.

By most accounts, the White House thought it was providing a great service through its inclusion of $9.1 billion in mandatory funding for the Indian Health Service (IHS) within its request to the U.S. Congress, released on Monday.

“This proposal is intended to guarantee stable and predictable funding for IHS over time, and it begins to address longstanding needs,” Topher Spiro, a U.S. Office of Management and Budget (OMB) health-focused official, told tribal leaders in a virtual call on Tuesday. “…It is foremost about equity and honoring the United States’ trust responsibilities to tribal nations.”

Spiro said the request came as a result of numerous tribal consultations and longstanding recommendations from tribes and tribal organizations.

But the support — along with ten years of proposed mandatory funding for IHS that would increase annually over each of the next 10 years to $36.7 billion in fiscal year 2032 under the plan — is a far cry from what tribal leaders have been asking for from the administration on this front.

Spiro and his bosses have only just begun to hear that message, tribal leaders say.

In fact, the Tribal Budget Formulation Workgroup (TBFWG), a consortium of tribal health leaders, have been repeatedly telling the administration that due to the growing Indian population, the rising costs of healthcare — along with ongoing effects of the pandemic — over $49.8 billion is needed at IHS to properly serve Native citizens this year alone.

The workgroup is made up of two representatives from each of the 12 IHS areas, and it regularly advises U.S. Department of Health and Human Services officials.

However, the Biden administration, including officials within OMB, are of the mind that the workgroup’s number is a “vast overreach,” according to stymied tribal health officials, some of whom are affiliated with the National Indian Health Board (NIHB).

NIHB officials, in turn, think that the $6.6 billion provided by the U.S. Congress for IHS in the recent omnibus is a drop in the bucket that fails to meet the trust and treaty responsibilities of the federal government for Indian health.

“Congress could only manage to fund IHS at $6.6 billion – literally not enough to cover inflation and population growth; so, a net loss to Indian health,” NIHB Chairman William Smith, a citizen of the Valdez Native Tribe, said in a statement.

The administration, NIHB-affiliated officials lament, also thought it was okay to wait until March 9 — a year and a couple of months into the president’s tenure — to nominate a permanent director of the Indian Health Service during a pandemic that has killed many Native Americans.

Under the administration’s current proposal, even by 2032, the federal government would fall approximately $13 billion short of funding levels being called for by tribal health advocates to serve tribal citizens in 2022.

In a policy alert issued Tuesday, the National Council of Urban Indian Health (NCUIH) specifically noted a whopping $40.7 billion shortcoming:

On March 28, 2022, President Biden released his Fiscal Year (FY) 2023 Budget. The budget includes $9.1 billion in mandatory funding for the Indian Health Service (IHS) for the first year, an increase of $2.9 billion above FY 2021, and $40.7 billion less than requested by the Tribal Budget Formulation Workgroup (TBFWG).

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. Funding for Contract Support Costs and 105(l) leases also shifted from discretionary to mandatory funding in the FY 2023 budget.

The NCUIH also noted that the president’s budget does not include advance appropriations for IHS. Tribal health officials have been calling for multiple years of funding to be delivered as advance appropriations to the IHS so as to overcome problems related to sequestration and continuing resolution budgets that tend to put Indian healthcare in jeopardy. The Veterans Health Administration receives such advance appropriations.

Mark Trahant, who has previously covered IHS funding issues and is now the editor-at-large of Indian Country Today, writes in a recent column that “growing the Indian health budget in a decade to $36.7 billion is significant.”

Still, Trahant notes that even if Congress appropriates the full request for $9.1 billion, that equates to only $3,554 per person. “A funding level of $36.7 billion works out to $14,336 per person (at current population levels which will increase in a decade),” he adds.

Aaron Payment, chairperson of the Sault Ste. Marie Tribe of Chippewa Indians, told Indigenous Wire that he’d like to give the administration some leeway here.

“I would love $48B for IHS rather than just over $9B, which is an increase but far below tribal advisory requests,” Payment said in an email. “But the president’s requests have to balance out overall and must conform to budget caps.”  

White House officials are likely to appreciate receiving political cover from supporters like Payment, according to knowledgeable sources, who say top Biden staffers have felt stung by criticism that Biden’s Indian Country budget request for fiscal year 2023 is a blow to strong federal-tribal consultation (because it drastically reduces the amount requested by the Biden White House for tribes in fiscal year 2022 when consultation did not occur).

Trouble selling the president’s commitment to Indian health is not a problem White House officials want to be experiencing in an election year, so they will continue to work to message strong health goals for Indian Country, according to administration officials.