On February 13, 2012, President Obama submitted to Congress his proposed FY 2013 budget for federal agencies. In this Memorandum we report on proposed FY 2013 appropriations for the Indian Health Service (IHS). The FY 2012 numbers in this Memorandum reflect the 0.16 percent across-the-board reduction applied to programs in the FY 2012 Interior, Environment and Related Agencies Appropriations Act (PL 112-74).
FUNDING OVERVIEW
Increases. The Administration proposes a 2.6 percent increase in the IHS budget, which is $116 million over the FY 2012 enacted level. Nearly half of the increase is for staffing and operation of six new facilities ($49 million). The rest of the increase is for a 3.6 percent inflationary increase for Contract Health Services ($34 million) and a 1.7 percent pay increase for Commissioned Officers ($2.4 million). It also includes program increases for Contract Health Services ($20 million); Contract Support Costs ($5 million); Health Information Technology ($6 million); Direct Operations ($1.1 million); and Maintenance and Improvement ($1.7 million).
Decreases. There is a proposed decrease of $3.5 million in the Health Care Facilities Construction account. Funds are requested, however, to complete construction of the San Carlos Health Center and to continue work on the Kayenta Health Center.
Staffing of New Facilities. The proposed budget (Services and Facilities accounts combined) includes $49.2 million for staffing and operating costs for the following new facilities: Norton Sound Regional Hospital ($10.6 million); Chickasaw Nation Health Clinic in Ardmore ($8.9 million); Cherokee Nation Health Center ($2.8 million); Chickasaw Nation Health Clinic in Tishomingo ($5.3 million); Southcentral Foundation Valley Primary Care Center ($13.5 million); and Tanana Chiefs Conference Interior Health Center ($8.1 million). All but the Norton Sound Hospital (which was funded through the Recovery Act) are joint venture projects.
Lack of Funding for Built-in Costs. The Administration’s proposal does not provide, with the exception of Contract Health Services, for inflationary increases. It also does not include funding for population growth or civilian pay raises, although the President has proposed a 0.5 percent pay increase for federal employees. These costs, as with fiscal years 2011 and 2012, will need to be absorbed from existing program funds. The President requested $255 million in built-in costs for FY 2012 which Congress did not fund.
LEGISLATIVE PROVISIONS
Maintain the Restriction of IHS Funds in Alaska to Regional Native Organizations. In what is a departure from its FYs 2011 and 2012 requests, the Administration does not propose to discontinue the provision that provides that IHS funds for Alaska be made available only to regional Alaska Native health organizations (with some exceptions). The FY 2012 appropriations act (PL 112-74) extended this policy until October 1, 2013. (This provision is Sec. 416 in the Federal Budget Appendix).
Sec. 435. (a) Notwithstanding any other provision of law and until October 1, 2013, the Indian Health Service may not disburse funds for the provision of health care services pursuant to Public Law 93-638 (25 U.S.C. 450 et. seq.) to any Alaska Native village or Alaska Native village corporation that is located within the area served by an Alaska Native regional health entity.
(b) Nothing in this section shall be construed to prohibit the disbursal of funds to any Alaska Native village or Alaska Native village corporation under any contract or compact entered into prior to May 1, 2006, or to prohibit the renewal of any such agreement.
(c) For the purpose of this section, Eastern Aleutian Tribes, Inc., the Council of Athabascan Tribal Governments, and the Native Village Eyak shall be treated as Alaska Native regional health entities to which funds may be disbursed under this section.
Contract Support Costs Cap. The Administration proposes, consistent with previous appropriations acts, to continue a statutory cap on IHS Contract Support Costs – $474,446,000.
Contract Support Limitation. The Administration proposes, consistent with the Interior appropriations acts for FYs 1999-2012, to attempt to limit the ability of the IHS and BIA to fund past-year shortfalls in contract support funding from remaining unobligated balances for those fiscal years.
IDEA Data Collection Language. The Administration proposes to continue to authorize the BIA to collect data from the IHS and tribes regarding disabled children in order to assist with the implementation of the Individuals with Disabilities Education Act (IDEA):
Provided further, That the Bureau of Indian Affairs may collect from the Indian Health Service and tribes and tribal organizations operating health facilities pursuant to Public Law 93-638 such individually identifiable health information relating to disabled children as may be necessary for the purpose of carrying out its functions under the Individuals with Disabilities Education Act, (20 U.S.C. 1400, et. seq.)
Prohibition on Implementing Eligibility Regulations. The prohibition on the implementation of the eligibility regulations published on September 16, 1987, would be continued.
Services for non-Indians. The provision that allows the IHS and tribal facilities to extend health care services to non-Indians, subject to charges, would be continued. The provision states:
Provided, In accordance with the provisions of the Indian Health Care Improvement Act, non-Indian patients may be extended health care at all tribally administered or Indian Health Service facilities, subject to charges, and the proceeds along with funds recovered under the Federal Medical Care Recovery Act (42 U.S.C. 2651-2653) shall be credited to the account of the facility providing the service and shall be available without fiscal year limitation.
Assessments by DHHS. The Administration proposes to continue bill language that has been in the Interior appropriations act for a number of years and provides that no IHS funds can be used for any assessments or charges by DHHS “unless identified in the budget justification and provided in this Act, or approved by the House and Senate Committees on Appropriations through the reprogramming process.” The Administration has in the past several years proposed to delete this language, but did not do so in its FY 2013 budget submission.
Limitation on No-Bid Contracts. The Administration proposes to continue the provision from FY 2010 regarding the use of no-bid contracts. The provision specifically exempts Indian Self-Determination agreements and reads:
Sec. 411. None of the funds appropriated or otherwise made available by this Act to executive branch agencies may be used to enter into any Federal contract unless such contract is entered into in accordance with the requirements of the Chapter 33 of title 41 United States or chapter 137 of title 10, United States Code, and the Federal Acquisition Regulations, unless:
(1) Federal law specifically authorizes a contract to be entered into without regard for these requirements, including formula grants for States, or federally recognized Indian tribes; or
(2) such contract is authorized by the Indian Self-Determination and Education and Assistance Act (Public Law 93-638, 25 U.S.C. 450 et seq., as amended) or by any other Federal laws that specifically authorize a contract within an Indian tribe as defined in section 4(e) of that Act (25 U.S.C. 450b(e)); or
(3) Such contract was awarded prior to the date of enactment of this Act.
FUNDING FOR INDIAN HEALTH SERVICES
FY 2011 Enacted $3,665,273,000
FY 2012 Enacted $3,866,181,000
FY 2013 Admin. Request $3,978,974,000
SPECIAL DIABETES PROGRAM FOR INDIANS
While the entitlement funding for the Special Diabetes Program for Indians (SDPI) is not part of the IHS appropriations process, those funds are administered through the IHS. The SDPI is currently funded through FY 2013 at $150 million annually (PL 111-309).
HOSPITALS AND CLINICS
FY 2011 Enacted $1,762,865,000
FY 2012 Enacted $1,810,966,000
FY 2013 Admin. Request $1,849,310,000
Built-In Costs. The Administration proposes $1.4 million for Commissioned Officers pay increase and $31.9 million for staffing and operation of new facilities to be distributed as follows: Norton Sound Regional Hospital ($7.6 million); Chickasaw Nation Health Clinic in Ardmore ($5.4 million); Cherokee Nation Health Center ($1.6 million); Chickasaw Nation Health Clinic in Tishomingo ($3.2 million); Southcentral Foundation Valley Primary Care Center ($8.6 million); and Tanana Chiefs Conference Interior Health Center ($5.5 million).
Increase. The Administration proposes a $5 million increase for Health Information Technology for a total of $177 million. The increase would be used as follows:
IHS will use funds to complete systems development for the ICD-10 conversion and to deliver an acceptable level of national training for affected staff. Funding is essential to provide necessary training and implementation support in order to prevent delays in filing claims, erroneous and rejected claims, reduced third party capture, and potentially reduced services to underserved patients from IHS and Tribal health care facilities. (CJ-76)
The IHS received a $3.4 million increase for Health Information Technology security in FY 2012, a portion of which, IHS explains, will be distributed to tribal programs.
The IHS and other Department of Health and Human Services agencies participate in Department-and Government-wide information initiatives, and IHS notes that it will contribute $880,962 of its FY 2013 budget “to support Department-wide enterprise information technology and Government-wide E-Government initiatives.”
(CJ-182)
Indian Health Care Improvement Fund. The Administration’s proposal includes $57.5 million for the Indian Health Care Improvement Fund (IHCIF), which is the same as the FY 2012 enacted level and $12 million above the FY 2011 level. The IHS has been in consultation with tribes regarding the possible changes in the IHCIF formula. On November 25, 2011, IHS Director Roubideaux wrote tribal leaders informing them of her decisions relating to the IHCIF. In that letter the IHS Director said the following:
• No change will be made to the IHCIF formula until all programs reach at least
55 percent of their estimated level of need
• Data and technical improvements to the formula are approved and the IHS will continue to evaluate whether a prototype Medicaid spending index would be a possible replacement for the existing 25 percent alternate resource factor
• The IHCIF will not be expanded to include new services authorized by the Indian Health Care Improvement Act until funding is made available for those services (i.e., long term care)
Other. Funding for the 12 epidemiology centers would be $4.7 million, the same as the FY 2012 enacted level. There is no specific funding level requested for the Domestic Violence Initiative but bill language would be continued providing that funding made available for the methamphetamine and suicide prevention and treatment and the domestic violence prevention initiatives are to be allocated at the discretion of the Director.
DENTAL SERVICES
FY 2011 Enacted $152,634,000
FY 2012 Enacted $159,440,496
FY 2013 Admin. Request $166,297,000
Built-In Costs. The Administration proposes $268,000 for Commissioned Officers pay increase and $5.6 million for staffing and operation of new facilities to be distributed as follows: Norton Sound Regional Hospital ($950,000); Chickasaw Nation Health Clinic in Ardmore ($1.1 million); Cherokee Nation Health Center ($508,000); Chickasaw Nation Health Clinic in Tishomingo ($513,000); Southcentral Foundation Valley Primary Care Center ($1.6 million); and Tanana Chiefs Conference Interior Health Center ($882,000).
Increase. The Administration proposes a $1 million increase to be used to implement the Electronic Dental Record at 18 additional sites, bringing the total to 118 out of 230 planned sites.
MENTAL HEALTH
FY 2011 Enacted $72,786,000
FY 2012 Enacted $75,588,864
FY 2013 Admin. Request $78,131,000
Built-In Costs. The Administration proposes $29,000 for Commissioned Officers pay increase and $2.5 million for staffing and operation of new facilities to be distributed as follows: Norton Sound Regional Hospital ($300,000); Chickasaw Nation Health Clinic in Ardmore ($559,000); Cherokee Nation Health Center ($94,000); Chickasaw Nation Health Clinic in Tishomingo ($376,000); Southcentral Foundation Valley Primary Care Center ($841,000); and Tanana Chiefs Conference Interior Health Center ($343,000).
The IHS notes that in FY 2013 they will “continue to focus on integration of behavioral health into primary care. IHS supports changing the paradigm of mental health services from being episodic, fragmented, specialty, and/or disease focused to being part of primary care and the ‘Medical Home’.” (CJ-85)
The IHS reports that over 50 IHS and tribal facilities in eight IHS Areas offer some level of telebehavioral health services, with the remaining four Areas developing or using those services. While technological barriers to utilizing telehealth-based services are decreasing, the primary barrier to expansion of these services is the lack of adequate infrastructure and clinical professionals. The IHS states, “the expansion of telebehavioral health cannot be separated from the need for infrastructure and staffing resources.”
(CJ-83)
ALCOHOL AND SUBSTANCE ABUSE
FY 2011 Enacted $194,409,000
FY 2012 Enacted $194,296,627
FY 2013 Admin. Request $195,378,000
Built-In Costs. The Administration proposes $27,000 for Commissioned Officers pay increase and $1 million for staffing and operation of new facilities to be distributed as follows: Norton Sound Regional Hospital ($96,000); Chickasaw Nation Health Clinic in Ardmore ($273,000); Cherokee Nation Health Center ($91,000); Chickasaw Nation Health Clinic in Tishomingo ($183,000); Southcentral Foundation Valley Primary Care Center ($285,000); and Tanana Chiefs Conference Interior Health Center ($126,000).
CONTRACT HEALTH SERVICES (CHS)
FY 2011 Enacted $779,927,000
FY 2012 Enacted $843,575,117
FY 2013 Admin. Request $897,562,000
Built-In Costs. The Administration proposes $34 million to cover the cost of inflation which was calculated at 3.6 percent. (In FY 2012 the Administration requested, but Congress did not approve, $79 million to address inflation and population growth in the CHS account.)
Increase. In addition to funding to offset inflation, the Administration requested a $20 million program increase. The IHS estimates that this funding would purchase the following additional services: 848 inpatient admissions; 31,705 outpatient visits; and 1,166 one-way patient travel trips.
The IHS also notes that the demand for CHS, which always exceeds the available funding, will be even more in demand as five hospitals have been or are planned to be replaced by ambulatory health centers with no inpatient services. Those health centers will be required to purchase inpatient care from the private sector using CHS funding.
Catastrophic Emergency Health Fund (CHEF). Within the total CHS amount is $51.5 million for CHEF, the same as the FY 2012 enacted level and $6.5 million below the FY 2011 level.
PUBLIC HEALTH NURSING
FY 2011 Enacted $63,943,000
FY 2012 Enacted $66,632,218
FY 2013 Admin. Request $69,868,000
Built-In Costs. The Administration proposes $84,000 for Commissioned Officers pay increase and $3.15 million for staffing and operation of new facilities to be distributed as follows: Norton Sound Regional Hospital ($500,000); Chickasaw Nation Health Clinic in Ardmore ($720,000); Cherokee Nation Health Center ($121,000); Chickasaw Nation Health Clinic in Tishomingo ($486,000); Southcentral Foundation Valley Primary Care Center ($969,000); and Tanana Chiefs Conference Interior Health Center ($356,000).
HEALTH EDUCATION
FY 2011 Enacted $16,649,000
FY 2012 Enacted $17,056,666
FY 2013 Admin. Request $17,450,000
Built-In Costs. The Administration proposes $2,000 for Commissioned Officers pay increase and $391,000 million for staffing and operation of new facilities to be distributed as follows: Norton Sound Regional Hospital ($48,000); Chickasaw Nation Health Clinic in Ardmore ($91,000); Chickasaw Nation Health Clinic in Tishomingo ($61,000); Southcentral Foundation Valley Primary Care Center ($114,000); and Tanana Chiefs Conference Interior Health Center ($77,000).
The IHS reports that the number of patient visits in which health education was provided has more than tripled from FY 2004 to FY 2011. The funding supports 23 IHS health education field positions and 75 tribal health education staff. Areas of emphasis in FY 2013 include the development of “standardized, nationwide patient and health education programs through the integration of IHS Patient Education Protocols into all IHS software packages.” (CJ-106)
COMMUNITY HEALTH REPRESENTATIVES (CHR)
FY 2011 Enacted $61,505,000
FY 2012 Enacted $61,406,592
FY 2013 Admin. Request $61,531,000
Built-In Costs. The Administration proposes $4,000 for Commissioned Officers pay increase and $120,000 for staffing and operating costs for the Cherokee Nation Health Center.
Of the total amount, $59.7 million is for administration of the CHR program through Self-Determination contacts and compacts. An additional $1.8 million is for training, information technology, special projects and national education meetings.
Issues to be addressed in FY 2013 include coordinating data validations, improving connectivity for remote sites, and ensuring federal security requirements for tribal members to request access to RPMS.
HEPATITIS B and HAEMOPHILUS
IMMUNIZATION (Hib) PROGRAMS IN ALASKA
FY 2011 Enacted $1,930,000
FY 2012 Enacted $1,927,000
FY 2013 Admin. Request $1,927,000
The Hepatitis B and Immunization (Hib) programs would be funded at their
FY 2012 levels. The IHS reports that in 2011 65 percent of American Indian/Alaska Natives in Alaska with chronic Hepatitis B or and 56 percent with Hepatitis C infection were screened for liver cancer and inflammation. There continues to be an increase in Hepatitis C, and the IHS estimates that within 5-10 years, an estimated 25-33 percent of patients will need therapy for Hepatitis C.
URBAN INDIAN HEALTH
FY 2011 Enacted $43,053,000
FY 2012 Enacted $42,984,115
FY 2013 Admin. Request $42,988,000
Built-In Costs. The Administration proposes $4,000 for Commissioned Officers pay increase.
The IHS proposes in FY 2013 to provide third party billing training; increase the number of urban Indian health programs using Resource and Patient Management System (RPMS)/Electronic Health Record (EHR); and to increase the number of accredited programs.
Among the 41 urban Indian health sites which receive IHS funds, there are 21 full ambulatory facilities, six limited ambulatory programs, and seven outreach and referral programs.
INDIAN HEALTH PROFESSIONS
FY 2011 Enacted $40,661,000
FY 2012 Enacted $40,595,942
FY 2013 Admin. Request $40,598,000
Built-In Costs. The Administration proposes $2,000 for Commissioned Officers pay increase.
Programs funded under Indian Health Professions and their estimated FY 2013 amounts are: Health Professions Prepatory and Pre-Graduate Scholarships ($3.8 million); Health Professions Scholarships ($10.5 million); Extern Program ($1.18 million); Loan Repayment Program ($21.3 million); Quentin N. Burdick American Indians into Nursing Program ($1.76 million – 5 grants); Indians Into Medicine Program ($1.16 million – 3 grants); and American Indians into Psychology
($757,386 – 3 grants).
Proposed bill language allows for up to $36 million to be utilized for the Loan Repayment Program – IHS Area Offices and Service Units are authorized to provide supplemental funds, and in FY 2011 the Loan Repayment Program received $5 million from the Hospitals and Clinics account.
The Administration proposes to continue allowing funds collected on defaults from the loan repayment and health professions scholarship programs to be used to recruit health professionals for Indian communities:
Provided further, That the amounts collected by the Federal Government as authorized by sections 104 and 108 of the Indian Health Care Improvement Act (25 U.S.C. 1613a and 1616a) during the preceding fiscal year for breach of contracts shall be deposited to the Fund authorized by section 108A of the Act (25 U.S.C. 1616a-1) and shall remain available until expended and, notwithstanding section 108A(c) of the Act (25 U.S.C. 1616a-1(c)), funds shall be available to make new awards under the loan repayment and scholarship programs under sections 104 and 108 of the Act (25 U.S.C. 1613a and 1616a)
With regard to IHS scholarship programs, the IHS states that it reduced from 140 to 90 days the time within which it hires scholarship recipients who have completed their health profession degree or training.
TRIBAL MANAGEMENT
FY 2011 Enacted $2,581,000
FY 2012 Enacted $2,577,000
FY 2013 Admin. Request $2,577,000
Funding is for new and continuation grants for the purpose of evaluating the feasibility of contracting the IHS programs, developing tribal management capabilities, and evaluating health services. Funding priorities are, in order, 1) tribes that have received federal recognition or restoration within the past five years; 2) tribes/tribal organizations that are addressing audit material weaknesses; and 3) all other tribes/tribal organizations. The IHS estimates 30 awards in FY 2013 (three more than in FY 2012).
DIRECT OPERATIONS
FY 2011 Enacted $68,583,000
FY 2012 Enacted $71,653,171
FY 2013 Admin. Request $72,867,000
The IHS states in its budget submission that 56.5 percent of the Direct Operations budget would go to Headquarters and 43.5 percent to the 12 Area Offices. Tribal Shares funding for Title I contracts and Title V compacts are also included.
Built-In Costs. The Administration proposes $99,000 for Commissioned Officers pay increase.
Program Increase. The Administration proposes a program increase of $1.15 million for the following purposes:
Program Increase +$1,115,000 to fund: (a) continuing investments to maintain improvements and reforms made to-date and to continue enhancements in the IHS’ capacity for providing comprehensive oversight and accountability in key administrative areas such as Human resources, property, financial management, performance management and CHS program improvements developed through CHS consultation recommendations on improving business practices related to CHS and third party reimbursements; (b) addressing recent Congressional oversight and reports issued by the General Accountability Office and the Office of Inspector General to make improvements in management of IHS programs, such as the CHS program (c) addressing unfunded mandates for national initiatives associated with privacy requirements, facilities, and personnel security; and (d) improving responsiveness to external authorities such as Congress, GAO, OIG on questions related to oversight recommendations and the implementation and continuing accountability for new permanent authorities of the reauthorization of the IHCIA.
The IHS has placed a high priority on the issues raised in the Senate Committee on Indian Affairs (SCIA) investigation of the IHS Aberdeen Area, and, in addition to implementing a corrective action plan to address findings in the Aberdeen Area, IHS has established a schedule to conduct comprehensive reviews of all IHS Areas to ensure that the findings of the investigation are not happening in other Areas. In FY 2011, the Agency investigated four other IHS Areas and conducted a follow-up review in another Area that had previously undergone a management review prior to the SCIA investigation. (CJ-132)
SELF-GOVERNANCE
FY 2011 Enacted $6,054,000
FY 2012 Enacted $6,044,314
FY 2013 Admin. Request $6,044,000
The Self-Governance budget supports implementation of the IHS Tribal Self-Governance Program including funding required Tribal Shares; oversight of the IHS Director’s Agency Lead negotiators; technical assistance on tribal consultation activities; analysis of Indian health Care Improvement Act new authorities; and funding to support the activities of the IHS Director’s Tribal Self-Governance Advisory Committee.
The IHS projects that in FY 2013 approximately $1.5 billion will be transferred to support 90 tribal compacts and 115 funding agreements.
CONTRACT SUPPORT COSTS
FY 20101 Enacted $397,693,000
FY 2012 Enacted $471,437,491
FY 2013 Admin. Request $476,446,000
Increase. The Administration proposes a $5 million increase for Contract Support Costs (CSC). While the budget justification does not list the current CSC shortfall, the IHS estimates that the shortfall at the end of FY 2012 will be $45-$50 million.
The IHS states that the proposed $5 million increase will be applied to the CSC shortfall associated with ongoing contracts and compacts:
The CSC base funding will be distributed according to the CSC policy as a regular Pool 2 distribution. The CSC funding increase of $5,009,000 will be distributed according to the CSC policy as Pool 3 funds to address existing CSC shortfalls associated with ongoing contracts and compacts. The IHS Manual, Part 6, Chapter 3, specifies that fifty percent of the CSC increase will be allocated to those Tribes with the greatest unfunded CSC level of need in such a way as to raise the minimum CSC level of need funded to the highest possible level – a bottom up approach. The remaining 50 percent of the FY 2013 increase will be allocated to all Tribes who have a CSC shortfall, in proportion to their overall share of CSC.
The requested FY 2013 program increase of $5,009,000 will be applied to the CSC shortfall associated with ongoing contracts and compacts. However, if other program increases are approved in the FY 2013 budget, they may generate additional CSC need that will be included in the FY 2014 CSC Needs Report that will summarize the total CSC deficiency as of the end of FY 2013. (CJ 139-140)
Indian Self-Determination (ISD) Fund. The Administration proposes again to authorize up to $10 million of the total CSC funds for an Indian Self-Determination Fund. The IHS may allocate funds to the ISD Fund to support new or expanded self-determination contracts, grants, self-governance compacts or annual funding agreements.
Cap on Contract Support Costs. The Administration proposes, consistent with past appropriations acts, to continue language regarding a cap on contract support costs:
Provided further, That, notwithstanding any other provision of law, of the amounts provided herein, not to exceed $476,446,000 shall be for payments to tribes and tribal organizations for contract or grant support costs associated with contracts, grants, self-governance compacts or annual funding agreements between the Indian Health Service and a tribe or tribal organization pursuant to the Indian Self-Determination Act of 1975, as amended, prior to or during fiscal year 2012, of which not to exceed $10,000,000 may be used for contract support costs associated with new or expanded self-determination contracts, grants, self-governance compacts or annual funding agreements.
Contract Support Limitation. The Administration proposes, consistent with the Interior Appropriations Acts for FYs 1999-2012, to attempt to limit the ability of the IHS and BIA to fund past-year shortfalls in contract support funding from remaining unobligated balances for those fiscal years:
Sec. 408. Notwithstanding any other provision of law, amounts appropriated to or otherwise designated in committee reports for the Bureau of Indian Affairs and the Indian Health Service by Public Laws 103-138, 103-332, 104-134, 104-208, 105-83, 105-277, 106-113, 106-291, 107-63, 108-7, 108-108, 108-447, 109-54, 109-289, division B and Continuing Appropriations Resolution, 2007 (division B of Public Law 109-289, as amended by Public Law 110-5 and 110-28), Public Laws 110-92, 110-116, 110-137, 110-149, 110-161, 110-329, 111-6, 111-8 and 111-88, 112-10, 112-74 and ___ for payments for contract support costs associated with self-determination or self-governance contracts, grants, compacts, or annual funding agreements with the Bureau of Indian Affairs or the Indian Health Service as funded by such Acts, are the total amounts available for fiscal years 1994 through 2013 for such purposes, except that for the Bureau of Indian Affairs, tribes and tribal organizations may use their tribal priority allocations for unmet contract support costs of ongoing contracts, grants, self-governance compacts or annual funding agreements.
The above quote is from the FY 2013 IHS Budget Justification (CJ-23). The FY 2013 Budget Appendix for the entire federal government identifies this provision as Sec. 407, and references fiscal years 1994 through 2012 (rather than 2013).
FUNDING FOR INDIAN HEALTH FACILITIES
FY 2011 Enacted $403,947,000
FY 2012 Enacted $440,346,317
FY 2013 Admin. Request $443,502,000
MAINTENANCE AND IMPROVEMENT
FY 2011 Enacted $53,807,000
FY 2012 Enacted $53,720,909
FY 2013 Admin. Request $55,470,000
Increase. An increase of $1,749,000 is requested.
Maintenance and Improvement funds are provided to Area offices for distribution to projects in their regions. Funding is for the following purposes: 1) approximately $51.9 million for routine maintenance; 2) approximately $3 million for environmental compliance; 3) approximately $500,000 for demolition of vacant or obsolete health care facilities replaced through federal funding; and 4) limited funding for projects that improve the condition of facilities or make improvements to support health care delivery.
The IHS estimates that as of October 2011, the Backlog of Essential Maintenance list is $427 million (down $45 million from October 2010).
The IHS states with regard to insufficient funds in this program:
Adequate funds are not available to fully achieve the goals of the Energy Policy Act of 2005; Executive Order 13423, “Strengthening Federal Environmental, Energy, and Transportation Management”; the Energy Independence and Security Act of 2007; and Executive Order 13514, “Federal Leadership in Environmental, Energy and Economic Performance.” (CJ-159)
FACILITIES AND ENVIRONMENTAL HEALTH SUPPORT
FY 2011 Enacted $192,701,000
FY 2012 Enacted $199,413,427
FY 2013 Admin. Request $204,379,000
Built-In Costs. The Administration proposes $510,000 for Commissioned Officers pay increase and $4.45 million for staffing and operation of new facilities to be distributed as follows: Norton Sound Regional Hospital ($1.12 million); Chickasaw Nation Health Clinic in Ardmore ($774,000); Cherokee Nation Health Center ($220,000); Chickasaw Nation Health Clinic in Tishomingo ($541,000); Southcentral Foundation Valley Primary Care Center ($1 million); and Tanana Chiefs Conference Interior Health Center ($773,000).
MEDICAL EQUIPMENT
FY 2011 Enacted $22,618,000
FY 2012 Enacted $22,582,000
FY 2013 Admin. Request $22,582,000
The IHS notes that they expect to distribute the FY 2013 funds as follows: $16.6 million for routine replacement medical equipment at over 1,500 federally- and tribally-operated health care facilities; $5 million for new medical equipment in tribally-constructed health care facilities; and $500,000 each for the TRANSAM and ambulance programs.
CONSTRUCTION
Construction of Sanitation Facilities
FY 2011 Enacted $95,665,000
FY 2012 Enacted $79,582,464
FY 2013 Admin. Request $79,582,000
Four types of sanitation facilities projects are funded by the IHS: 1) projects to serve new or like-new housing; 2) projects to serve existing homes; 3) special projects such as studies, training, or other needs related to sanitation facilities construction; and 4) emergency projects. The IHS sanitation facilities construction funds cannot be used to provide sanitation facilities in HUD-built homes.
The IHS proposes to distribute up to $48 million to the Area Offices for prioritized projects to serve existing homes; up to $5 million for projects to clean up and replace open dumps on Indian lands; and $2 million will be reserved at IHS Headquarters ($1 million for special projects and emergency needs; $500,000 to collect homeowner data and demographic information in three IHS Areas; and $500,000 for improving data collection systems to help fund a Water Resource Center to develop teaching materials and techniques for homeowners and communities to support usage in a way that promotes health). The Resource Center would be a partnership with the Alaska Native Tribal Health Consortium.
Construction of Health Care Facilities
FY 2011 Enacted $39,156,000
FY 2012 Enacted $85,047,706
FY 2013 Admin. Request $81,489,000
The Administration proposes no new health care facilities starts, but would complete construction of the San Carlos Health Center ($41.5 million) and continue construction for the Kayenta replacement health center ($40 million).
The IHS notes the strong tribal interest in the Joint Venture Construction Program:
The Joint Venture Construction Program (JVCP) allows IHS to enter into agreements with Tribes that construct their own health facilities. Through this competitive process, applicants can and do fund equipment for the projects. Upon completion by the respective Tribe, IHS requests Congressional appropriations for staffing and operations based on the Tribes’ projected dates of completion and opening. Between FY 2001 and FY 2011, sixteen joint venture project agreements signed by IHS and Tribes were initiated and eight have been completed. The JVCP continues to receive strong support by Tribes based upon the 55 positive responses to the FY 2009 congressionally directed solicitation for the JVCP FY 2010-FY 2012 cycle. The IHS will continue to work on the applications received for the FY 2010-FY 2012 cycle in accordance with ongoing construction projects and appropriation levels. (CJ-164-5)
OTHER
Transam Equipment, Ambulances, Demolition Fund. The Administration proposes to continue funding of up to $500,000 to purchase TRANSAM equipment from the Department of Defense and $500,000 to be deposited in a Demolition Fund to be used for the demolition of vacant and obsolete federal buildings. Up to $2.7 million is proposed for the purchase of ambulances.
THIRD PARY COLLECTIONS
The IHS estimates a total IHS and tribal Medicare, Medicaid and private insurance collections of $921,717,000 in FY 2013:
Medicare: $135 million federal; $64 million tribal
Medicaid: $495 million federal; $146 million tribal
Private Insurance: $81 million
If we may be of further assistance regarding FY 2013 Indian Health Service appropriations, please contact us at the information below.
