GM 17-059

House-Senate FY 2018 Indian Health Service Appropriations Recommendations

In this Memorandum we report on the Senate “Chairman’s Mark” making recommendations on the FY 2018 budget for the Indian Health Service (IHS) and compare it to the House-passed bill.

We reported on the House Appropriations Committee recommendations for FY 2018 funding for the IHS in our General Memorandum 17-039 of July 27, 2017 and on the House-passed FY 2018 omnibus appropriations bill which includes funding for the IHS in our General Memorandum 17- 047 of September 18, 2017. The House Interior Appropriations bill and report are HR 3354 and H. Rept. 115-238, respectively.

The House and Senate have not agreed on any appropriations bills for FY 2018 and consequently have had to pass two Continuing Resolutions (CR) funding programs, by and large, at FY 2017 levels and conditions. The current CR extends through December 22, 2017 (PL 115-90) (see our General Memorandum 17-058 of December 8, 2017). Hindering progress is the uncertainty regarding what the defense and non-defense spending caps will be – whether Congress will amend the Budget Control Act to allow for increased spending caps for FY 2018. Some members of Congress favor raising the cap for defense only, while the general position of Congressional Democrats is that the cap should be raised by the same amount for defense and non-defense discretionary spending alike.

Neither the Senate Appropriations Committee nor its Interior Appropriations Subcommittee marked up a FY 2018 Interior, Environment and Related Agencies bill. However, Interior Appropriations Subcommittee Chairman Murkowski (R-AK) released a “Chairman’s Mark” and an Explanatory Statement on November 20, 2017, which will be used in negotiations with the House when crafting a final bill.


FY 2017 Enacted $5,039,886,000
FY 2018 Admin. Request $4,739,291,000
FY 2018 House $5,136,873,000
FY 2018 Senate Mark $5,040,886,000

Both the House and Senate bills reject the large IHS budget cuts proposed by the Trump Administration so increases provided in FY 2017 would be retained. The Administration had proposed decreases for behavioral health initiatives, accreditation emergencies, prescription drug monitoring, detoxification, small ambulatory construction program, domestic violence, clinic leases, and the Facilities account. Those proposed decreases were rejected. Notable among the differences between the House and Senate recommendations are in the areas of pay costs increases, staffing for new facilities, Indian Health Care Improvement Fund, small ambulatory program; and quarters funding. The Senate bill has new provisions regarding housing subsidies for civilian personnel at IHS hospitals and Medicare Low Volume Payment Adjustments.

Pay Costs Increases. The House recommended $36.7 million for pay costs in the Services Account which compares to a FY 2017 enacted amount of $13.2 million. For the Facilities Account, the House recommended $3.6 million for pay costs which compares to an FY 2017 enacted amount of $1.2 million. The Senate bill does not contain funding for pay costs increases.

Staffing Packages. The House recommended $20 million for the staffing of two newly constructed Joint Venture projects – the Flandreau Health Center in Flandreau, SD and the Choctaw Nation Regional Medical Center in Durant, OK. This is the same as the Administration’s request. The Senate recommended $70 million and notes that the requested amount was $50 million short of need. The Explanatory Statement describes the Red Tail Hawk Health Center and the Phoenix Indian Medical Center in Arizona, the Fort Yuma Health Center in California and the Muskogee Creek Choctaw Nation Health Center in Oklahoma as needing staffing money (in addition to Flandreau and Choctaw). All the increases over FY enacted in the Senate Mark in the Services account are for the staffing of the new facilities.

Indian Health Care Improvement Act Unfunded Authorities Report. The House Report repeats the language from FY 2017 regarding funding for Indian Health Care Improvement Act authorizations. In the FY 2018 Budget Justification, IHS stated that 90 days is an insufficient time to provide the required report and also that the cost of it would be significant. The Committee language is as follows:

It has been over six years since the permanent reauthorization of the Indian Health Care Improvement Act (IHCIA), yet many of the provisions in the law remain unfunded. Tribes have specifically requested that priority areas for funding focus on diabetes treatment and prevention, behavioral health, and health professions. The Committee requests that the Service provide, no later than 90 days after the date of enactment of this Act, a detailed plan with specific dollars identified to fully fund and implement the IHCIA.

Reimbursable Funding. The House Report also directs the IHS to report on population and service growth over the past 10 years and the funding sources used to address these needs:

The Committee directs the Service to report, within 180 days of enactment of this Act, on patient population and service growth over the past ten years and the funding sources used to provide for these medical services. The IHS is to include a breakdown, by dollar amount and percentage, of funding sources which supplement appropriated dollars to cover the provision of medical services at IHS operated and tribally contracted and compacted facilities. The Committee is interested in detailed information on whether medical services have been able to expand over this time period as a result of increases in the ability to charge medical services to supplementary funding sources. As a point of comparison, and to the extent possible, the Service shall compare these impacts across the twelve IHS areas, with the degree to which patient populations services in the respective states has increased.

Appropriations Structure. Both bills would continue language that has been in the bill for a number of years that the appropriations structure of the IHS may not be altered without advance notification to the House and Senate Committees on Appropriations. The Administration proposed to delete this provision in order “to maximize operational flexibility.”


FY 2017 Enacted Such sums as may be necessary
FY 2018 Admin. Request Such sums as may be necessary
FY 2018 House Such sums as may be necessary
FY 2018 Senate Mark Such sums as may be necessary

The House and Senate have the same proposals regarding Contract Support Costs (CSC). The recommendations, consistent with the Administration’s request for IHS and the Bureau of Indian Affairs (BIA), does not make any major changes in the structure or amount of CSC appropriations—although the IHS estimated expenditures are lower than predicted for FY 2017. Funding for CSC in each agency remains a separate appropriation account with an indefinite amount—”such sums as may be necessary.”

The estimation for CSC spending for IHS is $717,970,000, the same as in the Administration’s budget justification.

The Senate proposal, consistent with the House recommendation, did not include two CSC restrictions proposed in the President’s Budget: (1) a command to count unspent CSC against a tribe’s requirement in the next year—a provision that could be read to deny the carryover authority in the ISDEAA; and (2) a “notwithstanding” clause that IHS has relied on, in part, to deny CSC for some programs, such as the Substance Abuse and Suicide Prevention program and the Domestic Violence Prevention Initiative. These provisions last appeared in the FY 2016 appropriations act, but tribes successfully advocated for their removal in FY 2017.

Both bills would continue prior language in the General Provisions section:

Contract Support Costs, Prior Year Limitation
Sec. 405. Sections 405 and 406 of division F of the Consolidated and Further Continuing Appropriations Act, 2015 (Public Law 113-235) shall continue in effect in fiscal year 2018.

Contract Support Costs, Fiscal Year 2018 Limitation
Sec. 406. Amounts provided by this Act for fiscal year 2018 under headings “Department of Health and Human Services, Indian Health Service, Contract Support Costs” and “Department of the Interior, Bureau of Indian Affairs and Bureau of Indian Education, Contract Support Costs” are the only amounts available for contract support costs arising out of self-determination or self-governance contracts, grants, compacts, or annual funding agreements for fiscal year 2018 with the Bureau of Indian Affairs or the Indian Health Service: Provided, That such amounts provided by this Act are not available for payment of claims for contract support costs for prior years, or for repayment of payments for settlement or judgments awarding contract support costs for prior years.


FY 2017 Enacted $3,694,462,000
FY 2018 Admin. Request $3,574,365,000
FY2018 House $3,867,260,000
FY 2018 Senate Mark $3,759,258,000


FY 2017 Enacted $1,935,178,000
FY 2018 Admin. Request $1,870,405,000
FY 2018 House $1,966,714,000
FY 2018 Senate Mark $1,982,312,000

Tribal Clinic Leases. Both bills would provide $11 million for tribal clinic leases, the same as FY 2017 enacted. The Administration proposed only $2 million for this purpose. They also rejected the Administration’s proposal for bill language to amend the law in order to avoid full compensation for section 105(l) Indian Self-Determination and Education Act leases which would be contrary to the decision in Maniilaq Association v. Burwell, 170 F. Supp.3rd 243 (D.D.C. 2016).

Accreditation Emergencies. Both bills would provide $29 million for hospital accreditation emergencies, the same as the FY 2017 level. The Administration proposed only
$2 million for this purpose. The House Committee Report states:

Accreditation Emergencies.—The Committee considers the loss or potential loss of a Medicare or Medicaid agreement with the Centers for Medicare and Medicaid Services (CMS) at any facility to be an accreditation emergency. The recommendation includes a total of $29,000,000 for accreditation emergencies at an alarming number of facilities over the past year. Funds may be used for personnel or other expenses essential for sustaining operations of an affected service unit, including but not to exceed $4,000,000 for Purchased/Referred Care. These are not intended to be recurring base funds. The Director should reallocate the funds annually as necessary to ensure that agreements with CMS are reinstated, and to restore third-party collection shortfalls. Shortfalls should be calculated relative to a baseline, which should be the average of the collections in each of the two fiscal years preceding the year in which an agreement with CMS was terminated or put on notice of termination.

The following House Committee Report language is related to the accreditation crisis and related reform:

The accreditation crisis in the Great Plains and the subsequent House provision have highlighted the need for IHS facilities to be significantly more inclusive of Tribes in the decision-making process. The Committees on Appropriations are encouraged by the IHS’s own recent initiative to reform its governing boards, but reforms are limited under existing statutes. The Committees are aware that the authorizing committees of jurisdiction are examining this issue and support these efforts to improve the communication and collaboration between the IHS and Tribes at direct service facilities.

The Senate Explanatory Statement likewise strongly disagrees with the proposal to virtually eliminate funding for accreditation emergencies:

The Committee strongly disagrees with the Service’s request to virtually eliminate funding for accreditation emergencies when this has proven to be such a persistent problem that jeopardizes necessary healthcare delivery at numerous locations. The Committee has maintained funding for accreditation emergencies at the fiscal year 2017 level of $29,000,000. The Committee remains extremely concerned with the potential loss of Medicare or Medicaid agreements with the Centers for Medicare and Medicaid Services (CMS) at any facility. This has been a particular problem in the Great Plains region and the Committee expects the Service to use these funds in order to correct problems at those facilities and to keep the Committee apprised of its progress.

Domestic Violence Prevention Initiative. Both bills recommend $12.9 million for this program, equal to the FY 2017 enacted level.

Prescription Drug Monitoring. Both bills recommend $1 million to fund the multi-state prescription drug monitoring program authorized by Section 196 of the Indian Health Care Improvement Act, equal to the FY 2017 enacted level.

Teleophthalmology Program. The Senate Explanatory Statement proposes $1 million for the teleophthalmology program for retinal camera upgrades.

FY 2017 Enacted $182,597,000
FY 2018 Admin. Request $179,751,000
FY 2018 House $185,920,000
FY 2018 Senate Mark $189,790,000

The House Committee Report states:

The Committee has recognized for many years the dire need to increase oral health care to American Indians/Alaska Natives. Because of funding increases, an additional 263,565 dental services were provided in fiscal year 2016. However, the demand for dental treatment remains overwhelming due to the high incidence of dental caries (cavities) in AI/AN children. Over 80 percent of AI/AN children ages 6–9 and 13–15 years suffer from dental caries, while less than 50 percent of the U.S. population in the same age cohort have experienced tooth decay. The Committee recognizes that more needs to be done to fully address the need for oral health care.

The Senate Explanatory Statement encourages the IHS “to coordinate with the Bureau of Indian Education (BIE) to integrate preventive dental care at schools within the BIE system.”

FY 2017 Enacted $94,080,000
FY 2018 Admin. Request $82,654,000
FY 2018 House $95,450,000
FY 2018 Senate Mark $97,201,000

Included in both bills is funding for a Behavioral Health Integration Initiative and the Zero Suicide Initiative ($21.4 million and $3.6 million, respectively, the same as in FY 2017).

FY 2017 Enacted $218,353,000
FY 2018 Admin. Request $205,593,000
FY 2018 House $220,280,000
FY 2018 Senate Mark $219,655,000

IHS states that its request includes $101.5 million for drug control activities which will maintain the program’s progress “in addressing the alcohol and substance abuse needs by improving access to behavioral health services through tele-behavioral health efforts and providing a comprehensive array of preventive, educational and treatment services.”

The Senate notes that the IHS is to continue its partnership with the Na’Nizhoozhi Center in Gallup, NM and “to distribute funds provided for detoxification services in the same manner as fiscal year 2017.” With regard to alcoholism and opioid addiction, the Senate Committee “encourages the Service to employ the full spectrum of medication assisted treatments (MAT) for alcoholism and opioid addiction, including non-narcotic treatment options that are less subject to diversion combined with counseling services.”

FY 2017 Enacted $928,830,000
FY 2018 Admin. Request $914,139,000
FY 2018 House $928,830,000
FY 2018 Senate Mark $930,484,000

Of the total, $53 million is for the Catastrophic Health Emergency Program. The House expresses concern regarding distribution of funds and encourages, in certain circumstances, agreements with non-IHS federal facilities:

The recommendation includes $928,830,000 for Purchased/Referred Care (PRC), equal to the fiscal year 2017 enacted level. The Committee remains concerned about the inequitable distribution of funds as reported by the Government Accountability Office (GAO– 12–446). The IHS is encouraged to evaluate the feasibility of entering into reimbursable agreements with Federal health facilities outside of the IHS system for patient referrals. Such agreements should be considered only when such referrals save costs and patient travel times relative to referrals to the nearest non-Federal health facilities, and when such referrals do not significantly increase patient wait times at such Federal facilities.


The House recommended $130 million for the Indian Health Care Improvement Fund. It is listed as its own line item under the Services account. Report language notes it is provided “in order to reduce disparities across the IHS system.” Bill language would provide that the Fund “may be used, as needed, to carry out activities typically funded under the Indian Health Facilities Account.” The Senate Mark does not include funding for the Indian Health Care Improvement Fund.


FY 2017 Enacted $78,701,000
FY 2018 Admin. Request $77,498,000
FY 2018 House $80,372,000
FY 2018 Senate Mark $82,546,000

FY 2017 Enacted $18,663,000
FY 2018 Admin. Request $18,313,000
FY 2018 House $18,896,000
FY 2018 Senate Mark $19,193,000

FY 2017 Enacted $60,325,000
FY 2018 Admin. Request $58,906,000
FY 2018 House $60,825,000
FY 2018 Senate Mark $60,325,000

FY 2017 Enacted $2,041,000
FY 2018 Admin. Request $1,950,000
FY 2018 House $2,058,000 FY 2018 Senate Mark $2,058,000

FY 2017 Enacted $47,678,000
FY 2018 Admin. Request $44,741,000
FY 2018 House Committee $47,943,000
FY2018 Senate Mark $47,678,000

Native Veterans. The House Report comments on the need for culturally appropriate services for Native veterans and also notes the provision in the FY 2018 House Veterans Administration appropriations bill requiring a report regarding the cost differential for VA to reimburse IHS for services rather than to provide services directly to urban Indian veterans:

The recommendation includes $47,943,000 for Urban Indian Health, $3,202,000 above the budget request. IHS is expected to continue to include current services estimates for Urban Indian Health in future budget requests. Seven out of ten American Indians/Alaska Natives live in urban centers and receive vital culturally appropriate health services from urban Indian health organizations. As such, many Indian veterans obtain their health care services from these organizations. Currently the Veterans’ Administration (VA) and the Indian Health Service are operating under a memorandum of understanding (MOU) which is effective through June 30, 2019. Under this agreement, VA reimburses care provided to Indian veterans at IHS facilities and Tribal health programs. The MOU recognizes the importance of a coordinated and cohesive effort on a national scope to meet the needs of individual tribes, villages, islands, and communities, through VA, IHS, Tribal and Urban Indian health programs; however, to date, there has not been equitable reimbursement for the culturally appropriate services provided to Native individuals, including Native veterans. This year, House Report 115–188 accompanying the fiscal year 2018 Military Construction, Veterans’ Administration, and Related Agencies Appropriation bill included a directive requiring the VA to prepare a report for the Appropriations Committee examining the impact of Indian veterans receiving health services at urban clinics and the annual estimated cost differential for VA to reimburse IHS rather than provide services directly in these urban areas. The report is also to estimate the capacity of Indian urban clinics to treat increased Indian veteran caseloads and include any data supporting the use of the higher negotiated reimbursement rate in urban settings versus rural areas. The report is due 90 days after enactment of the Act, and the Committee directs IHS to work with the VA to complete this report.

FY 2017 Enacted $49,345,000
FY 2018 Admin. Request $43,342,000
FY 2018 House $49,943,000
FY 2018 Senate Mark $49,345,000

Programs funded under Indian Health Professions are: Health Professions Preparatory and Pre-Graduate Scholarships; Health Professions Scholarships; Extern Program; Loan Repayment Program; Quentin N. Burdick American Indians Into Nursing Program; Indians Into Medicine Program; and American Indians into Psychology.

Loan Repayment Program. Both bills include $36 million for the loan repayment program. The House Report also comments:

Loan repayment has proven to be the Service’s best recruitment tool for staffing health professionals. The Committee was dismayed to learn that the Service has three thousand vacancies for health professionals. Overall, this is a vacancy rate of 20 percent, with a physician shortage rate of 30 percent and a dentist rate of 18 percent. The Committee has included $49,363,000 to better enable the Service to recruit and retain health providers. The Service is urged to consider making health administrators a higher priority for loan repayments, in consultation with Tribes.

The Senate Committee notes that funding for the Americans into Nursing Program, Indians into Medicine Program, and American Indians into Psychology Program are to be funded “at no less than fiscal year 2017 levels.”

The Senate Committee, in addition, comments on issues regarding extension services, patient wait times, and quality of care:

Extension Services. The Committee continues to be concerned about the urgent need for skilled health providers in AI/AN communities and is encouraged by the success of the University of New Mexico’s Project ECHO—Extension for Community Healthcare Outcomes—in delivering timely care to underserved communities. The Service shall consider how Project ECHO could support existing Indian Health Service providers, and how potential partnerships with Project ECHO could aid in the recruitment and retention of healthcare providers to IHS sites, thereby expanding the provider network and improving access to care.
Patient Wait Times. The Committee is encouraged by the Service’s recent focus on improving wait times for patients seeking primary and urgent care, including the August 2017 publication of Circular No. 17–11 and related efforts to track, report, and improve patient wait times. The Committee directs the Service to provide a report to the Committee on the status of these efforts no later than 90 days after enactment of this act. This report shall include a clear explanation of how these efforts will address GAO’s recommendation in report number GAO–16–333 of setting and monitoring Agency-wide standards for patient wait times in federally operated facilities and an analysis of any potential barriers to continued monitoring of wait times caused by IT infrastructure limitations or incompatibility.

Quality of Care. The Committee is extremely concerned about the lack of access to quality healthcare for Tribes around the Nation, including the ongoing healthcare quality problems in the Great Plains. In order to address these issues, the Committee recommendation includes a pilot program and related directives to improve access to quality health services and to improve recruitment and retention of qualified medical personnel as detailed below [Housing Improvements; Workforce Development; Title 38 Personnel Authorities]:

Housing Improvements. In addition to funds provided for staffing quarters within the Facilities Appropriation, the administrative provisions section of the bill also contains new language [see below] allowing for a program to provide a housing subsidy to medical personnel at facilities operated by the Indian Health Service. The Committee is concerned that the lack of affordable and available housing plays a significant role in the agency’s personnel vacancy rates and contributes to lowering the quality of care. The Committee expects the Service to provide a plan within 90 days of enactment of this Act that details how the agency plans to use this authority is fiscal year 2018, including the measures it will use to determine whether the authority is successful and how it should be expanded in future years. The Committee notes that it has restored funds for accreditation emergencies that could be made available for this purpose. The Committee also directs the Service to work with Tribes and with the Department of Housing and Urban Development to develop a long-term strategy to address professional housing shortages in Indian Country and to ensure that the Service and its partner agencies are fully utilizing existing authorities to improve the availability of housing stock.

(The Senate bill language regarding housing subsidies is: “Provided further, That the Indian Health Service may provide to civilian medical personnel serving in hospitals operated by the Indian Health Service housing allowances equivalent to those that would be provided to members of the Commissioned Corps of the United States Public Health Service serving in similar positions at such hospitals.”)

Workforce Development. The Committee believes that expanded workforce development training for all Service personnel—including non-clinical personnel—must be part of efforts to improve healthcare quality. In addition to continuing skills development opportunities, the Committee believes that IHS should expand its efforts to provide education to all staff and Federal employee management training to facility and area leadership that will provide employees a better understanding of their obligations to report failures in quality of care.

Title 38 Personnel Authorities. The Committee is aware of significant differences between the personnel authorities used by the Service versus the Department of Veterans Affairs under Title 38 of the United States Code. The Committee believes that an analysis of these differences—which include hiring and benefits authorities—may provide strategies for recruiting and retaining qualified personnel in the same rural and remote locations as the VA. The Committee directs the Service to work with the Department of Health and Human Services to analyze the differences between the two agencies’ personnel authorities and to submit a report no later than 90 days after enactment of this Act that details the differences and makes specific legislative recommendations as appropriate to provide parity between the two agencies.

FY 2017 Enacted $2,465,000
FY 2018 Admin. Request -0-
FY2018 House $,2465,000
FY 2018 Senate Mark $2,465,000

The Tribal Management grant program, authorized in 1975 under the authority of the Indian Self-Determination and Education Assistance Act (ISDEAA), provides competitive grant funding for new and continuation grants for the purpose of evaluating the feasibility of contracting IHS programs, developing tribal management capabilities, and evaluating health services.

FY 2017 Enacted $70,420,000
FY 2018 Admin. Request $72,338,000
FY 2018 House $72,338,000
FY 2018 Senate Mark $70,420,000

IHS estimates that 58.7 percent of the Direct Operations budget would go to Headquarters and 41.3 percent to the 12 Area Offices. Tribal Shares funding for Title I contracts and Title V compacts are also included.

FY 2017 Enacted $5,786,000
FY 2018 Admin. Request $4,735,000
FY 2018 House $5,806,000
FY 2018 Senate Mark $5,786,000

The Self-Governance budget supports implementation of the IHS Tribal Self-Governance Program including funding required for 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 notes in its FY 2018 budget justification that in FY 2016, $1.9 billion was transferred to tribes to support 89 ISDEAA Title V compacts and 115 funding agreements.


While the entitlement funding for the Special Diabetes Program for Indians (SDPI) is not part of the IHS appropriations process, tribes and tribal organizations routinely include support for this program in their testimony on IHS funding. SDPI is currently funded through December 31, 2017 at a rate of $150 million annually. The program needs to be extended this year. Tribes and tribal organizations are advocating for a $200 million annual funding level.


FY 2017 Enacted $545,424,000
FY 2018 Admin. Request $446,956,000
FY 2018 House $551,643,000
FY 2018 Senate Mark $563,658,000

The Administration’s proposal for the Facilities Account was especially harsh, proposing a $100 million reduction. The House and the Senate Mark reject the proposed cut and recommend $6 million and $18 million, respectively, over the FY 2017 enacted level.

FY 2017 Enacted $75,745,000
FY 2018 Admin. Request $60,000,000
FY 2018 House $77,502,000
FY 2018 Senate Mark $77,527,000

As of October 1, 2016, the Backlog of Essential Maintenance, Alteration, and Repair is $515.4 million. Maintenance and Improvement (M&I) funds are provided to Area Offices for distribution to projects in their regions.

FY 2017 Enacted $226,950,000
FY 2018 Admin. Request $192,022,000
FY 2018 House $231,412,000
FY 2018 Senate Mark $232,913,000


FY 2017 Enacted $22,966,000
FY 2018 Admin. Request $19,511,000
FY 2018 House $22,966,000
FY 2018 Senate Mark $22,966,000

Both bills would provide up to $500,000 for TRANSAM equipment and up to
$2.7 million for purchase of ambulances. The IHS Budget Justification stated that IHS expects to provide $450,000 to purchase TRANSAM equipment from the Department of Defense and no funding for the purchase of ambulances, but both bills would restore those amounts.


Construction of Sanitation Facilities

FY 2017 Enacted $101,772,000
FY 2018 Admin. Request $ 75,423,000
FY 2018 House $101,772,000
FY 2018 Senate Mark $101,772,000

The House and Senate rejected the Administration’s proposals to greatly reduce funding for sanitation projects to serve new or like-new housing, existing homes, emergency projects, and studies and training related to sanitation facilities construction projects.

The IHS sanitation facilities construction funds cannot be used to provide sanitation facilities for HUD-built homes.

Construction of Health Care Facilities

FY 2017 Enacted $117,991,000
FY 2018 Admin. Request $100,000,000
FY 2018 House $117,991,000
FY 2018 Senate Mark $128,480,000

The House Report does not specify specific construction projects; while The IHS proposed construction funding for the following specific projects:
• $45 million to complete construction of the Rapid City Health Center, Rapid City, SD;
• $50 million to continue construction of the Dikon Alternative Rural Health Center, Dikon, AZ; and
• $5 million for design/build activities for the Alamo Health Center, Alamo, NM

Small Ambulatory Program/New and Replacement Quarters. The House recommends level funding for the Small Ambulatory Program ($5 million) and for New and Replacement Quarters ($8.5 million). The Senate Mark, on the other hand, recommends $10 million for the Small Ambulatory Program and $11.5 million for new and replacement quarters.

Facility Construction Analysis. The House Report repeats language from the FY 2017 Explanatory Statement (conference report) addressing the need for a project-level funding distribution plan for healthcare facilities construction, and calls for a gap analysis of the level of healthcare services across the IHS system:

The Committee remains dedicated to providing access to health care for IHS patients across the system. The IHS is expected to aggressively work down the current Health Facilities Construction Priority System list as well as work with the Department and Tribes to examine alternative financing arrangements and meritorious regional demonstration projects authorized under the Indian Health Care Improvement Act that would effectively close the service gap. Within 60 days of enactment of this Act, the Service shall submit a spending plan to the Committees that details the project-level distribution of funds provided for healthcare facilities construction.

The IHS has no defined benefit package and is not designed to be comparable to the private sector health system. IHS does not provide the same health services in each area. Health services provided to a community depend upon the facilities and services available in the local area, the facilities’ financial and personnel resources (42 CFR 136.11(c)) and the needs of the service population. In order to determine whether IHS patients across the system have comparable access to healthcare, the IHS is directed to conduct and publish a gap analysis of the locations and capacities of patient health facilities relative to the IHS user population. The analysis should include: facilities within the IHS system, including facilities on the Health Facilities Construction Priority System list and the Joint Venture Construction Program list; and where possible facilities within private or other Federal health systems for which arrangements with IHS exist, or should exist, to see IHS patients.


The Senate bill contains a provision that would allow retroactive payment of Medicare Low Volume Payment Adjustments to be made for tribal and non-tribal hospitals. Section 437 of the bill would extend the right of certain tribal and non-tribal hospitals who see a low volume of Medicare patients to receive the low volume payment adjustments retroactively to 2014.


Both bills would continue language from previously enacted bills, including the following:

Restriction of IHS Funds in Alaska to Regional Native Organizations Extended to October 1, 2019. The Consolidated Appropriations Act, 2014 (PL 113-76) extended to October 1, 2018, the provision that provides that IHS funds for Alaska be made available only to regional Alaska Native health organizations (with some exceptions). Section 436 of the FY 2018 Senate bill would extend that period to October 1, 2019. We repeat here the language from the FY 2014 Appropriations Act:

Alaska Native Regional Health Entities SEC 424. (a) Notwithstanding any other provision of law and until October 1, 2018, 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 of Eyak shall be treated as Alaska Native regional health entities to which funds may be disbursed under this section.

IDEA Data Collection Language. Both bills would continue the BIA authorization 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). The provision is:

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. Both bills would continue the prohibition on the implementation of the eligibility regulations, published September 16, 1987.

Services for Non-Indians. Both bills would continue the provision that allows the IHS and tribal facilities to extend health care services to non-Indians, subject to charges. The provision states:

Provided, That 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. Both bills would continue the provision which provides that no IHS funds may be used for any assessments or charges by the Department of Health and Human Services “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.”

Limitation on No-Bid Contracts. Both bills would continue the provision regarding the use of no-bid contracts. The provision specifically exempts Indian Self-Determination agreements:

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 Chapter 33 of title 41 United States Code 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.) 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.

Use of Defaulted Funds. Both bills would continue the provision that allows funds collected on defaults from the Loan Repayment and Health Professions Scholarship programs to be used to make new awards under the Loan Repayment and Scholarship programs.

Please let us know if we may provide additional information or assistance regarding FY 2018 Indian Health Service appropriations.