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Mark Trahant
Indian Country Today

President Joe Biden unveiled his budget proposal for the fiscal year 2023 on Monday with significant increases for Indian health programs over the next decade.

A fact sheet from the White House says “for the first time in U.S. history, the President’s Budget is informed by direct consultation with Tribal communities, recognizing their inherent sovereignty, and honoring the Federal Government’s trust and treaty obligations to Tribal Nations. We are best served when Tribal governments are empowered to lead their communities and when Federal officials listen to and work together with Tribal leaders when formulating budgets that affect Tribal Nations.”

The president’s budget is a formal wish list. It remains the task of Congress to actually budget and appropriate the funding. So there is often a gap between what the White House proposes and what Congress actually spends. But the White House budget is critical because it frames the debate.

Over history this works both ways, sometimes Congress ignores the White House and spends more than the president asked for and during other cycles Congress appropriates less. The Indian Health Service budget is a good example of that push and pull and this budget is no different.

Last year the Congress did not enact the Indian health funding request. “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,” said National Indian Health Board Chairman William Smith in a statement. Smith is a citizen of the Valdez Native Tribe and is Eyak.

The president’s budget calls for a shift from discretionary to mandatory funding and a total of $9.1 billion, an increase of $2.9 billion above 2021. “After that, IHS funding would automatically grow to keep pace with healthcare costs and population growth and gradually close long standing service and facility shortfalls. Providing IHS stable and predictable funding will improve access to high quality healthcare, rectify historical underfunding of the Indian Health system, eliminate existing facilities backlogs, address health inequities, and modernize IHS’ electronic health record system,” the White House said.

“Only Congress can appropriate the dollars to meet the budget request,” Smith said. “Congress is the ballgame. The permanent reauthorization of the Indian Health Care Improvement Act was brought into the Affordable Care Act and ultimately passed, because of the leadership of House Speaker Nancy Pelosi with huge bipartisan support. The Late Congressman Don Young was a champion of every helpful legislative proposal that sought to make life better for Native Peoples and strengthened sovereignty.”

(Related: Joe Biden nominates Indian Health Service director)

Smith said the president’s budget is a “bold, 10-year vision” for mandatory spending. “The President is showing Tribes, through the priorities and vision he put in his 2023 Budget for Indian Health, that he is not just listening to Tribes, he is hearing us! Through this budget the President appears to be embracing a bold vision to end America’s long-demonstrated health and public health investment inequities for Tribal sovereign nations.”

President Joe Biden signs proclamations on the North Lawn at the White House in Washington, D.C., on Oct. 8, 2021, during an event announcing that his administration is restoring protections for two sprawling national monuments in Utah that have been at the center of a long-running public lands dispute, and a separate marine conservation area in New England that recently has been used for commercial fishing. (AP Photo/Susan Walsh)

Growing the Indian health budget in a decade to $36.7 billion is significant.

Let’s look at the math. The official service population for the Indian health system (the federal Indian Health Service and facilities operated by tribes, nonprofits and urban centers) is 2.56 million American Indians and Alaska Natives in 37 states. The most recent National Health Expenditure report from the Centers for Medicaid and Medicare show that the U.S. spends a total of $4.1 trillion on healthcare, or $12,530 per person.

The Indian health numbers are far less. If Congress appropriates the full request for $9.1 billion that’s only $3,554 per person. That total does not include Medicaid and Medicare funding for those eligible or private insurance that is billed by an Indian health facility. But even if that number is doubled; it’s still significantly behind other federal health spending.

A funding level of $36.7 billion works out to $14,336 per person (at current population levels which will increase in a decade.)

The second health provision in the budget is “mandatory” spending. But what does that mean?

“The President's Fiscal Year 2023 Budget proposes the first-ever fully mandatory budget for the IHS. This proposal is a historic step forward towards securing adequate, stable, and predictable funding to improve the overall health status of American Indians and Alaska Natives. It also ensures we never repeat the disproportionate impacts experienced during the pandemic.” said IHS acting director Elizabeth Fowler.

Fowler said the budget proposal would authorize and appropriate funding for IHS for ten years, from FY 2023 to FY 2032.

The federal government has two types of funding: Discretionary spending and mandatory spending.

The first goes through a regular appropriations process that is matched to the overall budget that Congress enacts. The second is automatic. The money is guaranteed. Even then there are two types of mandatory spending, one that is capped, or an entitlement that essentially follows the person. So if a person is eligible for Medicare, Medicaid, or Social Security, the funding is automatic.

The IHS news release said the IHS funding would be mandatory and exempt from sequestration provisions.

That longer approach to spending would “create predictability, stability and adequacy in IHS funding,” the National Indian Health Board said.

"It remains to be seen how it would actually play out, but by having the mandatory moniker ... it's that is the way you get those very large increases by tying to the medical rate of inflation, population growth and the cost of staffing. When you put that together, and over time it creates that almost 300 percent increase in a 10 year span, right?" Stacy A. Bohlen, chief executive officer for the National Indian Health Board, and a citizen of the Sault Ste. Marie Tribe of Chippewa Indians said.

"Is it perfect? It's not perfect, but it is major progress. And it really demonstrates, as I said before that the president is listening and he's putting his presidential credentials behind this for the tribes. She said this is something that no president has ever before proposed.

The president’s budget also proposes:

  • A $1.1 billion increase for tribal nations at the Department of Interior. Investments will support public safety and justice, social services, climate resilience, and educational needs to uphold federal trust and treaty responsibilities and advance equity for Native communities. It also proposes $156 million increase to support construction work at seven Bureau of Indian Education schools, providing quality facilities for culturally-appropriate education with high academic standards, as well as $7 million for the Federal Boarding School Initiative.
  • Directs money to address the crisis of Missing and Murdered Indigenous People. The Budget provides $632 million in Tribal Public Safety and Justice funding at the Department of the Interior, which collaborates closely with the Department of Justice, including on continued efforts to address the crisis of Missing and Murdered indigenous Persons.
  • And $670 million fund for transitioning tribal communities to renewable energy, plus $150 million for homes and tribal college energy improvements.

FYI: White House fact sheet on budget proposal.

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Mark Trahant, Shoshone-Bannock, is editor-at-large for Indian Country Today. On Twitter: @TrahantReports Trahant is based in Phoenix. The Indigenous Economics Project is funded with a major grant from the Bay and Paul Foundations. 

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