1. Indian Health Legislative Update
Presented by:
Caitrin Shuy, Director of Congressional Relations

2. SAVE THE DATE!
Joint Agency Consultation on the Opioid Crisis – Monday, March 21 and Tuesday, March 22
SAMHSA, IHS, and NIH

3. FY 2018 Omnibus Appropriations Act
March 23 – Congress passed the FY 2018 Omnibus Appropriations Act
$1.3 trillion in discretionary spending
$10.1 billion increase for Department of Health and Human Services
$5.5 billion (10% increase over FY17) for IHS major gains in:
Hospitals and Clinics: +$ million
Health Care Facilities Construction: +$125.9 million
Maintenance and Improvement: +$91.7 million
Sanitation Facilities Construction: +$90.3 million
Indian Health Care Improvement Fund: +72 million
Language that “encourages” IHS to provide funding for SASP; DVPP; Zero Suicide through contracts and compacts so Tribes can get CSC
In the FY 2018 Consolidated Appropriations Act, the Indian Health Service would receive $5.5 billion for IHS which is an increase of just under $500 million (10%) above the FY 2017 enacted level. The legislation allocates $3.9 billion for services, $867 million for facilities and $718 million for Contract Support Costs.
The Indian Health Care Improvement Fund (IHCIF) would receive $72.3 million in the legislation. This fund has been authorized by Congress to improve funding discrepancies across the IHS. This is the first time funding has been made available since FY The IHCIF Workgroup continues to meet to discuss the formula for distributing these funds.
The legislation also includes $58 million for IHS to address "accreditation emergencies" at Direct Service facilities. This includes those facilities who have or have the potential to lose the ability to bill the Centers for Medicare and Medicaid Services due to deficiencies in the system. It also encourages IHS to share information about these cases with the Tribes and with Congress.
Funding is also allocated for domestic violence prevention ($4 million); and $1,000,000 to continue prescription drug monitoring program (equal to FY 2017). Alcohol and Substance Abuse programs would see an $8 million increaseincluding $6.5 million for the Generation Indigenous Initiative; $1.8 million for the youth pilot project; and $2,000,000 to fund essential detoxification and related services provided by the Service's public and private partners to IHS beneficiaries. Purchased/Referred Care would get an increase of $32 millionfor total funding of $962.7 million.
The agreement also directs IHS to report to Congress about the progress they are making on patient wait times as outlined in IHS Circular 17-11 within 90 days of enactment. The report should include how Health IT issues impact patient wait times. The legislation also requires the agency to report to Congress on detailed funding amounts it would take to fully implement the Indian Health Care Improvement Act. This was also requested in the FY 2017 appropriations bill, but IHS never provided the information to Congress.
Within 180 days, IHS is also required to report to Congress on "patient population and service growth over the past ten years and the funding sources used to provide for these medical services." This report is to include funding sources which supplement appropriated dollars to cover the provision of medical services at IHS-operated facilities. The Appropriations Committee would like to understand how services have expanded over time due to additional funding available. Congress also requests an analysis of the different personnel hiring and recruitment authorities used by the Department of Veteran Affairs (VA) and the IHS and to report such findings to Congress.
The spending agreement also contains language that allows IHS to provide a housing subsidy for medical personnel at IHS operated sites. It also requires IHS to conduct additional training for all IHS personnel on how to improve quality of care, so that staff understand their obligations to improve quality of care.
Finally, the agreement also contains language that "encourages" IHS to provide funding for the Substance Abuse and Suicide Prevention Program, Domestic Violence Prevention Program, Zero Suicide Initiative, and aftercare pilots at Youth Regional Treatment Centers through contracts and compacts rather than through grant based programs to ensure that Contract Support Costs are available.
Facilities The spending agreement also contains a total of $867.5 million for facilities funding which is an increase of $303.4 million over FY This includes $243 million for Health Care Facilities Construction, which is 106% more than the FY 2017 enacted amount. Within that amount, there is $15,000,000 for small ambulatory clinics and $11,489,000 for staff quarters.
The spending agreement also directs the HHS Secretary to prioritize Indian Health Services facilities from the Nonrecurring Expenses Fund which include Indian Health Services facilities. This fund is comprised of unobligated appropriations at HHS since FY 2008.
Click here to view a chart of FY 2018 IHS Appropriations as outlined in the Consolidated Appropriations Act.

4. FY 2018 Omnibus Appropriations Act
Opioid Crisis
$50 million Tribal set aside (out of $1 billion) that would allow Tribes access to the State Targeted Response to Opioid Crisis Grants at SAMHSA
$5 million for Tribal set aside Medication Assisted Treatment programs at SAMHSA
Other Programs
Good Health and Wellness in Indian Country (CDC) - $16 million
Equal to FY 2017 Funding
Tribal Behavioral Health Grants (SAMHSA) - $15 million
American Indian and Alaskan Native Suicide Prevention Initiative (SAMHSA) -
Zero Suicide Initiative for American Indians and Alaska Natives (SAMHSA) - $2 million
That $1,000,000,000 shall be for State Opioid Response Grants for carrying out activities pertaining to opioids undertaken by the State agency responsible for administering the substance abuse prevention and treatment block grant under subpart II of part B of title XIX of the PHS Act (42 U.S.C. 300x–21 et seq.): Provided further, That of such amount $50,000,000 shall be made available to Indian Tribes or tribal organizations

5. FY 2019 President’s Budget
Meanwhile…. The President Submitted his FY 2019 budget to Congress on February 12
$3.6 trillion in domestic spending cuts, including a 21% cut to the Department of Health and Human Services
Eliminates LIHEAP
Major cuts to Cuts SNAP
Eliminates the Community Services Block Grant
$10 billion investment in opioid funding at HHS
$150 million in “competitive grants” at IHS to address the opioid crisis
The president submitted a (partial) budget to Congress on February 12. This budget is a guideline for Congress to consider as it works on FY 2019 appropriations. Congress will make the funding decisions.
The full details contained in the Congressional Justifications have not been released. We don’t know when they will be but it is assumed they are working on them to re write for the Bipartisan Budget Act numbers. .
Overall, the president's budget request eliminates $3.6 trillion from domestic spending programs including for Medicare, Medicaid, public health and social safety net programs. Many of these programs are at HHS which, as a whole, would take a 21% cut in the President's budget.
Many programs are
Proposes Medicaid block grants  Congress opposed this during the summer. Would be a ddrastic

6. FY 2019 President’s Budget – Indian Health Service
FY 2019 proposes $5.4 billion for IHS in FY 2019 (8% increase from current levels)
Increases to Hospitals and Clinics / Purchased Referred Care / Mental Health Alcohol and Substance Abuse
Eliminates Community Health Representatives; Health Education programs
 "to prioritize direct health care services and staffing and operating costs for new and replacement facilities."
No (known) investment in Health IT, despite VA receiving $1.2 billion
Moves SDPI (and certain other health programs) from “mandatory” to “discretionary” funding.
February 16 – Tribal Budget Formulation Workgroup wrote to the Office of Management and Budget Director asking for better consultation on the budget and emphasizing the support for CHRs and Health Education
Deadline to Testify before House Appropriations is April 6, 2018 for Hearings on May 9 and 10 – visit and go to the Interior, Environment Subcommittee
The IHS budget does not have a full detail yet, but many disturbing cuts to Community Health Representatives and Health Education
This represents lack of consultation – TBFWG recommended increases for both of these programs – not CUTS

7. Opioid Crisis in Indian Country
NIHB testified on March 14 and March 22 on the opioid crisis in Indian Country before Senate Committee on Indian Affairs and House Energy and Commerce Committee
Emphasized the need to fund Tribes directly; embrace traditional health with federal funds; consultation on PDMPs; and Health IT upgrades
Bills introduced S. 2270; S (10% set aside); and H.R. 5140
All grant access to the State Targeted Response to Opioids
Other opportunity such as Tribal Access to Substance Abuse and Mental Health Services Act

8. Restoring Accountability in the IHS Act
Senate Committee on Indian Affairs was scheduled to markup S but cancelled do to weather. Likely markup in April.
Bill’s amendment key changes:
Self Governance Exemption Clarification on the fact that the provisions would not impact self-governance contracts/compacts.  (They accepted NIHB’s suggested language)
Indian preference waived for hiring of an employee only “at the request of an Indian tribe.” It also changes language from “shall” to “may”
IHS Tribal Consultation policy – Adds language that requires “meaningful consultation with representatives of affected Indian Tribes” in the development of the consultation policy.  Took out specific language on the negotiated rulemaking process.
IHS Employment Provisions Re-written The reason for this is to improve upon the introduced language that was originally borrowed from reform at the Veterans’ Administration legislation.  The new language will better address some constitutionality issues that the original language had. 
Democrats on Committee have concerns on the effectiveness of the employment reforms based on experiences with VA.

9. Veterans’ Health Legislation
S – Caring for our Veterans Act introduced and passed out of committee on December 5. Includes language supporting the MOUs:
Section 101(d)(1): The Secretary of Veterans Affairs shall continue all contracts, memorandums of understanding, memorandums of agreements, and other arrangements that were in effect on the day before the date of the enactment of this Act between the Department of Veterans Affairs and the American Indian and Alaska Native health care systems as established under the terms of the Department of Veterans Affairs and Indian Health Service Memorandum of Understanding, signed October 1, 2010, 5 the National Reimbursement Agreement, signed December 5, 2012, and agreements entered into under sections 102 and 103 of the Veterans Access, 8 Choice, and Accountability Act of 2014 (Public Law 9 113–146).
Provision Likely to be retained in conference
Trying to add language (or report language) emphasizing that PRC could be repaid through the MOU/MOA arrangements
Bill Status -- ??
Will possibly (likely?) pass this year, but cost is an issue.
S2193:
the Secretary of Veterans Affairs shall continue all contracts, memorandums of understanding, memorandums of agreements, and other arrangements that were in effect on the day before the date of the enactment of this Act between the Department of Veterans Affairs and the American Indian and Alaska Native health care systems as established under the terms of the Department of Veterans Affairs and Indian Health Service Memorandum of Understanding, signed October 1, 2010, 5 the National Reimbursement Agreement, signed December 5, 2012, and agreements entered into under sections 102 and 103 of the Veterans Access, 8 Choice, and Accountability Act of 2014 (Public Law 9 113–146).

10. Other Issues Farm Bill Priorities
Authorize Tribes to enter into self-determination contracts pursuant to P.L for administration of food assistance programs.
Expand the Food Distribution Program on Indian Reservations (FDPIR) through increased funding for purchasing of traditional foods, infrastructure development, and nutrition education.
Provide Tribes with base funding to develop or expand traditional foods programs
Require a CBO or CRS inquiry into the impact of drastic cuts or elimination of food assistance programs on the overall food security of Tribes.
Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPA)
Up for Reauthorization
Asking for Tribes to be included in Hospital Preparedness Program (ASPR) and the Public Health Emergency Preparedness Cooperative Agreements (CDC)
Senate legislation coming soon – will be controlling language
IHS Task Force Update
Group continues to meet
Hopefully doing report in coming months, NIHB to assist
Tribal Leader Meeting with Members of Congress April 11

11. Contacts More info: www.nihb.org
Stacy Bohlen, Executive Director:
Jessica Steinberg, Director of Center for Native American Health Care Policy and Research,
Devin Delrow, Director of Policy,
Caitrin Shuy, Director of Congressional Relations:
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