The Indian Health Service (IHS) Delivers Vital Health Care Amid Chronic Underfunding
The Indian Health Service (IHS) is an agency within the U.S. Department of Health and Human Services that provides federal health services to American Indians and Alaska Natives. The mission of the IHS is “to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest levels” and defines its vision as “healthy communities and quality health care systems through strong partnerships and culturally responsive practices.”
While the IHS provides vital health care services, the funding that enables the agency to care for patients is continually threatened and unpredictable. Just last year, Republicans in the U.S. House of Representatives voted to pass H.R. 2811, which would have had dire effects on IHS funding. The Biden Administration’s fiscal year 2025 budget, on the other hand, seeks to support funding for the IHS that is more robust and predictable than in the past.
Health Disparities in Native Communities
Native communities experience stark health disparities, making access to high quality health care through the IHS essential. When looking at life expectancy in recent years, American Indian and Alaska Native individuals have the lowest life expectancy (71.8 years) when compared with other races and ethnicities. Heart diseases, malignant neoplasm, unintentional injury, and diabetes are the leading causes of death for American Indians and Alaska Natives.
IHS Operations & Services
Approximately 2.6 million American Indians and Alaska Natives who belong to 574 federally recognized tribes across 37 states receive health care from IHS. Across the United States, the IHS directly operates 27 hospitals, 59 health centers, 9 school health centers, and 32 health stations. A health station is a facility that is physically separate from a hospital or health center but where clinical treatment - including physician, dentist, or nursing services - are available. Tribes and Tribal organizations also operate more than 56% of the IHS budget through contracts and compacts and provide health care in additional hospitals, health centers, school health centers and health stations. In addition, the IHS or Tribes and Tribal organizations operate 12 regional youth substance use treatment centers, and the IHS provides funding for Indian health centers located in 34 urban areas. The IHS is organized into 12 regions, with an office to administer each region, including the Billings Area Office in Billings, Montana.
Six IHS-operated Service Units (health clinic or hospital) located on the Fort Peck, Fort Belknap, Northern Cheyenne, Crow, and Blackfeet Reservations
Two tribally-owned and operated health departments on Flathead and Rocky Boy’s Reservation; and
Five non-profit urban Indian health programs in Missoula, Great Falls, Billings, Helena, and Butte. Private, non-profit corporations, Urban Indian Health Programs (UIHPs) provide health and social services, ranging from outreach and referral to ambulatory care.
Funding Challenges and Complexities
The IHS faces chronic funding challenges. The IHS is a discretionary program, which means that its limited funding depends on money that must be appropriated by Congress each fiscal year. This process leads to uncertainty about the exact amount of funding that will be appropriated and the typical delays in the appropriations process can lead to delays or disruptions in care. Starting in fiscal year 2023, Congress took action to provide more stability in the event of delays in passage of funding or government shutdowns. Nevertheless, funding amounts are still dependent on the dollars that Congress appropriates. In addition to chronic underfunding and a complex web of state and federal regulations to navigate, the IHS struggles with shortages of trained health professionals to staff the agency and provide care, leading to long wait times and mistrust of the care provided.
COVID-19 Pandemic Funding for IHS
During the COVID-19 pandemic crisis public health emergency, Congress appropriated $9 billion in funding for the IHS, which includes the funds that were appropriated through the American Rescue Plan Act (ARPA), which provided $6 billion to the IHS for direct care and facility needs. This increase in funding allowed IHS to provide care to more patients, but the influx of funding has since ceased.
Current and Future Funding Challenges
In April 2023, Republicans in the U.S. House of Representatives voted to pass H.R. 2811, the Limit, Save, Grow Act of 2023. The legislation did not become law, but its goal was to reduce federal spending by cutting funding for assistance and services Americans rely on. The legislation would have drastically reduced funding for IHS, including by rescinding unspent COVID-19 relief supplemental appropriations funding. In addition, the legislation would have placed caps on discretionary spending that would have reduced funding for the agency dramatically. Specifically, the funding reductions proposed in the legislation would have reduced inpatient admissions by more than 10,000 and outpatient visits by almost 4 million. Furthermore, the cuts would have reduced dental visits by more than 275,000 and reduced mental health visits by more than 200,000.
In addition, the recent Medicaid eligibility redetermination process – often called “unwinding” – has made Native Americans especially likely to lose coverage through the program and face barriers to re-enrolling in the program or enrolling in other coverage. Unwinding is a process of eligibility redetermination in response to the end of the COVID-19 Public Health Emergency (PHE) during which Congress provided increased funding for the joint state/federal Medicaid program for expanded eligibility and other flexibilities in the program.
While the redetermination process is still continuing and policy makers continue to gather data, the National Indian Health Board (NIHB) estimated that as many as 236,000 American Indians and Alaska Natives could lose Medicaid coverage as a result of unwinding. Almost 12,800 children and adults with a tribal affiliation lost coverage in Montana.
The Administration’s fiscal year 2025 budget enacts advance appropriations – a Congressional commitment to provide money in a future year - for the IHS in order to “help ensure more stable, predictable funding and improved access to high quality health care.” The budget also seeks to shift IHS funding to mandatory spending which takes place apart from the appropriations process. Most programs that are funded through mandatory spending continue through multiple years without new authorization. A shift from discretionary to mandatory spending status would likely mean increased stability for the funding of the agency and insulate it from the yearly battles of the appropriations process.
Despite ongoing funding challenges and complexities, the IHS continues to provide much needed and important health care services to American Indians and Alaska Natives. In light of the stark health disparities experienced by Native communities, access to high quality and dependable care from the IHS is especially important to individuals and families.
