On March 28, 2022, the President delivered his State of the Union Address in which he outlined his “Unity Agenda for the Nation”, that is “four big things we can do together” including “beat the opioid epidemic” and “take on mental health.” As part of that agenda, he stressed “increase[d] funding for prevention, treatment, harm reduction, and recovery” and “let’s get all Americans the mental health services they need.”  

Before the COVID-19 pandemic, Tribal communities faced stark behavioral health issues. According to the National Center for Health Statistics, American Indian and Alaska Native (AI/AN) women experienced the highest increase in suicide rates of 139 percent from 1999 to 2017. The AI/AN men between the ages of 15 to 44 had the highest rates of suicide of all race and ethnicity groups. 

The pandemic devastated Tribal communities, made worse by the consequences of chronic underfunding. For example, according to the Substance Abuse and Mental Health Service Administration (SAMHSA), 13 percent of the AI/AN population needs substance abuse treatment, but only 3.5 percent receive any treatment. 

The Native Behavioral Health Access Improvement Act, H.R. 4251/S.2226, is one piece of legislation that provides important base funding for Tribal communities to address behavioral health issues. Senator Smith (D-MN) introduced S.2226 and Representative Pallone (D-NJ) introduced H.R. 4251. As Tribal nations propose for this legislation, the Native Behavioral Health Access Improvement Act would be an excellent part of the behavioral health initiative.

Congress has begun taking action to develop a mental health initiative. The Senate Finance Committee has requested information for a mental health package for Medicaid and Medicare. The Committee established working groups on various focus areas for the package. It is anticipated that these efforts will result in a bill being developed and considered by the Committee by June, 2022. It is also anticipated that the Senate Health, Education, Labor, and Pensions Committee may also pursue its initiative as early as this summer as well. 

On April 5, 2022, the Subcommittee on Health of the Committee on Energy and Commerce held a hearing on a slate of bills, including H.R. 4251, which may be a part of its mental health package. The National Indian Health Board is working on Indian health-related proposals for these Committees. So stay tuned and stay engaged.

On March 28, 2022, the President released his FY 2023 Budget Request and proposed shifting the Indian health care funding from discretionary to mandatory funding. This proposal is a significant change, in response to Tribal leaders’ priorities and voice, but will take a massive effort to achieve. While the details of the Budget Request and agency spending outlined in the Congressional Justifications for the Indian Health Service (IHS) have not been released, it is important to understand the basics of what mandatory spending (funding) is, what all could be involved in achieving mandatory spending, and why this is important to Tribal nations.

Mandatory vs Discretionary Funding. According to the Congressional Budget Office’s semiannual report The Budget and Economic Outlook, mandatory spending refers only to the outlays that result from budget authority provided in laws other than appropriation acts. This authority is set forth in the law establishing or authorizing the program. In other words, “the authorization law controls the amount of spending and also contains an appropriation to fund it.” (Source: §015a. (CB) Appropriated Entitlement – Budget Counsel)

For example, the Special Diabetes Program for Indians was set forth in the Balanced Budget Act of 1997, P.L. No. 105-33 as follows:

There are different types of mandatory funding. There is an “appropriated entitlement” or “appropriated mandatory” funding. For this type of spending, “the authorization law controls the amount of spending but does not contain the necessary appropriation to fund it. Instead, such appropriations are provided through the annual appropriations process.” (Source: §015a. (CB) Appropriated Entitlement – Budget Counsel)

Whereas, for discretionary funding, the budget authority typically is set forth in the appropriations acts, even though the general authority for the program itself, including the authorized funding level (the appropriators may actually fund it that level, at a different level, or not at all) and other criteria are set forth in the authorizing statute. For example, the Americans Indians into Psychology grant program was authorized under the Indian Health Care Improvement Act (IHCIA) as follows:

IHS has engaged in Tribal consultation on mandatory consultation this past year, see here and established a subgroup within the National IHS-Tribal Budget Formulation Workgroup to examine further mandatory spending for the IHS.

What Could Be Involved in Achieving Mandatory Spending. Legislation must be passed to authorize mandatory spending. That legislation may also set forth the levels of funding, eligibility, and other criteria. Accordingly, Tribal leaders and the respective Congressional Committees of jurisdiction must be actively involved in examining and approving the legislation. Likewise, the Budget Committees must also be engaged in securing the needed budget authority. Typically, for any off-sets needed for new mandatory spending, the White House Office of Management and Budget, Congressional leadership, the Budget Committees, and potentially, the Finance and Ways and Means Committees could all be involved to find appropriate and sufficient off-sets, if needed. 

Why is This Important to Tribal Nations. Mandatory funding for Indian health care has been the subject of debate for many years among the Tribal nations. Very early on, it had been a subject for consideration within the reauthorization of the Indian Health Care Improvement Act (IHCIA). While it was not in the IHCIA, Tribal leaders have continued to debate and press for its passage. 

Each year, the discretionary IHS funding is subject to limitations in Appropriations Subcommittee allocation caps, so unless the overall total government spending and Subcommittee caps are significantly increased, the IHS funding may not be increased. Moreover, it is often subject to Continuing Resolutions or, in more extreme cases, government shutdowns. In these cases, the Indian health system is denied the full year of funding and cannot appropriately administer the necessary health care services.

Much work is needed to achieve mandatory funding for IHS. Advance appropriations are still needed, in the interim, until mandatory funding is achieved. The National Indian Health Board (NIHB) will continue to engage on these issues and urge Tribal leaders to join in these efforts.  

Senator Dianna Feinstein is currently serving her sixth term in the U.S Senate and sits as the fifth spot on the Senate's seniority list. Her top issue priorities are national and security intelligence, gun reform, and human rights including climate change and health care.

Feinstein introduced S. 144, the Desert Sage Youth Wellness Center Access Improvement Act on February 1, 2021. This bill would construct and improve the road to the Indian Health Service (IHS) Youth Regional Treatment Center in California. It is the only IHS youth treatment center in California that provides substance use disorder treatment and is accessible only by a rundown dirt road. Senator Feinstein sponsored the bill in the 116th Congress which passed the Senate and then was included as part of H.R. 2, the Moving Forward Act, which passed the House, but not the Senate. 

She co-sponsored S.1797, the Urban Indian Health Providers Facilities Improvement Act which Senator Padilla (D-CA) sponsored. The bill would amend the Indian Health Care Improvement Act to authorize the urban Indian health programs to use their funding for the purpose of improving urban Indian health facilities.

Senator Feinstein co-sponsored Senator Warren's (D-MA) bill, S. 2907, the Truth and Healing Commission on Indian Boarding School Policies Act. This would establish a Commission to investigate the effects of the boarding school policy era and then make recommendations to the federal government for the purpose of healing trauma resulting from those policies. Read the National Indian Health Board's Resolution no. 22-01 on Boarding School Healing here that was passed on February 24, 2022.

Senator Alex Padilla is currently serving his first term in the U.S Senate after becoming appointed to fill then-Senator Kamala Harris's seat after her election to Vice President. He is up for re-election in the November election. Prior to his Senate appointment, Alex Padilla served as California's Secretary of State. Then-Secretary of State, Padilla created a task force on Native voter participation to advise election officials on Native voting rights. Senator Padilla aims to create an inclusive democracy through immigration reform, environmental justice such as climate change, and health care.

Senator Padilla introduced S. 1797, the Urban Indian Health Providers Facilities Improvement Act on May 25, 2021. This bill would amend the Indian Health Care Improvement Act to authorize urban Indian providers to use Indian Health Service (IHS) funds to update their health facilities.

Senator Padilla co-sponsored S. 3444, the Tribal Medical Supplies Stockpile Access Act of 2022 which Senator Warren introduced. This bill would authorize IHS, Tribal and urban health programs direct access to the Strategic National Stockpile. The Strategic National Stockpile is a federal, medical and drug repository for public health emergency uses if the local supplies are exhausted.

Senator Padilla co-sponsored Senator Feinstein's bill, S.144, the Desert Sage Youth Wellness Center Access Improvement Act, Senator Warren’s bill, S. 2907, the Truth and Healing Commission on Indian Boarding School Policies Act, and Senator Lujan’s bill, S.2985, the Indian Programs Advance Appropriations Act of 2021. 

Representative Ruiz is currently serving his fifth term for California's 36th district in the U.S House of Representatives. He is up for re-election in the November election. As an emergency room physician, his interests intersect with the disparities of disadvantaged communities and healthcare. Experiencing and witnessing the disparities within healthcare, Representative Ruiz focuses his legislation on healthcare, veteran affairs, education, housing, and environmental justice.

Representative Ruiz introduced H.R. 4283, the Native Health and Wellness Act on June 30, 2021. It is a new grant program to mentor and train Native youth and young adults pursuing careers in the health field. It would establish a grant program for infrastructure in Tribal communities called the Public Health Block Grant program.

He also co-sponsored H.R. 4251, the Native Behavioral Health Access Improvement Act introduced by Rep. Pallone on the same day. Together, these two bills aim to achieve parity in Tribal health care resources and outcomes. 

He sponsored H.R. 1708, the Tribal Health Care Protection Fund Act which would provide additional appropriations to the Indian Health Service for replacing lost reimbursements from third-party payers and restore funds that were used to respond to COVID-19.  Rep. Ruiz introduced H.R. 667, the Desert Sage Youth Wellness Center Access Improvement Act, the House companion bill to Senator Feinstein’s bill, S. 144.

He cosponsored H.R. 1811, a bill to amend the Indian Health Care Improvement Act to authorize additional funding for planning, design, construction, modernization, and renovation of hospitals and outpatient health care facilities.  In addition, he co-sponsored H.R. 5567, the Indian Programs Advance Appropriations Act of 2021, the House companion bill to S.2985.  

Rep. Ruiz introduced H.R. 1888, the Improving Access to Indian Health Services Act which would extend certain Medicaid flexibilities and require a Federal Medical Assistance Percentage of 100 percent for urban Indian health care providers. It was introduced on March 12, 2021. Similarly, Rep. Ruiz sponsored H.R 1373, the Urban Indian Health Parity Act which also establishes Federal Medical Assistance Percentage of 100 percent to urban Indian organizations. 

The Native Behavioral Health Access Improvement Act, H.R. 4251/S.2226, is modeled, in part, on the Special Diabetes Program for Indians. It is intended to provide important base funding for Tribal communities to address behavioral health issues. The legislation has support in Congress. Senator Smith (D-MN) introduced S.2226 and Representative Pallone (D-NJ) introduced H.R. 4251.

Currently under consideration and in the refinement process, this legislation is an emerging method of funding behavioral health programs and complements the comprehensive behavioral health programs in Title 8 of the Indian Health Care Improvement Act. The bill would create behavioral health programs for Tribes, the Indian Health Service (IHS), and urban Indian organizations to develop culturally-appropriate solutions for prevention, treatment, and recovery. It would authorize $200 million per year from FY 2022 to FY 2026. The bill requires the Director of the IHS to provide technical assistance to awardees and collect and evaluate information on the program. 

The House bill has received a hearing, but the Senate bill is still awaiting a hearing – which could occur during May, 2022. As Tribal nations propose for this legislation, the Native Behavioral Health Access Improvement Act could be a model for the President’s mental health initiative and other Indian health-related funding. Join the National Indian Health Board in educating Congress on these bills and learn how they would be important pieces of the mental health initiatives.

Register for the National Tribal Public Health Summit 2022

Do not miss Dr. Anthony Fauci, Chief Medical Advisor, The White House; Director, National Institute of Allergy and Infectious Diseases during the National Tribal Public Health Summit (TPHS) 2022! Register now for the National Indian Health Board's (NIHB) invites you to register for the virtual premiere Indian public health event that attracts over 700 Tribal public health professionals, elected leaders, advocates, researchers, and community-based service providers. 

This year’s summit theme is Tribal Health is Public Health and will feature dynamic national speakers, interactive workshops and roundtable discussions, a welcome reception, a fitness event, as well as the presentation of the Native Public Health Innovation Awards. 

Register here.