The Indian Health Service (IHS) within the Department of Health and Human Services (HHS) is the lead federal agency charged with improving the health of American Indians and Alaska Natives. IHS provides health care for approximately 2.2 million eligible American Indians/Alaska Natives through a system of programs and facilities located on or near Indian reservations, and through contractors in certain urban areas. IHS provides services to members of 566 federally recognized tribes. It provides services either directly or through facilities and programs operated by Indian Tribes or Tribal Organizations through self-determination contracts and self-governance compacts authorized in the Indian Self-Determination and Education Assistance Act (ISDEAA).
The IHS has three major sources of funding, described here in order of magnitude: (1) discretionary appropriations, (2) collections, and (3) mandatory appropriations.
IHS receives its discretionary appropriations through the Interior/Environment appropriations act, unlike most agencies within HHS, which receive their appropriations through the Labor-Health and Human Services and Education appropriations act. IHS’s discretionary appropriations are divided into three accounts: (1) Indian Health Services, (2) Contract Support Costs, and (3) Indian Health Facilities.
IHS collects reimbursements for health services it provides. IHS, unlike other federal agencies, has the authority to receive reimbursement from other federal programs such as Medicaid, Medicare, and the Department of Veterans Affairs. IHS also receives reimbursements from state programs (such as workers compensation) and from private insurance. In addition to reimbursements (its largest source of collections), IHS collects rent from facilities it owns.
Since FY1998, IHS also has received a mandatory appropriation each fiscal year to support the Special Diabetes Program. Under current law, FY2017 is the last year for which mandatory appropriations have been provided for this program.
This fact sheet focuses on the funding that IHS has received between FY2010 and FY2018 (proposed).
The Indian Health Service (IHS) within the Department of Health and Human Services (HHS) is the lead federal agency charged with improving the health of American Indians and Alaska Natives. IHS provides health care for approximately 2.2 million eligible American Indians/Alaska Natives through a system of programs and facilities located on or near Indian reservations, and through contractors in certain urban areas.1 IHS provides services to members of 566 federally recognized tribes. It provides services either directly or through facilities and programs operated by Indian Tribes or Tribal Organizations through self-determination contracts and self-governance compacts authorized in the Indian Self-Determination and Education Assistance Act (ISDEAA).2
The Snyder Act of 19213 provides general statutory authority for IHS.4 In addition, specific IHS programs are authorized by two acts: the Indian Sanitation Facilities Act of 19595 and the Indian Health Care Improvement Act (IHCIA).6 The Indian Sanitation Facilities Act authorizes the IHS to construct sanitation facilities for Indian communities and homes. IHCIA authorizes programs such as urban health, health professions recruitment, and substance abuse and mental health treatment, and permits IHS to receive reimbursements from Medicare, Medicaid, the State Children's Health Insurance Program (CHIP), the Department of Veterans Affairs (VA), and third-party insurers.
The IHS has three major sources of funding, described here in order of magnitude: (1) discretionary appropriations, (2) collections, and (3) mandatory appropriations. The IHS receives its discretionary appropriations through the Interior/Environment appropriations act,7 unlike most agencies within HHS, which receive their appropriations through the Labor, Health and Human Services and Education appropriations act.8 IHS's discretionary appropriations are divided into three accounts: (1) Indian Health Services, (2) Contract Support Costs, and (3) Indian Health Facilities.
As a second source of funding, IHS collects funds as reimbursement for health services provided. IHS has the authority to receive reimbursement from other federal programs such as Medicaid, Medicare, and the Department of Veterans Affairs. IHS also receives reimbursements from state programs (such as workers compensation) and from private insurance. IHS, under the authority for reimbursements given in IHCIA, is able to retain these payments to increase services available to its beneficiaries. In addition to reimbursements (its largest source of collections), IHS collects rent from facilities it owns.
The third and smallest source of IHS funding is a mandatory appropriation of $150 million annually to support Special Diabetes Programs for Indians.9 This mandatory funding was extended through FY2017 in the Medicare Access and CHIP Reauthorization Act (MACRA, P.L. 114-10), but no further appropriations have been enacted for FY2018. The President's budget requests continued mandatory funding for this program for FY2018.
Table 1 presents IHS's funding from FY2010 through the amounts proposed in the President's FY2018 budget submission. The table shows increases in both appropriated funds and funds collected by IHS. The table presents IHS's three budget accounts—Indian Health Services, Contract Support Costs, and Indian Health Facilities—and the funds collected and allocated to programs under these accounts. Collections, and proposed and actual mandatory funding, are subtracted from program-level funding to show the agency's discretionary budget authority.
Program or Activity |
2010 |
2011 |
2012 |
2013 |
2014 |
2015 |
2016 |
2017 |
2018 Req. |
Indian Health Services Account |
4,300a |
4,335a |
4,500a |
4,432a |
4,714a |
4,820a |
4,909 |
5,035 |
4,918 |
Clinical and Preventive Services |
4,139 |
4,171 |
4,335 |
4,277 |
4,566 |
4,652 |
4,737 |
4,860 |
4,753 |
Clinical Services |
3,845 |
3,877 |
4,038 |
3,987 |
4,271 |
4,348 |
4,431 |
4,553 |
4,446 |
Hospitals and Health Clinics |
1,754 |
1,763 |
1,811 |
1,749 |
1,791 |
1,837 |
1,857 |
1,935 |
1,870 |
Purchased/ Referred Care |
779 |
780 |
844 |
801 |
879 |
914 |
914 |
929 |
914 |
Collections |
891 |
915 |
954 |
1,021 |
1,172 |
1,151 |
1,194b |
1,194b |
1,194b |
Mental Health/Alcohol and Substance Abuse |
267 |
267 |
270 |
259 |
264 |
272 |
287 |
312 |
288 |
Dental Services |
153 |
154 |
159 |
157 |
165 |
174 |
178 |
183 |
180 |
Preventive Health |
144 |
144 |
147 |
143 |
148 |
154 |
156 |
160 |
157 |
Special Diabetes Program for Indians |
150 |
150 |
150 |
147c |
147c |
150 |
150 |
147c |
150 |
Other Health Services |
162 |
162 |
165 |
155 |
148 |
168 |
171 |
175 |
165 |
Urban Health Projects |
43 |
43 |
43 |
41 |
41 |
44 |
44 |
48 |
45 |
Indian Health Professions |
41 |
41 |
41 |
38 |
33 |
48 |
48 |
49 |
43 |
Tribal Management/Self-Governance |
9 |
9 |
9 |
8 |
6 |
8 |
8 |
8 |
5d |
Direct Operations |
69 |
69 |
72 |
68 |
68 |
68 |
72 |
70 |
72 |
Contract Support Costs Accounte |
398 |
398 |
471 |
448 |
587 |
663 |
718 |
718 |
718 |
Indian Health Facilities Account |
401 |
410 |
448 |
427 |
460 |
469 |
532 |
554 |
456 |
Maintenance and Improvement |
60 |
60 |
61 |
59 |
62 |
62 |
82 |
84 |
69 |
Rental of Staff Quarters |
6 |
6 |
8 |
8 |
8 |
8 |
9 |
9 |
9 |
Sanitation Facilities Construction |
96 |
96 |
80 |
75 |
79 |
79 |
99 |
102 |
75 |
Health Care Facilities Construction |
29 |
39 |
85 |
77 |
85 |
85 |
105 |
118 |
100 |
Facilities/Environmental Health Support |
193 |
193 |
199 |
194 |
211 |
220 |
223 |
227 |
192 |
Medical Equipment |
23 |
23 |
23 |
21 |
23 |
23 |
23 |
23 |
20 |
Total, Program Level |
5,100 |
5,144 |
5,418 |
5,307 |
5,761 |
5,951 |
6,160 |
6,307 |
6,092 |
Less Funds from Other Sources |
|||||||||
Collections |
891 |
915 |
954 |
1,021 |
1,172 |
1,151 |
1,194 |
1,194 |
1,194 |
Rental of Staff Quarters |
6 |
6 |
8 |
8 |
8 |
8 |
9 |
9 |
9 |
Special Diabetes Program for Indiansf |
150 |
150 |
150 |
147 |
147 |
150 |
150 |
147 |
150 |
Total, Discretionary Budget Authority |
4,052 |
4,069 |
4,307 |
4,131 |
4,435 |
4,642 |
4,808 |
4,957 |
4,739 |
Sources: Funding amounts are from HHS Budget documents available at http://www.hhs.gov/budget/. Amounts for FY2010-FY2015 and FY2018 are from IHS's congressional justifications. FY2016 and FY2017 are from IHS's operating plan for FY2017 available at https://www.ihs.gov/budgetformulation/includes/themes/newihstheme/display_objects/documents/FY2017-IHS-Operating-Plan.pdf.
Notes: Individual amounts may not add to subtotals or totals due to rounding.
a. From FY2010-FY2015, Contract Support Costs were included in the Indian Health Services account.
b. Estimated amount of collections included in the FY2018 Budget Justification.
c. PHSA Section 330C provides an annual appropriation of $150 million for this program, this amount was reduced in FY2013, FY2014, and FY2017 by 2% because of budget sequestration. See CRS Report R42050, Budget "Sequestration" and Selected Program Exemptions and Special Rules.
d. The FY2018 budget does not request funds for Tribal Management Grants.
e. Beginning in FY2016, Contract Support Costs were funded as an indefinite discretionary appropriation.
f. This was previously referred to as "Contract Health Services."
IHS facilities collect reimbursements from third-party payors for services provided to IHS beneficiaries who are also enrolled in other programs. These collections comprise a growing percentage of IHS's clinical services budget (see Table 1). Medicaid is the largest source of IHS's collections—approximately 69% of all reimbursements collected in FY2015, the most recent year of final data available—followed by Medicare (22% in FY2015) and private insurance (9% in FY2015). Beginning in FY2014, IHS began receiving reimbursements from the VA for services provided to IHS beneficiaries who were also enrolled in the VA (these reimbursements were 0.7% of all of IHS's third-party collections in FY2014 and FY2015). For FY2013, reimbursements were approximately $340,000; therefore, these funds are not visible in Figure 1.
Figure 1. IHS Reimbursements by Source, FY2010-FY2015 (Actual), FY2016-FY2018 (Expected) |
Sources: Figure created by CRS. Funding amounts for FY2010-FY2015 and FY2018 are taken from IHS's congressional budget justification documents, available at http://www.hhs.gov/budget/. FY2016 and FY2017 are from IHS's operating plan for FY2017, available at https://www.ihs.gov/budgetformulation/includes/themes/newihstheme/display_objects/documents/FY2017-IHS-Operating-Plan.pdf. |
Author Contact Information
1. |
For more information about the Indian Health Service (IHS), see CRS Report R43330, The Indian Health Service (IHS): An Overview. |
2. |
P.L. 93-638; 25 U.S.C. §§450 et seq. |
3. |
P.L. 67-85, as amended; 25 U.S.C. §13. |
4. |
The Snyder Act established this authority as part of the Bureau of Indian Affairs within the Department of the Interior. The Transfer Act of 1954 (P.L. 83-568) transferred this authority to the U.S. Surgeon General within the Department of Health, Education, and Welfare (now the Department of Health and Human Services). |
5. |
P.L. 86-121; 42 U.S.C. §2004a. |
6. |
P.L. 94-437, as amended; 25 U.S.C. §§1601 et seq., and 42 U.S.C. §§1395qq and 1396j (and amending other sections). This act was permanently reauthorized as part of the ACA. See CRS Report R41630, The Indian Health Care Improvement Act Reauthorization and Extension as Enacted by the ACA: Detailed Summary and Timeline. |
7. |
For more information, see CRS Report R44470, Interior, Environment, and Related Agencies: FY2017 Appropriations. |
8. |
For more information, see CRS Report R44691, Labor, Health and Human Services, and Education: FY2017 Appropriations. |
9. |
U.S. Department of Health and Human Services, Indian Health Service, "Special Diabetes Program for Indians," January 2015, http://www.ihs.gov/newsroom/factsheets/diabetes/. |