Advance Appropriations for the Indian Health Service: Issues and Options for Congress

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. In FY2019, IHS provided health care to approximately 2.6 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.

Current IHS Funding: Continuing Resolutions and Shutdowns

IHS is the only major federal provider of health care that is solely funded through regular appropriations on an annual basis. Other federal health care providers, such as the Veterans Health Administration (Department of Veterans Affairs, (VA)), receive the majority of their funding through advance appropriations, and a number of health programs, including Medicare and Medicaid, receive mandatory funding, which is controlled outside of appropriations acts. Since FY1997, IHS has once (in FY2006) received full-year appropriations by the start of the fiscal year. As a consequence, IHS activities generally have been funded for a portion of each year under a continuing resolution (CR). Receiving its funding under a CR has limited the activities that IHS can undertake, in part because IHS can only expend funds for the duration of a CR, which prohibits the agency from making longer-term, potentially cost-saving purchases. In addition, most of IHS’s services are provided by Indian tribes under contracts with the federal government. Under a CR, these contracts can be issued only for the duration of the CR and must be reissued for each subsequent CR (or when full-year appropriations are enacted). This can be a time-consuming process for both IHS and the tribes, which may divert resources from other needed activities.

In addition to the challenges associated with receiving funding through a continuing resolution, there are instances when funding for IHS (and other agencies) has lapsed due to an absence of funding under regular or continuing appropriations. In these cases, agencies typically initiate a partial shutdown of services, unless they meet an exception that requires the services to continue, such as the protection of life or property. The majority of IHS services qualify for this exception. As such, even without appropriations, IHS continues to provide health services—doing so with unpaid providers and the related hurdles of restocking supplies, among other concerns. The use of regular appropriations to fund IHS has created a number of challenges for the agency, which have been the subject of several congressional hearings, as well as a 2018 report from the Government Accountability Office (GAO).

Potential IHS Funding: Advance Appropriations

In response to the funding challenges faced by IHS, some have proposed providing the agency with advance appropriations. Doing so would make funds available at the start of a fiscal year that comes after the fiscal year for which that appropriations act was enacted. For example, an advance appropriation in an FY2021 appropriations act would provide budget authority that would become available at the start of FY2022 (or later). Advance appropriations could help ensure that full-year funding is available at the start of the fiscal year, and that IHS is not subject to a funding lapse or a temporary appropriation. Such funding might pose certain operational challenges to the agency and budget process concerns to Congress. Since 2014, legislation has been introduced in each Congress that would authorize advance appropriations for IHS; these proposals have not advanced beyond the committees.