Indian Health Service (IHS) FY2022 Budget Request and Funding History: In Brief

Indian Health Service (IHS) FY2022 Budget Request and Funding History: In Brief

Indian Health Service (IHS) FY2022 Budget
January 6, 2022
Request and Funding History: In Brief
Elayne J. Heisler
The Indian Health Service (IHS), within the Department of Health and Human Services (HHS),
Specialist in Health
is the lead federal agency charged with improving the health of American Indians and Alaska
Services
Natives. IHS provides health care for 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. IHS provides services to members of

574 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: (1) discretionary appropriations, (2) collections, and (3) mandatory
appropriations. In FY2020, IHS received additional funding through emergency-designated discretionary appropriations in
multiple laws enacted in response to the Coronavirus Disease 2019 (COVID-19) pandemic. In FY2021, IHS received
mandatory appropriations in the Consolidated Appropriations Act, 2021 (P.L. 116-260), and the American Rescue Plan Act
(ARPA, P.L. 117-2) for COVID-19 response. In addition, IHS received $3.5 billion in emergency-designated discretionary
funding the Infrastructure Investment and Jobs Act (IIJA, P.L. 117-58) to support sanitation facility construction. The first
$700 million is provided in FY2022, with the same amount provided annually through FY2026.
Unlike most agencies within HHS, which receive appropriations through the Labor, Health and Human Services, and
Education Appropriations Act, IHS receives its discretionary appropriations through the Interior/Environment 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 payments for the health services it provides. Unlike other federal agencies, IHS has the authority to receive
payments from other federal programs, such as Medicaid, Medicare, and the Department of Veterans Affairs, for the health
services it provides to IHS beneficiaries who are enrolled in those programs. IHS also receives payments from state programs
(such as workers’ compensation) and from private insurance. In addition to these payments, IHS collects rent from the
facilities it owns.
In each fiscal year since FY1998, IHS has received a mandatory appropriation to support the Special Diabetes Program for
Indians. This funding source was most recently extended in the Consolidated Appropriations Act, 2021 (P.L. 116-260),
which provided funding through FY2023.
This report focuses on the funding that IHS received between FY2016 and FY2021, and the funding that President Biden has
proposed for FY2022.
The FY2022 budget request would increase IHS discretionary appropriations by more than $2 billion over the FY2021-
enacted level. Much of that increase ($1.3 billion) would be for IHS’s largest budget item—clinical services—which is used
to support most of IHS’s clinical activities. In addition, the budget request would increase funding to IHS’s facilities account
by $585 million. Other proposals include funding for electronic health records, which IHS is in a multiyear process of
updating ($284.5 million, an increase from the $34.5 million provided in FY2021), and the creation of a new budget account,
similar to Contract Support Costs, that would pay for the lease costs when Indian tribes or tribal organizations use their
facility for ISDEAA programs.

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Contents
IHS Overview .................................................................................................................................. 1
Funding Sources ........................................................................................................................ 1
FY2022 Budget Request and Funding History ......................................................................... 2

Tables
Table 1. IHS Budget FY2016-FY2022 (Request) ........................................................................... 4

Contacts
Author Information .......................................................................................................................... 6

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Indian Health Service (IHS) FY2022 Budget Request and Funding History: In Brief

IHS Overview
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.1 IHS provides health care for 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.2 IHS provides services to members
of 574 federally recognized tribes.3 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).4 IHS also awards grants to 41 Urban Indian Organizations (UIOs),
which operate programs in urban areas.5
The Snyder Act of 19216 provides general statutory authority for IHS.7 In addition, specific IHS
programs are authorized by two acts: the Indian Sanitation Facilities Act of 19598 and the Indian
Health Care Improvement Act (IHCIA).9 The Indian Sanitation Facilities Act authorizes IHS to
construct sanitation facilities for Indian communities and homes (e.g., providing water to
American Indian/Alaska Native 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. Also, the Public
Health Service Act provides funds for the Special Diabetes Program for Indians grants
administered by IHS.
Funding Sources
In general, IHS has three major sources of funding, described here in order of magnitude: (1)
discretionary appropriations,10 (2) collections, and (3) mandatory appropriations. In FY2020, IHS

1 The Indian Health Service (IHS) does not provide care to Native Hawaiians. They instead may receive services
through the Native Hawaiian Health Care Program administered by the Health Resources and Services Administration
(HRSA) at the Department of Health and Human Services (HHS). See HHS, HRSA, “Justification of Estimates for
Appropriations Committees, FY2022,” https://www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-justification-
fy2022.pdfhttps://www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-justification-fy2022.pdf, p. 66.
2 For more information about IHS, see CRS Report R43330, The Indian Health Service (IHS): An Overview.
3 HHS, IHS, “Justification of Estimates for Appropriations Committees, FY2022 https://www.ihs.gov/sites/
budgetformulation/themes/responsive2017/display_objects/documents/FY_2022.pdfhttps://www.ihs.gov/sites/
budgetformulation/themes/responsive2017/display_objects/documents/FY_2022.pdf (hereinafter, FY2022 CJ).
4 P.L. 93-638; 25 U.S.C. §§450 et seq.
5 IHS, “IHS Profile,” https://www.ihs.gov/newsroom/factsheets/ihsprofile/https://www.ihs.gov/newsroom/factsheets/
ihsprofile/.
6 P.L. 67-85, as amended; 25 U.S.C. §13.
7 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).
8 P.L. 86-121; 42 U.S.C. §2004a.
9 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 Patient Protection and Affordable Care Act (ACA; P.L.
111-148). See CRS Report R41630, The Indian Health Care Improvement Act Reauthorization and Extension as
Enacted by the ACA: Detailed Summary and Timeline.
10 Because IHS’s main funding source is annual discretionary appropriations, the agency is affected by lapses in
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received additional funding through emergency-designated discretionary appropriations in
response to the Coronavirus Disease 2019 (COVID-19) pandemic. In addition, these laws also
provided funds to Indian tribes, tribal organization, and UIOs directly. (Because these funds were
not appropriated or transferred to IHS, they are not discussed in this report.)11 In FY2021, IHS
received emergency-designated discretionary appropriations in the Consolidated Appropriations
Act, 2021 (P.L. 116-260); these funds were appropriated to other HHS accounts but were
transferred to IHS (see Table 1). In FY2021, IHS also received mandatory appropriations in the
American Rescue Plan Act (ARPA, P.L. 117-2), another COVID-19 response measure.12 For
FY2022-FY2026, IHS will receive $700 million in emergency-designated discretionary funding
each fiscal year, for a total of $3.5 billion for sanitation facility construction in the Infrastructure
Investment and Jobs Act (IIJA, P.L. 117-58).
Unlike most agencies within HHS, which receive their appropriations through the Labor, Health
and Human Services, and Education Appropriations Act, IHS receives its discretionary
appropriations through the Interior/Environment Appropriations Act.13 IHS’s discretionary
appropriations are divided into three accounts: (1) Indian Health Services, (2) Contract Support
Costs, and (3) Indian Health Facilities.
In addition to funds appropriated to the agency, IHS collects and expends funds received as
payment for health services provided. IHS has the authority to receive payments from other
federal programs such as Medicaid, Medicare, CHIP, and the VA. IHS also receives payments
from state programs (such as workers’ compensation) and from private insurance. Under its
IHCIA collection authority, IHS can retain these payments to increase services available to its
beneficiaries. In addition to these collections, IHS collects rent from the facilities it owns.
In most years, the smallest source of IHS funding is a mandatory annual appropriation of $150
million to support the Special Diabetes Program for Indians.14 The Consolidated Appropriations
Act, 2021 (P.L. 116-260) provided $150 million for each of FY2021 through FY2023 for this
program. For FY2020, emergency discretionary appropriations provided in response to COVID-
19 were $2.846 billion, including funds that were appropriated directly or transferred to IHS,
making these funds a significant source of agency funding in FY2020. In FY2021, the ARPA
funds totaled $6.094 billion, approximately 70% of the budget authority requested for the agency
in FY2022 ($8.47 billion).
FY2022 Budget Request and Funding History
Table 1 presents IHS’s funding from FY2016 through the President’s proposed FY2022 budget
submission. (Note that the FY2020 and FY2021 emergency supplemental discretionary
appropriations for COVID-19 response and FY2021 mandatory ARPA funds are displayed in the

appropriations, which some have raised as an issue. The FY2022 IHS Budget request includes a legislative proposal for
advance appropriations. See FY2022 CJ, p. 265. The House Appropriations Committee rejected this request, requiring
more information, among other things. See H.Rept. 117-83, p. 123. For further discussion of advance appropriations,
see CRS Report R46265, Advance Appropriations for the Indian Health Service: Issues and Options for Congress.
11 For information about funding made available to the Indian Health Service, Indian tribes, tribal organizations, and
UIOs in response to COVID-19, see CRS Insight IN11333, COVID-19 and the Indian Health Service, and CRS Report
R46711, U.S. Public Health Service: COVID-19 Supplemental Appropriations in the 116th Congress.
12 CRS Report R46834, American Rescue Plan Act of 2021 (P.L. 117-2): Public Health, Medical Supply Chain, Health
Services, and Related Provisions.
13 For more information, see CRS Report R44934, Interior, Environment, and Related Agencies: Overview of FY2019
Appropriations, and CRS Report R45083, Labor, Health and Human Services, and Education: FY2018 Appropriations.
14 U.S. Department of Health and Human Services, Indian Health Service, “Special Diabetes Program for Indians,”
October 2016, http://www.ihs.gov/newsroom/factsheets/diabetes/http://www.ihs.gov/newsroom/factsheets/diabetes/.
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Indian Health Service (IHS) FY2022 Budget Request and Funding History: In Brief

Coronavirus Testing, Treatment and Related Services row of the table.) The table shows that
during that time period, both discretionary appropriated funds and funds collected by IHS
increased, whereas the mandatory appropriations generally remained level. 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. To show
regular discretionary budget authority only, collections and proposed and actual mandatory
funding are subtracted from program-level funding. The FY2020 emergency supplemental
discretionary appropriations for COVID-19 response and FY2021 ARPA funds are also
subtracted.
Regular discretionary appropriations for IHS have increased over time, with the largest funding
increase relative to the prior year being in FY2018. In particular, FY2018 funding included
increases for a number of programs funded under the Indian Health Facilities account, which
includes maintenance and improvement and construction of new facilities. In addition, the
FY2018 appropriation increased funding for mental health and alcohol and substance abuse
services, and provided new funding for the Indian Health Care Improvement Fund, which
distributes funds to facilities that have low funding levels relative to the populations they serve.15
These increases generally were sustained in FY2019, FY2020, and FY2021. The FY2022 budget
request would increase IHS regular discretionary appropriations by more than $2 billion over the
FY2021-enacted level. Much of that increase ($1.32 billion) would be for IHS’s largest budget
item—clinical services—which is used to support most of IHS’s clinical activities. The budget
request would also increase funding to IHS’s facilities (this account also will receive $700 million
under the IIJA in FY2022). Other items proposed for increased funding include Indian Health
Professions, which supports scholarship and loan repayment for health professionals in exchange
for providing care at IHS-funded facilities. The agency has long-standing staffing challenges and
high vacancy rates for certain positions and in certain geographic areas.16
The President’s FY2022 budget request includes funding for two new line items. First, it proposes
funding for electronic health records, which IHS is in a multiyear process of updating.17 The
President’s budget would provide $284.5 million for this activity, an increase from the $34.5
million provided in FY2021. The second budget item is a legislative proposal for a new indefinite
appropriation that would be similar in structure to the Contract Support Costs account; however,
in this instance, the appropriation would be for tribal leases. As it does with the Contract Support
Costs account, IHS has a legal obligation to pay for these lease costs pursuant to a 2016 court
decision, Maniilaq Association v. Burwell,18 which requires IHS to reimburse “the Tribe or Tribal

15 HHS, IHS, “Indian Health Care Improvement Fund,” https://www.ihs.gov/ihcif/https://www.ihs.gov/ihcif/.
16 U.S. Government Accountability Office, Indian Health Service: Agency Faces Ongoing Challenges Filling Provider
Vacancies, 18-580, August 15, 2018, https://www.gao.gov/products/gao-18-580https://www.gao.gov/products/gao-18-
580.
17 FY2021 CJ, pp. 101-103.
18 170 F. Supp. 3d 243 (D.D.C. 2016). To carry out ISDEAA programs to deliver services on behalf of IHS, Indian
tribes or tribal organizations may “lease” their facilities to IHS. These leases are entered into under the authority of
Section 105(l) of ISDEAA (and are also referred to as Section 105(l) leases). A 2016 court decision, Maniilaq
Association v. Burwell, required that IHS enter into a “lease,” upon request, with any tribe or tribal organization
furnishing a facility that supports ISDEAA programs, and that under any such lease, IHS reimburse “the Tribe or Tribal
Organization for its reasonable facility expenses.” This holding could extend to other instances when an Indian tribe or
tribal organization furnishes a tribally leased or owned facility in support of the programs, services, functions, and
activities carried out under its ISDEAA contract or compact. In other words, if an Indian tribe or tribal organization
provides the facility for an ISDEAA program, IHS may be responsible for paying reasonable facility costs under these
leases. Based on IHS’s interpretation of the decision, it is responsible for these costs and has been paying them since
FY2018. In FY2021 appropriations, these funds were provided separately for the first time. See P.L. 116-260 and
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Organization for its reasonable facility expenses” when IHS enters into a “lease,” upon request,
with any tribe or tribal organization that is furnishing a facility that supports ISDEAA programs.19
In other words, since FY2018, IHS has been paying lease costs in instances when an Indian tribe
or tribal organization provides the facility for an ISDEAA program. Lease costs have increased
from $6 million in FY2018 to an estimated $123 million in FY2021 (according to the FY2022
President’s budget).20 In Table 1, the lease costs amounts for FY2018-FY2020 are not delineated
separately; instead, they are included within the Indian Health Services account. In FY2021
appropriations, payments for tribal leases were provided in a separate account and received an
appropriation of “such sums as may be necessary.” (At that time, the FY2021 budgetary costs
were estimated to be $101 million, as reflected in the table.)21 The FY2022 President’s budget
would provide $150 million for these leases, continuing the practice of funding them as a “such
sums” appropriation in a separate discretionary account.22
Table 1. IHS Budget FY2016-FY2022 (Request)
(Dollars in Millions)
FY2022
Program or Activity
FY2016
FY2017
FY2018
FY2019
FY2020
FY2021
(Request)
Coronavirus Testing,
—
—
—
—
1,846b
7,094c
—
Treatment and Related
Servicesa
Indian Health
4,908
5,035
5,296
5,447
5,553
5,536
6,952
Services Account
Clinical Services
4,430
4,553
4,800
4,934
4,942
4,986
6,303
Hospitals and Health
1,857
1,935
2,055
2,147
2,178
2,238
2,704
Clinics
Electronic Health Records
—
—
—
—
8
35
285
Dental Services
178
183
193
205
211
215
287
Purchased/ Referred Care
914
929
963
965
965
976
1,192
Collection for Health
1,194
1,194
1,194
1,194
1,084
1,084
1,127
Services Providedd
Mental Health/Alcohol and
287
312
323
351
355
367
392
Substance Abuse
Indian Health Care
—
—
72
72
72
72
317
Improvement Fund
Preventive Health
156
160
160
167
178
179
193

discussion in FY2022 CJ, pp. 254-256.
19 Language drawn from Letter from Michael D. Weahkee, Assistant Surgeon General, United States Public Health
Service, and Acting Director, Indian Health Service to Tribal Leaders and Urban Organization Leader, July 18, 2018,
https://www.ihs.gov/newsroom/includes/themes/responsive2017/display_objects/documents/2018_Letters/
DTLL_DUIOLL_07102018.pdfhttps://www.ihs.gov/newsroom/includes/themes/responsive2017/display_objects/
documents/2018_Letters/DTLL_DUIOLL_07102018.pdf.
20 See IHS FY2022 Budget Justification, pp. 255-256
21 See IHS, “Indian Health Service, Operating Plan for FY2021,” https://www.ihs.gov/sites/budgetformulation/themes/
responsive2017/display_objects/documents/FY2021_OperatingPlan.pdfhttps://www.ihs.gov/sites/budgetformulation/
themes/responsive2017/display_objects/documents/FY2021_OperatingPlan.pdf.
22 See IHS FY2022 Budget Justification, pp.18 and 255-256.
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FY2022
Program or Activity
FY2016
FY2017
FY2018
FY2019
FY2020
FY2021
(Request)
Special Diabetes Program
150
147
147
150
150
150
147
for Indians
Other Health
172
175
179
188
204
221
309
Services
Urban Health Projects
44
48
49
51
59
63
100
Indian Health Professions
48
49
49
57
65
67
93
Tribal Management/Self-
8
8
8
8
8
8
8
Governance
Direct Operations
72
70
72
72
72
82
108
Contract Support
718
800
763
822
820
916
1,142
Costs Account
Payment for Tribal
—
—
—
—
—
101
150
Leases
Indian Health
532
554
876
887
920
927
2,212
Facilities Account
Maintenance and
82
84
176
176
177
179
234
Improvement (includes
rentals of staff quarters)e
Sanitation Facilities
99
102
192
192
194
197
1051f
Construction
Health Care Facilities
105
118
243
243
259
259
526
Construction
Facilities/Environmental
223
227
241
252
262
264
300
Health Support
Medical Equipment
23
23
24
24
28
29
101
Total, Program Level
6,158
6,389
6,935
7,156
10,985
14,574
10,456
Less Funds from Other

Sources
Col ections for Health
1,194
1,194
1,194
1,194
1,084
1,084
1,127
Services Provided
Rental of Staff Quarters
9
9
9
9
9
10
12
Special Diabetes Program
150
147
150
150
150
150
147
for Indiansg
Covid-19 Response
—
—
—
—
1,846
7,094c
—
Infrastructure Funding
—
—
—
—
—
—
700f
Total, Regular
4,805
5,039
5,582
5,795
6,050
6,237
8,471
Discretionary Budget
Authority
Sources: Funding amounts are from HHS budget documents available at https://www.ihs.gov/budgetformulation/
congressionaljustifications/https://www.ihs.gov/budgetformulation/congressionaljustifications/. Totals may not sum
due to rounding. Amounts in italics indicate they are included in the bold italicized total above (i.e., they are
included as part of the clinical services total). Amounts for FY2015, FY2016, FY2017, FY2018, FY2019, FY2020,
FY2021, and FY2022 requests are from IHS’s congressional justifications. The FY2020 and FY2021 amounts for
Coronavirus Testing, Treatment and Related Services are from CRS analysis of FY2020 supplemental
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Indian Health Service (IHS) FY2022 Budget Request and Funding History: In Brief

appropriations acts in CRS Report R46711, U.S. Public Health Service: COVID-19 Supplemental Appropriations in the
116th Congress. American Rescue Plan Funding amounts are from CRS analysis of P.L. 117-2. Infrastructure
Investment and Jobs Act amounts are from are from CRS analysis of P.L. 117-58. FY2022 funding for IHS has
been provided under continuing resolutions; see CRS Report R46582, Overview of Continuing Appropriations for
FY2021 (P.L. 116-159), and P.L. 117-43.
a. Includes activities funded under both the Indian Health Services and Indian Health Facilities accounts.
b. Includes $1.096 bil ion directly appropriated to IHS in FY2020 and $750 mil ion transferred to IHS from
other HHS accounts in FY2020. See CRS Report R46711, U.S. Public Health Service: COVID-19 Supplemental
Appropriations in the 116th Congress, Table 1.
c. This amount includes the $1 bil ion that was transferred to IHS under P.L. 116-260 and $6.094 bil ion
appropriated to IHS in P.L. 117-2. See CRS Report R46834, American Rescue Plan Act of 2021 (P.L. 117-2):
Public Health, Medical Supply Chain, Health Services, and Related Provisions, and CRS Report R46711, U.S. Public
Health Service: COVID-19 Supplemental Appropriations in the 116th Congress, Table 1.
d. For information on IHS col ections, see IHS budget requests, available at https://www.ihs.gov/
budgetformulation/congressionaljustificationshttps://www.ihs.gov/budgetformulation/
congressionaljustifications.
e. Rental of staff quarters is a form of col ections used to supplement funds available to maintain facilities.
f.
Reflects funding appropriated to IHS for FY2022 in P.L. 117-58.
g. PHSA Section 330C provides an annual appropriation of $150 mil ion for this program; this amount was
reduced in FY2017 by 2% because of budget sequestration in FY2017 and wil be reduced by that amount in
FY2022. See CRS Report R42050, Budget “Sequestration” and Selected Program Exemptions and Special Rules.

Author Information

Elayne J. Heisler

Specialist in Health Services

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