On the Standing Rock Indian Reservation, which straddles the border between North and South Dakota, people line up at 6 a.m. in the freezing winter, hoping to get one of only four dentist appointments.
“If you don’t catch those four, you’re out, you don’t understand,” Standing Rock Sioux Tribe chairwoman Janet Alkire, who described the scene at an April hearing of the House Natural Resources Subcommittee on India and Island Affairs .
And the lack of adequate medical care goes far beyond dental care, he told lawmakers.
“Our babies can’t be born on our reservation,” she said. “Mothers have to leave their support networks, their families, sometimes dads, definitely grandmas, and travel over 75 miles to deliver a baby.”
Through the Indian Health Service, the federal government provides free medical care to Native Americans, which the United States promised in various treaties with indigenous nations when it forced them off their lands in the mid-19th century.
However, many Native Americans complain that the US government breaks this promise by underfunding the Indian health service.
To address this, the Biden administration wants to drop NHS funding from the annual budget negotiation process and turn it into law instead. His plan would culminate in funding of about $44 billion in fiscal 2033, six times more than current funding levels but still below what experts and advocates think is necessary.
Indian Health Service funding has increased by 68% over the past decade, culminating in $7.1 billion for the agency for fiscal year 2023. But the agency’s funding is significantly less than other federal health programs . In 2017, the Indian Health Service’s per capita spending was less than half that of the Veterans Health Administration and less than a third that of Medicare, according to a report by the Government Accountability Office.
The National Tribal Budget Formulation Workgroup, a group of Native American advocates and tribal representatives that advises the Indian Health Service on its annual budget request, estimates that nearly seven times more funding is needed for the agency to meet health care needs of the natives.
In his testimony, Alkire described the impact of this lack of adequate funding.
“IHS Standing Rock is over 60 years old,” he said. “It’s falling apart and has no room for life-saving equipment.”
“We recently purchased a CT scan (machine) with our limited funds,” Alkire added. “There was no space and we had to build it into the back entrance of the building. But we do what we have to do, right?”
These problems are not limited to that specific hospital. According to the working group’s report on its fiscal 2024 budget recommendations, NHS hospitals have only 52 percent of the space they need based on the size of the population the agency cares for. Hospitals in Indian Country are also nearly four times older than the national average, the report said.
In its FY 2024 budget proposal released in March, the Biden administration called for full mandatory funding for the Indian Health Service by FY 2025. The agency currently receives the bulk of its funding through discretionary spending, which must be debated by Congress each year through the appropriation process. Programs like Medicare and Medicaid receive mandatory funding, which means they automatically receive a certain amount each year as set by law.
The White House is seeking $9.7 billion in total Indian Health Service funding for fiscal year 2024, including $1.6 billion in proposed mandatory funding for some expenditures. By fiscal year 2025, the administration wants all Indian NHS funding to be mandatory, with automatic increases in spending to address rising costs, existing backlogs and major operational needs.
In its Congressional budget justification, the Indian Health Service says that compulsory funding is necessary to get the full amount of funding it needs, otherwise it is limited by discretionary budget limits. The debt ceiling deal signed by Biden last week keeps discretionary non-defense spending stable next year and allows for just a 1% increase in fiscal 2025.
White House press secretary Karine Jean-Pierre said this change is part of the Biden administration’s goal to lift up groups that have historically been underserved.
“There are communities, whether it’s Indian Country, Native American, whether it’s rural America, whether it’s urban America, where people have felt left behind,” she said in April. “This is a story that is part of[Biden’s]economic policy, leaving no one behind, making sure people get the assistance, get the help they desperately need.”
Native American advocates have been pushing for compulsory funding of the Indian health service for years. One such group, the National Council of Urban Indian Health, advocates for the health care needs of Native Americans living in urban areas. The council’s vice president of policy and communications, Meredith Raimondi, said unpredictable funding creates barriers to health care delivery.
“If you’re a healthcare clinic and you’re looking to hire staff, and you don’t know what your funding will be next year, it’s much more difficult to plan and retain staff. It is more difficult to buy laboratory equipment. It’s harder to know if you can pay (for) your lab tests and your providers,” Raimondi said. “So it makes it extremely difficult to deliver health care at a time when our health care needs are at an all-time high.”
Making Indian Health Service funding mandatory would require an amendment to the Indian Health Care Improvement Act, authorizing funding for the agency.
Congress appears divided on the issue.
In an interview, Senator Brian Schatz (D-Hawaii), who chairs the Senate Committee on Indian Affairs, said he supports making Indian health service funding mandatory. But Rep. Harriet Hageman (R-Wyo.), chair of the House Natural Resources Subcommittee on Indian and Island Affairs, criticized the idea at a May hearing, suggesting the agency’s problems are actually the result of poor management.
“We need to see significant progress before the way IHS is funded can change significantly,” Hageman said.
He said it was important to focus on cutting the federal deficit.
“I just polled this week on some of the most important issues to my constituents in the state of Wyoming, and federal and government budgets and spending are at the top of the list,” Hageman said.
However, Ranking member Teresa Leger Fernández (DN.M.) pointed out that Biden’s proposed budget would actually reduce the deficit. Biden has proposed cutting the deficit by nearly $3 trillion over the next 10 years, largely by raising taxes on the wealthiest Americans.
“There are ways to reduce the deficit while also investing in what’s important,” Fernández said.
Raimondi said native health care should not be cut to reduce the deficit.
“Native Americans who have given up their land and who have entered into treaties and have a relationship of trust with the federal government are entitled to health care, whether or not the federal government needs to fix its deficit or cut costs Raimondi said.
Biden also requested full mandatory funding for the NHS last year, the first time a president has done so, according to the NHS congressional budget justification that year. While that ultimately didn’t materialize, the latest budget made a significant change by providing advance appropriations for the agency, meaning that some FY2024 funding was provided a year in advance. Prior to this change, the Indian Health Service was the only major federal healthcare provider to be funded solely by regular annual appropriations.
This change means the agency will have greater protection from government shutdowns. The 2018-2019 closure, which lasted 35 days, caused severe disruptions to the agency’s services. At least five Indian Health Service patients have died during the shutdown, according to the National Council of Urban Indian Health.
Raimondi said the advance appropriations are an important step, but they still need to be approved by Congress each year. He said mandatory funding is needed to ensure adequate health care for Native Americans.
“You have to have the compulsory funding so that it’s not subject to the whim of political struggles,” Raimondi said. “And so we know that American Indians and Alaska Natives will have access to the health care they deserve and have earned.”
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