Testimony from RADM Michael D. Weahkee, M.B.A., MHSA on “H.R. 1128 (Rep. Betty McCollum) Indian Programs Advanced Appropriations Act” and “H.R. 1135 (Rep. Don Young), Indian Health Service Advance Appropriations Act of 2019” before House Natural Resources, Subcommittee for Indigenous Peoples of the United States

Good afternoon, Chairman Gallego, Ranking Member Cook, and Members of the Subcommittee.  I am Rear Admiral Michael Weahkee, the Principal Deputy Director of the Indian Health Service (IHS). Thank you for the opportunity to testify on H.R. 1128, the Indian Programs Advanced Appropriations Act, and H.R. 1135, the Indian Health Service Advance Appropriations Act of 2019.  The IHS mission is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.  As an agency within the Department of Health and Human Services (Department), the IHS provides federal health services to approximately 2.6 million American Indians and Alaska Natives from 573 federally recognized tribes in 37 states, through a network of over 605 hospitals, clinics and health stations.

H.R. 1128 would authorize advance appropriations beginning in fiscal year 2020, for several covered appropriations accounts for the Bureau of Indian Affairs (BIA) and the Bureau of Indian Education (BIE) within the Department of the Interior, and the IHS.  Advance appropriations become available for obligation one or more fiscal years after the budget year covered by the appropriations act. The covered accounts within the BIA and the BIE include their Operation of Indian Programs, Contract Support Costs, and the Indian Guaranteed Loan Program Account.  H.R. 1128 addresses the accounts within the IHS that include Indian Health Services and Contract Support Costs.  H.R. 1128 also requires the President's budget and the supporting documents submitted to Congress to include detailed estimates related to advance appropriations.

H.R. 1135 would authorize advance appropriations for both the “Services” and “Facilities” accounts of the IHS.  H.R. 1135 differs from H.R. 1128 in that it solely authorizes advance appropriations for IHS and does not include the BIA or BIE.  However, similar to H.R. 1128, H.R. 1135 requires the President's budget request to include information on estimates for the advance appropriations.

Both bills, H.R. 1128 and H.R. 1135, would amend the Indian Health Care Improvement Act to authorize advance appropriations for the IHS by providing authority for two fiscal years in succession, and for other purposes, and, relatedly, to amend 31 U.S.C. § 1105(a) to make a conforming change to budget submission requirements.  HHS defers to the Department of Interior on the impacts and applicability of both bills on the BIA and BIE.

Through the IHS’s robust annual Tribal Budget Consultation process, Tribal and Urban Indian Organization leaders have repeatedly and strongly recommended advance appropriations for the IHS as an essential means for ensuring continued access to critical health care services.  The Department continues to hear directly from tribes advocating support for legislative language that would provide the authority of advance appropriations for the IHS.  The issues that tribes have identified present real challenges in Indian Country and we are eager to work with Congress on a variety of solutions.  

Advance appropriations for the IHS could ensure continuity of health care provided to American Indian and Alaska Native people, especially in the event of a lapse in appropriations, such as the lapse that occurred from late December 2018 to late January 2019. During regular order, it could enable timely and predictable funding for IHS-funded programs.  As this Subcommittee is aware, the Department of Veterans Affairs (VA) Veterans Health Administration similarly provides direct health care and receives advance appropriations.  Beginning with the Consolidated Appropriations Act, 2010 (P.L. 111-117), Congress has provided advance appropriations for medical care one fiscal year in advance to the VA (pursuant to 31 U.S.C. 1105(a) and 38 U.S.C. 117).  Extending advance appropriations to the IHS would provide parity between federal health service agencies and facilitate a continuum of care to some of the most remote parts of the country. 

In September 2018, the Government Accountability Office (GAO) published their report GAO-18-652, Indian Health Service: Considerations Related to Providing Advance Appropriation Authority.  Through this study, the GAO reviewed the use of advance appropriations authority, such as what is currently authorized for the VA, and its potential applications to the IHS.  In particular, their report highlights the effects of budget uncertainty on health care programs and operations, including provider recruitment and retention, administrative burden and costs, and financial effects on tribes.

Currently, over 60 percent of funding appropriated for the IHS is administered by tribes in carrying out health programs under the Indian Self-Determination and Education Assistance Act (ISDEAA).  Tribally-operated health programs are disproportionately affected by disruptions in federal appropriations since they rely on IHS funding transferred through ISDEAA contracts and compacts, but are not authorized the same emergency authorities granted to federal agencies during a lapse.  The recent 35-day partial government shutdown forced many tribal and urban Indian programs to make the difficult decision to reduce health services, temporarily lay off staff, and in some cases discontinue services. 

Advance appropriations could mitigate the effects of budget uncertainty on the health care programs operated across the Indian health system.  The IHS could disburse funds more quickly, which could enable IHS, tribal, and urban Indian health program managers to effectively and efficiently manage budgets, coordinate care, and improve health quality outcomes for American Indians and Alaska Natives.  This planning stability could reduce unnecessary contract and administrative costs.  Funding continuity could also alleviate concerns from potential recruits, especially health care providers, about the stability of their employment.  Events like the lapse in appropriations experienced earlier this year undermine our efforts to recruit and retain a quality workforce and provide a continuum of care that our patients deserve. 

We remain firmly committed to improving quality, safety, and access to health care for American Indians and Alaska Natives.  We appreciate all your efforts in helping us provide the best possible health care services to the people we serve.

Thank you, and I am happy to answer any questions you may have.