National Tribal Budget Update & Funding Priorities
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Indian Health Service
Budget Update
JILLIAN E. CURTIS
CHIEF FINANCIAL OFFICER
MARCH 9, 2023
Road Map
FY 2025 Tribal Budget Formulation Update
Mandatory Funding Sub-Work Group Update
Advance Appropriations Implementation
Interim CRRSAA Reporting Guidance
Section 105(
l
) Transition
FY 2024 President’s Budget
2
FY 2025 National Tribal Budget
Formulation Work Session
3
NTBFW Work Session
The FY 2025 National Tribal Budget Formulation
Work Session took place on Feb. 14-15, 2023.
The total recommended funding level for
FY 2025 is $53.8 billion in mandatory funding.
This number serves as a “proxy” for a full funding
budget, and is $46.6 billion above FY 2023
Enacted.
4
NTBFW Work Session
(Cont.)
The top 5 funding priorities are:
Hospitals & Health Clinics
Purchased/Referred Care
Alcohol & Substance Abuse
Mental Health
Indian Health Care Improvement Fund
5
Next Steps
The NTBFW Technical Team will work to create a
document outlining the recommendations of the
workgroup, and hot topics raised by each Area
.
The NTBFW Co-Chairs will present the
recommendations during the HHS Tribal Budget
Consultation taking place on
April 18 & 19, 2023
.
IHS will use the Tribal Budget Recommendations as the
foundation for developing the FY 2025 budget request.
6
Mandatory Funding Sub-Work Group
The NTBFW mandatory funding sub-work group
will convene for the first time later this month.
The kick-off meeting is scheduled for March 27,
2023.
IHS will be following up with the sub-work group
members to schedule a specific time, and provide
a draft agenda for consideration.
7
Future Tribal Budget Formulation Dates
At the work session, the NTBFW identified dates
for the following upcoming meetings:
The FY 2025/FY 2026 Planning & Evaluation
Session will take place on
August 16, 2023
.
FY 2026 National Tribal Budget Formulation Work
Session will take place on
February 14-15, 2024
.
8
Advance Appropriations Update
9
Advance Appropriations
For the first time ever, the FY 2023 budget includes a total of
$5.1 billion in advance appropriations for the Indian Health
Service. This includes almost all programs in the Services and
Facilities Accounts.
For programs that received Advance Appropriations, the
FY 2024 funding levels are flat with FY 2023.
The full year funding level will be available for these
programs on October 1, 2023 regardless of whether
Congress enacts a Continuing Resolution, or if there is a
government shutdown.
10
Advance Appropriations
(cont.)
Since FY 2024 advance appropriations funding levels are flat
with FY 2023, the IHS will have to seek anomalies for any
funding needs above that amount under a FY 2024
Continuing Resolution.
For example, the IHS will likely need to request additional
funding through an anomaly for FY 2024 Staffing and
Operating Costs for New Facilities under an FY 2024
Continuing Resolution.
11
Advance Appropriations
(cont.)
Activities that did not receive advance appropriations
include:
Electronic Health Record Modernization
Indian Health Care Improvement Fund
Health Care Facilities Construction
Sanitation Facilities Construction
Contract Support Costs
Section 105(
l
) Lease Payments
12
Advance Appropriations
(cont.)
FY 2024 funding for activities that did not receive advance
appropriations varies depending on Congressional action.
13
Advance Appropriations
(cont.)
The IHS’s goal is to start the allocation process for the
FY 2024 Advance Appropriation as soon as possible once the
funds become available on October 1, 2023.
The IHS is collaborating with the HHS Office of the
Assistant Secretary for Financial Resources (ASFR) to
finalize an implementation plan.
The IHS and ASFR will work collaboratively with OMB
to ensure apportionment timelines support this goal.
14
COVID-19 Reporting Guidance
15
Interim Guidance Update
The Coronavirus Response and Relief Supplemental
Appropriations Act (CRRSAA) appropriated $750 million for
COVID-19 testing related activities. The statute includes the
following reporting requirements:
Updated COVID-19 testing plans required by the Paycheck
Protection Program and Health Care Enhancement Act.
Updated plans must be publically available.
Quarterly reports to Congress outlining the uses of the
funding, as well as commitments and obligations.
16
Interim Guidance Update
(Cont.)
The CDC received the same funding and requirements in the
CRRSAA. CDC currently collects funding data from its grantees
on “uses” of funds in the following categories:
17
Interim Guidance Update
(Cont.)
The IHS plans to match CDC’s reporting approach,
given that the funds are from the same source.
The IHS expects to provide written interim guidance to
Tribal Leaders on this approach
before the end of the
month
.
18
Section 105(
l
) Leases Transition
19
Section 105(
l
) Lease Transition
On January 15
th
, the IHS published its work plan for 2023.
Including in that work plan is a goal to “further develop a
national section 105(
l
) lease program.”
This goal aligns with IHS Strategic Plan Objective 3.2:
Secure and effectively manage assets and resources.
The IHS secured the indefinite discretionary
appropriation for section 105(
l
) leases in FY 2021.
As section 105(
l
) leases grow, the IHS must adapt
accordingly to support that growth.
20
Section 105(
l
) Lease Transition
(Cont.)
Specific goals for developing a national section 105(
l
) lease
program include:
Building capacity and institutional expertise.
Supporting current Area Office functions.
Developing/enhancing systems to streamline processes.
Creating policies, procedures, guidance, tools, and other
materials to assist Tribes in accessing 105(
l
) leases.
21
Section 105(
l
) Lease Transition
(Cont.)
Preliminary future state vision for section 105(
l
) leases:
Public facing Section 105(
l
) policy, guidance, tools and
performance measures.
Consistent application of IHS regulations/policies to
section 105(
l
) agreements.
Enterprise-wide section 105(
l
) lease tracking system with
UFMS interface.
Dashboards with easily accessible information about
current status of section 105(
l
) lease agreements and
performance metrics.
22
Section 105(
l
) Lease Transition
(Cont.)
Preliminary future state vision for section 105(
l
) leases:
Agreement on section 105(
l
) lease cost methodology for
budget formulation purposes.
HHS, OMB, and Congressional confidence in IHS’s
management and oversight of section 105(
l
) leases.
Regular training for IHS and tribal staff on section 105(
l
)
lease policies and processes.
Continuous, proactive progress improvement process in
place.
23
Section 105(
l
) Lease Transition
(Cont.)
Actions taken to date include:
Building capacity and institutional expertise.
Supporting current Area Office functions.
Developing/enhancing systems to streamline
processes.
Creating policies, procedures, guidance, tools, and
other materials to assist Tribes in accessing 105(
l
)
leases.
24
Section 105(
l
) Lease Transition
(Cont.)
Actions taken to date include:
On boarding Dr. Chris Poole on a 50 percent basis to
support the transition of HQ section 105(
l
) lease activities
to the Office of Finance and Accounting.
Identified internal administrative steps to complete
transition.
Developed roles and responsibilities, as well as immediate
and longer-term priorities.
Reviewed existing work flow and identified opportunities
for internal streamlining.
25
Section 105(
l
) Lease Transition
(Cont.)
Actions for the next 60 - 90 days:
Update delegation of authority for approval of section
105(
l
) lease agreements.
Update functional statements in the Federal Register.
Complete personnel actions and initiate hiring.
Examine existing systems for possible quick wins.
Review DOI section 105(
l
) lease handbook and
determine if appropriate for IHS use as well.
26
FY 2024 President’s Budget
27
FY 2024 President’s Budget
The FY 2024 President’s Budget builds on the FY 2024
advance appropriation using a two-pronged approach.
In FY 2024, the Budget requests $9.7 billion, which is
$2.5 billion or 36% above FY 2023 Enacted.
Funding for Services & Facilities activities are
requested as discretionary.
The Budget proposes to reclassify Contract Support
Costs and section 105(
l
) leases as mandatory, and
exempt the full IHS budget from sequestration.
28
FY 2024 President’s Budget
(Cont.)
Starting in FY 2025, the budget requests a mandatory funding
formula for the next 9 years, culminating in a total score of
$44 billion in FY 2033.
This proposal would provide a total of $192 billion over
10 years for the IHS budget, which is a 519 percent
increase over FY 2023 Enacted.
The funding formula would automatically adjust for
inflation and pay costs, population growth, staffing and
operating costs for new facilities, and new federally-
recognized Tribes.
29
FY 2024 President’s Budget
(Cont.)
Over the 10 year budget window, the FY 2024 President’s Budget
would fully fund:
The FY 2018 Level of Need Funded analysis, and provide
additional growth for direct health care services;
Electronic Health Record modernization;
The 1993 Health Care Facilities Construction Priority List;
The current Backlog of Essential Maintenance and Repair
(BEMAR).
30
FY 2024 President’s Budget
(Cont.)
Over the 10 year budget window, the FY 2024 President’s
Budget would also support new or expanded initiatives
including:
The Cancer Moonshot;
Public Health Capacity Building; and
COVID-19 response activities including for long-COVID.
31
FY 2024 President’s Budget
(Cont.)
The FY 2024 President’s Budget also proposes to extend the
Special Diabetes Program for Indians (SDPI) for three years
beginning in FY 2024.
The Budget proposes to increase funding for SDPI to
$250 million, and index that growth to medical
inflation.
The approach would provide $260 million in FY 2025
and $270 million in FY 2026 for SDPI.
32
33
The National Tribal Budget Formulation Work Session for FY 2025 discussed a recommended funding level of $53.8 billion, addressing key priorities such as hospitals, health clinics, mental health, and substance abuse. The session outlined future steps, including the presentation of recommendations at the HHS Tribal Budget Consultation in April 2023 and upcoming meetings for FY 2026 planning.
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Presentation Transcript
Indian H ealth Service Budget Update JILLIAN E. CURTIS CHIEF FINANCIAL OFFICER MARCH 9, 2023
Road Map FY 2025 Tribal Budget Formulation Update Mandatory Funding Sub-Work Group Update Advance Appropriations Implementation Interim CRRSAA Reporting Guidance Section 105(l) Transition FY 2024 President s Budget 2
FY 2025 National Tribal Budget Formulation Work Session 3
NTBFW Work Session The FY 2025 National Tribal Budget Formulation Work Session took place on Feb. 14-15, 2023. The total recommended funding level for FY 2025 is $53.8 billion in mandatory funding. This number serves as a proxy for a full funding budget, and is $46.6 billion above FY 2023 Enacted. 4
NTBFW Work Session (Cont.) The top 5 funding priorities are: Hospitals & Health Clinics Purchased/Referred Care Alcohol & Substance Abuse Mental Health Indian Health Care Improvement Fund 5
Next Steps The NTBFW Technical Team will work to create a document outlining the recommendations of the workgroup, and hot topics raised by each Area. The NTBFW Co-Chairs will present the recommendations during the HHS Tribal Budget Consultation taking place on April 18 & 19, 2023. IHS will use the Tribal Budget Recommendations as the foundation for developing the FY 2025 budget request. 6
Mandatory Funding Sub-Work Group The NTBFW mandatory funding sub-work group will convene for the first time later this month. The kick-off meeting is scheduled for March 27, 2023. IHS will be following up with the sub-work group members to schedule a specific time, and provide a draft agenda for consideration. 7
Future Tribal Budget Formulation Dates At the work session, the NTBFW identified dates for the following upcoming meetings: The FY 2025/FY 2026 Planning & Evaluation Session will take place on August 16, 2023. FY 2026 National Tribal Budget Formulation Work Session will take place on February 14-15, 2024. 8
Advance Appropriations For the first time ever, the FY 2023 budget includes a total of $5.1 billion in advance appropriations for the Indian Health Service. This includes almost all programs in the Services and Facilities Accounts. For programs that received Advance Appropriations, the FY 2024 funding levels are flat with FY 2023. The full year funding level will be available for these programs on October 1, 2023 regardless of whether Congress enacts a Continuing Resolution, or if there is a government shutdown. 10
Advance Appropriations (cont.) Since FY 2024 advance appropriations funding levels are flat with FY 2023, the IHS will have to seek anomalies for any funding needs above that amount under a FY 2024 Continuing Resolution. For example, the IHS will likely need to request additional funding through an anomaly for FY 2024 Staffing and Operating Costs for New Facilities under an FY 2024 Continuing Resolution. 11
Advance Appropriations (cont.) Activities that did not receive advance appropriations include: Electronic Health Record Modernization Indian Health Care Improvement Fund Health Care Facilities Construction Sanitation Facilities Construction Contract Support Costs Section 105(l) Lease Payments 12
Advance Appropriations (cont.) FY 2024 funding for activities that did not receive advance appropriations varies depending on Congressional action. Shutdown on Oct. 1 CR on Oct. 1, then Shutdown Program/Activity CR on Oct. 1 EHR Modernization Pro-rata No new funding Pro-rata until lapse Indian Health Care Improvement Fund Pro-rata No new funding Pro-rata until lapse Health Care Facilities Construction Pro-rata No new funding Pro-rata until lapse Sanitation Facilities Construction Pro-rata No new funding Pro-rata until lapse Contract Support Costs Full Funding No new funding Full Funding Section 105(l) Leases Full Funding No new funding Full Funding 13
Advance Appropriations (cont.) The IHS s goal is to start the allocation process for the FY 2024 Advance Appropriation as soon as possible once the funds become available on October 1, 2023. The IHS is collaborating with the HHS Office of the Assistant Secretary for Financial Resources (ASFR) to finalize an implementation plan. The IHS and ASFR will work collaboratively with OMB to ensure apportionment timelines support this goal. 14
Interim Guidance Update The Coronavirus Response and Relief Supplemental Appropriations Act (CRRSAA) appropriated $750 million for COVID-19 testing related activities. The statute includes the following reporting requirements: Updated COVID-19 testing plans required by the Paycheck Protection Program and Health Care Enhancement Act. Updated plans must be publically available. Quarterly reports to Congress outlining the uses of the funding, as well as commitments and obligations. 16
Interim Guidance Update (Cont.) The CDC received the same funding and requirements in the CRRSAA. CDC currently collects funding data from its grantees on uses of funds in the following categories: CDC Reporting Categories Salary Supplies Fringe Other Equipment Contractual Travel Indirect 17
Interim Guidance Update (Cont.) The IHS plans to match CDC s reporting approach, given that the funds are from the same source. The IHS expects to provide written interim guidance to Tribal Leaders on this approach before the end of the month. 18
Section 105(l) Lease Transition On January 15th, the IHS published its work plan for 2023. Including in that work plan is a goal to further develop a national section 105(l) lease program. This goal aligns with IHS Strategic Plan Objective 3.2: Secure and effectively manage assets and resources. The IHS secured the indefinite discretionary appropriation for section 105(l) leases in FY 2021. As section 105(l) leases grow, the IHS must adapt accordingly to support that growth. 20
Section 105(l) Lease Transition (Cont.) Specific goals for developing a national section 105(l) lease program include: Building capacity and institutional expertise. Supporting current Area Office functions. Developing/enhancing systems to streamline processes. Creating policies, procedures, guidance, tools, and other materials to assist Tribes in accessing 105(l) leases. 21
Section 105(l) Lease Transition (Cont.) Preliminary future state vision for section 105(l) leases: Public facing Section 105(l) policy, guidance, tools and performance measures. Consistent application of IHS regulations/policies to section 105(l) agreements. Enterprise-wide section 105(l) lease tracking system with UFMS interface. Dashboards with easily accessible information about current status of section 105(l) lease agreements and performance metrics. 22
Section 105(l) Lease Transition (Cont.) Preliminary future state vision for section 105(l) leases: Agreement on section 105(l) lease cost methodology for budget formulation purposes. HHS, OMB, and Congressional confidence in IHS s management and oversight of section 105(l) leases. Regular training for IHS and tribal staff on section 105(l) lease policies and processes. Continuous, proactive progress improvement process in place. 23
Section 105(l) Lease Transition (Cont.) Actions taken to date include: Building capacity and institutional expertise. Supporting current Area Office functions. Developing/enhancing systems to streamline processes. Creating policies, procedures, guidance, tools, and other materials to assist Tribes in accessing 105(l) leases. 24
Section 105(l) Lease Transition (Cont.) Actions taken to date include: On boarding Dr. Chris Poole on a 50 percent basis to support the transition of HQ section 105(l) lease activities to the Office of Finance and Accounting. Identified internal administrative steps to complete transition. Developed roles and responsibilities, as well as immediate and longer-term priorities. Reviewed existing work flow and identified opportunities for internal streamlining. 25
Section 105(l) Lease Transition (Cont.) Actions for the next 60 - 90 days: Update delegation of authority for approval of section 105(l) lease agreements. Update functional statements in the Federal Register. Complete personnel actions and initiate hiring. Examine existing systems for possible quick wins. Review DOI section 105(l) lease handbook and determine if appropriate for IHS use as well. 26
FY 2024 Presidents Budget The FY 2024 President s Budget builds on the FY 2024 advance appropriation using a two-pronged approach. In FY 2024, the Budget requests $9.7 billion, which is $2.5 billion or 36% above FY 2023 Enacted. Funding for Services & Facilities activities are requested as discretionary. The Budget proposes to reclassify Contract Support Costs and section 105(l) leases as mandatory, and exempt the full IHS budget from sequestration. 28
FY 2024 Presidents Budget (Cont.) Starting in FY 2025, the budget requests a mandatory funding formula for the next 9 years, culminating in a total score of $44 billion in FY 2033. This proposal would provide a total of $192 billion over 10 years for the IHS budget, which is a 519 percent increase over FY 2023 Enacted. The funding formula would automatically adjust for inflation and pay costs, population growth, staffing and operating costs for new facilities, and new federally- recognized Tribes. 29
FY 2024 Presidents Budget (Cont.) Over the 10 year budget window, the FY 2024 President s Budget would fully fund: The FY 2018 Level of Need Funded analysis, and provide additional growth for direct health care services; Electronic Health Record modernization; The 1993 Health Care Facilities Construction Priority List; The current Backlog of Essential Maintenance and Repair (BEMAR). 30
FY 2024 Presidents Budget (Cont.) Over the 10 year budget window, the FY 2024 President s Budget would also support new or expanded initiatives including: The Cancer Moonshot; Public Health Capacity Building; and COVID-19 response activities including for long-COVID. 31
FY 2024 Presidents Budget (Cont.) The FY 2024 President s Budget also proposes to extend the Special Diabetes Program for Indians (SDPI) for three years beginning in FY 2024. The Budget proposes to increase funding for SDPI to $250 million, and index that growth to medical inflation. The approach would provide $260 million in FY 2025 and $270 million in FY 2026 for SDPI. 32
