Written Testimony of President Fawn Sharp of the National Congress of American Indians in Support of H.R. 5549

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Written testimony of President Fawn Sharp of the National Congress of American Indians (NCAI) in support of H.R. 5549, the Indian Health Service Advance Appropriations Act, for the House Committee on Natural Resources Subcommittee for the Indigenous Peoples of the United States, dated July 28, 2022. The testimony says H.R. 5549 has a strong list of 15 bipartisan co-sponsors and that advance appropriations are a budget-neutral and flexible solution to the outsized impacts of funding disruptions. It says advance appropriations and mandatory funding are not mutually exclusive requests. It states that Congress provides Indian Health Service funding with a per user investment more than 56% less than national health spending, per capita, and that IHS hospitals have an average age of 37 years.

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“Written Testimony of President Fawn Sharp of the National Congress of American Indians in Support of H.R. 5549.” Original at docs.house.gov. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/hhrg-117-ii24-wstate-sharpf-20220728-eb767103f9d9-1465c90c5c/, SHA-256 eb767103f9d975ada2b9258b424d81296bc3020c151efcdd63a7631b3241c0ce.

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NATIONAL CONGRESS OF AMERICAN INDIANS

Written Testimony of President Fawn Sharp
of the National Congress of American Indians
in Support of H.R. 5549, the Indian Health Service Advance Appropriations Act
for the House Committee on Natural Resources
Subcommittee for the Indigenous Peoples of the United States
July 28, 2022
EXECUTIVE COMMITTEE
P RESIDENT On behalf of the National Congress of American Indians (NCAI), the oldest and largest
Fawn R. Sharp
Quinault Indian Nation organization comprised of American Indian and Alaska Native (AI/AN) tribal
1 ST V ICE P RESIDENT
Mark Macarro
governments and their citizens, thank you for this opportunity to provide testimony on
Pechanga Band of Luiseño Indians H.R. 5549, the Indian Health Service Advance Appropriations Act. My name is Fawn
R ECORDING S ECRETARY
Stephen Roe Lewis
Sharp. I am the Vice President of the Quinault Indian Nation and President of NCAI.
Gila River Indian Community

T REASURER
Shannon Holsey
Introduced by the late Representative Young, and originally co-sponsored by
Stockbridge-Munsee Band of
Mohican Indians
Representatives McCollum, Kilmer, Kind, Mullin, Cole, Johnson, and Strickland, H.R.
5549 has a strong list of 15 bipartisan co-sponsors. Indian Country has long supported
REGIONAL VICE
PRESIDENTS advance appropriations as a solution to the outsized impacts funding disruptions have
ALASKA on the Indian Health Care system. Recognizing the importance of this issue, the NCAI
Mike Williams
Akiak Native Community (IRA) Executive Committee unanimously passed resolution ECWS-19-0011 in support of
E ASTERN O KLAHOMA advance appropriations for Indian Health Service (IHS) in 2019.
Norman Hildebrand
Wyandotte Nation

G REAT P LAINS Advance appropriations for IHS are a bipartisan and bicameral policy initiative that
Harold Frazier
Cheyenne River Sioux Tribe increases tribal and federal government efficiency, reduces federal taxpayer waste, and,
M IDWEST
Rebecca Crooks-Stratton
most importantly, saves Native lives by providing more effective funding for health
Shakopee Mdewakanton Sioux
Community
care service in Indian Country. Since advance appropriations are merely advance
N ORTHEAST
agreements to provide funding at a later date, they are a budget-neutral and flexible
Lance Gumbs
Shinnecock Indian Nation
solution to the outsized impacts of funding disruptions on Indian Country. Advance
N ORTHWEST appropriations can be rescinded or modified before they are obligated—allowing
Melvin Sheldon, Jr.
Tulalip Tribes of Washington
Congress to respond to changing circumstances based on real-world challenges. The
P ACIFIC result is continuity of services that reduce bureaucratic inefficiencies and uncertainty
Jack Potter
Redding Rancheria for IHS and for Tribal Nations.
R OCKY M OUNTAIN
Mark Pollock
Blackfeet Nation The Biden-Harris Administration supports advance appropriations and mandatory
S OUTHEAST funding for IHS—a historic shift in the paradigm of Nation-to-Nation relations that
Reggie Tupponce
Upper Mattaponi Indian Tribe seeks to restore the promises made between our ancestors and the United States.
S OUTHERN P LAINS
Gonzo Flores
Advance appropriations and mandatory funding are not mutually exclusive requests.
Apache Tribe of Texas However, once IHS obligations are provided through mandatory direct appropriations,
S OUTHWEST
Joe Garcia
there will be no need for advance appropriations through the annual regular
Ohkay Owingeh Pueblo appropriations process. Until such time that mandatory appropriations are provided,
W ESTERN
Bernadine Burnette
advance appropriations are a fiscally responsible solution to the outsized impacts of
Fort McDowell Yavapai Nation
disruptions and uncertainty in funding on the Indian health care system.
CHIEF EXECUTIVE OFFICER
Dante Desiderio
Sappony

NCAI HEADQUARTERS
1516 P Street, N.W.
Washington, DC 20005 1
202.466.7767
NCAI Resolution No. ECWS-19-001, In Support of Advance Appropriations for the Bureau of Indian
202.466.7797 fax Affairs and the Indian Health Service, available at:
www.ncai.org
https://www.ncai.org/attachments/Resolution_vkouAZmrehTqskEUMrBcxaBCihXkHApCJyGwXAw
yjOkhwIcYAGi_ECWS-19-001%20Advance%20Appropriations%20FINAL.pdf, accessed on: July
23, 2022.
Advance appropriations for IHS is an ongoing policy priority for Indian Country. At NCAI’s most
recent Mid Year Conference in June 2022, tribal leaders and keynote speakers advocated for the
enactment of advance appropriations for IHS, and detailed policy discussions took place during NCAI
Committees and the Budget Task Force. Enactment of advance appropriations for IHS is long overdue
and H.R. 5549 is the vehicle to get this done the right way. NCAI urges Congress to pass this
bipartisan policy solution to end the undue suffering of our people and unnecessary drain on taxpayer
resources.

Enactment of H.R. 5549 cannot be timelier, as Indian Country faces a combination of ongoing
crises affecting IHS operations and service delivery:

A Funding Crisis
As documented in the Broken Promises: Continuing Federal Funding Shortfall for Native Americans
report, we face an ongoing funding crisis that is a direct result of the United States’ chronic
underfunding of Indian health care for decades, which contributes to vast health disparities between
Native Americans and other U.S. population groups.2 Congress continues to provide funding for the
Indian Health Service as discretionary spending with a per user investment by Congress that is more
than 56% less than national health spending, per capita.3 At an average age of 37 years, IHS hospitals
are nearly four times older than hospital facilities nationwide, and could not be replaced for nearly
400 years based on the amount of funding currently provided. Although funding for IHS has increased
significantly since 2009, after adjusting for inflation and population growth, the IHS budget has
remained static in recent decades.4 With federal expenditure metrics such as these, it is no surprise
that Indian Country is in a state of crisis by national standards—a 400-year waitlist and less than half
the per capita investment in health services is unacceptable.

The chronic underfunding and funding instability of the Indian health care system is particularly
egregious because Tribal Nations paid in full for the provision of payments and services, including
the promise to provide health care to tribal citizens, when they exchanged the land that created the
foundation of the bounty and wealth of the United States.5 Through the United States’ acquisition of
land and resources, it formed a fiduciary relationship with Tribal Nations whereby it has recognized

2
See, U.S. Commission on Civil Rights, Broken Promises: Continuing Federal Funding Shortfall for Native Americans
(hereinafter “Broken Promises”), 65, available at: https://www.usccr.gov/files/pubs/2018/12-20-Broken-Promises.pdf,
accessed on: July 23, 2022.
3
IHS National Tribal Budget Formulation Workgroup FY 2023 Budget, May 2021, accessed at:
https://www.nihb.org/docs/02072022/FY%202023%20Tribal%20Budget%20Formulation%20Workgroup%20Recomm
endations%20Vol%201.pdf, accessed on: July 23, 2022.
4
Broken Promises at 67.
5
See, e.g., Treaty with the Makah, 12 Stat. 939, art. 11 (Jan. 31, 1855)(“And the United States further agrees to employ
a physician to reside at the said central agency, or as such other school should one be established, who shall furnish
medicine and advice to the sick, and shall vaccinate them; the expenses of said school, shops, persons employed, and
medical attendance to be defrayed by the United States and not deducted from the annuities.”); Treaty with the
Klamath, 16 Stat. 707, art. 5 (Oct. 14, 1864)(“The United States further engages to furnish and pay for the service and
subsistence . . . for the term of twenty years of one physician . . . .”); Treaty with the Kiowa and Comanche, 15 Stat.
581, art. 14 (Oct. 21, 1867)(“The United States hereby agrees to furnish annually to the Indians the physician . . . and
that such appropriations shall be made from time to time, on the estimates of the Secretary of the Interior, as will be
sufficient to employ such [person].”); see also, U.S. Department of Health and Human Services, Indian Health Service,
Indian Health Service Gold Book—The First 50 Years of the Indian Health Service: Caring and Curing (2005), 8,
accessed at:
https://www.ihs.gov/newsroom/includes/themes/responsive2017/display_objects/documents/GOLD_BOOK_part1.pdf,
accessed on: July 23, 2022.
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a trust relationship6 by which the United States “charged itself with moral obligations of the highest
responsibility and trust.”7

A Health Crisis
Indian Country also faces a health crisis that is exacerbated by the ongoing coronavirus pandemic
and disproportionately impacts American Indian and Alaska Native (AI/AN) communities due to
underlying health and living disparities. With a life expectancy that is 5.5 years less than the national
average, Native Americans die at higher rates that those of other Americans from chronic liver disease
and cirrhosis, diabetes mellitus, unintentional injuries, assault/homicide, intentional self-
harm/suicide, and chronic lower respiratory disease.8 Native American women are 4.5 times more
likely than non-Hispanic white women to die while pregnant or “within 42 days of the termination of
pregnancy, irrespective of the duration and site of the pregnancy or its management, but not from
accidental or incidental causes.”9 The Centers for Disease Control and Prevention (CDC) found that,
between 2005 and 2014, every racial group experienced a decline in infant mortality except for Native
Americans10 who had infant mortality rates 1.6 times higher than non-Hispanic whites and 1.3 times
the national average.11 Additionally, Native Americans experience some of the highest rates of
psychological and behavioral health issues as compared to other racial and ethnic groups12 which
have been attributed, in part, to the ongoing impact of historical trauma.13 Native Americans are also
more likely than people in other U.S. demographics to experience trauma, physical abuse, neglect,
and post-traumatic stress disorder.14

Additionally, the coronavirus pandemic is not over and funding certainty and stability are critical to
saving Native lives as we continue to combat the ongoing effects of COVID-19. According to Indian
Health Service data, the total number of coronavirus cases per week has been on the rise since April
2022 (See Fig. 1.1). Further, the Centers for Disease Control and Prevention (CDC) indicates that
community transmission levels are dangerously high in nearly all parts of the country (See Fig. 1.2).

6
See, Johnson v. M’Intosh, 21 U.S. 543 (1823); Cherokee Nation v. Georgia, 30 U.S. 1 (1831); and Worcester v.
Georgia, 31 U.S. 515 (1832).
7
Seminole Nation v. United States, 316 U.S. 286, 296-97 (1942).
8
Broken Promises at 65.
9
Broken Promises at 65.
10
Broken Promises at 65.
11
Broken Promises at 65.
12
Walls, et al., Mental Health and Substance Abuse Services Preferences among American Indian People of the
Northern Midwest, COMMUNITY MENTAL HEALTH J., Vol. 42, No. 6 (2006) at 522,
https://link.springer.com/content/pdf/10.1007%2Fs10597-006-9054-7.pdf, accessed on: July 23, 2022.
13
Kathleen Brown-Rice, Examining the Theory of Historical Trauma Among Native Americans, PROF’L COUNS,
available at: http://tpcjournal.nbcc.org/examiningthe-theory-of-historical-trauma-among-native-americans/, accessed
on: July 23, 2022.
14
Broken Promises at 79-84.
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Figure 1.1 - New COVID-19 Cases in Last 14 Weeks - Overall IHS

5000 4653 4725
4393
~3226
4000 to
3689
2962
3000 2427
1940 1773 2091
2000
892 1071 992
828 830 834
1000
N/A
0
4/3/2022 4/10/2022 4/16/2022 4/24/2022 5/1/2022 5/7/2022
5/15/2022 5/22/2022 5/29/2022 6/6/2022 6/12/2022 6/19/2022
6/26/2022 7/3/2022 7/9/2022 7/17/2022

Source: NCAI Policy Research Center Data as of 7/24/2022 at 12:38 p.m. EDT, collected on a rolling basis
from https://www.ihs.gov/coronavirus/

Figure 1.2 - CDC Community Transmission Levels by County

Source: Data as of 07/24/2022 at 12:38 p.m. EDT; https://covid.cdc.gov/covid-data-tracker/#county-
view?list_select_state=all_states&list_select_county=all_counties&data-type=CommunityLevels&null=Risk

Even though the published data indicates high community transmission throughout the United States
and in Indian Country, experts believe the actual number of cases is much higher. An estimate from
the University of Washington’s Institute of Health Metrics and Evaluation indicates that actual
infection numbers in the first week of July were about seven times higher than the number of reported

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cases.15 These quantitative findings and estimates of COVID-19 infection underscore the ongoing
nature of the pandemic, indicating that the disparate impacts on Native communities and on the IHS
system will persist in the short- and medium-term future.

Further, the seasonal cycle is a consistent feature of respiratory viral infections16 lending to the
widely-held prediction that, even after we transition out of a global pandemic phase of COVID-19
infection, the virus will exhibit some form of seasonality.17 In consideration of healthcare system
efficiency and federal cost reduction, this means that advance appropriations for the IHS will provide
funding certainty and continuity of services for the fall and winter months when surges in patient
need due to respiratory illness and disruptions in federal funding are most probable. Congress should
welcome solutions that increase efficiency at times of increased program service volume because
efficiencies ultimately result in improved value ratios of input to desired output—in simple terms,
good governance.

An Economic Crisis
Indian Country also faces an economic crisis. Beginning in February 2022, the Bureau of Labor
Statistics published monthly data on AI/AN employment using data that was previously available
through the U.S. Census Bureau’s Current Population Survey. The newly published data reveals a
labor market that would be considered catastrophic if it were representative of the full U.S.
economy—Indian Country has an unemployment rate more than double the national rate.18 The data
further highlights that Indian Country is still recovering from the effects of the pandemic with
unemployment rates reaching 28.6% during the peak of the pandemic fallout—an amount comparable
to the national unemployment rate during the Great Depression.19 As of January 2022, the
unemployment rate for Native Americans was still greater than the peak unemployment rate for white
workers during the pandemic.20

Even when controlling for a host of factors, the Brookings Institute posits that structural racism in the
U.S. economy affects AI/AN access to education and attainment as well as employment
opportunities.21 As traditionally place-based peoples with strong cultural and historical ties to the
land, AI/ANs do not tend to move away regardless of economic situations. This means that the
structural impediments to economic growth are focused and exacerbated on tribal lands, underscoring
the importance of federal investment through regular federal appropriations. These broken promises

15
Institute of Health Metrics and Evaluation, COVID-19 Projections, Daily Infections and Testing, available at:
https://covid19.healthdata.org/global?view=infections-testing&tab=compare&test=infections, accessed on: July 23,
2022.
16
Martinez M.E., The calendar of epidemics: seasonal cycles of infectious diseases, PLoS Pathog. 2018;14 doi:
10.1371/journal.ppat.1007327, available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6224126/, accessed on:
July 23, 2022.
17
Liu X., et al., The role of seasonality in the spread of COVID-19 pandemic, Environ Res. 2021 Apr; 195: 110874,
available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7892320/, accessed on: July 23, 2022.
18
Robert Maxim, Randall Akee, and Gabriel R. Sanchez, For the first time, the government published monthly
unemployment data on Native Americans, and the picture is stark, https://www.brookings.edu/blog/the-
avenue/2022/02/09/despite-an-optimistic-jobs-report-new-data-shows-native-american-unemployment-remains-
staggeringly-
high/#:~:text=Prior%20to%20the%20pandemic%2C%20Native,unemployment%20during%20the%20Great%20Depres
sion, Accessed: May 4, 2022.
19
Id.
20
Id.
21
Id.
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of the United States dampen local, regional, and national U.S. economic productivity and negatively
impact the safety and wellbeing of Americans—Native and non-Native alike.

In Indian Country, due to the large role public administration jobs—such as healthcare—play in tribal
communities and economies, coupled with low average household wealth, disruptions in federal
funding uniquely harm Native families. During a shutdown, thousands of IHS employees—many of
whom are tribal citizens—are furloughed or work without pay, which means that IHS employees
during those times struggle to pay household bills and mortgages. A single salary may support an
extended Native family, sending harmful ripples throughout a Tribal Nation and surrounding
communities. While this is the most extreme example of IHS funding disruption, the effects of short-
term Continuing Resolutions also harm IHS and the communities it serves by forcing tribal
governments to cover expenses until funds can be received—funds that start out at pennies on the
dollar of the actual duty owed and are often expended before they can even be received as a result of
the time it takes to complete the apportionment, warrant, and obligation process associated with each
provision of funds. The uncertainty compounds the challenges of attracting and retaining
professionals to work in health care and other skilled professions that are critical to fulfilling the
programmatic mission of IHS. This effect is especially damaging in rural reservation communities
that have acute difficulty recruiting and retaining medical personnel.

Conclusion:
While H.R. 5549 is one solution to allow Congress to enact advance appropriations for IHS, budget
resolutions can also provide this authority and have been similarly used for the Veterans Health
Administration. The Concurrent Budget Resolution for FY 2022 included this exception for certain
IHS accounts; however, advance appropriations were ultimately not included in the final FY 2022
spending package. H.R. 5549 is an improvement on the exception for IHS accounts provided in last
year’s Budget Resolution because it includes all of the accounts for the Indian Health Service. This
is important because of the nature of inherently federal functions as they relate to the operation of
programs pursuant to the Indian Self-Determination and Education Assistance Act (P.L. 93-638, as
amended). Advance appropriations are not about more money in a single accounting period, they are
about advance agreements by Congress that provide certainty and continuity of services that promote
efficiencies and reduce taxpayer waste on costly duplicative tribal and federal budgetary functions.
If only certain funded accounts are provided continuity of services while necessary and inherently
federal IHS functions remain subject to the stops and starts of the annual appropriations process, then
Congress is not utilizing the policy of advance appropriations to maximize its best fiscal features.

Advance appropriations for IHS are a simple promise: a promise that the United States honors and
upholds its treaty and trust obligations; a promise that Congress will enact solutions that cease the
generational trauma and undue and unnecessary suffering of Native people; and a promise of certainty
and security for Native communities and our most vulnerable populations. As Congress works to
restore the promises made, all options must be on the table. Native lives cannot wait.

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