Written Testimony — Alberta Unok, Alaska Native Health Board, on H.R. 5549 (July 28, 2022)

Summary

Written testimony of Alberta Unok, President and CEO of the Alaska Native Health Board, before the House Committee on Natural Resources Subcommittee for Indigenous Peoples of the United States, Legislative Hearing on H.R. 5549, Indian Health Service Advance Appropriations Act, July 28, 2022. The testimony states that the Board represents 229 federally recognized Alaska Tribes, supports advance appropriations for the Indian Health Service, and says Congress has enacted continuing resolutions in all but four of the last 40 fiscal years. It says the IHS Tribal Budget Formulation Workgroup recommended funding IHS at $49.8 billion in FY 2023 while current IHS funding is just $6.6 billion. The conclusion calls on the subcommittee to move H.R. 5549.

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                                 Written Testimony of
                           Alberta Unok, President and CEO
                              Alaska Native Health Board
                  Before the House Committee on Natural Resources
               Subcommittee for Indigenous Peoples of the United States
   Legislative Hearing on H.R. 5549 (Rep. Don Young, R-AK), Indian Health Service
                             Advance Appropriations Act”
                                            July 28, 2022
       Good afternoon Chairwoman Leger Fernandez, Ranking Member Obernolte, and
Distinguished Members of the Subcommittee. My name is Alberta Unok, President and CEO of
the Alaska Native Health Board (ANHB or the Board). Established in 1968, ANHB serves as the
statewide voice of the Alaska Tribal Health System (ATHS) on Alaska Native health issues. ANHB
represents 229 federally recognized Alaska Tribes that provide health services to over 180,000
Alaska Native people. The ATHS is a true system of care that is comprised of 180 Small
Community Primary Care Centers; 25 Sub-Regional, Mid-Level Care Centers; six Regional
Hospitals; four Multi-Physician Health Centers; and the Alaska Native Medical Center.

Support for Indian Health Service Advance Appropriations

       I would like express appreciation to the late Congressman Young for introducing H.R.
5549 which would extend advance appropriations to the Indian Health Service (IHS).
Congressman Young served Alaskans for nearly five decades in the U.S. House, and he
understood full well how critical this bill is for the Indian health system. He introduced it in five
consecutive Congresses going back as far as 2013. The bill has a strong bipartisan list of co-
sponsors, including several members of the Appropriations Committee. I would also like to
acknowledge and thank Congresswoman Betty McCollum (D-MN) for introducing H.R. 5567
which would also extend advance appropriations to IHS, among other programs serving Indian
Country. I would also like to acknowledge and commend the Biden Administration for including
IHS advance appropriations in its FY 2022 Budget Request to Congress for the first time.

        Last year, Senate Budget Resolution, S.Con.Res.14, also provided authority for Advance
Appropriations paving the way for this important change and the Senate Appropriations
Committee included it in their FY 2022 Draft Interior, Environment and Related Agencies
Appropriations bill. The Government Accountability Office (GAO) also issued a 2018 Report
indicating that Advance Appropriations can help alleviate negative effects upon the Indian health
system arising from budget uncertainty, such as Continuing Resolutions and government
shutdowns. 1

        This bipartisan legislation would ensure that critical health services to Alaska Natives and
American Indians (AN/AIs) are not hampered by unrelated partisan budget disagreements in
Washington by appropriating the IHS budget a year in advance. Funding would not be able to be
used until the start of the fiscal year for which it was intended, and therefore would have little
impact on the overall federal budget. Nonetheless, it would have a major impact for IHS, Tribal
and Urban Indian Health providers and the people they serve by providing stable funding source
for those who depend on these resources’ life-saving health programs.


1 See U.S. Gov’t Accountability Off., GAO-18-652, Indian Health Service: Considerations Relating to

Providing Advance Appropriation Authority (2018).
          Tribal Nations from throughout the United States support this common-sense effort, as
do national Tribal organizations such as the National Congress of American Indians and the
National Indian Heath Board. In short, IHS advance appropriations has universal support from
Indian Country, is supported by the Administration, and a bipartisan list of Members of Congress.
It is a common-sense solution to help ensure stability for IHS and Tribal health programs as they
work to provide health care to AN/AIs in fulfillment of the federal trust responsibility to Tribal
Nations.

Funding Challenges for the Indian Health System

           ANHB supports advance appropriations, which would increase access to health care
services, improve health outcomes, help to maintain facilities infrastructure in a timelier manner,
enhance financial planning, hiring, and to increase the quality of health care through stability and
flexibility in our programs. IHS remains the only federal health program that is not advance funded
or funded through much more stable mandatory funding mechanisms.

         All of this is made more urgent by flawed congressional actions which has left us decade
after decade with funding which arrives late and in small portions. Sadly, it has become the norm
for Congress to enact spending for the upcoming fiscal year well into the start of that year and
keep the federal government limping along with continuing resolutions (CRs). In all but four of
the last 40 fiscal years, Congress has enacted CRs. Over the last twenty years, Congress has
only authorized funding for the IHS once prior to the start of the fiscal year. In FY 2022, for
example, the fiscal year was halfway over before IHS received its full appropriation. The GAO
found that IHS and Tribes are given significant administrative burden due to the fact that the IHS
has to modify contracts each time there is a CR. This means that tribes completed between two
and 21 reconciliations in every year CRs were used to keep programs open. Those are resources
that could otherwise be directed to health services and patient care. CRs also bring uncertainty
in their duration which can range from one to 187 days. This uncertainty of funding duration has
led to lower credit ratings and thusly to higher interest rates on loans needed to support
construction and/or operations.

          While CRs create significant challenges, federal government shutdowns create an even
more dire situation for the Indian Health system. Recent shutdowns in FYs 2013 and 2019 (the
later of which was the longest in history - 35 excruciating days) cause serious financial pain for
Tribal health organizations as well as federally operated IHS facilities who must keep doors open
for critical services without any guaranteed funding. Tribal health organizations (THOs) who often
operate on very thin margins are forced to cobble together resources to just keep staff in our
clinics. As you know, the health care sector is currently one of the most difficult places to recruit
and retain employees in the best of circumstances. Employing medical providers without a
guaranteed funding source is virtually impossible, especially in our remote, rural locations. In
many cases, the Alaska Tribal Health system provider is the only health provider in rural villages.

Challenges Operating Programs under CRs

          Even if Congress did not enact CR after CR, the need for advance appropriations is urgent
– planning for something as complex as a health care system is time-consuming. Specifically,
the areas of (1) budgeting; (2) recruitment and retention; (3) provision of services; and (4) facility
maintenance and construction efforts, among other sectors pose significant problems under CRs.
Short term funding creates the need for tribes and THOs to shift program funding to support the
most critical, life-saving services and prevents tribes from planning or moving forward entirely with
critically needed facilities improvements and expansions. Ultimately, tribal health programs,
whose purpose is to protect life and health, are left to make long-term decisions, with only short-
term money guarantees.

        Also, of note is that Continuing Resolutions explicitly prohibit the IHS from initiating during
the CR timeline new initiatives supported and funded by Congress, initiatives intended to improve
health care delivery.

       In Alaska especially, challenges of climate and geography are substantial factors in the
need for advance appropriations. Alaska spans over 660,000 square miles with over 80% of our
communities off the road system and therefore rely on large bulk purchases of items such as
heating fuel to support operations. Without the ability to purchase heating oil in bulk for the winter
season when the barges are running, heating oil would have to be flown in to communities in
small bush planes at exorbitant cost. For the same reasons, and even more so, the transport of
construction materials must be transported to the villages via the barge system.

        As another example of adverse impact, multiple CRs also impede the IHS Joint Venture
Construction Program (JVCP) where tribes invest in development of building of facilities and in
exchange, the IHS commits to requesting staffing for those facilities. IHS estimates that the
current backlog of needed funding for construction would take 400 years to clear if it was all done
with federal funding. Tribes and tribal organizations cannot wait this out, whether it be via the
JVCP or otherwise. CRs represent uncertainty in lending for tribes wanting to take advantage of
the JVCP system or other forms of construction. The uncertainty results in a downgrade to credit
rating levels and consequently higher interest rates increasing the cost of financing.

Long Term Funding Solutions for IHS

        ANHB acknowledges that IHS Advance Appropriations would not be the full solution to
challenges that the Indian health system which suffers from decades of chronic underfunding. To
be sure, it will provide much needed relief when planning and delivering health care services to
know the full year’s appropriation at the start of the fiscal year. However, that the Indian health
system still experiences significant underfunding. The IHS Tribal Budget Formulation Workgroup
(TBFWG) recommended funding IHS at $49.8 billion in FY 2023 2, yet, current IHS funding is just
$6.6 billion.

         To address this challenge, the Biden Administration recommended enacting mandatory
funding for IHS in FY 2023. As noted in the President’s budget request, “Mandatory funding for
the IHS provides the opportunity for significant funding increases that could not be achieved under
discretionary funding caps.” 3 We look forward to working collaboratively with Congress and the
Administration on further developing this proposal, as it would provide a pathway to achieving
more stable and adequate appropriations for IHS in the long-term. We also support the interim
steps of enacting mandatory funding for Contract Support Costs (CSC) and 105(l) leases to better
reflect the true nature of these appropriations and to take pressure off the remainder of the IHS
discretionary budget.




2 Building Health Equity with Tribal Nations: The National Budget Formulation Workgroup’s

Recommendations on the Indian Health Service Fiscal Year 2023 Budget. The IHS Tribal Budget
Formulation Workgroup. May 2021, p. 3.
3 Department of Health and Human Services, Fiscal Year 2023, Indian Health Service, Justification of

Estimates for Appropriations Committees, p. CJ-3.
        We continue to support IHS advance appropriations, given its widespread support, in the
near term to help alleviate some of the previously mentioned funding challenges for IHS and Tribal
health programs. Advance appropriations would allow for planning to support timely health
construction and planning for development of much needed health services.

Addressing Advance Appropriations Assumptions

        Some have said that IHS advance appropriations would create implementation challenges
for the agency. For example, it is true that the Appropriations Committee would have to address
funding levels needed well in advance of the next fiscal year. However, like the VHA, Congress
would also have the opportunity to enact funding changes during the current year appropriation
that could respond to immediate challenges. And with, as previously mentioned, a $43.2 billion
gap between current funding and estimated need, there should not be a concern about the
Appropriations Committees accidently providing too many resources for this chronically
underfunded health system.

        Tribes, through the TBFWG, already collaboratively work on the Tribal budget request on
a 3-year cycle and provide recommendations to IHS in advance of the agency’s development of
their upcoming request each year. While some discrete needs will change from year to year,
overall, the provision of health services and the base budget of IHS is consistent from year to year
and able to be predicted based on inflation, population growth and anticipated needs.

        We have also heard the criticism that if IHS receives advance appropriations then other
“interest groups” will similarly request such authority. This uninformed belief does not
acknowledge the fact that the federal trust responsibility for health is not just one of the federal
government’s many programs. The IHS carries out federal government’s obligation to ensure
the health and wellbeing of AI/AN people and communities, a government-to-government
relationship established in the Constitution, and given substance through subsequent treaties,
Congressional legislation, Supreme Court decisions, and Executive Orders. When permanently
renewing the Indian Health Care Improvement Act in 2010, Congress declared that “it is the policy
of this Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians— to
ensure the highest possible health status for Indians and urban Indians and to provide all
resources necessary to effect that policy…” 4

       Enacting IHS advance appropriations would not provide unique or “special treatment” to
the IHS. But it would help the federal government meet its sacred obligation to Tribal Nations by
ensuring that the Indian health system is afforded a funding stream that is stable and less
dependent on the whims of yearly federal budget politics.

Conclusion

       To conclude, we call upon the members of this subcommittee to not only swiftly move H.R.
5549, but to advocate with your colleagues on the Appropriations Committee and the Budget
Committee to also support IHS advance appropriations.

         The IHS is responsible for providing health services to AN/AIs and acts as the funding
mechanism for Tribes and Tribal organizations carrying out these services. This is done in
fulfillment of the federal trust responsibility to Tribal Nations. Yet, this solemn obligation is
significantly compromised when funding needed by Tribal and IHS health providers is not enacted

4 25 U.S.C. § 1602
by the beginning of the fiscal year. This late funding impacts budgeting, recruitment and retention,
provision of services, facility maintenance and construction efforts. Enacting IHS advance
appropriations will help insulate critical, life-saving health services.

      Thank you for holding this important hearing. I am happy to answer any questions you
may have.


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