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Tribal nations saw it as a culmination of years of work when President Joe Biden unveiled his plan to grow the budget of the Indian Health Service and secure its funds over time.
But in Congress, particularly among key lawmakers, the announcement this week was a surprise. These members say they aren’t ready to commit to Biden’s plan, largely because the administration hasn’t explained its benefits to them.
American Indian groups have lobbied Congress and previous administrations to end lawmakers’ control over the annual budget of the Indian Health Service, which provides care to federally recognized tribes. They say the move is necessary to meet the needs of its beneficiaries, where the U.S. has historically fallen short.
Biden has allies in Congress but must overcome aversion to automatic, or mandatory, government spending from some lawmakers, in particular from Republicans.
Rep. Rosa DeLauro (D-Conn.), head of the House Appropriations Committee, said Thursday she was “just beginning to look” at the proposal. Sen. Brian Schatz (D-Hawaii), chairman of the Senate Indian Affairs Committee, said he “didn’t know much about this” when asked about it.
Sen. Richard Shelby (R-Ala.), the top Republican on the Senate Appropriations Committee, said he, too, hasn’t been briefed on Biden’s proposal.
Shelby said he generally prefers to keep federal programs under discretionary funding—where Congress must decide their budget each year—instead of mandatory, which is automatic funding set over time for programs like Medicare.
“Once you create an entitlement, it’s automatic spending, it’s outside the appropriators process, and that’s part of the runaway spending we have,” Shelby said.
Supporters of Biden’s plan inside and outside Congress say the time has come for the U.S. to fully meet its centuries-old compact with tribal nations by growing the IHS and protecting it from year-to-year budget fluctuations and government shutdowns.
Health and Human Services Secretary Xavier Becerra on Thursday told the House Appropriations Committee that the proposal to increase IHS’s budget to $9.1 billion in fiscal 2023 and shift it to mandatory funding would be a “historic first step toward finally delivering on our long-overdue commitment to tribal nations.”
The Biden administration sought a 37% boost for IHS’s total funding in fiscal 2023, compared to fiscal 2022, and proposed adjusting the budget based on health care costs and population growth. That change would help close longstanding gaps in care for IHS beneficiaries, Becerra said.
“I’ve seen these shortfalls firsthand in my visits to Indian country,” he said. HHS didn’t immediately respond on a request for comment on its consultations with Congress.
The Biden budget also sought mandatory funding for Interior’s Bureau of Reclamation to carry out completed and future Indian water rights settlements between tribes and the federal government.
“It’s something I would work with them on, yes,” said Sen. Jon Tester (D-Mont.), a senior appropriator on the Energy and Water Development Appropriations Subcommittee. The panel oversees the Reclamation budget. “These water settlements are settlements that have been agreed to, and they have to be paid for sometime,” he said this week on Capitol Hill. “Working to get them paid for in a timely manner is really important.”
The settlements, stemming from a 1908 Supreme Court decision, seek to ensure tribes have access to water they’ve possessed rights to since before the federal government forced indigenous communities to reservations in the 19th century. Tribes have pursued their water rights through litigation and settlements over the years, with the federal government preferring the latter avenue. Congress or the administration can approve or implement the settlements, which often require more infrastructure, are expensive, and can take decades to resolve.
As of 2021, the government had approved 38 Indian water rights settlements costing more than $8 billion, according to a January Congressional Research Service report.
Typically, Congress has approved discretionary funding for the settlements, but some of them have received mandatory funding. Congress enacted the 2009 Reclamation Water Settlements Fund (Public Law 111-11) to provide additional money for the program, investing $120 million per year in mandatory funding for settlements through fiscal 2029, with the availability of the funds expiring in fiscal 2034. The 2021 bipartisan infrastructure law (Public Law 117-58) appropriated $2.5 billion for the Indian Water Rights Settlement Completion Fund.
“I’ll be looking at all these issues raised by the president’s budget,” said Sen. Jeff Merkley (D-Ore.), who specifically cited the proposal related to the Indian Health Service. Merkley is chairman of the Interior-Environment Appropriations Subcommittee, which oversees the IHS budget.
“I advocated for advance funding to make sure the Indian Health Service never shuts down during a government shutdown. So, since this is a different idea, I would look forward to a full conversation with the administration about it,” he said in a hallway interview this week.
Tribal governments and lawmakers who back these proposed shifts say they must now explain to lawmakers that the U.S. has fallen far short on its agreements to Native Americans.
“There are tremendous health disparities across Indian country and those exist because the U.S. has not honored its promises,” said Kitcki Carroll, executive director of the United South and Eastern Tribes Sovereignty Protection Fund.
Carroll said his group has spent years lobbying to secure more consistent funding for the IHS and other programs. As discretionary programs, IHS services get hit by government shutdowns and Congress’s propensity for short-term spending bills, interrupting needed care. That also means IHS health programs often can’t give health-care providers multiyear employment contracts, making it hard to attract doctors, Carroll said.
American Indians and Alaskan Natives born today have a life expectancy that is 5.5 years less than the average for all Americans, according to the IHS.
Rep. Tom Cole (R-Okla.), who sits on the House Appropriations Committee and is a citizen of the Chickasaw Nation of Oklahoma, said Biden’s proposal is “long overdue.”
“The reality is there’s just not enough money in the discretionary budget to take care of the needs of Indian health,” he said.