Indian Health Service (IHS)
The mission of the Indian Health Service is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.
IHS Budget Overview
(Dollars in millions)
|Purchased/Referred Care (non-add)||914||914||962||+48|
|Contract Support Costs||663||718||800||+82|
|Indian Health Professions||48||48||59||+11|
|Special Diabetes Program for Indians||150||150||150||--|
|Health Care Facilities Construction||85||105||132||+27|
|Sanitation Facilities Construction||79||99||103||+4|
|Facilities and Environmental Health Support||220||223||234||+11|
|Maintenance and Improvement||62||82||85||+3|
|IHS Budget Totals – Less Funds From Other Sources||2015||2016||2017||2017
|Total, Program Level||5,951||6,160||6,562||+402|
|Tribal Crisis Response Fund||--||--||15||15|
|Health Insurance Collections||1,151||1,194||1,194||--|
|Rental of Staff Quarters||8||9||9||--|
|Special Diabetes Program for Indians||150||150||150||--|
|Indian Health Professions Expansion||--||--||10||10|
|Total, Budget Authority||4,642||4,808||5,185||+377|
IHS Programs and Services
The FY 2017 Budget requests $6.6 billion for the Indian Health Service (IHS), an increase of $402 million above FY 2016 and 53 percent since FY 2008. The President is committed to a legacy of bettering the lives of Native people, especially youth, through improved access to quality health care services. Increases within the FY 2017 Budget are intended to help close the gap in health disparities experienced by American Indians and Alaska Natives and improve their overall health and well-being for generations to come. Specific investments include maximizing the benefits of the Affordable Care Act and Medicaid expansion for Indian Country, integrating medical and mental health services, expanding behavioral health services and supports for Native youth, supporting
self-determination by fully funding Contract Support Costs of tribes who manage their own programs, ensuring increased health care access by fully funding staffing for new IHS health care facilities, addressing critical health care facilities infrastructure needs and renovating the IHS health information technology systems.
Strengthening the Administration's Commitment to Indian Country through the Indian Health Service
Long standing treaties between some Indian Tribes and the federal government ensures that comprehensive and culturally competent health services are accessible to nearly 2 million American Indians and Alaska Natives. This relationship gives the IHS the unique responsibility of providing health care to members of 566 federally recognized Tribes through hospitals, health centers, and clinics. Additional services are delivered through the Purchased/Referred Care program to ensure the full care needs of American Indians and Alaskan Natives are met. Through this program, gaps in specialized care and services are filled by purchasing care that the IHS and tribally managed programs are unable to fulfill.
Consultation with tribes is fundamental to ensuring that the care provided is focused on programs that will have a significant impact on Indian Country and ensuring that the IHS continues to respect traditional practices by providing culturally competent care. This goal is accomplished by working with tribes as partners to implement a complete health care system as authorized by the Indian Self‑Determination and Education Assistance Act. Through this system, IHS and its tribal partners deliver crucial health care services throughout Indian Country.
Beyond the provision of health care, IHS provides additional public services through partnerships with other federal agencies by building sanitation systems to provide water and waste disposal for Native homes, providing scholarships and loan repayment awards to recruit health professionals, including American Indians and Alaska Natives, and supporting tribal self-governance and consultation.
Prioritizing Health Care Services
The FY 2017 Budget includes an increase of $356 million to maintain and grow health care services and programs for American Indians and Alaska Natives. Over the course of the Administration, IHS has made significant strides and improvements including lowered rates of diabetes, increased services in preventative, primary and behavioral health through increased funding, reforms effected by the Affordable Care Act, and the permanent reauthorization of the Indian Health Care Improvement Act. Although significant progress has been made towards reducing health disparities, American Indian and Alaska Native people continue to experience lower health status when compared with other Americans. For example, suicide rates, drug induced death, and unintentional injuries, remain elevated across Indian Country. Targeted funding increases to expand successful programs and promising practices, particularly for behavioral health services are important to improving the health of tribal communities.
Investments in Health Information Technology
Health Information Technology systems are critical to IHS’s responsibility in improving patient healthcare outcomes of over 2 million patients who receive medical care from federal, tribal, and urban facilities. The Budget includes an increase of $20 million to ensure the IHS Health Information Technology system is poised to continue to make tremendous strides in a variety of areas, including Meaningful Use as established by the 2009 Health Information Technology for Economic and Clinical Health Act. Other goals of Health Information Technology include better clinical outcomes, improving population health outcomes, increasing transparency and efficiency, and empowering individuals while providing more robust research data on health systems.
Increases for Behavioral Health Services: The Budget includes a total of $363 million to increase access to critical behavioral health services for youth and families. Services include the expansion of multiple successful substance abuse, mental health, and domestic violence programs. Specifically, the Budget continues to propose increasing funding of $15 million for the Generation Indigenous program, to expand the effective Substance Abuse and Suicide Prevention Program (formerly the Methamphetamine and Suicide Prevention Initiative) by increasing the number of child and adolescent behavioral health professionals who provide direct services and implement youth‑based programming at IHS, tribal, and Urban Indian Health Programs, school-based health centers, and youth-based programs. The Substance Abuse and Suicide Prevention Program resulted in 12,209 individuals entering treatment for methamphetamine abuse; 16,569 encounters via tele-behavioral health; 16,250 professionals and community members trained in suicide crisis response; and 690,597 encounters with youth provided as part of evidence-based and practice-based prevention activities from 2009 to 2015. Additionally, IHS is focused on changing the paradigm of mental health and substance abuse disorder services by incorporating them into the patient-centered medical home. To support this effort, the Budget requests $21 million to facilitate the integration of behavioral health with primary care services. In addition, the Budget includes $4 million to implement Zero Suicide, a comprehensive strategy to reduce and eliminate suicide in 10 pilot projects. IHS also requests $2 million in FY 2017 to test aftercare services at Youth Regional Treatment Centers to ease the transition to the community once residential treatment is completed.
The Budget also includes a $4 million expansion of the successful Domestic Violence Prevention Program (formally the Domestic Violence Prevention Initiative) to fund additional IHS, tribal, and urban Indian projects as well as fund its tribal forensic health care training program. Over 78,500 direct service encounters for crisis intervention, victim advocacy, case management, and counseling services were provided between August 2010 and August 2015. During the same period, more than 45,000 referrals were made for domestic violence services, culturally based services, and clinical behavioral health services. In addition, 8 Sexual Assault Examiner programs submitted 688 forensic evidence collection kits to federal, state, and tribal law enforcement.
Additionally, the Budget creates a new $15 million Tribal Crisis Response Fund, which will assist Tribes experiencing behavioral health crises, such as mass shootings, high rates of alcohol- and drug-related death rates, school violence, suicide clusters, and other emergencies. This fund will provide tribal communities with specialized crisis response staffing, technical assistance, and community engagement services.
The Budget also provides a $10 million expansion to the Indian Health Professions Scholarship Program for a total of $59 million. This expansion will focus on increasing the number of American Indian and Alaska Native behavioral health professionals through the American Indians into Psychology program, loan repayment, and scholarships. These and other programs will support the Administration’s goal of providing adequate and effective behavioral health and domestic violence prevention and services to Native youth and families across the country.
Tribal Behavioral Health Initiatives
In the FY 2017 Budget, the Administration continues to prioritize behavioral health services across Indian Country. IHS has strived to implement innovative solutions to ensure that youth and families receive increased access to mental health and substance abuse services, including interagency and external partnerships. Specifically, IHS has worked with federal agencies to help meet the Administration’s goal of reducing teen suicide. Additionally, HHS is articulating a Department-wide Tribal Health and Well-Being Coordination Plan that calls on several HHS agencies—IHS, ACF, SAMHSA, HRSA, and CDC—to collaborate to improve health outcomes for American Indian and Alaska Native populations.
Purchased/Referred Care: The Budget includes $962 million, an increase of $48 million over FY 2016, for the Purchased/Referred Care program. This program provides access to essential health care services that IHS and tribally‑managed facilities are unable to provide by contracting with hospitals and other health care providers to purchase care. This program is a high priority for Tribes as it ensures that critical health services are available for eligible American Indians and Alaska Natives.
This program uses a medical priority review system to rank cases to determine eligibility for purchasing care due to limited funding. A 66 percent increase in funding since FY 2008 has allowed many facilities to pay for health care priorities beyond emergent services care. The requested FY 2017 funding increase ensures IHS can maintain the current level of services, while accounting for medical inflation and population growth.
Health Insurance Reimbursements: Third party collections from Medicare, Medicaid, the Veterans Health Administration, and private insurance allows IHS and contracting Tribes to provide additional health care services, purchase new equipment, hire necessary medical staff, and make essential building improvements. IHS estimates that in FY 2017, it will collect approximately $1.2 billion in combined health insurance reimbursements. By law, IHS is the payer of last resort, so it is important that efforts be made to ensure the correct entity funds care provided to IHS eligible American Indians and Alaska Natives.
Improving the Quality of Health Care Delivery: Systems that support the delivery of health care across Indian Country are crucial to ensuring the provision of high‑quality care. The IHS health information technology systems are used in over 400 facilities across 35 states at the point of care and support patient engagement with their health information. The request includes an increase of $20 million over FY 2016 to support the development, modernization, and enhancement of IHS’ critical Health IT systems, including the electronic health record system, the personal health record portal, hospital administrative and billing systems, security systems, data exchange and interoperability services, and the IHS Integrated Data Collection System. Additionally, the request includes $2 million for the Hospital Consortium Initiative, a new program which will focus on reducing medical errors that adversely affect patients every year. The goal of this program is to reduce patient safety risks, improve patient satisfaction, and reduce costs of care. Similar efforts have been shown to reduce avoidable readmissions, hospital acquired conditions, and adverse events.
Increasing Access to Quality Health Care Services
Tribes receive direct care services in over 650 facilities managed by IHS, Urban Indian Health Programs, and contracting and compacting Tribes. This system of care gives each tribe the ability to provide services for its members in the best way possible.
Long-Term Solution for Contract Support Costs
In FY 2016, Congress fully funded Contract Support Costs through an indefinite discretionary appropriation, marking a major achievement for tribes. In FY 2017, Contract Support Costs are continued as a discretionary indefinite appropriation and in FY 2018 and beyond, the Administration proposes to reclassify Contract Support Costs as a mandatory, three-year appropriation with sufficient increases year over year to fully fund the estimated need for Contract Support Costs. This policy supports self-determination by fully funding Contract Support Costs of tribes who manage their own programs and provides a long term solution to Contract Support Costs, which provides basic health services across Indian Country.
Construction: Building new health care facilities and maintaining existing facilities are critical for providing quality health care services in for Indian people. Since 2008, the Administration has prioritized construction projects with the goal of decreasing construction backlogs. The FY 2017 Budget includes a total of $570 million for facilities and environmental health programs. Of that total, $132 million is allocated to begin new construction projects and complete ongoing construction projects within IHS. These projects include continuing construction for the Rapid City Health Center in Rapid City, South Dakota, and the Dilkon Health Center in Dilkon, Arizona; completing construction for the Salt River Northeast Health Center in Scottsdale, Arizona; as well as beginning the design for the renovation and expansion of the Whiteriver Hospital in Whiteriver, Arizona. In total, these facilities will serve a user population of approximately 63,000 patients.
Other facilities funding will allow IHS to build new health care and sanitation facilities and improve current infrastructure to ensure today’s standards are met, purchase new equipment, and provide facilities and environmental health support. The $103 million requested for sanitation facilities construction, and IHS’s key partnership with the Environmental Protection Agency, will help to expand on the 190,000 homes that will receive sanitation facilities for the first time under this Administration.
Staffing New and Replacement Health Facilities: The Budget requests a total of $33 million to fully staff five new state-of-the-art facilities, which are anticipated to open between FY 2015 and FY 2017. Of the newly opening facilities in FY 2017, three are Joint Venture projects, which leverage both tribal and IHS funding to ensure construction and staffing of safe and modernized facilities for American Indians and Alaska Natives. These partnerships allow IHS to provide funding for staffing, equipping, and operating the facility while the participating tribe covers the costs of design and construction. When implemented, Joint Venture projects have been successful and vital to improving access to care and reducing health disparities throughout Indian Country. The Joint Venture projects coming to completion in FY 2017 are Muskogee (Creek) Nation Eufaula Indian Health Center, Oklahoma; Flandreau Health Center, South Dakota; and Choctaw Nation Regional Medical Center, Oklahoma.
In addition to these Joint Venture projects, one other facility, the Northern California Youth Treatment Center, is scheduled to open in FY 2017. When these facilities are fully operational, they will serve an approximate user population of 13,000.
Supporting Indian Self-Determination
IHS understands that quality local health care cannot be implemented without consultation with Tribes and tribal organizations who understand the deep needs and proprieties of the local community. IHS highly values tribal partnerships and nearly 60 percent of the IHS budget is operated by tribes through the authority provided under the Indian Self Determination and Education Assistance Act, under which Tribes may assume the administration of programs and functions previously carried out by the federal government.
Contract Support Costs: The Budget fully funds estimated Contract Support Costs at $800 million, an increase of $82 million above FY 2016. In FY 2018 and beyond, the Administration proposes to reclassify Contract Support Costs as a mandatory, three-year appropriation with sufficient increases year over year to fully fund the estimated need for such costs, for both the IHS and the Bureau of Indian Affairs. This funding supports self-determination by supporting the operational costs of Tribes who administer health programs under self-determination contracts and self-governance compacts. The Budget maintains the indefinite appropriation for Contract Support Costs provided by Congress in FY 2016. This funding approach continues the policy to fully fund Contract Support Costs and guarantee program reliability.
Tribal Consultation: The Administration has made tribal consultation a priority by continuing to meet with tribal leaders, ensuring that extensive solicitation of tribal input is used to determine how programs are designed and implemented. The Administration recognizes that Tribes are in the best position to understand the unique needs of their diverse communities, and tribes play a critical role in the budget and policy making process.
In addition, HHS hosts an annual, Department-wide Tribal Budget Consultation at the beginning of each calendar year, which allows tribal leaders the opportunity to communicate with all the operating and staff divisions of HHS on budgetary issues. Tribal leaders provide HHS with their top priorities and recommendations for the upcoming year, connect with department staff, and meet colleagues who face similar challenges. Tribes also provide input through the Secretary’s Tribal Advisory Committee whose goal is to seek consensus and provide recommendations to facilitate intergovernmental responsibilities or administration of HHS programs. Whenever possible, tribal recommendations are incorporated to ensure a continued legacy of health improvements throughout Indian Country.
Special Diabetes Program for Indians
In response to the growing diabetes epidemic among American Indian and Alaska Native people, Congress established the Special Diabetes Program for Indians. This effort is a $150 million per year program that provides grants for diabetes treatment and prevention services to 404 IHS, tribal, and Urban Indian Health Programs across the United States. This program has been extremely successful, including slowing the rate of increase in diabetes in American Indian and Alaska Native adults (aged 20+), with the rate climbing only from 15.2 percent to 15.9 percent from 2006 through 2012 and between 2000 and 2011, incidence rates of end stage renal disease in American Indian and Alaska Native people with diabetes decreased 43 percent—more than for any other racial group in the U.S.