CHAPTER 3- Federal Funding for Indian Programs Legislative Commitments Page 3-22 Over the past 75 years the federal government's obligation to provide health care services to American Indians and Alaska Natives, has been explicitly set forth in a series of federal laws, executive orders, and court decisions. Among the most important legislative actions are: The Snyder Act of 1921 - Congress, for the first time, enacted legislation permanently authorizing appropriations for American Indian health care. The act authorized the BIA to expend federal funds and employ physicians "for the relief of distress and conservation of health." During congressional debate, legislators characterized health care as one of the fundamental obligations of the United States to American Indian people. The Transfer Act of 1954 - Under This act, the federal government transferred responsibility for health services from the Interior Department to a newly created Division of Indian Health (re-titled the Indian Health Service in 1955) under the U.S. Public Health Service in the Department of Health, Education, and Welfare. A primary motivation for the transfer was the desire to improve the quality of medical services to American Indian people through supervision by an agency with more expertise in health care. The Indian Sanitation Facilities and Services Act of 1959 - This act expanded the scope of IHS programs by authorizing the agency to provide sanitation facilities including water supplies, drainage, and waste disposal facilities for American Indian homes, communities, and lands. The Indian Self-Determination and Education Assistance Act of 1975 (P.L. 93-638) - In recognition of the federal government's "historical and special legal relationship with, and resulting responsibilities to, American Indian people . . .", the act authorized the IHS to turn over full administrative responsibility for IHS programs, through contracts, to the tribes upon their request. It also authorized the IHS to make grants to tribes for planning, developing, and operating health programs. With the 1988 amendments, known as Title II and Title III of P.L. 100-472, the Bureau of Indian Affairs was authorized to initiate Self-Governance Demonstration Projects with tribes. In 1992, the Indian Health Care Amendments, P.L. 102-573, extended selfgovernance to the IHS. Funded by compacts that are negotiated with the federal government, self-governance allows tribes to assume responsibility for resource management and service delivery. This allows a tribe more flexibility to design and develop programs that better meet the needs of its members, with no abrogation of the federal government's trust responsibility. The Indian Health Care Improvement Act of 1976 (P.L. 94-437) - This act authorizes a series of health programs based on a "community health model" approach and directs increased appropriations for such programs. The act includes the first specific legislative CHAPTER 3 - Federal Funding for Indian Programs Page 3-23 acknowledgment of the special federal responsibility for American Indian health services, and sets forth the mission statement of the IHS: to elevate the health status of American Indians and Alaska Natives to the highest possible level. Further, the act provides for the establishment of programs to make health services more accessible to American Indians who reside in urban areas. Administrative Commitments The Surgeon General's Report on Health Promotion and Disease Prevention: “Objectives for the Nation" (1980): This Publication included goals to reduce health disparities among Americans and identified the American Indian/Alaskan Native as a special population that deserved emphasis. Health Conditions and Risks The shameful conditions of Indian communities should be an embarrassment to America given its current unprecedented prosperity. The health indicators below clearly describe a situation that requires that the resource level must not only be adjusted to preserve purchasing power but be significantly increased. • The American Indian and Alaska Native (AI/AN) age adjusted death rate for all causes is 35% higher than that of the general population. • The AI/AN infant mortality rate is 30% above the general population. • The AVAN age adjusted accident death rate is more that three times that of the general population. • The AV/AN age adjusted alcoholism death rate is nearly 7 times that of the general population. • The AI/AN age adjusted diabetes death rate is between 3 and 4 times that of the general population. • The AI/AN age adjusted suicide rate is 70% higher than that of the general population. • The years of potential life lost (YPLL) for AI/AN is 73% greater than the general population. • The ratio of 74 physicians per 100,000 in AI/AN communities is significantly lower CHAPTER 3- Federal Funding for Indian Programs Page 3-24 These overall statistical measures and many others can be found in the Indian Health Service publication entitled, "Trends in Indian Health, 1997." These measures are reflective of aggregated information. In many cases the regional differences are dramatically more severe as noted in the annual IHS publication "Regional Differences in Indian Health, 1997." The American Indian and Alaska Native population is much younger that the general population with a median age of 24.2 compared to 32.9 for the U.S. all races. Reservation populations generally have fewer economic and educational opportunities than the rest of America's citizens. Consequently, family incomes are lower, educational levels are lower, unemployment is higher and a significantly higher percentage of American Indians and Alaska Natives live in poverty than any other minority group. These social indicators contribute to the poor overall health status picture. Although health risk factors have not been quantified for the entire AI/AN population, Behavioral Risk Factor Surveys, completed in various Indian communities by the Centers for Disease Control (CDC), suggest some common health risk patterns (obesity, low levels of physical activity, excessive use of Alcohol and tobacco products, etc.). Each of these factors have serious long term health consequences which are reversible with education and behavior modification. It is essential that investments be made to target health risks to reduce the future health care financing burden. The Indian Health Service Budget Preserving the purchasing power of the base program should be IHS' first budget principle, not an afterthougnt. The omission of the appropriate level of mandatories critically undermines the entire budget process. Tribes have one overriding concern that is crucial to this discussion. There must be a trusting relationship between tribes who are concerned about improving the health status, the Administration that is charged with that responsibility, and the Congress who determine the resource commitments. Despite significant gaps in health status for the Indian population, the Indian Health Service budget has contributed savings to achieve the national goal of a balanced budget. Now that that has been accomplished, tribes, IHS and Congress must refocus on the goals and objectives of the Indian Health Service Program and assure that the necessary resources are available to continue to make improvements in health status. In the past, tribes had no opportunity to participate in budget development and therefore were compelled to react to budgets developed by the Administration. It is encouraging that the IHS now conducts area level workshops as part of the budget development process. Tribes have recommended this approach for many years and welcome the opportunity to engage in open discussion of the problems and issues facing every American Indian and Alaska Native CHAPTER 3 - Federal Funding for Indian Programs Page 3 -25 measures and strategic plans, but resources are needed to meet the objectives set by these plans. Tribes belong in the budget formulation process and should not be on the sidelines when the IHS budget is being developed. The President's proposed FY 1999 budget was another in a long line of disappointments. The President has kept his promise to balance the budget, but has broken promises made to tribes to do so. Tribes cannot be content with an underfunded program that so deeply affects their communities. Fortunately, in FY 1999 the Congress realized the commitment to Indian health required a larger budget increase and approved an IHS budget of $2,239,787,000, which represents an increase of 6.7% over the prior year. Mandatories Continue to be Inadequate Mandatories are cost increases necessary to maintain the current level of services. They are unavoidable and include medical and general inflation, pay costs, and staff for recently constructed facilities. Federal workers receive pay increases as required by law as proposed by the President's budget. The basic health program is not guaranteed the funds needed to compensate for inflation. Unfunded cost increases result in service reductions in many cases. The Congressionally approved FY 1999 budget did allocate funds sufficient to pay for 75% of congressionally approved pay increases and inflation. The effect of underfunding mandatories is that both IHS direct programs and tribal contracted and compacted programs are forced to absorb over 25% of the required mandatories and inflation requirements. In the previous four years very little funding was provided for mandatories and the increased cost of operating programs had to be absorbed. Mandatories should be the first consideration in budget formulation. Funding for "Population Growth" Eliminated Tribes have long testified that resources must increase to compensate for population growth just as they must increase for actual inflation costs. No funding for population growth in any program activity has been proposed or approved since 1994. This compounds the problem of underfunding the traditional mandatories described above. Indian health programs are not treated fairly when compared to Medicare and Medicaid budgets. Because Medicare and Medicaid are entitlement programs they automatically receive population growth increases. As the number of participants increase, funds increase accordingly. It is inequitable that health services for American Indians/Alaska Natives are reduced when population increases. Funding should be adjusted for population growth in CHAPTER 3 - Federal Funding for Indian Programs Health Services Activities Page 3-26 Unfunded mandatories and the absence of adjustments for population growth have the greatest impact on the health services portion of the budget. The compounding effect of these factors is dramatic. Figure 3-1 demonstrates the loss of real resources in the health services account due to increases that have been inadequate to pay for cost increases due to inflation (medical and general) and population growth (ranging from 2.0% to 2.3% over the period). The loss over the past seven years is estimated at $834 million. This estimate is based on a simple model that applies the medical rate of inflation to 50% of the health services budget and the general inflation rate is applied to the remaining 50%. If the Health Services account had received full funding of mandatories in each budget beginning with FY 1993 the FY 1999 Health Service Appropriation would be $ 2.78 billion not $1.95 billion. Increased collections have restored a small fraction of these lost resources, but budget growth continues to fall far below the requirements to sustain current health care operations. The situation is more grave for most Indian communities because a significant portion of the budget increases have been earmarked for staffing and operating costs associated with major health facility construction projects that only affect a small number of Indian communities. Of the $425 million increase in Health Services (1993-1999) $90 million or 22% was identified for newly constructed facilities. This loss of purchasing power in the health service categories is a sad testimony to the federal obligation that has been reiterated in legislative language and federal administrative |