# Presentation: 031779

## Honoring the Promise

- Presented by:
- Don Kashevaroff, President, SVT
- & Co-Chair, IHS Budget Workgroup
- Carole Anne Heart, Executive Director, AATCHB
- & Co-Chair, IHS Budget Workgroup

## Presentation Overview

- Honoring the Promise to Indian People
- Federal Health Responsibilities
- Policy Foundation, Tribal Consultation
- Comparisons
- I/T/U Budget Team’s vs President’s Request
- Diminished Purchasing Power
- IHS Increases compared to Medicaid Growth
- Per Capita Expenditures
- Veteran’s Health Administration & Indian Veterans
- Health Priorities
- Budget Recommendations

## President’s Healthcare Concerns

- 	“There is no question in my mind that a proper role for the federal government is to help the poor and the elderly and the diseased get health care. We’ll do that. And to the extent that these important programs need to be reformed and strengthened, we will do that, as well...And so we will do our duty at the federal level, and when we find deficiencies in federal programs we will work to correct them, for the good of citizens and the taxpayers...”
- 			~President George W. Bush, January 25, 2007

## 	“And the mission...of government is to make sure that the quality of health care received by our patients around this country remains the best in the world. Private medicine works. And we need to make sure private medicine is the norm, quality care is given to as many Americans as possible.” 

			~ President George W. Bush, February 21, 2007

- 			~ President George W. Bush, February 21, 2007

**President’s Healthcare Concerns**

## The Indian Health Care Improvement Act, as codified 1996. DECLARATION OF HEALTH OBJECTIVES

- 	SEC. 3  (a).  The Congress hereby declares that it is the policy of this Nation, in fulfillment of its special responsibilities and legal obligations to the American Indian people to assure the highest possible health status for Indians and urban Indians and to provide all resources necessary to affect that policy.

## Honoring the Promise:Federal Health Responsibilities

- U.S. Constitution – Article I, Section 8
- “Congress regulates commerce among states...and with Indian tribes”
- Over 800 Ratified Treaties
- Statutory and Case Law – Snyder Act
- Executive Orders
- NGA Resolution HHS-18 (formerly HR-31, Winter 2002) – Winter 2006
- Acknowledges federal trust responsibility
- Supports federal funding level without requiring state subsidy

**Notes:**
For American Indian and Alaska Native people, the federal responsibility to provide health services represents a prepaid entitlement, paid for by the cession of over 400 million acres of land to the United States.  

The foundation for the provision of health care services between the United States and American Indian and Alaska Native tribes is embodied in over 800 ratified treaties, Executive Orders and statutory case law.  

The 1921 Snyder Act continues to provide the legal basis for providing annual appropriations for funding American Indian and Alaska Native health care.  

In the winter of 2001, the National Governor’s Association acknowledged the federal trust relationship that the United States has with tribes with a resolution.  HR-31 supports full federal funding without requiring State subsidies for programs such as health care.  

## Policy Foundation Tribal Consultation

- Executive Order
- EO 13175 – Consultation and Coordination with Indian Tribal Governments issued 11/06/2000
- President Bush Affirms Tribal Consultation
- Memorandum for the Heads of Executive Departments & Agencies issued 9/23/2004
- Executive Order 13336 – American Indian & Alaska Native Education issued 4/30/2004

**Notes:**
Since the Johnson Administration there have been a number of Executive Orders and Presidential proclamations that reaffirm the policy of self-determination for Indian tribes and their government-to-government relationship with the U.S.

This policy has been embraced by both Republican and Democratic administrations since the late 1960’s. 

The Executive Order is very similar to the Executive Order on Federalism and the two should be seen as complimentary.  Federalism is rooted in the belief that issues that are not national in scope or significance are most appropriately addressed by the level of government closest to the people. 

Recently, it was brought to Tribal Leaders’ attention that IHS has been requested to submit its budget with no more than a 2% increase and that any information with respect to the IHS budget was considered to be embargoed until further notice from the Department.  This is disturbing to Tribal Leaders who feel they should be able to collaborate with the agency to discuss budgetary concerns and priorities and is contrary to the principles of Tribal Consultation.  In order to address the unique needs of American Indian people, we would like to work more closely with the Department and Agency staff in developing budget submissions.  

## I/T/U Budget Formulation Recommendation vs President’s Request

## Real 

- Real
- Resources
- Lost = Broken Promise

**Notes:**
Need to add the unfunded pop and inflation

## IHS Increases compared to Medicaid Growth

- *FY’08 is proposed off the President’s Budget

## Per Capita Expenditures

## VHA & Indian Veterans

- American Indians/Alaska Natives have participated with distinction in United States military actions for more than 200 years.
- American Indians/Alaska Natives who are also Veterans will seek care within the Indian health care system because:
- Access: care can be provided closer to home
- Culturally Competent Care

## Top 5 Health Priorities

- Diabetes
- Cancer
- Heart Disease
- Alcohol/ Substance Abuse
- Mental Health

## Chronic Disease Inequalities (disparities)

- Source: 1988-89 IHS Trends Report available at _[www.](http://www.ihs.gov/)__[ihs](http://www.ihs.gov/)__[.](http://www.ihs.gov/)__[gov](http://www.ihs.gov/)_

**Chronic Disease Inequalities ****(disparities)**

## Behavioral Health Inequalities (disparities)

- Chart indicates deaths per 1000 people. Blue = AI, Burgundy = U.S. Average
**Source**: 1988-89 IHS Trends Report available at _[www.](http://www.ihs.gov/)__[ihs](http://www.ihs.gov/)__[.](http://www.ihs.gov/)__[gov](http://www.ihs.gov/)_

## Methamphetamine Use

- National Survey on Drug Use and Health, “Methamphetamine Use, Abuse, and Dependence: 2002, 2003, and 2004. Available online: _http://oas.samhsa.gov/2k5/meth/meth.htm_, accessed March 3, 2006.

## Current Services Recommendations

**Pay Costs****	****$74,483**
**Inflation****	****$66,372**
**Additional Medical Inflation****	****$17,952**
**Contract Support Costs****	****$71,741**
**Population Growth****	****$20,651**
**Health Care Facilities Construction****	****$100,000**
**Staffing New/Replaced Facilities****	****$5,037**
**TOTAL CURRENT SERVICES****	****$356,236**

- Dollars in Thousands

## Program Services Recommendation

**Hospitals & Clinics****	****$110,000**
**  ****Indian Health Care Improvement Fund****	****$40,000**
**  ****Information Technology****	****$5,000**
**Dental****	****$20,000**
**Mental Health****	****$25,000**
**Alcohol and Substance Abuse****	****$30,000**
**Contract Health Services****	****$110,000**
**Public Health Nursing****	****$4,000**
**Health Education****	****$1,000**
**Community Health Representatives****	****$4,000**
**Urban Indian Health*****	****$3,500**

- Dollars in Thousands

- *Assumes base funding for Urban Indian Health is restored in the FY 2008 funding base.

## Program Services Recommendation

**Indian Health Professions****	****$1,000**
**Tribal Management****	****$1,000**
**Self-Governance****	****$160**
**Contract Support Costs****	****$2,845**
**Maintenance & Improvement****	****$10,000**
**Sanitation Facilities Construction****	****$20,000**
**Facilities & Environmental Health Support****	****$2,391**
**Equipment****	****$5,000**
**Joint Venture, Small Ambulatory, YRTC****	****$30,000**
**TOTAL PROGRAM SERVICES INCREASES****	****$424,896**

- Dollars in Thousands

***Continued***

## Total Requested

- 	Budget Formulation Workgroup Recommendation (in thousands):

## Conclusion

***Promises made to Indian Country by the U.S. Government can be honored by accepting and enacting the budget recommendations as brought forward by the I/T/U Budget Formulation Workgroup!***