GAO Report: INDIAN HEALTH SERVICE Considerations Related to Providing Advance Appropriation Authority


The Indian Health Service (IHS), like most federal agencies, must use appropriations in the year for which they are enacted. However, there has been
interest in providing IHS with advance appropriation authority, which would give
the agency authority to spend a specific amount 1 or more fiscal years after the fiscal year for which the appropriation providing it is enacted. Currently, the
Department of Veterans Affairs (VA) is the only federal provider of health care
services to have such authority.

Stakeholders interviewed by GAO, including IHS officials and tribal
representatives, identified effects of budget uncertainty on the provision of IHSfunded health care as considerations for providing IHS with advance
appropriation authority. Budget uncertainty arises during continuing resolutions
(CR)—temporary funding periods during which the federal government has not
passed a budget—and during government shutdowns. Officials said that
advance appropriation authority could mitigate the effects of this uncertainty. IHS
officials and tribal representatives specifically described several effects of budget
uncertainty on their health care programs and operations, including the following:

• Provider recruitment and retention. Existing challenges related to the
recruitment and retention of health care providers—such as difficulty recruiting
providers in rural locations—are exacerbated by funding uncertainty. For
example, CRs and government shutdowns can disrupt recruitment activities
like application reviews and interviews.

• Administrative burden and costs. Both IHS and tribes incur additional
administrative burden and costs as IHS staff calculate proportional allocations
for each tribally operated health care program and modify hundreds of tribal
contracts each time a new CR is enacted by Congress to conform to limits on
available funding.

• Financial effects on tribes. Funding uncertainty resulting from recurring CRs
and from government shutdowns has led to adverse financial effects on tribes
and their health care programs. For instance, one tribe incurred higher interest
on loans when the uncertainty of the availability of federal funds led to a
downgraded credit rating, as it was financing construction of a health care

GAO identified various considerations for policymakers to take into account for
any proposal to change the availability of the appropriations that IHS receives.
These considerations include operational considerations, such as what
proportion of the agency’s budget would be provided in the advance
appropriation and under what conditions changes to the funding provided
through advance appropriations would be permitted in the following year.
Additionally, congressional flexibility considerations arise because advance
appropriation authority reduces what is left for the overall budget for the rest of
the government. Another consideration is agency capacity and leadership,
including whether IHS has the processes in place to develop and manage an
advance appropriation. GAO has reported that proposals to change the
availability of appropriations deserve careful scrutiny, an issue underscored by
concerns raised when GAO added IHS to its High-Risk List in 2017.