1. Policy & Legislative Update May 20 th, 2015 Salt Lake City, Utah

2. Overview Introduction – Rudy Soto, Policy Analyst 114 th Congress Update Congress Demographics Dates to watch Top 5 Appropriation Issues 2016 Battle Ground 2016 Presidential Election Landmark Supreme Court Case: King vs Burwell Medicare & Medicaid: 50 Years Anniversary Montana ACA Medicaid Expansion Generation Indigenous Update on Key Legislative Issues IHS Budget Formulation Process Training and Technical Assistance Questions/Contact Information

3. 114 th Congress Update Congress Demographics Graphics from http://www.cq.com/graphics/weekly/2014/11/06/wr20141106_CQWeekly.pdf

4. Text from http://www.cq.com/graphics/weekly/2014/11/06/wr20141106_CQWeekly.pdf

5. October 1 st -Start of Fiscal Year 2016. -Authorization expires for most higher education programs. -Authorization expires for the Federal Aviation Administration. 114 th Congress Update Dates to watch May 15 th The House begins to consider annual appropriations bill May 31 st Last day of authority for federal surface transportation programs financed by the Highway Trust Fund. July 30 th Export-Import Bank charter expires. September 30 th Healthy, Hungry-Free Child Act expires. Text from http://www.cq.com/graphics/weekly/2014/11/06/wr20141106_CQWeekly.pdf

6. 114 th Congress Update Top 5 Appropriation Issues SPENDING CAPS/SEQUESTER Unless Congress acts, strict spending caps will be back in effect for fiscal 2016 that could result in billions of dollars in across-the-board spending cuts to defense and non-defense programs, known as sequester. 12 DEBT LIMIT The suspension of the debt limit expires on March 15, 2015. BUDGET RECONCILIATION Republicans are likely to use a streamlined legislative process, known as budget reconciliation, to force changes in federal entitlements, the largest long term driver of the deficit. 3 TAX REFORM The 114th Congress may finally be the one to push through what would be the first federal re-write of the tax code in three decades. 4 5 POLICY RIDERS McConnell has made clear that the Republican controlled Congress will seek to roll back administration policies by attaching policy riders to the annual spending bills. Text from http://info.cqrollcall.com/rs/cqrc/images/35_Issues_To_Watch.pdf

7. 114 th Congress Update 2016 Battleground Graphics from http://www.cq.com/graphics/weekly/2014/11/06/wr20141106_CQWeekly.pdf

8. 114 th Congress Update 2016 Presidential Elections DEMOCRATIC PARTY Probably, Probably not Former Governor Lincoln Chafee (Rhode Island) Running Former US Secretary of State Hillary Clinton (New York) Probably Former Governor Martin O'Malley (Maryland) REPUBLICAN PARTY Running US Senator Ted Cruz (Texas) Running US Senator Rand Paul (Kentucky) Running US Senator Marco Rubio (Florida) Running Former Governor Jeb Bush (Florida) Running Governor Scott Walker (Wisconsin) Probably Governor Chris Christie (New Jersey) Running Neurosurgeon Ben Carson (Michigan) Probably Former US Senator Rick Santorum (Pennsylvania) Probably Former Governor Rick Perry (Texas) Running US Senator Bernie Sanders (Vermont) Probably Former Arkansas Governor Mike Huckabee (Florida) Running Business Executive Carly Fiorina (California) Possibly Business Executive Donald Trump (New York)

9. The Issue - The challengers argue that the text of the ACA only allows for subsidies on state-run exchanges, and that the regulation as implemented by the IRS providing for subsidies on state-run exchanges as well as federal exchanges, exceeded the authority Congress granted to it. If the Supreme Court decides in favor of King - 5 million Americans who obtained coverage through federal exchanges could lose their tax credits and their health insurance coverage. There could be 8.2 million more uninsured people in 34 states. A decision should be made soon - Oral arguments were heard on March 4, 2015 and a decision is expected by late June or early July 2015. Landmark Supreme Court Case King vs Burwell Text from http://en.wikipedia.org/wiki/King_v._Burwell

10. Medicare was created to provide health insurance for the nation's seniors beginning in 1966. The law was signed by President Johnson in 1965. Nearly 50 years later, the program covers nearly 55 million people - primarily seniors but also others under age 65 with permanent disabilities. “…this logical extension of our proven social security system will supply the prudent, feasible and dignified way to free the aged from the fear of financial hardship in the event of illness.” -President LBJ Text & Photo from http://kff.org/medicare/timeline/medicare-timeline/ Medicare & Medicaid 50 Years Anniversary

11. Update on ACA Medicaid Expansion Montana HELP Act signed into by Republican Governor According to the 2010 U.S. Census - There are 62,555 American Indian and Alaskan Natives living in Montana. 176,000 uninsured residents Data from 2010 US Census http://www.census.gov/2010census/popmap/ipmtext.php?fl=30 According to the Henry J. Kaiser Family Foundation, 29 states and DC have expanded Medicaid Alaska looks like it is most likely the next…

12. Generation Indigenous President Obama’s Initiative Kickoff event occurred in Albuquerque, NM at Gathering of Nations FY2016 Budget Request includes key investments for a new Tribal Behavioral Health Initiative for Native Youth worth a total of $50 million for IHS and SAMHSA Within the IHS request includes $25 million to expand MSPI to increase the number of child and adolescent behavioral health professionals who provide direct services and implement youth-based programming at IHS, tribal, Urban Indian Health Programs, school-based health centers, or youth-based programs

13. First converted to develop FY 2000 request Ensures that Tribe, Indian organizations, and other participants are actively involved in and have significant input in the IHS Budget formulation process Prior to FY 2000 Tribal Consultations took place at the national level with NIHB and served as an internal “enhancement” proses IHS Budget Formulation Overview

14. IHS Budget Formulation The Process Evaluation Session June Individual Area Workshops Oct-Dec National Budget Workshop February HHS Consultation March IHS Preliminary Budget Submission June June: Evaluation/Planning Meeting October – December: Area work sessions February – March: National Budget meeting Consolidate budget recommendations March – HHS Tribal Consultation

15. IHS Budget Formulation The Phases Planning: IHS, Tribal Governments, Tribal and Urban Indian Health Programs Formulation:IHS > HHS > OMB Present to Congress:Appropriations Subcommittee/ Full Committee, House and Senate, Conference Comm. Execution: IHS, Tribal Governments, Tribal and Urban Indian Health Programs

16. Two Tribal representatives from each of 12 IHS Areas Co-Chairs selected at National Work Session Technical staff participate and support the Area Representatives National Indian Organizations also participate at the discretion of the IHS Director IHS Budget Formulation Budget Formulation Work Groups

17. UIHPs present in 11 of 12 Regions Each area chooses Hot Topics for highlight as well as their Top 5 Budget Priorities Examples Priorities and Topics: Mental Health, Behavioral Health, Alcohol & Substance Abuse, Dental, Maintenance & Improvement, Incarceration Alternatives, Diabetes, Suicide Prevention Initiatives 6 Areas where Urbans were featured as hot topics & priorities IHS Budget Formulation Budget Formulation Area Meetings

18. Summer 2014: FY 2017 Budget instructions October – December 2014: FY 2017 Budget Area Work Sessions January – December 2015:National FY 2017 Budget Work Sessions/HHS Consultations/OMB February 2016: President releases FY 2017 BudgetMarch – Oct 2016: Congress Works on FY 2017 Budget October 2016: FY 2017 Appropriations Enacted/Budget Executed IHS Budget Formulation FY 2017 Budget Formulation Activities

19. Phase In Full Funding of IHS – Total Tribal needs Budget of $29.96 Billion over 12 years Present a 22% increase in the overall IHS budget from FY 2016 President's Budget requesting planning base for total of $6.2 billion Restore Cuts/Shortfalls in FY 2013-16 resulting from sequestration Permanently exempt Tribes and Tribal programs from sequestration The urban line item recommendation increase for $10 million IHS Budget Formulation FY 2017 Tribal Budget Recommendations

20. Provide additional $300 million to implement the provisions authorized in the IHCIA Support President’s proposal to reclassify CSC from discretionary to the mandatory appropriations and to be reauthorized every 3 years Request a higher percentage budget increase in the Hospital and Clinics budget line to allow flexible service expansion funding which can be used to fund local budget priorities IHS Budget Formulation FY 2017 Tribal Budget Recommendations

21. Attend regional meetings – Assign representatives & alternates Attend Regional Tribal Conferences and build Tribal Leader support Get on Area priorities list for each region - $2 million per Area minimum Next stage: UIHPS gather #’s on tribal members served. Send those to tribal leaders NCUIH Funding Increase Strategy

22. Indian Country & UIHPs Intensify Advocacy and Outreach – Work w/ both political parties. Focus on strengthening relationships w/ new Members, staffers, in-district, and Washington, DC Site visits and news coverage to personalize impact of funding shortages. Highlight success stories and program stewardship of federal resources How to Talk to Congress 101 Handouts Congressional Member Profiles Guide to Schedule Site Visits with Congressional Members Key Committees for Urban Programs

23. 100% Federal Medical Assistance Percentage – Total FMAP reimbursement to UIHPs Federal Tort Claims Act – Include UIHPs under protections of FTCA Definition of “Indian” – Create consistent definition for the ACA Special Diabetes Programs for Indians – Multi-year SDPI renewal to ensure stable stream of funding and uninterrupted care Advanced Appropriations – Protection against sequestration cuts and government shutdowns Legislative Priorities SDPI passed a 2 year renewal

24. Advocacy & Technical Assistance Examples of Support for Membership Advocacy Trainings Legislative Research Bill Tracking Coordinating Hill Visits Drafting Testimony In-district or DC House/Senate staff contact information Policy Briefs Congressional Correspondence

25. Questions? Discussion To request legislative advocacy and/or technical assistance, please contact NCUIH Policy Analyst: Rudy Soto rsoto@ncuih.org 202-544-0344