Background IHS Health Care System  and Tribal Health Care IHS was established within the Public Health Service in 1955 to provide  certain health services to members of federally recognized AI/AN tribes,  primarily in rural areas on or near reservations. IHS provides services  directly through a network of hospitals, clinics, and health stations  operated by IHS, and also funds services provided at tribally operated  facilities. As of October 2017, IHS, tribes, and tribal organizations operated 168  service units, 48 hospitals, and 560 ambulatory care centers—including  health centers, school health centers, health stations, and Alaska village  clinics. See table 1. According to IHS officials, the agency provides services almost  exclusively in locations designated as Health Professional Shortage  Areas, with most locations identified as extreme shortage areas. In  addition, IHS data indicate that about 35 percent of certain IHS facilities,  including four hospitals, were identified as isolated hardship posts in  2016. IHS oversees its health care facilities through a decentralized system of  12 area offices, which are led by area directors; 10 of these 12 IHS areas  have federally operated IHS facilities. IHS’s headquarters office is  responsible for setting health care policy, helping to ensure the delivery of  quality comprehensive health services, and advocating for the health  needs and concerns of AI/AN people. The IHS area offices are  responsible for distributing funds to the facilities in their areas, monitoring  their operation, and providing guidance and technical assistance. IHS’s estimated budget authority for fiscal year 2018 is over $5.6 billion,  an increase of almost $580 million from its enacted budget authority of  just over $5 billion in fiscal year 2017. IHS has agreements with tribes  and tribal organizations by which it transfers a substantial portion of its budget authority to tribes and tribal organizations. For example, in 2017,  the agency transferred approximately 54 percent of its total budget  authority to tribes and tribal organizations to operate part or all of their  own health care programs through self-determination contracts and self- governance compacts. Self-determination contracts: IHS had 373 self-determination  contracts in place with 220 tribes in 2017. Self-governance compacts: IHS had 98 self-governance compacts in  place—including 124 funding agreements—with 360 tribes in 2017.  See figure 1 for the percentage of IHS’s total budget authority  transferred to tribes in fiscal year 2017. According to IHS officials, over the last few years an increasing number of  tribes have sought to enter into contracts and compacts with IHS to  assume responsibility for some or all of their health care programs, and  thereby receive funding from IHS. Federal Budget  Environment Unless otherwise specified in law, funding included in annual  appropriation acts is available for obligation during a single fiscal year,  after which it expires. For this reason, the continuation of normal  government operations depends upon the enactment each fiscal year of a  new appropriations act. Any lapse in appropriations—a funding gap— causes most government functions to shut down. To avert a  government shutdown, Congress may enact one or more CRs. CRs are  spending bills that provide funds to allow agencies to operate during a  specified period of time while Congress works to pass an annual  appropriations act. Relevant aspects of the federal budget environment  include the following. Frequency of CRs and shutdowns. In all but 4 of the last 40 fiscal  years—including fiscal year 2018—Congress has enacted CRs. Since  fiscal year 1999, CRs have varied greatly in their number and duration— the number of CRs enacted in each year ranged from 2 to 21, and the  duration of CRs has ranged from 1 to 187 days. Regarding lapses in  appropriations that resulted in government shutdowns, in January 2018  the government partially shut down for 3 calendar days after the CR in  place expired. Other shutdowns have lasted longer—16 calendar days in  October 2013 and 21 calendar days in December 1995 through January  1996. We have previously reported on the effects of CRs and shutdowns  for federal agencies. Budget authority during a CR. CRs provide “such amounts as may be  necessary” to maintain operations consistent with the prior fiscal year’s  appropriations and authorities. To control spending in this manner, CRs  generally prohibit agencies from initiating new activities and projects for  which appropriations, funds, or other authorities were not available in the  prior fiscal year. They also require agencies to take the most limited  funding actions necessary to maintain operations at the prior fiscal year’s  level. Budget authority during a funding gap. Certain federal health care  programs have various budget authorities that can allow for continued  operations during a funding gap. For example, VA’s advance  appropriations authority for its health care programs allows operations to  continue after one appropriation expires, using the previously enacted  budget for the next year. Although IHS does not have this authority,  Congress has enacted longer periods of availability for certain IHS  appropriations that would allow the activities they support to continue  during a funding gap, assuming the appropriation has not run out. For  example, IHS’s appropriation for Indian health facilities remains available  until expended, in contrast to its appropriation for Indian health services,  which is generally available for a single fiscal year. In this regard, funds for Indian health services that IHS transfers to tribes  and tribal organizations during the 1-year period of availability are  deemed to be obligated at the time of the award and thereafter remain  available to the tribes to operate their own health care programs without  fiscal year limitation. Thus, to the extent sufficient funding remained  available from federal or other sources during a lapse in appropriations, a  tribe could continue to operate its own health care programs during a  shutdown. To operate IHS’s health care system on an emergency basis  during a funding gap, IHS would need to determine what programs and  activities qualified for an emergency exception under the law. Contingency planning for government shutdowns. Federal agencies  must determine what activities and programs they are permitted or  required to continue prior to a potential shutdown. This includes  designating certain employees as “excepted” employees who would be  expected to continue to work during the shutdown and who would be paid  upon the enactment of an appropriation. Employees who are not  “excepted” would be subject to furlough. Interest in Advance  Appropriation Authority for  IHS Citing funding uncertainty associated with continued use of CRs, AI/AN  advocacy groups such as the National Indian Health Board have  requested that Congress grant IHS advance appropriation authority;  legislation to provide IHS this authority has been introduced more than  once. The most recent such legislation, H.R. 235, introduced in January  2017 (not enacted), would have provided IHS with 2-year fiscal budget  authority for its Indian health services and Indian health facilities  accounts, similar to the authority that VA currently has for its health care  appropriation accounts. HHS, on behalf of IHS, has not requested that  IHS be granted advance appropriation authority during its annual budget  submissions to Congress. VA’s Advance  Appropriation  Authority for Health  Care VA, through the VHA, operates one of the nation’s largest health care  systems, with 171 VA medical centers, more than 1,000 outpatient  facilities, and total health care budget authority of about $69 billion in  fiscal year 2017. VA provided health care services to about 6.8 million  veterans in fiscal year 2017, and the agency forecasts that demand for its  services is expected to grow in the coming years. VA was granted advance appropriation authority for specified medical  care accounts in the Veterans Health Administration in 2009. Currently,  VA’s annual appropriations for health care include advance  appropriations that become available in the fiscal year after the fiscal year  for which the appropriations act was enacted. Under this authority, VA  receives advance appropriations for VHA’s Medical Services, Medical  Support and Compliance, Medical Facilities, and Medical Community  Care appropriations accounts and is required to provide Congress with  detailed estimates of funds needed to provide its health care services for  the fiscal year for which advance appropriations are to be provided.  According to VA officials, veterans service organizations were the primary  advocates who sought advance appropriation authority for VA’s health  care program. In its health care budget proposal each year, VA submits a request for the  upcoming fiscal year, as well as an advance appropriation request for the  following year. In early 2018, for example, VA submitted a request for  fiscal year 2019, as well as a fiscal year 2020 advance appropriation  request. According to VA, more than 90 percent of its budget request is  developed using an actuarial model that is based in part on VA’s actual  health care utilization data from prior years; for example, the 2020  advance appropriation request used fiscal year 2016 data. VHA officials  said that the agency calculates its advance appropriation request to fund  needed care as estimated by its actuarial model, with less funding  requested for other expenses (such as non-recurring maintenance) and  officials told us this is consistent with direction provided by OMB. OMB  officials told us that the amount provided in the advance appropriation is  intended to provide VA with some assurances that it will be able to  continue health care operations seamlessly across fiscal years. In the subsequent year (the year during which the advance appropriation  can be used), VA may request an adjustment to the amount previously  provided through advance appropriations—referred to by agency officials  as a “second bite”—an arrangement that is intended by design to help  respond to more recent policy changes or significant events. For  example, VA requested a “second bite” increase of $2.65 billion for fiscal  year 2018, to the $66.4 billion initially provided to its VHA accounts  through its advance appropriation. Both OMB and VHA officials said this  “second bite” provides an opportunity to make an adjustment to VA’s  advance appropriation using updated utilization data. VHA officials told us  that changes in policy (such as determining which veterans or what health  benefits can be covered) sometimes drive changes from the initial budget  request. For example, policy changes can include adding an additional  presumptive condition—such as health conditions associated with Agent  Orange exposure—resulting in a new health benefit, or a costly new drug  treatment, as in the case of the addition to the drug formulary of a new  Hepatitis C drug treatment. Despite having advance appropriation authority, VA has faced challenges  in budget formulation, in addition to the general management and  oversight challenges we cited in adding VA to our High-Risk List in  2015. Specifically, we reported in our 2017 update to the High-Risk List  that VA faces challenges regarding the reliability, transparency, and  consistency of its budget estimates for medical services, as well as  weaknesses in tracking obligations for medical services and estimating  budgetary needs for future years. These challenges were evident in  June 2015, when VA requested authority from Congress to move funds  from another appropriation account because agency officials projected a  fiscal year 2015 funding gap of about $3 billion in its medical services  appropriation account. Budget Uncertainty  Effects on the  Provision of IHS- Funded Health Care  That Were Cited by  Stakeholders IHS officials, tribal representatives, and other stakeholders we spoke with  described how budget uncertainty resulting from CRs and government  shutdowns can have a variety of effects on the provision of IHS-funded  health care services for AI/ANs. The following summarizes these  effects, along with the views of IHS officials, tribal representatives, and  other stakeholders on how advance appropriation authority could mitigate  them, and VA’s related experiences:  Provision of health care services. IHS officials said that, in general,  most health care services would be expected to continue at IHS-operated  facilities during a shutdown, as health care providers would be deemed  “excepted” personnel under the agency’s contingency plan. However,  officials noted some health care procedures could be delayed, as  determined on a case-by-case basis at the local level. IHS officials also  acknowledged that tribal health care programs may not have access to  furloughed IHS staff who do not work during a shutdown, such as support  staff at local IHS area offices, who may carry out administrative duties on  their behalf. For example, tribal representatives told us that during a  previous government shutdown, finance employees from the local IHS  area offices were furloughed (and thus not permitted to work), which  created challenges for tribal health care operations that depended on  these IHS employees to process payments and agreements. IHS officials stated they believe advance appropriations could help  ensure continuity of health care services through certainty of funding. IHS  officials also said that while lapses in appropriations do not halt patient  care, they do create complications—such as the determination of  excepted personnel as described above—that could be eliminated by  funding provided through advance appropriations. Tribal representatives  said the certainty of funding that would come with IHS having advance  appropriations would create a sense of stability in tribal health care  programs as well. VA VISN officials we spoke to said having advance appropriations has  improved their ability to manage resources for continuity of services and  allowed them to avoid the substantial additional planning that occurs  before a potential government shutdown when agencies are determining  which providers and staff would be deemed excepted. According to the  VISN officials, knowing that funding is coming—as opposed to having  less certainty—would allow an agency to plan and prioritize its services  more efficiently. Health care program planning. Tribal representatives said operating  health care programs with short-term funding provided through a series of  CRs—and facing potential government shutdowns—rather than a full  year’s apportionment hinders their ability to plan for new programs and for  improvements that need to be carried out across budget years or that  require large up-front investments, such as an electronic medical records  system or other significant information technology purchases. Tribal  representatives said there are often plans that they have to set aside  because they don’t have enough funds to start a project during a CR,  and—if there are multiple CRs—there is not enough time left in the  budget year to start bigger projects once an annual appropriation is  passed. Tribal representatives also told us that they believe that advance  appropriations would help tribal health care programs plan for current and  future needs. For example, one tribal official told us advance  appropriations would allow tribes to plan for long-term health initiatives.  The official’s specific tribe has a gestational diabetes program in  conjunction with a local university that the tribe could plan to take full  responsibility for if they had more funding stability. VA VISN officials we interviewed provided several examples of how they  believe advance appropriations facilitate their planning. For example,  VISN officials told us advance appropriations allow them to plan  strategically for equipment purchases: if they need to buy a CT scanner,  they would plan to do site preparation in one year—for example,  reconfiguring the space for the new equipment by moving walls, electrical  rewiring, etc.—and buy the scanner in the next year. With advance  appropriations, they know they are going to have funds for an expensive  equipment purchase available the next year; without an advance  appropriation, they would not be sure, and could spend funds on  preparation and then ultimately not have the funds to make the equipment  purchase. These officials also said having advance appropriations gave  them confidence in making current plans to provide the new shingles  vaccine for their over-50 population in 2019, including the ability to secure  an adequate supply of the vaccine from the manufacturer. Provider recruitment and retention. IHS officials and tribal  representatives said existing challenges related to their recruitment and  retention of health care providers—many of which are related to the rural  and remote locations of many of IHS’s facilities—are exacerbated by  funding uncertainty resulting from CRs or potential government  shutdowns. IHS officials said CRs and government shutdowns can  disrupt recruitment activities such as IHS marketing efforts, job  advertisements, application review, interviews, and candidate site visits.  Additionally, when recruiting health care providers, IHS officials said CRs  and potential government shutdowns create doubt about the stability of  employment at IHS amongst potential candidates, which may result in  reduced numbers of candidates or withdrawals from candidates during  the pre-employment process. IHS officials said that many providers in  rural and remote locations are the sole source of income for their families,  and the potential for delays in pay resulting from a government shutdown  can serve as a disincentive for employees considering public service in  critical shortage areas that do not offer adequate spousal employment  opportunities. Tribal representatives said CRs create challenges for tribes  in funding planned pay increases—such as cost-of-living adjustments— for health care staff at their facilities, and they may, as a result, defer  increases. IHS officials and tribal representatives stated they believe advance  appropriations could mitigate these challenges. For example, IHS officials  said that with advance appropriations, recruitment and outreach activities  could continue without disruption, and selected candidates could be  brought on board as scheduled. One tribal representative stated that  advance appropriations could help with recruitment by providing  perceived job stability that is similar to VA or the private sector. According to VA VISN officials, the agency’s experience with advance  appropriation authority suggests that advance appropriations can facilitate  physician recruitment, including hiring. If, for example, they were far along  in the hiring process at the end of a fiscal year, but could not finalize the  hire before the end of the year, having advance appropriations for the  next fiscal year provides the certainty that they will be able to make the  hire in the new fiscal year. Commercial contracts and vendor negotiations. IHS officials and tribal  representatives said budget uncertainty can lead to vendor reluctance to  provide services to IHS and tribally operated facilities. IHS officials said  they have heard from vendors—who are typically Indian- or veteran- owned small businesses in the communities being served by IHS—that  they lose trust in IHS and federally-funded tribal health care programs  when they are affected by budget uncertainty. One tribal organization told  us delays in receiving full funding because of CRs has inhibited its ability  to pay invoices for pharmaceuticals in a timely manner, which has  harmed its relationship with its vendors. VISN officials told us that advance appropriations can provide an element  of stability to agency funding that may serve to reassure potential  vendors. According to VISN officials, vendors can be hard to find in  remote and rural areas, and their perception of funding certainty can play  a role in encouraging their participation as government contractors. As  contracting with the federal government can be burdensome, particularly  for smaller vendors, VISN officials said, any measures—such as advance  appropriations—that could enhance the stability of agency contracting  could make these vendors more likely to participate in government  contracting. Administrative burden and costs. IHS officials and tribal  representatives said the agency and tribes incur additional administrative  burden and costs when the government is funded through multiple CRs,  due to the high proportion of IHS funding that is transferred to tribes  through contracts and compacts. Specifically, IHS officials said there is  an additional administrative burden generated by each CR that results in  the distribution of funds to tribes. For each CR period, IHS headquarters  staff generate proportional funding allotments, which they provide to  individual area offices, which then also conduct processing activities to  generate payments from these allotments to the tribes in their areas. As  part of this process, IHS officials said they modify hundreds of tribal  contracts and make amendments to funding agreements associated with  tribal compacts, and those efforts represent a significant administrative  burden for IHS staff. Tribal representatives also described administrative  burden associated with CRs. As one representative of a group  representing several tribes told us, each CR requires the same  processing and manpower for each partial payment as for a full  apportionment, and moreover, CRs require tracking and reconciliation  that is not necessary for a single, full apportionment. IHS officials and  tribal representatives noted that time and money spent on these  additional administrative activities detract from other priorities, including  patient care. IHS officials said that advance appropriations would reduce this  administrative burden, and added that having advance appropriations  would allow for more efficiency in processing payments to tribes. IHS  officials suggested that the agency would have to do less administrative  work overall, because currently, under a single year appropriation (with  recurrent CRs), they may modify or amend agreements 7 or 8 times  within a fiscal year. Although acknowledging that advance appropriation  authority would entail the additional burden of preparing budget requests  for more than one fiscal year, they expect this administrative burden to be  less than those under repeated CRs. Financial effects on tribes. According to tribal representatives we spoke  with, funding uncertainty from recurring CRs and from government  shutdowns has led to particular adverse financial effects on tribes that  operate their own health care programs with funding from IHS. For  example, according to tribal representatives, Funding uncertainty surrounding a CR results in more expensive  commercial loans (with higher interest rates) to finance construction of  new health care facilities. Specifically, a tribal representative said the  uncertainty of the availability of funds due to a CR resulted in a  downgrading of the tribe’s credit rating, and hence higher interest  rates, as it was planning a clinic expansion. During a government shutdown, some tribes must redistribute funds  from other budget categories to replace health care funding from IHS  in order to continue providing health care services. Some tribes have  economic development activities that provide additional funding and  facilitate this redistribution, but others do not. For example, one tribal  organization said that during the 2013 government shutdown, it had to  take out loans and maintain a line of credit in order to pay for services  and make payroll. Subsequently, that tribal organization had to pay  interest on those loans, causing greater financial hardship. Tribes attempt to mitigate the challenge of not knowing their final  annual payment from IHS under recurrent CRs by keeping extra funds  in reserve for emergencies, which limits the remaining funds available  for providing health care services. Short-term funding under CRs or delayed funding after a lapse in  appropriations can limit the ability of tribes and tribal organizations to  invest funds from IHS and generate interest that can be reinvested in  tribal health care programs. CRs have affected the ability of tribes to reduce costs by planning for  bulk purchases at favorable rates. For example, some tribes in Alaska  prefer to make bulk purchases of heating oil during “barge season’’— when waterways are still navigable and not frozen. If they do not have  enough money for a bulk purchase because of a CR’s limited funding,  they must purchase fuel in smaller quantities, which is ultimately  significantly more expensive. Tribal representatives told us one  beneficial financial effect of advance appropriations for tribes could be  providing opportunities for longer term contracts with vendors, which  could result in cost savings that could be used for tribal health care  programs. Considerations for  Policymakers Related  to Providing Advance  Appropriation  Authority to IHS We identified three types of considerations for policymakers related to  providing advanced appropriation authority to IHS—operational,  congressional flexibility, and agency capacity and leadership  considerations. We identified these considerations based on a review of  our 2009 testimony that examined considerations for granting VA  advance appropriation authority, in which we identified key questions that  would be applicable to any agency being granted such authority, and our  interviews with VA, IHS, and other officials. In our 2009 testimony, we  noted that proposals to change the availability of the appropriations for  VA deserved careful scrutiny, given the challenges the agency faces in  formulating its health care budget and the changing nature of health  care. Similar consideration would apply to IHS. Operational considerations. If Congress were to grant IHS advance  appropriation authority, it would need to make operational decisions  regarding what amount of IHS funding would be provided in advance  appropriations, with input from OMB and IHS as appropriate. Specifically,  Congress could consider the following questions:  (1) What proportion of IHS’s estimated budget would be provided in  the advance appropriation—the full amount, or less (as is the case for  VA)? Which appropriations accounts would be included? Further,  would funds intended for transfer to tribes be handled differently?  (2) Under what conditions, if any, would there be changes to funding  provided through advance appropriations during the next budget  cycle? For example, would Congress expect to adjust the advance  appropriation amount through a “second bite,” as is the case with VA? Congressional flexibility considerations. We reported in 2009 that  consideration of any proposal to change the availability of the  appropriations VA receives for health care should take into account the  impact of any change on congressional flexibility and oversight. These  same considerations hold merit regarding potential changes to the  appropriation status of any federal agency, including IHS. Specifically,  advance appropriation authority reduces flexibility for congressional  appropriators, because it reduces what is left for the overall budget for the  rest of the government—meaning the total available for appropriations for  a budget year is reduced by the amount of advance appropriations for  that year, when budgets have caps. Agency capacity and leadership considerations. IHS officials told us  they believe the agency’s current budget planning processes would be  adequate for estimating advance appropriation budget requests, because  IHS begins planning for its budget request 3 years in advance. Officials  added that IHS plans its budget so far in advance to have sufficient time  to work with tribes in formulating recommendations for its budget request.  IHS officials said that a downside to planning so far in advance is that  they do not necessarily have the most current information while  formulating the budget request. In addition, we noted prior to VA receiving  advance appropriation authority that advance appropriation authority  could potentially exacerbate existing challenges when developing or  managing a budget, generally, due in part to the higher risk of uncertainty  when developing estimates that are an additional 12 months out from the  actual budget year (e.g., 30 months out instead of 18 months). We raised certain capacity and leadership concerns based on our  previous work when we added IHS to our High-Risk List in 2017.  Further, in June 2018, we found that while IHS had taken some actions to partially address these concerns, additional progress was needed to fully  address these management weaknesses. For example, IHS still does  not have permanent leadership—including a Director of IHS—which is  necessary for the agency to demonstrate its commitment to improvement.  Additionally, while the agency has made some progress in demonstrating  it has the capacity and resources necessary to address the program risks  we identified in our reports, there are still vacancies in several key  positions, including in the Office of Finance and Accounting. While not  directly related to consideration of advance appropriations, IHS’s high-risk  designation and continuing challenges in mitigating the deficiencies in its  program point to questions about the agency’s capacity to implement  such a change to its budget formulation process. Agency Comments  and Third-Party Views We provided a draft of this report to HHS and VA for review and  comment. HHS did not have any comments. We received general  comments from VA that are reprinted in appendix I. We also provided relevant draft portions of this report to NIHB, which  represents tribal and AI/AN interests. NIHB provided technical comments,  which we incorporated as appropriate. We are sending copies of this report to the Secretaries of the Department  of Health and Human Services and the Department of Veterans Affairs,  and other interested parties. In addition, the report is available at no  charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or farbj@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page   of this report. GAO staff who made key contributions to this report are  listed in appendix II. Appendix I: Comments from the Department  of Veterans Affairs Appendix II: GAO Contact and Staff  Acknowledgments GAO Contact Staff  Acknowledgments In addition to the contact named above, Kathleen M. King (Director),  Karen Doran (Assistant Director), Julie T. Stewart (Analyst-in-Charge),  Kristen J. Anderson, and Leonard S. Brown made key contributions to  this report. Also contributing were Sam Amrhein, George Bogart,  Christine Davis, and Vikki Porter.
IHS, an agency within the Department of Health and Human Services (HHS), receives an annual appropriation from Congress to provide health care services to over 2 million American Indians and Alaska Natives (AI/AN) who are members of 573 tribes. IHS generally provides services through direct care at facilities such as hospitals and health centers. Some tribes receive IHS funding to operate their own health care facilities. Tribal representatives have sought legislative approval to provide IHS advance appropriation authority stating that it would facilitate planning and more efficient spending. Experts have reported that agencies can use the authority to prevent funding gaps, and avoid uncertainties associated with receiving funds through CRs. House Report 114-632 included a provision for GAO to review the use of advance appropriations authority and applications to IHS. Among other things, this report (1) describes advance appropriation authority considerations identified by stakeholders for providing IHS-funded health care services, and (2) identifies other considerations for policymakers related to providing the authority to IHS. GAO reviewed its prior reports related to IHS, VA, government shutdowns, and CRs, and interviewed officials from IHS, several tribes and other organizations representing AI/AN interests, the Office of Management and Budget, VA and other experts. GAO provided a draft of this report to HHS, which had no comments; to VA, which provided general comments; and to tribal representatives, which provided technical comments that were incorporated as appropriate. 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 IHS-funded 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 facility. 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.