[Senate Hearing 110-393]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-393
 
 THE STATE OF FACILITIES IN INDIAN COUNTRY: JAILS, SCHOOLS, AND HEALTH 
                               FACILITIES

=======================================================================

                                HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 6, 2008

                               __________

         Printed for the use of the Committee on Indian Affairs



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                      COMMITTEE ON INDIAN AFFAIRS

                BYRON L. DORGAN, North Dakota, Chairman
                 LISA MURKOWSKI, Alaska, Vice Chairman
DANIEL K. INOUYE, Hawaii             JOHN McCAIN, Arizona
KENT CONRAD, North Dakota            TOM COBURN, M.D., Oklahoma
DANIEL K. AKAKA, Hawaii              JOHN BARRASSO, Wyoming
TIM JOHNSON, South Dakota            PETE V. DOMENICI, New Mexico
MARIA CANTWELL, Washington           GORDON H. SMITH, Oregon
CLAIRE McCASKILL, Missouri           RICHARD BURR, North Carolina
JON TESTER, Montana
       Allison Binney, Majority Staff Director and Chief Counsel
     David A. Mullon Jr. Minority Staff Director and Chief Counsel


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on March 6, 2008....................................     1
Statement of Senator Barrasso....................................    10
Statement of Senator Dorgan......................................     1
Statement of Senator Johnson.....................................    10
    Prepared statement...........................................    10
Statement of Senator Murkowski...................................    26
Statement of Senator Tester......................................    30

                               Witnesses

Davidson, Valerie, Senior Director, Legal and Inter-Governmental 
  Affairs, Alaska Native Tribal Health Consortium; accompanied by 
  Rick Boyce, Director, Health Facilities Support................    52
    Prepared statement with attachment...........................    55
Grinnell, Randy, Deputy Director, Management Operations, Indian 
  Health Service, U.S. Department of Health and Human Services; 
  accompanied by Gary Hartz, Director, Office of Environmental 
  Health and Engineering, and Rick Olson, Director, Clinical and 
  Prevention Services............................................    16
    Prepared statement...........................................    17
Herraiz, Domingo S., Director, Bureau of Justice Assistance, U.S. 
  Department of Justice..........................................    18
    Prepared statement...........................................    20
Nosie, Wendsler, Chairman, San Carlos Apache Tribe...............    37
    Prepared statement...........................................    39
Ragsdale, W. Patrick, Director, Office of Law Enforcement 
  Services, Bureau of Indian Affairs, U.S. Department of the 
  Interior; accompanied by Jack Rever, Director of Facilities....    11
    Prepared statement...........................................    14
Roessel, Charles Monty, Superintendent, Rough Rock Community 
  School.........................................................    46
    Prepared statement...........................................    48

                                Appendix

His Horse Is Thunder, Ron, Chairman, Standing Rock Sioux Tribe, 
  prepared statement.............................................   103
Holt, Linda, Chairperson, Northwest Portland Area Indian Health 
  Board; Suquamish Tribal Council Member, prepared statement.....    99
National Indian Education Association (NIEA), prepared statement.   109
Prior, Kyle, Chairman, Shoshone-Paiute Tribes of the Duck Valley 
  Reservation, prepared statement................................   106
Response to written questions submitted to Domingo S. Herraiz by:
    Hon. Maria Cantwell..........................................   111
    Hon. Byron L. Dorgan.........................................   110
Written questions submitted to Jack Rever and W. Patrick Ragsdale 
  by:............................................................
    Hon. John Barrasso...........................................   113
    Hon. Byron L. Dorgan.........................................   112
    Hon. Tim Johnson.............................................   113
Written questions submitted to Randy Grinnell by Hon. Maria 
  Cantwell.......................................................   114


                   THE STATE OF FACILITIES IN INDIAN 
                  COUNTRY: JAILS, SCHOOLS, AND HEALTH 
                               FACILITIES

                              ----------                              


                        THURSDAY, MARCH 6, 2008


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 10:00 a.m. in 
room 628, Dirksen Senate Office Building, Hon. Byron L. Dorgan, 
Chairman of the Committee, presiding.

          OPENING STATEMENT OF HON. BYRON L. DORGAN, 
                 U.S. SENATOR FROM NORTH DAKOTA

    The Chairman. We are going to begin the hearing. This is an 
oversight hearing on the state of facilities in Indian Country: 
jails, schools and health facilities by the Senate Committee on 
Indian Affairs here in the United States Senate.
    My colleagues will join me shortly, but because of time 
constraints, we need to begin. We will likely have a Senate 
vote at about 10:45 this morning. We will have to have a brief 
recess when that occurs.
    Today, the Committee will examine the current state of 
health facilities, schools, detention facilities and more in 
Indian Country. We will receive testimony from the agencies 
responsible for administering the programs to build new and to 
repair existing facilities. We will also hear about the 
obstacles they face in trying to complete these facilities.
    Early in the Federal Government's relationships with Indian 
tribes, the Government itself owned and operated facilities for 
health care, education and, to a lesser extent, for detention. 
Over the past 33 years, however, many tribes have contracted or 
compacted with the United States to take control of these 
facilities and their operations.
    Nevertheless, the primary source of funds for the 
construction of and the operation of these facilities still 
remains the Federal Government.
    Before touching on the three areas--schools, health care 
and detention facilities--that are the subject of this hearing, 
I want to highlight the erratic and insufficient funding and 
the nature of Federal spending in dealing with these issues. 
Taking health care as an example with chart 1--I am going to 
show a number of charts this morning--over the last 25 years, 
annual Federal spending has ranged from under $15 million to 
almost $140 million for health care facilities.



    The Administration's budget request for the 2009 fiscal 
year is extremely low, at the low end of this at the $15.8 
million range, yet the amount necessary to fund the facilities 
on the current priority list of the Indian Health Service for 
Fiscal Year 2009 through the out years is an estimated $2.6 
billion. Let me repeat, the funding needed for the facilities 
on the current priority list is $2.6 billion, yet in 2009, the 
Administration is requesting little more than one half of 1 
percent of that amount. At that rate, final funds for 
facilities on the current priority list would be available at 
the end of 165 years.
    With respect to schools, the Bureau of Indian Affairs funds 
approximately 4,500 schools or school facilities in Indian 
Country. Most of these are found at 184 Indian schools and 27 
tribal colleges. What I meant to say was 4,500 buildings or 
facilities that are attached to those schools.
    These facilities provide more than 60,000 students with 
facilities for education. The greatest concentration of Bureau 
schools is in the Southwest, the Great Plains, and the 
Northwest. As of the year 2000, half of the school facilities 
in the BIA's inventory exceeded their useful lives of 30 years, 
and more than 20 percent were over 50 years old.
    The Interior Department's Inspector General recently 
visited 13 BIA schools located just in the State of Arizona. 
The Inspector General found severe deterioration that directly 
affects the safety and the health of Indian children. 
Deterioration ranged from leaking roofs to classroom walls 
buckling and separating from their foundation. The Inspector 
General warned, in issuing a flash report in May of 2007, that 
the failure to mitigate these conditions will likely cause 
injury or death to children and/or to school employees.
    Here are some examples of the conditions of schools in 
Indian Country taken from the Inspector General's report. Chart 
2 is a montage of deterioration--a broken cinder block in a 
wall, a corroded sink, a buckled sidewall, an abandoned 
dormitory seen through a broken window. The Keams Canyon School 
in Keams Canyon, Arizona was constructed in 1928. On the 
grounds are condemned buildings that have not been properly 
boarded up, which is seen now in chart 3. Those are buildings 
that have not been boarded up that have been condemned.





    In chart 4, you will see that leaking water has 
significantly damaged ceilings. In both chart 4 and chart 5, 
you will see in this case damaged ceilings from water. In chart 
5, you will see that the main boiler has been leaking. The 
boiler was last inspected in 2002. It failed inspection and 
still displayed the ``failed'' tag, but it is still in 
operation.





    The boarding school in Many Farms, Arizona, has a crumbling 
foundation. You will see that in chart 6. And the crumbling 
foundation has actually resulted in a moving wall, which is 
chart 7. If you look at the bottom, you will see that the 
entire wall has moved in this particular building. Note the 
widening gap between the vertical side of the box and the 
slanting wall.





    At the Kayenta Boarding School, mold covered an office 
wall. That is chart 8. These are from the Inspector General's 
report. That same school with mold on the wall had water leaks 
near electrical outlets and buckled sidewalls.



    Well, I don't need to go through more of those charts that 
show these problems, but we have very serious facility problems 
in health care, in education, in juvenile detention and jails. 
The detention facilities are a longstanding problem. Let me 
talk about them just for a moment. Back in 1998, the Attorney 
General testified before this Committee that the 73 small jails 
that exist in Indian Country are severely inadequate and 
antiquated. Most Indian Country jails are in such poor 
condition they are completely out of compliance with building 
codes and professional jail standards.
    The Interior Inspector General reported this to the 
Committee in June of 2004. He said the condition of Indian 
jails was in desperate shape. He deemed the state of Indian 
jails a ``national disgrace.'' That problem remains unsolved, 
and we will hear from tribal officials today about that. One 
tribe that will testify today says they have a new detention 
facility and it is only staffed now at minimum capacity, which 
is another problem and an issue.
    I am going to, when we discuss this later, ask Mr. Ragsdale 
who is with us, and Mr. Rever, questions about a consulting 
study that has been done that has not been made available to 
this Committee. There was a consulting study that follow on the 
Inspector General's report given to this Committee in 2004. The 
report was, ``Neither safe nor secure in assessment of Indian 
detention facilities.'' In February, 2006, two years ago, the 
BIA contracted with Shubnam Strategic Management Applications 
to visit 38 Indian jails and assess the conditions, and provide 
a cost analysis.
    In March of last year, Mr. Rivera testified before the 
Prison Rape Elimination Commission about the state of Indian 
Country jails. He indicated that the Shubnam report is in 
preliminary stages. Once it has gone through Director Ragsdale, 
it will be open for public information. I think it will be a 
month or two months, that was March of 2007.
    The Committee staff met with Mr. Ragsdale to discuss this 
issue. He stated the report should be ready by December. That 
report is not ready. It has not been made available to this 
Committee. My understanding is it is 1,000 pages. Interior now 
says it was just made available to them, which contradicts what 
we heard last year.
    So I talked to the Interior Secretary personally to ask 
that it be made available to this Committee. It seems to me 
when you are holding a hearing on the very subject, the 
taxpayers have paid for the consulting report, and the report 
was described to us last March as awaiting Mr. Ragsdale's 
review, and would be done in a matter of months. Mr. Ragsdale 
said it would be done in December.
    I don't understand why this Committee does not have that 
information today. I think it is arrogant and it is wrong. This 
Committee should have been provided that information. I will 
give Mr. Ragsdale and others a chance to respond to that and 
answer some questions about it.
    My colleagues have joined me. Mr. Barrasso, do you have an 
opening statement? I indicated we are going to have a vote I 
think at 10:45 a.m., so we will proceed with opening 
statements, and then have the witnesses begin, and we will have 
to take a short recess.

               STATEMENT OF HON. JOHN BARRASSO, 
                   U.S. SENATOR FROM WYOMING

    Senator Barrasso. Thank you very much, Mr. Chairman. Yes, I 
would, and I want to follow up on some of the examples that you 
have given because that is exactly what I have seen in Wyoming 
as well, Mr. Chairman.
    On the Wind River Reservation in Wyoming, different 
buildings sit condemned, vacant due to gas leaks, due to fires, 
general maintenance issues. Meanwhile, our law enforcement 
department already is stretched to the maximum: short staff, 
large areas to cover. It operates out of a building that is 
shared with four other offices.
    The Fort Washakie Health Center operates today for 11,000 
users out of a building that was built in 1877 for the cavalry. 
So what is happening there is absolutely unacceptable and I am 
thankful, Mr. Chairman, that you have scheduled this hearing 
and I look forward to working with you and making sure we can 
revamp those broken programs.
    With that, Mr. Chairman, I will reserve for questions.
    The Chairman. Senator Barrasso, thank you very much.
    Let me call on Senator Johnson.

                STATEMENT OF HON. TIM JOHNSON, 
                 U.S. SENATOR FROM SOUTH DAKOTA

    Senator Johnson. Thank you, Mr. Chairman.
    In light of the 10:45 vote, I will submit my statement for 
the record.
    [The prepared statement of Senator Johnson follows:]

 Prepared Statement of Hon. Tim Johnson, U.S. Senator from South Dakota

    Thank you Chairman Dorgan and Vice-Chairwoman Murkowski for holding 
this hearing. The provision of adequate educational, health and law 
enforcement facilities are essential to upholding our treaty and trust 
responsibilities to American Indians. It is also a moral obligation. 
There are nine BIA schools in my state that have been found to be in 
need of ``Major Repairs or Replacement.'' The conditions at these 
schools are shocking; they include inadequate fire protection, outdated 
electrical systems, improperly maintained furnaces and condemned 
buildings.
    The affects of these conditions on tribal children are even more 
shocking. This past December school had to be canceled at Cheyenne 
River-Eagle Butte because temperatures in the building had dropped to 
48 degrees due to problems with the heating system and the increased 
costs of heating fuel. At the Crow Creek School, children are living 
and taking classes in trailers because the lack of resources has 
prevented construction of a new dormitory to replace the one lost in a 
fire. Simply put, the health and education of tribal children are at 
risk because their schools are literally crumbling down around them.
    To try to address these challenges I, along with Representative 
Pomeroy, have introduced the Indian School Construction Act. This bill 
has passed the Senate before and would create a tax credit bonding 
program for tribal schools, similar to the Qualified Zone Academy 
Bonds, to allow an additional funding mechanism for the construction of 
BIA schools. The tribes in my state are not asking for much, only a 
safe and productive place for their children to learn, which we are 
obligated to provide by treaty, trust and moral obligations. While the 
Indian School Construction Act is not under the jurisdiction of Indian 
Affairs, I hope the members of this Committee will support the bill and 
help take this important step to improve education facilities in Indian 
Country. Thank you.

    The Chairman. Senator Johnson, thank you very much.
    We are joined today by a number of witnesses. I want to 
begin to call on them in the following order. First, Mr. Pat 
Ragsdale, Director of the Office of Law Enforcement Services, 
accompanied by Mr. Jack Rever, Director of Facilities at the 
Department of Interior.
    Then, I will call on Mr. Randy Grinnell, Indian Health 
Service Deputy Director of Management Operations, accompanied 
by Gary Hartz, the Director of the Office of Environmental 
Health and Engineering, and Dr. Rick Olson, Director of 
Clinical and Prevention Services. And finally, we will call on 
Mr. Domingo Herraiz, Director of the Bureau of Justice 
Assistance, United States Department of Justice. Mr. Herraiz 
will discuss the Indian jail construction program.
    Mr. Ragsdale, you may proceed.

   STATEMENT OF W. PATRICK RAGSDALE, DIRECTOR, OFFICE OF LAW 
            ENFORCEMENT SERVICES, BUREAU OF INDIAN 
           AFFAIRS, U.S. DEPARTMENT OF THE INTERIOR; 
       ACCOMPANIED BY JACK REVER, DIRECTOR OF FACILITIES

    Mr. Ragsdale. Good morning, Mr. Chairman. If I may, I will 
defer to Mr. Rever to provide the Administration's statement.
    The Chairman. Mr. Rever?
    Mr. Rever. Good morning, Mr. Chairman and members of the 
Committee. My name is Jack Rever and I am the Director of 
Facilities, Environmental, Cultural Resources, Safety and a 
couple of other things within the Bureau of Indian Affairs.
    The Bureau owns or provides funding for a broad range of 
buildings and other facilities across this Nation. The Bureau's 
construction and maintenance program is multifaceted and the 
operation is challenged with meeting facility needs in the 
areas of education, public safety and justice, dams and 
irrigation projects, and general administration.
    I am here today to discuss the status of the education and 
justice facilities in Indian Country.
    Bureau-owned to funded education facilities serve 184 
schools and dormitories that provide educational opportunities 
for approximately 44,000 students, including almost 1,600 
resident-only boarders. From 2002 through 2008, the 
Administration invested more than $1.7 billion in the 
maintenance, repair and construction of education facilities 
across Indian Country.
    The Bureau operates or funds detention and law enforcement 
facilities throughout Indian Country to support Bureau and 
tribal law enforcement programs. There are currently 84 
detention facilities across Indian Country. Of these, 38 are 
owned and operated by the Federal Government, five are owned by 
the tribes and operated by the Federal Government, and 41 are 
owned and operated by tribes.
    Through its appropriations, the Department of Justice from 
Fiscal Year 1997 to Fiscal Year 2002 provided funds to tribes 
on a cost-sharing basis for major projects. This funding has 
enabled various tribes to build 21 new detention centers. The 
construction center is responsible for correcting identified 
code and standard deficiencies at BIA facilities.
    In order to accomplish this, the BIA has established a 
facility condition index--we call it an FCI--to track and 
report the status of facilities. The FCI is a Government-wide 
performance measure to describe the condition of a facility or 
group of facilities and it is calculated by dividing the cost 
of correcting the deferred maintenance work by the cost of 
replacing the facility at its current size and capacity.
    The FCI is used to develop and revise the BIA five year 
deferred maintenance and construction plan and monitor 
performance in maintaining assets. The plan provides the Bureau 
with a clear strategy for addressing facilities with the 
greatest needs. Each fiscal year plan reflects the projects in 
priority ranking order based on critical health and safety 
requirements.
    Over the past seven years, there has been significant 
progress in improving the condition of Bureau Indian education 
schools. In 2001, 120 of the 184 schools and dormitories were 
ranked as being in poor condition as measured by the FCI. When 
all of the construction work authorized by Congress through the 
Fiscal Year 2008 and proposed by the President for 2009 is 
completed, 50 schools will have been improved from fair to good 
condition, or a total of 114 schools of the 184 schools.
    The BIA prioritizes education construction projects 
separately for replacement of the entire campus, replacement of 
separate facilities on that campus, and projects to improve and 
repair buildings. The priority in each category is given to the 
facility with the most critical fire and life safety issues. 
The replacement school priority list was established in the 
year 2004 and includes the replacement of 14 schools. The 
replacement facilities construction list is prioritized every 
year, with a two year projection. Improvement and repair 
projects are prioritized annually.
    In September, 2003, as you have mentioned, sir, the 
Inspector General found that the BIA's process for forecasting 
future student enrollments was not adequate, resulting in new 
construction with excess space and unwarranted cost. As a 
result, BIA has adopted an enrollment projection methodology in 
2004 to right-size school projects.
    This methodology uses the past 10 year enrollment history 
to predict future enrollments. This new methodology provides 
realistic assessments of the future enrollment for BIA schools 
to prevent schools from being over- or under-built.
    Indian Affairs has also taken steps to create consistent 
and efficient school designs for construction. In 2005, the BIA 
revised the space guidelines that define the needs of schools 
based on academic curriculum and projected student enrollment, 
and in 2006 Indian Affairs published the first architectural 
and engineering standards for design and construction to 
establish common design elements for classrooms, cafeterias, 
gymnasiums, heating and cooling systems, and other operating 
systems.
    In addition, Indian Affairs adopted the U.S. Green Building 
Council's leadership in energy and environmental design, 
commonly called LEED, as goals for energy-efficient design in 
our schools. In fact, Indian Affairs schools were the first 
ones built in both Arizona and in New Mexico to achieve 
designation as LEED-compliant schools, criteria now adopted by 
those States in their education construction programs.
    Beginning in 2006, Indian Affairs adopted new procedures 
and methods of school construction programming. Indian Affairs 
started a plan to design projects in the two years prior to 
requesting of funds for construction, with the goal of 
beginning construction on major projects in the year of 
appropriation.
    This strategy has multiple benefits. Projects have been 
completed. Planning and design are ready to begin construction 
when funds are available. And projects that start on time 
minimize the construction cost and the cost of inflation. The 
new procedures have already increased the annual obligation 
rate for our funds from 44 percent to 87 percent, thereby 
significantly reducing the carryover and therefore the cost of 
our program.
    Many of the school construction projects funded since 2001 
have been delayed for a variety of reasons. That created the 
need for additional funding due to inflation. In 2007, Indian 
Affairs created a shortfall recovery plan to permit the 
construction of all school projects at their authorized scope 
of work as specified in the revised space guidelines. The plan 
proposed delaying the start of a few schools in construction 
and reprogramming those funds to address the shortfalls.
    We are pleased and grateful that the Fiscal Year 2008 
appropriation bill authorized the execution of our shortfall 
recovery plan. We are even more pleased to report that the plan 
continues on schedule to eliminate the shortfall by the end of 
the current fiscal year. We anticipate that we will achieve our 
mutual objective to build schools at scopes of work necessary 
to meet educational objectives.
    In the area of public safety and justice facility 
construction, recently the BIA concluded a two year master 
planning effort to accomplish three objectives regarding the 
needs of justice systems across Indian Country: one, assess the 
condition and current operating standards of the Indian Country 
justice system; two, prepare a comprehensive plan of justice 
facilities including size, estimated construction cost, and 
estimated cost to operate the facilities, including staffing 
and preferred location of justice system facilities; and three, 
establish standards for the operation, design and 
organizational structure of the justice system.
    The effort took two years and we visited 38 justice system 
facilities including law enforcement, detention and tribal 
courts, both tribally and federally-owned, and we conducted 
telephone interviews with law enforcement and detention staffs 
from both Indian Affairs and tribal programs. Based on the 
demographic and facility information collected, BIA formulated 
a comprehensive solution to address justice facilities in 
Indian Country, and it is under review at the present time. 
Those results will be provided to the Committee at a later 
date.
    We will work with the tribes and in consultation with the 
Department of Justice to ensure that any future construction or 
renovation of justice system facilities meets the needs of the 
tribes for an efficient and effective law enforcement court and 
incarceration program.
    Mr. Chairman, thank you for the opportunity to appear 
before you today. I will be happy to answer any questions you 
may have.
    [The prepared statement of Mr. Rever follows:]

  Prepared Statement of Jack Rever, Director of Facilities, Bureau of 
            Indian Affairs, U.S. Department of the Interior

    Good morning, Mr. Chairman, Ms. Murkowski, and Members of the 
Committee. My name is Jack Rever. I am the Director of Facilities, 
Environmental, Safety, and Cultural Resources Management in the Bureau 
of Indian Affairs in the Department of the Interior. The Bureau owns or 
provides funding for a broad variety of buildings and other facilities 
across the nation. The Bureau's construction and maintenance program is 
a multifaceted operation challenged with meeting facility needs in the 
areas of Education, Public Safety and Justice, Dams and Irrigation 
Projects, and General Administration. I am here today to discuss the 
status of education and justice facilities in Indian Country.
    Bureau-owned or funded education facilities serve 184 schools and 
dormitories that provide educational opportunities for approximately 
44,000 students, including almost 1,600 resident only boarders. From 
2002 through 2008, the Administration invested more than $1.7 billion 
in the maintenance, repair and construction of education facilities 
across Indian Country.
    The Bureau operates or funds detention and law enforcement 
facilities throughout Indian Country to support Bureau and Tribal law 
enforcement programs. There are currently 84 detention facilities 
across Indian Country. Of these, 38 are owned and operated by the 
Federal Government, 5 are owned by Tribes and operated by the Federal 
Government, and 41 are owned and operated by Tribes. Through its 
appropriations, the Department of Justice from FY 1997 to FY 2002 
provided funds to Tribes on a cost sharing basis for major projects. 
This funding enabled various Tribes to build 21 detention facilities.
    The construction program is responsible for correcting identified 
code and standard deficiencies at BIA facilities. In order to 
accomplish this, the BIA has established a Facilities Condition Index 
(FCI) to track and report the status of facilities. The FCI is a 
Government-wide performance measure to describe the condition of a 
facility or group of facilities. It is calculated by dividing the cost 
of correcting deferred maintenance work by the cost of replacing the 
facility at its current size and capacity.
    The FCI is used to develop and revise the BIA Five-Year Deferred 
Maintenance and Construction Plan and monitor performance in 
maintaining assets. The plan provides the Bureau with a clear strategy 
for addressing facilities with the greatest need. Each fiscal year plan 
reflects the projects in priority ranking order based on critical 
health and safety requirements.
Education Construction
    Over the past seven years, there has been significant progress in 
improving the condition of Bureau of Indian Education (BIE) schools. In 
2001, 120 of the 184 schools and dormitories were rated as being in 
poor condition as measured by the FCI. When all of the construction 
work authorized by Congress through FY 2008 and proposed by the 
President for FY 2009 is complete, 50 schools will have improved to 
fair or good condition, for a total of 114 schools.
    The BIA prioritizes education construction projects separately for 
replacement of an entire campus, replacement of separate facilities and 
projects to improve and repair buildings. Priority in each category is 
given to facilities with critical fire and life safety issues. The 
Replacement School Construction priority list was established in 2004 
and included replacement of 14 schools. The Replacement Facilities 
Construction list is prioritized every year with a two year projection. 
Improvement and repair projects are prioritized annually.
    In September 2003, the Inspector General found that BIA's process 
for forecasting future student enrollments was not adequate, resulting 
in new construction with excess space and unwarranted costs. As a 
result, BIA adopted an enrollment projection methodology in 2004 to 
right size school projects. This methodology uses the past ten year 
enrollment history to project future enrollments. The new methodology 
provides realistic assessment of the future enrollment for the BIE 
schools to prevent schools from being over- or under-built.
    Indian Affairs has also taken steps to create consistency and 
efficiency in school design and construction. In 2005, the BIA revised 
the Space Guidelines that define the needs of the school based on 
academic curriculum and projected student enrollment and in 2006, 
Indian Affairs published the first architectural and engineering 
standards for design and construction that established common design 
elements for classrooms, cafeterias, gymnasiums, heating and cooling 
systems, and other operating systems. In addition, Indian Affairs 
adopted the U.S. Green Building Council's Leadership in Energy and 
Environmental Design (LEED) goals for energy efficient design. In fact, 
Indian Affairs schools were the first ones built in Arizona and New 
Mexico to achieve designation as LEED compliant schools, criteria now 
adopted by those states in their education construction programs.
    Beginning in 2006, Indian Affairs adopted new procedures and 
methods of school construction programming. Indian Affairs started to 
plan and design projects in the two years prior to requesting funds for 
construction with the goal of beginning construction on major projects 
in the year of appropriation. This strategy has multiple benefits. 
Projects that have completed planning and design are ready to begin 
when funds become available and projects that start on time minimize 
the impacts of inflation. The new procedures have already increased the 
annual obligation rate from 44 percent 87 percent thereby significantly 
reducing carryover.
    Many of the school construction projects funded since 2001 have 
been delayed for a variety of reasons, which created a need for 
additional funding due to inflation. In 2007, Indian Affairs created a 
shortfall recovery plan to permit the construction of all school 
projects at their authorized scope of work as specified in the revised 
space guidelines. The plan proposed delaying the start of a few school 
construction projects and reprogramming project funding to address 
project shortfalls. We are pleased and grateful that the Fiscal Year 
2008 appropriation bill authorized the execution of our shortfall 
recovery plan. We are even more pleased to report that the plan 
continues on schedule to eliminate the shortfall by the end of Fiscal 
Year 2008. We anticipate that we will achieve our mutual objective to 
build schools at scopes of work necessary to meet education objectives.
Public Safety and Justice Facility Construction
    Recently, the BIA concluded a two year master planning effort to 
accomplish three objectives regarding the needs of justice systems in 
Indian Country:

        1. Assess the condition and current operating standards of the 
        Indian Country Justice System;

        2. Prepare a comprehensive plan of justice facilities, 
        including size, estimated construction cost, the estimated cost 
        to operate the facilities including staffing and preferred 
        location of justice system facilities; and

        3. Establish standards of operation, design and organizational 
        structure of the justice system.

    The effort took two years as we visited 38 justice system 
facilities, including law enforcement, detention facilities and tribal 
courts, both tribally and federally owned and conducted telephone 
interviews with law enforcement and detention staffs of both Indian 
Affairs and tribal programs. Based on the demographic and facility 
information collected, BIA formulated a comprehensive solution to 
address justice system facility requirements in Indian Country. A draft 
Master Plan for justice facilities in Indian Country is under review, 
and the results will be provided to the Committee at a later date.
    We will work with the Tribes, in consultation with the Department 
of Justice, to ensure that any future construction or renovation of 
justice system facilities meets the needs of the Tribes for an 
efficient and effective law enforcement, court, and incarceration 
program.
    Mr. Chairman, thank you for the opportunity to appear before you 
today. I will be happy to answer any questions you may have.

    The Chairman. Mr. Rever, thank you very much.
    Next, we will hear from Mr. Randy Grinnell from the Indian 
Health Service, who is accompanied by Gary Hartz, the Director 
of the Office of Environmental Health and Engineering, and Dr. 
Rick Olson, Director of Clinical and Prevention Services.
    Mr. Grinnell, you may proceed.

         STATEMENT OF RANDY GRINNELL, DEPUTY DIRECTOR, 
         MANAGEMENT OPERATIONS, INDIAN HEALTH SERVICE, 
         U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; 
        ACCOMPANIED BY GARY HARTZ, DIRECTOR, OFFICE OF 
ENVIRONMENTAL HEALTH AND ENGINEERING, AND RICK OLSON, DIRECTOR, 
                CLINICAL AND PREVENTION SERVICES

    Mr. Grinnell. Good morning. I am Randy Grinnell, Deputy 
Director for Management Operations in the Indian Health 
Service.
    As you mentioned, today I am accompanied by Dr. Rick Olson, 
Acting Director of the Office of Clinical and Preventive 
Service; and Mr. Gary Hartz, Director, Office of Environmental 
Health and Engineering.
    We are pleased to have the opportunity to testify on the 
state of health facilities in Indian Country. The mission of 
the Indian Health Service, in partnership with American Indian 
and Alaska Native people, is to raise their physical, mental, 
social and spiritual health to the highest level. In supporting 
that goal, IHS and tribes provide optimum availability to 
functional, well-maintained and accredited health care 
facilities and staff housing.
    Collectively, the IHS and tribes currently provide access 
to health care services for American Indians and Alaska Natives 
through a total of 679 facilities, including 48 hospitals, 304 
ambulatory health centers, 166 Alaska village clinics, 143 
health stations, and 20 school health centers. During regular 
reviews of IHS and tribal hospitals by the Joint Commission on 
Accreditation of Health Care Organizations, the Accreditation 
Association for Ambulatory Health Care and the Centers for 
Medicare and Medicaid Services to ensure the provision of 
quality patient care, the area most frequently cited for 
improvement relates to physical structure and efficiency.
    The average age of these facilities is 33 years old, as 
compared to 9 years old for health care facilities in the 
United States. The Indian Health Service has identified a 
backlog of deferred maintenance of approximately $370 million 
to maintain these facilities within their current footprint. 
Issues such as modernization or expansion due to population 
growth are addressed through the health care facilities 
construction priority system and the priority list it 
established.
    The IHS currently estimates that completing the 22 
facilities on the current priority list totals $2.6 billion. To 
expand access, tribes have successfully partnered with IHS 
under the joint venture program and small ambulatory program. 
These programs complement the health care facilities 
construction priority list by providing mechanisms for tribes 
to become involved in the acquisition of facilities.
    From 1998 to present, seven tribes have entered into joint 
venture program agreements to construct facilities and lease 
them to the IHS at no cost. In exchange the IHS agreed to 
equip, staff and operate these facilities. Five of these 
facilities have been completed, and 27 tribes have received 
funding through the small ambulatory program to provide 
improved facilities space for health care programs.
    Mr. Chairman, this concludes my statement and I would be 
happy to answer any questions that you may have.
    Thank you.
    [The prepared statement of Mr. Grinnell follows:]

   Prepared Statement of Randy Grinnell, Deputy Director, Management 
Operations, Indian Health Service, U.S. Department of Health and Human 
                                Services

    Good Morning. I am Randy Grinnell, Deputy Director for Management 
Operations in the Indian Health Service. Today I am accompanied by Dr. 
Richard Olson, Acting Director of the Office of Clinical and Preventive 
Services, and Mr. Gary Hartz, Director, Office of Environmental Health 
and Engineering. We are pleased to have the opportunity to testify on 
the state of health facilities in Indian Country.
    The mission of the Indian Health Service, in partnership with 
American Indian and Alaska Native people, is to raise their physical, 
mental, social, and spiritual health to the highest level. In 
supporting that goal the IHS and Tribes provide optimum availability to 
functional, well maintained and accredited health care facilities and 
staff housing. Currently the IHS provides access to healthcare services 
for American Indians and Alaska Natives through 31 Hospitals, 50 health 
centers, 31 health stations and 2 school health centers. Tribes also 
provide healthcare access through an additional 15 hospitals, 254 
health centers, 166 Alaska Village Clinics, 112 health stations and 18 
school health centers.
    The Joint Commission on Accreditation of Healthcare Organizations, 
the Accreditation Association for Ambulatory Health Care, and the 
Centers for Medicare and Medicaid Services regularly conduct in-depth 
quality reviews of IHS and Tribal hospitals. IHS has consistently 
maintained 100 percent accreditation of all hospitals and facilities 
and expects to continue to do so in FY 2009. This is an ambitious goal 
but one that IHS considers critical to ensuring that high quality 
patient care is being provided.
    During these reviews, the area most frequently cited for 
improvement is related to the physical structure and efficiency. The 
average age of IHS facilities is 33 years as compared to 9 years for 
healthcare facilities in the United States; many are overcrowded and 
were not designed in a manner that permits them to be utilized in the 
most efficient manner in the context of modern healthcare delivery. The 
condition of these facilities varies greatly depending on age and other 
factors. Some are in need of maintenance. In addition to maintenance, 
there is a need for modernization or expansion to address population 
growth, to accommodate modern equipment, or to meet the needs of 
rapidly changing health care delivery protocols. The process that the 
IHS has used since 1991 to evaluate healthcare facilities need and 
prioritize projects for funding is the Healthcare Facilities Priority 
System (HFCPS) and the Priority List it established. The IHS currently 
estimates that completing the new or replacement facilities on the 
current Priority List totals $2.6 billion. The 22 facilities on this 
Priority List are those facilities with the greatest need.
    The IHS continues to improve access to services by replacing old 
facilities or constructing new ones. In FY 2007, the IHS opened three 
Federally-owned healthcare facilities to increase access to services at 
Clinton, Oklahoma, Sisseton, South Dakota, and Red Mesa, Arizona. The 
IHS also increased access to substance abuse treatment with a new 
regional youth treatment center in Wadsworth, Nevada. These new health 
facilities are designed to serve 22,100 American Indian and Alaska 
Natives, which is an increase of 50 percent in access to health care in 
those communities.
    We have also partnered with Tribes to expand access under the Joint 
Venture Program and the Small Ambulatory Program. These programs 
complement the Healthcare Facilities Construction Priority List by 
providing mechanisms for Tribes to become involved in the construction 
of facilities. Since 1998 under the Joint Venture Program, 7 Tribes 
have entered into agreements to construct facilities and lease them to 
the IHS at no cost; in exchange, the IHS agreed to equip, staff, and 
operate these facilities. Five of these facilities have been completed. 
Under the Small Ambulatory Program, 27 Tribes have received funding to 
provide improved facility space for healthcare programs since 1998.
    In the House Report accompanying the FY 2000 Appropriations Act, 
Congress directed the IHS, in consultation with the Tribes and the 
Administration, to review and revise the existing HFCPS. IHS has been 
working with Tribes and the Department on a revised system.
    We anticipate this revision would provide an assessment of health 
services and facilities needs today and would rank those facilities 
needs based upon contemporary criteria developed through extensive 
consultation of IHS and the Tribes.
    Mr. Chairman, this concludes my statement and I would be happy to 
answer any questions you may have. Thank you.

    The Chairman. And you are Mr. Hartz?
    Mr. Hartz. Yes.
    The Chairman. Mr. Grinnell, thank you.
    Mr. Hartz has been with us before. I am sorry about that. 
Thank you.
    Mr. Hartz. No problem. I am not in uniform today.
    [Laughter.]
    The Chairman. And Mr. Domingo Herraiz, the Director of the 
Bureau of Justice Assistance at the U.S. Department of Justice. 
Mr. Herraiz, you will be discussing the Department's Indian 
jails construction program.

 STATEMENT OF DOMINGO S. HERRAIZ, DIRECTOR, BUREAU OF JUSTICE 
             ASSISTANCE, U.S. DEPARTMENT OF JUSTICE

    Mr. Herraiz. Chairman Dorgan, Vice Chairwoman Murkowski and 
members of the Committee, the Department of Justice appreciates 
the opportunity to testify before this Committee regarding 
priorities for correctional facilities in Indian Country.
    The Department recognizes the critical role of planning to 
ensure the construction and renovation of tribal correctional 
facilities are appropriate for the intended population, 
supportive of cultural and traditional values, safe and secure 
when completed, and adhere to the Bureau of Indian Affairs' 
standards regarding correctional operations programs and 
design.
    The Attorney General and the Department remain committed to 
partnering with tribes to cost-effectively plan for and 
renovate facilities associated with incarceration and 
restoration of juvenile and adult offenders subject to tribal 
jurisdiction.
    My name is Domingo Herraiz and I am the Director of the 
Bureau of Justice Assistance. BJA has the privilege of 
administering tribal programs to help reduce and prevent crime 
and violence in Indian Country. Based on BJA's involvement in 
these vital initiatives, I would like to provide you an update 
on four key areas: cooperation with tribes and related 
partners; the state of tribal correctional facilities; factors 
considered for funding tribal correctional facilities; and 
strategies to maximize the effectiveness of tribal correctional 
facilities.
    The President and the Attorney General remain committed to 
addressing the most serious criminal justice problems in Indian 
Country and to ensure the federally-recognized Indian tribes 
are full partners in this effort. It is in the spirit of 
partnership that BJA has been a principal supporter of the 
Office of Justice Programs in departmental tribal consultation, 
training and technical assistance sessions. These sessions have 
expanded to include five Federal departments.
    At each of these sessions, BJA, OJP, and our Federal 
partners have offered expertise to participants for training 
workshops and technical assistance. Through tribal consultation 
sessions, we have solicited priorities for detention and 
corrections in their communities. After consulting with tribes 
about challenges and barriers to accessing OJP grant resources, 
BJA and OJP implemented a new tribal grant policy. The new 
policy will help Native communities seeking OJP resources 
through our competitive grant solicitation process.
    BJA has also had an active role in the Justice Programs 
Council on Native American Affairs, which includes all senior-
level OJP leadership and representatives from other Department 
of Justice agencies.
    Partnerships also provide the foundation for BJA's 
administration of the Department's construction of correctional 
facilities on tribal lands discretionary grant program. BJA 
staff meet regularly with the OJP Senior Advisor for Tribal 
Affairs, Department of Health and Human Services' Indian health 
representatives, the Office of Juvenile Justice and delinquency 
prevention tribal staff, and Substance Abuse and Mental Health 
Services Administration representatives to discuss the wide 
range of issues impacting Indian Country, including 
correctional facilities and construction projects.
    Equally as important is the partnership these agencies have 
with tribal organizations and tribal grantees who share 
invaluable information through focus groups and other forums 
regarding ways to better support criminal justice systems in 
Indian Country.
    This information reflects the criminal justice system in 
Indian Country's clear need of better management. In 2004, the 
Department of Interior's Office of Inspector General issued a 
report, Neither Safe Nor Secure: An Assessment of Indian 
Detention Facilities, indicating that many of the more than 72 
tribal detention and correctional facilities in Indian Country 
were outdated and unsafe for both staff and inmates, serving 
only as detention facilities and providing little in the way of 
rehabilitation or programming services.
    Simply replacing all correctional facilities is not the 
answer. Other cost-effective strategies for construction of 
tribal correctional facilities must be examined. We are looking 
closely at these issues, including the use of correctional 
alternatives or non-custody programs, renovating existing 
buildings for correctional-related functions, and the provision 
of less expensive lower security beds.
    Joint county, tribal and regional tribal solutions should 
also be considered when sites are in close proximity to 
strengthen services and save resources. DOJ's Tribal 
Construction Grant Program has provided resources to 26 
American Indian and Alaska Native communities between 1998 to 
the present. Of these awards, 22 have gone to communities for 
new correctional facilities. Four awards have been made for 
renovation of existing facilities.
    By April 2007, 17 tribes had completed construction of 
their new facilities, five were actively engaged in design and 
construction, and four tribes were renovating existing 
structures to achieve Federal compliance and become fully 
operational. Today, DOJ is in the process of awarding 25 grants 
to tribes to facilitate construction efforts, while eight 
tribes will receive funding for the renovation of existing 
structures and another 17 tribes will receive awards for 
construction planning.
    Key elements of the application process for each new 
construction grants includes tribes must demonstrate a capacity 
need, provide a development plan to help prevent overcrowding, 
discuss the involvement of an executive level planning team, 
including the tribe's capacity to oversee the project and 
manage costs, and submit a reasonable budget for the proposed 
design.
    Likewise, applicants for DOJ's renovation of tribal 
correctional facilities funding are required to provide details 
regarding BIA's assessment supporting the renovation request 
and a cost-effective design for completion within a rigorous 18 
month time frame, thus demonstrating that the renovation will 
lead to continued BIA support for operation and maintenance of 
the facility, and the tribe's capacity to successfully sustain 
the facility in the future.
    The comprehensive planning process is also well established 
with the construction of correctional facilities of the tribal 
lands discretionary grant program. To support planning efforts, 
BJA provides training and technical assistance from experts 
dedicated to correctional issues tribes face to maximize the 
cost-effectiveness of construction projects and to plan for the 
long-term effectiveness of the tribal justice system.
    We are constantly listening and learning from our tribal 
partners. Best practices emerge from lessons learned. Knowing 
what one tribe has discovered does work allows us to share that 
knowledge with others experiencing similar issues to save 
critical time and resources. Offering locally based training to 
correctional officer staff and engaging a wide range of tribal 
partners to develop policies and procedures for tribal 
correctional facilities will also serve to strengthen related 
services in Indian Country.
    Community-based alternatives to help reduce the burden of 
overcrowding while offering many offenders a hopeful solution 
to breaking the cycle of alcohol and substance abuse, and 
linking efforts to results, the Department will continue to 
seek ways to improve its programs in practical ways that tribes 
themselves have helped to identify and design.
    This concludes my statement, Mr. Chairman. I welcome the 
opportunity to answer any questions from you or the Committee.
    [The prepared statement of Mr. Herraiz follows:]

 Prepared Statement of Domingo S. Herraiz, Director, Bureau of Justice 
                 Assistance, U.S. Department of Justice

    Chairman Dorgan, Vice-Chairman Murkowski, and Members of the 
Committee: The Department of Justice (DOJ) appreciates the opportunity 
to testify before the Committee regarding priorities for correctional 
facilities in Indian Country. The Department recognizes the critical 
role of planning to ensure that the construction and renovation of 
Tribal correctional facilities are appropriate for the intended 
population, supportive of cultural and traditional values, safe and 
secure when completed, and adhere to Bureau of Indian Affairs (BIA) 
standards regarding correctional operations, programs, and design. The 
Attorney General and Department remain committed to partnering with 
Tribes to cost effectively plan for and renovate facilities associated 
with the incarceration--and restoration--of juvenile and adult 
offenders subject to Tribal jurisdiction.
    My name is Domingo S. Herraiz, and I am the Director of the Office 
of Justice Programs' (OJP) Bureau of Justice Assistance (BJA). BJA is 
committed to preventing and controlling crime, violence, and substance 
abuse, and improving the functioning of the criminal justice system. 
BJA has the privilege of administering Tribal programs to help reduce 
and prevent crime and violence in Indian Country. Based on BJA's 
involvement with these vital initiatives, I would like to provide you 
an update in four key areas:

        1) Cooperation with Tribes and related partners;

        2) The state of Tribal correctional facilities;

        3) Factors considered for funding Tribal correctional 
        facilities; and

        4) Strategies to maximize the effectiveness of Tribal 
        correctional facilities and improve planning, construction, and 
        renovation programs.

    The President and the Attorney General remain committed to 
addressing the most serious criminal justice problems in Indian country 
and to ensuring that federally recognized Indian tribes are full 
partners in this effort. It is in this spirit of partnership that BJA 
has been a principal supporter of OJP's Interdepartmental Tribal 
Consultation, Training and Technical Assistance Sessions held in FY 
2007 and FY 2008. These sessions have expanded to include five federal 
departments and ten of their agencies, several of which, have direct 
responsibility or touch on this area. At each of these sessions, BJA, 
OJP and our federal partners have offered our expertise to all 
participants for training workshops, technical assistance, general 
session panels demonstrating challenges as well as cooperative 
opportunities available, and through tribal consultation sessions, we 
have solicited tribal priorities for detention and corrections in their 
communities. Our latest session began yesterday in Washington, D.C. and 
will conclude tomorrow.
    After consulting with tribes about challenges and barriers to 
accessing OJP grant resources, in September 2007, BJA and OJP 
implemented a new Tribal Grants Policy. The new policy will help Native 
communities seeking OJP resources through our competitive grant 
solicitation process. We are implementing the policy starting with the 
Fiscal Year 2008 grants solicitations.
    BJA also has an active role in the Justice Programs Council on 
Native American Affairs, which includes all senior-level OJP leadership 
and representatives from other Department of Justice offices and 
agencies. The council coordinates OJP's efforts on behalf of tribes and 
serves as a liaison with other Department of Justice components on 
Tribal issues.
    Another important outcome from our Council efforts and Tribal 
consultations has been our establishing a Tribal Justice Advisory Group 
(TJAG). The TJAG provides advice and assistance to me and other OJP 
leadership on Tribal justice and safety issues. It convened its initial 
meeting in November and will meet again tomorrow.
    Partnerships also provide the foundation for BJA's administration 
of the Department's Construction of Correctional Facilities on Tribal 
Lands Discretionary Grant Program. BJA staff meet regularly with the 
Senior Advisor for Tribal Affairs from the Office of Justice Programs' 
Office of the Assistant Attorney General; Department of Health and 
Human Services' Indian Health representatives, Office of Juvenile 
Justice and Delinquency Prevention (OJJDP) tribal staff, and Substance 
Abuse & Mental Health Services Administration (SAMSHA) representatives 
to discuss the wide range of issues impacting Indian Country, including 
correctional facilities and construction projects. Equally as important 
are the partnerships these agencies have with Tribal organizations and 
Tribal grantees, who share invaluable information through focus groups 
and other forums regarding ways to better support the criminal justice 
system in Indian Country.
    This information reflects that the criminal justice system in 
Indian Country is clearly in need of better management. In 2004, DOI's 
Office of the Inspector General issued a report, ``Neither Safe Nor 
Secure: An Assessment of Indian Detention Facilities,'' indicating that 
many of the more than 72 Tribal detention and correctional facilities 
in Indian Country were outdated and unsafe for both staff and inmates, 
serving only as detention facilities and providing little in the way of 
rehabilitation or programming services. Underscoring these concerns, 
BIA shared information indicating that many of the Tribal detention and 
corrections facilities are in disrepair.
    Simply replacing all correctional facilities is not the answer. 
Other cost effective strategies for construction of Tribal correctional 
facilities must be examined. We are looking closely at these, including 
the use of correctional alternatives, or non-custody programs; 
renovating existing buildings for correctional-related functions; and 
provision of less expensive, lower security beds. This last strategy 
can be very cost effective, and relies heavily on thorough needs 
assessments and population profiles. Finally, joint county-Tribal and 
regional Tribal solutions should be considered when sites are in close 
proximity to strengthen services and save resources. In addition, the 
Department has worked closely with the Tribes to expand the scope of 
its Tribal programs to include training and technical assistance to 
Indian Country.
    DOJ's Tribal construction grant program has provided resources to 
26 American Indian and Alaska Native communities, between 1998 to the 
present. Of these, 22 awards have gone to communities for new 
correctional facilities, and 4 awards have been made for renovation of 
existing facilities. By April 2007, 17 Tribes had completed 
construction of their new facilities; were actively engaged in design 
and construction; and 4 Tribes were renovating existing structures to 
achieve federal compliance and become fully operational.
    Today, DOJ is in the process of awarding grants to 25 additional 
Tribes to facilitate construction efforts. While 8 Tribes will receive 
funding for the renovation of existing structures, another 17 Tribes 
will receive awards for construction planning. BJA anticipates these 
awards will be made in April 2008.
    The following are key elements of the application process for each 
new construction grant: Tribes must demonstrate a capacity need for the 
new facility; provide a developed plan to help prevent overcrowding of 
the projected facility by tapping into community-based alternatives; 
discuss the existence and involvement of an executive-level planning 
team--including the Tribe's capacity to oversee the project and manage 
costs; and submit a reasonable budget for the proposed design. 
Likewise, applicants for DOJ's renovation of Tribal correctional 
facilities funding are required to provide details regarding a BIA 
assessment supporting the renovation request and a cost-effective 
design for completion within a rigorous 18 month timeframe, thus 
demonstrating the renovation will lead to continued BIA support for 
operation and maintenance of the facility and the Tribe's capacity to 
successfully sustain the facility in the future.
    A comprehensive planning process is well established with the 
Construction of Correctional Facilities on Tribal Lands Discretionary 
Grant Program. Tribes must: (1) examine population projections; (2) 
demonstrate a need for the facility, determine operational costs, and 
the ability to cover these costs; (3) determine the ability to recruit, 
train, and retain qualified staff; (4) explore the use of alternatives 
such as sanction programs, pre-trial release, day reporting,treatment, 
and electronic monitoring; (5) determine the availability of treatment 
and other services such as substance abuse, health, mental health, 
education, employment, and housing; and (6) demonstrate that Tribal 
leaders and other community stakeholders have fully participated in the 
planning and needs assessment process.
    To support planning efforts, BJA provides training and technical 
assistance at no cost from experts dedicated to the correctional issues 
Tribes face to maximize the cost effectiveness of construction projects 
and to plan for the long-term effectiveness of the Tribal justice 
system. For example, more than a dozen Tribal Construction of 
Correctional Facilities Project Guides, from ``Selecting an 
Architect,'' to ``Site Selection,'' and ``Population Profiles, 
Population Projections and Bed Needs Projections,'' have been published 
and distributed to Tribes to guide them throughout their planning, 
construction, and renovation efforts.
    To ensure our programs remain relevant to the needs of Indian 
County, the Department continues to seek ways to improve and enhance 
its Tribal grant initiatives. For example, the President's proposed 
Fiscal Year 2009 budget consolidates multiple funding streams and 
burdensome requirements to create four new competitive grant programs 
that will provide states, localities, and Indian Tribes with the 
flexibility they need to address their most critical criminal justice 
needs. A total of $200 million is requested for the Byrne Public Safety 
and Protection Program in Fiscal Year 2009. Another new initiative in 
the President's proposed budget is the Violent Crime Reduction 
Partnership Program to help communities suffering from high rates of 
violent crime form law task forces including local state, Tribal, and 
federal agencies. A total of $200 million is requested for this program 
in Fiscal Year 2009. The Department has taken other steps, as well. In 
the past two years alone, training and technical assistance to Tribes 
has increased and further collaborations have been built toward 
regional and multi-service facility exploration and development.
    We are constantly listening and learning from our Tribal partners. 
Best practices emerge from lessons learned. Knowing what one Tribe has 
discovered does not work allows us to share that knowledge with others 
experiencing similar issues to save critical time and resources. 
Offering locally-based training to correctional officer staff, and 
engaging a wide range of Tribal partners to develop policies and 
procedures for Tribal correctional facilities will also serve to 
strengthen related services in Indian Country. Community-based 
alternatives help to reduce the burden of overcrowding while offering 
many offenders a hopeful solution to breaking the cycle of alcohol and 
substance abuse. Linking efforts to results, the Department will 
continue to seek ways to improve its programs in practical ways that 
the Tribes themselves have helped to identify and design.
    This concludes my statement Mr. Chairman. I would welcome the 
opportunity to answer any questions you or other Members of the 
Committee may have. Thank you.

    The Chairman. Mr. Herraiz, thank you very much.
    I thank the entire panel. We have testimony from the BIA, 
from the Indian Health Service, and the Department of Justice.
    I am trying to understand. I have looked at the President's 
budget on these issues and you all have painted a pretty 
optimistic picture. I think, frankly, the picture is pretty 
pessimistic. So I want to ask a few questions about that.
    Mr. Rever, the replacement school construction program went 
from $83 million down to $46 million, now down to the 
President's budget request of $22 million. We have a $1.8 
billion backlog and we cut it in half and cut it in half again, 
and you are telling me that, gee, things are pretty optimistic 
here. I don't understand that. Why is this funding being cut in 
half when the need is so great?
    Mr. Rever. Mr. Chairman, if I may answer. The entire 
program of 184 schools are being addressed in accordance with 
our priority list of facility conditions. We certainly have 
made huge progress in correcting those in the most serious 
condition. That is where we concentrated our budgets in the 
first few years of this program.
    As we have moved forward and as we have assessed the 
facilities themselves, and as we have gone back and taken a 
look at do we really need to replace every school in the entire 
campus because there is a question here on do we really need to 
replace the entire campus. I personally have toured a number of 
schools and facilities, and it is my personal professional 
opinion, having been in this business a long time, is that 
maybe we don't have to replace the entire campus. Maybe we can 
take some of the buildings that are made out of concrete block 
and they have adequate roof structures and the design is 
current, that we ought to take a look at the way we are 
programming the replacement or replacement of individual 
facilities, and repair and upgrade of the existing facilities.
    The Chairman. I understand what you are saying, but did you 
recommend these budgets be cut? Notwithstanding what you just 
said, we still have replacement requirements. In the context of 
that question, the flash report by the Inspector Report of your 
department on May 31, 10 months ago, went out and looked at a 
number of schools and said these are severe deficiencies that 
have the potential to seriously injure or kill students and 
faculty, and require immediate attention to mitigate the 
problems.
    We have very serious problems, and it takes an Inspector 
General to go find them? I don't understand that. Why would you 
not have found these and corrected them?
    Mr. Rever. Well, in fact, Mr. Chairman and members of the 
Committee, I personally have found publication of that report 
by the Inspector General addressing those 14 schools, led a 
team of investigators, including safety officials and 
engineers, on a tour of every one of those facilities to take a 
look at the findings of the Inspector General. I will be more 
than happy to provide the Committee of our response to the 
Inspector General, including my trip report from that event.
    What I found was that we have what I would call a 
satisfactory process to identify all of the deficiencies listed 
in that report. In fact, when I went back and checked to make 
sure that we had identified and had corrective action plans in 
place for all of those facilities, that is what we found. Our 
database, and if I may, sir, the one that comes to mine 
immediately is the Chin-Lee Boarding School. I visited the 
Chin-Lee Boarding School because that was the one that the 
Inspector General pointed out as having the greatest life-
threatening deficiencies.
    What I found when I arrived on site were two structural 
engineering reports assessing the deterioration of the 
facility, making recommendations for repair and arrest of the 
subsidence that was evidenced in the foundations, and 
establishing a risk factor that was satisfactory to their 
professional judgment and opinion that were good enough to last 
for at least seven years, from five years to seven years, and 
the design and engineering contract to accomplish those 
corrective actions was already in place.
    So in fact, sir, we did know exactly what the condition of 
those facilities were. So we did the thing that all engineers 
do. We did a risk assessment. We relieved that risk. We have 
now programmed the replacement of that facility in our 
replacement facility construction program, and in the Fiscal 
Year 2009 budget it is in our program.
    The Chairman. I understand your answer. I don't understand, 
you come to us and you speak in positive terms after you have 
cut in half and cut in half again the school replacement 
program for Indian schools that have a requirement of $1.8 
billion backlog. We have Inspector General reports. I have been 
to these schools. All of us have been to these schools. The 
fact is, Indian kids are going to schools that are in 
disrepair. There is a big backlog, and you come to us 
suggesting we cut the budget in half last year, suggesting we 
cut it in half again with the President's budget, and you are 
happy with that.
    I understand you are paid to represent the President's 
budget, but I am telling you I think it shortchanges kids in 
these schools.
    Now, well, just let me go through this again. The Indian 
Health Service, all of us understand the backlog here. The 
suggest in the President's budget is let's cut that in half. 
Let's cut the funding in half for the facilities construction 
program in Indian health. That stands logic on its head.
    BIA jails repair and renovation program, let's cut that by 
30 percent. Department of Justice Tribal Jails program, let's 
zero that out. Let's not do anything. I mean, the fact is this 
makes no sense to me.
    Now, let me go back to this issue of jails, if I might. I 
have been to an Indian jail and seen a young teenage kid 
intoxicated laying on the floor of that jail in which adults 
are moving around incarcerated as well. We all understand what 
is going on. We have enough reports that will fill a library 
telling us what is going on.
    Now, Mr. Ragsdale, I said when I started, the fact is we 
had the Inspector General report. Then the Americans taxpayers 
have paid for a consulting study. In testimony, one of the BIA 
employees said that was going to be done, this was last March. 
Mr. Rivera testified before the Prison Rape Elimination 
Commission. He said the consultant report, the Shubnam 
Strategic Management Application report, which the taxpayers 
paid for, he said that is going to be ready. It is going 
through Director Pat Ragsdale, and then it will be open for 
public information I think in a month or two. That was a year 
ago. That was March a year ago.
    Now, my Committee staff met with you in August of last year 
to discuss these issues. We asked you about the Shubnam report. 
You said it would be ready by December. I called Carl Artman 
and talked to the Interior Secretary in preparation for this 
hearing, saying I want that released for this hearing. I want 
to find out what that consulting company found about the 38 
Indian jails that they assessed. Both said it is not going to 
be made available.
    I think that is arrogant. We paid for that report, and I 
don't understand why, if in March of last year you were 
apparently in possession of the report and your BIA folks said 
it was going to be released in a couple of months, and then you 
tell us it is going to be released in December, why are we 
sitting here in March of this year not able to access 
information about 38 different Indian detention centers?
    Mr. Ragsdale. First, Mr. Chairman, I will tell you that my 
projection that the report would be completed by December was 
my best estimate at the time. It has taken longer than that to 
fully review the report.
    With respect to Mr. Rivera's, not to be confused with Mr. 
Rever, statement before the commission, I think what Mr. Rivera 
was referring to--he was the head of corrections at the time, 
and I was the Director of the Bureau at the time and had been 
kept informed about the progress of the report--I think what 
Mr. Rivera was referring to was the first part of the report, 
the phase one part of the report.
    But I have been kept apprised of the progress of the 
report. We took our first look at the preliminary report, which 
was fairly complete----
    The Chairman. When was the report contracted?
    Mr. Rever. Mr. Chairman, the report was contracted in the 
year 2006.
    The Chairman. What did the contract require with respect to 
completion?
    Mr. Rever. The contract was modified several times.
    The Chairman. What did it require originally as a 
completion date?
    Mr. Rever. One year, sir.
    The Chairman. And so, when would it have been done?
    Mr. Rever. It would have been done in 2007, but if I may, 
sir, what happened was that it was two-phased and always 
planned to be a two phase report. One was a condition 
assessment of existing detention centers across Indian Country. 
We wanted to know what the condition was, not only the 
condition, but the operation concepts that were going on on 
tribally owned and BIA-owned and operated jails because we 
wanted to confirm what we knew, but expand the concept.
    We then took a look at what was being discovered as our 
consultant visited these jails. For the first time, we have had 
a chance to look at the combination of facilities and their 
condition, and the condition of those, and unfortunately the 
deteriorated condition of those facilities, had on the 
operation of the detention centers.
    We don't have heliports. We don't have adequate detention 
facilities. We have looked at the fact that we are putting more 
offenders in jail than we ever have before and we are letting 
some go. The statistics that we were getting for what the need 
was was much greater than what we anticipated because we didn't 
know, and now we do know.
    So in addition to that, it became very apparent to us that 
we can't just address the detention aspect of a justice system. 
That is why I talk about justice systems. It is the law 
enforcement and policing. It is the court system and then 
eventually the incarceration.
    The Chairman. Mr. Rever, I am sorry to interrupt you. All 
of us understand that. We understand that. I am asking you 
about a 1,000 page report that the taxpayers have paid for, and 
you have decided you would not share with this Committee 
because someone hasn't yet reviewed it. I am so tired of the 
bureaucracy and I am especially tired of the bureaucracy in the 
BIA. The fact is, we ought to have access to find out what did 
they discover about those 38 facilities. We paid money to 
discover that. We were told it was going to be available, and 
when we scheduled this hearing we expected it to be made 
available to us and it has not been. As you can tell, I am not 
happy about it because I think it is arrogant.
    Now, the fact is you come to us, all of you come to us, and 
say things are really swimmingly good. You know that they are 
depressing with respect to facilities in Indian Country on 
jails, health care and education. And you are recommending 
budget cuts--I don't know if you believe in them or not--but 
you come here and defend them. I mean, it is unbelievable to 
me.
    Well, I have taken more time. I have more questions, but we 
will have a second round.
    Senator Murkowski?

               STATEMENT OF HON. LISA MURKOWSKI, 
                    U.S. SENATOR FROM ALASKA

    Senator Murkowski. Thank you, Mr. Chairman.
    To continue with the Chairman's line of questioning on the 
report, recognizing that the report isn't here, I would agree 
with Chairman Dorgan, you have to question why. I think it is 
unacceptable that this many months after the fact we still 
don't have the report.
    But Mr. Rever, you have indicated that the assessment that 
you have made, or that you have been part of, recognizes that 
these facilities in, your word was ``deteriorating'' condition. 
So I think we can all assume that when we get this report, it 
is not going to be a pretty report. It is going to tell us what 
we know, and that is that these facilities are in deteriorated 
condition. They are completely inadequate. They were built for 
an era that has passed many decades ago. These inadequacies 
lead to a potential public safety crisis in Indian Country.
    I am not convinced that we are going to find anything in 
this report that is going to be a positive. I think we are 
going to learn that it is, as you say, a deteriorated condition 
and perhaps even worse. We know that.
    So the question then is, if you know that it is bad and is 
getting worse, why has the Administration asked for so little 
funding to make is work? Now, the Chairman has indicated in his 
comments that I think you said it was a 30 percent decrease in 
detention funding. I have just asked, and apparently there is 
some discrepancy in terms of the numbers, but whether it is a 
30 percent decrease or whether it is a $600,000 increase over 
last year, the question is why has the Administration not 
sought adequate funding, whether it is in this year's budget or 
beginning seven years ago when we recognized that we were going 
to be faced with this really terrible problem?
    Mr. Rever. I would like to take the opportunity to answer 
that, Senator.
    First of all, I have to clear up the purpose of the report. 
The purpose of the report was not to discover the condition of 
the facilities. We know what the condition of the facilities 
are. We do an annual inspection to determine what the condition 
of those facilities are. What the purpose of the report is is 
to identify the need. Nobody that I am aware of, that we have 
spoken to, has ever been able to quantify the deficiencies in 
detention facilities, law enforcement facilities, and tribal 
facilities across this great Nation of ours.
    We took the opportunity to do a master plan. What this is 
is a plan to correct what is this deficiency. We start out by 
determining what is the existing condition, and that took a 
year.
    Senator Murkowski. So are you saying that until you have a 
plan that recognizes the full extent of the situation that you 
are in, you are not willing to start work on some of the most 
clearly deficient facilities and increase that budget to allow 
for correction of that? That you are going to hold off until 
you know entirely what the full analysis is of all these 
facilities?
    Mr. Rever. Not at all, Senator. What we are looking at is a 
plan to integrate across Indian Country a cost-effective 
solution to the justice problem we have to address the rising 
crime rate on Indian reservations. It is a monumental task to 
be able to do that.
    We believe, and I think we are supported consistently by 
the Department of Justice, that we can't just solve individual 
problems. This is such a big problem that we have to look at 
the way the justice system works along Indian Country. Until we 
know what the need is and come up with a cost-effective 
solution--for instance, we know as a result of our study, that 
we are only incarcerating about 50 percent of the offenders 
that truly should have been incarcerated.
    Now, that number will not be reflected in any report that I 
see or Mr. Ragsdale sees because until you go out and actually 
visit the detention center and the law enforcement center and 
see that they take in offenders in the morning and release them 
before dawn to keep the count down because of health and other 
considerations, when we put four times and five times as many 
offenders in a jail than it was built for--until we knew that 
we wouldn't be able to identify the need.
    Now, this plan simply identifies the need. It identifies 
where we should have detention centers, and we created tiers, 
what should be locally----
    Senator Murkowski. But recognizing that you are waiting for 
a plan that clearly identifies the need without allowing for 
increases in the budget to take on what you know you are going 
to be faced with, I think is closing your eyes to the reality 
of your own report. You are going to get this report in a month 
or two or maybe more, and will be dealing with a budget that is 
hopefully not what the President has recommended, but it will 
have been your recommendation that we don't need to increase 
the budget at this point in time. So you basically put yourself 
yet another year behind.
    I want to ask one quick question of Mr. Herraiz, if I may. 
This is to the budget request that would, again, eliminate the 
tribal set asides for the grant allocations for detention 
construction, and instead would require that tribes basically 
compete with States and local governments for construction 
funding.
    I understand that there is a new tribal grant policy, but I 
am not quite sure what it says or what it does. What is this 
policy and what is the Department doing to make sure that the 
tribes can compete on an equal footing with the States and 
local governments as they go after these facilities 
construction funds?
    Mr. Herraiz. Senator Murkowski, members of the Committee, I 
became Director of the Bureau of Justice Assistance in 2004. I 
came from a background of working at the State level doing 
exactly what I do now in Washington for the Department of 
Justice, overseeing grant administration, linking the public 
policy.
    One of the experiences I have had has been recognizing that 
many times grant application processes are very cumbersome, 
require a lot of red tape solicitations that have way too much 
information and are confusing to the average person at the 
local level in tribal communities as well. So in 2005, I 
sponsored, with the Department, a listening tour if you will. 
We held a session in Alaska. We held two in the Lower 48, to 
focus on tribal issues, to figure out what are some of the 
concerns they had with the Indian Alcohol Substance Abuse 
Initiative that we had, Tribal Courts program that 
administered, as well as tribal construction.
    Within that context, a lot of the feedback we received was 
burdensome, the cumbersome process, not unlike I had heard 
before in my career. So working with the OJP tribal policy, the 
tribal initiative, the first piece that we were able to address 
is just that issue, to streamline the grant process and to make 
sure that burdensome requirements are not in there.
    Certainly, we have the requirements to partnership with BIA 
and make sure that those requirements are met, but in 
particular as it relates to the requirements of other things 
that we absolutely have in control that may be guidelines on 
our end, but are not regulations and are not statute that you 
all have created, we bypass that.
    So within that context, we have also created since I have 
been at BJA a tribal justice unit, as well as we have a tribal 
justice unit in the Office of Justice Programs, to oversee 
specifically those requests. What that means to you is that we 
can concentrate our effort, not diminish the results of other 
corrections programming that we have in BJA or other law 
enforcement initiatives, but absolutely concentrate 
specifically on tribal communities, so that we can address 
whatever planning issues, whatever construction issues, 
whatever translates.
    Drug courts, we have found in this time period, don't work 
the same, but healing to wellness courts do. So we need to 
tailor to the needs and conditions of the tribes to make sure 
that those resources are spent effectively.
    Senator Murkowski. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Senator Johnson?
    Senator Johnson. Between high schools, jails and schools, I 
don't know where to begin. But Mr. Rever, a specific example of 
the Lower Brule Indian Tribe is an excellent jail facility 
built by the Department of Justice, and it is woefully 
understaffed. The problem is there are no women, no juveniles, 
and a small amount of males allowed in the jail. The BIA police 
aren't even allowed to move their offices to the facility.
    Do you ever talk to the Department of Justice about that? 
How do you explain that?
    Mr. Ragsdale. Thank you, Senator.
    With regard to Lower Brule, let me first of all say that 
Chairman Jandreau, the leader of the Lower Brule Tribe, has 
exercised a lot of forbearance, and we do have a schedule to 
make the facilities fully operational, including moving the 
police department into the facility, which the tribe wants us 
to do.
    We have had difficulty fully staffing the facility. In the 
report that we talked about that has not been released, we 
address some of the other ancillary problems that we have in 
staffing when we have a lack of housing and so forth. I regret 
that we have not been able to fully staff the facility, but we 
do have a plan and a schedule to do that that we have shared 
with your staff, and we have made significant progress.
    With regard to the police department being allowed to move 
into the facility, we have had some difficulty with GSA, who is 
the responsible office to authorize leasing of space for 
Federal agencies. We have not been granted a delegation of 
authority from GSA to lease the space, even though the Chairman 
has graciously offered to give us a $1 lease or a no-cost lease 
to staff the facility. We are anxious to move our police 
department in there, but have not been able to do so thus far.
    Senator Johnson. What is your estimation of the time line 
to get the police department folks in there?
    Mr. Ragsdale. Well, I believe that we do have the staffing 
for the adults, and we just have so many different schedules 
for facilities and operations. I don't recall the specifics, 
but we did provide that to your assistant just this week. We 
had a full meeting and gave him a progress report, so I would 
rather defer.
    Senator Johnson. Do you understand the terrible 
inefficiency of hauling prisoners hundreds of miles away, 
utilizing the police for to transport the prisoners? The police 
force is already understaffed in too many cases.
    Mr. Ragsdale. Yes, sir. I totally agree with you. It is 
inefficient, and it does put a strain on the limited law 
enforcement personnel that we have to have to transport not 
only for Lower Brule, but for many other tribes, inmates and 
juveniles for hundreds of miles.
    Senator Johnson. Mr. Chairman, I have no other questions.
    The Chairman. Thank you.
    Senator Barrasso.
    Senator Barrasso. Thank you, Mr. Chairman.
    I share the concerns and we have problems in Wyoming with 
health facilities, with schools, with the same things we are 
talking about in terms of law enforcement, and continue to ask 
questions, and I will continue to ask questions about that.
    We look at our two health care facilities and our centers 
in Wyoming. The Fort Washakie Health Center, as I mentioned 
earlier, was built in 1877 to house cavalry units. Tribal 
leaders tell me that it was renovated in the late 1990s, but 
just with the addition of some exam rooms. This is not 
adequate. The conditions that we have really don't meet the 
needs of our 11,000 users of the reservation's health system so 
it can operate.
    Mr. Grinnell, could you explain to me how the Indian Health 
Service is working to provide a fair system to make sure that 
the Indian health care facilities in Wyoming are updated to 
meet a reasonable standard of care?
    Mr. Grinnell. I would like to defer to my colleague, Mr. 
Hartz, please.
    Mr. Hartz. Thank you, Senator.
    The facilities are in good shape from a maintenance 
standpoint, we look at the supportable space, the health space 
that the tribes run as well as what we run, and we distribute 
resources based on the space identified in each of the 
locations.
    As far as addressing the needs of facilities to be replaced 
or to build new, we have direction from the Congress to develop 
a priority system to take a look at all of the health services 
and facilities needs across Indian Country. First looking at 
what the health service requirements are, health services 
needs, and then from that determination, whether in fact there 
is a need for replacement of a health facility or a new one or 
some other means by which the health services would be 
addressed. But it is a comprehensive effort that is underway 
per congressional direction, sir.
    Senator Barrasso. Mr. Chairman, I have additional 
questions. Maybe I could submit those, because I know the vote 
has been called and Senator Tester hasn't had a chance yet. So 
with your permission, I would defer.
    The Chairman. Senator Barrasso, thank you.
    Senator Tester?

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Senator Barrasso, you are too kind.
    Thank you, Mr. Chairman. I really appreciate it.
    Just to recap real quick, Mr. Rever, you are facilities for 
jails and schools, correct?
    Mr. Rever. Yes, sir.
    Senator Tester. And Mr. Grinnell, you are IHS facilities 
for medical facilities, right?
    Mr. Grinnell. Yes, sir.
    Senator Tester. How many years have you been on the job, 
Mr. Rever?
    Mr. Rever. I have been on this job two and a half years.
    Senator Tester. Two and a half years?
    Mr. Rever. Yes, sir.
    Senator Tester. Mr. Grinnell?
    Mr. Grinnell. Six months in this position.
    Senator Tester. Six months in this position.
    Can you give me any idea, Mr. Rever, how many dollars have 
been spent on construction during your two and a half year 
tenure?
    Mr. Rever. Yes, sir. We have put in the ground upwards of 
$300,000 a month. So I would say over the last two years, we 
have been able to, about $280 million.
    Senator Tester. At $300,000 a month, that correlates to 
$280 million?
    Mr. Rever. I am extrapolating to cover other items as well. 
We spend a lot of money on architect, engineer, design studies.
    Senator Tester. I am talking about building facilities, not 
architecture, not design, none of the stuff--actually building 
a facility. How many dollars have been spent?
    Mr. Rever. Sir, I may ask----
    Senator Tester. Bricks and mortar.
    Mr. Rever. Schools only?
    Senator Tester. Schools and jails.
    Mr. Rever. Schools and jails. I haven't built any jails 
since 1993. That is not part of our purview, but we are putting 
$8 million a year into improvements and repairs over the last 
two years.
    Senator Tester. Okay. And this isn't architectural stuff; 
this is actually hiring the people to lay the foundations and 
build?
    Mr. Rever. Yes, sir. And probably over the last two years, 
put about $300 million in the ground.
    Senator Tester. Okay, $300 million you have spent on bricks 
and mortar?
    Mr. Rever. Yes, sir.
    Senator Tester. What was the $8 million for?
    Mr. Rever. The $8 million was improvement and repairs to 
detention facilities, sir.
    Senator Tester. Improvement. How many dollars have been 
spent on studies?
    Mr. Rever. Just on the study that we have completed, 
probably $40,000 or $50,000 all together.
    Senator Tester. About $40,000 or $50,000 all together.
    Mr. Rever. Yes, sir.
    The Chairman. Senator Tester, if you would yield, what was 
the cost of the Shubnam Report?
    Mr. Rever. I don't know, sir, in exact dollars. I will have 
to provide that to you.
    The Chairman. That can't be included in your estimate.
    Mr. Rever. No, sir, it was not.
    The Chairman. That would be a very large contract, I 
assume, or a significant contract. This is a California 
consulting company that worked for you. So that is not a part 
of your answer, right?
    Mr. Rever. No, sir. It was a very reasonably cost study, 
sir.
    Senator Tester. And that $300 million you spent is over 
your two and a half years in this job?
    Mr. Rever. Yes, sir.
    Senator Tester. Could I get a list of those projects?
    Mr. Rever. Yes, sir. You certainly may.
    Senator Tester. Okay.
    How about you, Mr. Grinnell? Can you give me an idea on 
what you spent? I don't know. It has been six months, so it is 
kind of a null and void. Let me get to my point, because we do 
have a vote going.
    It appears to me just from the limited testimony that I 
have seen here today, and I want to tell you something. I come 
out of the Montana legislature, and the last people I want to 
attack are people who work for the government. Truthfully, I 
appreciate your being here and I appreciate the job you do. 
But, and this is a big ``but,'' when you get out of bed in the 
morning you have to ask yourself how you are going to make 
things better in Indian Country because there are a lot of 
things that need to be made better.
    In your particular area, it is about construction of 
schools and medical facilities and jails. I am going to focus 
on schools and medical facilities, although jails are probably 
equally as important. If we don't have adequate medical 
facilities, it doesn't matter how much money we pump into 
Indian health care. It is not going to improve.
    The same thing with schools. In Montana, every at-risk kid 
in the State of Montana is Native American. That is the one 
thing No Child Left Behind has done that is good. And part of 
that is the people in the classroom, but the other part of it 
is the classroom.
    And so when you get out of bed in the morning, I would hope 
you say to yourself, if somebody above you is saying, you know 
what, we are going to cut school reconditioning from $83 
million to $46 million to $22 million, that you protest 
violently. Because I think every one of you people have skills 
and if they fire you for that reason, that is a reason to get 
fired. And it is the same thing for health care facilities.
    I don't mean to lecture anybody here, but we have seven 
reservations in the State of Montana. I am sure it applies in 
North Dakota. I am sure it applies to Wyoming. Alaska's got a 
little different thing going, but it probably applies to 
Alaska, too. We have major problems. And when we send dollars 
out and they are spent on study after study after study and 
nothing is done, that is almost criminal and it is certainly 
not what I would anticipate from the people who are in the 
positions you are in. Because we can do all the policy-making 
we can here, and if you don't carry it out on the ground, it is 
all for nought. You guys make it happen.
    With that, I do have some questions. We do have a vote. I 
do have some questions I will submit for the record.
    Thanks you folks for being here. I want the next time we 
come together to meet to be positive and talk about the things 
we have going and talk about the future and what the long-term 
plan is, and how we can move forward to make things better. But 
the truth is, the Chairman pointed it out, you can't be 
positive about this budget and there is no harm in saying that, 
because it is a wreck in Indian Country. It honest to God is a 
wreck. And we have to fix it and we will. With your help, we 
will fix it right.
    The Chairman. Senator Tester, they would lose their job if 
they said it was a wreck. That is the problem. I mean they come 
here representing the Administration's budget, but the Bureau 
of Indian Affairs education construction account, that is not 
the replacement for schools. That is the go in and repair. It 
is to respond to what the Inspector General says in their flash 
warning. Kids could die, very serious problems.
    The proposal, you know, we used to be $250 million a year. 
In 2007, it went from $205 million down to $142 million. Now, 
they request it down to $115 million. You are presiding over a 
substantial reduction in the amount of money available to meet 
a dramatic need. I described earlier the school replacement 
program cut in half and cut in half again. I mean, it just 
doesn't work.
    I understand how you answer these questions, but I am very 
disappointed because we are faced with responsibilities, trust 
responsibilities, treaty responsibilities. And then we see 
these budgets and you are trying to suggest that, you know 
what, things are going pretty well. And frankly, they are not.
    Senator Domenici last year, a year ago, asked both Justice 
and BIA whether you have responded. The Inspector General 
recommended that there be a strategic plan between Justice and 
BIA with respect to this issue of jail replacement and 
renovation. He asked for a response from you, and we would like 
as well a response. Have you done a strategic plan between the 
two? If so, what is it? Can you submit it to this Committee?
    Because there is a vote ongoing, if you will just think 
about that. We will take a 10 minute recess, go vote and be 
back. We appreciate your indulgence.
    [Recess.]
    The Chairman. The Committee will come back to order.
    Senator Murkowski?
    Senator Murkowski. Thank you, Mr. Chairman.
    I just had one very quick question for you, Mr. Grinnell. 
This is on the status of the Barrow Hospital up north. Under 
the current facilities priority system, we have approximately 
five in-patient facilities. Barrow and Nome are at the top of 
that. The question is when do you anticipate that you will be 
able to finish the final stage of construction for the Barrow 
Hospital?
    Mr. Grinnell. Mr. Hartz, he has the specifics on that 
project.
    Senator Murkowski. Okay.
    Mr. Hartz. Thank you, Senator Murkowski.
    We are pleased, as you probably well know, to announce that 
construction is underway with the participation of the Denali 
Commission. They started laying rock on the pad that IHS 
purchased for the new site. Our five year plan that outlines 
the schedule for completion of the project is obviously 
dependent upon the level of appropriations. The $15.8 million 
that we are asking for in the current fiscal year, 2009, will 
permit us to continue that process of moving forward on the 
construction of the facility.
    Senator Murkowski. So you haven't told me when you 
anticipate construction to be complete.
    Mr. Hartz. I have all this stuff here and I do have it.
    Senator Murkowski. If you could just provide that.
    Mr. Hartz. Here we go. No, we have it right here. I am 
sorry. We had so much fun at the break that I mislaid some of 
my papers. Here we go.
    Based on our projections of how the project could proceed 
forward and where we have identified the mid-point of 
construction, we would look at the completion of the funding in 
Fiscal Year 2011. So we would be looking at completion of the 
project probably in Fiscal Year 2012, late 2012.
    Senator Murkowski. As you know, we are anxiously awaiting 
not only completion of that facility, but the one up in Nome.
    Mr. Hartz. Yes, we understand that. We are anxious, too.
    Senator Murkowski. Thank you, Mr. Chairman.
    The Chairman. Mr. Grinnell, describe for me again the 
justification for an Indian Health Services construction 
program being reduced from what used to be $90 million four 
years ago, down to last year at $30 million, and this year at 
half of that, down to $15 million. Describe the rationale for 
that.
    Mr. Grinnell. Yes, Mr. Chairman. I would like again to 
defer to Mr. Hartz, as he has the specifics on that.
    Mr. Hartz. Thank you, Senator.
    As we all recognize, we are in tight budget times, but I 
would like to highlight the fact that even the facility at Fort 
Washakie that Senator Barrasso identified, as aged as it is, we 
did make major efforts to maintain accreditation of these 
facilities and to ensure that they qualify for Medicare/
Medicaid reimbursements, et cetera. And that is really critical 
to the business that we are in, namely health care delivery.
    Other than the fact that we are in severely tight budget 
times and the priorities that the agency puts on the delivery 
of much-needed health care, I don't have a better answer than 
that today, sir.
    The Chairman. Could you tell me what was requested from 
your agency going up through the budget process? Did you 
request a reduction by 50 percent in Indian Health Service 
facility construction?
    Mr. Hartz. The agency per congressional request develops 
and provides a five year plan to the Congress. It is a public 
document that we provide. It is from that I responded to 
Senator Murkowski's question about what the projections are in 
the out years for keeping these projects moving off the 
priority list. As these projects develop, the designs develop, 
and they come ready for construction, you folks fund 
construction, and we get ready to identify the next phase, 
trying not to delay the mid-point of construction which is 
critical to these cost estimates. We actually do identify a 
could use column on our chart that is part of the public 
record.
    The Chairman. And what does it suggest ``could use'' for 
Fiscal Year 2009?
    Mr. Hartz. For the facilities on the priority list that we 
have discussed over many years with the staff and the 
congressional delegation runs about $260 million.
    The Chairman. About $260 million.
    Mr. Hartz. That is a public document that relates to 
priority projects.
    The Chairman. I understand. That is in Fiscal Year 2009?
    Mr. Hartz. That is not a request. That is a ``could use.''
    The Chairman. I understand.
    Mr. Hartz. Okay.
    The Chairman. Well, what is it, then? I understand it is 
not a request, but tell me what the line is?
    Mr. Hartz. It is approximately $260 million.
    The Chairman. You said it is not a request. So what is it?
    Mr. Hartz. It is a ``could use,'' because projects 
progress.
    The Chairman. I understand.
    Mr. Hartz. They go through varying stages and as we get 
closer in the development of the need, we deal with it in 
``could use'' amounts.
    The Chairman. So first of all, we have a need that we have 
identified. We have a total backlog of about $9 billion, 
regrettably. You have identified that you could use in this 
fiscal year $260 million and you request $15 million. Is that 
accurate?
    Mr. Hartz. We request the priority for the health delivery. 
Facilities in IHS, HHS and across Government facilities are not 
the priority need as other services.
    The Chairman. I understand. First of all, we asked you to 
be here. I appreciate your coming. You serve in public service. 
I appreciate your service in public service. But I hope you 
understand that when I say I am terribly disappointed with this 
budget, and I would not want to be in your position, to come to 
a committee and try to paint this as something that is good 
news. It is not good news. It is not in my judgment an accurate 
reflection of where our responsibilities are. We are moving 
backwards, not forwards, on things that deal with life and 
death, especially with respect to health care issues.
    I can tell you that I went to a facility recently that is 
in disrepair and crowded and so on, and they said, well, this 
is the space we are going to get the new x-ray machine, which 
is going to be a dramatic improvement for us. They said they 
have not been able to get it. It has been two years now since 
we have been able to get the request in and get it responded 
to.
    And I said, why is that? Well, we don't know. The money was 
available, but it just took a long, long time to get it through 
the area office and the regional office. And I walked away 
thinking again, so we have people out in the waiting room, a 
full waiting room, and they don't get the access to a brand new 
machine, an x-ray machine that should have been there, because 
of the bureaucracy. It just drives me--well, I am very 
disappointed.
    These numbers reflect in my judgment a lack of progress and 
a lack of recognition of the urgency and the need. I wish that 
you would come to us with better news. I understand and wish 
that you could answer my questions. Dr. Grim never would 
because he said he never could. But my question would be, what 
did you request? And if you could answer it and would, you 
would probably be fired for answering it on the record, but if 
you could answer it and told me you requested a cut by 50 
percent in this Indian health care account, I would say you 
should not be in this job, either of you.
    But I don't think that is what you requested. I think you 
would have requested some additional funds because you know 
they are needed and that it goes through the machinations and 
up through the crawl spaces in Government and through the 
Office of Management and Budget and it turns out they want to 
cut that particular account in half, and they send you up here 
to put a necktie on and a suit on to justify it. And that can't 
be very comfortable if you feel as I think you probably feel. 
So I don't mean to lecture, but I am not happy.
    Mr. Ragsdale, I would tell you I am not happy at all with 
how this has worked out with the Shubnam report. I understand 
it is a two-phase report and almost a year ago you got the 
preliminary report, at least in the first phase. The first 
phase is the most important phase for us. The first phase is 
the most important. Let's understand what they found in those 
38 facilities. You have had that for a long period of time, and 
I am going to get to the bottom of that and I hope you have 
testified accurately about it.
    Mr. Ragsdale. Mr. Chairman, if I may. We are anxious, and I 
know that the Assistant Secretary is anxious to release this 
report. I believe this report will provide the executive and 
legislative bodies of this Government a blueprint of where we 
need to go in the future. It is a very comprehensive report. It 
has been reviewed internally within the Bureau of Indian 
Affairs, that in fairness we want to share that with the 
Department of Justice and go through the report, it is a very 
detailed report, and make it available to the Committee and to 
the Indian tribes as soon as possible.
    I regret that it has taken longer than I thought it would, 
but that is just part of our process.
    The Chairman. Well, the Department of Justice is no more 
important than this Committee, and to the extent that you are 
sharing things, you ought to share it with this Committee as 
well as the Department of Justice. I have people calling the 
consulting company to find out, (A) what it would cost, and (B) 
when did you get the two phases. And I believe you have had the 
first phase for a long period of time. That first phase should 
have been made available to this Committee for this hearing. 
There is no excuse for it not being made available. I spoke to 
the Secretary specifically and personally. I spoke to the head 
of the BIA personally. And we have been informed, you informed 
us, that it had been available last December. You informed our 
Committee of that, Mr. Ragsdale.
    So I am a pretty unhappy guy about this because I think the 
BIA has stiffed this Committee. We will see.
    Let me with that happy note, thank you for being here. At 
our request, you have come today to give us your description of 
where we are. I will ask if the Committee members have 
additional written questions they wish to submit to you that 
you would respond to those written questions and give us the 
opportunity to inquire further.
    Let me thank you for being here and we will release you and 
ask if we can have the final set of witnesses come forward.
    I would like to call up the second panel, the Honorable 
Wendsler Nosie, Chairman of the San Carlos Apache Tribe. From 
the Navajo Nation, we have Mr. Monty Roessel, Executive 
Director of the Rough Rock Community School in Chinle, Arizona. 
We have Ms. Valerie Davidson, Senior Director of Legal and 
Government Affairs at the Alaska Native Tribal Health 
Consortium located in Anchorage, Alaska. Ms. Davidson is 
accompanied by Mr. Rick Boyce, the Director of Health 
Facilities at the Consortium.
    We appreciate very much you coming, and we are sorry that 
we have been delayed some, first by a vote and then a lengthier 
stay with the first panel. But you have traveled in many cases 
long distances to be with us to provide some of your testimony.
    We will ask that you summarize your testimony. Your entire 
testimony will be made a part of the record. So if you would do 
us the service of summarizing it, we would appreciate that.
    We will call first on the Honorable Wendsler Nosie, the 
Chairman of the San Carlos Apache Tribe. Mr. Chairman, thank 
you very much. You may proceed.

 STATEMENT OF WENDSLER NOSIE, CHAIRMAN, SAN CARLOS APACHE TRIBE

    Mr. Nosie. Thank you, Mr. Chairman and the Committee.
    First of all, I just want to again say my name is Wendsler 
Nosie, Sr., the San Carlos Apache Tribal Chairman in Arizona. I 
have with me Councilwoman Bernadette Goode and also I have 
Ollie Benaly, who is the Chief of Police, Todd Winger, who is 
the Construction Director for the new health care facility, and 
Paul Nosie, who is with the detention center.
    What I would like to express deeply is to be very frank. I 
am very honored to be here, and with the chosen words of the 
Committee, with the amount of feeling that was put into it. At 
one point in your discussion, I wish I was sitting at your 
panel and asking questions as well, because there are many 
reports that we do for the Federal Government, the BIA, that 
are submitted, and also with IHS, which outlines the total 
needs of Indian problems in Indian Country. I come to wonder 
where do those reports go and who is reading them? Because in 
those reports, it outlines the great needs.
    What I would like to discuss is the health care issue. The 
health care with the facility has been a great need, like any 
other tribe. I have been with the Tribal Council as a 
councilman for seven and a half years and served as the Tribal 
Chairman for one and a half years. As I travel around Indian 
Country, the voices are the same. The cries are the same. The 
great need of more funding and appropriations, that if 
Washington could only earmark more money to the tribes, then we 
would become--well, two things will actually happen. The care 
of our people will be taken care of, and in the future we would 
have a better vision of where we are going as a tribe.
    It is important that all agencies understand that. One of 
the things that we also talk about is the government-to-
government relationship, the partnership. That actually should 
be exercised to the fullest. As I have learned and come to 
understand the reports that are given here to Washington are 
very crucial because they tell you of Indian Country and the 
great needs.
    Now, we can relate back to our elders to where they had 
discussed to us, the younger people, waiting for the time that 
things will be better and still waiting for health care. We 
have many of our elders who have passed away because of the 
type of services we are getting, based on lack of funding for 
staff. The hospital is obsolete. Just like in any other 
community, the numbers are rising. We are up to more than 
13,000 people, and that does not include other people from 
other nations that live within the tribe. So it seems that 
funding-wise, it is never being planned for the future, for the 
increase in numbers.
    So now we are at a point with our health facility of taking 
on self-determination. We have pictures here that you can see 
our health care what it looks like. It is important for us to 
become self-governing. I think in 1975, it was once passed and 
talked about that self-governance is a very important policy. 
At this time and age, the tribes have taken that initiative to 
become self-governing. Why? Because if IHS was giving the 
services that we needed, we won't going that route, if it was 
acceptable.
    At this point, we know that we have to establish our own 
destiny of where we are going to go, but it has to be in a 
partnership in the agreements of the long treaties that have 
set between the Apaches and here in Washington, but also with 
all tribes. So it is important that we understand, that the 
agencies understand, that self-governance is very important to 
us, to create a future for our unborn children so that we know 
what our greatest needs are. We know what our greatest health 
care should be, but we need the cooperation in order to get it 
done.
    An example is the detention center. I can honestly say that 
with the funding, the agencies were able to listen, listen to 
the needs of what was needed for the tribe. And so building, 
the facility was built with a lot of cultural input, so that we 
can not only have it as incarceration, but also have it as a 
healing place as Native people, because these people here are 
our community members, our friends and neighbors, our children. 
It is important that this type of process is taking place so 
that we can work in a unified effort in the better need of our 
people.
    But we have that information. That is why I go back to the 
very first thing I said. I kind of wonder. I see monthly 
reports from our 628 programs that are submitted to the BIA 
agency. Now, where does it go from there? Those reports outline 
the great needs. I have been here, as I was saying, a year and 
a half as the tribal chairman, and have been here several times 
lobbying for more funds, that your appropriation would be 
higher so that it could benefit all tribes across this Country.
    Mr. Dorgan, I want to thank you for the bill that was 
passed last week. It is very important for us to know that 
there is people here in Washington that know the living 
conditions, the education conditions and the environment that 
we're living in is very important. Because if those issues are 
not addressed, it is very harming to our people, because 
actually what are we teaching them? What are we teaching them 
through the detention center. What are we teaching them through 
health care and education? If the Indian people have a future, 
then it is very, very important that the United States 
Government relates back to its trust responsibility.
    That is basically just listening, hearing the great needs 
of the tribes. I realize that I sit here probably representing 
all of the nations that are not able to be here. I know that 
that is one thing that I would really stress is the 
appropriation of funds.
    We can't live this way. We can't continue this way. We need 
a true partnership, a true government-to-government 
relationship. Because I like to see those in our community that 
only have so many years to live to know that the Federal 
Government is finally exercising the true trust responsibility 
that they had mentioned years and years ago.
    Mr. Dorgan, again I want to thank you. I appreciate this 
opportunity and this hearing because it is very vital. We are 
talking about lives. We are talking about souls. And we are 
talking about the future for Indian Country. I know we have a 
rightful place in this Country if we are given that 
opportunity.
    So Mr. Dorgan and your Committee, I thank you for this 
opportunity and we do have our written testimony submitted.
    [The prepared statement of Mr. Nosie follows:]

Prepared Statement of Wendsler Nosie, Chairman, San Carlos Apache Tribe

Introduction
    Thank you, Chairman Dorgan, Vice-Chair Murkowski, and other Members 
of the Senate Indian Affairs Committee, for allowing me the opportunity 
to testify today. My name is Wendsler Nosie, Chairman of the San Carlos 
Apache Tribe, based in San Carlos, Arizona. We commend the Committee 
for holding this important hearing on the state of facilities in Indian 
Country so that we can shine a light on this very serious problem. The 
backlog for jails, schools, and health facilities is staggering. Like 
other tribal communities, the needs on my Reservation for adequate 
facilities to provide the health care, law enforcement, and educational 
services that my people deserve far exceed the level of support 
provided by the Federal Government.
    My testimony primarily focuses on our experiences and struggles to 
build a new IHS outpatient clinic replacement facility and our recently 
built Adult and Juvenile Detention and Rehabilitation Center. But I 
would be remiss if I did not mention that I recently received 
information from the BIA that it plans to condemn San Carlos' police 
building, which houses the San Carlos Police Department, Tribal Courts, 
and the BIA criminal office, because of its poor condition without 
offering any assistance to find resources to construct a new building 
even though Secretary Kempthorne and the Department of the Interior 
have used San Carlos and its violent crime and serious methamphetamine 
problem as an example in its budgets in brief and press conferences 
over the past few years to justify increases to law enforcement. 
Indeed, two years ago, San Carlos testified before this Committee about 
the devastating effects of meth on its community. The Tribe has a self-
determination contract for police services, but the BIA owns the 
facility and is responsible for its maintenance and operations. Due to 
its poor condition, the BIA wants the Tribe to assume ownership of the 
building.

Failure of the Federal Government to Provide Adequate Facilities
    The Federal Government has failed in its trust responsibility to 
provide adequate facilities to the San Carlos Apache Tribe and to other 
tribes across the country. The agencies, the White House, the Office of 
Management and Budget, and the Congress, have all shirked their 
responsibilities to provide adequate resources to Indian Country so 
that we can rebuild and provide for our communities.
    The condition of facilities on my Reservation and in the rest of 
Indian Country is unacceptable in this great country of ours. Let me be 
clear that the San Carlos Apache Tribe supports our troops in Iraq, 
Afghanistan, and other parts of the world. The Apaches have many 
decorated war veterans that have served with distinction in the United 
States military throughout this country's history. However, I wonder 
about some of the priorities of the United States when my community 
needs to be rebuilt, my people need decent health care, my people need 
safe communities, and my people need infrastructure. When I hear about 
the billions and billions of dollars the United States is spending to 
rebuild Iraq, to build homes, jails, governmental buildings, hospitals, 
and schools for the Iraqi people, I wonder why the United States will 
do these things for the Iraqi people but not for its own citizens in 
the United States.
    The solution to this problem is obvious. The Administration and the 
Congress must dramatically increase funding to construct new facilities 
as well as funding to operate and maintain these facilities when they 
go on-line. Because of the Federal Government's failure to provide 
adequate funding over the past decade, we are seeing astronomical 
backlogs. In the area of health facilities, there is an avalanche 
effect where tribes with unmet health facilities needs in certain parts 
of the country are seeking to redistribute funding for health 
facilities that could adversely impact other tribes, such as San 
Carlos, who have equally, if not more pressing, unmet health facilities 
needs. This unfortunate situation played out on the floor of the Senate 
during passage of S. 1200, the Indian Health Care Improvement Act.
    For example, the appropriations for IHS health facilities over the 
past 9 years have been stark as illustrated by the chart below:



    The President's budget requests and as well as the budget requests 
under the Clinton Administration for facilities construction have been 
deplorable. In FY 2005, the President's budget requested a moratorium 
on IHS facilities construction using the rationale that steel prices 
were too expensive. Needless to say, this explanation does not make 
sense when construction is going on all around us and all over the 
world. Unfortunately, the President's budgets' utter lack of support 
for IHS facilities construction has set a tone that Congress has 
followed over the years as the Congress has only provided minimal 
funding for health facilities. For example, for FY 2008, $32.6 million 
was allocated for facilities construction even though there are at 
least 24 facilities on the construction priority list ready for 
planning, design, or construction dollars. If you are familiar with 
construction, then you know $32.6 million does not go far when building 
new health facilities that must be able to serve the community for at 
least the next 60 years.
    Our hope is that all of our efforts within Indian Country, in the 
Administration, and in the Congress can be used in a positive direction 
to significantly increase appropriations. We must work together and, 
through our collective strength, address the facilities backlog. The 
San Carlos Apache Tribe urges a Call to Action of the Congress from 
Indian Country to increase appropriations. We understand that other 
tribes and tribal organizations are also discussing this same idea. We 
stand ready to assist in this effort.
    I believe that this hearing will help jumpstart the efforts to 
secure badly needed appropriations for facilities in Indian Country. 
Also, I believe it would be helpful if the Committee could hold some 
field hearings or listening sessions in Indian Country on this issue, 
so that Members could see for themselves the conditions that families, 
community leaders, health care personnel, social services staff, 
detention personnel, police officers, school administrators, teachers, 
and students in Indian Country must grapple with every day due to poor 
facilities.
    In addition to improving the bleak appropriations situation, we are 
hopeful that this hearing and subsequent hearings and meetings will 
spur action within the agencies to reform their current processes to 
provide us and other tribes with increased flexibility, greater self-
determination, less administrative burden, and greater control over the 
construction and operations of new health care facilities. For example, 
the Tribe's experience working with DOJ in constructing its Adult and 
Juvenile Detention and Rehabilitation Center in the late 1990's is a 
true success story and illustrates what tribes can achieve when given 
sufficient funding and flexibility. The Tribe has had, unfortunately, a 
less than optimal experience with the IHS in its struggle to build a 
new outpatient clinic due to limited funding and an overreaching 
construction process. The current process at IHS is not 
institutionalized and allows the goal post to be moved. This is 
problematic as it indicates to us that the sovereignty of tribes is not 
truly understood and that the principle of government-to-government 
transfer of control to tribes in the construction and operation of 
health care facilities is paid little heed.

Background on the San Carlos Apache Indian Reservation
    To better understand the needs on the San Carlos Apache Indian 
Reservation as well as the Unites States' trust responsibility to the 
San Carlos Apache Tribe, it is helpful to know about the Reservation 
itself as well as the history of the Apache people. The aboriginal 
territory of the Apache Nation included the western part of Texas, the 
current states of Arizona and New Mexico, and part of the country of 
Mexico. The Apache Treaty of Santa Fe in 1852 was executed by Mangus 
Colorado and others on behalf of the Apaches. Pursuant to the Treaty, 
lands within the aboriginal territories of the Apache Nation were to be 
set aside for a permanent Tribal homeland and the United States 
promised to provide for the ``humane'' needs of the Apache people. In 
exchange, the Apache Nation agreed to the end of hostilities between 
the two nations.
    The San Carlos Apache Indian Reservation was established by an 
executive order of President Grant on November 9, 1871. Through the 
concentration policies of the United States, various bands of Apaches 
were forcibly removed to the San Carlos Apache Indian Reservation. 
These bands included the Coyoteros, Mimbrenos, Mongollon, Aravaipa, 
Yavapai, San Carlos, Chiricahua, Warm Springs, and Tonto Apaches. 
Famous Apache leaders who were located at San Carlos included Geronimo, 
Cochise, Loco, Eskiminzin, Nachie, Chatto, and others. Throughout 
history, the United States in 1873, 1874, 1876, 1877, 1893, and 1902 
diminished the size of the Reservation several times by executive order 
due to the discovery of silver, copper, coal, water, and other minerals 
and natural resources.
    The San Carlos Apache Reservation is located 2 hours by car from 
Phoenix. Our land base is 1.8 million acres, but only a small 
percentage of the Reservation can be used for building purposes. The 
remainder of the Reservation is comprised of some of the most rugged 
terrain in the Southwest, including deep stands of timber, jagged 
outcroppings, and rocky canyons. As a result, the Reservation lacks 
infrastructure in all but two general areas. On the western edge of the 
Reservation, the Tribe has 3 districts: 7-Mile Wash, Gilson Wash, and 
Peridot. Located on the eastern edge of the Reservation is the District 
of Bylas. All together, these 4 districts are home to 13,456 tribal 
members. Approximately 84 percent of our tribal members live on the 
Reservation. Although we have worked hard to develop our Reservation 
economy, 76 percent of our population is unemployed, and the poverty 
rate on the Reservation is 77 percent. The population of the Tribe 
continues to increase and more than 30 percent of the population is now 
under the age of 18 years. New young families are in desperate need of 
decent health care, education, and safe communities.

Struggle to Build IHS Replacement Health Facility
Antiquated Current Facility
    Our existing facility is located in San Carlos in Gila County. It 
was built 48 years ago in 1962. It has 8 beds and its limited services 
include ambulatory care, emergency room, community health programs, 
dental, and administration. Patients requiring surgical procedures and 
complex medical cases are referred to the Phoenix Indian Medical Center 
in Phoenix or to contract health care hospitals. This means that 
helicopters frequently go back and forth between Phoenix and San Carlos 
to rush urgent care and trauma patients to hospitals in the valley.
    IHS has documented numerous deficiencies at our current health care 
facility rendering it inadequate for present operations. The current 
health care facility is being used beyond its full capacity. The 
facility is severely understaffed and lacks adequate equipment, program 
services, and physical space to adequately meet the medical and other 
healthcare needs of tribal members. To give an idea of the space 
deficiencies in the clinic, IHS, based upon workloads at the current 
clinic, has determined that the new clinic needs 31 examination rooms. 
The current clinic only has 13 examination rooms. Due to lack of space, 
sick and elderly patients currently have to wait a long time to be 
examined or to get prescriptions filled. The current clinic sees on 
average 200 patients a day with a total of over 6,000 patients per 
month. The Tribe over the years has heard frequently from IHS staff 
that the current San Carlos health clinic is one of the worst 
facilities in the IHS system.

Long Road To a Project Justification Document for a New Facility
    The project plan for the new clinic would allow the Tribe to bring 
some fundamental healthcare services back home to the Reservation as 
well as address unmet medical needs of the Tribe. For example, as part 
of the project plan, the new outpatient clinic would have a low risk 
birthing unit. The current clinic is not equipped for labor and 
delivery services even though there are a high number of births of San 
Carlos tribal members each year (the 2001 figures of IHS show 234 
births per year of San Carlos tribal members). Currently, the women of 
San Carlos must travel off the Reservation and often to locations far 
from their homes to deliver their babies. The closest delivery service 
from San Carlos is 40 minutes away at Cobre Valley Community Hospital 
while the Bylas community is an hour from Cobre Valley and 50 minutes 
from Mt. Graham Community Hospital. The women of San Carlos are eager 
to deliver their babies at home on the Reservation and the new clinic 
would allow them to do so. Also, the new clinic would be equipped and 
staffed to provide the following new services, which are badly needed 
on the Reservation: telemedicine, diagnostic imaging, expanded 
specialty care such as ambulatory surgery and endoscopy, physical 
therapy, and expanded diabetes treatment. The new facility would 
provide for more than 3 times the staff at the current facility. The 
existing facility has 118 staff and the new facility would have 358.2 
staff. The size of the current facility is 3,580 square meters. The 
size of the new facility is proposed to be 18,767 square meters. The 
cost for the new facility and staff quarters, according to IHS, is 
approximately $110 million (but this cost will only increase as costs 
go up over time and given site circumstances that IHS did not factor in 
its initial estimates).
    Our struggle for a replacement health care facility began over 20 
years ago. In and around 1988, IHS evaluated IHS health care delivery 
programs nationwide. The proposal to construct a replacement facility 
to provide health care services space at San Carlos was among those 
selected for further evaluation. IHS assessed the health care needs of 
the Indian population at San Carlos and evaluated the ability of the 
existing health care delivery system to meet those needs. The major 
factors that IHS considered were the use of the existing system, the 
size and condition of existing space, the ability of the existing space 
to support an accessible, modern health care delivery system, and the 
proximity of other health care facilities. The findings of this 
evaluation concluded that the existing San Carlos Indian Hospital was 
inadequate and required a complete replacement.
    IHS placed the San Carlos facility on its list of facilities in 
need of replacement in the early 1990s. It is now 2008 and we still do 
not have a new health care facility. For over a decade, IHS and the 
Tribe went round and round ``negotiating'' the Project Justification 
Document (PJD), which is the project plan that IHS must approve before 
a facility can be placed on IHS's health care facilities priority 
construction list. IHS and the Tribe could not come to an agreement 
over the size of the facility and the level and types of services that 
could be provided at the facility. The main issue was whether an 
inpatient or outpatient health care facility should be built. Even 
though the user population at San Carlos supported such a facility and 
San Carlos previously had an inpatient facility, IHS was firm in its 
position that it would not support an inpatient facility due to IHS's 
limited budget and because it was trending away from building inpatient 
facilities. Inpatient facilities offer more types of services on site 
than do outpatient facilities. Many tribes navigating the IHS 
construction process are having this same issue with IHS. Many tribes 
have been in the ``PJD preparation'' phase for many years because they 
are being asked to compromise on the health care needs of their people 
even before the shovel breaks ground.
    Further, IHS informed the Tribe that, if the Tribe sought an 
inpatient facility, then it would be practically impossible to 
construct the facility in the foreseeable future due to the scarce 
appropriations for inpatient facilities. IHS pointed to the proposed 
inpatient facility at Whiteriver, AZ, for the White Mountain Apache, 
our sister tribe, and indicated that it would be very long time before 
Whiteriver would receive construction funding. The Whiteriver inpatient 
clinic has been on the priority construction list from the beginning, 
like San Carlos, and has yet to receive any appropriations to start its 
project.
    In 2003, the Tribe, after intensive internal discussions, 
determined that it would consent to an outpatient facility instead of 
an inpatient facility. This was a very difficult decision for the Tribe 
because an outpatient facility will not meet all of the health care 
needs of its people but would certainly allow for better services and a 
much better facility. Even after the Tribe decided to pursue an 
outpatient facility, the negotiations were difficult. The Tribe felt 
that it had to capitulate on issue after issue because IHS, at each 
step, would inform the Tribe that it would not approve the PJD if the 
Tribe did not consent to the reduced services to be provided at the new 
facility. For example, the Tribe sought cardio-rehabilitation, case 
management, and patient advocacy services, but IHS informed the Tribe 
that it would have to ``start all over'' in the process if it continued 
to seek such services. IHS rejected these service requests on the basis 
that, even though these services are reasonable services to offer at a 
non-IHS facility, IHS had not developed national templates for the 
services and, therefore, would not allow any tribe to provide these 
services at their facilities.
    Another example was a difference in views over the number of beds 
at the new facility. The Tribe sought 23 beds for the new facility. 
Previously, the service area had 26 beds between the 1960s and 1980s 
but these services were lost when the facility underwent patchwork 
renovations. IHS will only allow for 8 beds (the number of beds in the 
current facility) in the new facility due to budgetary constraints. 
Even with the compromises of the Tribe, IHS still was reluctant to 
approve the PJD because we believe it knew in 2003-2004 that the 
Administration was going to propose a moratorium on funding for health 
facilities construction in FY 2005. As perceived by the Tribe, IHS's 
plan was to stagger the PJD approval process so that only a few PJD's 
would be approved every few years. Due to congressional pressure, IHS 
approved the San Carlos outpatient replacement facility PJD in 2004 and 
placed the facility on IHS's priority outpatient construction list.
    Even with the approval of the PJD and the placement of the San 
Carlos outpatient replacement facility on the priority construction 
list, the process has been extremely difficult at every turn. Without 
the strong commitment of the Tribe to this project and the tremendous 
support for this project by the Tribe's Congressman and Appropriators, 
this project would have languished without any funding. The Tribe 
received planning and design funding from FY 2005 to FY 2007 (FY 2005 
Interior appropriations bill specified $555,000 for San Carlos for 
planning and design, the FY 2006 Interior appropriations bill specified 
$6.139 million for planning for San Carlos, and IHS allocated $2 
million to San Carlos under the FY 2007 Continuing Resolution). 
Currently, for FY 2008, the Tribe is not slated to receive any funding 
at this point in FY 2008 from the facilities construction account as 
this funding was appropriated in a lump sum amount without allocations 
for specific facilities and IHS has determined that it will allocate 
this funding to Barrow, Cheyenne River, and Ft. Yuma ($36.6 million in 
FY 2008). IHS has indicated to the Tribe that it is looking for funding 
in other IHS accounts to keep the project moving along and we are 
hopeful that IHS can find this funding for us.
    Even with funding that was allocated to the Tribe for FY 2007 in 
the amount of $2 million, the Tribe has had difficulties drawing down 
this funding. At one point, the IHS construction office stated that it 
would not release these funds to the Tribe until it ``has a certain 
comfort level'' with the Tribe's designs and plans. It would be more 
helpful if IHS could provide us with consistent, concrete guidelines 
and criteria to which they want us to adhere to draw down funds. When 
the Tribe has requested the procedures for drawing down its funds, the 
IHS construction office responded in an email, ``Yea right.'' There 
should be consistency, transparency, and cooperation in the agency 
process.
    Previously, the Tribe entered into a self-determination contract 
under P.L. 93-638 for the construction of the contract and recently 
submitted a notice of intent to IHS that it plans to submit a self-
determination contact for the operations of the facility. We believe 
that IHS could improve upon its appreciation for the purpose of a self-
determination agreement to provide for the government-to-government 
transfer of responsibility. It is our belief that the IHS construction 
office tends to micromanages the project contrary to the government-to-
government transfer of responsibility. The self-determination agreement 
states that ``tribal preferences will be honored,'' but sometimes we do 
not feel that this is the case. For example, we have registered design 
architects and engineers as part of the Tribe's project team but IHS 
second guesses their work and pressures us to do things their way.
    Another example is the Program of Requirements (POR). The POR for 
the project was created by IHS for the Tribe, even though P.L. 93-638 
states that the Tribe has the right to generate its own POR. 
Essentially, these facilities are designed as IHS wants them designed 
and do not necessarily reflect the true health care needs in the 
community. We believe that there should be a mechanism to update the 
POR so that the up-to-date health care needs in the community are 
addressed.
    We recently were told by the construction branch at IHS that IHS is 
a ``bottom up'' organization and that, unless the project manger from 
engineering services has a personal level of comfort with what the 
Tribe is doing, then the project will not be supported by anyone in 
Washington. We have been told that we can talk to anyone we want to in 
Washington; but, unless the Dallas Project Manager is satisfied with 
the direction of the project, the project will receive no support and 
no funding. We have had individuals from IHS threaten not to approve 
the design package from the Tribe at the next approval phase, unless 
things are done their way. We have had the IHS project managers show up 
at tribal meetings with Service Unit staff uninvited, totally disrupt 
the meeting, insult our medical staff, and have had our meeting delayed 
for over an hour while we calmed them down enough so that they could 
sit in on the meeting without interruption.
    Further, IHS recently informed us that we must alter our design to 
shift the burden of maintenance responsibility to the Tribe instead of 
IHS. IHS wants all utility systems developed for the health facility to 
be operated and maintained by the Tribe even though there are no funds 
provided for this. We believe that IHS should be responsible to 
maintain systems designed to exclusively support the hospital.

Suggestions for Improving the Construction Process at IHS
    In addition to dramatically increased appropriations, IHS needs to 
be pro-active in introducing funding into the projects on the priority 
list, and they need to get the message ``from the top down'' that the 
reason IHS exists is to provide better health care and new facilities 
for the Tribe. IHS should work to improve their construction process to 
fulfill the purpose of their self-determination agreements, which is to 
provide for the government-to-government transfer of responsibility for 
the construction and operations of the facility.
    The IHS system needs to be re-organized to streamline the design 
and construction process. The projects are originated in the Phoenix 
area office, then are transferred to Dallas for the construction phase, 
then the maintenance and operations are transferred back to the Phoenix 
area office after the project is completed. This is extremely 
inefficient. There should be continuity throughout the construction 
process from conceptual development through design, construction, and 
maintenance and operations. The Dallas project managers travel to 
Arizona to oversee projects that the Phoenix Area Engineering staff 
could easily oversee. It would be most cost effective and much more 
efficient to originate, design, and construct these projects at the 
Area Office level. We find that the area office engineering staff have 
a high level of understanding of these projects, are very professional, 
and have a vested interest in providing the best buildings possible as 
they will be responsible for the maintenance and operation of the 
facility once it is built.
    We understand that questions have been raised about the seeming 
high cost of IHS facilities construction projects. However, according 
to our project team that has extensive experience in hospital 
construction, these projects are lower in cost compared to what is 
spent in the private sector on hospital construction. Our budget was 
conceptualized before all the engineering challenges on our site were 
identified; and, as a result, our budget does not accurately reflect 
the actual project cost. There are many glaring omissions in our 
proposed budget as provided by IHS. These budgets need to be accurately 
updated in cooperation with the Tribe.

Experience Constructing and Operating New Adult and Juvenile Detention 
        and Rehabilitation Facility
Construction of Adult and Juvenile Detention and Rehabilitation Center
    San Carlos was in dire need of a juvenile detention facility and a 
new adult jail for many years. From 1994 until 1999, the Tribe pushed 
for a new facility and was placed on the BIA's ``waiting list.'' In 
1999, San Carlos attended a conference in Albuquerque sponsored by DOJ. 
With technical assistance from DOJ, Office of Justice Programs (OJP), 
the Tribe prepared an application and received funding approval for a 
Juvenile Detention/ Rehabilitation Center for $2,153,550.00.
    While the Tribe was pleased that the juvenile project was approved 
for funding, the need for a new adult detention center still existed. 
Determined to obtain funding, the Tribe expressed its concerns about 
the condition of the adult facility to OJP. This effort led to San 
Carlos preparing a second application for both an adult and juvenile 
complex. On September 29, 1999, this application was approved, 
resulting in the Tribe obtaining a combined total of $10,787,272.00 in 
a lump sum to construct an Adult and Juvenile Detention and 
Rehabilitation Complex. From a funding perspective, the response from 
OJP, DOJ, was remarkable. DOJ listened to Tribal representatives, 
recognized the Tribe's problems and needs, and addressed them 
immediately. The Tribe entered into a self-determination contract to 
construct the facility and then later entered into a self-determination 
contract to operate and maintain the facility. The program at OJP back 
in the late 1990's should be a model for most other Federal agencies. 
We understand that this program is not now the program that it once 
was.
    The next step involved the construction phase. The Tribal Planning 
Department took the lead in grant management and development. The first 
action involved preparing a Request for Proposals (RFP) for 
Architectural and Engineering services. The Tribe evaluated and hired a 
firm from Phoenix. One of the keys to success was the fact that DOJ 
authorized hiring a project manager from the overall budget so that the 
design and construction phases could go forward without any major 
glitches or delays. Reimbursements and advances from DOJ were timely 
and DOJ was very responsive to any questions posed or modifications 
needed. Overall, the design and engineering phase went very well. The 
construction of the facility was completed in 2003. The principle of 
self-determination worked well in the self-determination contract for 
construction with DOJ. The Center is an example of the timely and 
positive effects that can occur when tribes have flexibility and 
control over the construction of their facilities and they do not have 
to navigate a bureaucratic maze.
    Obtaining funding and completing the design and construction of 
this complex were tremendous accomplishments, but another major 
obstacle needed to be addressed. Even though DOJ was responsible for 
the construction side of the new facility, BIA was and remains 
responsible for the operations and maintenance for the new facility. 
Here, the right hand did not know what the left hand was doing. 
Although the Tribe had requested that the BIA include funding for the 
operation of the facility because the facility was ready to go on-line, 
the Tribe learned that the President's budget in FY 2003 did not 
contain funding to operate and maintain the new facility. The Interior 
appropriations bill for that fiscal year did not contain operations and 
maintenance funding for the new facility, so we had a situation where 
the Federal Government had constructed a multi-million dollar facility 
that could not be used. The Tribe did not and does not have the 
resources to hire staff, operate the facility, and maintain it. 
Fortunately, after intense lobbying by the Tribe and other tribes 
across the country through the formation of a coalition, the BIA agreed 
to reprogram FY 2003 funds so that the facilities that had completed 
construction could hire and train staff and furnish and equip their 
facilities.
    For FY 2004, the coalition of tribes, including San Carlos, 
advocated strongly for funding for operations and maintenance in the 
Interior appropriations bill. The effort was successful, and the 
appropriations bills for FY 2004 and going forward contained funding 
for operations and maintenance for San Carlos new detention and 
rehabilitation center. However, the funding that the Tribe receives is 
not enough.
    The annual amount the Tribe receives is inadequate to support 
administrative functions, basic operational costs, and the 
``detention'' staff. For the short term, the Center is managing at a 
minimal level. The Tribe is able to manage at the minimum level due to 
the fact that the program has some carry over funding to supplement the 
annual budget. However, these funds will be exhausted shortly even 
though the Center is not operating at the recommended staffing level. 
If the base level of funding is not increased by the BIA, continued 
operation of the Detention/Rehabilitation Center will be seriously 
jeopardized, as the Tribe simply does not have the financial resources 
to supplement the estimated $1.5 to 2 million annual deficit. Even with 
the shortfalls in funding, the BIA honors the government-to-government 
transfer of control to the Tribe for operations and maintenance as 
contemplated in the self-determination contract, and we appreciate 
that.
    At the present, the FY 2008 budget for the operations of the 
detention center is less than the budget of its employees' salaries. 
The current salary budget is $3.1 million; however, the budget from the 
BIA for the total operations for FY 2008 is $ 2.6 million. Our total 
budget need is $4,047,353. We are short $1,434,011 of what is needed to 
operate the detention center efficiently. We are not at full capacity 
in filling the positions that are needed and are presently short 
staffed. Presently, we have a total of 42 permanent employees, 22 are 
adult correctional officers and 11 are juvenile correctional officers. 
Our projected staffing needs in the beginning indicated a staffing of 
64. Taking this into account, we are 22 positions short.
    It should be noted that the discussion above does not include the 
costs associated with the rehabilitation component of the Center. In 
the initial planning stages, the Tribe felt very strongly, especially 
its elders, that it did not want a detention facility that was simply a 
jail, especially for juveniles. It believed that incarceration does not 
help individuals become healthy, happy, productive members of the 
community, and they wanted to ensure that rehabilitation services were 
an integral part of the overall program for both adults and juveniles. 
Most of the offenses at San Carlos are related to alcohol and substance 
abuse. With effective rehabilitation and re-entry programs, these 
offenders have a chance at leading productive lives.
    San Carlos is very fortunate to have the opportunity to design, 
construct, and operate the San Carlos Detention and Rehabilitation 
Center serving both adults and juveniles. While the Tribe now has a 
modern, clean, and functional facility, at the present time, the 
reality is that it is functioning as little more than a jail. This fact 
is discouraging to the Tribe. As stated above, the original intent of 
the Center was to be a place where troubled youth, adults, and affected 
family members could receive the services and support they need to 
become productive and positive members of their community.
    The Detention Center staff is doing a commendable job in 
maintaining the facility, providing a clean and safe environment, and 
treating all residents with dignity and respect. However, with the 
exception of limited education programming and emergency medical and 
dental services, there is minimal on-going treatment programming taking 
place. The staff at the Center is extremely dedicated and spend their 
personal resources and time to develop programming for mentorships for 
the detainees, especially the juveniles. For example, with personal 
funds from donations, Center staff have taken the juveniles over the 
past few years to participate in a 300-mile sacred run, which is a 
relay race from Whiteriver to Mt. Graham. I help to organize in the run 
and run in it myself with my family. This 3-day experience focuses on 
teamwork, relationship building, and fun. The juveniles tell me they 
cherish their experience because they feel that they are part of 
something bigger than themselves. Our juvenile staff do such an 
excellent job (all of it on a shoestring with little federal support) 
that they are asked to give presentations in other parts of the country 
and in Arizona about their innovative juvenile program.
    Issues related to this situation are identified and briefly 
described below:

   The Tribe simply does not have the financial resources to 
        provide the funds needed and the BIA is funding the contract at 
        a level that meets minimal ``detention'' staffing and operating 
        levels only.

   IHS has demonstrated only a willingness for finding reasons 
        why they can not provide services to detainees rather than 
        making an earnest effort to find solutions.

   Some grants under SAMHSA like the Tribal Capacity Expansion 
        (TCE) grant and other federal grants that could provide at 
        least a portion of the funding necessary to start providing 
        treatment services require a minimum of two years experience 
        providing treatment services to be eligible for funding 
        consideration. As a result, it puts the Tribe in a no-win 
        situation as they need funding to get their treatment services 
        started but they can't obtain funding unless they have been 
        providing treatment services for at least two years.

   Programs, such as the Arizona Health Care Cost Containment 
        System (AHCCCS) and the SAMHSA ATR programs, could assist the 
        Tribe greatly; but it is our understanding that they both have 
        prohibitions regarding serving individuals in detention.

   The State of Arizona is one of a few states that allocates 
        funding for education for juveniles in detention, but all of 
        the funds are distributed to County detention facilities. The 
        Detention Center is attempting to work with the local school 
        district and the Gila County Superintendent of Schools, but 
        what is really needed is that Tribes should receive separate, 
        direct funding from the State.

    It seems that the BIA, IHS, SAMHSA, OJJDP, and other federal 
agencies have the opportunity to showcase the San Carlos Detention/
Rehabilitation Center and use it as a model program that other tribes 
can use as the foundation for designing and developing their facilities 
and programming. San Carlos has an excellent facility, but the 
provision of comprehensive, substantive programming (treatment) is a 
real and frustrating challenge for the Tribe. It would seem that rather 
than putting tribes in a position where they have to ``piece-meal'' a 
program together, some type of block grant format could be established 
where tribes could obtain the services (operational and treatment) they 
need through one proposal/application.
Conclusion
    We appreciate your efforts to help us address the facilities crisis 
in Indian Country, and we look forward to working with you to ensure 
that the Apache people and other Indian people across the country have 
the tools that they need to help their communities become strong and 
vibrant.

    The Chairman. Chairman Nosie, thank you very much.
    This Committee will be holding a hearing in Phoenix, 
Arizona I believe it is two weeks from next Monday. Senator 
John Kyl will be joining me in Arizona. We will be holding a 
hearing specifically on law enforcement issues. I hope perhaps 
you might be there as well. I know that you come from that 
area.
    Next, we will hear from Mr. Monty Roessel, Superintendent 
of the Rough Rock Community School in Chinle, Arizona, from the 
Navajo Nation. Thank you very much for being here. You may 
proceed.

STATEMENT OF CHARLES MONTY ROESSEL, SUPERINTENDENT, ROUGH ROCK 
                        COMMUNITY SCHOOL

    Mr. Roessel. Thank you, Mr. Chairman and members of the 
Committee, for the invitation to speak before this Committee, 
not as an elected official or an issues advocate, but as a 
person who is directly responsible for the safety and education 
of more than 500 Navajo students.
    My name is Charles Monty Roessel. I am Superintendent of 
Rough Rock Community School. Rough Rock is a K-12 residential 
school located in the northeast part of Arizona on the Navajo 
Nation. To say that the Rough Rock Community School is in need 
of adequate school facilities is an understatement. Rough Rock 
was originally built in 1965 and opened its doors in 1966.
    We were a leader in bilingual-bicultural education then and 
we continue to be today. Despite our substandard condition of 
our facilities, parents nonetheless continue to enroll their 
children at Rough Rock. Recent research has confirmed what many 
educators have always held as common sense: the quality of a 
school's facility has an impact on the student's academic 
achievement. The research on school building conditions and 
student outcomes finds a consistent relationship between poor 
facilities and poor performance.
    Here are some of the facilities-related hardships we 
routinely face at Rough Rock. Sometimes our students wake up at 
4:30 in the morning just so they can take a shower because the 
pipes under our two dorms have corroded to such a level that 
only half of the shower heads work in each dorm wing. Our 
middle and high school students have to share a cafeteria that 
was originally built for 75 students and today must accommodate 
more than 300. When it rains and snows or when the wind blows, 
as it often does, they must stand outside and wait their time 
to eat and sit down.
    Our high school does not have a biology or chemistry lab 
and this puts them at a disadvantage if they want to attend 
college. Even worse, the quality of water is severely 
compromised. It is high in arsenic because the pipes are old 
and not compatible with the water filtering system. We must 
choose between high arsenic or high chlorine levels. Our school 
must operate its own water system, which was also built in 
1965. Yes, there is a great need for adequate and safe 
facilities at Rough Rock.
    A recent study has shown that students attending schools in 
newer and better facilities score 5 to 17 points higher on 
standardized tests. If a classroom is cold, noisy or dark, 
students are losing instructional time. At Rough Rock, we have 
classrooms and dorms that are cold because of outdated 
mechanical systems, dark because of old lighting systems and 
little daylight, and noisy from thin walls and deteriorating 
structures. They were built to code in 1965. The codes have 
changed, but the buildings haven't. Just imagine how many 
Bureau-funded schools could make AYP if our facilities were 
only adequate.
    In March of 2004, the Rough Rock Community School was 
listed as number eight on the school construction priority 
list. Yet construction dollars will not be requested until 
2011. It will take at least seven years before a shovel hits 
the ground just for the first phase of construction. This cost 
of inaction and slow action is hurting Indian children all 
across this Country. This is unacceptable and our Indian 
children deserve better.
    Some might think that being placed on a priority ranking 
list for a new school is a good thing. Well, it is, but it also 
comes at a heavy price. Because we are now slated for a new 
school, many of the safety repairs I mentioned are declined by 
the OFMC. For example, in some buildings our high school and 
vocational classes do not have a fire alarm system installed. 
The dorm's plumbing problem cannot be fixed because the pipes 
have asbestos. In both cases, we are told to wait for new 
construction.
    Every time a hear a fire alarm in the buildings that have 
one, my heart skips a beat. I understand the logic. Why would 
you put money into something that you are going to tear down? 
But is it right? No. We are tired of band-aid solutions and 
alarmed at the hazards to which our students and children are 
exposed.
    Since our elementary school was constructed in 1965, a 
revolution has taken place in education. Computers have 
replaced and supplemented books. The internet has replaced the 
encyclopedia. And what was adequate 40 years ago is not anymore 
today.
    We all know the answer is more money, and I understand that 
money is scarce. But rather than look at facilities as an 
expenditure, we need to look at them as an investment--an 
investment in our future and in our children. Without a 
commitment to our future, we will never have the willpower to 
ensure that every Indian child has the same opportunity as any 
other child in this Country. At the very least, this is an 
issue of fairness, and at the very most, it is a moral issue. 
It is time that we offer our students the best facilities 
possible that are safe, dependable and adequate to ensure that 
no Bureau-funded school student is left behind.
    I was taught by my dad that you can't complain about a 
situation unless you at least are willing to recommend some 
changes to that. So I have some recommendations to streamline 
the process so that from start to finish it takes three years 
and not eight years. Right now, we are looking at 10 years 
passing before our school would even be open. That is almost an 
entire set of grades that are losing out on the brand new 
school. In order to speed up the process and reduce the 
backlog, I believe it would be beneficial to allow schools that 
are ready, such as Rough Rock, to jump up on the priority list.
    Also, encourage standard designs. There is no reasons to 
continually redesign and redesign and redesign new dorms. A 
dorm is a dorm and the process could be streamlined and save 
money if people would use standardized designs. I think to 
create the capacity for Bureau-funded schools to utilize 
bonding to build new facilities and to encourage that projects 
be funded in phases like we are trying to do at Rough Rock to 
proceed at a faster rate.
    On behalf of all Indian children, I thank you for looking 
into these troublesome construction matters, and I am happy to 
answer any questions the Committee might have.
    [The prepared statement of Mr. Roessel follows:]

Prepared Statement of Charles Monty Roessel, Superintendent, Rough Rock 
                            Community School

    Thank you, Mr. Chairman and members of the Committee for the 
invitation to speak before this Committee. I would like to briefly go 
over my written testimony and touch on a few points.
    My name is Charles Monty Roessel. I am a Navajo from Round Rock, 
Arizona working as superintendent of Rough Rock Community School. I 
have held this position for eight years. Rough Rock is a K-12 North 
Central Association accredited residential school located in the 
northeast part of Arizona on the Navajo Nation. Our enrollment is 
around 500 with one-half of the student population staying in an 
elementary and high school dorm during the week. Our students come from 
throughout the Navajo Nation. We operate the school under a Tribally 
Controlled Schools Act grant (P.L. 100-297) from the Bureau of Indian 
Education.
    To say that the Rough Rock Community School is in need of adequate 
school facilities is an understatement. Rough Rock was originally built 
in 1965 and opened its doors in 1966, as the Rough Rock Demonstration 
School, the first Indian community-controlled school in the country. In 
fact, community control of our school pre-dated the enactment of the 
Indian Self-Determination Act by nine years.

Bilingual and Bicultural Focus
    Rough Rock was a leader in bilingual and bicultural education then 
and continues to be today. The philosophy is simple and it is backed by 
research. If students know their culture and are proud of who they are, 
they are more likely to have academic success. Therefore, at the 
elementary school we have implemented a Navajo language immersion 
program. And at the high school, in order to graduate a student must 
take four (4) credits of Navajo history, language and culture. At the 
time it was a revolutionary idea to think that Indians could control 
their own education. Well to say the least, we have demonstrated and 
proven that Indian people can and are able to control their own 
education.
    Despite the sub-standard condition of our facilities, parents 
nonetheless continue to enroll their children at Rough Rock because 
they highly value the benefits of our bilingual/bicultural curriculum 
and our focus on encouraging our students to be proud to be Navajos.
Impact of Facilities on Learning and Achievement
    It would be naive to say that the quality of school facilities does 
not matter. Of course it does. At Rough Rock, we lack what most schools 
all across this country take for granted--a safe and habitable 
environment that enables students to enjoy learning and to achieve.
    Recent research has confirmed what many educators have always held 
as common sense--the quality of a school facility has an impact on 
students' experiences and ultimately on their educational achievement. 
The research on school building conditions and student outcomes finds a 
consistent relationship between poor facilities and poor performance: 
When school facilities are clean, in good repair, and designed to 
support high academic standards, there will be higher student 
achievement, independent of student socioeconomic status. (AFT, 2006)
    Here are some of the facilities-related hardships we routinely face 
at Rough Rock:

   Sometimes our students wake up at 4:30 am just so they can 
        take a shower because the pipes under our two dorms have 
        corroded to such a level that sometimes only half of the shower 
        heads work in each dorm wing.

   Our middle and high school students have to share a 
        cafeteria that was originally built for 75 students and today 
        must accommodate more than 300. And, when it rains or snows or 
        when the wind blows as it often does, they have to stand 
        outside and wait for their time to sit and eat.

   Our high school does not have a biology or chemistry 
        laboratory so that students who take these science courses 
        learn only through books; they do not get exposure to hands-on 
        learning. This puts them at a disadvantage if they want to 
        attend college.

   Our students quickly learn that ceiling tiles might fall at 
        any moment because of leaky ceilings and wind damaged roofs.

   Even worse, the quality of water is severely compromised; is 
        high in arsenic because the pipes are old and not compatible 
        with the water filtering system. We must choose between high 
        arsenic or high chlorine levels. Our School must operate its 
        own water system--which also dates back to 1965.

    Yes, there is a great need for safe and adequate facilities.
    A study in Tennessee has shown that students ``attending school in 
newer, better facilities score five to seventeen points higher on 
standardized tests than those attending in substandard buildings'' 
(Young, Green, Roehrich-Patrick, Joseph & Gibson, 2003). Inadequate 
facilities have the biggest impact on time on task. If a classroom is 
cold, dark or noisy, students are losing instructional time. At Rough 
Rock, we have classrooms and dorms that are cold because of outdated 
mechanical systems, dark because of old lighting systems and no 
daylight, and noisy from thin walls and deteriorating structures. They 
were built to code in 1965 but the codes have changed while our 
buildings have not.
    Safe and modem facilities also have a huge impact on the 
recruitment and retention of highly qualified teachers. A study by 
Boston College found that the correlation between facility improvement 
and retention of teachers can be greater than pay increases. (Buckley, 
Schneider & Shang, 2004)
    It is also important to note that because of Rough Rock's location, 
we must provide housing for our teachers, as there is no off-
reservation town with a private housing market within commuting 
distance. Our campus housing, too, is plagued by safety issues and 
inadequacies.
    Rough Rock School thus has to act in several critical capacities--
as the local educational agency, as the municipality responsible for 
the water/sewer system, as the landlord for our employees and as the 
transportation department fixing potholes within our school compound.

Replacement School Priority List
    In March, 2004, Rough Rock Community School was listed as number 
eight on the school construction priority list as ranked by the Bureau 
of Indian Affairs, Office of Facilities Maintenance and Construction 
(OFMC). Our project has four elements: construction of a new high 
school dormitory (grades 9-12) with cafeteria; construction of an 
elementary dorm to house students in grades 1-8; construction of a new 
elementary/middle school (K-8); and renovations to our existing high 
school building to up-grade its capabilities, repair building systems, 
and add wings for essential educational spaces such as science labs. We 
proposed to OFMC that our project--now estimated at about $30 million 
but originally projected at $16M in 2001--be funded and constructed in 
phases for maximum economy and efficiency. The dorms would be built 
first; then the elementary/middle school; then we will pursue the high 
school renovations.
    In the four years since achieving our priority list ranking we 
inched our way up to the planning phase. Within seven months after 
receiving planning funds, we had that phase completed, including the 
identification of acreage for construction of the new buildings. Now we 
are poised to begin the design phase next month--April 2008.
    However, our school was notified that funds for the construction 
phase will not be requested until, at the earliest, the budget request 
for Fiscal Year 2011. Even if this expectation is met and Congress 
appropriates the requested funds, it means from the time BIA approved 
the priority ranking list it will have taken 7 years before a shovel 
hits the ground--just for the first phase of our construction. 
Completion of that first phase will take about 2 years before students 
can occupy. The next phases will follow after that. Thus, it will be 12 
or 13 years, if all goes well, before our full project is completed. 
Inaction has a cost. In 2001, our project was originally projected to 
cost $16M, today it is projected to be around $30M. At this rate, our 
project might cost $40M in 2011. This is unacceptable. Our Indian 
children deserve better.

Repairs on Existing Facilities Have Ceased
    Some might think that being placed on the priority ranking list for 
new school construction is a good thing. It is. But, it comes at a 
heavy price. Because we are now slated for a new school, many of the 
safety repairs I mentioned that need to be addressed are declined by 
the OFMC. For example, some buildings--such as our high school 
gymnasium and vocational education classrooms--do not have fire alarm 
systems installed. The dorm plumbing problems cannot be fixed because 
the pipes have asbestos. In both cases, we are told to wait for new 
construction.
    In other words, our students and parents and staff are told to 
endure these unsafe conditions based on the promise of being number 8 
on a priority ranking list. Every night we pray that nothing happens. 
Every time I hear the fire alarm go off, my heart skips a beat. I 
cannot believe that parents in Scottsdale or Boston would allow such 
safety hazards to persist. And yet, this is business as usual in 
Bureau-funded schools. I understand the logic; why would you put money 
into something that you are going to tear down? But, is it right? No. 
We are tired of band aid solutions and alarmed at the hazards to which 
our children are exposed.

Poor Facilities Thwart NCLBA Mandates
    Our school is being held accountable under the No Child Left Behind 
Act, but who is holding the BIA accountable to provide the facilities 
to adequately provide an education for our students? Every year new 
standards of accountability seem to be imposed but we must make do with 
the same old tools we always have had. Our accreditation is mandated by 
the Bureau of Indian Education and yet, our facilities do not allow us 
to offer the full academic programs required of us.
    We all know the answer is more money. I understand that money is 
scarce but rather than look at our facilities as an expenditure we need 
to look at them as investments--investments in our future and in our 
children. Without a commitment to our future we will never have the 
willpower to ensure that every Indian child has the same opportunity as 
any other child in this country. At the very least, this is an issue of 
fairness and at the very most it is a moral issue.
    Our staff is getting very adept at making do with less. It would be 
nice if we didn't have to. About a week ago, after ceiling tiles 
crashed to the floor (thankfully no child was injured), I was 
inspecting the facility with our maintenance director. When I peered 
through the hole I was appalled. My maintenance director just chuckled 
and said ``old Indian trick.'' He was referring to pipes being held 
together with duct tape and bailing wire. It is sad to think that this 
is not the exception but the norm in Indian Country. By the Bureau's 
own criteria only 39 percent of its school facilities are acceptable.
    Since our elementary school was constructed 1965, a revolution has 
taken place in education: Computers have replaced/supplemented books; 
the Internet has replaced the encyclopedia. What was adequate 40 years 
ago is not today. These old buildings were built when there were no 
computers and as such, their electrical systems can not handle 
computers in classrooms and computer labs in classrooms. Plus, adding 
cabling to these old buildings runs the risk of disturbing the asbestos 
that infests them.
    Sometimes you just can't wait for your name and number to come up 
on the school construction priority list. This January, Rough Rock 
opened the doors to our new high school library. I want to thank OFMC 
and Congress for providing us with this much needed educational 
facility. They recognized the drastic need for our high school students 
and somehow found the money to build this essential education facility. 
We no longer are one of the few, if not only, high schools that did not 
have a library. It makes me very sad to think of how many high school 
students have passed through Rough Rock School over the past 42 years 
without the benefit of a library--a very basic educational support 
tool.
    In Arizona, the public school system has invested millions upon 
millions to improve the state of their facilities. All around Rough 
Rock, public schools are building two story schools with gymnasiums 
bigger than those at many colleges. And yet, parents still choose to 
send their child to Rough Rock because they want their child to receive 
the type of educational program we offer. It is time that we offer our 
students the best facilities possible--not the largest gymnasiums--but 
the most up to date classrooms that are safe, dependable and adequate 
to ensure that no Bureau-funded school student is left behind.
My Recommendations

   Streamline the process so from start to finish it takes 3 
        years and not 8 years or more just to get funding appropriated, 
        and 10 years before a facility can be constructed and occupied. 
        Ten years means ten graduating classes!

   In order to speed up the process and reduce the backlog, I 
        believe it would be beneficial to allow schools that are 
        ready--such as Rough Rock--to move ahead of schools that are 
        not. This would be an incentive for schools to move rapidly to 
        complete a project in a timely manner, and also enable a school 
        which is ready to benefits its students sooner rather than make 
        them wait for a project higher on the priority list but slower 
        on the progress scale.

   Encourage the use of standardized designs to speed up the 
        construction process and more economically use the funds that 
        are available. For example, we plan to use standardized plans 
        for our dorm construction--with some ``tweaking'' to 
        accommodate our local needs. Not only do we believe this is a 
        sensible way to save money on design costs, it will also enable 
        us to get the dorms built and occupied more quickly.

   Create the capacity for bureau-funded school to utilize 
        bonding to build new facilities.

   Encourage that high-cost projects be funded in more than one 
        phase--like Rough Rock is proposing in order to proceed at a 
        faster rate.

Conclusion
    On behalf of all Indian students, I thank you for looking into 
these troublesome construction backlog matters. I am happy to answer 
any questions the Committee has.

    The Chairman. Mr. Roessel, thank you very much.
    Now, we will hear from Ms. Valerie Davidson, the Senior 
Director of Legal and Governmental Services at the Alaska 
Native Tribal Health Consortium in Anchorage, Nebraska. She is 
accompanied by Mr. Rick Boyce.

   STATEMENT OF VALERIE DAVIDSON, SENIOR DIRECTOR, LEGAL AND 
              INTER-GOVERNMENTAL AFFAIRS, ALASKA 
  NATIVE TRIBAL HEALTH CONSORTIUM; ACCOMPANIED BY RICK BOYCE, 
              DIRECTOR, HEALTH FACILITIES SUPPORT

    Ms. Davidson. Thank you and good morning. We really 
appreciate this Committee's attention to the deplorable health 
positions as clearly evidenced by your great work in the 
passage of the Indian Health Care Improvement Act not only out 
of this Committee, but also shepherding it through the Senate 
and its transmittal over to the House.
    Clearly, this Committee understands the deplorable health 
conditions, and we appreciate the attention that this Committee 
is giving to the status of the health facilities.
    Today, I would like to be able to cover five topics very 
briefly: first, the state of Indian health facilities; second, 
the opportunities or innovation that are before us today; 
third, the other support needs that go into maintaining 
existing facilities; fourth, the impact of the lack of funding 
of health facilities that they have on health disparities; and 
finally, fifth, the new prioritization system.
    This Committee, of course, is very well aware from your 
questions earlier and your statements about the unmet need for 
health facilities. As you indicated earlier, if you add the 
$6.5 billion unmet need for primary care health facilities to 
the IHS's $2.65 billion, that is of course over $9 billion just 
for primary health care facilities.
    You asked the question earlier, how much would an 
appropriate amount be? And clearly, if the unmet need is almost 
$10 billion, anything less than $1 billion a year is simply 
unacceptable.
    The average age of the IHS facility as indicated earlier is 
about 33 years, but some facilities we know are over 40 years 
to 66 years. Even a really new hospital like the Alaska Native 
Medical Center in Anchorage is over 10 years old and it is 
considered one of the brand new facilities in Indian Country. 
But the typical IHS facilities are old. They are dilapidated. 
They are in very, very poor condition. The Nome Hospital, for 
example, was constructed in 1948 with an addition in the 1970s. 
The replacement for that facility has been on the IHS priority 
list since 1991. Another facility in Barrow was constructed 
with wood frame construction in 1964 and it has also been on 
the priority list since 1991.
    In addition, though, to the simple inpatient facilities, 
there is also a great need in other parts of the Country that 
don't even have hospitals at all. For example, the Portland 
area, which represents Washington, Oregon and Idaho, and the 
California area, there are no inpatient hospital facilities at 
all. None. And necessarily, they are contract health-dependent. 
Even though we have seen a shift in population to the west 
coast and the east coast of the United States, there are 
virtually no inpatient hospital facilities on either coast.
    With regard to health clinics, there are some examples of 
health clinics that are, for one, on the Colville reservation 
that is over 70 years old. Also on page six of the written 
testimony that we have provided, you can see an example of the 
clinic in Nukduk, also known as Newtok, which has no running 
water, and you can imagine providing health care in a facility 
where you may have an emergency blood and there is no running 
water. You can imagine the sanitation problems and the health 
issues that that causes.
    The other, though, is that so clearly there is a huge unmet 
need across Indian Country, and I think you are well aware of 
those. That said, there tremendous opportunities for innovation 
development, specifically with regard to the Joint Venture 
Program, the Small Ambulatory Clinic Program, and a new 
recommendation from the Facilities Appropriations Advisory 
Board which is the Area Distribution Program.
    You are familiar probably with the Joint Venture Program 
and the Small Ambulatory Program. With regard to the Area 
Distribution Program, though it was recommended by the FAB, it 
provides a methodology for allocating funds to each area office 
to address the highest priority projects in each area. The 
great thing about that program is it can also be used to match 
other local, State and private funds to complete a project that 
would take many more years if only IHS funds were used.
    Now, that said, there is some disagreement across Indian 
Country with regard to that program, and some areas have 
expressed concern about projects identified back in 1991 that 
remain on the priority list. They question whether the area 
distribution fund may dilute the facilities appropriation and 
further delay funding for those existing projects.
    What we do know, though, is that the Joint Venture and 
Small Ambulatory Clinic Program funding lines have been in 
place on the facilities appropriation and Congress has 
continued to provide funding for other facilities, along with 
the funding of individual projects on the priority list. We 
would ask Congress to continue that practice with the Area 
Distribution Program.
    So that gives you a little bit of the opportunities for 
innovation. However, one of the things that we would be remiss 
is if Congress and tribes and the IHS spend all of these 
resources to getting these facilities built. That is only half 
the equation. The other half is all of the efforts that need to 
be undertaken to be able to make sure that those facilities 
continue to be viable. Those includes funds for medical 
equipment replacement, facility and environmental support 
funding, maintenance improvements, and the Village Built Clinic 
Program.
    As one example, the medical equipment replacement fund, 
medical equipment should be replaced every six years. Right now 
with the current funding mechanism, the only funding that is 
provided would mean that that medical equipment couldn't be 
replaced for 18 years. So a baby born into the hospital has the 
prospect of coming back as an 18 year old adult and seeing that 
same medical equipment. Clearly, that is a health safety issue 
that cannot be tolerated.
    Unfortunately, what happens is that tribes are often forced 
to divert direct patient care dollars into upgrading that 
medical equipment. It just doesn't make any sense.
    The facility and environmental support funding obviously 
pays for maintenance staff and basic operation of health 
facilities including utilities. We are at a time in many parts 
of the Country and Alaska in particular, we are paying over $5 
a gallon for heating oil. The line item for this amount has 
remained flat, and in fact we are actually taking a back step 
in the proposed 2009 budget.
    One of the things that happened is that although in Fiscal 
Year 2009, the President's budget proposes no change from 2008, 
what it actually does, if you look into the details, is it 
allocates $25 million out of the base funding for staffing and 
operational cost of new facilities that are coming online in 
2009. So in addition, what that really means is that we have 
experienced, even though the budget shows flatline, we have 
experienced a $25 million net loss.
    The other is of course maintenance and improvement funds. 
There is a $371 million maintenance and improvement backlog. It 
is embarrassing and quite simply it is unacceptable. The 
Village Built Clinic Lease Program has seen no significant 
improvement since the program was authorized. We estimate that 
it takes at least another $5.8 million to be able to meet the 
need.
    Now, once you have that unfortunate bleak picture, let's 
talk about the real life impact on health disparities. The 
biggest impact obviously, as you identified earlier, is the 
decrease in access to care, which of course exacerbates already 
the health disparities that know exist. The things that we 
haven't even talked about are the needs for long-term care, 
including skilled nursing in assisted living facilities, 
residential alcohol and substance abuse facilities, and the 
huge unmet sanitation facilities.
    Right now, we know that American Indians and Alaska Natives 
suffer from alcoholism and substance abuse challenges more than 
any other population. Right now, we have people who are lucky 
if they only have to wait for six months to be able to get into 
a residential treatment program. Using Alaska as an example, 
one in eleven Alaska Native deaths is alcohol induced. Alcohol 
contributed to 85 percent of reported domestic violence cases, 
80 percent of reported sexual assault cases between 2000 and 
2003, and suicide among Alaska Natives remains at two times the 
national average. These are almost all alcohol-related. We have 
people who are ready to get help, who are ready to get into 
treatment programs and there are not sufficient facilities to 
be able to meet that need.
    We know that also on the inpatient side when facilities are 
unavailable, entire areas become dependent upon contract 
health. When facilities are not adequately funded, these funds 
will necessarily come out of funds that were originally 
intended for direct patient care, which we know is already 
grossly under-funded by about 50 percent, like the replacement 
of medical equipment. Chronic lack of funding also contributes 
to the lack of facilities, overburdening of other budget line 
items, and rationed health care on a systemic level.
    But finally, I wanted to congratulate the Facilities 
Advisory Appropriations Board, as well as the IHS, who have 
worked over the last eight years on developing a new facility 
priority system that was sent out numerous times through 
extensive consultation. You can read the last about seven or 
eight pages of my written testimony to get more detail there.
    In conclusion, we just wanted to let this Committee know 
that we know from experience, unfortunately, that as resources 
get tighter, individual American Indians and Alaska Natives and 
the facilities that provide their care, are going to feel the 
impact more than any other.
    As I said before, the funding really should remain in the 
billions. The real life task that we have to ask ourselves is 
not how much we do and how much the need is, but at the end of 
the day if individual American Indians and Alaska Natives don't 
get the access to the care they need, then we have collectively 
failed them miserably. Alaska Natives and American Indians 
deserve so much more than that.
    We appreciate the attention that this Committee has 
provided to highlight some of those issues.
    Thank you.
    [The prepared statement of Ms. Davidson follows:]

  Prepared Statement of Valerie Davidson, Senior Director, Legal and 
  Inter-Governmental Affairs, Alaska Native Tribal Health Consortium; 
     accompanied by Rick Boyce, Director, Health Facilities Support

    Good morning, Chairman Dorgan, Vice-Chair Murkowski and Members of 
the Committee. Quyana (thank you) for the opportunity to testify today 
about the state of Indian health facilities.
    I was privileged to work for seven years for the Yukon-Kuskokwim 
Health Corporation, the tribal health program that serves 58 federally-
recognized tribes in a region roughly the size of Oregon, of which 
Bethel is the hub. I am now honored to work for over 2 years for the 
Alaska Native Tribal Health Consortium, a statewide tribal health 
program that serves all 229 tribes in Alaska, co-manages with 
Southcentral Foundation the Alaska Native Medical Center (ANMC), the 
tertiary care hospital for all American Indians and Alaska Natives (AI/
ANs) in Alaska, and carries out all non-residual Area Office functions 
of the IHS that were not already being carried out by Tribal health 
programs as of 1997. With me today is Rick Boyce, Director of Health 
Facility Support, for the Alaska Native Tribal Health Consortium. Mr. 
Boyce also serves as the Alternate Alaska Representative to the 
Facilities Appropriations Advisory Board.
    The deplorable health status of AI/ANs is clearly understood by 
this Committee as evidenced by your commitment to modernizing the 
Indian Health System through your recent efforts to advance the Indian 
Health Care Improvement Act (IHCIA). We thank the Committee for your 
efforts in highlighting the unmet needs in Indian Country and 
congratulate you on your successful passage of the bill in the Senate 
and its transmittal to the House.
    We look forward to the day when we can take advantage of these 
modern advances. In the meantime, we know that in order to make headway 
on health disparities, we need to put adequate resources toward 
improving access to care. In addition to providing resources for direct 
care, we also need to focus our efforts and resources on building 
facilities where they do not exist, and improving facilities that are 
in disrepair because the maintenance and improvement needs have not 
been sufficiently funded.
    For those of you who have not visited Indian country or seen a 
tribal health facility first hand, I will try to paint a picture. It 
will be incomplete. It is impossible to understand the diversity and 
challenges faced by Tribes without visiting a number of them. However, 
not everyone can visit. So today, I hope to help you understand why 
adequate health facilities are so important to the Indian health 
system.
    The stories I will tell you come from my experience in Alaska, and 
from the experience of other tribes across the country, where tribal 
members experience the same difficulties accessing health care, and 
tribal governments and clinics experience the same pain of having to 
deny health care to people in need because there just isn't enough 
money to pay for it, and because there are just not enough resources to 
provide adequate facilities.
    We specifically recommend that Congress adequately fund the full 
range of facility construction and operational needs, including primary 
health care needs, Long-Term Care Skilled Nursing and assisted living 
facilities, residential alcohol and substance abuse facilities, and our 
huge unmet sanitation facilities needs.
I. The Indian Health Service System
    The Federal Government has a duty--acknowledged in treaties, 
statutes, court decisions and Executive Orders--to provide for the 
health and welfare of Indian Tribes and their members. \1\ In order to 
fulfill this legal obligation to Tribes, it has long been the policy of 
the United States to provide health care to American Indians and Alaska 
Natives through a network made up of the Indian Health Service 
programs, tribal health programs and urban clinics.
---------------------------------------------------------------------------
    \1\ See Federal Basis for Health Services, January 2007 
(info.ihs.gov/Files/BasisForServices-Jan2007.doc).
---------------------------------------------------------------------------
    The Indian Health Service (IHS), directly and through tribal health 
programs carrying out IHS programs under the Indian Self-Determination 
and Education Assistance Act, Pub. L. 93-638, as amended (ISDEAA), 
provides health services to more than 1.9 million American Indians and 
Alaska Natives. We are members of 562 federally-recognized tribes in 
the United States, located in 35 different states. According to the 
IHS, these services are offered from the following facilities: \2\
---------------------------------------------------------------------------
    \2\ Indian Health Service Fact Sheet, IHS/OD/PAS January 2007 
(info.ihs.gov/Files/IHSFacts-Jan2007.doc).

------------------------------------------------------------------------
                                              IHS Directly    Tribally
                                                Operated      Operated
------------------------------------------------------------------------
Hospitals                                               33            15
Health centers                                          54           229
Health stations                                         38           116
Alaska Community Health Aide (CHA) clinics               0           162
------------------------------------------------------------------------

    There are also 34 urban Indian health programs funded by IHS under 
Title V of the IHCIA that provide care to approximately 600,000 AI/ANs. 
\3\ When health care cannot be provided through these facilities, IHS 
and tribal programs use funding to purchase ``Contract Health 
Services'' from providers outside of the IHS system.
---------------------------------------------------------------------------
    \3\ Indian Health Service Year 2007 Profile, January 2007 
(info.ihs.gov/Files/ProfileSheet-Jan2007.doc).
---------------------------------------------------------------------------
    The number of facilities does not really tell the story though. The 
Indian health system is a real system of care. It is reflected in the 
IHCIA, which addresses health provider workforce issues, and a full 
range of health care services from preventive health care services to 
critical inpatient care, from prenatal care and deliveries to services 
needed at the end of one's life.
    The IHCIA also encompasses services that have been woefully 
inadequate or simply unavailable like nursing home services and 
behavioral health, including a continuum of mental health and substance 
abuse services. In addition, the IHCIA addresses those critical 
infrastructure issues that are so easily overlooked when a suffering 
patient and her family require immediate attention--the facilities that 
are needed to provide this vast array of services and basic public 
health services like safe water and sanitation.
    There is a desperate need for additional resources even with 
reliance on supplemental funding through Medicaid, Medicare and SCHIP. 
The system simply cannot remain viable without adequate facilities.
II. State of Indian Health Facilities
    The unmet need for health facilities for the IHS and tribal health 
system is $6.5 billion. This includes only the highest priority need 
for inpatient hospitals, health centers, staff quarters, and youth 
regional treatment centers. It does not include adult treatment 
centers, residential long-term care facilities, nor sanitation 
facilities, which are sorely needed.
    Currently, the average age of an IHS facility is 32 years. Even 
more startling is that there are 17 installations throughout the IHS 
where the facility age is between 40 and 66 years.
    The state of individual health facilities in Indian Country varies 
greatly. They range from a few ``newer'' health facilities to the more 
common old, poorly maintained facilities that are in desperate need of 
repair. Even more striking is that entire IHS Areas do not have certain 
kinds of health facilities at all.
    An example of a newer inpatient hospital facility is the Alaska 
Native Medical Center (ANMC), jointly operated by Southcentral 
Foundation and ANTHC. Although it was constructed over ten years ago, 
it is considered a very new facility in the Indian Health System. The 
planning documents for this facility were completed 10 years before the 
facility was constructed. In the meantime, it languished on a very long 
``facilities list'' along with other crucial but unfunded projects. The 
ANMC facility is a significant improvement over the previous hospital 
that was constructed in 1953, but it is clear that the facility is not 
large enough to keep up with population growth. This is a common 
occurrence when limited construction funds are available to meet the 
need for facilities that have been sitting for years on the IHS 
facility list.
    The more typical IHS inpatient hospital is old and dilapidated. For 
example, the Nome hospital was constructed in 1948 with an addition in 
the 1970s. A replacement facility has been on the IHS priority list 
since 1991. Another Alaskan facility, the Samuel Simmonds Memorial 
Hospital in Barrow was constructed with wood frame construction in 
1964. Although wood framed buildings are short-lived, the Barrow 
hospital has been on the IHS priority list since 1991.



    Some areas, like the Portland Area (representing Washington, 
Oregon, and Idaho) and the California Area, have no inpatient hospital 
facilities at all. Because there is no hospital for AI/AN patients in 
their respective IHS Area, these facilities depend on Contract Health 
Services (CHS) funds. In fact, despite the population shifts to the 
west and east coasts of the United States, there are very few IHS 
inpatient hospitals in the western United States. Likewise, there are 
very few IHS inpatient hospitals located on the east coast. There is 
clearly a need for additional inpatient hospitals.
    Like inpatient hospitals, health centers are also in various 
stages. For example, health clinics in the Portland Area are an average 
of 40-50 years old. One clinic on the Colville Indian Reservation is 
over 70 years old. Other clinics in the Portland Area make do with 
mobile homes. \4\
---------------------------------------------------------------------------
    \4\ Testimony of Linda Holt, Chairperson, Northwest Portland Area 
Indian Health Board, before the Senate Finance Committee, March 22, 
2007.



    The continuing ``pause'' on facility construction has delayed 
attempts to address the aging health care facilities within the IHS 
system. We strongly recommend that Congress appropriate more resources 
for the construction of desperately needed health facilities and to 
take advantage of other opportunities for innovation. At a minimum, we 
recommend that the 2010 budget restore funding to $93.6 million, 
allowing the IHS to replace its high priority healthcare facilities 
with modern facilities, and to significantly expand capacity at its 
most overcrowded sites.
III. Innovations in Facility Development
    We have seen the benefit of pursuing and leveraging additional 
resources in the construction of sanitation facilities. Between 1986 
and 1990 project contributions from other sources to IHS sanitation 
facilities construction projects averaged $55.7 million annually. After 
the Sanitation Deficiency System (SDS) was established, annual average 
contributions for the five years following (1991-1995) averaged $105.6 
million. \5\ This resulted in a $50 million annual increase in 
contributions from other sources. Thus, contributions almost doubled as 
a result of SDS.
---------------------------------------------------------------------------
    \5\ The Indian Sanitation Facilities Act, P.L. 86-121, authorizes 
the IHS to provide essential sanitation facilities, such as safe 
drinking water and adequate sewerage systems, to Indian homes and 
communities.
---------------------------------------------------------------------------
    We anticipate that these same opportunities can be replicated in 
making additional resources available to address the unmet need for 
health facilities by increasing appropriations for two successful 
programs and providing additional resources to implement the FAAB 
recommendations. Because of the limited amount of funds available for 
health facility construction, tribes worked with Congress to develop 
two innovative programs, the Joint Venture Program (JV) and the Small 
Ambulatory Program (SAP), to leverage other funds to get projects 
completed. Another opportunity yet to be realized is the FAAB's 
recommendation for the Area Distribution Program.
    Tribes have built approximately three times more health care space 
than the IHS has been able to with limited funds through the Joint 
Venture Program and the Small Ambulatory Program.
    The Joint Venture program was developed to help assist tribes with 
their unmet facilities needs. This competitive program provides the 
medical equipment funds and the complete staffing package for a 
selected facility that is constructed with tribal resources so long as 
it meets IHS planning requirements. \6\
---------------------------------------------------------------------------
    \6\ The Joint Venture program was enacted as an amendment to the 
IHCIA under Section 818 and authorizes Congress to appropriate 
recurring funds for increased staffing, operation and equipment for new 
or replacement facilities constructed with non-IHS funding acquired by 
tribes.
---------------------------------------------------------------------------
    The Small Ambulatory Program (SAP) also assists tribes with their 
unmet facilities needs. This competitive program provides the 
construction funds, facility maintenance costs, and medical equipment 
costs, while the tribe provides the staffing package. \7\
---------------------------------------------------------------------------
    \7\ The Small Ambulatory Program is only available to tribes who 
contract or compact to operate a facility under the Indian Self-
Determination and Education Assistance Act, Pub.L. 93-638.
---------------------------------------------------------------------------
    One recommendation from the FAAB is the creation of an Area 
Distribution Program (ADP). The ADP is intended to provide funds to 
each IHS area to fund projects on the national priority list that are 
high priorities for the Area but don't rank high enough to receive 
direct Congressional funding in the near future. Thus, it provides a 
methodology for allocating funds to Area Offices to address the highest 
priority projects within the Area. These funds can be used to match 
other local, state, and federal funds to complete a project that would 
take many more years to complete if they were limited to using IHS 
funds.
    The ADP would be initiated only when Congress appropriates funds 
for this purpose, the fund would be another line item in the facilities 
appropriation just as Joint Venture, Small Ambulatory Clinic, Dental, 
and Priority List Construction are separate line items now.
    The ADP proposal would require these funds to be distributed to the 
highest priority Area Office facilities where the Area and Tribes agree 
that only limited new staffing is required. Upon completion of ADP 
projects, the facility will be allocated only about 40 percent of the 
additional staffing and operational funds usually allocated to new 
facilities. As proposed by the FAAB, the ADP funds would be allocated 
as follows:

   In a given year, the Area Offices may not participate in the 
        ADP if the line-item amount in the Facilities Appropriation 
        exceeds 20 percent of the total appropriations for facilities 
        construction.

   Those Areas that receive 20 percent or less of the annual 
        line-item facilities appropriation are allocated a portion of 
        the Area Distribution Program funds using a formula based on 
        Area user population and location cost adjustments.

    The benefit of this process is every IHS Area is able to 
participate. Other matching funds can be used to build, renovate, and 
expand a facility; and some staffing is provided. Each Area can 
complete a high area priority project, and M&I funds can now be used 
for code and infrastructure type projects like boilers, chillers, 
pumps, air handlers and life-safety code issues. More projects 
addressing the overall unmet needs are completed more quickly and at a 
lower costs since non-IHS partners like private foundations and other 
granting agencies contribute funding for some of the staffing and/or 
construction costs.
    Some Areas have expressed concern about projects identified back in 
1991 that are now on the national priority list. They question whether 
the Area Distribution Funds may dilute the facilities appropriation and 
further delay funding for their projects. However, the Joint Venture 
and SAP funding lines are already in place on the facilities 
appropriation and Congress has continued to provide funding to these 
programs along with funding individual projects on the priority list. 
We ask that Congress continue this practice with the Area Distribution 
Program so that it provides another option for Congress to allow more 
tribes to participate in what has been a closed priority system since 
1991.
    There have been 7 Joint Venture projects and 27 Small Ambulatory 
Program projects awarded since 1998. The JV program and the SAP are 
examples of the best available opportunities to leverage funds to get 
desperately needed facilities constructed in Indian Country, but the 
funds available have been very limited. We recommend that Congress 
increase Joint Venture funding and Small Ambulatory Program funding and 
add new appropriations for the Area Distribution Program to accelerate 
the completion of needed facilities.
IV. Facility Operational Needs
    When addressing facility needs, it is important to look beyond new 
construction. In order for existing facilities to remain functional and 
provide maximum use, it is also important to adequately fund Medical 
Equipment Replacement, Facility and Environmental Support Funding, 
Maintenance & Improvement and the Village Built Clinic Lease Program. 
Adequate funding for these programs will ensure that the facilities we 
build today will be available for continued use into the future. Thus, 
we recommend adequate funding for these needs as more specifically 
described below.
A. Medical Equipment Replacement
    In order to assure patient safety, medical equipment should be 
replaced on an average of every 6 years. Unfortunately, current funding 
levels cover only one-third of the level of need. Thus, equipment that 
should have been replaced after 6 years may continue to be used for 18 
years or longer. Medical equipment maintenance and replacement presents 
obvious patient safety issues, and some tribes may divert funds from 
direct patient care to make up this gap.
    The annual medical equipment funding is $21.3 million, when the 
annual need is actually $64 million. We urge Congress to increase IHS 
appropriations to this line item to ensure that neither patient safety 
nor direct patient care is compromised.
B. Facility and Environmental Support Funding
    Facility and Environmental Support (FES) funding provides for the 
maintenance staff and basic operations of health facilities, including 
utilities. These funds also pay for Area office programs, like core 
staffing for health facilities, environmental health, and sanitation 
construction.
    The level of funding has stayed relatively flat or received small 
increases (less than 2 percent). With the rising cost of salaries and 
double digit annual increases in energy costs, this funding line is not 
keeping pace. In fact, the FY09 President's budget proposes no change 
from FY08 even though it allocates $25 million out of the base funding 
for staffing and operational costs for new facilities opening in FY09. 
Historically, new funds were made available to meet these additional 
FES costs for new facilities in addition to any necessary nationwide 
programmatic increases. However, the effect of the President's FY09 
budget recommendation is that new facility needs are being funded at 
the expense of existing programs.
    We recommend that Congress increase this appropriation by $4.2 
million annually to meet the current national need. We also recommend 
that Congress appropriate an additional $25 million recurring need for 
new staffing requirements associated with new facilities opening in 
FY09.
C. Maintenance & Improvement
    Maintenance & Improvement (M&I) funds are used to maintain 
facilities so they can continue to be used in the future. 
Unfortunately, the level of M&I funding is substantially lower than 
what is needed. It is estimated that the base M&I funding needed to 
just sustain the facilities in their current condition should be funded 
at $80 million annually. Because funds have not kept pace with the 
need, there is a tremendous backlog of maintenance needs. The IHS 
estimates $371 million is needed just to get caught up. The FY08 M&I 
funding level of $52.9 million is grossly insufficient to sustain the 
facilities. It fell far short of the estimated $120 million needed to 
address the backlog.
    Failing to maintain existing facilities will only hasten the need 
for new construction. Health programs with existing facilities have 
tremendous and growing maintenance and improvement needs especially 
those with older facilities. We recommend that the Maintenance and 
Improvement appropriation be substantially increased to sustain 
existing facilities and to address the $371 million backlog of 
maintenance and improvement issues.
D. Village Built Clinic Lease Program
    The Village Built Clinic (VBC) Lease Program funds rent, utilities, 
insurance, janitorial, and maintenance costs of healthcare facilities 
in rural Alaska communities. \8\ Despite an increase in the number and 
size of clinics throughout Alaska as well as the rapidly increasing 
fuel costs, funding for the VBC Lease Program has barely increased 
since 1996. Village clinics have also incurred more costs in recent 
years due to increases in the scope and level of medical services 
provided, expanded village healthcare programming, new technology, and 
accreditation standards. Current lease funding covers only 
approximately 55 percent of the current operating costs and those costs 
are expected to continue to increase sharply as energy costs continue 
to skyrocket in rural Alaska.
---------------------------------------------------------------------------
    \8\ Reprinted from The Village Built Clinic Programs: Village 
Clinics in Crisis, Alaska Native Health Board, May 2007.
---------------------------------------------------------------------------
    Without additional funding for the VBC Lease Program, Alaska 
villages are forced to subsidize the day-to-day operating costs of 
their clinics and defer long term maintenance and improvement projects. 
Therefore, without an increase in funding to the VBC Lease Program, 
village clinics will be increasingly forced to reduce clinic 
operations, and these clinics will continue to fall into disrepair. 
This situation reduces the health care available locally to village 
residents and threatens the almost 200-million-dollar investment in 
these facilities by the Federal Government, Alaska villages, and the 
regional tribal health organizations in the Alaska Native health care 
system.
    Thus, we recommend an increase of $5.8 million in funding for the 
VBC Lease Program to the current program base of the VBC Lease Program. 
These funds are required immediately to sustain the program, covering 
the expected operating costs in FY09 as well as establishing funding 
for long-term maintenance and improvement. Without this funding, many 
of Alaska's villages will not be able to continue supporting local 
clinics, eventually leading to serious consequences for the health and 
safety of Alaska Native people.
V. Impact of the Lack of Funding for Facilities & Facility Operational 
        Needs
    The biggest impact of inadequate facilities is decreased access to 
care, which in turn exacerbates health disparities. While we have 
provided a snapshot of the unmet primary health care needs, we would be 
remiss if we did not highlight for the Committee the lack of other 
types of facilities like Long-Term Care, Skilled Nursing and assisted 
living facilities, residential alcohol and substance abuse facilities, 
and our huge unmet sanitation facilities needs.
    Most AI/ANs do not have access to Long-Term Care services, 
including skilled nursing and assisted living services. For example, in 
the Alaska Tribal Health System which has a relatively comprehensive 
range of services, there are currently no assisted living facilities 
and only one long term care skilled nursing facility. Public health 
measures, such as childhood vaccinations and improved sanitation in 
rural Alaska, have increased the life expectancy of Alaska Natives and 
we are now living longer than we ever have. From 1950 to 1997, Alaska 
Native life expectancy rose from 46 years of age to 68 years of age. 
\9\ As our population is aging, there are no facilities to provide 
desperately needed community-based health care. For instance, if I were 
an elder living in Bethel, Alaska, and my family could not provide the 
medical care I needed at home, I would have to be sent to a nursing 
home in Anchorage, hundreds of miles and hundreds of dollars away from 
my family, community, and culture in order to get the care I need. Our 
elders make the daily choice to forego this care because such a 
separation is unconscionable in our communities. Unfortunately this 
situation occurs throughout the Indian health system because there are 
only a handful of long term care facilities to meet this need.
---------------------------------------------------------------------------
    \9\ Status of Alaska Natives Report, Institute of Social and 
Economic Research, 2004.
---------------------------------------------------------------------------
    Many AI/ANs still do not have access to behavioral health services 
despite the clear need. An integrated health system requires 
availability of qualified and trained behavioral health providers in 
every community. Prevention and treatment approaches to behavioral 
health must be provided in a seamless integrated fashion, use best and 
promising practices; and they must start at the community level. The 
full implementation of this vision is only possible with resources that 
ensure services are available in the right place and the right time to 
prevent escalation of the need for more intensive and costly services.
    Specifically, there is an overwhelming shortage of residential 
alcohol and substance abuse facilities for AI/AN throughout the 
country. Without sufficient facilities to meet this need people 
continue to be turned away at the door of existing residential 
treatment programs or wait listed for extended periods of time at the 
crucial moment in their addiction where they acknowledge they have a 
problem and are seeking help. Unfortunately, the current reality is 
that AI/ANs who need residential alcohol and substance abuse services, 
can expect to wait 6 months to a year for services. For many, treatment 
is simply not available. The consequences are profound. Again, to use 
Alaska as an example, 1 in 11 Alaska Native deaths is alcohol-induced; 
\10\ Alcohol contributed to 85 percent of reported domestic violence 
cases and 80 percent of reported sexual assault cases between 2000-
2003; \11\ and, Suicide among Alaska Natives remained steadily at 2 
times the non-Native rate from 1992-2000. \12\ Many AI/ANs still do not 
have access to behavioral health services facilities despite the 
overwhelming need. An integrated and modern health system requires not 
only the services but the facilities in which to provide those 
services.
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    \10\ Alaska Bureau of Vital Statistics.
    \11\ Status of Alaska Natives Report, Institute of Social and 
Economic Research, 2004.
    \12\ Alaska Bureau of Vital Statistics.
---------------------------------------------------------------------------
    Inadequate sanitation continues to plague much of Indian Country 
and is especially problematic in Alaska where 26 percent of Alaska 
Native homes lack adequate water and wastewater facilities. It is 2008 
and, despite the fact that we know that people live longer, healthier 
lives in communities with water and sewage systems, there are over 
6,000 homes in rural Alaska without safe drinking water and about 
14,000 homes that require upgrades or improvements to their water, 
sewer, or solid waste systems to meet minimum sanitation standards. 
Increased sanitation facilities will improve these statistics and the 
health of these communities, as well as contribute to increasing the 
Alaska Native life expectancy, as discussed previously.
    Funding for these services have been sorely lacking even though we 
know that improvements in these areas can result in significant 
improvements in health status. For example, infants in communities 
without adequate sanitation facilities are 11 times more likely to be 
hospitalized for respiratory infections and 5 times more likely to be 
hospitalized for skin infections when compared to all U.S. infants. 
\13\
---------------------------------------------------------------------------
    \13\ Impacts of Water and Sewer Service on the Health of Infants, 
American Journal of Public Health, In Press, May, 2008.
---------------------------------------------------------------------------
    In addition, the lack of facilities also increases costs to other 
IHS budget line items. For example, tribes who are served in an IHS 
area in which there is no hospital to refer patients to are become 
dependent on Contract Health Services (CHS) resources and pay private 
facilities premium rates for care that is too often culturally 
insensitive. The CHS line item is already substantially under-funded 
without adding facilities inadequacies into the equation. In order to 
provide necessary patient care, IHS and Tribal providers are forced 
into ``robbing Peter to pay Paul'' in life and death situations. We 
also know that when facility needs are not adequately funded, these 
funds necessarily come out of direct patient care dollars especially 
when life-safety issues are involved, like the replacement of medical 
equipment. Chronic under-funding of the IHS facilities line items 
contributes to the lack of adequate facilities, the overburdening of 
the other budget line items, and rationed health care on a systemic 
level.
VI. Efforts to Update the Healthcare Facilities Construction Priority 
        System
    In FY 2000, Congress recognized the significant and growing unmet 
facility needs, and directed the IHS to consult with Tribes and the 
Administration to revise the Healthcare Facilities Construction 
Priority System (HFCPS). Congress highlighted the need ``to reexamine 
the current system for construction of health facilities'' and to 
develop ``a more flexible and responsive program.that will more readily 
accommodate the wide variances in tribal needs and capabilities.'' \14\
---------------------------------------------------------------------------
    \14\ Conference Report, H.R. 2466, FY00 Interior Appropriations, 
Congressional Record--October 20, 1999.
---------------------------------------------------------------------------
    Over the course of 8 years, the IHS, working with tribal leaders, 
undertook a major overhaul of the facilities priority system. Although 
the resulting proposal is a vast improvement over the current process, 
it has not yet been implemented by the IHS. We describe the planning 
process and resulting system below. We recommend that Congress direct 
the IHS to implement this new system and that Congress provide 
additional appropriations to ensure the new system is fully effective.
    In early 2001, the Facility Appropriations Advisory Board (FAAB) 
\15\ established an IHS Facility Needs Assessment and Priority Criteria 
Workgroup (Workgroup) to develop specific recommendations to improve 
the IHS construction priority system. The Workgroup, comprised of 19 
tribal leaders, health directors, planners, urban health directors and 
regional tribal associations, worked on specific recommendations 
regarding:
---------------------------------------------------------------------------
    \15\ The 14 member FAAB is comprised of a tribal representative of 
each of the 12 IHS Areas plus 2 IHS members.

   Criteria to be used for establishing and annually reviewing 
---------------------------------------------------------------------------
        the need for facilities construction need in Indian Country;

   Criteria (and their relative weight) to prioritize competing 
        projects of the same type; and

   Strategies for prioritizing needs of different construction 
        programs (inpatient facilities; outpatient facilities; dental 
        units program; Joint Venture Program; Small Ambulatory Program; 
        the proposed Loan Guarantee Program; etc.).

    The Workgroup's recommendations, IHS Facility Needs Assessment and 
Priority Criteria Recommendations, were forwarded to the FAAB and to 
the IHS in February, 2002 and became the foundation for the final 
recommendation for the new priority system. \16\
---------------------------------------------------------------------------
    \16\ IHS Facilities Needs Assessment and Prioritization Criteria 
Workgroup Report on Findings and Recommendations, February, 2002.
---------------------------------------------------------------------------
    The FAAB spent the next two and a half years refining the 
Workgroup's recommendations. Extensive tribal consultation began in 
June 2004 when the IHS sent out a ``Dear Tribal Leader'' letter in June 
2004 with a draft copy of the FAAB priority system proposal. The IHS 
received 80 responses from 11 IHS Areas containing over 1,200 total 
comments. The FAAB spent the next two years incorporating comments and 
working with IHS and tribal leaders on the final recommendation. The 
final recommendation was forwarded to the U.S. Department of Health & 
Human Services in November, 2007.
VII. The New Healthcare Facilities Construction Priority System
    The new Healthcare Facilities Construction Priority System (HFCPS) 
is more robust than the current system in that it is very orderly and 
uses reliable data. It is also based on the master plan concept which 
ensures that service needs of the local population are used for 
facility planning. It also provides for a tremendous amount of tribal 
involvement throughout all phases of the process. Among the highlights 
are the development of a Master Planning process that recognizes the 
needs of smaller communities, and an Area Distribution Program.
A. Area Health Services and Facilities Master Plan (Area Master Plan)
    The Master Planning process is central to the new priority system. 
Using the IHS ``Health System Planning'' (HSP) software/model, the 
services and facilities required in individual service areas are 
determined nation-wide. Based upon these community-specific or service 
area specific HSP analyses, a community specific Master Plan would be 
generated to quantify the costs associated with the potential 
construction of expanded, replaced or new facilities.
    From there, these data can then be integrated at the Area level to 
produce a State-wide Health Services and Facilities Master Plan. A 
Master Plan will help establish relative priority within an Area for 
construction and development of new services and support decision-
making consistent with the Area-wide service delivery system, which in 
turn, will provide the basis for an integrated Area-wide Master Plan.
    The key to this approach to master planning is facility planning 
and construction decisions will be based on accurate factual 
information about the system-wide health service needs in each Service 
Unit and Area. As the area wide service delivery plan is developed 
decisions will be made about where and how each service will be 
provided. Then, the discussion will move on to deciding what the 
facility need is and how best to meet the need. Effectively, tribes 
engage in an analysis of whether renovation and expansion of an 
existing facility or whether construction of a new facility is 
warranted and what will best serve their population's needs.
B. HFCPS Ranking Methodology
    Once the facility requirements of each area have been identified in 
the Area Master Plans, these projects will then be scored according to 
the HFCPS. The HFCPS ranking is implemented in two phases. Phase I is 
designed to assess all of the facility needs through the creation of 
the Comprehensive National Listing of Facility Need (Unmet Needs List). 
Phase II is designed to further refine the application and allow 
innovative solutions to be applied to the scoring criteria. This two-
phased process allows the IHS and the Tribes to use limited resources 
to both identify all of the facility needs (phase I), and to allocate 
the necessary time and resources for concentrating analysis on those 
facilities that have the opportunity to move forward to receive full 
funding within 5 years.
1. Process Overview
    In Phase I, all health care facilities in IHS Area Healthcare 
Services and Facilities Master Plans are evaluated and scored by IHS 
Headquarters using a HFCPS formula. Facilities on this list are 
categorized according whether they are an inpatient hospital, health 
center, small clinic, or other health facility, ranked and compiled 
into the ``Comprehensive National Listing of Facility Need.''
    In Phase II, facilities selected from the Comprehensive National 
Listing of Facility Need are reviewed by the HFCPS Validation 
Committee. \17\ The IHS will apply the HFCPS Phase II Formula to data 
about these proposed facilities to develop the Priority List. 
Facilities are selected from the Comprehensive National Listing of 
Facility Need. The method for selecting facilities for Phase II review 
differs based on the requirements of the specific facilities 
construction funding program.
---------------------------------------------------------------------------
    \17\ The Healthcare Facilities Validation Committee is a standing 
committee consisting of seven individuals appointed by the Director of 
IHS. Membership may include but not be limited to IHS Headquarters and 
Area Offices, Tribal, and other health oriented professionals.
---------------------------------------------------------------------------
    Six evaluation factors are employed to evaluate and score facility 
projects over two phases. The evaluation criteria are:

------------------------------------------------------------------------
                                      Phase I              Phase II
------------------------------------------------------------------------
   Facility Resources   400 points           400 points
 Deficiency
   Health Status        200 points           200 points
   Isolation            100 points           100 points
   Barriers to Care                          50 points
   Facility Size        150 points           150 points
   Innovation                                100 points
------------------------------------------------------------------------
    Total                       850 points           1,000 points
------------------------------------------------------------------------

2. Implementation of Phase I
    Implementation of Phase I should take approximately 6 months. Phase 
I scores will be recalculated every five years to maintain a relatively 
up-to-date Comprehensive National Listing of Facility Need. All Area 
Health Services and Facilities Master Plans will be updated 24 months 
before Phase I is recalculated.
    The data required for completion of Phase I are:

   User population from the IHS National Patient Information 
        Reporting System;

   Existing facility size, age, and condition from the IHS 
        Facility Data System;

   The following indicators from the Federal Disparity Index 
        (FDI):

          -- The Birth Disparities Indicator,

          -- The FDI Percent of the population over 55 years old,

          -- The Composite Poverty Indicator, and

          -- The Disease Disparity Indicator

   The distance from the proposed facility to the nearest 
        emergency room.

   The size of the new/expanded facility from the Area Master 
        Plan

    Validation of the data used is obtained from existing IHS databases 
or will be verified by qualified professionals, e.g., certified 
professional engineers, architects, etc.
3. Implementation of Phase II
    The entire Phase II process should take approximately 1 year to 
complete. Phase II of the HFCPS will be recalculated every year that 
funding is available for one or more facilities construction program to 
assure an up to date list of high priority projects.
    The Phase II list will reflect the changes in funding status of 
each project. The criteria for Phase II will be implemented and applied 
slightly differently for each of the congressionally authorized 
facilities construction programs. \18\ The basic formula will remain 
the same, but other factors, identified in law and regulations, will be 
used to select projects for Phase II review. Data for the scoring is 
developed from the approved Program Justification Document (PJD).
---------------------------------------------------------------------------
    \18\ These programs include the line-item program authorized under 
Section 301 of the Indian Health Care Improvement Act (IHCIA), Public 
Law (P.L) 93-437; the Small Ambulatory Program, authorized under 
Section 316; the Joint Venture Program authorized under Section 818, 
etc.; and projects considered under the Area Distribution Program 
within each Area.
---------------------------------------------------------------------------
    For Validation purposes, each PJD is approved by the Director, 
Office of Environmental Health and Engineering. The HFCPS Validation 
Committee will review the documentation supporting Innovation and 
Barriers to Service proposals along with any Tribal facilities 
information that is not included in the Facility Data System (FDS).
    The IHS applies the HFCPS formula to the approved and validated 
data. Finally, facilities under consideration, are prioritized 
according to their scores and placed on the Priority List in rank 
order.
    Clearly the new process is based on more reliable data and improved 
needs based planning. It also allows greater tribal involvement 
throughout all phases of the process. We applaud the FAAB and the IHS 
on the development of the new model and implore them to implement it 
expeditiously. It is one more example of the opportunities in 
innovation that arise when the IHS and tribes work collaboratively in 
addressing our facilities needs. However, in order for the new system 
to be successful more resources are necessary. To realize the full 
potential of the new facilities priority system, and we urge Congress 
to provide such funding.
Conclusion
    For those of you who deal with the size and complexities of a 
variety of appropriation needs a regular basis, the improvements we 
seek here may seem inconsequential. That could not be farther from the 
truth. As American Indians and Alaska Natives, we are a people with 
painful legacies of forced removal--to boarding schools, to cities, to 
faraway hospitals--and rampaging epidemics that disrupted families for 
generations. Despite this, we still have very strong ties to our 
communities.
    We know from experience, that as resources get tighter, individual 
AI/ANs and the IHS facilities that provide their care will feel the 
impact more than any other. Why? The highest rates of unemployment are 
in Indian Country. We have some of the lowest income levels; some of 
the poorest health status; and we are primarily rural where access to 
care is a problem. There is a high cost of providing care, and a high 
cost of living where limited incomes get stretched even more. What this 
means is that, when our people do finally get the care they need, they 
have traveled farther with money they simply don't have, are sicker 
than the average person, and are seen in clinics/hospitals that have 
fewer resources than most other facilities in the country. Also, 
because of their rural nature, our facilities have a higher cost of 
providing care.
    As one of the younger members of my Tribe, with the privilege and 
opportunity to work in our health programs, it is my duty to try to 
overcome this history and to assure that no AI/AN will have to make the 
choice to forego medical care due to a lack of facilities or to receive 
culturally insensitive care because we are buying care from others that 
we can provide for ourselves. It is my duty to be sure that we protect 
the health status improvements that have been made and that we 
accomplish more. We must leave a better health system for our children 
and grandchildren than we inherited. It is for that reason that I am 
here today to testify before you.
    The strategies we are discussing today will authorize many 
important steps toward the goal of quality health care in our home 
communities and in ways that respond to our needs and respect our way 
of life. I know that we cannot knock down all of these barriers 
overnight, but these recommendations will make a significant 
improvement.
    In closing, I want to thank the Committee again for all your work 
and leadership in addressing these critical issues.
Attachment






























































    The Chairman. Ms. Davidson, thank you very much.
    Senator Murkowski?
    Senator Murkowski. Thank you, Mr. Chairman.
    I want to thank all those of you on the panel for your 
testimony, your perspective, Chairman Nosie speaking to the 
detention issues and Mr. Roessel to appreciate a specific 
situation within the school that you have addressed today, and 
to also offer the Committee some specific recommendations. I 
appreciate that.
    Valerie, I always appreciate your testimony. As usual, you 
have summed it up in a very well thought out and comprehensive 
way. I wanted to just ask you very quickly, you mentioned the 
reality that we face when we don't have the facilities, when we 
don't have the providers, the Alaska Natives and the American 
Indians have to go somewhere for care. And so what happens is 
we see increased expenses to contract health services.
    Has there been an effort to assess what is actually spent, 
or the increase that we see in contract health care services 
because we are not spending money adequately on the facilities? 
Do we know what that number is?
    Ms. Davidson. I can provide that number for you nationally 
later, but I can provide you a more specific example that just 
happened in the last couple of months in Alaska. For example, 
we had a RSV epidemic in Alaska, in Barrow. We have had it 
before in Bethel. My daughter had it when she was eight months 
old. As facilities become overwhelmed with their inability to 
be able to house patients, those patients get sent into the 
Alaska Native Medical Center in Anchorage, and then when we are 
full, they get sent over into Providence, in which contract 
health dollars kick in.
    As we indicated earlier, there are entire areas where there 
are no inpatient beds available at all. California, Portland 
area, there are entire States on the east coast, entire States 
on the west coast that have no inpatient facilities, and those 
are all contract health.
    The other thing I wanted to point out is, as Chairman 
Dorgan indicated earlier, that it is common knowledge in Indian 
Country that contract health dollars run out in June. So if you 
are fortunate enough to get sick, which is a terrible thing to 
say, in those months, you are in a much better position. 
Unfortunately, when contract health cannot pay anymore, there 
is no way to be able to capture that data from what the patient 
incurs when they are forced to go to a private facility. They 
get sent bills. They get sent to collections. It is staggering 
if you consider the cost.
    Senator Murkowski. But the reality, then, is again, these 
folks are going to have to go somewhere. So do they go to the 
private clinic where they have to pay out of their own pocket? 
Do they go to the emergency room? How are you going to pay 
there? The reality is that this cost doesn't go away. It is 
just allocated differently.
    I also wanted to ask you just very briefly on the long-term 
care facilities. We know that in the State of Alaska, we just 
don't have the facilities for long-term care, and that is 
something that we want to change. How did these types of 
facilities, how will they be included in this newly revised 
construction priority system?
    Ms. Davidson. I am going to let my technical expert, Mr. 
Boyce, answer how those are incorporated into the master plan.
    Mr. Boyce. Actually, right now they are not included in the 
master plan. The way the process is set up is they are 
characterized under other facilities when they are identified 
through the process, so they have been identified. Right now, 
the IHS has not developed the staffing and service delivery 
plans which would support that type of health care delivery. So 
therefore, they don't have the planning models in place to 
actually plan that type of facility.
    So they are being identified. The costs are being captured, 
but since that is not a service that they currently provide, 
then they are not prepared to design and construct those 
facilities.
    Senator Murkowski. It is something that under the Indian 
Health Care Improvement Act we said is an important aspect of 
the health care we provide. So we want to make sure that this 
doesn't get lost in the shuffle just because it hasn't been 
part of that priority list in the past.
    Valerie?
    Ms. Davidson. Let me give you a snapshot of how that is 
actually handled in our current system. Since we don't have 
long-term care facilities throughout Indian Country, what 
happens is when a patient needs long-term care, what happens is 
they actually stay in the hospital for months and months and 
months at a time. So when another patient presents who needs 
inpatient care, they get put on divert, so they have to be sent 
somewhere else. It is unacceptable.
    Senator Murkowski. Think about the costs that are involved 
with that.
    Ms. Davidson. Exactly.
    Senator Murkowski. Again, I want to thank the panel for 
coming such a long distance to be with us today and for your 
very important testimony.
    Thank you, Mr. Chairman.
    The Chairman. Senator Murkowski, thank you very much.
    I regret that I have some up against the clock here. We had 
a vote in the middle of this hearing, and I guess we have now 
gone 2 hours and 15 minutes. I have to be somewhere that I 
cannot change. So I am going to submit some questions to the 
panel that I would like you to respond to. I appreciate very 
much your filling in a gap of information this morning.
    Chairman Nosie, I indicated it was two weeks from Monday. I 
am told it is one week from Monday that I will be chairing a 
hearing in Phoenix on law enforcement issues, and Senator Kyl 
will also a part of that hearing. I would invite you to join us 
there.
    Mr. Roessel, thank you for your testimony. I have a couple 
of specific questions I want to ask you.
    And we appreciate your traveling, Ms. Davidson, all the way 
from Alaska. I appreciate the two of you coming down and being 
a part of the hearing this morning.
    With that, this hearing is adjourned.
    [Whereupon, at 12:15 p.m., the Committee was adjourned.]

                            A P P E N D I X

Prepared Statement of Linda Holt, Chairperson, Northwest Portland Area 
          Indian Health Board; Suquamish Tribal Council Member

    Chairman Dorgan, Vice-Chair Murkowski, and members of the 
Committee, thank you for this opportunity to include our statement into 
the record concerning the state of Indian health facilities. Before I 
begin, I want to take this opportunity to thank and congratulate the 
Committee for its hard work in getting the Indian Health Care 
Improvement Act (IHCIA) passed out of the Senate.
    I am Linda Holt and service as the Chairperson of the Northwest 
Portland Area Indian Health Board (NPAIHB) and am a Tribal Council 
Member of the Suquamish Tribe located in Washington State. Established 
in 1972, NPAIHB is a P.L. 93-638 tribal organization that represents 43 
federally recognized Tribes in the states of Idaho, Oregon, and 
Washington on health related matters. \1\ The Board facilitates 
consultation between Northwest Tribes with federal and state agencies, 
conducts policy and budget analysis, and operates a number of health 
promotion and disease prevention programs. NPAIHB is dedicated to 
improving the health status and quality of life of Indian people and is 
recognized as a national leader on Indian health issues.
---------------------------------------------------------------------------
    \1\ As defined in the Indian Self-Determination and Education 
Assistance Act, P.L. 93-638, 25 U.S.C., Section 450(b) a Tribal 
organization is a legally established governing body of any Indian 
tribe(s) that is controlled, sanctioned, or chartered by such Indian 
Tribe(s) and designated to act on their behalf.
---------------------------------------------------------------------------
    This hearing has been a long time coming and is timely given the 
movement of the IHCIA. The status of Indian health facilities is 
deplorable when compared to mainstream facilities in which most 
Americans receive health care. The Medicare and Medicaid programs 
provide tens of billions of dollars for facilities construction 
annually, but there is no discussion of facilities construction before 
the Congress and no separate appropriation for facilities construction 
in connection with the Medicare or Medicaid program. Yet most Americans 
receive care in the most modern clinics and hospitals in the world. 
Indeed it is remarkable, but true, that poor Americans who are eligible 
for Medicaid in Washington, Oregon, and Idaho now receive their care in 
the same facilities as other non-poor Americans, that's right, in the 
very same clinics and hospitals that are the envy of the world. But 
what about Indian people? Our clinics in the Northwest are notable 
exceptions; most on average are more than 40-50 years old. A clinic on 
the Colville Indian reservation is over 70 years old; and in other 
Northwest Tribal communities, clinics are housed in mobile homes. The 
clinics are not just old; they are also inadequate. They are often too 
small, the equipment is often outdated, and the staff is forced to make 
do as best they can. That is, the staff that is willing to stay under 
these less than desirable conditions. Many tribes continually battle 
recruitment and retention of medical doctors and nurses because of the 
less than desirable working conditions. Who can blame someone for not 
wanting to work up to his or her potential in a modern state of the art 
facility?
I. Indian Health Service
    The Federal Government has a duty--acknowledged in treaties, 
statutes, court decisions, and Executive Orders--to provide for the 
health and welfare of Indian Tribes and their members. In order to 
fulfill this legal obligation to Tribes, it has long been the policy of 
the United States to provide health care to American Indians and Alaska 
Natives (AI/AN) through a network made up of the Indian Health Service 
programs, tribal health programs and urban clinics. The Indian Health 
Service (IHS), directly and through tribal health programs carrying out 
IHS programs under the Indian Self-Determination and Education 
Assistance Act, P.L. 93-638, as amended (ISDEAA), provides health 
services to more than 1.9 million AI/AN people. These services are 
provided to members of 562 federally-recognized tribes in the United 
States, located in 35 different states.
    Currently, IHS provides access to healthcare services for AI/ANs 
through 31 Hospitals, 50 health centers, 31 health stations and 2 
school health centers. Tribes also provide healthcare access through an 
additional 15 hospitals, 254 health centers, 166 Alaska Village 
Clinics, 112 health stations and 18 school health centers. There are 
also 34 urban Indian health clinics that provide outreach and referral 
services, or that provide direct medical care.
II. Why the Poor Condition of Indian Facilities?
    Unfortunately, it is the budget process itself that annually under 
funds the IHS budget that is the cause of the poor condition of our 
facilities. There is no doubt that again this year little progress will 
be made to address our backlog of facilities need. The average age of 
IHS facilities is 33 years as compared to 9 years for healthcare 
facilities in the United States; many are overcrowded and were not 
designed in a manner that permits them to be utilized in the most 
efficient manner in the context of modern healthcare delivery. It is 
estimated by some Indian health experts that the unmet need for health 
facilities for the IHS and tribal health system is at least $6.5 
billion. This includes only the highest priority need for inpatient 
hospitals, health centers, staff quarters, and youth regional treatment 
centers. It does not include adult treatment centers, residential long-
term care facilities, or sanitation facilities, which are sorely 
needed.
    As a discretionary program, the Congress will ask tribes the annual 
question: Do you want this year's proposed $100-150 million increase to 
go to health services programs or facilities? This choice is unfair. No 
one asks Medicare recipients if they want facilities or programs--they 
get both. The health plans that deliver care to Medicaid and Medicare 
patients take out a portion of each dollar paid by these programs to 
provide adequate facilities. It is bad health care and bad business to 
have poor facilities. The idea of slicing off a portion of our 
inadequate health services dollars for facilities is not realistic. 
There is nothing to slice. Because the Indian Health Service is a 
discretionary program our funding is limited and proposals for 
facilities construction are the low hanging fruit that is chopped off 
every year. In fact, it is wrong that we don't ask for more than we do 
each year. More facilities funding is needed within the Indian health 
system.
    Recommendation: While the need to provide more funding to address 
facilities construction is great, there must also be a methodology to 
access the resources that is fair and equitable to all Tribes 
nationally.
III. Authorities for Indian Health Facilities
    Tribes have seen the benefit of pursuing and leveraging additional 
resources in the construction of health and sanitation facilities. 
Between 1986 and 1990 project contributions from other sources to IHS 
sanitation facilities construction projects averaged $55.7 million 
annually. Between 1991 and 1995, the Sanitation Deficiency System (SDS) 
program--established to fund water and waste facilities--averaged 
approximately $106 million in funding. During this same period, the 
program resulted in a $50 million annual increase in contributions from 
other sources. Thus, funding almost doubled because of Tribal 
contributions from other sources. This type of collaboration can 
benefit the facilities construction program if established by the 
Congress and implemented by the IHS. The IHCIA provides the authority 
for construction and maintenance of Indian health facilities.

        Section 301 authorizes the establishment of a Health Facility 
        Construction Priority System (HFCPS) that serves to evaluate 
        and rank the facility construction projects for the Indian 
        health system. The significance of Section 301 projects is that 
        they are provided a comprehensive funding package that provides 
        for facility construction, a staffing package, and for medical 
        equipment; and that they are continually provided funding.

        Section 302 provides authority for the sanitation, waste, and 
        facilities programs which provide for development and operation 
        of safe water, wastewater, and solid waste systems, and related 
        support to facilities.

        Section 306 provides authority for the Small Ambulatory Program 
        (SAP), which serves to assist Tribes with their unmet 
        facilities needs. This competitive program provides the 
        construction funds, facility maintenance costs, and medical 
        equipment costs, while the tribe provides the staffing package. 
        The SAP program has not been consistently funded by the 
        Congress nor has the IHS requested adequate funding.

        Section 818 provides authority for the Joint Venture Program 
        (JV), which was developed to help assist tribes with their 
        unmet facilities needs. This competitive program provides the 
        medical equipment funds and the complete staffing package for a 
        selected facility that is constructed with tribal resources so 
        long as it meets IHS planning requirements. Again, the JV 
        program has been inconsistently funded by Congress and the IHS 
        has not requested adequate funding for the program.

    Recommendation: The IHS could extend the benefits of appropriated 
funds under the proposed HFCPS to a significantly larger number of 
tribes and communities by consistently providing adequate funding for 
the SAP and JV programs. Tribes have built approximately three times 
more health care space than the IHS has under the HFCPS and have done 
this with limited funds through the Joint Venture and the Small 
Ambulatory Programs.
    Recommendation: A recommendation developed by Tribes is the 
creation of an Area Distribution Program (ADP). The ADP is intended to 
provide funds to each IHS Area to fund projects on the national 
priority list that are high priorities for the Area but don't rank high 
enough to receive direct Congressional funding in the near future. 
Thus, it provides a methodology for allocating funds to Area Offices to 
address the highest priority projects within the Area. These funds can 
be used to match other local, state, and federal funds to complete a 
project that would take many more years to complete if they were 
limited to using IHS funds. Congress should pilot this recommendation 
as a demonstration in FY 2010.
IV. Health Facility Construction Priority System (HFCPS)
    In FY 2000, Congress recognized the significant and growing unmet 
facility needs, and directed the IHS to consult with Tribes and the 
Administration to revise the Healthcare Facilities Construction 
Priority System (HFCPS). The Interior Appropriations Conference Report 
(106-406) directed the IHS ``to reexamine the current system for 
construction of health facilities'' and to develop ``a more flexible 
and responsive program. . .that will more readily accommodate the wide 
variances in tribal needs and capabilities.'' Over the last eight years 
the IHS Facilities Advisory Appropriation Board (FAAB) and Tribes have 
been working collaboratively to make a major overhaul of the 
construction priority system. Although the resulting proposal is a vast 
improvement over the current process, it has not yet been implemented 
by the IHS.
    One recommendation from the FAAB is the creation of an Area 
Distribution Program (ADP) that is described above. The ADP provides an 
alternate funding method for facilities construction that is a hybrid 
of the JV and SAP program. There is precedent for an area funding 
distribution in the Sanitation Deficiency System (SDS). The program 
strategically aligns project funds with healthcare mission by 
eliminating or reducing deficiencies in water supply and waste disposal 
facilities. It uses a methodology ``developed by the Secretary. . .and 
applied uniformly to all Indian tribes and communities'' to address an 
identified inventory of needed facilities. The system has worked to 
minimize complaints and concerns from Tribes over access to funds and 
has met the needs of most Tribal communities. An ADP could achieve the 
same outcomes.
    The ADP would be initiated when Congress appropriates funds for 
this purpose, the fund would be another line item in the facilities 
appropriation just as Joint Venture, Small Ambulatory Clinic, Dental, 
and Priority List Construction are separate line items now.
    The ADP proposal would require these funds to be distributed to the 
highest priority Area Office facilities where the Area and Tribes agree 
that only limited new staffing is required. Upon completion of ADP 
projects, the facility will be allocated only about 40 percent of the 
additional staffing and operational funds usually allocated to new 
facilities. As proposed by the FAAB, the ADP funds would be allocated 
as follows:

   In a given year, the Area Offices may not participate in the 
        ADP if the line-item amount in the Facilities Appropriation 
        exceeds 20% of the total appropriations for facilities 
        construction.

   Those Areas that receive 20% or less of the annual line-item 
        facilities appropriation are allocated a portion of the Area 
        Distribution Program funds using a formula based on Area user 
        population and location cost adjustments.

    The benefit of this process is every IHS Area is able to 
participate. Other matching funds can be used to build, renovate, and 
expand a facility; and some staffing is provided. Each Area can 
complete a high area priority project, and M&I funds can now be used 
for code and infrastructure type projects like boilers, chillers, 
pumps, air handlers and life-safety code issues. More projects 
addressing the overall unmet needs are completed more quickly and at a 
lower costs since non-IHS partners like private foundations and other 
granting agencies contribute funding for some of the staffing and/or 
construction costs.
    Some Areas have expressed concern about projects identified back in 
1991 that are now on the national priority list. They question whether 
the Area Distribution Funds may dilute the facilities appropriation and 
further delay funding for their projects. However, the Joint Venture 
and SAP funding lines are already in place on the facilities 
appropriation and Congress has continued to provide funding to these 
programs along with funding individual projects on the priority list.
    Recommendation: Tribes have recommended that $20 million be 
provided for an ADF during the FY 2010 IHS budget formulation process. 
Congress should pilot this recommendation as a demonstration in FY 
2010. The recommendation provides equity for facilities construction 
that is supported by most Tribes nationally.
V. Facilities Funding Inequities
    Generally, tribes nationally support funding for facilities 
construction as long as resources fund all authorities for facilities 
construction on an equal basis. Those Areas such as Portland, 
California, Nashville, and Bemidji have never had the opportunity to 
compete for facilities construction funding on the same basis as other 
Areas of the IHS system. The California and Portland Areas do not have 
no inpatient facilities at all and rely on the Contract Health Service 
(CHS) program to provide specialty and inpatient services. These Areas 
are often referred to as CHS dependent Areas.
    Because the CHS program is chronically under funded and the fact 
that CHS dependent Areas have never had an equal opportunity to compete 
for facilities construction funding that provides for staffing and 
equipment packages, they are not supported facilities construction 
funding. The significance of staffing new facilities is that it removes 
funds necessary to maintain current services (pay costs, inflation, and 
population growth) from the IHS budget increase, which then become 
recurring appropriations. This results in a disproportionate share of 
resources to only a few of the IHS Areas and results in developing gaps 
in the level of health services throughout Indian Country. Tribes 
nationwide ask, ``Why did our health program only receive less than a 1 
percent increase in funding, when the overall IHS budget received a 5 
percent increase? The answer to this is due to phasing in staffing at 
new facilities.


    The graph above illustrates the significance of staffing new 
facilities on the IHS budget increase. Staffing packages for new 
facilities are like pay act costs in two respects: (1) They come ``off 
the top,'' (i.e. they are distributed before other increases), and; (2) 
They are recurring appropriations. In FY 2004, the new staffing was 
over 60 percent of the IHS budget increase. In FY 2005 and FY 2006, new 
staffing costs consumed over 50 percent of the increase. This year, the 
proposed FY 2009 IHS budget was decreased by $21.3 million, yet a new 
facility within the IHS system will receive $25 million for new 
staffing. Clearly, the Agency proposes to cut the health budgets of 560 
Tribes in order to fund staffing packages.
    In addition to the staffing concerns, CHS dependent Areas are not 
afforded the same opportunity to access facilities construction funding 
that comes with staffing and equipment packages (Section 301 projects) 
as other Areas. The graph below illustrates those Areas that have 
received Section 301 funding between 1991 and 2008.


    Recommendation: Tribes have demonstrated by building approximately 
three times more health care space than the IHS, that alternative and 
innovative forms of facilities construction financing should be 
supported. If Tribes nationally are to support facilities construction 
funding, a methodology that ensures equal access must be developed and 
supported. If this does not happen, Tribes will continue to be divided 
over facilities construction funding. Establishing the FAAB's 
recommendation for and ADP would address this concern.
VI. Conclusion
    The challenges in providing care to AI/AN people are unlike any 
other. It serves the poorest, sickest, and most remote populations in 
the United States. Despite the effective use of a public health 
delivery model and the advances the Indian health system has made 
toward addressing health disparities, the funding constraints often 
result in rationing health services. It has been because of the access 
to Medicare and Medicaid programs that have often kept many Tribal 
health programs from going bankrupt. In order to provide quality health 
care you must have access to services and facilities to provide them. 
There is no doubt that the condition of Indian health facilities is 
woeful and that funding is the root cause. There is also no doubt that 
more new facilities are needed throughout Indian Country.
    If the Congress is to provide more funding to address the state of 
Indian health facilities, than it must also ensure that there is a 
method that allows all federally recognized Tribes an equal opportunity 
to access there sources. If an equitable system is not created it will 
only result in inequities in the level of health services delivered 
across Indian Country. Those Areas and Tribes that are fortunate to 
receive new facilities will be able to expand their health services 
base, while those that do not will continue to ration care.
    Any new funding should also go beyond just addressing facility 
construction and maintenance needs. It should also support medical 
equipment replacement, facility and environmental support, and support 
Alaska Native village programs. Adequate funding for these programs 
will ensure that the facilities we build today will be available for 
continued use into the future.
    Thank you!
                                 ______
                                 
Prepared Statement of Ron His Horse Is Thunder, Chairman, Standing Rock 
                              Sioux Tribe

    My name is Ron His Horse Is Thunder and I am the Chairman of the 
Standing Rock Sioux Tribe. Our Reservation is 2.3 million acres and is 
located in North and South Dakota. We have 14,000 tribal members, 7,000 
of whom live on the Reservation. I appreciate the Committee's attention 
to the longstanding issue of facilities in Indian country and I thank 
you for holding this hearing. I would like to tell you the story of our 
efforts to build a juvenile detention facility at Standing Rock and the 
obstacles we have encountered.
    The question of how to deal with young offenders on our Reservation 
is a significant problem. Nearly half of our population is below the 
age of 25, and our young population is disproportionately affected by 
risk factors known to increase the likelihood of delinquent behavior. 
We have very high unemployment rates: 91 percent of our population in 
South Dakota and 56 percent of our population in North Dakota is 
unemployed. \1\ Educational attainment among our members is low: almost 
one quarter of our members over the age of 25 did not finish high 
school and only 9.5 percent of our members have completed four or more 
years of college. \2\ Our members also deal with chronic health 
problems \3\ and substandard housing. \4\ Drug and alcohol abuse and 
dependency is the number one health problem among our members, 
including youth. \5\ Standing Rock was the site of a much-discussed 
suicide cluster in 2004-2005 and we continue to struggle with one of 
the highest youth suicide rates in the Nation. Given the risk factors 
faced by our youth, juvenile crime is an urgent problem here, and only 
effective interventions can begin to stem this tide.
---------------------------------------------------------------------------
    \1\ U.S. Dep't of the Interior, Bureau of Indian Affairs, American 
Indian Population and Labor Force Report (2003).
    \2\ Census 2000 American Indian and Alaska Native Summary File, 
Table DP-2, Profile of Selected Social Characteristics, Educational 
Attainment for Standing Rock Sioux Tribe (2000).
    \3\ Fifty-percent of our members aged 60 and older have been 
diagnosed with diabetes; 43.6 percent have heart disease and 80 percent 
suffer from hypertension. Fort Yates Indian Health Service Unit, GPRA/
DM Audits (2007). Only 3.6 percent of our members are over the age of 
65, indicating a very low life expectancy. Census 2000 American Indian 
and Alaska Native Summary File, Table DP-1, Profile of General 
Demographic Characteristics, Sex and Age for Standing Rock Sioux Tribe 
(2000).
    \4\ Nearly 40 percent of houses on the Reservation we built before 
1970 and 22 percent were built before 1960. Census 2000 American Indian 
and Alaska Native Summary File, Table DP-4, Profile of Selected Housing 
Characteristics, Year Structure Built for Standing Rock Sioux Tribe 
(2000).
    \5\ Standing Rock Sioux Tribe Comprehensive Chemical Prevention 
Program, CY 2006 Annual Report (March 2007), at 2.
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    Law enforcement services on our Reservation are provided by the 
Bureau of Indian Affairs. For many years, the Tribe has considered 
contracting with the BIA to provide these services for our own people, 
but the financial resources available to the BIA which Indian tribes 
may assume under a P.L. 93-638 contract are so severely inadequate that 
we believe it would be impossible to provide an acceptable level of law 
enforcement services to our members. We are unwilling to assume 
responsibility for these services without the assurance of at least 
minimally adequate base funding. So we continue to work with the Bureau 
to ensure that services are provided.
    The BIA operates an adult detention facility on the Reservation. 
That facility is outdated by today's standards. For example, according 
to a 2004 report by the Bureau of Justice Statistics, only routine 
counseling and psychotropic medication are provided, but mental health 
screenings, psychiatric evaluations, 24-hour mental health care, and 
even on-site medical care are not available. \6\ Staff is not trained 
in suicide prevention, and only basic intake screening and suicide 
watch are provided when needed. \7\ Domestic violence and sex offender 
counseling is not provided. \8\ An older adult facility such as ours is 
also not physically equipped to house juveniles. BIA standards, which 
mirror federal policies set forth in the Juvenile Justice and 
Delinquency Prevention Act, require that juveniles be separated by 
``sight and sound'' from adult offenders, and our building cannot 
accommodate this. \9\ BIA standards also require that staff who work 
with juvenile offenders be specially trained. Our facility has neither 
the architecture nor the staffing and services necessary to handle 
young offenders.
---------------------------------------------------------------------------
    \6\ U.S. Dep't of Justice, Bureau of Justice Statistics, Jails in 
Indian Country, 2004 (Nov. 2006, revised Feb. 7, 2007), at 18, 24.
    \7\ Id. at 25.
    \8\ Id. at 26.
    \9\ See 42 U.S.C. Sec. 5633(13) and 42 U.S.C. Sec. 5633(14) for 
Juvenile Justice and Delinquency Prevention Act requirements.
---------------------------------------------------------------------------
    When a young person is arrested on Standing Rock, he or she can be 
temporarily held in the adult facility for a maximum of six hours. 
After adjudication, if a young person is given a disposition of 
detention, the first challenge is to find bed space at an off-
Reservation detention facility. If we can find a bed, BIA law 
enforcement officers must then transport the juvenile off-Reservation 
to a facility at Cheyenne River Sioux or to a county facility. This 
takes staff time from the limited number of BIA law enforcement 
officers on the Reservation, making those officers unavailable to 
respond to calls or to investigate crimes. Our youth must serve out 
their detention miles from their home community. As you can imagine, 
this situation makes it very difficult for family members to visit 
youth while they are detained. Distance also makes it difficult for 
family counseling to be effective. Even worse, many youth are not 
arrested or treated at all because of the lack of facility space. BIA 
law enforcement employ a ``catch and release'' strategy which leaves 
young offenders unmonitored and untreated, leaving those youth to 
create disruptions in our schools and our community. It sends a poor 
message.
    In 2004, to address the need for a safe and effective juvenile 
facility, the Tribe began working with architects, planners and agency 
officials to design a juvenile detention and rehabilitation facility. 
The facility is planned as an 18-bed facility--just large enough to 
meet our need to house young offenders. More importantly, it will 
permit young offenders to be treated on the Reservation in a 
culturally-appropriate setting. It will be staffed by professionals who 
can address the behavioral, family, mental health and alcohol and drug 
issues that our youth face.
    In FY 2004, we received a $3 million grant from the Department of 
Justice (DOJ) to build this facility and in FY 2006 we received a 
supplemental grant from DOJ of $695,000. The Tribe contributed $900,000 
towards the project. In December 2006, we secured a Finding of No 
Significant Impact (FONSI) from the BIA, but our efforts have been 
slowed due to lack of funding. We are grateful for the assistance 
provided so far, but the amount we received is far short of the actual 
cost of planning, designing and constructing a facility. Through our 
planning and budgeting process, we have identified an estimated project 
cost of $5.7 million. Our total budget so far is $4.5 million 
(including $3.7 million in DOJ funding and nearly $1 million in Tribal 
funds). This leaves the Tribe scrambling to cover a shortfall of $1.2 
million.
    Our Tribe battles extremely high poverty rates. Over 40 percent of 
tribal households have incomes below the poverty line. \10\ Our rural 
location means that economic development opportunities are limited. The 
Tribe primarily raises revenue through various taxes, leasing of tribal 
lands for grazing, and through operation of the Prairie Knights Casino 
in North Dakota and the Grand River Casino in South Dakota. While the 
casinos are an important source of jobs for Tribal members, they 
contribute only modest revenues to tribal operations, due mostly to our 
remote location. Simply put, we cannot afford to make up for these 
federal shortfalls for construction of essential detention space.
---------------------------------------------------------------------------
    \10\ Census 2000 American Indian and Alaska Native Summary File, 
Table DP-3, Profile of Selected Economic Characteristics, Employment 
Status for Standing Rock Sioux Tribe (2000). The rates were similar in 
2007.
---------------------------------------------------------------------------
    Because of funding shortages, we also had to cut a portion of the 
original design. The facility was originally planned as a 36-bed unit 
and included a Transitional Living Unit along with a secure detention 
facility. This unit would contain eight beds and classroom space 
designed to help youth transition from detention back into the 
community. Transition and aftercare are extremely important pieces of 
effective intervention and rehabilitation in order to ensure that young 
people do not return to the destructive habits that brought them into 
the system in the first place. Yet the Transitional Living Unit portion 
alone would have cost an additional $1.5 million, so we were forced to 
eliminate it from the project. We also reduced the planned number of 
beds from 36 to 18. Yet even with this cutback, the facility has not 
yet been completed.
    Despite the Bureau's responsibility to provide law enforcement and 
detention services at Standing Rock and the clear need for a facility 
devoted to juveniles, the Tribe has had to work hard to make this 
facility happen. The Tribe applied for the initial DOJ grant, 
contributed a substantial amount of money, and has worked closely with 
architects and planners to make sure construction continues to 
progress. Quite simply, we have stepped in where the Bureau is failing 
to provide adequate facilities to meet our population's needs. And yet 
we still lack the resources to complete the facility. We have also not 
been assured by the Bureau that program funds will be added to the BIA 
budget for recurring staffing and operation and maintenance (O&M) 
costs.
    I know that you have heard from many tribes concerning the need for 
juvenile detention facilities. While some funding has been made 
available through DOJ to build facilities, the amount provided is not 
enough to build a detention facility, nor does there seem to be any 
coordination between DOJ, the Tribal grantees and BIA. BIA 
participation is necessary because BIA is required to fund staffing and 
operations and maintenance costs of such facilities. Many facilities 
similar to ours have been fully constructed, but they stand empty 
because of lack of staffing and O&M money. Idle facilities benefit no 
one. We are not interested in building another substandard facility, 
but a quality detention facility can easily cost $5-10 million to 
construct. We were lucky-some tribes need detention facilities but did 
not receive a DOJ grant at all. The outlook for more funding is not 
good; DOJ has recently stated that only small grants (less than $1 
million) are available for rehabilitation of existing facilities 
because the entire DOJ facilities budget is only about $6 million 
annually.
    I understand the Bureau plans to release a report on the need for 
detention facilities in Indian country, along with a plan to address 
this need. I hope this plan prioritizes completion of the facilities 
all over Indian country that are incomplete or lack adequate staffing. 
I also hope that BIA and DOJ will coordinate in order to make enough 
money available to construct, staff, operate and maintain new 
facilities, rather than leaving Tribes stuck with the piecemeal 
approach of requesting annual earmarks to complete construction, staff 
and operate their projects. Detention facility construction and 
operations seems to have fallen through the cracks between these two 
agencies, with Indian youth and Native families as the main victims. I 
hope that Congress will continue to encourage the agencies to work 
together to correct this flawed system.
    Thank you for giving me the opportunity to present this testimony.
                                 ______
                                 
 Prepared Statement of Kyle Prior, Chairman, Shoshone-Paiute Tribes of 
                      the Duck Valley Reservation

    Chairman Dorgan, Vice Chair Murkowski, and members of the 
Committee, thank you for accepting this testimony. My name is Kyle 
Prior. I am the Chairman of the Shoshone-Paiute Tribes of the Duck 
Valley Reservation. I am experienced in the area of juvenile justice 
and I am a member of the Idaho Juvenile Justice State Advisory Group. 
The story I want to tell you involves what I believe is an ongoing 
problem for the BIA-the absolute failure to proved safe and effective 
juvenile justice services to Indian children and the refusal to assist 
tribes when they step in to create these services themselves. I know 
all too well that facilities of all types in Indian country are in 
dismal condition. At Duck Valley, we have seen our share of dilapidated 
schools, outdated hospitals, makeshift office buildings, and 
substandard housing. I want to focus on juvenile facilities because 
this is our most pressing need at Duck Valley right now. I also believe 
the problems we at Duck Valley have faced in trying to open a juvenile 
detention facility are similar to the problems faced by many other 
tribes in the same situation. Somewhere in the process of designing, 
building, opening, staffing and maintaining a facility, the BIA always 
seems to fall through. This is an area in which the BIA's inept 
management of facilities is having serious consequence for Indian youth 
and for tribal governments seeking to create effective community-based 
interventions for those youth.
I. The Duck Valley Reservation
    We live on a remote, rural reservation located in Idaho and Nevada. 
The nearest population centers, Mountain Home, Idaho and Elko, Nevada, 
are 100 miles away. A two-lane road runs through the Reservation 
between these towns, and the road is sometimes closed during storms. 
Approximately 2,300 tribal members live on the Reservation. Like many 
isolated, rural tribes, our community is relatively poor. The 
unemployment rate is 60 percent, and 95 percent percent of students are 
poor enough to qualify for free or reduced lunch. \1\ In the area of 
law enforcement, we are a direct service tribe. The Bureau of Indian 
Affairs provides our police and detention services. Attracting and 
retaining adequate law enforcement staff has always been an issue at 
Duck Valley. We are now down to only 3 police officers, including the 
Chief of Police.
---------------------------------------------------------------------------
    \1\ University of Nevada, Nevada Cooperative Extension, ``MAGIC'' 
(Making a Group and Individual Commitment): A Program for Entry-Level 
Juvenile Offenders in Owyhee, Nevada (2000), available at http://
www.unce.unr.edu/publications/files/cd/2000/fs0031.pdf, at 2.
---------------------------------------------------------------------------
II. The Need for a Juvenile Detention Facility
    Several years ago, juvenile crime rates on the Duck Valley 
Reservation were very high. At that time, we had no place to send youth 
on the Reservation when they got into trouble. Although we have a BIA-
run adult jail in Owyhee, we do not have a facility in which to house 
juvenile offenders. Our 27-bed adult facility is the only BIA facility 
in Nevada, and it serves as a regional facility, housing offenders from 
several other reservations. Our area has a similar lack of juvenile 
facilities. Delinquent youth are sent by the BIA to a county facility 
100 miles away in Elko, where the BIA rents detention beds. However, we 
have encountered at least two problems with this system. First, the 
local community is often overwhelmed by its own juvenile justice needs. 
Often, no beds are available for youth from Duck Valley. Sometimes, we 
send a young person there, only to receive a call several days later 
saying the bed is needed and the juvenile has to be sent home. Second, 
youth in Elko are usually detained for only a few days, whereas Duck 
Valley youth are frequently given detention terms of weeks or months. 
Because Elko is run as short-term facility, it is not well equipped to 
handle offenders with longer terms.
    The other option available to the BIA at that time was to send 
youth several states away to Peach Springs, Arizona. At that time, the 
Peach Springs facility was the only BIA-run juvenile facility in the 
area. When your children are sent so far away, it is very difficult to 
monitor their well-being or be sure they are safe. Parents were not 
familiar with the Peach Springs facility. They didn't know what type of 
programs and recreation were available, how closely the youth were 
monitored, or whether adequate health care was provided. In one 
instance, a young boy from Duck Valley was beaten up by other juveniles 
while at Peach Springs. His tooth was knocked out, and his mother was 
left to find him medical care. Incidents like these caused concern in 
the community about what was happening to our children in this distant 
facility. As it turned out, our concerns were well-founded. The Peach 
Springs facility was closed by the BIA for several years after 
questions were raised about the adequacy of supervision and whether 
some youth were bringing contraband into the facility. Today, offenders 
requiring longer detention terms are sent to a juvenile facility is in 
Towaoc, Colorado, which is run by the Ute Mountain Tribe. In my 
opinion, it is much better than Peach Springs; unlike BIA-run juvenile 
facilities, it offers recreation facilities and an on-site nurse. 
Nevertheless, our Tribes' overall experience with sending children away 
from the community led us to begin searching for ways to bring a 
juvenile facility to Duck Valley.
III. Planning and Building Our Facility
    As you might expect, the BIA was unresponsive to our requests for a 
juvenile facility. The Tribes then approached the state with a proposal 
for a state-run juvenile detention facility in Owyhee. In our view, 
having a state-run facility in our community was a better option than 
letting our youth go to an Indian facility located hundreds of miles 
away. This plan fell through, however, because the State saw the remote 
Reservation as an ideal location to build a juvenile super-prison 
containing several hundred beds. This was not the type of local 
facility we had in mind.
    In 1998, we were awarded a grant through the Department of 
Justice's ``Correctional Facilities on Tribal Lands'' program. Planning 
began in 2000, but we did not have enough money for the size of the 
facility we sought to construct because of a significant increase in 
fuel prices and construction costs. We received a supplemental grant 
from DOJ, and construction began in 2002. The total cost of the project 
was over $4 million, with the Tribes contributing the required 10 
percent match (about $500,000). In addition to the basic building 
costs, the Tribes also built the access road and the infrastructure 
(e.g., water, power, sewer). Construction on the 28- bed facility was 
finally completed in 2004, with building furnishings provided by the 
BIA.
    We worked closely with the BIA during the planning and building 
process. As this was to be a BIA-run facility, we were careful to 
follow all of the BIA requirements. We were in close contact with the 
Owyhee office and the Regional office; the District Commander for 
District 3 approved our plans. In 2004, the completed facility was 
inspected by BIA's Office of Facilities Management and received all the 
necessary certifications. After years of planning and building, the 
Tribes expected that our new juvenile facility would open the following 
year.
IV. Staffing and Operational Failures
    It is now 2008 and our brand new juvenile facility has never 
opened. Soon after we received our facility certification, officials 
from the BIA Office of Law Enforcement Services visited the facility. 
The staff of OLES at that time was almost all different people from 
those involved in the planning process. These new staff had new ideas 
about how a juvenile detention facility should look, and ours did not 
fit that idea. For example, we were told our security glass was not 
positioned correctly and that our doors were not made of the correct 
type of reinforced steel. The type the BIA wants to see is the type 
used in places where the most serious offenders are housed, places 
where high-security reinforcements are needed to keep unruly offenders 
from breaking down doors.
    This is not the kind of issue we face at Duck Valley, and the 
Tribes did not intend to build a high-security facility for the most 
serious offenders. The Shoshone-Paiute Tribes are committed to a 
community-based, treatment-focused approach to juvenile justice, rather 
than an overly punitive model. While building the new facility, the 
Tribes also worked to improve juvenile diversion and intervention 
services through our MAGIC (Making A Group and Individual Commitment) 
program, which teaches first time and non-violent offenders and their 
parents the skills needed to avoid delinquent behavior. Working with 
BIA and DOJ staff, we designed a built a facility suited to the type of 
offender we most often encountered at Duck Valley, generally less 
serious and nonviolent offenders. Yet at the very end of the process, 
the BIA informed the Tribes that several changes that would need to be 
made to bring the facility up to its new standards, standards that were 
not communicated to us before. Of course, they never explained how 
these changes were to made, who would pay for them, or whether the BIA 
would assist with them or expected the Tribes to make these changes on 
our own. In fact, during my tenure as Chairman, we have not even 
received a comprehensive list of the changes that must be made.
    Knowing that some changes would need to be made, the Tribes sought 
to open half the facility to house juveniles. Our staffing plan calls 
for about 30 staff to run the entire facility, meaning we need about 15 
staff to open half of it. We have only 6 staff now. We have asked the 
BIA many times about hiring staff, but the only answer we get is that 
it's hard to find qualified staff people and hard to pass background 
inspections. The Duck Valley Council passed a resolution long ago 
waiving the BIA Indian preference, allowing them to hire non-Indian law 
enforcement and detention officers. Yet even with this additional 
leeway, they can find no one. In my view, the BIA's inattention to the 
facility is to blame. We have hired juvenile detention officers. At one 
point, we had 12 officers, nearly enough to open half the facility. 
Currently, we have a highly qualified Juvenile Corrections Supervisor 
from Chicago working on the Reservation. But the facility remains 
closed, the space is used for BIA office space, and our juvenile 
detention officers are detailed into other positions. One by one, they 
grow frustrated and leave.
    We are in a Catch-22. We are told the facility cannot open because 
of a lack of adequate staff, but qualified staff do not stay long 
because the BIA's failure to open to facility means they have no work 
to do. The Bureau makes only minimal effort to recruit and hire staff. 
And the question of whether the facility needs improvements, and what 
kinds, looms. Meanwhile, the building itself is aging and will slowly 
begin to deteriorate. Because it is not open, the BIA is not performing 
any maintenance. Many tribes complain that they need new jails, 
hospitals and schools. We have a new building, but it has been sitting 
empty for over 4 years. We have traveled to Washington several times to 
ask the BIA why our facility is not open. Each time, new Central Office 
personnel say they will look into it. Each time, nothing happens at 
all.
V. The Problem
    Beyond the BIA's general failure to build and maintain facilities, 
there are several factors at work here that should be remedied. First, 
there is a lack of communication between the Central Office and the 
field offices, which sometimes results in inconsistent policies. This 
is how a multi-million dollar project that was approved by Regional 
supervisors can be later disapproved and ignored by Central Office. 
This is an expensive lack of communication.
    Second, the policy shifts within the Office of Law Enforcement 
Services (now Office of Justice Services) are frequent and abrupt. The 
BIA's disapproval of our facility is based on the opinion of certain 
Bureau personnel that it doesn't fit the current BIA mold, which is a 
highly secure lockdown facility. My experience with juvenile justice 
has taught me that such facilities are a poor choice, especially in a 
community like ours, which does not have very many extremely violent 
offenders. While I understand that BIA policies will change, these 
shifts cannot be used as an excuse to completely abandon a tribally-
driven project just because it doesn't match the Bureau's preference 
that young offenders be locked in high-security warehouses.
    Finally, when issues arise, the Bureau utterly fails to communicate 
with tribes. We know our facility is not open, but we have never been 
given a clear explanation of why no staff have been hired, what aspects 
of the building need to be changed, and whether the BIA intends to 
assist us with making these changes and to begin maintaining the 
building. This is especially inexcusable on a Reservation like ours 
where the BIA is responsible for the delivery of law enforcement 
services. Not only has the agency completely failed to meet the needs 
of the Tribes in the area of juvenile justice, it continues to stand in 
the way of solutions pursued by the Tribes.
    Thank you for providing me the opportunity to present this 
testimony, and thank you for your attention to the important issue of 
facilities in Indian country. Chairman Dorgan, I hope you will consider 
ways to address construction, operation and maintenance, and staffing 
of detention facilities in your law enforcement bill. I would be 
pleased to provide further information and recommendations as needed.
                                 ______
                                 
 Prepared Statement of the National Indian Education Association (NIEA)

    Founded in 1969, the National Indian Education Association is the 
largest organization in the nation dedicated to Native education 
advocacy issues and embraces a membership of nearly 4,000 American 
Indian, Alaska Native and Native Hawaiian educators, tribal leaders, 
school administrators, teachers, elders, parents, and students.
    NIEA makes every effort to advocate for the unique educational and 
culturally related academic needs of Native students. NIEA works to 
ensure that the federal government upholds its responsibility for the 
education of Native students through the provision of direct 
educational services. This is incumbent upon the trust relationship of 
the United States government and includes the responsibility of 
ensuring educational quality and access. Recognizing and validating the 
cultural, social and linguistic needs of these groups is critical to 
guaranteeing the continuity of Native communities. The way in which 
instruction and educational services are provided is critical to the 
achievement of our students to attain the same academic standards as 
students nation-wide.
    A pattern has developed in recent years where Native education 
programs get smaller increases in years where overall funding is up and 
larger cuts in years when overall funding is down. This is 
unconscionable and must be corrected! Over the years, the President's 
budget requests have proposed many significant cuts in Native 
education, which have deepened the negative effects of previous cuts. 
If these budget cuts to Native education are not reversed, then Native 
children and Native communities will be further harmed as well as 
future generations, especially given the tragic reality that the 
standard of living in Native communities continues to be far lower than 
any other group in the United States. Native communities continue to 
experience the highest rates of poverty, unemployment, morbidity, and 
substandard housing, education, and health care.
    There are only two educational systems for which the federal 
government has direct responsibility: the Department of Defense Schools 
and federally and tribally operated schools that serve American Indian 
students. The federally supported Indian education system includes 
48,000 students, 29 tribal colleges, universities and post-secondary 
schools. Despite all of the funding needs for educational services for 
American Indian, Alaska Native, and Native Hawaiians, many of the 
programs critical to successful Native students academic achievement, 
including stable and healthy learning environments and facilities, are 
unmet year after year.

Indian School Construction and Facilities Improvement and Repair
    The inadequacy of Indian education facilities is well documented 
and well known. The continued deterioration of facilities on Indian 
land is not only a federal responsibility; it has become a liability of 
the federal government. Old and exceeding their life expectancy by 
decades, Bureau of Indian Affairs/Bureau of Indian Education (BIA/BIE) 
schools require consistent increases in facilities maintenance without 
offsetting decreases in other programs, if 48,000 Indian students are 
to be educated in structurally sound schools.
    Of the 4,495 education buildings in the BIA/BIE inventory, half are 
more than 30 years old and more than twenty percent are older than 
fifty years. On average, BIA/BIE education buildings are 60 years old; 
while, 40 years is the average age for public schools serving the 
general population. Sixty-five percent of BIA/BIE school administrators 
report the physical condition of one or more school buildings as 
inadequate. Of the 184 BIA/BIE Indian schools, \1/3\ of Indian schools 
are in poor condition and in need of either replacement or substantial 
repair.
    In May of 2007, the Department of Interior visited 13 schools as a 
part of a Department wide audit and found ``severe deterioration at 
elementary and secondary schools, including boarding schools, that 
directly affects the health and safety of Indian children and their 
ability to receive an education.'' In this report, the Department of 
Interior found sever deficiencies such as classroom walls buckling and 
separating from their foundation, outdated electrical systems, 
inadequate fire detection and suppression systems, improperly 
maintained furnaces, and condemned schools buildings.
    At the Chinle Boarding School located in Many Farms, Arizona, the 
children have to be transported by bus to an alternative meal site 
because the cafeteria is condemned. As a result of the off site 
``cafeteria'', injuries have been sustained to students and staff 
related to transportation, and buses often return late resulting in 
cold meals for the students. At the Shonto Preparatory School, located 
in Shonto, Arizona, an employee and her husband were diagnosed with 
carbon monoxide poisoning due to an aging wall furnace that had not 
been properly maintained.

Funding for Indian School Construction and Maintenance for Fiscal Year 
        2009
    For FY 2009, the President's budget will only allow for the 
replacement of one school and the replacement of structures at another 
school. There are currently BIA/BIE schools that are in need of major 
repairs or replacements. At the funding level recommended in the 
President's budget, the backlog for new BIA/BIE schools will not be 
reduced at all. The need for additional school construction dollars is 
so great that there should be no slow down in appropriations. Instead, 
there should be an increased effort to get Tribes and the BIA/BIE to 
work more efficiently on completing school construction projects while 
recognizing that schools take time to plan and build.
    NIEA requests a $120.47 million increase from the FY 2008 enacted 
level of $142.935 million for a total of $263.4 million in FY 2009 to 
the BIA for Indian school construction and repair.
    After FY 2005, the funding levels have dramatically decreased for 
this critical program. The funding level in FY 2005 was instrumental in 
reducing the construction and repair backlog. BIA's budget has 
historically been inadequate to meet the needs of Native Americans and, 
consequently, Indian school needs have multiplied. The Administration 
has sought to justify the decrease over the past few years by stating 
that it wants to finish ongoing projects. The amounts over the past few 
years have failed to fund tribes at the rate of inflation, once again 
exacerbating the hardships faced by Native American students. Further, 
the funding that has been allocated over the past few years will not 
keep pace with the tremendous backlog of Indian schools and facilities 
in need of replacement or repair.
    In 1997, GAO issued a report ``Reported Condition and Costs to 
Repair Schools Funded by the Bureau of Indian Affair'' that documented 
an inventory of repair needs for education facilities totaling $754 
million. In 2004 the backlog for construction and repair was reported 
to have grown to $942 million. We believe that we must keep pace with 
the FY 2005 level of funding in order to finally make some headway in 
the construction backlog. The purpose of education construction is to 
permit BIA funded schools to provide structurally sound buildings in 
which Native American children can learn without leaking roofs and 
peeling paint. It is unjust to expect our students to succeed 
academically, if we fail to provide them with a proper environment to 
achieve success.
    The Mandaree Day School located in Mandaree, North Dakota has taken 
out a loan in the amount of $3 million to cover the costs of building a 
new education facility. The Mandaree Day School could not wait any 
longer for the funding from the Department of Interior to build their 
school. The loan only covers the facility structure and the 210 
children attending this school have no playground and the teachers do 
not have a paved parking lot.
    Although education construction has improved dramatically over the 
last few years, the deferred maintenance backlog is still estimated to 
be over $500 million and increases annually by $56.5 million. As noted 
by the House Interior Appropriations Subcommittee in its Committee 
Report accompanying the FY 2006 Interior appropriations bill, ``much 
remains to be done.'' Of the 184 BIA/BIE Indian schools, \1/3\ of 
Indian schools are in poor condition and in need of either replacement 
or substantial repair.
    For the past three school years, only 30 percent of BIA schools 
made AYP goals established by the state in which the school was 
located. Department of Education statistics indicate that student 
performance at BIA/BIE schools is lower than students at public 
schools. NIEA strongly believes that there is a correlation between 
academic achievement and the environment in which one is expected to 
learn.

Conclusion
    NIEA thanks the Committee for its tremendous efforts on behalf of 
Native communities. With your support we are hopeful that we can begin 
to provide the funding for education that Native communities deserve. 
The National Indian Education Association thanks Chairman Dorgan and 
Vice-Chairman Murkowski for championing on behalf of all Native 
students and their successful educational achievements.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Byron L. Dorgan to 
                           Domingo S. Herraiz

    Question 1. Your testimony indicates that 17 Tribes have received 
funding for construction planning. How many of these 17 planning grants 
will be for new construction? Is the Department's Indian Jails 
Construction program moving away from new construction? If yes, please 
explain why.
    Answer. While these 17 grants are not for new construction, the 
funding will directly support the Tribes' ability to effectively assess 
their projected correctional needs to accurately determine whether new 
construction, renovation, or incarceration alternatives will best serve 
their communities' correctional needs.
    With input from Tribal leaders, the Department has implemented a 
comprehensive approach to supporting Tribes as they plan for short and 
long term correctional facility needs. In this way, Tribal partners, 
the Department, and the Bureau of Indian Affairs (BIA) can better 
identify new construction and renovation priority projects that not 
only comply with BIA standards, but are safe, secure, appropriate for 
the intended population, and reflect cultural and traditional values.

    Question 2. What is the Department's long term plan for meeting the 
jails/detention center needs of Indian Country? And have you consulted 
with Tribes on that plan?
    Answer. The Department's long term plan for meeting jail and 
detention center needs of Indian Country supports Tribal leaders as 
they assess their own correctional needs and develop strategies to 
address those needs through renovation, construction, and correctional 
alternatives. Funding and technical assistance for planning, 
construction, and renovation efforts is provided to Indian Country, 
with activities based on input from Tribal leaders, BIA's Office of Law 
Enforcement Services, and the Office of the Inspector General's 
recommendations for Tribal jails. The Department will continue to find 
ways to collaborate with Tribal and federal partners to maximize 
current and future correctional resources to Indian Country.
    The Department of Justice regularly consults with Tribes regarding 
correctional needs. In 2005, the Department hosted ``Listening 
Conferences'' with Tribal leaders and related partners regarding their 
priorities for Tribal justice programs. Based on their feedback, the 
Bureau of Justice Assistance (BJA) hosted a focus group with BIA for 
Tribal leaders in September 2006. In addition, the Interdepartmental 
Tribal Consultation, Training and Technical Assistance Sessions held in 
FY 2007 and FY 2008 included several tribal consultation sessions and 
training focusing on Tribal corrections.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Maria Cantwell to 
                           Domingo S. Herraiz

    Question. In my home state of Washington, our tribes have seen a 
drastic increase in gang activity and meth use on their reservations. 
This criminal activity not only causes reservations to be less safe, 
but many times the communities around them as well. Tribal police and 
law enforcement have been chronically underfunded and the tribes are 
struggling to gain control of the rising crime on their reservations. 
How, in a time where crime is on the rise and the need for more law 
enforcement funding crystal clear, do you justify the proposal to 
eliminate funding for New Jails Construction in the DOJ budget?
    Answer. The Department's Office of Justice Programs (OJP) has 
developed a close working relationship with many American Indian and 
Alaskan Native (AI/AN) tribes and remains committed to helping these 
communities meet the unique challenges they face in the areas of law 
enforcement and criminal justice.
    The FY 2009 budget request proposes a reorganization of OJP's state 
and local law enforcement and criminal justice assistance programs, 
streamlining its many existing programs into three competitive, 
multipurpose, discretionary grant programs: (1) Violent Crime Reduction 
Partnership Initiative; (2) Byrne Public Safety and Protection Program; 
and (3) Child Safety and Juvenile Justice Program. This reorganization 
will enhance OJP's ability to direct assistance to those jurisdictions 
demonstrating the greatest need, providing tribal grant recipients with 
greater flexibility in using their grant funds.
    In September 2007, OJP implemented a new Tribal Grants Policy, 
which will help Tribal communities seeking OJP resources through our 
competitive grant solicitation process. OJP will continue its support 
for the Tribal Criminal Justice Statistics Program and victims 
assistance initiatives serving AI/AN populations through discretionary 
funding. OJP's tribal budget plan for FY 2008 estimates spending of 
nearly $44 million in funding for programs to assist MAN tribes, an 
increase of more than $6 million over FY 2007 funding levels.
    In addition, OJP will continue hosting Tribal Consultations and 
Training & Technical Assistance (T&TA) sessions. These sessions will 
focus on tribal priority issues related to public safety for families 
and communities. They will address drugs, tribal court systems, multi-
jurisdictional coordination and communication, sex offender registry, 
and other law enforcement areas.
    OJP will also continue to support efforts to expand federal 
outreach to tribal governments, such as the Tribal Justice and Safety 
website (http://www.tribaljusticeandsafety.gov) launched last year to 
assist tribal governments. The website features information on a 
variety of justice issues, as well as grant funding and training. These 
efforts are designed to improve communication and to help build tribes 
capacity to create and leverage resources.
                                 ______
                                 
        Written Questions Submitted by Hon. Byron L. Dorgan to 
                  Jack Rever and W. Patrick Ragsdale *
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    * Response to written questions was not available at the time this 
hearing went to press.
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Tribal Jails/Detention Centers
    Question 1. How many jails and detentions centers in Indian Country 
are newly built, but remain empty due to lack of staff? Please explain 
why they are empty?
    Question 2. Your testimony states that ``there are currently 84 
detention facilities across Indian Country. Of these, 38 are owned and 
operated by the Federal Government, five are owned by Tribes and 
operated by the Federal Government, and 41 are owned and operated by 
Tribes.'' However, the Bureau's Budget Justifications for Fiscal Year 
2009 states that ``The OJS Division of Corrections funds 67 tribally-
operated detention programs and directly operates 24 detention programs 
facilities.''

    (1) Please explain the discrepancy, and
    (2) provide the exact number of the following based on your latest 
information:
        (a) total number of tribal jails/detention centers;
        (b) number of juvenile detention centers;
        (c) number of jails/detention centers owned and operated by the 
        Federal Government;
        (d) number of jails/detention centers owned by Tribes and 
        operated by the Federal Government;
        (e) number of jails/detention centers owned and operated by 
        Tribes.

    Question 3. The Budget also requests a nominal increase in 
staffing. However, I note that of the 146 new staff that would come on 
board if Congress granted your Budget request--only 20 staff would go 
to fund staff at the 67 Tribally-owned and operated jails. The 
remaining 126 new corrections staff would be placed at 24 directly 
operated BIA jails. Please provide an explanation justifying this 
request.

    Question 4. The poor state of Indian Jails is a long standing 
problem. Attorney General Reno testified in 1998 about this issue. The 
Inspector General recommended in 2004 that Justice and Interior develop 
a strategic plan for jails replacement and renovation. What the status, 
if any, of the strategic plan between the two Departments to replace 
and renovate Indian jails?

    Question 5. Mr. Guillermo Rivera discussed the Shubnum Indian Jails 
Report last March before the Prison Rape Elimination Commission. He 
reported that Shubnum found an approximate $6 billion backlog in Indian 
jails for construction and maintenance. Can you confirm that number?

    Question 6. Have you shared any portion of the Shubnum Report with 
the Department of Justice who is responsible for administering funds 
for new Indian jails construction?

    Question 7. We know that the backlog for Indian jails is in the 
billions of dollars. However, the Department requested less than $8 
million for Indian jails renovation--a $3 million dollar cut from last 
year's appropriated figure. Can you explain the Department's 
justification for this request?

    Question 8. What is the condemnation process at the Bureau and what 
do you do to help tribes once you've condemned their building?

    Question 9. A number of Tribes have to transport their inmates to 
far away jails. It is my understanding that your office does not 
include a line item for prisoner transportation. Please explain why 
transportation costs are not included in your budget, and answer 
whether the Department will include a line item for corrections 
transportation in the future?
Tribal Schools
    Question 10. The Committee understands that in addition to the 14 
schools on the priority construction list, over 70 schools need 
replacement or repair.

    Question 11. What it the cost to complete the 14 schools on the 
2004 priority list?

    Question 12. What is the estimated cost to replace or repair the 
additional 70 schools?

    Question 13. The Committee understands that a new priority list for 
school construction will be developed this year with the goal of 
releasing a new list in 2009. What is the current status of forming a 
team to work on the list? Will it be open to all tribal leaders? What 
process will you use to develop the list?

    Question 14. We received testimony today describing a lengthy 
process for school facilities construction. It appears that some 
schools have been in the planning stage for 7 years and will likely 
take 12-13 years for completion. Why does the process take so long? 
What is the Bureau doing to address this backlog?

    Question 15. How would you suggest the Bureau streamline the 
process? Do you currently allow schools that are ready to move to the 
next phase do so, or do you hold them up until schools ahead of them on 
the list have progressed?

    Question 16. The Inspector General released a Flash Report in May 
2007 warning of the dangers that existed at Indian schools. It is our 
understanding that a final report will be released within the next 
month.

    Question 17. What has the Bureau done to address these emergency 
conditions?

    Question 18. What is the Bureau doing to ensure these types of 
situations don't occur in the future?

    Question 19. We understand that in addition to those schools 
identified in the Inspector General report, other schools face similar 
emergency situations. For example, the Committee has been informed that 
the Laguna Elementary School in New Mexico was temporarily shut down in 
November due to ``unsafe'' conditions until a review of the structural 
stability of the building could be completed.

    Question 20. What has the BIA done in terms of follow-up since the 
November engineer's report and re-opening of the school?

    Question 21. Will the BIA provide any funding to temporarily cure 
defects of the facility?
                                 ______
                                 
          Written Questions Submitted by Hon. Tim Johnson to 
                  Jack Rever and W. Patrick Ragsdale *
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    * Response to written questions was not available at the time this 
hearing went to press.
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    Question 1. It seems that one of the major problems facing 
detention facilities is actually the staffing issue. I find this ironic 
because unemployment is one of the most severe problems facing Indian 
tribes. What is the BIA doing to recruit detention officers in Indian 
Country?

    Question 2. Is there any coordination with tribal employment 
programs or tribal colleges?
                                 ______
                                 
         Written Questions Submitted by Hon. John Barrasso to 
                  Jack Rever and W. Patrick Ragsdale *

    In 2006, the Drug Enforcement Agency in cooperation with BIA and 
local law enforcement officials took down the Hermosillo 
Methamphetamine Trafficking Group operating on the Wind River 
Reservation. This was one of the largest drug busts in Wyoming's 
history. Yet, it is my understanding that Wind River Reservation law 
enforcement officials are operating out of very limited facilities and 
the detention center has even less space. There is clearly a trend of 
drug gangs using Indian reservations to operate their criminal 
enterprises, and the Wind River Reservation has already seen this 
firsthand.

    Question 1. As such, do you believe the Wind River Reservation's 
law enforcement facilities are adequate to deal with this new trend?

    We have fundamental problems meeting the needs of tribal facilities 
in both funding and construction. Yet, we also need to focus on the 
maintenance needs of these structures to get return on the investment 
of federal dollars.

    Question 2. How can the system be improved to ensure that money and 
manpower is available and accountable for maintaining BIA properties?

    On the Wind River Reservation, the one tribal school--St. Stephens' 
school--was approved for a new high school facility. It is my 
understanding that the much-needed construction project has been 
reduced in scope several times since it was first approved by the BIA. 
As a result, there will be no room for additional students.

    Question 3. What BIA actions can be expected if the school 
enrollment exceeds the new facility's capacity?

    Question 4. Would the school be placed on a separate priority list 
for expansion or would it be required to compete for funding with all 
other replacement facilities?

    Question 5. Considering the disparities in BIA facilities funding 
allocated to certain tribes and regions in recent years, do you believe 
the current priority system of facilities funding equitably distributes 
federal dollars?

    Question 6. How can it be revised to meet our obligation to all 
tribal members?
                                 ______
                                 
         Written Questions Submitted by Hon. Maria Cantwell to 
                            Randy Grinnell *
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    * Response to written questions was not available at the time this 
hearing went to press.
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    Question 1. Mr. Grinnell, I understand that the revised Health 
Facilities Construction Priority System was submitted to the Indian 
Health Service by the Facilities Advisory Appropriation Board in March 
2007. It has now been a year, and we have seen no action by the Indian 
Health Service on the Board's recommended changes.
    When can we expect to see a decision on the revised system?
    Given the backlog under the current priority list, how long do you 
expect it will take to implement the new priority system?

    Question 2. Mr. Grinnell, as you know, the current state of Indian 
health facilities in Washington state is appalling. Our tribes do not 
have access to their own Indian Health Service inpatient facility, and 
some are making do with clinics operated out of mobile homes. Despite 
the pressing need for health facilities, the Portland Area has not 
faired very well under the current priority system, which includes no 
project for Washington state under the locked priority list.
    Your written testimony mentions that a revised Health Facilities 
Construction Priority System would ``provide an assessment of health 
services and facilities needs today and would rank those facilities' 
needs based upon contemporary criteria.''
    Can you elaborate on what you mean by ``contemporary criteria? '' 
How would the revised system address the facility needs of the Portland 
Area?

                                  
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