[Senate Hearing 111-471]
[From the U.S. Government Publishing Office]
S. Hrg. 111-471
HEARING ON VA AND INDIAN HEALTH SERVICE COOPERATION
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
NOVEMBER 5, 2009
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West Richard Burr, North Carolina,
Virginia Ranking Member
Patty Murray, Washington Lindsey O. Graham, South Carolina
Bernard Sanders, (I) Vermont Johnny Isakson, Georgia
Sherrod Brown, Ohio Roger F. Wicker, Mississippi
Jim Webb, Virginia Mike Johanns, Nebraska
Jon Tester, Montana
Mark Begich, Alaska
Roland W. Burris, Illinois
Arlen Specter, Pennsylvania
William E. Brew, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
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November 5, 2009
SENATORS
Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 1
Tester, Hon. Jon, U.S. Senator from Montana...................... 2
Murray, Hon. Patty, U.S. Senator from Washington................. 3
Burr, Hon. Richard, Ranking Member, U.S. Senator from North
Carolina....................................................... 4
Begich, Hon. Mark, U.S. Senator from Alaska...................... 5
Murkowski, Hon. Lisa, U.S. Senator from Alaska................... 29
WITNESSES
Park, William Clayton Sam ``Clay'', Director, Native Hawaiian
Veterans Project, Papa Ola Lokahi.............................. 6
Prepared statement........................................... 7
Howlett, S. Kevin, Director, Health and Human Services
Department, Confederated Salish and Kootenai Tribes of the
Flathead Nation................................................ 10
Prepared statement........................................... 11
Attachments.............................................. 13
Response to post-hearing questions submitted by Hon. Daniel
K. Akaka................................................... 17
Joseph, Andrew, Jr., Chairman, Northwest Portland Area Indian
Health Board, National Indian Health Board (NIHB), and Tribal
Council Member, Confederated Tribes of the Colville Reservation 18
Prepared statement........................................... 19
Floyd, James R., FACHE, Network Director, VA Heartland Network
(VISN 15), Veterans Health Administration, U.S. Department of
Veterans Affairs; accompanied by W.J. ``Buck'' Richardson,
Minority Veterans Program Coordinator, Rocky Mountain Health
Network and the Montana Health Care System, Helena, Montana;
and James Shore, M.D., Psychiatrist and Native Domain Lead,
Salt Lake City VA medical center............................... 32
Prepared statement........................................... 34
Response to post-hearing questions submitted by Hon. Daniel
K. Akaka................................................... 38
Attachments.............................................. 40
Response to requests arising during the hearing by Hon. Mark
Begich.....................................................68, 78
Grinnell, Randy E., Deputy Director, Indian Health Service, U.S.
Department of Health and Human Services; accompanied by Theresa
Cullen, M.D., Director of Information Technology, Indian Health
Service........................................................ 56
Prepared statement........................................... 58
Response to post-hearing questions submitted by Hon. Daniel
K. Akaka................................................... 61
APPENDIX
Burris, Hon. Roland W., U.S. Senator from Illinois; prepared
statement...................................................... 81
Keel, Jefferson, President, National Congress of American
Indians; prepared statement.................................... 81
Loudner, Don, National Commander, National American Indian
Veterans, Inc.; prepared statement............................. 83
Scott, Carol Wild, Chair, Veterans Law Section, Federal Bar
Association; prepared statement................................ 85
Northwest Portland Area Indian Health Board (NPAHB); prepared
statement...................................................... 88
HEARING ON VA AND INDIAN HEALTH SERVICE COOPERATION
----------
THURSDAY, NOVEMBER 5, 2009
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:06 a.m., in
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka,
Chairman of the Committee, presiding.
Present: Senators Akaka, Murray, Tester, Begich, and Burr.
Also present: Senator Murkowski.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Chairman Akaka. The hearing of the Senate Committee on
Veterans' Affairs will come to order.
Aloha and good morning, everyone. I am delighted that the
Committee is focusing on the joint efforts of the Department of
Veterans Affairs and the Indian Health Service to improve care
for Native American veterans.
Native American veterans have a rich and storied history of
service to our Nation, and like all veterans they deserve the
care and benefits that they have earned. Many Native American
veterans served with distinction, but returned home to a very
difficult transition. Substance abuse, extreme poverty, and
unemployment still plague parts of Indian Country. American
Indian and Alaska Native veterans are nearly 50 percent more
likely than other veterans to have a service-connected
disability and twice as likely to be unemployed. And as we will
hear from a witness from my home State, challenges also extend
to other Native veterans, including the many Native Hawaiians
who have and are serving our Nation.
Today's hearing focuses on health care. Despite dual
eligibility for VA and IHS health care, American Indian and
Alaska Native veterans report unmet health care needs at four
times the rate of other veterans. In 2003, VA and IHS signed a
Memorandum of Understanding agreeing to mutual goals and
actions to improve cooperation and collaboration. I look
forward to hearing from today's witnesses on the progress being
made toward those goals.
Senator Tester has been a leader on this issue and an
advocate for Native Americans in Montana and across the Nation.
Indeed, today's hearing is in response to his request, and I
will be turning the gavel over to him momentarily.
Also, I want to say that Senator Murray has also been a
leader in this area from the State of Washington.
As I speak, Tribal leaders are gathering for a White House
summit, as you know. Such summits remind us of the government-
to-government relationship the U.S. has with Tribal Nations and
their members. Therefore, for VA to effectively serve the many
Native Americans who have shared in our mutual defense, it must
also collaborate with the federally-recognized Tribal
governments whose citizens serve with pride and patriotism.
And now, I would like to call on Senator Tester for any
statement that he has to make, and I will call on Senator
Murray following that. Senator Tester.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. I want to thank you, Mr. Chairman. Thank
you for your remarks, and I want to thank you for agreeing to
hold this hearing as quickly as you did.
I want to thank the witnesses for being here today. A
special thanks to Kevin Howlett for being here to lend his
considerable expertise on the subject of Indian health care. As
the Director of Tribal Health for the Confederated Salish and
Kootenai Tribes in Montana, Kevin is literally on the front
lines of American Indian health care.
I also want to thank Buck Richardson for being here. Mr.
Chairman, I know you will do a full introduction of the
witnesses, but let me just say this. Buck is a fine man, has a
great reputation, and does some great work for the VA as it
applies to our Native Americans and VA folks across the board.
This is a critically important topic in my State. We have
11 tribes and seven reservations--over 4,500 American Indians
who are enrolled in the VA alone. Of course, the number of
American Indian veterans is likely much, much higher. Over the
short time that I have been a U.S. Senator, I have heard many
VA and Defense Department officials discuss the problems that
they have had in assuring a seamless transition of a veteran
from the DOD health program to the VA. Many veterans have told
me firsthand about how they have fallen through the cracks
caused by imperfect records, transfers, and red tape. It seems
to me that if an agency as well-funded as the DOD has problems
ensuring a seamless transition with the VA, we are facing an
especially tall order with Indian Health Service.
Some of this is about resources. Everyone in the room knows
how underfunded IHS has been. The agency actually spends less
per American Indian for health care than the Federal Bureau of
Prisons spends on Federal inmates. And it has only been in the
last couple years that the VA has been adequately funded.
But beyond the question of dollars and cents, it is clear
that neither agency has the unique needs of the Indian veterans
front and center. As a result, we hear the horror stories of a
veteran walking into an IHS facility, only to be told to go to
a VA hospital hundreds of miles away, and of the veteran
walking into a VA facility, only to be sent to an IHS facility.
This so-called ping-ponging veterans is at odds with each
agency's mission to care for the patient first.
We have no reliable data on the progress being made between
VA and IHS on their 2003 Memorandum of Understanding. In the
age of information we live in, I see this as not acceptable.
The lines of command and the role of each agency in
providing assistance to the veteran are not always as clear as
they need to be. One of the most important aspects of a true
government-to-government relationship is communication. Tribes,
clinics, and individual Indian veterans need to know what their
options are for obtaining the quality health care that they
deserve.
One of the areas that seems to be working, where we have
had decent results is the roll-out of the telehealth
capabilities. As you know, Mr. Chairman, telehealth is
particularly important in rural States, like my State. Many
times, it is the only opportunity for folks in frontier areas
to see a doctor or a mental health provider. Many of these
telehealth opportunities are the product of funding approved by
Congress in the past year for VA rural health programs. That is
a good story for both the VA and the IHS, and we need to build
on it. We have made good progress, but the work is not done.
Our goal today is to find out about some of the progress.
At the same time, we need the VA to be a willing partner at all
of its levels to work with us to find ways to improve health
care and the quality-of-life for American Indian veterans.
So, I look forward to this hearing very, very much. From
the witnesses, we are going to hopefully gain some ground on
where we are and move forward. We all know there is much more
work to be done, but by working together, we can get a lot of
good things done.
I want to thank you again, Mr. Chairman, for calling this
hearing and appreciate the witnesses for their presence here.
Chairman Akaka. Thank you very much, Senator Tester.
Senator Murray, your opening statement.
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Thank you very much, Mr. Chairman, Senator
Burr, Senator Tester, for holding this hearing today. I am
looking forward to a discussion on cooperation between the
Department of Veterans Affairs and the Indian Health Service so
that we can improve health care and benefits for American
Indian, Native Alaskan, and Native Hawaiian veterans.
I join in thanking all of our witnesses who are appearing
before this Committee today. I look forward to hearing your
thoughts and perspectives on the cooperation between these two
agencies since the implementation of the Memorandum of
Understanding.
Mr. Chairman, I especially want to welcome and thank
Councilman Andrew Joseph. He comes from the Confederated Tribes
of Colville and has traveled all the way across the country to
be here today to testify from my home State of Washington and I
really appreciate his being here today.
I do want to take a moment to say how proud I am of all the
veterans in this room. All of you have sacrificed so much in
service to our country. We owe it to you to honor the promises
we have made to take care of you when you come home. And one of
the most important ways to do this is by making sure that
veterans have access to a system that treats you fairly.
Tribal veterans, in particular, have made tremendous
sacrifices for our country. In fact, Native Americans serve in
the Armed Forces at a higher rate per capita than any other
ethnic group. And I also know that Tribal veterans face some of
the toughest barriers to accessing the services they have
earned. Many Tribal veterans don't live anywhere near VA
services. They face communication barriers. And too often,
Tribal veterans face issues with coordination between the
Indian Health Service and the VA. So, it is our job to do
everything within our power to break down those barriers and
help our Tribal veterans access the care they need. You fought
for us. We need to fight for you now.
We began moving in the right direction 6 years ago when the
Memorandum of Understanding was signed, but enough time has
gone by for us to see some tangible results from the
cooperation this agreement was meant to develop.
So, Mr. Chairman, I appreciate your holding this hearing
and I look forward to hearing from our witnesses today on the
progress of this cooperation. Thank you.
Chairman Akaka. Thank you, Senator Murray.
And now, the Ranking Member of this Committee, Senator
Burr.
STATEMENT OF HON. RICHARD BURR, RANKING MEMBER,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Thank you, Mr. Chairman. Aloha. Welcome to
our witnesses this morning.
We are here today to ensure the resources of the Department
of Veterans Affairs and the Indian Health Service are being
used to deliver timely, quality, and coordinated care services
to Native American veterans.
Mr. Chairman, Native Americans have the highest record of
military service per capita when compared to other ethnic
groups. I believe this record of service to our Nation and to
the country is rooted in their culture and their traditions.
Courage, duty, honor, sacrifice--these are values that make up
our military men and women and make them second to none, and
they are the values that run thick in the culture of so many
from Indian Country.
And when they return from military service with medical
needs, they should expect a well-coordinated health care
system. Today, I hope to learn how VA and the Indian Health
Service coordinate the health care for those enrolled in both
systems. For example, the Tribal Hospital in Cherokee, NC, has
700 enrolled veterans. One hundred forty of them are also
enrolled in VA care. I hope to learn whether the remaining 560
veterans are aware of the VA health care benefits they may be
entitled to.
This is just a snapshot of an issue I am sure exists for
North Carolina's 7,600 Native American veterans and others
across the country. VA and IHS need to do a better job in
sharing information to determine whether a patient is dual
eligible. This information will lead to a more efficient
allocation of resources, better planning, and well-informed
sharing agreements.
In 2003, VA and Indian Health Service developed a
Memorandum of Understanding outlining five mutual goals. One,
improve access to quality care; two, improve communications;
three, encourage the development of partnerships and sharing
agreements; four, ensure appropriate resources are available;
and five, improve health promotion, disease, and preventative
services. Today, I hope to learn where we are meeting these
important goals, but more importantly, where we still need
work.
It is extremely important that these goals be taken
seriously. For too long, when it comes to fair dealing with
Indian Country, our actions have not matched our words. We must
not let this be the case here, especially when we are talking
about those who have worn the uniform of our country.
Mr. Chairman, again, I thank you for convening this hearing
and I look forward to what our witnesses might instill with us.
Chairman Akaka. Thank you very much, Senator Burr.
Now I will call on Senator Begich for any opening remarks.
STATEMENT OF HON. MARK BEGICH,
U.S. SENATOR FROM ALASKA
Senator Begich. Thank you very much, Mr. Chairman. And to
the first panel, thank you for being here. Thank you for
patiently waiting as we go through our opening remarks, because
to be honest with you, I am looking forward to your comments,
and I really am looking for the next panel because we are going
to have a lot of questions for them.
In my State of Alaska, a huge percentage--120,000 of the
population are Alaska Natives. We have the very unique problem
of delivery of services to our veterans in rural parts of
Alaska, which is much different than the Lower 48, where in
some cases you can drive to facilities. But in Alaska, you may
not even be able to get to a facility until the weather is
correct, when you can then fly or snow machine, depending on
the conditions of the area.
I am interested not only in the dual enrolled recipients,
but also for Alaska, for unique opportunities in how we deliver
services to those veterans that are in very remote areas--
literally a plane ride away--yet a very short distance away are
Indian Health Service facilities and how they can access those.
Maybe they need not be dual-enrolled, but may need access
because we don't have a VA hospital in Alaska, and also the
distance travel can put great pressure onto the health issue
they may be moving forward on and getting services for. So, I
am anxious for that.
I am anxious for the first panel because hopefully you will
give us your very open thoughts on what is working, what is
not, but also where you can see some improvements. Even though
it is not necessarily from an Alaska perspective, I think it is
very important from the first people's perspective of what we
need to do to improve a service that is earned, but also
important to deliver to our veterans, especially in rural
communities, and Alaska Native American Indians have unique
situations.
I can only tell you that in Alaska I hear from veteran
after veteran who has served and now lives back in their home
village, that when they need services it is very difficult at
times to get that access. We have some demonstration projects
up there that seem to have some success and we are anxious to
share those. But I am anxious to talk to the next panel in
specific regard to how do we ensure that the veterans in rural
communities, and especially in Alaska, access health care in a
reasonable timeframe and get quality health care.
But again, thank you to the first panel. Thank you for
patiently listening to us giving our opening remarks. Thank
you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Begich.
I want to welcome the witnesses on our first panel. Clay
Park, Native Hawaiian Veterans Program Director at Papa Ola
Lokahi, will begin our discussion by giving voice to a
sometimes neglected portion of the Native American community,
and that is the Native Hawaiians.
Our second witness is Mr. Kevin Howlett, Director of the
Salish and Kootenai Tribal Health Department.
Our third witness, I am pleased to introduce, is Andrew
Joseph, a Councilman from the Confederated Tribes of Colville,
who is testifying on behalf of the National Indian Health
Board.
Mr. Park, we will please begin with your statement.
STATEMENT OF WILLIAM CLAYTON SAM ``CLAY'' PARK, DIRECTOR,
NATIVE AMERICAN HAWAIIAN VETERANS PROJECT, PAPA OLA LOKAHI
Mr. Park. Good morning. Welina. Chairman Akaka, members of
the Senate Committee on Veterans' Affairs, Papa Ola Lokahi
wishes to express to you its sincere gratitude for inviting us
to participate today in this important hearing.
My name is William Clayton Sam Park, Director of Papa Ola
Lokahi's Native Hawaiian Veterans Project. I am a retired
Master Sergeant with 3 years active duty, 21 years of service
with the Hawaii Army National Guard. I am also retired from the
Department of Veterans Affairs and a disabled veteran.
Mr. Chairman, in your letter, you specifically wanted us to
address Papa Ola Lokahi and the Native Hawaiian Health Care
Systems collaborating with the VA and the Indian Health
Service. Papa Ola Lokahi has had a longstanding relationship
with the VA, going back more than 10 years to a time when Mr.
David Burge, a Native Hawaiian, served as its Hawaii Director.
We have participated in past trainings and provided training to
the local VA on cultural trauma and other areas around cultural
competency.
Recently, we have established at each of our five Native
Hawaiian Health Care Systems, which operate throughout the
State, veterans ``Aunties'' and ``Uncles'' groups, which act as
enablers for Native Hawaiians and other veterans with issues
and/or concerns. These men and women serve as volunteers to
hear out our veterans and their issues and offer advice. In
turn, these groups are facilitated by health care professionals
from the Native Hawaiian Health Care Systems, who are trained
specifically in VA programs and, in turn, serve as links for
veterans on their respective islands into the VA structure.
Likewise, Papa Ola Lokahi has developed a relationship with
the Indian Health Service over the past 15 years. This
relationship has afforded the provision of primary care service
for American Indians and Alaska Native residents in Hawaii.
Presently, these services are provided through Ke Ola Mama, one
of the largest Native Hawaiian Health Care Systems, directed by
Lisa Mao Ka'anoi, an Alaska Native of Native Hawaiian ancestry.
Over the years the Indian Health Service has provided
guidance to Papa Ola Lokahi on, one, formation of its
Institutional Review Board, which currently reviews and
approves all health research undertaken by researchers through
the Native Hawaiian Health Care Systems and other service
providers. Two, establishment of the Native Hawaiian Epi
Center, which is similar in form and function to the 11 Native
American Epi Centers across Indian Country. And three, the RPMS
reporting system, which some of the Native Hawaiian Health Care
Systems are considering adopting.
In conclusion, these two agencies have continued to support
the efforts of Papa Ola Lokahi in the Native Hawaiian Health
Care Systems and we have supported their missions as well.
Presently, we receive our base Federal support through the
Native Hawaiian Health Care Improvement Act and the Health
Resources and Services Administration, U.S. Department of
Health and Human Services.
Thank you again, Chairman Akaka and members of the Senate
Committee on Veterans' Affairs, for this opportunity to share
with you my thoughts today. There is an olelo, a verse, in my
traditional language which states, ``Ke kaulana pa'a 'aina on
na ali'i,'' which is simply translated as ``The famed
landholders of the chiefs.'' The meaning here is the best
warriors were awarded the best lands by our chiefs because of
their bravery and service. This is why we are here today. We
simply want the best health care possible for our warriors who
have given so much, often sacrificing their own health for this
Nation's benefit. Our recommendation for specific actions to
accomplish this objective has been submitted in the written
testimony.
Mr. Chairman, I will be pleased to answer any questions you
or Members of the Committee have. Mahalo.
[The prepared statement of Mr. Park follows:]
Prepared Statement of William Clayton Sam ``Clay'' Park, Director,
Native Hawaiian Veterans Project, Papa Ola Lokahi
Welina. Chairman Akaka and Members of the Senate Committee on
Veterans' Affairs, Papa Ola Lokahi wishes to express to you its sincere
gratitude for inviting us to participate today in this important
Hearing.
My name is William Clayton Sam Park, director of Papa Ola Lokahi's
Native Hawaiian Veterans Project. I am a retired Master Sergeant with 3
years active duty and 21 years of service with the Hawaii Army National
Guard. I am also retired from the DVA with 28 years of service and a
disabled veteran.
Papa Ola Lokahi is the Native Hawaiian Health Board that was
established by the Native Hawaiian community in 1987 to plan and
implement programs, coordinate projects and programs, define policy,
and educate about and advocate for the improved health and wellbeing of
Native Hawaiians, an Indigenous Peoples of the United States. These
tasks were incorporated within U.S. policy when the U.S. Congress
established its policy in 1988 ``to raise the health status of Native
Hawaiians to the highest possible level and to provide existing Native
Hawaiian health care programs with all the resources necessary to
effectuate this policy'' (Public Law 102-396).
Native Hawaiians have served in the military services of the United
States almost from the very beginning of the Nation. Young Prince
George Kaumuali'i enlisted in the U.S. Navy and fought in the War of
1812 in the Mediterranean. In following conflicts including the
American Civil War, the Spanish-American War, World Wars I and II,
Korea, Vietnam, Iraq, and, now, again Iraq and Afghanistan, Native
Hawaiians have continued to serve and serve with distinction. As a side
note, a number of Native Hawaiians historically have also served in the
Armed Forces of other countries including England and Canada.
In 1997 when the VA released the results of the late Senator Spark
Matsunaga-initiated study on the impacts of exposure to war zones on
Native Hawaiian and Asian veterans, it became clear that along with
American Indians and Alaska Natives, Native Hawaiians have borne a
larger burden of battle-related stress and trauma. More than one in
every two Native Hawaiian veterans experienced war-related trauma in
Vietnam. The report goes on . . . Upon returning home after one or more
tours in Vietnam many Native Hawaiian veterans struggle with extremely
severe problems that neither they nor their families, friends, or
communities know how to understand or cope with: depression, shame,
guilt, isolation and emotional emptiness, alienation, unable to relax,
addiction. One in three Native Hawaiians have full or partial PTSD
currently . . . More than one in two Native Hawaiians have had full or
partial PTSD sometime since Vietnam.
With conflicts in the 1990s in Iraq and now on-going conflicts in
Iraq and Afghanistan, and with Reserve and National Guard units being
heavily utilized along with regular military and the particularly
brutal nature of the current warfare, these PTSD episodes will only
greatly increase. An additional factor in these conflicts is the full
participation of women now integrated into positions which formerly
were all male forces.
Current US Census data indicates that there are about 30,000 Native
Hawaiian and Pacific Islander veterans in the United States. A large
portion of this number is resident in Hawaii and Native Hawaiians have
been actively engaged with the Hawai'i Office of the VA (Veterans'
Affairs) for many years. Increasingly, however, almost as many Native
Hawaiians now live on the continental United States and more and more,
Native Hawaiians will become part of the VA structure throughout the
Nation. In previous testimony before this Committee, Papa Ola Lokahi
provided historical reviews and analysis of VA activities and the
Native Hawaiian community in Hawaii.
Mr. Chairman, in your letter you specifically wanted us to address
Papa Ola Lokahi and the Native Hawaiian Health Care Systems'
collaboration with the VA and the Indian Health Service. Papa Ola
Lokahi has had a long-standing relationship with the VA going back more
than ten years to a time when Mr. David Burge, a Native Hawaiian,
served as its Hawai'i Director. We have participated in past trainings
and provided training to the local VA in cultural trauma and other
areas around cultural competency. Recently, we have established at each
of the five Native Hawaiian Health Care Systems which operate
throughout the State, veterans ``Aunties'' and ``Uncles'' groups which
act as ``enablers'' for Native Hawaiian and other veterans with issues
and/or concerns. These men and women are Native retirees who serve as
volunteers to hear out veterans and their issues and offer advice. In
turn, these groups are facilitated by health care professionals from
the Native Hawaiian Health Care Systems, who are trained specifically
in VA programs and, in turn, serve as links for veterans on their
respective islands into the VA structure.
Likewise, Papa Ola Lokahi has developed a relationship with the
Indian Health Service over the past fifteen years. This relationship
has afforded the provision of primary care services for American
Indians and Alaska Natives resident in Hawaii. Presently, these
services are provided through Ke Ola Mama, one of the larger Native
Hawaiian Health Care Systems, and directed by Lisa Mao Ka'anoi, an
Alaska Native with Native Hawaiian ancestry. Over the years, the Indian
Health Service has also provided guidance to Papa Ola Lokahi on (1)
formation of its Institutional Review Board which currently reviews and
approves all health research undertaken by researchers through the
Native Hawaiian Health Care Systems and other service providers, (2)
establishment of the Native Hawaiian Epi Center which is similar in
form and function to the twelve Native American Epi Centers across
Indian Country, and (3) the RPMS reporting System which some of the
Native Hawaiian Health Care Systems are considering adopting.
In conclusion, these two agencies have continued to support the
efforts of Papa Ola Lokahi and the Native Hawaiian Health Care Systems
as we have supported their missions as well. Presently, we receive our
base Federal support through the Native Hawaiian Health Care
Improvement Act and the Health Resources and Services Administration,
US Department of Health and Human Services.
Given our relationships and vantage point, we come before you today
with the following recommendations:
1. Enhance VA capacity to address health and wellness issues not
only of the VA beneficiary but also those of the VA beneficiary's
family;
While addressing the VA beneficiary's health needs is critical to
the VA mission, there needs to be the ability within the VA also to
address the resultant health issues and needs of the VA beneficiary's
family. This is particularly true with those VA beneficiaries with TBI
and/or PTSD. Without this ability, there is often a family breakdown
and a less than satisfactory outcome for the VA beneficiary, the family
and the community.
2. Develop VA capacity to contract with Native groups and
organizations to provide outreach services to VA beneficiaries and
their families;
In Hawai'i, the VA has not been able to reach out to rural
communities and provide needed services to VA beneficiaries living in
these areas. We would ask that the VA contract with Native Hawaiian and
other appropriate groups and organizations to provide outreach services
to VA beneficiaries and their families.
3. Develop VA capacity to contract with FQHCs and tribal and Native
Hawaiian Health Care Systems to provide VA beneficiaries and their
families with primary care services in rural areas;
For the same reasons noted previously, the VA simply does not have
the capacity at this time to reach out into rural areas where there are
currently primary care service providers. It would make sense for the
VA to contract for primary care services with these existing entities
in these rural communities. In Hawai'i, there are only 3 VA community-
based outpatient clinics (CBOC) while there are 14 community health
centers and 5 Native Hawaiian Health Care Systems, all of which provide
primary care
4. Train VA service providers working with Native populations in
history, cultural sensitivity, and cultural competency;
historical context and cultural sensitivity and competency can improve
VA service provider and VA beneficiary understanding and compliance
with good outcomes.
5. Expand VA capacity to provide traditional Native healing
practices and alternative and complementary healing practices to VA
beneficiaries and their families;
Native cultures have traditional healing practices such as lomilomi
(Hawaiian massage), ho'oponopono (counseling), and la'au lapa'au
(herbal medicine) in our Native Hawaiian culture. This includes
traditional practices and protocols transitioning the 'warrior'' back
into civilian society. All of these have demonstrated effectiveness for
the Native VA beneficiary. The VA needs to support these traditional
methods and practices. In addition, there are numerous alternative and
complementary health care practices such as acupuncture, chiropractic,
Chinese medicine, and naturopathy which may be of particular interest
and therapeutic to VA beneficiaries. These, too, should be allowable
and available.
6. Support and develop specific work plans for each of the
recommendations of the Advisory Committee on Minority Veterans' July 1,
2008 and July 1, 2009 reports;
In 1994, legislation was passed which established the Advisory
Committee on Minority Veterans. The work and recommendations of this
Committee need to be actively supported and implemented respectively.
It is strongly recommended that a Native Hawaiian representative be
added to the Committee as soon as appropriate. In addition, Native
Hawaiians look forward to participating with the federally-chartered
National American Indian Veterans group and applaud the recently
produced DVD entitled ``Native American Veterans: Storytelling for
Healing,'' which includes American Indian, Alaska Native, and Native
Hawaiian veterans' stories produced by the Administration for Native
Americans, US Department of Health and Human Services.
7. Collect, analyze, and report data on VA beneficiaries and their
families in accordance with 1997 OMB 15 revised standards, including
disaggregating Native Hawaiian from Other Pacific Islander data;
In 1997, OMB disaggregated the Asian Pacific Islander (API)
identifier and established two distinct categories; Asian (A) and
Native Hawaiian and Other Pacific Islander (NHOPI). The VA needs to
incorporate this disaggregation within its reporting systems.
Additionally, ``Native Hawaiians'' need to be distinctively identified
apart from ``Other Pacific Islanders'' as Native Hawaiians have put
forth their self-determination efforts. This is critical for Native
Hawaiians as, like American Indians/Alaska Natives, they need to be
identified as a body of individuals with a special political
relationship to the Federal Government.
8. Enhance VA capacity to undertake research on ways to improve
health and wellness outcomes for VA beneficiaries and their families.
The VA's research budget has been limited over the past decade.
Additional funds need to be allocated to research how better outcomes
can be accomplished for VA beneficiaries and their families. This is
particularly critical for those with TBI and PTSD.
Additionally, we strongly recommend that the VA increase its
research capacity to investigate what the health and wellness issues
are for returning Native men and women veterans from today's war zones.
It is hoped that many of these studies could be undertaken by Native
health researchers themselves.
Thank you again Chairman Akaka and Members of the Senate Committee
on Veterans Affairs for this opportunity to share with you my thoughts
today. There is an ``olelo, a verse, in my traditional language which
simply states:
ke kaulana pa`a `alna on na ali`i
Which is simply translated as ``The famed landholders of the
chiefs.'' The meaning here is that the best warriors were awarded the
best lands by our chiefs because of their bravery and service. That is
why we are here today. We simply want the best health care possible for
our warriors who have given so much and often sacrificed their own
health for this Nation's benefit. Mahalo.
Chairman Akaka. Thank you very much, Mr. Park.
Mr. Howlett, we will receive your testimony.
STATEMENT OF S. KEVIN HOWLETT, DIRECTOR, CONFEDERATED SALISH
AND KOOTENAI TRIBAL HEALTH DEPARTMENT
Mr. Howlett. Mr. Chairman, Members of the Committee, I am
pleased and honored to appear before you today to present
testimony related to health care of Native American veterans.
For the record, I am Kevin Howlett, a member of the Salish
Kootenai Tribes, and Director of the Tribes' Health and Human
Services Department.
I would like to thank Senator Tester for his recognition
and support for my being here and his commitment to providing
health care to Native American veterans.
Today, I will address those areas I feel that affect the
access and quality of care I spoke of when then-Secretary Peake
visited Montana. Let me assure you that while I speak as one
Tribal health director, the issues I will address span the
universe of Indian Country and the needs I believe exist in
every reservation community.
Specifically, there has been a longstanding belief that
health care for Native Americans is the responsibility of the
Indian Health Service. While I agree that the IHS has principal
responsibility as the Federal agency designated to provide
care, I also know that as citizens of the States in which
Indians live, they are entitled to the services provided to the
citizens of that State. In addition, by having served our
country in the Armed Services, veterans have earned the right
to care provided by the Veterans Administration medical system.
Most reservations are remotely located, underfunded,
understaffed, resulting in a very real rationed care scenario.
While Tribal or IHS clinics do the best they can, the level of
care is often less than needed. This is amplified by a severe
shortage of clinical personnel evident in virtually every
clinic setting.
When the level of care is not available in the local IHS
clinic, IHS uses what is referred to as a Contract Health
Service Program to refer care to outside specialty providers or
inpatient facilities when that care is not available. The CHS
program has operated on a shoestring budget for many years. The
care that can be approved utilizing CHS funds must be
threatened if IHS assumes financial responsibility.
Consequently, these services are not provided.
We are aware of the existence of a Memorandum of
Understanding between the Indian Health Service and the VA. We
are also aware that it represents more symbolism than action.
Without question, the full implementation of the existing MOU
linked to specific Tribal recommendations would go a long way
in providing a more comprehensive level of care to our
veterans. Specifically, the agencies agreed to many things,
including the sharing of information technology and an
interagency work group to oversee proposed national
initiatives.
Mr. Chairman, if the agencies who are a party to this
agreement would, as a matter of priority, establish an internal
and external--including Tribal--work group to begin developing
a strategy, then they could discuss how that strategy should be
resourced and implemented.
An item not covered in the existing MOU concerns payment to
Tribal facilities for care rendered to eligible veterans in
Tribal clinics. The Tribes rely heavily upon third-party
collections to support clinic operations. It seems logical that
for Medicare and Medicaid and privately insured individuals,
the clinics can seek reimbursement. We are aware that the VA
does have the ability to contract with the private sector to
pay for the care of veterans, yet Tribally-operated clinics
cannot, as we understand, seek the same. It would be easily
incorporated into statute if this Committee were so inclined.
Absent the reimbursement, we will still provide what care we
can, but the resources or the absence of resources controls the
scope of care.
Mr. Chairman, I could speak for hours about the specific
needs of the 480 veterans living on my reservation. My purpose
and goal today is to enlighten you from my perspective about
the organization, structural, and resource issues that comprise
the maze of health care for veterans on the Flat Head Indian
Reservation. I truly believe that the level of care that is
afforded must equal the services they have rendered. I also
believe that we can find solutions if we stay focused on the
task and spend less time trying to point fingers. We need to
utilize the tools we have and the commitment all of us have in
this room share.
I look forward to this Committee providing the guidance and
direction to the VA and IHS to ensure that those who have worn
the uniform have the best care possible, to maximize limited
resources, and to work collectively in all areas of health
care, including behavioral health. We owe these dedicated men
and women nothing less.
Mr. Chairman, I have attached the MOU to my testimony. I
have also attached some correspondence from the manager of my
behavioral health program, correspondence that she relates to
me from her personal observations as a behavioral therapist,
the issues she has dealt with, and I think it will give you a
perspective that sometimes people in bureaucracy don't or can't
appreciate.
I would be happy to answer any questions the Committee may
have. Thank you.
[The prepared statement of Mr. Howlett follows:]
Prepared Statement of S. Kevin Howlett, Director, Health and Human
Services Department, Confederated Salish and Kootenai Tribes of the
Flathead Nation
Mr. Chairman and Members of the Committee: I am pleased and honored
to appear before you today to present testimony related to the health
care for Native American Veterans.
For the record, I am S. Kevin Howlett, a member of the Salish and
Kootenai Tribes and Director of the Tribes Health & Human Services
Department.
Let me thank our Senator Jon Tester for his recognition and support
for my being here and his commitment to providing health care to our
veterans.
Today, I will address those areas I feel that affect the access and
quality of care I spoke of when then Secretary Peake visited Montana.
Let me assure you that while I speak as one Tribal Health Director, the
issues I will address span the universe of Indian country and the needs
I believe exist in every reservation community.
Specifically, there has been a long-standing belief that health
care for Native Americans was the responsibility of the Indian Health
Service. While I agree that IHS has principal responsibility as the
Federal agency designated to provide care, I also know that as citizens
of the states in which Indians live they are also entitled to the
services provided to the citizens of that state. In addition, by having
served our country in the armed services, veterans have earned the
right to care provided by the Veterans Administration Medical system.
Most reservations are remotely located, under funded and under
staffed resulting in a very real rationed care scenario. While Tribal/
IHS clinics do the best they can, the level of care is quite often less
than needed. This is amplified by a severe shortage of clinical
personnel evident in virtually every clinic setting.
When the level of care is not available in the local clinic IHS
uses what is referred to as the contract health services (CHS) program
to refer to outside specialty care providers or in-patient facilities
when in-patient care is not available. The CHS program has operated on
a shoestring budget for many years. The care that can be approved
utilizing CHS funds must be life threatening if IHS assumes financial
responsibility; consequently these services are not provided.
We are aware of the existence of a Memorandum of Understanding
between the IHS and the VA. We are also aware that it represents more
symbolism then action. Without question the full implementation of the
existing MOU, linked with Tribal specific recommendations would go a
long way in providing a more comprehensive level of care for our
veterans. Specifically, the agencies agree to many things including the
sharing of information technology and an interagency workgroup to
oversee proposed national initiatives.
Mr. Chairman, if the agencies who are a party to this agreement
would as a matter of priority establish an internal and external
(tribal) work group to begin developing a strategy then we could
discuss how that strategy should be resourced and implemented.
An item not covered in the existing MOU concerns payment to Tribal
facilities for care rendered to eligible veterans in Tribal clinics.
The tribes rely heavily upon third-party collections to support the
clinic operations. It seems logical that for Medicare/Medicaid, and
privately insured individuals, the clinics can seek reimbursement. We
are aware that the VA does have the ability to contract with the
private sector to pay for the care of veterans, yet tribally operated
clinics cannot as we understand seek the same. It would be easily
incorporated into statute if this Committee were so inclined. Absent
the reimbursement, we will still provide what care we can, but
resources or the absence of resources controls the scope of care.
Mr. Chairman, I could speak for hours about the specific needs of
the 480 veterans living on my reservation. My purpose and goal today
was to enlighten you from my perspective about the organization,
structural and resource issues that comprise the maze of health care
for veterans on the Flathead Indian Reservation. I truly believe that
the level of care that is afforded must be equal to the services they
have rendered.
I also believe that we can find solutions if we stay focused on the
task, and spend less time trying to point fingers. We need to utilize
the tools we have, and the commitment all of us in this room share.
I look forward to this Committee providing the guidance and
direction to the VA and IHS to ensure that those who have worn our
uniform have the best care possible, to maximize limited resources, and
to work collectively in all areas of health care including behavioral
health. We owe these dedicated men and women nothing less.
______
Response to Post-Hearing Question Submitted by Hon. Daniel K. Akaka to
S. Kevin Howlett, Director, Health and Human Services Department,
Confederated Salish and Kootenai Tribes of the Flathead Nation
Question. Mr. Howlett, you testified that the VA can contract with
the private sector for services through contract health services (CHS)
but not with tribally-operated clinics. If the VA were able to contract
with tribally-operated clinics, would that greatly increase
accessibility for Native American veterans?
Response. Absolutely, in many places across the country, the only
care available is Indian Health Service or Tribal Health Services.
Chairman Akaka. Thank you very much, Mr. Howlett. We will
include the information in the record that you mentioned.
Now, we will receive the statement of Mr. Joseph.
STATEMENT OF ANDREW JOSEPH, JR., CHAIRMAN, NORTHWEST PORTLAND
AREA INDIAN HEALTH BOARD, NATIONAL INDIAN HEALTH BOARD (NIHB),
AND TRIBAL COUNCIL MEMBER, CONFEDERATED TRIBES OF THE COLVILLE
RESERVATION
Mr. Joseph. Chairman Akaka and Ranking Member and
distinguished Members of the Committee, [untranslated] is my
name in my language. I am Andy Joseph, Jr. I chair the Health
and Human Services Committee for the Confederated Tribes of
Colville. I am the Chair of the Portland Area Indian Health
Board and Delegate to the National Indian Health Board. Thank
you for inviting the National Indian Health Board to testify
today.
NIHB serves all federally-recognized Tribes by advocating
for the improvement of health care to all American Indians and
Alaskan Natives. Our organization believes that the Federal
Government must uphold its trust responsibility in the delivery
of quality health care to Indian people, especially our Native
veterans.
Native veterans are a special part of our Tribal
communities. American Indians and Alaskan Natives have a long
history of serving the U.S. Armed Forces. Indians have
volunteered to serve in the military at a higher percentage
than any other ethnic group. Our Native veterans are also
fellow Tribal members who are assured health care as part of
the Federal Government's trust responsibility to Tribes. As
veterans, the U.S. Government has made a commitment to provide
health care in honor for their military service. Therefore, our
Native veterans deserve quality health care.
The IHS and VA have collaborated to promote greater
cooperation for the improvement of health care for Native
veterans. In some areas, this coordination in care is working
out well. However, many Native veterans report a higher rate of
unmet health care needs and continue to deal with high rates of
illness associated with combat service. The lack of access and
coordination of care has created some of these issues.
There are Native veterans who may not consider the VA as an
option for their health care. Tribal members live in remote,
rural areas and must travel great distances to access any
medical facility, including VA. Another potential barrier is
the perception that VA will not appreciate, understand, or
accommodate the cultural needs of Native veterans. Some Native
veterans have expressed the frustration when VA has not
accepted a diagnosis from IHS. In these instances, Native
veterans have to travel long distances to a VA hospital so the
VA doctor can administer the same test and give the same
diagnosis that the IHS provided.
Other issues include lack of communication that exists
between VA and IHS regarding treatment. Some Native veterans
who access health care through both VA and IHS must manage
their own care by maintaining medical records, sharing the
medical diagnosis and care between VA and IHS. Without these
agencies directly talking with one another, there may be
increased risks, such as side effects from counteracting
medications.
We have provided some recommendations in our written
testimony. I would like to raise a couple here. First, a key
recommendation to address the health needs of Native veterans
is the need for additional funding to provide care to Native
veterans. Many times, IHS is the only facility in the area to
provide care for Native veterans. Supplemental funding to IHS
and Tribal facilities for services provided to Native veterans
would help ensure all the care needed can be provided to Native
veterans.
Second, more information must be shared about the available
services. One option is to expand the Tribal Veterans Service
Officers Program by establishing it as part of the VA with
permanent paid positions. In many areas, these representatives
help Native veterans navigate the VA system and serve as
advocates for Native veterans.
Another option is to bring VA health professionals
specialized in behavior and mental health treatment to Tribal
communities to treat Native veterans. Many of the IHS and
Tribal facilities have behavior health departments, but deal
with veterans returning home from combat requires specialized
care and treatment.
In closing, thank you for this opportunity to provide these
comments and I am happy to answer any questions the Committee
might have.
I would like to thank each of you for serving our country,
also. As a Tribal leader, I know you swore an oath to protect
and care for all of our people, the same as Tribal leaders
have, and your time is greatly appreciated. Thank you.
[The prepared statement of Mr. Joseph follows:]
Prepared Statement of Andrew Joseph, Jr., Chairman of the Northwest
Portland Area Indian Health Board, National Indian Health Board (NIHB),
and Tribal Council Member, Confederated Tribes of the Colville
Reservation
Chairman Akaka, Ranking Member Burr and Distinguished Members of
the Committee, I am Andrew Joseph, Jr., testifying on the behalf of the
National Indian Health Board (NIHB). Also, I serve as a Tribal Council
Member of the Confederated Tribes of the Colville Reservation and as
the Chairman of the Northwest Portland Area Indian Health Board.
Thank you for inviting the NIHB to testify today regarding the
cooperation and coordination between the Veteran Affairs and the Indian
Health Service (IHS) in providing care to our American Indian/Alaska
Natives (AI/AN) Veterans. Since 1972, the NIHB serves all federally
recognized Tribes by advocating for the improvement of health care
delivery to AI/AN. It is the belief of the NIHB that the Federal
Government must uphold its trust responsibility to AI/AN populations in
the provision and facilitation of quality health care to our people.
The results that we all wish to achieve are the enhancement of the
level and quality of health care and the adequacy of funding for health
services that are operated by Tribal governments, the Indian Health
Service and other Federal programs. As health care is the top priority
of Tribes across the Nation, and delivery of health care is unique and
individual to each Tribal nation and their tribal members in the United
States, it is fitting that the NIHB provides testimony regarding the
health care provided to our Native Veterans. Thank you for inviting us
to do so.
health care available for our ai/an veterans
AI/AN who have served in the US Armed Forces are a special segment
in our communities as they are both Tribal members and honored
veterans. They are fellow members, relatives and friends of the 564
federally recognized tribal communities in United States. As well as,
the long history of AI/AN serving in the United States Armed Forces
should never be forgotten.\1\ AI/AN have volunteered to serve the
United States at a higher percentage in all of America's wars and
conflicts than any other ethnic group on a per capita basis. In
addition, 25% of AI/AN population serve in military, which is higher
than any other in the U.S. Based on the association with both the AI/AN
and Veteran communities, AI/AN Veterans are entitled to health care
both as a right as a tribal member and as a benefit for their military
service.
---------------------------------------------------------------------------
\1\ See ``American Indian and Alaska Native Veterans: Lasting
Contributions'' by Lindsay Holiday, Gabriel Bell, Robert Klein and
Michael Wells, US Department of Veterans Affairs, Office of Policy
Assistant Secretary for Policy, Planning, and Preparedness, September
2006.
---------------------------------------------------------------------------
Indian Health Service
As a member of federally recognized Tribe, AI/AN Veterans are
entitled to health care. The provision of health services to AI/AN is
the direct result of treaties and executive orders that were made
between the United States and Indian Tribes. This Federal trust
responsibility forms the basis of providing health care to AI/AN people
and reaffirmed by judicial decisions, executive orders, and
congressional law.
The Indian Health Service (IHS) is responsible for health care to
all enrolled members of the 564 federally recognized Indian tribes,
bands, and Alaska Native villages in the US. The current Indian health
care delivery system provides culturally competent health care to AI/
AN, who reside in the most remote, isolated and poorest parts of this
Country. There is no consistent health benefits package across Indian
country. This health care delivery system consists of various health
care facilities across the country, including 45 hospitals, 635
ambulatory facilities (288 health centers, 15 school-based health
centers, 132 health stations, 34 urban Indian health program, and 166
Alaska Native village clinics).\2\ These health care facilities can be
grouped into three categories: those operated directly by IHS, those
operated by the tribes via contract or compact with IHS, and those
providing services to urban AI/AN (individuals not residing on or near
an Indian reservation).
---------------------------------------------------------------------------
\2\ Indian Health Service Year 2009 Profile. Available at http://
info.ihs.gov/Profile09.asp. Assessed October 31, 2009.
---------------------------------------------------------------------------
What is consistent, however, is that there is an overwhelming lack
of funding to support even the basic health care demands in all three
delivery models. Along with ambulatory primary care services, Tribal,
IHS or Contract Care facilities may offer inpatient care, sporadic
medical specialties, traditional healing practices, dental care, child
and emergency dental care, mental health care, limited eye care, and
substance abuse assessment or treatment programs. Many tribes are also
served by community health (e.g., childhood immunizations, home visits)
and environmental health (e.g., sanitation, injury prevention)
programs, which may be administered by the IHS or the Tribes. Specialty
services and types of medical care that are not available at a given
facility are often purchased from providers in the private sector
through contract health service (CHS) program. Due to lack of adequate
funding, the IHS and Tribes apply stringent eligibility criteria to
determine which patients qualify for CHS funding. The severely limited
pool of CHS dollars also means that most CHS programs limit
reimbursement to those diagnostic or therapeutic services that are
needed to prevent the immediate death or serious impairment of the
health of the patient. Long lists of denied or deferred CHS care are
commonplace at all IHS and Tribal facilities.
Veteran Health Administration
AI/AN veterans may be eligible for health care from the Department
of Veterans Health Administration (VHA). The eligibility of Veterans to
access health care through the VHA depends on factors such as service-
connected illness, income, the character of discharge from active
military service, and the length of active military service.\3\ VHA
provides comprehensive, free or low cost health care to eligible
veterans through facilities located throughout the entire country.
---------------------------------------------------------------------------
\3\ VA Health Care Eligibility & Enrollment. Available at http://
www4.va.gov/healtheligibility. Last accessed on October 31, 2009.
---------------------------------------------------------------------------
M e m o r a n d u m o f U n d e r s t a n d i n g b e t w e e n H H S
a n d t h e V e t e r a n s' H e a l t h Administration
Since 2003, the IHS and the VHA have collaborated via a memorandum
of understanding (MOU) between the two Federal agencies to promote
greater cooperation and resource sharing to improve the health of AI/AN
veterans. The MOU encourages VA and IHS programs to collaborate in
numerous ways to improve beneficiary's access to healthcare services,
improve communications between IHS and VHA and to create opportunities
to develop strategies for sharing information, services, and
information technology.
The MOU has served as an impetus for improving the coordination of
care between IHS and VHA. In some areas, this coordination between IHS
and VHA has improved but while in other areas, such coordination
necessitates improvement. A recent study examined the AI/AN veteran's
utilization of the IHS and VHA health services. Based the study's
survey, 25% of AI/AN Veterans receive care through both IHS and VHA,
while over 25% of AI/AN Veterans accessed care through VHA only and
nearly 50% of AI/AN Veterans accessed care through IHS only.\4\ Of the
dual use AI/AN Veterans, these individuals were more likely to receive
primary care from IHS and to receive diagnostic and behavioral
healthcare from VHA. Although such AI/AN Veterans are eligible to
receive health care from the VHA and IHS, AI/AN Veterans report a high
rate of unmet health care needs and exhibit high rates of disease risk
factors for Post Traumatic Stress Disorder (PTSD).\5\
---------------------------------------------------------------------------
\4\ Veterans Health Administration and Indian Health Service--
Healthcare Utilization by Indian Health Service Enrollees, by B. Josea
Kramer, Mingming Wang, Stella Jouldjian, Martin Lee, Bruce Finke, and
Debra Saliba. Medical Care, Vol 47, Number 6, June 2009Id.
\5\ Id.
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Some of the issues that lead to the unmet health care needs of AI/
AN veterans:
Access of Care: Tribal members are located in isolated areas and
must travel great distances to attend any medical facility--IHS or VA.
AI/AN veterans who live in rural, remote areas pay for the cost of such
travel more than cost of gas but also time away from their home and
families. Yet the decision to travel to the nearest facility may also
take into consideration what type of care the patient would receive at
that facility.
Type of Care: Although the VHA offers more specialized behavioral
and mental health care, AI/AN veterans may not consider the VHA as an
option. First, the criteria for establishing eligibility for VHA
services are much more stringent than IHS, which acts as a disincentive
for Indians to access VHA services. Whereas, an
AI/AN Veteran, if located on his/her home tribal community, may
assessed IHS with less paperwork. Another potential barrier is the
perception that the VHA will not appreciate, understand or accommodate
the cultural needs of AI/AN veterans. For example, when working with
the behavioral health PTSD issue, traditional treatment should be
considered as an option for tribal veterans. At some sites currently,
if a tribal veteran comes to the facility and requests a traditional
healer, the Tribal Veterans Representatives may provide a list of
traditional healers and call a traditional healer for the veteran.
However, this arrangement is not present at VA facilities.
Coordination of Care: For the AI/AN Veterans who accessed care at
VHA and IHS, many tribal veterans have expressed that the frustration
of VHA not accepting diagnosis from IHS. To resolve this issue, the
Native Veteran may travel for hours to a VA hospital so that the VHA
doctor could administer the initial tests and provide the same
diagnosis that IHS provided. In addition to the lack of communication
of appropriate coordination of care regarding diagnosis, there is also
minimal communication between VHA and IHS regarding treatment and
prescriptions. Those who assessed the care through VHA and IHS increase
the risk of receiving medications which create the risk of conflicting
medicine.
recommendations
Funding: The first and obvious answer to addressing the health
needs of AI/AN veterans is the need for additional funding providing
care to AI/AN veterans. Many times, IHS is the only facility in the
area to provide care to Indian Veterans. Supplemental funding to IHS/
Tribal facilities for services provided to AI/AN veterans would help
ensure all the care needed can be provided to AI/AN veterans.
Coordination of Care: Shared information about the services
provided and needed by AI/AN veterans would help facilitate improved
care. One option is to expand the Tribal Veteran Service Officers
program in VA and expand these roles into paid VA positions. Another
option is to bring the specialized the mental professional to the AI/AN
veterans. Many of the IHS facilities have behavioral health departments
but dealing with Veterans returning home form combat zones requires a
specialized type of treatment. If IHS could work with the VA on
collaborating efforts to address the Gulf War syndrome, such efforts
would benefit a majority of majority of current Veterans. For example,
the VHA and IHS could share mental health providers and public health
nurses who would work out of the tribal facility while treating the AI/
AN veterans. By sharing or rotating VHA employees--the health
professional would have the knowledge and expertise that the VA could
provide in addressing these issues, but IHS and Tribes could house the
provider in the community. Likewise, IHS facilities may want to
consider incorporate more specialization of PTSD for current veterans
coming home.
In closing, it is exciting to be a part of the Federal/tribal
partnership and all of us working together can improve the care offered
to our veterans better. Thank you for this opportunity and I will be
happy to respond to any question.
Chairman Akaka. Thank you very much, Mr. Joseph.
Let me ask one question and I will turn the gavel over. Mr.
Park, our discussion today regarding VA and IHS cooperation
revolves largely around an MOU, Memorandum of Understanding,
signed by the two parties. My question is, is there any similar
agreement between VA and the Native Hawaiian Health Care
Systems?
Mr. Park. Mr. Chairman, at this time, there is no
Memorandum of Understanding between the Native Hawaiian Health
Systems and the VA in Hawaii.
Chairman Akaka. Would you see any benefit in that kind of
sharing?
Mr. Park. We had a meeting with your VBA Director and we
are still working on that, sir.
Chairman Akaka. I will be following up with you in writing,
Mr. Park, and I have other questions.
But at this point, I am going to turn the gavel over to
Senator Tester, who called for this hearing, and he will be
leading this hearing. Senator Tester, the gavel is yours.
Senator Tester [presiding]. Thank you, Mr. Chairman.
I will see if the Ranking Member has any questions. Senator
Burr?
Senator Burr. I thank the Chair.
Mr. Park, if I understand you correctly, there are three VA
outpatient clinics in Hawaii, and 14 community health centers
and five Native Hawaiian Health Care Systems. Is that pretty
accurate?
Mr. Park. There are four CBOCs.
Senator Burr. OK, four CBOCs. Your recommendation is that
VA should do more contracting with non-VA providers. Let me ask
you, to what degree is there contracting right now going on?
Mr. Park. At this point, I don't see any partnering with
the community health centers or Native Hawaiian Health Systems.
Senator Burr. Share with us, if you can, what dialog you
have had with VA about expanding either the use of those
facilities or the increased use of contracting.
Mr. Park. We haven't talked with them about that, sir.
Senator Burr. Are veterans in Hawaii asking you if they can
just simply receive care under a contract?
Mr. Park. The veterans are trying to seek--we are seven
islands, and we are like Alaska in that in order to get to the
VA you have either got to fly or you have got to take a boat.
The veterans are looking for services that they can access on
the seven islands as best they can. And I think the community
health service--there are 14 on all the islands--to access the
community health service is one of the best ways to go. We have
only five Native Hawaiian Health Systems in the State, and to
access the CHS is the best way to go.
So, with only four CBOCs in Hawaii--and some of the
problems are if the veteran needs to go to Maui, to the CBOC
Maui, they need to fly to Honolulu first and catch a plane to
go to Maui. And there's a clinic in Honolulu, so if they're
going to fly to Honolulu, why don't they just go to the clinic
in Honolulu? So, I think the problem we're looking at is there
are not enough services for veterans on the neighbor islands.
Senator Burr. Clearly, I understand the challenge that you
have and that Senator Begich has in Alaska. My understanding of
the Memorandum of Understanding is that for some Tribes it is
working pretty good; for others, it is nonexistent.
Mr. Park. Like in Hawaii, it is nonexistent.
Senator Burr. I guess I would ask you, or any of the three
of you, what do you think needs to be done to look at those
meaningful partnerships that are working and emulate those
elsewhere? What would it take, Mr. Howlett?
Mr. Howlett. Mr. Chairman, Senator Burr, I think, first, it
takes a real commitment from the agency, not a piece of paper
that says how great we are. I really feel that solutions can be
found, as I said in my testimony. But I think that there needs
to be established a framework for finding that solution, and
that framework really needs to be an honest and candid
discussion of legislative barriers, of policy barriers, of
distance barriers, of weather barriers, and all these
discussions are things that are going to have a reflection on
the capacity to provide care.
If you don't factor those in or you don't discuss those,
there is a tendency to pretend they don't exist, and then when
you run up against them, you can't deliver. I just feel like if
the agencies would say this is a priority and they would set
about a task force to really examine these things--and fund
that task force--then I think you could come forward with the
legislative issues that are problems or the policy issues that
are problems.
I think this notion of one-size-fits-all really is
misguided when it comes to trying to provide health services in
Indian Country because of location, because of remoteness,
because of transportation, and because of weather. I mean, all
of these things are really important factors. So to me, let us
establish a framework for trying to find out what the issues
are.
Senator Burr. Would I be correct if I made the statement,
it would be a step in the right direction if VA was just
proactive?
Mr. Howlett. That would be--yes, yes, for sure. I agree.
Senator Burr. Thank you.
One last statement, Mr. Chairman, if I may. For all the
challenges we have got between VA and Indian Health, Senator
Coburn and I met with representatives from Indian Country
recently and pledged our commitment that if Indian Country
would work with us--we understand it needs more money, but we
didn't feel that it was just money alone. We need to make
Indian Health structurally work to provide the level of care
that is expected everywhere else. I say this to our
representatives today. That offer is still on the table. We
look forward to working with any and all to fix the Indian
Health Service and to fund it at a level that would provide
that level of care, that quality of care for all in Indian
Country.
I thank you.
Senator Tester. Thank you, Senator Burr.
Yes, Mr. Joseph?
Mr. Joseph. I guess I would like to answer that question,
also. In this building, in the White House, or anyplace where
law is written, it is just like our treaties. They are Orders
that the government is supposed to abide by. I take that very
seriously. I believe the VA should take this work that you do
here very serious. You have the ability to make the law the way
that you write it. Once you are given orders in the military,
you have to abide by those orders--and somebody needs to give
the VA orders. But I think that you have the power here to make
things happen. Thank you.
Senator Tester. Thank you.
Chairman Akaka has conferred to me that he is pleased with
the progress--this is for you, Mr. Park--is pleased with the
progress of the Hawaiian Uncles and Aunties project, having
used a kinship model to assist transitioning and distressed
veterans. The question to you is this. Do you believe that
something like the Uncles and Aunties model would work outside
Hawaii, perhaps as a model for Indian and Alaska Native
communities? And if you do believe it would work, how would it
work?
Mr. Park. Senator, I do believe that it is important to
extend the Uncles and Aunties program across the Nation. I have
on Maui three Uncles--actually four Uncles, one in a remote
area called Hana; I have eight on Oahu; one on the Island of
Lanai; one on the Island of Hawaii; and one on Molokai. I also
have five Uncles from Alaska and one from Guam. So, we are
expanding. And a lot of the Uncles, they are married. Their
wives are the Aunties. So, we have expanded the Uncles and
Aunties program within the State of Hawaii as well as on the
Mainland.
It will work because of the trust issue. The veterans, they
don't trust government, and I will give you an example. I have
just been to Hana to talk with the Vietnam veterans there and I
tell them, this is an insurance policy. You paid the premiums,
it is time for you to collect. The only way you are going to do
it is you need to put in your application, VHA and VBA
applications.
The Vietnam veterans are saying, when we came back, they
hated us. They spat on us. They called us baby killers. Why
would I want to go through that again? I can understand what
they are saying, but I can also understand the hurt. So, I
really try to get them to put in their application.
What I tell the veterans is if you don't put in your
application, they are not going to see you, so you need to do
that. And as far as the Aunties and Uncles program, I think it
will work anywhere because of the trust issue.
Senator Tester. Thank you.
Kevin, if a veteran comes to one of the facilities you
oversee, whether he or she is eligible for care from the VA--
say that he or she is--do you know where to direct them? If
they are eligible for VA care, they come to one of your
facilities, has anybody contacted you? Do you know where to
send them?
Mr. Howlett. Mr. Chairman, I wouldn't want to send them
anywhere. I would want to treat them.
Senator Tester. Right.
Mr. Howlett. If we have the capacity to meet their needs, I
would want to treat them. But, you know, in Montana, we have
two options, Fort Harrison or Spokane, depending on where you
live in the State. So, the answer to your question is, if they
are a veteran, we have personal relationships, although we
don't have formal agreements, with both VA centers. I have
visited with them both personally. They welcome the veterans.
They do the best they can. But there is no formal process in
place. I would think that we could treat within our capacity
their needs if they came to our particular clinic.
Senator Tester. You said in your testimony that the Indian
Health Service has primary responsibility for health care, and
I don't want to put words in your mouth, for Native Americans
that come in. Let me just put it this way, what determines--if
you have a veteran that comes through the door and you know
your budget is strapped, which for the most part you are
dealing with difficult budgets, what do you do? I mean, whose
responsibility is it then if you know----
Mr. Howlett. Well, they don't get turned away. I mean, we
will provide what care we can. And again, if it is something
that requires a level of care beyond our capacity which would
trigger CHS expenditures, then the Indian Health Service in all
likelihood, unless it is life-threatening, isn't going to pay
for it. That veteran then--we would do everything that we could
to get them connected to a VA center. But that is where it is
at this point.
Senator Tester. OK. You said in your testimony that you
felt they may be able to set up internal and external working
groups. I think your answer to Senator Burr's question was
spot-on when you talked about the different kind of factors
that impact the ability to provide the health care.
In your vision for the working groups to try to, as the
President would say, quit working in silos and start working
across agency lines, how would you do it, by region, or would
you have one working group for the entire country, or how do
you envision that working out?
Mr. Howlett. Somehow, I anticipated that question. I think,
initially, you would look at a national group that would be
comprised of a cross-section of people. And then I think you
would, of necessity, need to dissect that a little further to
deal with issues like Alaska and distance and weather and other
things. I think, initially, you would take this work group--and
it would take a lot of time and a lot of energy, believe me--to
really sit down and analyze the issues affecting health care
for Native American veterans. You are going to have a lot of
crosswalk between health care in general, but it just--it is
just confusing to a health administrator now. You know that a
veteran is eligible, but you don't know what an agency is going
to sponsor in terms of getting them to another place.
You were very instrumental in just getting mileage
reimbursement increased for veterans. That was a big deal. That
was a big deal. I mean, some of these people are having a
really difficult time, as we well know.
So, I would look at a national group first comprised of
Tribal people, Tribal health people. You need obviously some
Indian Health people with a willingness and a vision to solve
the problem. You need some VA people with that same kind of
capacity.
Senator Tester. OK. Could you just very briefly tell me,
the MOU between VA and Indian Health Service has been referred
to several times. There is really no lead agency, just work
together and try to find ways you can make things better. Have
you seen--that MOU, I think, went into effect about 6 years
ago. Have you seen any difference?
Mr. Howlett. Let me say, Senator, that there are many very
dedicated and hard-working people in the Indian Health Service.
But the agency itself, to the best of my knowledge and as much
as I have participated with them, has not forwarded the
recommendations or the body of that agreement.
Senator Tester. Thanks. Before I turn it over to Senator
Murray for questioning, I want to welcome Senator Murkowski.
She serves on the Indian Affairs Committee. We will get to your
comments as soon as we get through the first line of questions.
Senator Murray?
Senator Murray. Mr. Chairman, thank you very much, and let
me just follow up on the Chairman's last line of questioning on
the MOU that was signed 6 years ago between the IHS and VA. I
think it is fair to say that a lot of the goals haven't been
realized. Now, as the VA works over the next year, I would like
to ask each one of you what the top three priority items you
think the VA ought to be working on to improve Tribal health
care, and Mr. Park, I will start with you.
Mr. Park. At this time in Hawaii, we don't have an MOU with
the VA----
Senator Murray. So it doesn't apply to----
Mr. Park. Yes. We have nothing with them. So, I think we
need to partner with them and see where we can go with this.
Senator Murray. All right. Mr. Howlett?
Mr. Howlett. Senator, I would reflect back on my testimony.
First of all, a commitment to the structure, to the
organization, to the things that are already a part of the MOU
and how they would go about organizing that as an agency. I
think that would be first.
The second item in terms of a priority for Native American
veterans would be the whole issue of access and making sure
that they do appropriate outreach to the Native communities in
their region, and I think that could come about in a number of
different ways.
And probably the third item--and I am grasping here for
priority--I believe it would be the prevention and wellness
kinds of activities that I think they could put some resources
behind through some sort of a structured document with Tribes
to get some of these veterans, not just Iraq and Afghanistan
veterans, but some of these veterans that are older veterans,
involved in more preventative kinds of care.
Senator Murray. OK, excellent.
Mr. Joseph?
Mr. Joseph. I think it would be really great and maybe it
would help the VA if there was an office and a position in the
VA that is in there for Native Americans--Native American
Indian Affairs Office, and I would welcome the Native Hawaiians
be part of that, also. I think that the Native Alaskans and all
of us share the same situations. So, if we had an office in the
Veterans Affairs, maybe then they could see how everything is
working and make sure that we have this MOU actually working
the way it was intended to.
Second, I would say that the VA could learn from IHS. IHS
scored the highest out of any HHS Department on their report
card. With the limited funding that we have in IHS, I believe
that the VA could learn from how IHS is run. So I think that
would be my second thing.
You know, if they could help with their big budget, help
fund IHS to help serve our veterans, I think that would be
another way. I always wanted to see the Government utilizing
Public Health nurses and mental health providers to come and
get stationed right at our clinics so that they can go
throughout our reservation and serve any of our veterans,
whether they are Native or not.
Believe me, my reservation covers two counties and the
surrounding areas. I can relate to the Senator from Alaska in
his ruralness. Some of the people on our reservation have to
wait, and hopefully there is a ferry that is operating to get
to services. They have to travel over 2 hours just to go to the
VA, and that is if they can afford it to begin with. With the
economy the way it is, some of our veterans can't afford to
even get to a VA hospital. We don't have any hospitals--IHS
hospitals--in our area like Alaska or some of the other rural
areas. If there was funding to help work in IHS, it would be a
real benefit. Thank you.
Senator Murray. OK. I appreciate that.
And just really quickly, Mr. Chairman, I did want to ask
about cultural sensitivity. It comes up time and time again to
me as I am traveling around my State and talking to Tribal
veterans. Each of our 564 federally-recognized Tribes have some
unique cultural traditions. In my home State, we have made some
progress with sweat lodges, but I just wanted to ask quickly if
there is anything else that we could be doing to really be more
culturally sensitive.
Mr. Joseph. Well, in our State, I know I have personally
gone to the VA and had a sweat there. It is a place where we--I
guess it is kind of like our own type of psychology. We can get
to our young veterans that are having a hard time in a way that
we were brought up and taught to respect and honor different
things in life. It is like--I guess it is more like best
practices, where we have a better success rate than, say,
sending somebody to a talking circle that just makes them
angrier----
Senator Murray. So, just being more aware of those issues
that impact different Tribes differently?
Mr. Joseph. Yes. It saves lives. A lot of these people were
suicidal and they are living today. Thank you.
Senator Murray. OK. And my time is out, so I will pass to
the next. Thank you very much to all of you.
Senator Tester. Thank you, Senator Murray.
Senator Begich?
Senator Begich. Thank you very much, and thank you again
for your testimony.
I want to follow up, if I can, on a couple of things. Mr.
Howlett, your idea in your commentary to Senator Tester
regarding kind of--and I think it was your words--internal-
external working group, or a process that could help down the
road in setting up a better relationship in a sense. You talked
about kind of a national model and breaking it down by regions.
Do you see that in the process of setting that up, because I
read the MOU and it is a few pages. It has great one-liners;
they sound great. If we could achieve all that, the world would
be fantastic. But there are no goals; there are no measurable
timelines. There is nothing that you can come back and say, how
did you do it, when did you do it, who did you serve, and how
many did you serve?
I am assuming--it is kind of a leading question. Is that
your view of kind of how you set up this external-internal work
group, but also set some real measurable efforts here, because
what I have learned over at least my 10 months here is we do a
lot of this paper, but accountability is sometimes lacking. Let
me--I am trying to be very polite here. So, give me your
thoughts on if you could go one more step, how you would see
that.
Mr. Howlett. Well, I guess maybe a definition of where we
are, in its truest sense is abstract at this point. But good
things happen with ideas. So, I think you can take that and you
can move it to the next level and say, given that, what are
some realistic goals that could be established? But that would
be part of this work group's goals----
Senator Begich. So that is how you see it?
Mr. Howlett. Right. It currently doesn't define anything;
so, yes, I really believe that you could define that, and I
think that you have got to be honest. It took a long time to
get to where we are and it is going to take some time to get
these issues resolved. But I think that is a good start.
Senator Begich. As you develop that, do you think there is
a role for that working group? Let us assume they set a plan,
an action plan. Do you see a role for that working group after
the fact, in other words, kind of a reviewer and ensurer. Or do
you see that more of a Congressional role like this Committee,
for example, to ensure----
Mr. Howlett. I think, Senator, that their role would really
be dependent upon the issues that arise from that, whether
there are legislative barriers or there are policy barriers or
whatever, because I think that, obviously, if it is
legislative, there needs to be some input here. But, I would
give it enough life to, in your best estimate, complete the
job. But I don't think there is a necessity for a committee in
perpetuity.
Senator Begich. Good. OK. Thank you.
One other comment you made, and I want to explore this just
for a couple of seconds here, and that is the reimbursement
issue for Medicaid-Medicare. VA does it. From your perspective,
you are unable to----
Mr. Howlett. We do not have the ability to collect for
services on a fee-for-service basis for services provided in
our Tribal clinics to veterans through the VA. We can through
Medicare and Medicaid and private insurance now.
Senator Begich. Right, but not the VA?
Mr. Howlett. Right.
Senator Begich. When I campaigned, I talked about an idea--
because all three of you have mentioned kind of the uniqueness
of Alaska and it is very remote, and we have a very good Indian
Health Service delivery, but through nonprofit organizations,
travel consortiums, in some cases, very--I just talked on the
Senate floor about our South Central Foundation and the success
they have had in integrating traditional as well as cultural
and other medicine techniques.
And I have always had this idea, it seems so simple with
especially dual eligible veterans that you just issue them a
card that they, for example--the example you gave of flying
from one island, you are going through Honolulu, and it seems
so logical just to go in and get the service rather than extend
the time. You take the card in. You get the service. The
patient doesn't sit there and try to figure out who pays, but
the system manages that for them, in other words, makes it
seamless for the patient. Is that too simplistic? One thing I
have also learned around here is simple ideas are not the ones
that usually get implemented, but let me throw that out to any
one of you. Maybe, Mr. Park, from your example--that was a
great example.
Mr. Park. I think it is too simple.
[Laughter.]
Senator Begich. I thought so.
Mr. Park. I think one of the problems is when the VA puts
it onto a vendor and the VA doesn't pay the vendor, then the
vendor bills the veteran and now the veteran gets all amped out
and what have we got?
Senator Begich. What have we got, yes. It puts some
additional pressure, then, on the veteran.
Mr. Park. Yes.
Senator Begich. Mr. Howlett? Then my time is up.
Mr. Howlett. I, too, think it makes too much sense. No,
there are significant issues with Federal agencies paying their
bills. In Indian Health Service, there are thousands of people
whose personal lives have been ruined, their credit has been
ruined because IHS hasn't paid their bills on time. I mean,
these people have been turned over to collection and that is
just--that is the way it is. I don't know about the VA. We have
not worked with them. But that needs to be worked on.
Senator Begich. Very good. Thank you very much. My time has
expired. Thank you all.
Senator Tester. Thank you, Senator Begich.
Senator Murkowski, did you have a statement?
STATEMENT OF HON. LISA MURKOWSKI,
U.S. SENATOR FROM ALASKA
Senator Murkowski. I do, Mr. Chairman, and I appreciate the
indulgence of the Committee giving me the opportunity to be
here and listen to the witnesses and to just take no more than
5 minutes this morning to put on the record a statement about
some of the Alaska issues. I appreciate the leadership of my
colleague, Senator Begich, on this Committee as we try to find
solutions.
It is interesting to hear the responses to Senator Begich's
comment about it being just too simple, just too much common
sense. Well, I think the obligation that we owe to our veterans
is to provide for that level of care that was promised then;
and unfortunately, I think we find more and more that with the
systems that we have in place we have effectively
disenfranchised our veterans from their earned benefits. I am
hopeful that with the leadership that we have here in this
Committee with what we are attempting to do on the Indian
Affairs Committee, that we ought to be able to provide for this
more seamless transition within the systems.
I do appreciate, Chairman Akaka and Senator Burr, your
leadership in calling attention to the plight of our Native
veterans. I often refer to them as our forgotten veterans. What
a tragedy that is, because we recognize that from the very
beginning Native peoples throughout this country have served in
the Armed Services and the Armed Forces in greater numbers than
any other group.
So, I hope that this hearing and what you are doing here is
the first step in a very comprehensive examination of how well
the VA is serving our first Americans. I encourage your
Committee to work collaboratively with us on the Indian Affairs
Committee as we also follow these issues.
While I was the Vice Chairman of the Indian Affairs
Committee, I conducted a field hearing on the difficulties that
our Alaska Native veterans were encountering in accessing their
veteran health benefits, and the focus at that time was on the
Alaska National Guard's Third Battalion. They come from about
81 different communities scattered around the State of Alaska,
and a sizable number of these Guardsmen lived in the very small
bush villages. They live in communities that are not connected
by roads, by any connectors that we would imagine here.
To reach the nearest VA facility in Anchorage, they would
first have to take a single-engine or perhaps a twin-engine
bush plane to a hub, like Bethel or Dillingham or Nome, and
then they catch the jet into Anchorage. The total cost of the
trip could exceed well over $1,000, way out of reach for our
Native people who many of them live off subsistence resources
of the lands and the rivers.
But back in October 2006, the Third Battalion deployed to
Kuwait and they were going off to Southern Iraq after that.
They returned in October 2007, but the very notion of taking
our subsistence hunters and fishermen and sending them off to
the Middle East, I think was more than a little bit distressing
to some. They wondered out loud whether or not the VA was going
to be able to deal with them, to treat them with issues like
PTSD and other service-connected injuries. How are they going
to do this, are they going to treat them in remote Alaskan
communities? I certainly wondered the same.
And long before that deployment date, I called the VA in
and I asked them. I said, let us work with the Alaska Native
Tribal Health Consortium. Let us develop this unified plan for
caring for our Native veterans when they return. We had an
opportunity to discuss it with the Secretary of Veterans
Affairs, Secretary Nicholson. We continued to bring the VA
together with ANTHC during that year, and in spite of all these
discussions, in spite of the Memorandum of Understanding
between the VA and the Indian Health Service, there was very
little progress that was made in formulating that unified plan
during the year.
We knew that they were going to be gone for a year. We had
a whole year to put it together. But the VA took the position
that it is the payer of last resort and it disclaimed the
obligation, and to a large extent, the authority to reimburse
our Alaska Native Health System, which is a Tribal-run, not a
government-run, system for care that was provided to our Native
veterans.
So, you drill below the surface here and what I learned was
that there is just a very wide distrust--and I think, Mr. Park,
you mentioned that as I was coming in--a very wide distrust
between the VA and the Native Health System. The VA expresses
their concern that it would neither be able to control access
to care nor the cost of the care delivered in the Native Health
facility. The VA was concerned that the Native Health System
was really asking the VA to subsidize Congress's inadequate
funding of IHS. And for their part, the Native Health System
argued that, hey, we are only funded at 50 percent of the level
of need. They can't afford to subsidize the better-funded VA.
So, you have got this impasse going on here.
But it became very, very clear that the situation we face
is the needs of 6,000 of our Native veterans mired in the
bureaucracies, which is absolutely inappropriate. But under the
auspices of the Senate Committee on Indian Affairs, we
conducted a field hearing back then in November 2007. I think 2
years after the fact now, we are seeing a slight improvement in
services to our Native veterans. Senator Begich mentioned some
of the great successes that we have with South Central. We are
blessed with one of the Nation's best telemedicine systems. The
VA does make extensive use of this system to deliver care to
our veterans using the VA personnel. They have also hired a few
Native Veteran Benefits Representatives who are posted at the
Tribal Health facilities, and that is a good idea.
But, they also attempted to train Tribal employees to serve
as Tribal Veterans Benefits Representatives without any
compensation. I was told that a handful of Alaska's 229 Tribes
showed up for the training, but the problem was that the VA
declined to cover the travel expenses of the people who were
there attempting to train. The Tribes don't have the money to
cover those expenses. And the VA initially argues that, well,
we don't have the authority to cover those expenses.
So, I asked whether they had considered the invitational
travel authorities in the Federal Travel Regulation. They said
they had never heard of the authorities. And then following
consultation with their counsel, they came back and they
admitted that they do have the authority to cover the travel
expenses. But the VA has yet to implement a viable Tribal
Benefits Representative program in the State of Alaska. It is
just not happening.
The VA has recently implemented a Rural Alaska pilot, which
allows Community Health Centers and Tribal Health facilities to
bill the VA for a closely-controlled number of primary care
visits. But at the outset of this pilot, they didn't include
behavioral health visits, which seems incredible. So, we called
this omission to the VA's attention and they changed the pilot.
The protocol for this pilot requires that the veterans sign up
for it, and unfortunately, what we are hearing is the word is
not sufficient to get out to them and we have very few veterans
that have signed up. So, I don't know whether there is a better
way to implement the pilot. Time will tell on that.
In spite of what limited progress that is out there, I
regret to say that we are far from building this seamless
relationship between the VA and the IHS in Alaska that I have
long been working for and Senator Begich has, as well. And the
gaps aren't just affecting our Alaska Native veterans of Iraq
and Afghanistan, it goes back to our Vietnam-era veterans that
are living in rural Alaska.
Again, I appreciate the emphasis that this Committee is
placing on this. Collaboratively, we ought to be making better
progress, because we are certainly not keeping our commitment
to veterans. Right now, you can have the benefits that you have
earned as a veteran if you happen to live in the right spot,
and that was simply not the promise that we made.
Thank you, Mr. Chairman, for allowing me the opportunity to
make some comments this morning and to work with you on this
issue.
Senator Tester. Thank you, Senator Murkowski. I want to
thank the panel for their insight and their service. Now we
will call up the second panel. Thank you, folks, for being
here.
We will call up the second panel, and while the second
panel is coming up, I will introduce them. It is Mr. James
Floyd, Network Director for the VA Heartland Network, VISN 15,
for the Veterans Health Administration. He will testify on
VHA's IHS for Native American veterans. He will be accompanied
by Mr. Buck Richardson, Minority Veterans Program Coordinator
for the Rocky Mountain Health Network and the Montana Health
Care System, as well as Dr. James Shore, psychiatrist and
Native Domain Lead, VA Salt Lake City Health Care System.
We also have the pleasure on the Indian Health Service side
of hearing from Mr. Randy Grinnell, Deputy Director of the
Indian Health Service. He is accompanied by Dr. Theresa Cullen,
IHS Director of Information Technology.
I want to thank you all for being here. Your full written
testimony will appear in the record. I have been informed that
we have a vote at about 12:15. I personally would like to get
this hearing wrapped up by then, so I would ask you to be
concise in your testimony. I know that the Ranking Member,
Senator Burr, and Senator Begich have a bevy of questions, as
well as myself, and we will get to them as quickly as possible.
With that, I would like to ask Mr. Floyd to begin with your
testimony. Thank you all for being here.
STATEMENT OF JAMES R. FLOYD, FACHE, NETWORK DIRECTOR, VA
HEARTLAND NETWORK (VISN 15), VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY W.J.
``BUCK'' RICHARDSON, MINORITY VETERANS PROGRAM COORDINATOR,
ROCKY MOUNTAIN HEALTH NETWORK AND THE MONTANA HEALTH CARE
SYSTEM, HELENA, MONTANA; AND JAMES SHORE, M.D., PSYCHIATRIST
AND NATIVE DOMAIN LEAD, SALT LAKE CITY VA MEDICAL CENTER
Mr. Floyd. Thank you, Senator Tester. Again, thank you for
inviting me to be here this morning at this important hearing.
My name is James Floyd. I am Creek and Cherokee, a member of
the Muscogee Creek Nation of Oklahoma. As a Native American, I
have worked with my own tribe, the Muscogee Creek Nation of
Oklahoma, and their Tribal Health Program. I have also worked
with the Indian Health Service and currently work with the
Department of Veterans Affairs since 1997.
With me on this panel this morning, to my right, who needs
no introduction to you, is Buck Richardson, who is the Minority
Veterans Program Coordinator for the Rocky Mountain Health
Network, based out of Helena, Montana. To his right is Dr. Jay
Shore. Jay is the psychiatrist and Native Domain Leader from
the VA Salt Lake City Health Care System.
VA remains committed to working with the Department of
Health and Human Services to provide high-quality health care
for the thousands of American Indian, Alaska Native, and Native
Hawaiian veterans who have courageously served our Nation and
deserve exceptional care. My written statement, which I request
to be submitted to the record today, provides general
background information on our work with the Indian Health
Service. It reviews accomplishments secured because of our
collaboration and concludes with a discussion on the need for
the VA and the Indian Health Service to work together to
continue to care for our veterans.
The VA and the Department of Health and Human Services, as
mentioned earlier, signed a Memorandum of Understanding on
February 25, 2003. The MOU expresses the commitment of both
Departments and it expresses the need to continue to expand our
common efforts to provide quality policy support to local
planning and collaboration efforts and charges local leadership
to be more innovative and engaged in discharging our
responsibilities. The VA has encouraged its field facilities to
initiate and maintain effective partnerships at the local
level, especially in areas such as clinical service delivery,
community-based care, health promotion, and disease prevention
activities. We are also interested in promoting management and
prevention of chronic diseases, a challenge facing both
Departments.
We assess whether we can achieve success through local
partnerships or on a national mandate on a case-by-case basis.
Both methods have proved effective and productive and these
projects have been successful in elements of each.
For example, we recently supported a collaborative
expansion of home-based primary care, where 14 VA medical
centers have funded to collocate home-based primary care teams
at Tribal and Indian Health Service clinics and hospitals. In
September of this year, the first veterans began receiving care
through this project at two sites.
Much of the progress on the objectives outlined in the MOU
have been accomplished through local partnerships. However,
national initiatives also influence collaboration between VA
and the Indian Health Service. For example, the national focus
on outreach in rural health has led both the VA and IHS to
develop improved strategies for sharing information and
services, such as educational resources, traditional practices,
and information technology.
Improving communication and partnerships are essential
components of our collaborative efforts and we continue to
nurture our relationships both nationally and locally. Our
goals include improved access, communications, partnerships,
sharing agreements, resources, and health promotion and disease
prevention. We have found already incremental expansion of
initiatives such as the Tribal Veterans Representative Program
and expanded use of telehealth. We are also collaborating to
offer more Welcome Home events for returning OEF/OIF veterans,
to expand access to care and develop approaches that address
the unique physical, spiritual, economic, and demographic needs
of these veterans.
Using shared providers is yet another way to improve access
and cooperation. At the local level, several VA and Indian
Health Service facilities are sharing providers, including
appropriate shared access to the VA's Electronic Health Records
for joint projects and patients.
In October 2008, VA established Native Domain, an
infrastructure with a Native American focus. It is a national
resource on issues related to health care for rural Native
American veterans. It includes policy analysis, collects best
practices, supports clinical demonstration projects,
establishes collaboration with agencies and Native communities,
and disseminates information about these populations.
The VA and the Indian Health Service need to continue to
work together to ensure within current legal authority that
veterans who are eligible for health care from both the VA and
the Indian Health Service receive all needed care. The VA and
the Indian Health Service continue to discuss changing existing
policies and processes in regard to payment for veterans'
health care. A resource sharing provision was included in the
MOU that I referred to earlier to encourage the development of
responsible sharing services to meet the needs of patients and
communities.
In conclusion, Mr. Chairman, I thank you again for the
opportunity to be here to discuss the importance of
establishing and maintaining strong relationships and programs
and services between the VA and the Indian Health Service. We
are available to answer any questions you may have.
[The prepared statement of Mr. Floyd follows:]
Prepared Statement of James R. Floyd, FACHE, Network Director, VA
Heartland Network (VISN 15), Veterans Health Administration, U.S.
Department of Veterans Affairs
Good Morning Mr. Chairman and Members of the Committee: Thank you
for inviting me here today to discuss the cooperation and collaboration
between the Department of Veterans Affairs (VA) and its Veterans Health
Administration (VHA) and the Department of Health and Human Services
(HHS) and its Indian Health Service (IHS). Joining me today are Mr. W.
J. ``Buck'' Richardson, the Minority Veterans Program Coordinator,
Rocky Mountain Health Network and the Montana Healthcare System in
Helena, Montana, and Dr. James Shore, Psychiatrist and Native Domain
Lead, VA Salt Lake City Health Care System.
VA remains committed to working internally and in partnership with
HHS to provide high quality health care for the thousands of American
Indian/Alaska Native (AI/AN), and Hawaiian Native Veterans who have
courageously served our Nation and deserve exceptional care. This
commitment, in relation to AI/ANs, is principally fulfilled through VHA
cooperation and collaboration with IHS. My testimony will provide
general background information on our work with the IHS, review
accomplishments secured because of our collaboration, and conclude with
a discussion on the need for VHA and IHS to work together to take care
of these Veterans. I would like to note at the outset that VHA looks
forward to working with IHS to improve the quality and availability of
care for Native American Veterans throughout the country. We will
strengthen our existing partnerships and build new and even stronger
associations between VHA and IHS.
general information
VA and HHS signed a Memorandum of Understanding (MOU) on February
25, 2003. In summary, the MOU:
Expresses the commitment of both Departments to expand our
common efforts to improve the quality and efficiency of our programs;
Provides policy support to local planning and
collaboration; and
Charges local leadership to be more innovative and engaged
in discharging our responsibilities.
We expected at that time that most of our progress would be made
with effective local partnerships formed between IHS, VHA, and Tribal
governments, because these would be best suited to identify local needs
and develop local solutions. In this regard, VHA field facilities have
been encouraged to initiate and maintain effective partnerships at the
local level especially in areas such as clinical service delivery,
community-based care, and health promotion and disease prevention. We
are also interested in promoting the management and prevention of
chronic diseases, a challenge that confronts both VHA and IHS. We
anticipated the MOU would lead to creative solutions in case
management, home- and community-based care, and primary prevention
activities to improve the health of AI/AN Veterans.
Whether success is achieved most effectively through the efforts of
local partnerships or with a national mandate is assessed on a case-by-
case basis. Both methods have been effective; the challenge is to use
the appropriate tool, at the correct time, and in a suitable location.
Many times, success is achieved with a combination of national and
local efforts. We recently supported a collaborative expansion of home-
based primary care (HBPC) that exemplifies how national initiatives can
be implemented locally. In this effort, 14 VA medical centers have been
funded to co-locate HBPC teams at Tribal and IHS clinics and hospitals.
Our goals are to improve access to primary care services and to foster
mentoring relationships between VHA staff with geriatric expertise and
IHS and Tribal staff. In September, the first Veterans began receiving
care through this project at two tribal sites, one in Jackson, MS and
the other in Sacramento, CA. We expect the other facilities to be
active by the end of the calendar year.
Much of the progress on the objectives outlined in the MOU has been
accomplished through local partnerships. However national initiatives
also influence collaboration between VHA and IHS. For example, a
national focus on outreach and rural health has led VHA and IHS to
develop improved strategies for sharing information and services such
as educational resources, traditional practices, and information
technology (IT) sharing.
Experts in information technology at the Department as well as the
VHA and IHS levels are working together to enhance health-care
information sharing. This April, representatives from the Office of
Information Technology at IHS, VHA's Office of Health Information, and
VA's Office of Information and Technology met to develop a
comprehensive list of actions needed to strengthen the relationship.
The group identified a list of specific activities for collaboration,
and work continues to address the tasks identified on that list.
accomplishments
VHA and IHS, as the primary implementers, have used the MOU's goals
and objectives as a framework for establishing partnerships and
accomplishing individual achievements. Our goals include improved
access, communications, partnerships and sharing agreements, resources,
and health promotion and disease prevention.
Access. A mutual goal of IHS and VHA is to improve beneficiaries'
access to quality health care and services. As a tool to ensure steady
and effective progress, VHA established a performance monitor for
Veterans Integrated Service Networks (VISNs) with significant American
Indian/Alaska Native (AI/AN) populations to track and monitor how VISNs
were achieving the goals and objectives of the MOU.\1\ Examples from
the performance monitor reports of how VA's local facilities have
brought about easier access to VA services include:
---------------------------------------------------------------------------
\1\ Four of the 21 VISNs are exempt from this monitor because of
the small size of their
AI/AN Veteran populations. These include VISNs 4, 5, 9 and 10.
Establishing transportation programs;
Using home visits to provide both clinical care and
assistance with claims processing;
Providing supplies and equipment to clinics on
Reservations;
Expanding VA community-based outpatient clinic hours and
services; and
Using fee basis care to facilitate more timely, accessible
care, when necessary.
In fiscal year (FY) 2009, the Office of the Deputy Under Secretary
for Health for Operations and Management established a new template for
VISN semi-annual reporting of VHA/IHS activities. There appears to be
steady, incremental expansion of certain types of initiatives across
the country demonstrating an increased alignment with current national
priorities. These initiatives include:
Increased interest in, training for, and development of
the Tribal Veteran Representative (TVR) role across the country;
Expanded use of information technology and
telecommunications efforts, particularly to support telehealth
initiatives and tele-mental health;
Increased number of ``Welcome Home'' events for Operation
Enduring Freedom and Operation Iraqi Freedom Veterans, as well as
education and outreach efforts;
Steady expansion of rural health care initiatives with
progress toward bringing services closer to the Veterans being served;
Continued growth in culturally specific, holistic
approaches that address the unique physical, spiritual, economic, age
and gender specific needs of the population served; and
Coordinated efforts between local VHA and IHS entities to
increase awareness and communication regarding Veterans' needs and
available VHA services, as well as cooperative and creative outreach
efforts.
Another tool that VHA and IHS use to improve access is telehealth.
Telehealth uses information and communication technologies to provide
health care services in situations in which patient and provider are
separated by geographical distance. Telehealth, thus, provides a means
of providing health care services directly to Tribal communities,
obviating the need for AI/AN Veteran patients to travel long distances
to receive services. It also supplements health care services available
within Tribal communities.
VA has been collaborating with the IHS and other Federal agencies
to provide telehealth services in Alaska since 1997, when the Alaska
Federal Health Care Access Network began. Subsequent to that first
effort, the functionality of the telehealth and telecommunications
technologies has improved, and research has substantiated the benefits
of telehealth as a means of providing health care to the
AI/AN Veterans VA serves. Currently there are seven operational
telehealth programs providing services to Tribal communities and nine
programs in deployment. VHA telehealth programs to Tribal communities
predominantly involve clinical video-conferencing to provide mental
health services and home telehealth services for diabetes and mental
health conditions.
A cultural competency training program also has been developed and
is in use to ensure that providers are sensitive to the particular
circumstances of using telehealth to reach into Tribal communities to
deliver services. In addition to cultural awareness, other critical
success factors to implementing and sustaining telehealth services to
Tribal communities include adequate telecommunications bandwidth and
meeting appropriate credentialing and privileging requirements.
Using shared providers is yet another way to improve access. At the
local level, several VHA and IHS facilities are sharing providers,
including appropriate shared access to VA's electronic health records
for joint patients; this is demonstrated through the partnership
between VHA's Black Hills Health Care System and the Rosebud IHS
facility. Nationally, VA and IHS conducted a one-year pilot to test the
feasibility of using VA's electronic credentialing system, VetPro, to
credential IHS providers. Both VA and IHS participants believed the
pilot met its stated goals of ensuring a consistent credentialing
process that met all regulatory and agency requirements for IHS
facilities and demonstrating the feasibility of national sharing
agreements for information sharing between VA and IHS. Decisions about
expanding the pilot are pending.
Communications. There have been accomplishments in efforts to
improve communications among VA, VHA, AI/AN, HHS, IHS, and Tribal
governments and other organizations with assistance from IHS. Sharing
information and improving cultural awareness and competencies are
crucial to achieving this goal. Relevant information is shared through
several methods, including:
Participation at VHA/IHS conferences and VHA/IHS/Tribal
Veteran Service Organization (VSO) meetings, as well as Pow Wows and
local community events;
Outreach to IHS organizations and Tribal Governments,
including liaison with VA staff and leadership; and
Attendance at AI/AN cultural events.
IHS and VA continue to have regular communications at the national
level with a working group that meets regularly to exchange information
and track the status of several national programs, such as a recent
initiative to establish a pilot partnership between VHA's Consolidated
Mail Outpatient Pharmacy (CMOP) and IHS' pharmacy program. This pilot
will enable IHS beneficiaries to have access to pharmacy services
through VHA's nationally recognized CMOP program to process outpatient
prescriptions, based upon the electronic prescription data provided
from the IHS facilities. The possibility of IHS decreasing
capitalization costs, the reduction of needed space to house more drugs
and personnel in a centralized space, reduction of outdated
medications, and reduction in the numbers of patients entering IHS
facilities on a daily basis will make the use of the CMOP programs an
attractive technology for dispensing refills within the IHS. Rapid
City, South Dakota and Phoenix Indian Medical Center are currently
identified as the participating IHS locations. The coordinating CMOP is
in Leavenworth, KS. The necessary service agreement is in place, and IT
connectivity and testing have been accomplished. A formal interagency
agreement (IAA) is being developed. The pilot will commence as soon as
the IAA is in place. The working group ensures that projects such as
this remain on track and also identifies other new collaborations that
would lead to improvement of services.
The Tribal Veteran Representative (TVR) program is another example
of developing and maintaining effective communications at the local
level. This program uses volunteers who receive training on VA's health
care services and benefits to educate their Tribal members. The concept
used in the TVR program has been quite successful. VA and IHS held
several coordinated training sessions this spring for IHS Community
Health Representatives and the Contract Health Service program to bring
the TVR concept to them. The annual TVR training was held at the Naval
Reserve training facility at Ft. Harrison, MT during the last week of
April 2009. Seventy-two participants from VA, IHS, and different Tribal
organizations attended. Also, in May, VISN 7 held a training session
for VA's Transition Patient Advocates using the TVR model.
Partnerships and Sharing Agreements. Encouraging partnerships and
sharing agreements among VA Central Office and VA facilities, IHS
headquarters and IHS facilities, and Tribal governments in support of
AI/AN Veterans has been an important to improving access. Local VHA
facilities use sharing agreements and partnerships to operate clinics,
provide social work, offer laboratory services, and make available
other benefits. Again, the success of these projects depends on the
strength of local relationships. Building a strong partnership or
sharing agreement depends on fostering a trust relationship between the
AI/AN community and VHA facility staff and leadership. Meeting the
specific needs of a particular community is best done by fostering
communications at the local level.
Resources. Resources needed to support programs for AI/AN Veterans
include more than just funding projects and services. Time and staffing
resources are essential elements to supporting these endeavors and
helping AI/AN communities to identify needs, devise mutually agreeable
solutions that meet local requirements, and implement projects
effectively. In FY 2009, VA, through the Office of Rural Health,
acknowledged the need for increasing resources in this area by funding
specific projects and establishing a Native American Resource Center.
In October 2008, the Veterans Rural Health Resource Center-Western
Region established a Native Domain, an infrastructure with a Native
American focus. It is a national resource on issues related to health
care for rural Native American Veterans. It conducts policy analysis,
collects best practices, supports clinical demonstration projects,
establishes collaborations with agencies and Native communities, and
disseminates information about these populations.
Health Promotion and Disease Prevention. The final part of the
official MOU goal and objective framework is to improve health
promotion and disease prevention services to AI/ANs. This has been
addressed at the local level with projects ranging from health fairs to
diabetes prevention and other educational efforts.
medical care of dual eligible veterans
VHA and IHS need to continue to work together to ensure, within
current legal authority, that Veterans who are eligible for health care
from both VA through VHA and HHS through IHS receive all needed care.
VHA and IHS continue to discuss changing the existing policies and
processes in regard to payment for Veterans' health care. A resource
sharing provision was included in the MOU to encourage the development
of responsible sharing of services to meet the needs of patients and
communities.
There are circumstances where VA, through VHA and its local
facilities, contracts with or enters into sharing agreements with IHS,
Tribal governments, or Tribal organizations to provide health care
services to AI/AN Veterans. Many of these Veterans also are eligible
for services from IHS or through Tribal governments or organizations.
VA endorses the use of sharing agreements in these circumstances.
conclusion
Thank you again for the opportunity to discuss the importance of
establishing and maintaining strong relationships, programs, and
services between VHA and IHS at both the national and local levels to
effectively meet the health care needs of
AI/AN. VHA is strongly committed to continuing to make VA health care
services more accessible to AI/AN, and Hawaiian Native Veterans. In
this regard, it may be time to update the MOU and identify additional
opportunities for collaboration between VA, IHS, Tribal governments and
organizations. We are ready to do whatever it takes to find the best
ways to serve the needs of these Veterans. Thank you again for the
opportunity to testify. My colleagues and I are available to answer
your questions.
______
Response to Post-hearing Questions Submitted by Hon. Daniel K. Akaka to
James R. Floyd, FACHE, Network Director, VA Heartland Network (VISN
15), Veterans Health Administration, U.S. Department of Veterans
Affairs
Question 1. How many sharing agreements has VA entered into with
tribes, tribal facilities and Indian Health Service (IHS) facilities?
Please provide a list broken down by tribe, tribal and IHS facility,
describing these sharing agreements.
Response. Since the initial Memorandum of Understanding (MOU)
between VA and IHS in 2003, the amount and variety of activities has
steadily increased. Many of the activities are at the national level
and reflect an impact on many, if not all, federally recognized tribes.
Attached is a spreadsheet that reflects completed and ongoing
activities as of March 2010, itemizing partnerships, projects, status,
and where appropriate, the tribe(s) or IHS facility.
Question 2. Please provide the Department's best estimate of the
number of dual eligible and dual enrolled Native American Veterans.
Please also describe how these estimates were determined.
Response. This information is not currently available. A match is
technically possible, but extremely difficult. Challenges include, but
are not limited to, getting an overall estimate of Native American
Veterans from any source and exchanging demographic data.
Standards defining Veterans differ in the VHA and IHS systems. VHA
verifies past military service as a condition of enrollment and
provides care on the basis of degree of service-connected disability
and degree of impairment to determine Veteran status. In contrast, IHS
records rely on self-reported Veteran identification.
VHA and IHS continue to explore how to share clinical records and
are working through information security, privacy and other issues.
Question 3. Your testimony described a ``comprehensive list of
actions'' to strengthen the VA-IHS relationship. Please provide that
list.
Response. VA and IHS have embarked on a comprehensive series of
information technology activities as evidenced by the attached
spreadsheet. (See Attachment following the response to Question 9.) The
list of actions and/or activities referenced in Mr. Floyd's testimony
can best be seen on attachment pages 13 to 17. There are also other
information technology projects listed throughout the document.
Question 4. Your testimony described a ``performance monitor'' for
Veterans Integrated Service Networks (VISNs) with a significant
American Indians and Alaska Native populations to track progress toward
achieving the MOU's objectives. Please provide a description of that
performance monitor.
Response. A comprehensive monitor was developed in response to the
signing of the VA/IHS MOU in 2003; it has been periodically updated
since then. This performance monitor defines the MOU's desired outcomes
and currently requires the submission of quarterly progress reports
from each VISN. The purpose of the monitor is threefold:
To support continuous improvement in the coordination of
patient care between VHA and IHS;
To encourage referrals between IHS and VHA; and
To ensure that dual eligible American Indian and Alaskan
Native Veterans have coordinated access to appropriate services from
both agencies.
For quarterly reports, VISNs are instructed to report their
activities in the context of the five objectives set forth in the MOU.
These objectives are:
Improve beneficiary's access to quality health care and
services;
Encourage partnerships and sharing agreements among VA
Central Office and facilities, IHS Headquarters and facilities, and
Tribal Governments in support of American Indian and Alaskan Native
(AI/AN) Veterans;
Ensure appropriate organizational support for programs
targeted to AI/AN Veterans;
Improve health promotion and disease support for programs
targeted to AI/AN Veterans;
Improve communication among VA, AI/AN Veterans and Tribal
Governments with the assistance of IHS.
Question 5. Is VA considering entering into an MOU or sharing
agreement with Papa Ola Lokahi and/or the Native Hawaiian Health
Systems or other Native Hawaiian entities, to improve care and services
for Native Hawaiian Veterans?
Response. Yes. Papa Ola Lokahi is the Governance Structure/Entity
that represents the Native Hawaiian Consortium of health care programs
active throughout the state on every island. ``Papa,'' as they are
referred to, has an executive director, staff, and advisory board.
At this time, VA Pacific Islands Health Care System (VAPIHCS) is
exploring the enhancement of services to Veterans residing in the Hana
area of Maui. Both a federally Qualified Health Center and a Native
Hawaiian Health Care Clinic are serving the health care needs of Hana's
population. VAPICHS plans to visit Hana to meet with both entities and
discuss their potential roles as partners with VA to care for Veterans.
Question 6. Is VA considering expanding the concept of the Tribal
Veteran Representative to be inclusive of Native Hawaiians?
Response. Yes. The Tribal Veterans Representative (TVR) program is
national in scope and the VA Pacific Islands Health Care System is
identifying Native Hawaiian candidates to train as TVRs. The Native
Hawaiian TVR program will likely be somewhat different than the AI/AN
TVR program because it will serve a different population.
Question 7. Please provide a description of the Native American
Resource Center mentioned in VA's testimony.
Response. Over the past decade, VHA has taken important steps
toward meeting the health care needs of Native Veterans who reside in
rural areas. These have occurred nationally and at the local level as
collaborations have developed between regional VHA medical centers and
tribal programs. VHA's Office of Rural Health (OHR) recently
established the Veterans Rural Health Resources Center--Western Region
(VRHRC-WR) with a special population focus on rural Native Veterans--
the Native Domain. The Native Domain is intended to serve as a national
resource on issues surrounding health care for Native rural Veterans
through conducting policy analysis; collecting best practices;
fostering clinical demonstration projects; coordinating and partnering
with agencies and Native communities; and disseminating information
about these populations.
The Native Domain has defined Native Veterans to include American
Indians, Alaska Natives, Native Hawaiians, and Pacific Islanders. Of
note, Native Veterans comprise the largest proportion of Veterans
living in rural areas. The major philosophy of the Native Domain is
defined by the theme of national scope with a local focus.
Given the considerable cultural, social and geographic diversity of
rural Native Veteran populations, it is important to acknowledge that
while VHA policy is national in scope by its very nature, VHA programs
and activities targeted at this population may benefit from policy
strategies that embrace a national scope while maintaining a local
focus. Such programs effectively honor the cultural uniqueness of each
tribal, village, and islander group to address their health care needs.
Question 8. During a pre-hearing briefing, a VA representative told
Committee staff that VA has replaced the Chaplain guidelines concerning
American Indian and Alaska Native traditional practitioners with a more
comprehensive guideline. Please provide a copy of that guideline.
Response. The Revised VHA Handbook 1111.02, ``Spiritual and
Pastoral Care Procedures,'' dated July 18, 2008, did not replace the
Chaplain Service Guidelines concerning American Indian and Alaskan
Native Practitioners. The Chaplain Service Guidelines and the VHA and
Indian Health Service (IHS) Memorandum of Understanding from November
2005, are referenced in the Handbook, which is official VHA policy.
Both documents are still in use by VHA and the Handbook strengthens the
Chaplain Service Guideline document. The four references to ``American
Indian and Alaskan Native Veterans'' are highlighted on pages 11, 13
and 24, in the attached Handbook 1111.02. The Chaplain Service
Guidelines Concerning Native American Indian Traditional Practitioners
are also attached.
Question 9. An FY 2005 VHA-IHS issue update stated that ``. . . the
leadership of each organization has been asked to develop a joint
policy for the coordination of health care for dual use Veterans.''
Please comment on progress toward that joint policy, and whether VA and
IHS are still working toward that goal.
Response. In FY 2007, a Work Group was established to develop VHA
Directive entitled, ``VHA and IHS National Inter-Departmental
Coordinated Care Policy.'' VA and IHS continue to make strides toward
this goal.
Attachment for Question 3
Senator Tester. Thank you for your testimony, Mr. Floyd.
Mr. Grinnell, if you would proceed with your testimony.
STATEMENT OF RANDY E. GRINNELL, DEPUTY DIRECTOR, INDIAN HEALTH
SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES;
ACCOMPANIED BY THERESA CULLEN, M.D., DIRECTOR OF INFORMATION
TECHNOLOGY, INDIAN HEALTH SERVICE
Mr. Grinnell. Mr. Chairman and Members of the Committee,
good morning. I am Randy Grinnell. I am the Deputy Director for
Indian Health Service. Today, I am accompanied by Dr. Terri
Cullen. She is the Chief Information Officer and a family
practice physician, and we are pleased to have the opportunity
to testify on the collaboration of the IHS and the Veterans
Health Administration.
The Indian Health Service in the Department of Health and
Human Services is a health care system that was established to
meet the Federal trust responsibility to provide health care to
American Indians and Alaska Natives, with the mission to raise
their physical, mental, social, and spiritual health to the
highest level. The IHS provides the comprehensive primary care
services and public health services through a system of IHS-
operated, Tribally-operated, and urban-operated programs and
facilities that were based on treaties, judicial
determinations, and Acts of Congress. This system serves nearly
1.5 million American Indian and Alaska Natives through these
health facilities in 35 different States, and in many cases,
they are the only source of health care in many remote and
poverty-stricken areas of this country.
The partnership between the IHS and the VHA started in the
mid-1980s in the area of health information technology. The
Resource and Patient Management System, or RPMS, is the IHS's
comprehensive health information system that was created to
support high-quality care delivered at several hundred
facilities throughout the country. This system is a government-
developed and owned system that evolved alongside the VHA-
acclaimed VISTA system.
IHS and the VHA have also collaborated in the
implementation of the VA's VISTA imaging system now in use in
the IHS at over 45 sites. This system allows clinicians to have
access to images and data that assists them in making better
clinical decisions.
Several individuals today have talked about the MOU between
the IHS and the VHA. I am not going to go into detail about
that for time's sake.
I did want to mention that our system--we currently
estimate that there are about 45,000 veterans that are
registered within our system, and that includes both the IHS-
operated facilities as well as the Tribally-operated
facilities. In some cases, these veterans also live in urban
locations and may not have access to these facilities that are
out on the reservations and within Indian Country and they have
to rely on limited urban health programs as well as any local
facilities that may be available for their care.
IHS also recognizes the complexity of the Contract Health
Care Program that has been mentioned several times today in
other testimonies. As identified, there are rules and
regulations that we must adhere to. In many cases, this
presents a challenge in addressing the care needs of both our
elderly users as well as those Indian veterans.
I would like to talk about some of the collaborations that
have currently taken place. Because of the IHS's experience
with traditional healing, this has assisted the VHA in modeling
how to incorporate traditional approaches into healing for
Indian veterans. VHA's development and use of the Tribal
Veterans Representative Program has been and is critical to
communication and reducing barriers for VA services as well as
assisting those veterans in understanding the IHS Contract
Health Service Program and its rules and regulations.
As mentioned earlier in some of the testimony, the Alaska
area has partnered since 1995 via the Alaska Federal Health
Care Partnership that includes not only the IHS and the Alaska
Native Corporation, but the VA, Army, Air Force, and Coast
Guard partners. They have numerous initiatives, including
teleradiology, telehealth monitoring, and telebehavioral
health, as well. Some of their past projects have also included
the Alaska Tribal Health System Wide Area Network.
In Arizona, the IHS and VHA have worked together to
increase mental health services by the VA locating social
workers in several of the Navajo facilities as well as the Hopi
Reservation facility.
In Montana, the Billings Area IHS and the VA have worked
together to establish tele-psych at each of the service unit
locations to provide mental health services. Each of these
service units also have a designated VA liaison to assist the
veteran in understanding and accessing the services there.
At this time, there is a pilot project underway between the
IHS and VHA to where we are looking at the VA's consolidated
Outpatient Pharmacy Program to assist us in processing
outpatient prescriptions. This program, we feel like would be a
real benefit to our eligible users because it will decrease our
cost and also allow more time for our pharmacists to provide
clinical care, as well.
Some future opportunities between the two partnerships is
intended to improve access and to increase since 2003, but IHS
acknowledges that our joint efforts on issues related to access
to health care for Indian veterans needs to continue.
I would like to say that because Dr. Roubideaux is not
available today--she is currently at the meeting that the
President has with the Tribal leaders--but she is totally
committed to continuing this partnership and looking at new
ways to improve the relationship and also to further services
to Indian veterans.
Mr. Chairman, that concludes my testimony. We are here to
answer any questions you may have.
[The prepared statement of Mr. Grinnell follows:]
Prepared Statement of Randy E. Grinnell, Deputy Director, Indian Health
Service, Department of Health And Human Services
Mr. Chairman and Members of the Committee: Good afternoon. I am
Randy E. Grinnell, the Deputy Director of the Indian Health Service
(IHS). I am accompanied by Theresa Cullen, M.D., Director, Office of
Information Technology. I am pleased to have the opportunity to testify
on the Indian Health Service-Veterans' Administration (VA)
collaboration.
As you know, the Indian Health Service plays a unique role in the
Department of Health and Human Services because it is a health care
system that was established to meet the Federal trust responsibility to
provide health care to American Indians and Alaska Natives. The mission
of the Indian Health Service is to raise the physical, mental, social,
and spiritual health of American Indians and Alaska Natives to the
highest level. The IHS provides high-quality, comprehensive primary
care and public health services through a system of IHS, Tribal, and
Urban operated facilities and programs based on treaties, judicial
determinations, and acts of Congress. This Indian health system
provides services to nearly 1.5 million American Indians and Alaska
Natives through hospitals, health centers, and clinics located in 35
States, often representing the only source of health care for many
American Indian and Alaska Native individuals, especially for those who
live in the most remote and poverty-stricken areas of the United
States. The purchase of health care from private providers through the
Contract Health Services program is also an integral component of the
health system for services unavailable in IHS and Tribal facilities or,
in some cases, in lieu of IHS or Tribal health care programs. IHS
accomplishes a wide array of clinical, preventive, and public health
activities, operations, and program elements within a single system for
American Indians and Alaska Natives.
american indian/alaska native veterans' dual use of ihs and vha
In 2006, a joint VHA-IHS study was initiated to review dual use of
the two systems by American Indians. The findings of this study
indicate that American Indians and Alaska Natives using the VHA are
demographically similar to other VHA users with similar medical
conditions, such as Post Traumatic Stress Syndrome (PSTD),
hypertension, and diabetes. To date, the review has found that dual-
users are more likely to receive primary care from IHS, and diagnostic
and mental health care from the VHA. They are likely to be receiving
complex care from VA and IHS.
Many American Indians and Alaska Natives are eligible for
healthcare services from both Indian Health Service and Veterans Health
Administration. IHS has an estimated 45,000 Indian beneficiaries
registered as veterans in the agency's patient registration system.
Some American Indian and Alaska Native Veterans who live in urban
locations do not have geographic access to care in IHS facilities on or
near reservations and must use the local systems of care or urban
Indian clinics where they are available. In some of these locations
Urban Indian Health Programs provide limited direct care and assist
these patients in accessing VA and other services in the local area.
Indian veterans residing on reservations in some cases are not easily
able to access VA health facilities and services, as well.
IHS recognizes that the complexity of IHS Contract Health Services
and VA eligibility requirements may discourage Indian Veterans from
accessing care. IHS pays for the care referred outside of IHS for
American Indians and Alaska Natives including veterans if all rules and
regulations governing the CHS program are met. For the Indian veteran,
the VHA is an alternate resource along with Medicare, Medicaid and
private insurance under the CHS regulations. Other requirements include
membership in a federally-recognized Indian tribe, residence on the
reservation or within an IHS Contract Health Service Delivery Area
(CHSDA), meeting the CHS medical priority of care, exhaustion of
alternative resources of coverage, and compliance with the timelines
for notification of IHS. If the Indian Veteran patient is eligible for
Contract Heath Services and requires services outside the IHS facility,
i.e. specialty inpatient and outpatient services, she or he may be
approved for care pending relevant medical priority level on same basis
as any other American Indian and Alaska Native.
hhs/indian health service-va/veterans' health administration
memorandum of understanding
A Memorandum of Understanding (MOU) between the HHS/IHS and the
Department of Veterans Affairs (VA)/Veterans Health Administration
(VHA) was signed in 2003 to encourage cooperation and resource sharing
between the two Departments. It outlines joint goals and objectives for
ongoing collaboration between VA and HHS to be implemented primarily by
IHS and VHA. The MOU advances our common goal of delivering quality
health care services to and improving the health of the 189,000
veterans who are American Indian and Alaska Native as of 9/30/08. The
HHS and the VA entered into this MOU to further their respective
missions, in particular, to serve American Indian and Alaska Native
veterans who comprise a segment of the larger beneficiary population
for which they are individually responsible.
The MOU identifies 5 mutual goals to (1) improve beneficiary access
to healthcare and services; (2) improve communication among the VA,
American Indian and Alaska Native veterans and Tribal governments with
IHS assistance; (3) encourage partnerships and sharing agreements among
VHA, IHS, and Tribal governments in support of American Indian and
Alaska Native veterans; (4) ensure the availability of appropriate
support for programs serving American Indian and Alaska Native
veterans; and (5) improve access to health promotion and disease
prevention services for American Indian and Alaska Native veterans.
indian health service-veterans health administration collaborations
The principal focus of the interagency communication and
cooperation is to provide optimal health care for the American Indian
and Alaska Native veterans who rely on the IHS and/or VHA for their
medical needs. Together we strive to achieve multiple goals outlined by
the MOU by developing projects that, for example, improve access to VHA
services by allowing VHA staff to utilize Indian health facilities for
providing health care to Indian veterans while the joint working
relationship expands opportunities for professional development of
clinical skills by IHS providers. IHS experience with the use of
traditional healing in its system became a model for the VHA when it
began incorporating traditional approaches to healing for Indian
veterans. VA's development and use of the tribal veterans'
representative (TVR) program has been and is critical to addressing
issues related to communicating about and reducing barriers to VA
services and to the IHS CHS program for Indian veterans through the
coordinated training on benefits and eligibility issues for each of the
two programs.
Other collaborations that meet the goals of the MOU range from
expansion of access to VHA home based primary care for Indian veterans
through the use of IHS and Tribal health facilities to the improvement
of interagency partnership on health information and use of tele-health
modalities. The home based primary care program expansion will increase
availability of services for Indian veterans with complex chronic
disease and disability through 14 collaborative projects located in
states including New York, North Carolina, Oklahoma, Oregon, New
Mexico, South Dakota, California, Mississippi, and Minnesota. In
Arizona, the IHS -VHA are working together to increase mental health
services by locating VHA social workers in IHS health facilities on the
Navajo and Hopi reservations.
In Montana, the Billings Area IHS and the VA Montana Healthcare
System (VAMHCS) have on-going collaborative efforts such as tele-psych
established at each service unit to facilitate providing VA mental
health services for American Indian and Alaska Native veterans. Because
of the geographic remoteness and difficulty in accessing transportation
to a VA facility, this service greatly benefits the American Indian and
Alaska Native veterans. The Billings Area IHS and VAMHCS have
formalized a PTSD protocol that is utilized by the service units and
Fort Harrison. Among the protocol elements, the VA has created a
position designated as a Tribal Outreach Worker (TOW) who works on-site
to actively seek and educate veterans who may benefit from the services
provided through telepsyche clinics. Each service unit has a designated
VA liaison to help the American Indian and Alaska Native veterans
needing medical services as well as working with the TOW and local
Tribal Veteran Representative. As the primary IHS contact, they can
provide information, assistance, and guidance on VA services and health
benefits to American Indian and Alaska Native veterans. These
collaborative efforts are reviewed on an on-going basis in efforts to
address patient related issues, improved services, outreach, rural
initiatives, and to assist American Indian and Alaska Native veterans
to utilize both IHS/VHA systems.
The IHS and VHA have a long history of working jointly on health
information technology (HIT). Since the mid-1980s when the two agencies
both successfully fielded the Decentralized Hospital Computer Program
(DHCP) software, the VHA and IHS have sought opportunities to
collaborate in the sharing of HIT. The Resource and Patient Management
System (RPMS) is the IHS' comprehensive health information system
created to support the delivery of high quality health care to American
Indians and Alaska Natives at several hundred Federal and Tribal
hospitals and clinics nationwide. The RPMS is a government-developed
and owned system that evolved alongside the Veteran's Health
Administration's (VHA) acclaimed VistA system.
In addition, the model for the RPMS Electronic Health Record (EHR)
is the Veterans Health Administration (VHA) electronic medical record,
the Computerized Patient Record System (CPRS). CPRS has been
successfully deployed across the VHA hospital network over half a
decade ago. The EHR utilizes a technical infrastructure originally
developed for the VHA that displays various clinical functions in a
graphical user interface (GUI) format.
consolidated mail outpatient pharmacy (cmop)
The IHS and VHA will soon begin a pilot-test using VA's CMOP to
process IHS outpatient prescriptions, based upon the electronic
dispensing data provided from the IHS facilities. Through the IHS use
of the CMOP facilities, prescription filling can be centralized while
providing more efficient prescription delivery and increased pharmacy
billing collections. It will also provide facilities with the
capability to fill prescriptions for more than 30-day refills. The VA's
CMOP programs offer an attractive technology for dispensing refills
within the IHS because it offers the possibility of decreasing
capitalization costs, reduction of outdated medications, and freeing up
significant IHS pharmacist time for patient counseling, adverse drug
event prevention, and primary care. The IHS has been able to
successfully transmit prescriptions from an IHS RPMS test system to a
CMOP test system and transmit appropriate prescription information back
to the RPMS test system. The VA's CMOP is currently in beta testing at
Haskell Indian Health Center in Lawrence, Kansas; at the Phoenix, AZ
Indian Medical Center; and at the Indian health facility in Rapid City,
South Dakota.
vista imaging
A Memorandum of Understanding between the IHS and the VHA has
enabled telemedicine program coordinators from both Departments to
identify key areas for cooperation and possible shared resource
development. An example is the implementation of the VA's VistA Imaging
System (VI) in IHS, which is now up to approximately 45 RPMS systems
nationwide. VistA Imaging provides the multimedia component of the
VHA's Computerized Patient Record System (CPRS) and is also offered as
a multimedia tool to complement the IHS RPMS- EHR. The VI is an
extension to the RPMS hospital information system. The RPMS Health
Information System and Radiology Information System provide extensive
support for imaging and contain a full image management infrastructure.
VistA Imaging provides clinicians with access to all images and text
data in an integrated manner that facilitates the clinician's task of
correlating the data and making patient care decisions in a timely and
accurate way. Through this agreement, the VHA also provides the IHS
with on-site VI installation and training support.
alaska area ihs-va hit collaborations
The Alaska Area IHS has partnered with the VA since 1995 via the
Alaska Federal Health Care Partnership (AFHCP) which includes IHS/
Tribal, VA, Army, Air Force and Coast Guard partners. The Alaska
Federal Health Care Partnership office's primary responsibility is to
coordinate initiatives between the partners that result in increased
quality and access to Federal beneficiaries, or an overall cost savings
to the Federal Government. Current initiatives in the Alaska Area
include: joint training offerings, a neurosurgery contract services
agreement, a perinatology contract services agreement, tele-radiology,
sleep studies, home tele-health monitoring, partner staffing needs
assessment, emergency planning and preparedness, and tele-behavioral
health.
Past projects of AFHCP include Alaska Tribal Health System Wide
Area Network (ATHSAN) Telemedicine and the development of the Wide Area
Network. The AFHCP frequently shares workload data during its
investigations of possible joint services analyses; a recent example is
a study for joint-agency tele-dermatology and tele-rheumatology
contracts. One of the AFHCP committees is the Partnership Telehealth &
Technology Committee (PT&T) which brings together information
technology staff to discuss partner organization needs, identify
potential telehealth and technology applications to meet those needs,
and find avenues for shared technology resources. PT&T members and
their clinical champions will monitor patient results and gather
feedback on the use of new technologies to improve clinical outcomes
and access to care.
future opportunities of partnership
Local HIS-VHA efforts to improve access and develop formal
partnerships have increased since 2003 but IHS acknowledges that our
joint efforts on issues related to access to health care for Indian
veterans need to continue. We are committed to working on these issues,
within the Indian Health system, as well as with the Department of
Veterans Affairs and the Veterans Health Administrations. Indian
communities have always honored their Indian veterans and we are
committed to improving the health services they utilize and the quality
of their lives.
Mr. Chairman, this concludes my testimony. I appreciate the
opportunity to appear before you to discuss the collaboration between
the Department of Health and Human Services through the Indian Health
Service and the Department of Veterans Affairs I will be happy to
answer any questions that you may have. Thank you.
______
Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to Randy E.
Grinnell, Deputy Director, Indian Health Service, U.S. Department of
Health and Human Services
Question 1. How many sharing agreements has VA entered into with
tribes, tribal facilities and IHS facilities? Please provide a list
broken down by tribe, tribal and IHS facility, describing these sharing
agreements.
Question 2. Please provide IHS's best estimate of the number of
dual eligible Native American veterans. Please also include a
description of the methodology used to produce those estimates, and
information regarding ongoing efforts by IHS to improve these
estimates.
Question 3. How many staff has IHS dedicated to tracking and
implementing the VA-IHS MOU and IHS's obligations (consultation
included) to Native American veterans? Please provide the names and
titles of dedicated staff, and whether they focus on these
responsibilities on a full or part-time basis.
Question 4. In a FY2005 VHA-IHS issue update stated that ``. . .
the leadership of each organization has been asked to develop a joint
policy for the coordination of health care for dual use veterans.''
Please comment on progress toward that joint policy, and whether VA and
IHS are still working toward that goal.
[Responses were not received within the Committee's
timeframe for publication.]
Senator Tester. I thank you for that. Thank you for your
testimony. We will start the first round of questions with
Senator Burr.
Senator Burr. Thank you, Mr. Chairman.
Mr. Floyd, before I get to the issue of the day, I would
like to touch base with you about the VA hospital in Marion,
IL, that is now under your purview, and from the Inspector
General's report it is apparent there are still systemic issues
which have not fully been addressed in the last 2 years. Some
of those issues that have presented themselves over that period
of time: providers not credentialed or privileged; lack of peer
review; poor quality management; and not reporting adverse
health effects efficiently. Can you share with us your level of
commitment to make sure that these systemic problems are
solved?
Mr. Floyd. Senator Burr, in that report, beginning on page
20, are my statements to address those ten recommendations made
from that report. I would refer you and your staff to that. But
I will also be available to discuss that in further detail, to
specifically address any of those with you or other Members of
the Committee at an appropriate time.
Senator Burr. I appreciate that. Let me suggest to you that
it was unacceptable when it happened and I find it somewhat
unbelievable that we still have systemic problems. I realize
you have only been there a short period of time----
Mr. Floyd. Twelve months.
Senator Burr [continuing]. And I hope you will take this as
a warning shot, that this will not be the last time this
Committee looks at those systemic problems in that facility
specifically and across the network.
Let me, if I could, move to a question for one or both of
you. As I mentioned in my opening statement, the MOU between
the VA and IHS outlines five mutual goals. Mr. Howlett on the
first panel described the MOU as, quote, ``more symbolism than
action.'' So, let me mention these goals, and if you will, tell
me how your agencies are measuring the success or failure at
meeting them.
First, access to health care. How do you measure whether
access has improved since 2003?
Mr. Floyd. First of all, about the MOU, it is purposefully
vague so that we disregard work with individual areas, Indian
communities, urban areas and all, so that we can address unique
circumstances of each local community, Tribe, nonprofit
organization that exists that has Native American veterans. And
we have made strides in that.
If I could give you an example. When I was the Director of
the VA Salt Lake City Health Care System, we worked with the
Billings Area Indian Health Service and did a comparison of
databases between the VA and the Indian Health Service to
identify patients within the Indian Health Service system who
were veterans who weren't enrolled within the VA. We used that
as a method of outreach for patients in Wyoming, Montana,
Idaho, and Utah. That helped us increase the enrollments of
these individuals into the VA health care system. That is one
example.
Senator Burr. Communication--how do you measure
improvements since 2003?
Mr. Floyd. The VA and the Indian Health Service has ongoing
conference calls between the two of us. We have a spreadsheet
that identifies projects that we both identified as necessary
for action. We have identified the responsible parties for that
and on a monthly basis report on the progress of those. That is
a method which we use internally within both agencies to gauge
our success in improving services.
Senator Burr. The development of partnerships and sharing
agreements--how many existed in 2003? How many exist today?
Mr. Floyd. I am not sure how many existed in 2003. I can
speak for the ones that at the present time exist, which are at
least 15 of the 21 Veterans Integrated Service Networks within
the VA with varying levels of agreements in place, whether that
is for telehealth, traditional services, direct primary care,
the installation of the Electronic Health Record from the VA
into Indian Health Service or Tribal facilities. Those are
examples of where we use specific agreements to follow up from
the MOU to improve mechanisms for care.
Senator Burr. Ensuring appropriate resources are available,
does the VA know how much it provided to Indian Health Services
or Indian Health Service contract facilities under the sharing
agreement in 2003 versus the level it provides today?
Mr. Floyd. I am aware of several agreements specifically
between the VA and Indian Health Service or Tribal facilities--
the Muscogee VA in Oklahoma, for example, their work with the
Choctaw and the Cherokee Nations specifically on a contract
basis. However, there are other agreements in place, such as
what we have experienced in the Rocky Mountain area, where we
work with social workers or other transfer coordinators within
either Tribal or IHS facilities on specific cases to get them
in and coordinate their care, either from that level, primary
care, or specialty care in the VA system.
Now, I am not aware of a national database that rolls all
those up. However, I know that recently the VA has asked and
received information from each one of the facilities of
specific agreements that they have in place. So that
information is available.
Senator Burr. To improve health promotion and disease
prevention services. How do you measure that?
Mr. Floyd. The VA has benefited, actually, from the
development of the Indian Health Service, particularly in
diabetes education and hypertension education, and collaborated
on a level where they have actually helped train the VA in
their preventive practices for diabetes education,
hypertension, and the VA has utilized their resources to help
improve the knowledge of the VA practitioners. Those are the
examples that I am aware of, sir.
Senator Burr. I would like to thank the Chair, because he
has been kind to let me go over. Let me make a statement and
then I will end with one last question.
The Memorandum of Understanding was meant to cover all the
Native American geographical area. I think we have a tendency
to focus on certain successes, certain outreaches, and certain
partnerships. But I hope you got the gist I did from the first
panel, that this is not the overriding theme of the VA, to live
up to all the standards in that agreement. I am not sure that
there is an overriding commitment on the part of VA to make
sure that there is incredible access to quality health care
within Indian Country. I am not sure that there is a real focus
within the VA to make sure that the communications is open to
the degree that in all areas, they know exactly what is
available to them. And I could sort of go down the list.
But let me just ask, is there a database at VA of Native
American veterans?
Mr. Floyd. Well, within the electronic health records
system of the VA, as a veteran enrolls in the VA health care
system, there is a question asked of their racial designation.
It is a voluntary request on their part. Those who identify
Native American or Alaskan Native as their primary racial group
are in our database. Yes, sir, we have that information.
Senator Burr. If they are enrolled in the VA?
Mr. Floyd. Yes, sir.
Senator Burr. But we don't import into VA potentially all
the folks who qualify for VA services that may not be enrolled?
Mr. Floyd. Not to my knowledge. Not yet. However, as you
may be aware, the project especially with these soldiers who
are in Afghanistan and Iraq, the War on Terror, at the present
time--the project is called VLER, Virtual Electronic Record,
which would transmit that information from DOD directly into
the Department of Veterans Affairs. That project is in its
initial stages, but could address the issue that you just asked
about.
Senator Burr. Clearly, I would think that with this
Memorandum of Understanding in place, that there would have
been some thought process at VA as to how they could
proactively go after a population that may not be enrolled yet
qualified. Likewise, I would hope that the Indian Health
Service would push VA to do this. The first panel, I don't
think talked about the successes of the system or about the
outreach or, for that fact, about the quality of care within
the Indian Health Service. I actually think it has made
progress, but I think it falls woefully short of what they
deserve from the standpoint of a quality health care system.
So, Mr. Chairman, I do hope you will be persistent that we
will continue to follow up on this and that we will be at a
point where we can measure progress versus just cite
highlights. I think it is important that we have a matrix that
is constructive that allows us to gauge what we have done.
I thank all our witnesses. I thank the Chair.
Senator Tester. And I thank you, Senator Burr.
I am going to follow up on Senator Burr's questions here
real quickly, on the measurement aspect. I am going to
paraphrase what you said, but you basically merged medical
records between the VA and IHS and found which Native Americans
were out there that were veterans that weren't being served by
the VA. Is that fairly accurate?
Mr. Floyd. Yes, sir.
Senator Tester. And then you said that you did outreach.
How did you do outreach?
Mr. Floyd. Well, one of the things that we drew out of that
was the address of those individuals and their zip codes so
that we could target them with mailings. Also, as a follow-up
at that time, Mr. Richardson and myself, we went out to areas
where they had higher concentrations of veterans and held
meetings on those reservations or Indian communities.
Senator Tester. And how many folks did you have?
Mr. Floyd. In the beginning, sir, very few, but I think
with continued follow-up meetings, we began to enroll many
more. I am not sure of the exact number. I know in one
community in Utah, we were able to get about 300 people
enrolled that hadn't previously been using the VA.
Senator Tester. Does the VA keep metrics on the
effectiveness of this sort of stuff?
Mr. Floyd. With the communication between the VA and the
Indian Health Service, these types of initiatives are looked at
and discussed in terms of specific metrics. Reporting is
requested periodically from Central Office here in Washington
to the respective networks, such as the one I am at in Kansas.
Senator Tester. It would just seem to me that it would be
very, very difficult to do measurements if you do it in
generalities. How do you measure the effectiveness of your
outreach unless you know? I guess that is a statement. You
don't have to answer that.
You also talked about contracting facilities with Senator
Burr's question, and I had the impression that you do have
contracted services with some IHS facilities. Is that correct,
or did I hear you wrong?
Mr. Floyd. Well, we have the ability to contract for
primary care within the VA and locally within any facility.
They determine where they have the volume of patients to
support the contract.
Senator Tester. Can you tell me if there are any IHS
facilities that you have contracts with and where would they
be?
Mr. Floyd. Specifically, with the Indian Health Service, I
am not aware of any contracts with them.
Senator Tester. Why is that?
Mr. Floyd. Because it seems to be more appropriate for us
to co-manage the patients, although----
Senator Tester. But you do have contract agreements with
private facilities, correct?
Mr. Floyd. Yes, sir.
Senator Tester. So why is there a difference? I am just
curious, because as one of the people testified in the first
panel, a lot of the areas that the Native Americans live in are
pretty darn remote.
Mr. Floyd. Yes, sir.
Senator Tester. And one of the things that we have talked
about on this Committee is when you are in remote areas, it
makes more sense to deal with the veteran there than ship him a
few hundred miles, or in Alaska's case, a lot further than
that, to a CBOC or a hospital.
Mr. Floyd. The traditional usage we have seen in terms of
these co-managed patients, if I could use that term, is that
they generally receive their primary care locally, either in a
Tribally-run facility or Indian Health Service facility.
Senator Tester. So the reason you don't contract with them
is that IHS is already supposed to take care of them?
Mr. Floyd. No, they have a choice. If they want to be
exclusively served by the VA, then we do that. We do that with
many patients. We co-manage patients across the country in all
kinds of settings.
Senator Tester. OK. And I have got about a minute, so you
guys are going to have to be concise on this. This is for both
Mr. Grinnell and Mr. Floyd. If you were to analyze how well
your two agencies were working together to service Native
American veterans, what grade would you give yourself?
Mr. Floyd. Umm----
Senator Tester. No talking across the aisle. [Laughter.]
No bell curve; right?
Mr. Floyd. I don't know if I can represent the agency to
talk about that, Senator, but----
Senator Tester. The point I am trying to make is that from
my perspective as somebody who serves in the U.S. Senate that
represents everybody, whether they are Native American veterans
or regardless what their race is, I go into Indian Country--and
I have got all the statistics right here that talk about how
their health isn't as good, which I have heard spoken from many
agencies in the Obama administration, and I agree with them
wholeheartedly--that we need to figure out ways that we can
work together to maximize our ability to serve the people we
are serving, because IHS is funded by taxpayer dollars, VA is
funded by taxpayer dollars, and we have got an opportunity to
work together and get more bang for the buck.
And so that is why I want to know. Would it be accurate to
say that we could do better? How is that, Mr. Floyd?
Mr. Floyd. Well, I think we can always do better, sir.
Senator Tester. All right. Well, I left you off the hook.
Mr. Grinnell, what grade would you give us?
Mr. Grinnell. Well, I am going to punt like Mr. Floyd did
and not give myself a grade. But in discussions with the
Director, Dr. Roubideaux, about future partnerships, we clearly
see that there is an opportunity for improvement and ways to
bring services to the Indian veterans throughout Indian
Country----
Senator Tester. OK. If there is opportunity for
improvement, how does that information flow up and how do you
get it ultimately in the end to Dr. Roubideaux?
Mr. Grinnell. Well, one of the things that Mr. Floyd also
talked about is that many of these agreements and these
relationships are at the local level.
Senator Tester. Right.
Mr. Grinnell. In many cases, the agreement and the
relationship is between the VA and the Tribes that now manage
those programs, an example is Alaska. All the Alaskan programs
are now under 100 percent management of the Tribes up there. I
believe that the opportunities we have before us to bring the
partnership of the Tribes and the Alaskan Natives into that
partnership in a more open and equal manner, I think that will
help us move ahead.
Dr. Roubideaux, one of her priorities is to have more
consultation with Tribes on how we deliver health care across
this country, and she sees that as an opportunity here, as
well.
Senator Tester. OK. Thank you very much.
Senator Begich?
Senator Begich. Thank you very much, Mr. Chairman, and
thanks for calling for this hearing. I think it has been very
informative, but also gives us a chance to--I was trying to
figure out how to do the grading, too. When I went to
elementary school, they had ``N'' for needs improvement, ``O''
for outstanding, ``S'' for satisfactory, and this is probably a
combination, depending on where you are. I know in Alaska, as
you just mentioned, the Tribal Consortium has done, I think, an
exceptional job in advancing health care for Alaska Natives.
Again, I went on the floor today to explain the great value of
what they have done in improving and turning around the system.
Now, saying that, I think there are some improvements that
clearly need to be made, especially with, I will use the phrase
dual eligible veterans. You know, they are eligible in both
your systems. And in Alaska, again, as I said in my opening,
they are in areas that are very difficult to access quality
health care that is VA-delivered, if they live in rural Alaska,
so there has to be a better way.
But I want to go back to the Ranking Member's comment to
the VA, how you try to figure out who the folks are, because if
you don't know the number, if you can't put that in your
database--I understand why it is voluntary--but why can't you
have a question that says something like this. Are you
qualified under the Indian Health Service for any services?
Because you may be qualified for additional services.
Why can't you just ask that question, so then when they
check that box, you can actually create a database? I
understand the issue about asking their ethnic background, but
if you are asking them, are you qualified under Indian Health
Services today, a lot of folks will identify that, especially
if they are a veteran. So, they just check the box. It then
gives you the data to move forward in figuring out how to
provide dual services.
Mr. Floyd. If I could answer that, Senator. The VA in its
registration package asks for alternate resources information,
which is generally third-party insurance coverage. I know the
Indian Health Service is not an insurer----
Senator Begich. Right.
Mr. Floyd [continuing]. But a lot of patients do say, well,
it is Indian Health Service. They can note Indian Health
Service on there----
Senator Begich. But if I can interrupt you, if you ask the
question from that perspective, insurance, some will view it
differently. But if you ask, are you qualified under Indian
Health Service for any benefits, it is a simple yes or no, and
it immediately gives you a qualifier.
Mr. Floyd. We don't ask that specific question.
Senator Begich. Can you be more--I mean, can you?
Mr. Floyd. We could, but let me give you one hesitation on
my part to do so. Having run a medical center, I would not want
any of my staff to turn that person away and say, then we want
you to go to an Indian Health Service facility.
Senator Begich. I am not asking that. What I am saying is
it helps you create the database, so then as you do this MOU,
you now can say, we have 5,000, 2,000, 100, or ten qualified
based on the data we have collected. Now, how do we approach
that group in order to ensure that we are giving them the
benefits and the services earned? And then you can kind of
start drilling down. I have done a lot of MOUs as a former
mayor and I will tell you, if you don't have the data, there is
no way to perform on it. You just can't.
So, I would just encourage you to kind of look at how you
ask the question in order to extract the data in order to then
work together to figure out who that group is you are trying to
target. That is just a comment.
The other thing is, the MOU has been talked about a lot,
and like I said, I have developed a lot of MOUs as mayor, but
one of the things we always had was kind of, you have
interagency discussions on a regular basis. But the last time,
I think, that they have taken those issues and updated and
where they are, I think, was maybe in 2005 or later.
I am assuming you do this, and if you don't, I would highly
encourage you. I am assuming in your interagency group you will
have an MOU with your 15 or so items and you will note, here
are the action items, here is the progress. Do you have such a
chart that shows what you all work off of?
Mr. Floyd. Between the--if I could answer that----
Senator Begich. Between both of you, yes.
Mr. Floyd. Yes. We do share our database of the projects
that we are either working on individually or jointly. Those
are identified, then the objective, the status of the actions,
and who is responsible as the lead on those types of issues.
And then we discuss those on conference calls.
Senator Begich. So, you have some document where you keep
track of these?
Mr. Floyd. Yes, sir, we do.
Senator Begich. Is that something you can share with the
Committee?
Mr. Floyd. Yes, I think we can provide that information.
[The additional information requested during the hearing
follows:]
[Additional information about this topic can be found under
response to Question 3 from Hon. Daniel K. Akaka to Mr. James
R. Floyd, which appears previously.]
Senator Begich. Both of you? I don't know who is the right
person. Mine is a dual-eligible question, so----
Mr. Grinnell. Yes. It is maintained through this National
Committee that----
Senator Begich. OK. So you can provide that to us to give
us a sense?
In implementing that, is one of the pieces of the puzzle
funding? It doesn't matter if it is VA or Indian Health
Service, but on both sides, are any of the implementations of
those just a funding issue versus a desire or a combination?
Does that make sense, the question? In other words, do you get
to an item and say, we want to do it, but there is just no
money for it? And just to make sure you know, my second
question will be, if the answer is yes to that, then I would
ask, are you asking for that? Is it OMB and their magical black
box that kind of strips at the pieces and then you end up
having to take what you get? How is that for putting you on the
spot? I wanted to warn you of the second part of the question.
Mr. Floyd. The way the funds are allocated, having been in
the Indian Health Service and now in the VA, I know how money
is allocated in both. Within the Veterans Health
Administration, it is a capitated system. The money follows the
workload. So, the generation of the workload is going to
retrospectively provide the resources to sustain that service
for those individuals. So, there is through that system that we
have within the VA a way to reimburse us for going out and
getting that workload.
Senator Begich. Quickly--I know my time is over----
Mr. Grinnell. As far as the funding, I think that everybody
is aware of the funding of the Indian Health Service and the
programs that are administered by us and the Tribes. The 2010
budget is definitely an increase. We have 13 percent that is
now in place. The increases are very targeted and we are going
to see some advances in Contract Health Service, which will
have an impact on veterans that access that part of the system,
as well.
The other part is within Health Information Technology. We
are seeing some increases in our budget there that will be
targeted to move us into more of these telemedicine
partnerships that we have with the VHA to expand our services
to those veterans in those remote locations.
Senator Begich. Thank you very much. I will ask one
question, and it is a yes or no. Does Indian Health Service
believe they should be on a 2-year budgeting cycle like the VA?
Mr. Grinnell. I would have to----
Senator Begich. It is a yes or no. It is very simple.
Mr. Grinnell. I would have to defer on that question to the
Department. I am sorry.
Senator Begich. OK. No problem. Thank you.
Senator Tester. Thank you, Senator Begich.
A couple more questions, and the first one is for Mr.
Richardson. Buck, you are the guy who actually executes the
goals of the MOU on the ground. You go out to reservations. You
deal with the veterans, the IHS, and Indian Tribal Health. How
do you and other folks in the VA know what the challenges are
out there and how do you share your ideas among your
counterparts? How do you let them know what you are doing
outside your region to influence folks?
Mr. Richardson. We do a combination of things, Senator. It
is either through conference calls, and reports I do through
the VISN Director or actually taking other VA employees out.
Then Dr. Shore and I do a report monthly that shows what we are
actually doing at each one of the reservations, that shows the
activity that we are doing, and how many veterans we are seeing
through the different clinics. And then I have got a Web site
for the TVRs that shows what is going on with each reservation
and what is going on for the TVR, or the Tribal Veterans
Representative Program, so that they can see what is going on
in each one of the reservations.
Then in VISN 19 or the Rocky Mountain Health Care Network,
I have got 23 Sovereign Nations that I work with, so I keep
that up to date as to what is going on. So, I try to keep as
much information flowing, and when I run across employees that
are actually interested in trying to find out more about the
Sovereign Nations, I take them out to the Nation with me.
Senator Tester. Thank you.
Mr. Floyd and Mr. Grinnell, from your perspective, do you
co-manage patients at this point in time?
Mr. Floyd. Well, from my experience, yes, sir, we do.
Mr. Grinnell. Yes.
Senator Tester. OK. So, how do you effectively co-manage
patients when you don't have an interoperable recordkeeping
system and no one in either agency is really tracking how you
are doing, implementing these strategies?
Mr. Floyd. Well, my own experience, if I can answer that--
--
Senator Tester. Sure.
Mr. Floyd [continuing]. And maybe Buck can follow up, is it
is as simple as a phone call. Each VA facility has a Transfer
Coordinator. A lot of times, calls are made into the Transfer
Coordination Office or to some of us individually of the
specific case. At that point, we get the Transfer Coordinator
to work with the individual at the local site. They coordinate
the care to get the patient where they need to go.
Senator Tester. Mr. Richardson, did you want to further
respond?
Mr. Richardson. There will be occasions where maybe an OEF/
OIF Coordinator, either Iraq or Afghanistan, they will get
phone calls trying to find individual veterans, and they will
call me too. And what I will do is call the TVRs. The TVRs will
actually go out into the field and find the veteran.
Senator Tester. OK.
Mr. Richardson. And once they find that veteran, a lot of
times, there is a language barrier, so they have to get through
the language issue through the family of that veteran. Once
they get over the problem of the language and they get the
veteran found, whichever reservation it might be, then they
will get the veteran back in touch with me and then I will get
the veteran in touch with the appropriate employee so that they
can get them into whatever facility they might need to go to.
Senator Tester. How about you, Mr. Grinnell?
Mr. Grinnell. I would like Dr. Cullen to answer that, if
she could.
Senator Tester. Sure.
Dr. Cullen. If the patient is cared for primarily in our
system and identified as a veteran, they may be referred to the
VA. If they are referred--because we do have a similar
Electronic Health Record to the VA, especially in terms of
patient registration, we will have captured their veteran
status, we ask the nine questions the VA asks. In addition, we
can drill down and tick off war and other things like that. If
they are referred, we have a contract health and a referred
care software application that allows us to track the referral
out.
The question will be, can we get the records back in. At
the current time, we have locations that have what we call
read-only access into the VA systems, where the providers have
been credentialed appropriately and they can dial into, with
appropriate security, the VA VISTA system and get a read-only
access to that patient's chart.
Senator Tester. Let me restate what you just said. You are
telling me that health care professionals in Indian Health
Service can access those medical records in the VA?
Dr. Cullen. At certain locations where there have been
local sharing agreements developed and the provider has been
appropriately credentialed, yes.
Senator Tester. OK. Can the VA do the same thing, Dr.
Shore? Can the VA do the same thing with the Indian Health
Service records?
Dr. Shore. I can only speak for the series of clinics where
I work in Montana, Wyoming, and South Dakota. I run a series of
telehealth clinics for the VA mental health clinics. So in
those, with those specific sites, we do not have read-only
capacity. It depends on the medical record, although often, our
clinics are colocated in the actual IHS facility. So, we do a
lot of phone calling back and forth with the providers.
Senator Tester. All right. Thank you.
Senator Begich, did you have any other questions?
Senator Begich. I want to fall back in. Dr. Cullen, that is
interesting, how you crafted that answer. I just want to make
sure I am following you correctly here. If it is locally done,
it has credentials done locally, then it is a read-only into
the system, correct?
Dr. Cullen. Appropriate credentials and security, yes.
Senator Begich. Security. If I can ask you a question, how
many of your facilities have that, in percentage of total?
Dr. Cullen. We are only aware of five at the current time.
Senator Begich. What about the percentage? What would that
be--very small?
Dr. Cullen. Very small percentage.
Senator Begich. And is it successful?
Dr. Cullen. Yes.
Senator Begich. Why do we not model that nationally and do
it? If you want to kick it back to Mr. Grinnell, that is fine.
But if it is successful, why not just do it?
Mr. Grinnell. Resources.
Senator Begich. Is that the issue? Have you requested that
in the 2010 or 2011----
Mr. Grinnell. That has been part of the request that we
have made in the health IT line, is to begin to improve the
ability to increase our telemedicine capabilities.
Senator Begich. OK. Do you have a plan of action if you get
the resources? How long would it take you to convert, or not
convert, but to ensure that this occurs in this manner?
Mr. Grinnell. This----
Senator Begich. And to give you the pre-warning, if you say
yes, I will ask you for that document. [Laughter.]
In all fairness.
Mr. Grinnell. I think that at this point, the talk that is
going on nationally about the Health Information Network, I
think has been taking precedence over anything that we are
doing right now.
Senator Begich. It just seems that it is working, and I
think your request, Mr. Chairman, was really good. If it is
working, sometimes the stuff that is working, we kind of forget
about and we move on. But it seems like this is such a good
one, and this is such a need, to make sure the records are back
and forth. So I will follow that up at another time.
One last question, if I can, Mr. Chairman, and that is it
was asked earlier on the first panel on the ability to bill the
VA. Indian Health Service can bill Medicare and Medicaid but
they can't bill the VA to get reimbursed, I guess. Is that
correct? If you remember the earlier testimony, there was some
discussion about that.
Mr. Grinnell. Yes, that is correct.
Senator Begich. Is there a reason why we should not allow
that to occur? Why not? Again, you can kind of flip it to Mr.
Floyd if you would like, but whoever would like to answer that.
Or no answer.
[Laughter.]
Mr. Floyd. In all due respect, I am not quite sure that I
know the exact----
Senator Begich. That is fair.
Mr. Floyd. I could respond to that as a follow-up for this
hearing----
Senator Begich. I would appreciate that.
Mr. Floyd [continuing]. Question of the authority.
Senator Begich. Yes, if you could just answer that
question. It is more so that I understand it better and to
consider if there is something that we need to be thinking
about here in the process of how to improve that.
Mr. Chairman, thank you very much.
[The additional information requested during the hearing
follows:]
Response to Questions Arising During the Hearing by Hon. Mark Begich to
James R. Floyd, FACHE, Network Director, VA Heartland Network (VISN
15), Veterans Health Administration
Question: Senator Mark Begich (D-AK) requested information about a
statute that prohibits VA from reimbursing IHS for the cost of medical
care provided to Veterans.
Response. No statute prohibits VA from reimbursing IHS for the cost
of medical care provided to Veterans and VA does reimburse IHS for
services provided to Veterans in certain situations. VA currently
reimburses eligible Veterans for health care provided by non-VA
providers only in limited circumstances whereby the care that VA has
deemed necessary is otherwise not offered by VA Healthcare facilities.
VA seeks to control and monitor all care that eligible Veterans
receive.
Current law provides sufficient direction and authority for the
appropriate apportionment of costs for the care of Indian Veterans
between IHS and VA. In the event that VA determines that a Veteran
needs care at a non-VA facility, VA has the authority to enter into an
agreement with IHS under which VA would pay for that care.
Senator Tester. Yes, thank you, Senator Begich, and I want
to thank the panelists.
Let me give a quick overview. We had in the first panel
some folks that represent health care in Indian Country on the
ground. My sense is--and it is not just a sense but I think it
is reality--there is a level of frustration there that we could
be doing more work and getting it to the ground to really serve
the Native American veterans in a better way.
This panel we had here, and you are all great folks, I
sense much less attention on what is going on the ground. All I
would say is that the question asked by grading where you were
at--I mean, you are right, Mr. Floyd, we can always do better.
But I think we need to really, really work at doing better.
These are really tough issues, and sometimes it just comes down
to who is paying the bill. But more than that, I think it comes
down to working together and finding ways which we can service,
in this case, Native American veterans in a way that they
deserve.
As Senator Murray said, these folks worked for the
benefits. They served this country, in many cases, put their
lives on the line. Promises were made. We need to make sure
that those promises are kept.
I want to thank each and every one of the panelists today
for their service in their individual capacities and I want to
thank you for taking time out of your busy schedule to come
here and visit with us. Thank you very much.
This meeting is adjourned.
[Whereupon, at 12:07 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Roland W. Burris, U.S. Senator from Illinois
Thank you Mr. Chairman, I would like to begin by extending a ``Warm
Welcome'' to our distinguished guests, as well as fellow colleagues
from the Committee. Moreover, I would like to thank you and Senator
Tester for creating this opportunity to further discuss the ongoing
efforts in the Veterans Health Administration (VHA) to provide safe,
effective, efficient and compassionate health care to American Indian
and Alaska Natives (AI/AN) veterans residing in rural areas.
It is of course my desire to see that this hearing focus on the
progress between the VA and the Indian Health Service (IHS) in
delivering quality health care to (AI/AN) veterans. In particular, it
is my hope that we will examine the challenge of making health care in
rural and urban areas more accessible, as well as the VA's needs to
overcome cultural barriers to serve veterans in Indian Country.
Mr. Chairman, as you know, in February 2003 the Departments of
Health and Human Services-Indian Health Service and VA signed a
memorandum of understanding (MOU) to promote cooperation and sharing
between the Veterans Health Administration and the IHS to further each
Department's respective mission.
It is my understanding that over the past six and a half years
there has been limited progress made toward the goals of this MOU. That
said, it is also my understanding that overall the networks have made
some progress in developing closer relationships with IHS and the
Tribes and in considering means to improve services and access for AI/
AN veterans. This is a good start but I would like to see further
strides established toward the original intent of the MOU.
Furthermore Mr. Chairman, for a contributing ethnic group of the
U.S. population (who retains dual citizenship) that has a higher
percentage of people serving ``per capita'' in the Armed Forces than
that of the general US population (24% compared to 19%) I think it only
appropriate that these measures be carried out in an expedient manner.
With this in mind I want to bring to this Committee's attention a
few interesting points that I think are relevant to this discussion and
need to be factored in. To begin, studies and testimony from AI/AN
veterans indicate that travel distance and a lack of coordination
between the two agencies are key factors that inhibit AI/AN veterans'
access to health care at VHA.
Another barrier AI/AN veterans are dealing with is the perception
that VHA staff do not understand or accommodate the needs and unique
perspectives of Indian veterans and that VHA care is not culturally or
linguistically sensitive.
In addition, AI/AN veterans have indicated that the eligibility
requirements and application process for receiving care from VHA can be
very confusing. AI/AN veterans find the process particularly baffling
as many of them may have been receiving health care from the Federal
Government, IHS, all their lives under a different system of
eligibility and rules for access.
Mr. Chairman, I close simply with this: it is my belief--as I know
it is yours--that providing safe, effective, efficient and
compassionate health care to our (AI/AN) veterans, regardless of where
they live, should be the primary goal of the VHA and IHS.
______
Prepared Statement of Jefferson Keel, President,
National Congress of American Indians
Thank you for the opportunity for the National Congress of American
Indians to provide testimony regarding American Indian and Alaska
Native veterans and health care services provided by the Department of
Veterans Affairs and the Indian Health Service.
In addition to thanking Chairman Akaka and Ranking Member Burr for
the opportunity to present testimony, I want to acknowledge and thank
Senator Tester for requesting today's hearing and for his leadership on
the Rural Veterans Health Care Improvement Act, which includes
provisions for Native American veterans' health care, through this
Committee.
I believe that the Members of this Committee are aware of the valor
and service of American Indian, Alaska Native and Native Hawaiian
veterans to this country and that they have served in higher proportion
than any other ethnic group. You also may be aware that the lack of
health care to these veterans upon returning home is appalling,
considering what they have done in protecting our homelands.
With the advent of the Afghanistan and Iraq wars, the number of
veterans returning with injuries and disabilities, physically and
emotionally, has significantly increased. And as we have learned from
past wars and conflicts, the need for treatment of these warriors may
not be revealed for several years after these courageous men and women
return home.
The primary health care provider to tribal communities, including
American Indian and Alaska Native veterans, is the Indian Health
Service, which has always been woefully underfunded. Many veterans have
sought health care from Veterans Health Administration hospitals
because that is an option and a right. In an attempt to stretch their
health care dollars, both IHS and VA hospitals have denied services to
veterans, insisting they had to go to the other agency for treatment.
These proud veterans, who in some instances used their last dollars to
travel long distances to either facility, deserve better treatment.
As a tribal leader and veteran, I thought the days of transferring
responsibility from one agency to the other were over when a Memoranda
of Understanding between the IHS and Veterans Health Administration was
signed in 2003. It is my understanding that the issue is still with us
and it is my hope that this hearing will be a step forward in finally
resolving this situation to prevent more veterans from additional
suffering or worse.
There are far too many reports of inconsistency in delivery of
health care to American Indian and Alaska Native veterans. NCAI staff
members have been informed of concerns about delays in scheduling
appointments as well as the cancellation of appointments without notice
by both the Indian Health Service and Veterans Administration
hospitals. We have been made aware of the backlog of delivery of basic
services including dispensing eyeglasses and hearing aids. Many
veterans also have shared their complaints that they believe their
health problems have not been addressed because they met with medical
staff who rushed them through medical exams and sent them away quickly
without diagnosing problems or providing proper treatment including
medication.
There are some things that are under the purview of this Committee
that might help to alleviate the problems. The Veterans Health
Administration has authority to create Tribal Veterans Service Offices
in tribal communities, which would provide a resource for local
veterans to be informed of their best options for health, housing, and
other benefits and what additional resources are available for specific
assistance.
I am hoping that there will be additional resources available that
veterans will be able to draw from, including the reauthorization of
the Indian Health Care Improvement Act that is before Congress. But any
money appropriated for services authorized under the Indian Health Care
Improvement Act is desperately needed for the overall population of
tribal communities, and even though veterans may benefit, there still
is a need for increased VA health care funding.
Remoteness of IHS and VA health facilities will always be a
problem. Native veterans are likely to have scarce financial resources
to expend on travel to IHS or VA hospitals. The VA, perhaps in
cooperation with the Department of Transportation, should be able to
work with tribal governments to facilitate transportation from tribal
community hubs to Veterans Health Administration hospitals, which can,
in some instances, be over 200 miles roundtrip, and for Alaska Native
veterans, much, much further.
In providing services to Native American veterans, it is a basic
requirement that the two agencies' systems for data exchange and
communication are compatible. One of the agreements in the 2003 VA-IHS
MOU was to ``[d]evelop national sharing agreements, as appropriate, in
healthcare information technology to include electronic medical records
systems, provider order entry of prescriptions, bar code medication,
telemedicine, and other medical technologies . . .''
We are aware that the IHS received $85 million under the American
Recovery and Reinvestment Act for Health Information Technology. We
would hope that a portion of this funding--to be used for electronic
health record development and deployment, personal health record
development, telehealth and network infrastructure, and other
purposes--would benefit Native veterans through improved data exchange
and patient tracking. We would also like the Committee to consider
requesting that the IHS make some Recovery Act health IT dollars
available to tribally-administered health programs, perhaps including
Tribal Veterans Service Offices, in addition to internal IHS records
management and infrastructure development.
Members of the Committee can also assist American Indian and Alaska
Native veterans by supporting current legislation. The Indian Veterans
Housing Opportunity Act of 2009 (H.R. 3553) has been introduced by
Representative Ann Kirkpatrick (D-AZ), which will help disabled Native
American veterans and their survivors by providing eligibility for
housing assistance to which they are currently denied because they are
receiving veterans disability and survivor benefits. I ask that you
support this critical legislation.
The National Congress of American Indians (NCAI) passed a
resolution (SD-02-079) in 2002 at their Annual Convention, calling for
the development of a report on the health status of American Indian and
Alaska Native veterans. Today's hearing is a significant step in
pointing out that both the VA and IHS have roles and responsibilities
in the treatment and care of Native veterans. We all know that Native
peoples are subject to more studies than anyone in the country, but
perhaps a report of the nature called for in the NCAI resolution would
not be an infringement or intrusion on privacy when weighed with the
potential outcome and value of such a survey. I am offering the
assistance of the NCAI in supporting this effort and am sure that the
NCAI Veterans Committee would lend its assistance.
Because of the government to government relationship, nearly all
agencies have instituted an Indian affairs desk tasked with outreach
and communication to tribal governments and organizations. The NCAI has
always supported implementation of tribal affairs offices because they
enhance and advance program delivery and implement policies that better
serve tribal governments and communities. The Veterans Administration
currently has a Native American who serves as a tribal contact in the
Office of Minority Affairs. We strongly urge the VA to expand this
position and move it out from the Office of Minority Affairs and
establish an Office of Tribal Affairs staffed by American Indian and
Alaska Native personnel who report directly to the VA Secretary. The
creation of an Office of Tribal Affairs with VA also complies with the
Memorandum of November 5, 2009 on Tribal Consultation issued by
President Obama.
Thank you again on behalf of the National Congress of American
Indians for taking the time to conduct this hearing and to provide this
opportunity to hear from our organization, veterans and other
supporters in calling for comprehensive delivery of the best health
care available for the honorable men and women who deserve no less than
the best.
______
Prepared Statement of Don Loudner, National Commander,
National American Indian Veterans, Inc.
introduction
Good morning Chairman Akaka, Ranking Member Burr, and Members of
the Committee on Veterans Affairs. I am Don Loudner, the national
commander of the National American Indian Veterans, Inc. (``NAIV''), a
national not-for-profit organization dedicated to the welfare of
American Indian veterans who have proudly served this country for
generations. I am an enrolled member in the Crow Creek Sioux Tribe, SD,
and am a veteran of the Korean War.
I want to thank the Chairman for holding this important hearing on
the degree of cooperation that currently exists between the Indian
Health Service (``IHS'') and the Department of Veterans Affairs
(``DVA'') when it comes to providing the best quality health care to
our Native veterans. As you can imagine, Native veterans have many of
the same problems other veterans do, but also face unique challenges of
unemployment and poverty as well as living in geographically-remote
areas of the country.
health care and american indian veterans
I would like to provide the Committee with information pertaining
to the challenges faced by American Indian veterans regarding DVA
benefits and health care, as well as DVA memorial services (e.g. Indian
veteran's cemeteries). While I have worked my entire adult life to
improve the standard of care and living of these men and women, in my
capacity as national commander of the NAIV, I am in constant contact
with American Indian veterans in the States of Arizona, California,
Colorado, Montana, New Mexico, Oregon, South Dakota, Wisconsin,
Washington, and others.
Since 2004, the NAIV has hosted three National Conferences, the
last taking place in March 2009 at the Morongo Convention Center in
Cabazon, CA, with more than 500 American Indian veterans from
throughout the West and Southwest in attendance. The NAIV has the
support of the National Congress of American Indians, the National
Association of State Directors of Veterans Affairs, the National
Disabled American Veterans, and the National American GI Forum.
The chief of staff for the NAIV is the only American Indian to
serve as the Director of Veterans Affairs--serving the veterans of the
State of Arizona. He and I travel to the many Indian reservations
constantly. Although his job is to support all of Arizona's 600,000
plus veterans, Arizona is home to 22 federally-recognized Indian tribes
and American Indian veterans regularly attend his commission meetings.
As a result of these meetings, he relays to me concerns regarding the
lack of proper medical care delivered through the DVA to reservation-
dwelling Indian veterans.
On the Navajo Reservation, for example, there are more than 12,000
veterans, but DVA has rebuffed calls to locate a permanent Community-
based Outpatient Clinic (``CBOC'') there claiming the number of
veterans will not justify it. The fact is, the numbers will not support
a CBOC at Navajo because the reservation is divided into 3 Veteran
Integrated Service Network (``VISN'') and, given this division, the DVA
cannot count the number of veterans to justify the clinic. It is
precisely this type of bureaucratic red tape which results in inaction
and, ultimately, inferior or a complete lack of medical care to
American Indian veterans.
Recently the DVA's Office of Intergovernmental Affairs and the
Director of VISN 18 and others visited the Navajo Nation and witnessed
for themselves the urgent need for additional health care facilities.
They graciously called the Director of Veterans Affairs in Arizona for
his input which he, of course, provided. The reality is that I have
seen numerous visits over the years throughout Navajo, Pine Ridge and
other Indian reservations, with little follow-up action.
When a Navajo veteran can get to a Veterans Administration Medical
Center in Prescott, Arizona or Albuquerque, New Mexico, or Sioux Falls,
SD, the medical care is excellent, but few if any veterans can overcome
the vast distances to use such facilities. The distances are vast and
transportation is not always available. As a result, many American
Indian veterans try to obtain care at IHS facilities but do not receive
treatment because they are veterans.
In this regard, the Memorandum of Understanding (``MOU'') that was
entered in 2003 by the DVA and the IHS has been ineffective because the
level of cooperation is nowhere near where it needs to be for the
benefit of American Indian veterans.
The idea behind the MOU was that the American Indian veteran could
receive the treatment she needs at an IHS facility and the DVA would
reimburse IHS for those services. The reality is that the veteran is
usually the last to be seen at an IHS facility. The MOU can be
strengthened and this in itself would alleviate some of the need for
Community Based Outpatient Clinics on Indian reservations.
comments on the caregiver and veterans omnibus health services act
(s. 1963)
Mr. Chairman, I want to thank you for sponsoring the Caregiver and
Veterans Omnibus Health Services Act (S. 1963), which was introduced
last week and is already pending on the Senate Calendar. While we are
carefully studying S. 1963 in its entirety, there are many excellent
elements included in it that I would like to highlight.
The bill creates a much-needed Demonstration Project to examine the
feasibility and advisability of expanding care for veterans in rural
areas, including expanding coordination between the DVA and the IHS for
health care for American Indian veterans. The bill would also assign an
Indian Veterans Health Care Coordinator to each of the 10 Department
Medical Centers that serve communities with the greatest number of
American Indian veterans per capita, as well as an official or employee
of the Department to act as the coordinator of health care for Indian
veterans at the Medical Centers.
In an effort to bring the benefits of information technology to the
medical records of American Indian veterans, S. 1963 would bring real
advances in two key areas: (1) It would establish a Memorandum of
Understanding to ensure that the health records of Indian veterans can
be transferred electronically between facilities of the IHS and the
DVA; and (2) It would transfer and install surplus DVA medical and
information technology equipment to the IHS.
Perhaps most importantly, S. 1963 requires the Secretary of the DVA
and the Secretary of the Department of Health and Human Services to
jointly submit to Congress a report on the feasibility and advisability
of the joint establishment and operation by the Veterans Health
Administration and the Indian Health Service of health clinics on
Indian reservations to serve the populations of such reservations,
including Indian veterans.
naiv and its pursuit of a federal charter
In 2005, then-Senator Tom Daschle introduced legislation to award a
Federal Charter to NAIV. The legislation passed unanimously in the
Senate but languished in the House Committee on the Judiciary. At the
time, there were two bills seeking to award Federal charters to
veteran's organizations, one for NAIV and one for the Korean War
Veterans Association. In 2008, Congress passed legislation awarding a
charter to the Korean War Veterans Association, but failed to consider
the NAIV bill.
One question that NAIV faces constantly is why does NAIV need a
Federal charter? Indian veterans have come together to form their own
professional veterans service organization which was created out of the
necessity to support ourselves and not have to rely on other service
organizations like the American Legion, the VFW, or others to support
and advocate for them. With our own Federal charter, NAIV would be
officially sanctioned and as national commander I would be able to
testify before Congress on Native veteran's issues, just as the
American Legion, VFW, Am-Vets, and other organizations do each winter.
Chairman Akaka, American Indian veterans have earned the right to
have their own Federal charter and to be recognized by Congress. No
other group of Americans serves in our Nation's Armed Forces in
proportion to their numbers as do Native Americans. With a Federal
charter, NAIV could train and certify the required veterans benefits
counselors and certify them to work on Indian reservations. This would
alleviate some of the obstacles such as language barriers and access
which is one of the major complaints American Indian veterans now have.
Thousands of Indian veterans are going without claims being process for
them because of cultural barriers. Indian veterans are dying without
ever having filed a claim, leaving their widows destitute, and
dependent on their respective tribe.
american indian veterans cemeteries
Currently, there are no American Indian veterans cemeteries on
Indian reservations and many Indian veterans are being buried in tribal
cemeteries. The sad fact is that these tribal cemeteries are often in a
horrible physical condition. For example, the cemetery at Fort
Defiance, AZ is so decrepit and horrible that it brought me to tears
and should be closed immediately but the tribe does not have the funds
to close or rehabilitate it. Visitors from the VA's office of
Intergovernmental Affairs toured this cemetery and can vouch for this
accuracy of my statement.
american indian veteran representation at the va
Finally, there is great unhappiness among veterans in Indian
country at the lack of representation of Indian veterans at the VA
headquarters. All other veterans groups are represented in the ranks of
the Senior Executive Service--with the exception of Indian veterans.
There is only one Indian official working in the Center for Minority
Veterans and that person is a GS-13. The Center for Minority Veterans
in Washington, DC, has little to no credibility with American Indian
veterans, and for good reason: They seldom visit the reservations. I
conclude this report by stating sadly that as the situation now stands,
the American Indian veteran is the least-served veteran in the United
States by the VA and currently has no voice at the VA.
Unless Secretary Shinseki, who is highly respected by American
Indian veterans, pays special attention to this situation and directs
that the VA study the plight of Indian veterans, or Congress changes
the makeup of the Center for Minority veterans to make it more
accessible, nothing will change and the American Indian veterans will
continue to receive poor health and other services.
This concludes my prepared statement Mr. Chairman.
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Prepared Statement of Carol Wild Scott, Chair, Veterans Law Section,
Federal Bar Association
The National Congress of the American Indian estimates that 22% of
the Native American/Hawaiian and Alaskan Native population are either
members or the Armed Services or veterans. This represents the highest
level of participation of any identifiable group in our population in
the defense of this country. The service rendered to this Nation is
freely given by sovereign peoples among us chiefly out of patriotism
and the warrior tradition.
All veterans, including Native American veterans are entitled to a
wide range of benefits and services as a result of their military
service. Native American/Hawaiian and Alaskan Native veterans have less
access to and thus receive far fewer, VA benefits and services than
does the veteran population as a whole. Native American veterans who
live west of the Mississippi and in Alaska live in great part on
reservations. They do not have access to VA health care or meaningful
access to the Veterans Benefits system though which they may seek the
health care to which they are entitled. Accordingly, there are far
fewer appeals taken from denial of pension and compensation.
The estimates of the incidence of PTSD in the population of Vietnam
and Southwest Asia veterans as a whole range around 50%. For many
reasons grounded in cultural and economic circumstances, this may be a
low estimate in Native American veterans. Neither VA nor IHS provides
effective treatment modalities for these veterans. With very few
exceptions, there is no culturally compliant therapy available to
Native American veterans and their families, particularly in dealing
with the secondary effects of PTSD presenting as self-medication,
domestic violence and suicide. Native American women veterans
particularly receive nowhere near the mental health care they need for
Military Sexual Trauma (MST). Nor do they receive the other medical
care they need for service related trauma and illnesses from either VA
or IHS. Despite the existence of the MOU of 2003 between DVA and IHS
there is insufficient effective interface between IHS and VA health
care systems.
Traditionally, Vet Centers, in urban and suburban settings have
provided counseling and treatment for PTSD and other mental health
issues. There is currently legislation pending to expand the number of
these centers. The creation of ``Traditional Tribal Vet Centers''
(Centers) on the reservations, conjoined and complementing existing IHS
facilities, would address a wider range of issues for the Native
American veterans than those in urban and suburban settings.
These Centers would be a cooperative enterprise between DVA, IHS
and the Tribal governments, fully implementing the MOU of 2003 between
IHS and DVA. Through the Centers Native American veterans would receive
mental health services from Western and Traditional Healing
practitioners. The availability and presence of both modalities would
provide documentation for benefits purposes. In addition to the mental
health services, the VA/IHS cooperation would provide readily available
attention for medical issues arising from such matters as TBI, wound
care, damaged prostheses as well as medication. Such issues, once
identified would then be referred into the clinic/VAMC system. Native
American women veterans would particularly benefit from the
availability of mental health and medical care in this setting. Family
counseling and training for family care givers for severely wounded
veterans should also be available through these Centers.
The availability of adequate medical care is dependent on the grant
of service connection for injuries, illness and diseases incurred in or
the result of military service. Not only must the grant of compensation
be appropriate, but the rating must be adequate. The presence of
trained representatives designated as such by the Tribal Councils, and
most importantly, accredited and certified to the Agency on the same
footing as state and county employees is critical to the adequate
utilization of the Centers. This status is not provided for in the
current regulatory scheme, and would require modification of 38 CFR
Sect. 629.14(2), which currently provides only for state and county
employees, thus by definition excluding Tribal Veterans Representatives
(TVRs) as designees or employees of a sovereign entity.
The innovative concept of ``TVRs'' was designed and implemented by
James R. Floyd, currently Network Director of VISN 15 in Kansas City,
MO. This was an effort to provide Native American veterans with a
trustworthy emissary to assist in seeking benefits and dealing with the
VA benefits and health care bureaucracy. The drawback is that the TVRs
lack accreditation and all training is done by VA, which gives rise to
inherent conflict of interest issues as well as a wholly unintended
contribution to the inadequacy of representation because the TVRs
function largely as intermediaries rather than accredited
representatives. Provided with a training program independent of VA,
culminating in accreditation to the Agency, the TVRs would make a
tremendous contribution to the meaningful availability of compensation
and benefits to Native American/Hawaiian and Alaskan Native Veterans.
An important issue relating to the needs of Native American
veterans is trust, or lack of it. There is a profound reluctance to
discuss matters related to combat with anyone; including members of the
same tribe. A long history of racism, distrust of governmental
entities, and an unwillingness to approach representatives of
governmental entities exacerbate the situation. Intergovernmental
cooperation in establishing Traditional Tribal Native American Vet
Centers would provide at least some solutions. The establishment of an
Office of Native American Affairs within the Department of Veterans
Affairs would further considerably the development of programs and
services for Native American/Hawaiian and Alaskan Native veterans.
The Veterans Law Section of the Federal Bar Association urges your
recognition of the profound needs of these veterans, and consideration
and adoption of the measures discussed herein. The views and proposals
discussed herein are those of the Veterans Law Section and not
necessarily those of the Federal Bar Association as a whole.
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