[Senate Hearing 111-471]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 111-471

          HEARING ON VA AND INDIAN HEALTH SERVICE COOPERATION

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                            NOVEMBER 5, 2009

                               __________








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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

                              ----------                              

                            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.
---------------------------------------------------------------------------
    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.
                                 ______
                                 
 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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