[Senate Hearing 112-656]
[From the U.S. Government Publishing Office]






                                                        S. Hrg. 112-656

               PROGRAMS AND SERVICES FOR NATIVE VETERANS

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

                                HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 24, 2012

                               __________

         Printed for the use of the Committee on Indian Affairs














[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]









                                _____

                  U.S. GOVERNMENT PRINTING OFFICE

76-708 PDF                WASHINGTON : 2012
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
20402-0001




                      COMMITTEE ON INDIAN AFFAIRS

                   DANIEL K. AKAKA, Hawaii, Chairman
                 JOHN BARRASSO, Wyoming, Vice Chairman
DANIEL K. INOUYE, Hawaii             JOHN McCAIN, Arizona
KENT CONRAD, North Dakota            LISA MURKOWSKI, Alaska
TIM JOHNSON, South Dakota            JOHN HOEVEN, North Dakota
MARIA CANTWELL, Washington           MIKE CRAPO, Idaho
JON TESTER, Montana                  MIKE JOHANNS, Nebraska
TOM UDALL, New Mexico
AL FRANKEN, Minnesota
      Loretta A. Tuell, Majority Staff Director and Chief Counsel
     David A. Mullon Jr., Minority Staff Director and Chief Counsel






















                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on May 24, 2012.....................................     1
Statement of Senator Akaka.......................................     1
Statement of Senator Barrasso....................................     2
Statement of Senator Franken.....................................     3

                               Witnesses

Birdwell, Stephanie, Director, Office of Tribal Government 
  Relations, U.S. Department of Veterans Affairs.................     4
    Prepared statement...........................................     6
Burke, Hon. Wayne, Chairman, Pyramid Lake Paiute Tribe...........    21
    Prepared statement...........................................    23
Causley, Cheryl A., Chairwoman, National American Indian Housing 
  Council........................................................    29
    Prepared statement...........................................    31
Gover, Kevin, Director, National Museum of the American Indian...    15
    Prepared statement...........................................    16
Grinnell, Randy, Deputy Director, Indian Health Service, U.S. 
  Department of Health and Human Services; accompanied by Dr. 
  Susan Karol, Chief Medical Officer.............................     9
    Yvette Roubideaux, M.D., M.P.H., Director, Indian Health 
      Service, prepared statement................................    11
Kalipi, D. Noelani, President, TiLeaf Group......................    33
    Prepared statement...........................................    34
McKaughan, Lt. Col. Kelly, Director, Veterans Advocacy, Choctaw 
  Nation; accompanied by Maj. Nathaniel Cox, Director, Choctaw 
  Global Staffing, Choctaw Nation................................    26
    Prepared statement...........................................    28

                                Appendix

Adame, Richard Allen, Sergeant First Class, Retired U.S. Army, 
  Prairie Band Potawatomi Nation Veteran, prepared statement.....    51
Keel, Jefferson, President, National Congress of American 
  Indians, prepared statement....................................    42
Murkowski, Hon. Lisa, U.S. Senator from Alaska, prepared 
  statement......................................................    41
Papa Ola Lokahi Native Hawaiian Health Board, prepared statement.    47
Response to Written Questions Submitted by Hon. Daniel K. Akaka 
  to:
    Stephanie Birdwell...........................................    54
    Cheryl A. Causley............................................    57
    Randy Grinnell...............................................    59
Response to Written Questions Submitted by Hon. John Barrasso to:
    Stephanie Birdwell...........................................    55
    Cheryl A. Causley............................................    58
    Randy Grinnell...............................................    59

 
               PROGRAMS AND SERVICES FOR NATIVE VETERANS

                              ----------                              


                         THURSDAY, MAY 24, 2012


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 12:45 p.m. in 
room 628, Dirksen Senate Office Building, Hon. Daniel K. Akaka, 

Chairman of the Committee, presiding.

          OPENING STATEMENT OF HON. DANIEL K. AKAKA, 
                    U.S. SENATOR FROM HAWAII

    The Chairman. I call this hearing of the Committee on 
Indian Affairs to order.
    Aloha and thank you so much for being with us today.
    Before we begin our oversight hearing on the Programs and 
Services for Native Veterans, I would like to ask everyone to 
please for the presentation of the colors and veterans song by 
Dennis Zotigh, Cultural Specialist, at the National Museum of 
Indians.
    [Presentation.]
    The Chairman. Thank you very much.
    Carrying the colors today are members of the Lumbee 
Warriors Association, commanded by Staff Sergeant Harold Hunt, 
U.S. Army, Vietnam veteran; carrying the United States flag, 
Specialist Fourth Class James Edward Thomas, U.S. Army, 
Vietnam-era veteran; and carrying the Lumbee flag, Specialist 
James Taft Smith, U.S. Army, Vietnam veteran.
    Please present the colors.
    [Colors are presented.]
    The Chairman. Color guards, please proceed to the well and 
Mr. Zotigh will sing the veterans song.
    Mr. Zotigh. Thank you very much.
    Preceding this, I would like to say that American Indians 
have always been defenders of our lands, our lives, our 
families and our way of life. We honor our warriors with our 
songs. At this time, I would like to sing the veterans flag 
song which is analogous to our national anthem.
    [Presentation of flag song.]
    The Chairman. Please retire the colors.
    Please be seated.
    Thank you very much, Dennis Sotigh and the Lumbee Warriors 
Association for that wonderful opening.
    It is fitting that we conduct this hearing before Memorial 
Day in remembrance of the service of Native veterans to our 
country. It is important that we as a Nation are meeting our 
dual responsibility to them as veterans and as indigenous 
people.
    Native Americans, including American Indians, Alaskan 
Natives and Native Hawaiians, have served in the United States 
Armed Forces with honor for more than 200 years, fighting in 
the Revolutionary War, the Civil War and the Spanish American 
War long before they were acknowledged as American Citizens. It 
is a well known fact in this committee that Native Americans 
have the highest rate of service per capita of any group in the 
Nation.
    As a Native Hawaiian World War II veteran, I know the great 
sacrifice of leaving your family, your community and your home 
to fight for your country. As you look around this room, you 
can see the faces of the service and the sacrifice and I am 
humbled to be among them.
    The work of the Code Talkers in Wars I and II may well have 
meant the difference between victory and defeat and for many 
years, their contributions went unacknowledged. Still, the 
bravery and dedication of Native servicemen cannot go unnoticed 
forever. Over two dozen American Indians, Alaskan Natives and 
Native Hawaiians have received the Medal of Honor.
    As Chairman of this Committee, it has been my goal to 
conduct oversight in a way that ensures that the United States 
is meeting its unique responsibilities to Native Americans. As 
a former chairman and a current member of the Veterans Affairs 
Committee, my commitment to the veterans is the same.
    The Chairman. I am happy that my partner, friend and 
brother here from Wyoming, Vice Chairman Barrasso and I are 
able to work together on this Committee. Vice Chairman 
Barrasso, would you like to make an opening statement?

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

    Senator Barrasso. I would, Mr. Chairman.
    Good afternoon and thank you, Mr. Chairman, for holding 
this hearing on Programs and Services for Native American 
Veterans.
    I especially want to thank you, Mr. Chairman, for your 
service to this country as we head up to Memorial Day. Mr. 
Chairman, you served in the U.S. Army from 1945 to 1947, and 
you continue to serve this country honorably as one of only 
three U.S. Senators today who are World War II veterans, you 
along with your colleague from your home State, Senator Inouye, 
as well as Senator Lautenberg. Thank you for your service. 
Thank you for your leadership on veterans' issues.
    Native Americans have long played a very important role in 
protecting and preserving our freedoms. As many of you know and 
the Chairman referenced, the Native American Code Talkers, I 
believe, were instrumental. You said it could have been the 
difference between victory and defeat. I believe they were 
instrumental during both World Wars I and II in defeating the 
enemy. Indian Code Talkers communicated messages across enemy 
lines. They did it using secret codes derived from their Native 
languages and these were never, never deciphered by enemy 
forces.
    American Indians served in every one of our Nation's wars 
since the Revolutionary War. Many fought for our country before 
even being granted citizenship in 1924. They served in Vietnam, 
in Iraq, in Afghanistan and have sacrificed much for the 
freedoms of all Americans. Indian veterans deserve our 
gratitude, our respect and full access to the services afforded 
to all other veterans.
    It appears there have been some longstanding challenges 
with Native veterans accessing the benefits they are entitled 
to. We are going to hear more about that today, particularly in 
regard to health services for Native veterans. I would like to 
hear what the Federal agencies are doing to overcome these 
problems.
    I want to thank all of our witnesses for being here today. 
I appreciate your accommodating the schedule with a number of 
Senate votes scheduled for later this afternoon and allowing us 
to move up the hearing. I appreciate your providing the 
Committee with thoughtful testimony.
    Thank you again, Mr. Chairman, for your service to this 
body and to our Nation.
    The Chairman. Thank you very much, Vice Chairman Barrasso.
    Senator Franken, do you have any opening remarks?

                 STATEMENT OF HON. AL FRANKEN, 
                  U.S. SENATOR FROM MINNESOTA

    Senator Franken. Yes. Thank you, Chairman Akaka, for 
holding this very important hearing and for all the work you 
have done over the years on behalf of Native veterans. You are 
a true leader in this Congress' efforts to improve the lives of 
Native veterans.
    We owe so much to every veteran who has served our Nation. 
When they return home, they should have at a minimum, a job, a 
home and health care they need. That is equally true for Native 
veterans who serve in our Armed Forces in greater numbers than 
any other group of Americans and have served bravely as the 
Vice Chairman said in every conflict since the Revolutionary 
War.
    The Native veterans not only share the challenges that 
other veterans face in getting all they deserve, they also face 
unique challenges. That is certainly true for the thousands of 
Native veterans in Minnesota. Many of them, all of them live in 
rural areas which makes access to VA's excellent health care a 
real challenge.
    I have a bill called the Rural Veterans Health Care 
Improvement Act that I have introduced with Senator Boozman of 
Arkansas to help VA improve access to health care for all rural 
veterans, including, of course, Native veterans. The bill, 
which calls on VA's Office of Rural Health to develop a 
strategic plan so that it better uses the substantial resources 
that Congress has appropriated for that office, would have the 
strategic plan include a solution for better provision of care 
for Native veterans.
    I have also heard from Minnesotans that Indian veterans 
suffer from a lack of trust in the VA because of a history of 
poor treatment. I know VA, as well as our outstanding county 
and Tribal veteran service officers in Minnesota making mighty 
efforts to overcome that lack of trust, both through 
consultation, outreach, and through practical improvement in 
provision of services.
    I am looking forward to the hearing today. I don't want to 
get my first pow wow in Minnesota. The first thing Ms. Jibway, 
an advisor on my staff, said the opening procession will be led 
by veterans, by the warriors. I know the honored place that 
warriors have in our Native communities. I honor you as well. 
Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you very much, Senator Franken, for 
your opening remarks.
    As Chairman, it is my goal to ensure that we hear from all 
who want to contribute to the discussion. Therefore, the 
hearing record will be open for two weeks from today and I 
encourage everyone to submit your comments and written 
testimony.
    I want to remind the witnesses to please limit your oral 
testimony to five minutes.
    Today, serving on our first panel is Ms. Stephanie 
Birdwell, Director, Office of Tribal Government Relations, U.S. 
Department of Veterans Affairs in Washington, D.C.; Mr. Randy 
Grinnell, Deputy Director, Indian Health Service, U.S. 
Department of Health and Human Services in Rockville, MD, 
accompanied by Dr. Susan Karol, Chief Medical Officer, Indian 
Health Service; and Mr. Kevin Gover, Director, National Museum 
of the American Indian located in Washington, D.C. Welcome to 
every one of you.
    Ms. Birdwell, please proceed with your testimony.

  STATEMENT OF STEPHANIE BIRDWELL, DIRECTOR, OFFICE OF TRIBAL 
   GOVERNMENT RELATIONS, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Ms. Birdwell. Good afternoon, Chairman Akaka, Vice Chairman 
Barrasso and members of the Committee.
    Thank you for inviting me to discuss the Department of 
Veterans Affairs programs and services for Native American 
veterans.
    On November 5, 2009, President Obama signed a memorandum on 
Tribal consultation pronouncing Tribal consultation a critical 
ingredient of a sound and productive Federal/Tribal 
relationship. As part of the strategy to realize the 
President's vision of regular and meaningful consultation and 
collaboration with Tribal officials, VA created the Office of 
Tribal Government Relations and I was appointed as the Director 
of this new office last year.
    Guided by the Tribal Consultation Policy signed by 
Secretary Shinseki in February of 2011, our office has been 
charged with developing partnerships with American Indian and 
Alaskan Native Tribal governments for the purpose of enhancing 
access to services and benefits for Native veterans.
    Meaningful consultation is vital if we are to effectively 
address the unique needs of Native American veterans. Trust is 
the singlemost important aspect in our relationship with the 
Tribes and Native American veterans. VA's goal is to earn the 
trust of Tribal leaders and Native American veterans through 
consistent outreach and an open door policy.
    As an enrolled member of the Cherokee Nation of Oklahoma 
with over 15 years of experience in Indian affairs, I know it 
will take time but I believe it is a goal we can achieve. 
Serving both Indian country and our Nation's heroes is both a 
professional and deeply personal calling.
    With an estimated 383,000 Native American veterans and 556 
federally-recognized Tribal entities, there is much work to be 
done. VA is embarking on a robust outreach and consultation 
effort that will focus on listening, aiding and advocating. 
Listening includes receiving communications through email, 
phone and social media tools but we believe the best way to 
create lasting bonds of trust is to meet with Tribal leaders in 
their communities. VA has held listening sessions in Alaska, 
Montana, North Dakota and New Mexico.
    While we area in the communities, we are aiding and 
training Native American veterans. For example, VA staff have 
trained Tribal veteran representatives in Montana and Alaska 
and provided technical assistance to Native Americans seeking 
home loans during recent gatherings of northwest Tribal leaders 
and veterans in Spokane, Washington; Washington, D.C.; 
Minneapolis, Minnesota; and Albuquerque, New Mexico.
    Outreach and consultation is a vital tool that provides 
opportunities to increase Native American veteran enrollment in 
VA's health care system, educate veterans about benefits for 
which they may be eligible and connect them with online 
resources such as eBenefits and MyHealtheVet.
    We are working with the Veterans Health Administration to 
enhance access to health care in several ways. First, we 
facilitate technical assistance and assure best practices with 
the Indian Health Service as part of our effort to implement 
the Memorandum of Understanding between the VA and IHS. My 
office's role is to ensure Tribal concerns are heard and 
considered. To this end, we will hold annual listening sessions 
in addition to formal consultation to obtain recommendations, 
hear local priorities and advocate the Tribe's perspectives on 
practices that will improve access to care.
    Additionally, we have entered agreements with Tribal health 
programs in Alaska under which VA will reimburse Alaska Tribal 
health programs for direct services provided to eligible 
veterans. These agreements will strength both the VA and Tribal 
health program systems to increase access to care for Native 
and non-Native veterans, particularly those in remote and rural 
areas served by Alaska Tribal health programs. Special 
recognition goes to our partners at IHS and Tribal leaders in 
our ongoing work to establish a national agreement with IHS and 
the efforts in Alaska.
    The VA also offers a wide range of benefits for eligible 
veterans such as compensation and pension, employment services 
and the post-9/11 GI bill, to name a few. VA can and will do 
more to increase access to and utilization of established 
benefits that veterans have earned.
    For example, recent changes to the post-9/11 GI bill 
program illustrate the need for a direct link to Indian 
country. We are using every avenue available to ensure that 
veterans know how changes to this program will directly affect 
them and my office will be a vital resource for Tribal leaders 
and a conduit for feedback to VA.
    I am hopeful that our efforts will increase utilization 
rates for the Native American Direct Loan Program, a vital tool 
in VA's efforts to provide housing options for Native American 
veterans.
    We are committed to building a relationship with Tribal 
leaders built on a culture of trust and respect to increase to 
care and utilization of benefits. We see a bright future but 
there is still much to be done.
    I look forward to answering any questions you may have.
    [The prepared statement of Ms. Birdwell follows:]

 Prepared Statement of Stephanie Birdwell, Director, Office of Tribal 
       Government Relations, U.S. Department of Veterans Affairs
Introduction
    Good afternoon, Chairman Akaka and members of the committee, I 
appreciate the opportunity to discuss the Department of Veterans 
Affairs' (VA) programs and services for Native Veterans.
    On November 5, 2009, President Obama signed a Presidential 
Memorandum directing all U.S. Government agencies to develop detailed 
plans to fully implement the Executive Order 13175, ``Consultation and 
Coordination With Indian Tribal Governments.'' The President described 
tribal consultation as ``a critical ingredient of a sound and 
productive Federal-Tribal relationship.''
    In signing the Presidential Memorandum, the President set a 
standard of action to which he expects his Administration to be held, 
and we are being challenged to meet that standard. As such, VA created 
the Office of Tribal Government Relations (OTGR) and I was hired as the 
Director of the Office last year. In August 2011, VA hired four Tribal 
Government Relations Specialists to manage a portfolio of relationships 
with tribal governments within specific regions across the country. 
These specialists serve as a resource to tribal governments seeking to 
engage in productive relationships with VA.
    Guided by the VA's Tribal Consultation Policy, signed by Secretary 
Shinseki in February 2011, OTGR has been charged to develop 
partnerships with American Indian and Alaska Native Tribal governments 
to enhance access to services and benefits for Native Veterans. VA must 
build and maintain lasting bonds with Tribal leaders and Native 
American Veterans. Toward this end, meaningful consultation is 
absolutely vital if we are to effectively address the unique needs of 
Native American Veterans.
    Trust is the single most important aspect in our relationship with 
the Tribes and Native American Veterans. VA is working to earn the 
trust of Tribal leaders and Native American Veterans through consistent 
outreach and an open door policy. As an enrolled member of the Cherokee 
Nation of Oklahoma with over 15 years experience in Indian Affairs, I 
know it will take time, but I believe it is a goal VA will achieve. 
Serving both Indian Country and our Nation's heroes is both a 
professional and deeply personal calling.
Outreach and Consultation
    Within VA, OTGR serves as an entry point for American Indian and 
Alaskan Native Tribal Government concerns. With an estimated 383,000 
Native American Veterans and 566 federally-recognized tribal 
governments, there is much work to be done. VA is embarking on a robust 
outreach and consultation effort that consists of three pillars: 
listening, aiding, and advocating.
    While listening includes receiving communications from Tribal 
leaders through e-mail, phone, and social media tools, we believe the 
best way to create lasting bonds of trust is to meet with Tribal 
leaders and Native American Veterans in their communities. VA held 
listening sessions in Bethel, Alaska; Billings, Montana; Bismarck, 
North Dakota; and Albuquerque, New Mexico. OTGR has participated in 
conferences in Arizona, Montana, Idaho, Texas, Wisconsin, Oklahoma, and 
Washington. During April 2012, OTGR held four regional meetings 
throughout Indian Country with Tribes in an effort to facilitate 
discussions about increasing access to healthcare and benefits through 
informative presentations and interactive discussions about VA's 
efforts to reach Veterans in Indian Country. VA has also conducted site 
visits to key locations that deliver services to Native American 
Veterans, including the Consolidated Mail Outpatient Pharmacy in 
Leavenworth, Kansas, and Tribal courts in Navajo Nation, Hopi and 
Laguna Pueblo Tribes, and Tribal communities in South Dakota. OTGR is 
very grateful for the vast cooperation each of these Tribes has 
provided. Without this support, it would be difficult for OTGR to 
understand the challenges Native American Veterans are facing. 
Maintaining an aggressive outreach schedule to increase the number of 
American Indian and Alaska Native Tribal governments with which we are 
building relationships remains paramount.
    VA also provides training and assistance to Native American 
Veterans. For example, VA provided technical assistance to Native 
American Veterans seeking home loans during the recent meeting held in 
April. Our outreach provides a unique opportunity to deliver technical 
information to Native American Veterans. OTGR has sponsored outreach 
booths at the National Congress of American Indians annual convention, 
Gathering of Nations Pow-Wow, and Indian Health Service Self-Governance 
Conference, and will host a booth at the upcoming National Indian 
Health Board annual consumer conference. Officials can leverage these 
opportunities to increase Native American Veteran enrollment in VA's 
health care system, educate Veterans about benefits for which they may 
be eligible, and connect them with online resources such as eBenefits 
and My HealtheVet. Every encounter with Tribal leaders and Veterans in 
Indian Country is an opportunity to make a difference in a Veteran's 
life.
    OTGR is also advocating for Tribal governments. The Secretary of VA 
is committed to conducting meaningful consultation with Tribes; this 
means transforming words into action. VA conducted its first Tribal 
consultation in April 2012 in Washington, DC. Three more Tribal 
consultation sessions are scheduled in fiscal year (FY) 2012 for 
Alaska, Nebraska and Colorado. Tribal leaders will have an opportunity 
to voice their concerns on issues that affect the well being of 
Veterans and their families. With a direct link to the Tribes through 
OTGR, we will be able to address their concerns before new policies and 
procedures are implemented. OTGR is already serving as a vital 
intergovernmental link for VA's health, benefits, and memorial 
programs.
Sustainable Economic Opportunities
    The VA mission to ``care for him who shall have borne the battle, 
and for his widow, and his orphan'' extends to all Veterans, but VA 
officials understand that Veterans in Indian Country face unique 
challenges. My office works closely with the Veterans Benefits 
Administration (VBA) to address systemic economic issues within Tribal 
communities. VA can and will do more to increase access to and 
utilization of established benefits such as compensation and pension, 
vocational rehabilitation and employment services, and Post-9/11 GI 
Bill and other education benefits. Recent changes to the Post-9/11 GI 
Bill program illustrate the need for a direct link to Indian Country. 
We are using every avenue available to us to ensure that Veterans know 
how changes to that program will directly affect them, and OTGR will be 
a vital resource for Tribal leaders and a conduit for feedback.
    One area that VA believes deserves special attention is the Native 
American Direct Loan Program (NADL), a vital tool in VA's efforts to 
provide housing options for Native American Veterans. NADL is available 
for Native American Veterans, and for qualified non-Native American 
Veterans who are married to Native American spouses, to purchase, 
construct or improve a home on trust land or to refinance an existing 
NADL at a lower interest rate. OTGR is working with VBA to increase 
VA's efforts in Indian Country and Alaska to educate eligible Veterans 
about this important program. Our goal is to make sure every eligible 
Veteran understands the value of the NADL benefit as a long-term 
housing solution.
    OTGR will also work with Tribal leaders to address burial and 
memorial issues. On August 15, 2011, the Secretary approved the VA's 
first grant to establish a Veterans cemetery on Tribal trust land, as 
authorized in Public Law No. 109-461 (Dec. 22, 206). In FY 2011, VA 
made the first three Tribal Veterans cemetery grants. The Rosebud Sioux 
Tribe was awarded $6.9 million and the Yurok Tribe was awarded $3.3 
million to establish new Tribal Veterans' cemeteries, and the Pascua 
Yaqui Tribe was awarded $323 thousand to complete renovations to an 
existing cemetery.
    VA must measure our progress and hold ourselves to a high standard 
of achievement if we are to accomplish our goals. This starts with 
compiling recommendations from Tribal leaders and tracking these action 
items to completion. VA does not promise that every recommendation 
received will be adopted, but we do commit to ensuring Tribal leaders' 
and Veterans' voices are heard and considered. A stronger relationship 
between the Tribes and VA will lead to better results and outcomes for 
Native American Veterans.
Collaboration with Indian Health Service (IHS)
    On October 1, 2010, VA and IHS signed an updated Memorandum of 
Understanding (MOU). The Memorandum's principal goals are for VA and 
IHS to promote patient-centered collaborations in consultation with 
Tribes. Although national in scope, the MOU provides the necessary 
flexibility to tailor programs through local implementation. VA 
leadership believes that by bringing together the strengths and 
resources of each organization, we will improve the health status of 
American Indian and Alaska Native Veterans.
    VA and IHS staff have been working together to develop specific 
recommendations and action items related to the MOU. This work has been 
focused on areas such as services and benefits, coordination of care, 
health information technology, implementation of new technologies, 
payment and reimbursement, sharing of services, cultural competency and 
awareness, training and recruitment, and others. VA and IHS have made 
progress in many of these areas, and will continue to monitor progress 
through periodic meetings and quarterly updates to VA and IHS 
leadership.
    Most recently, VA and IHS produced a proposed draft agreement that 
sets forth the underlying terms and conditions for reimbursement by VA 
to IHS and Tribal health facilities for direct care services provided 
by IHS and tribal health facilities to eligible American Indian and 
Alaska Native Veterans. The proposed draft agreement, which was 
released for tribal consultation in April 2012, calls for demonstration 
sites; defines the eligible service populations and reimbursable 
services; discusses quality, payment methodologies, and claims 
submission; and includes appeals processes, confidentiality of health 
information, and information security. After tribal consultation, VA 
and IHS will make any needed revisions to the proposed draft agreement 
and design an implementation plan that will allow all parties to move 
forward expeditiously while having an opportunity to work through 
issues that may arise.
Collaboration with American Indian and Alaska Native Tribes
    On a separate but parallel track, and consistent with the 
Administration's goal to increase access to care for Veterans, the 
Alaska VA Healthcare System negotiated and entered into agreements with 
Tribal Health Programs in Alaska under which Alaska VA will reimburse 
Alaska Tribal Health Programs (ATHP) for direct care services provided 
to eligible Veterans. These agreements will strengthen both the VA and 
Alaska Tribal Health Program systems to increase access to care for 
Native and non-Native Veterans particularly those in remote and rural 
areas served by Alaska Tribal Health Programs.
    The effort to establish this agreement began one year ago following 
Secretary Shinseki's visit to Alaska. Since that time, the Alaska VA 
and the Alaska Tribal Health Program organizations have met on a 
regular basis to craft the agreement. We are now scheduling briefings 
to Tribal Leaders about VA health care eligibility and enrollment 
requirements. Additionally, the Alaska VA is coordinating training 
sessions for Alaska Tribal Health Program staff on VA benefits and 
eligibility and enrollment processes to encourage and facilitate 
enrollment of eligible Veterans into VA's system. Special recognition 
goes out to our partners at IHS and Tribal Leaders as our ongoing work 
to establish a national underlying agreement with IHS informed the 
efforts in Alaska.
    To address substance abuse and mental health issues among Veterans, 
VA has worked with Veterans Treatment Courts across the country. These 
Courts identify treatment options for many of our Veterans with 
substance use disorders or mental health conditions. OTGR is working 
with VHA to create a Veterans Treatment Court ``How To'' guide to help 
identify and link Native American Veterans involved with the criminal 
justice system with VA resources and other providers as an alternative 
to incarceration. The anticipated release of this guide is scheduled 
for September 2012. Our goal is to provide Tribal governments the 
resources they need to incorporate, at their discretion, elements of 
the Veterans Treatment Court model that may promote healing in their 
communities. This model may not work for every Tribal justice system, 
but these practices generally are consistent with the holistic approach 
to criminal justice practiced by many tribal justice systems and may be 
a valuable tool at their disposal. Local circumstances will help define 
our ability to implement many of these best practices, but we must 
learn from our experiences and leverage our successes.
Conclusion
    Secretary Shinseki's leadership has enabled VA to move forward with 
developing partnerships with Tribal Governments to enhance access to 
services and benefits for American Indian and Alaska Natives. VA 
provides high quality care and services to Native American Veterans and 
our partnerships with both IHS and Tribes will enhance our ability to 
provide care closer to home. We can and will do more to increase access 
to and utilization of benefits such as compensation and pension, 
vocational rehabilitation and employment services, and Post-9/11 GI 
Bill and other education benefits that they have earned. Additionally, 
we are pleased to have been able to move forward with the first grants 
for tribal cemeteries in 2011 and look forward to increase outreach for 
this program.
    We see a future where American Indian and Alaska Native Tribal 
governments view VA as an organization of integrity that advocates on 
behalf of Native American Veterans for their needs. We see a future 
where VA demonstrates its commitment to Native American Veterans by 
being culturally competent, respecting the unique sovereign status of 
Tribes, and reaching out to Veterans in their communities. We are 
committed to building relationships with Tribal leaders built on a 
culture of trust and respect. We see a bright future, but there is 
still much to be done.
    Thank you again for the opportunity to discuss VA's programs and 
services for American Indians and Alaska Natives. I look forward to 
answering any questions you may have.

    The Chairman. Mr. Grinnell, please proceed with your 
testimony.

         STATEMENT OF RANDY GRINNELL, DEPUTY DIRECTOR, 
       INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH 
   AND HUMAN SERVICES; ACCOMPANIED BY DR. SUSAN KAROL, CHIEF 
                        MEDICAL OFFICER

    Mr. Grinnell. Thank you, Mr. Chairman and members of the 
Committee.
    Good afternoon, I am Randy Grinnell, Deputy Director, 
Indian Health Service. I am accompanied by Dr. Susan Karol our 
Chief Medical Officer.
    Dr. Roubideaux has laryngitis today and she is very sorry 
that she is unable to attend. I am here to testify on behalf of 
IHS and programs and services for Native American veterans.
    American Indian and Alaska Native veterans may be eligible 
for health care services from both the IHS and the Department 
of Veterans Affairs. The IHS patient registration system 
documents approximately 45,000 veterans have received care in 
our system of IHS, Tribal and urban Indian health programs.
    American Indian and Alaska Native veterans have told us 
they want better coordination of services between VA and IHS. 
IHS is primarily a rural health system. Therefore, in some 
locations our facilities may be some distance from VA 
facilities. In addition, the eligibility rules for IHS and VA 
health care services differ which may cause confusion about 
coverage for services.
    For some American Indian and Alaska Native veterans 
navigating the two health care systems may prevent optimal use 
of health services for which they are eligible. VA and IHS will 
continue to work together to address the input we receive from 
Tribes and to improve services. We are making progress.
    The Department of Health & Human Services, IHS and VA have 
made progress in developing a draft agreement to facilitate VA 
reimbursement for direct care services for eligible American 
Indian and Alaska Native veterans by IHS and participating 
Tribal programs.
    IHS and VA initiated consultation on March 5 of this year 
to request input from Tribes on the main points of this 
agreement. IHS and VA also held a consultation session at the 
IHS Tribal Consultation Summit on March 13 here in Washington, 
D.C. On April 5, IHS and VA sent a letter to Tribes with the 
draft reimbursement agreement and requested input.
    The draft agreement focused on reimbursement for direct 
care services provided to veterans at IHS and participating 
Tribal facilities. IHS and VA proposed that implementation of 
these agreements begin with a demonstration project to be 
followed by national implementation. Tribes were asked to 
provide written comments on the draft agreement and 
recommendations for the demonstration project. The deadline has 
been extended to May 25 of this week.
    The national draft agreement also informed the recently 
signed agreements between VA and the Alaska Tribal Health 
Programs.
    IHS has a unique government-to-government relationship with 
Tribal governments and is committed to regular and meaningful 
consultation and collaboration. Comments from Tribes include 
requests to include specific types of services in the 
agreement, questions about timelines and process, and comments 
about reimbursements and copays.
    IHS and VA are reviewing Tribal input and plan to proceed 
soon on the demonstration and national implementation of the 
reimbursement agreement.
    In 2010, MOU between IHS and VA was renewed and signed to 
establish coordination, collaboration and resource-sharing 
between the two departments. It builds upon decades of 
successful collaboration. The MOU provides a framework for a 
broad range of IHS and VA collaboration at the local level by 
IHS area offices and Tribal health programs with the Veterans 
Health Administration.
    The MOU recognizes the importance of a coordinated and 
cohesive effort of national scope while acknowledging local 
adaptation to meet the needs of individual Tribes and 
communities. IHS and VA have consulted with Tribes on 
priorities for implementation of this MOU.
    The MOU sets five mutual goals for serving veterans: 
increasing access to and improving the quality of care; 
promoting patient-centered collaboration and facilitating 
communication; establishing consultation with Tribes, effective 
partnerships and sharing agreements; and ensuring appropriate 
resources are identified and improving health promotion and 
disease prevention services.
    To further these goals, IHS and VA actively collaborate and 
coordinate activities across several broad areas. Our written 
testimony cites several of these examples.
    In addition to our collaboration work with VA at the 
national level, the Director has instructed all of our area 
directors to meet with the VA's Veterans Integrated Services 
Networks in their areas and to consult with Tribes. We have 
included this work in partnership with the VISNs and Tribes at 
the local levels to improve the coordinated provision of health 
services to the veterans. It is also part of their performance 
contracts. Several new collaborative efforts have emerged from 
these partnerships and are detailed in our written testimony.
    In summary, the MOU has facilitated collaboration at the 
national, regional and local levels with the goal of providing 
quality access to care for veterans. The reimbursement 
agreement will help increase access for all of our veterans. 
IHS and VA are committed to working in partnership to improve 
the provision and coordination of services in consultation with 
Tribes.
    I want to recognize the strong support and commitment of 
Secretary Shinseki and his staff as we work together to more 
effectively serve our common missions. Our American Indian and 
Alaska Native veterans deserve our best efforts to honor their 
service. While we have made progress, we understand there is 
much more to do and both agencies are committed to this work.
    Mr. Chairman, that concludes my testimony and I will be 
happy to answer any questions.
    [The prepared statement of Ms. Roubideaux follows:]

Prepared Statement of Yvette Roubideaux, M.D., M.P.H., Director, Indian 
                             Health Service
    Mr. Chairman and Members of the Committee:
    Good afternoon. I am Dr. Yvette Roubideaux, the Director of the 
Indian Health Service (IHS). I am pleased to have the opportunity to 
testify on Programs and Services for Native American Veterans.
    As you know, the Indian Health Service (IHS) 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 (AI/AN). The 
mission of the Indian Health Service is to raise the physical, mental, 
social, and spiritual health of AI/AN 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. The Indian health system provides services to nearly 1.9 
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 AI/AN 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 
AI/ANs.
    American Indians and Alaska Natives have a long and proud record of 
service to this Nation. No other population group has a higher level of 
participation in military service. American Indian and Alaska Native 
Veterans may be eligible for healthcare services from both the Indian 
Health Service and the Department of Veterans Affairs (VA). IHS' 
patient registration system documents approximately 45,000 veterans 
have received care in our system of IHS, Tribal and Urban Indian health 
programs. American Indian and Alaska Native veterans have told us they 
want better coordination of services between VA and the IHS. IHS is 
primarily a rural health system; therefore, in some locations, our 
facilities may be a significant distance from VA facilities. In 
addition, the eligibility rules for IHS and VA health care services 
differ, which may cause confusion about coverage for services. For some 
AI/ANs Veterans the complexity of navigating two health care systems 
may prevent optimal use of federally funded health services for which 
they are eligible through IHS and VA. VA and IHS will continue to work 
together to address the input we receive from Tribes and to improve 
services for American Indians and Alaska Natives and we are making 
progress.
Indian Health Service--Department of Veterans Affairs Collaborations
VA Reimbursement for Services Provided by IHS to Eligible American 
        Indian and Alaska Native Veterans
    IHS and VA are committed to improving access to services and 
benefits for AI/AN Veterans. The Department of Health and Human 
Services/Indian Health Service and VA have made significant progress in 
developing a draft agreement to facilitate VA reimbursement for direct 
care services provided to eligible AI/AN Veterans by IHS and 
participating Tribal health programs. IHS and VA initiated a 
consultation on March 5, 2012 to request input from Tribes on the main 
points of the draft agreement between VA and IHS. IHS and VA also held 
a consultation session at the IHS Tribal Consultation Summit on March 
13-14, 2012 in Washington, D.C. On April 5, 2012, IHS and VA sent a 
letter to Tribes with the draft reimbursement agreement and requested 
input. The draft agreement focuses on reimbursement for direct care 
services provided to AI/ANs at IHS facilities and participating Tribal 
facilities. IHS and VA propose that implementation of these agreements 
begin with a demonstration project to be followed by national 
implementation. Tribes were asked to provide written comments on the 
draft agreement and recommendations for the demonstration project; the 
deadline for input has been extended to May 25, 2012. The draft 
national agreement also informed the recently signed agreements between 
VA and Alaska Tribal Health Programs.
    The IHS has a unique government-to-government relationship with AI/
AN Native Tribal governments and is committed to regular and meaningful 
consultation and collaboration with Tribes. The IHS considers 
consultation an essential element for a sound and productive 
relationship with Tribes. The initial analysis of comments from Tribes 
include requests to include specific types of services in the 
agreement, questions about timelines and process, and comments about 
reimbursements and copays. IHS and VA are reviewing Tribal input and 
plan to proceed soon with the demonstration and national implementation 
of the reimbursement agreement.
    IHS and VA staff have been working together to prepare for billing 
and collection under the agreement. To date, six webinar training 
sessions on VA eligibility and enrollment process have been held and 
more training on eligibility, enrollment, claims filing, and 
reimbursement processing are planned. These collaborative efforts 
support outreach of IHS, Tribal, and Urban health programs to assess, 
assist and inform AI/AN veterans about potential health benefits.
Indian Health Service--Veterans Health Administration Memorandum of 
        Understanding
    A Memorandum of Understanding (MOU) between the IHS and the 
Department of Veterans Affairs (VA) was renewed and signed in 2010 to 
establish coordination, collaboration, and resource-sharing between the 
two Departments; and it builds upon decades of successful 
collaboration. It outlines joint goals and objectives for ongoing 
collaboration between IHS and VA to further their respective missions, 
in particular, to serve AI/AN veterans who comprise a segment of the 
larger beneficiary population for which they are individually 
responsible. The purpose of the MOU is to foster an environment that 
brings together the strengths and expertise of each organization to 
actively improve the care and services provided by both agencies. It 
provides a framework for a broad range of IHS-VA collaborations at the 
local level by IHS Area Offices and Tribal Health Programs with the 
Veterans Health Administration (VHA). The MOU recognizes the importance 
of a coordinated and cohesive effort of national scope, while also 
acknowledging that implementation of such efforts requires local 
adaptation to meet the needs of individual Tribes and communities; and, 
VA and IHS have consulted with Tribes on priorities for implementation 
of the MOU.
    The MOU sets forth 5 mutual goals for serving Native American 
Veterans. These goals include (1) increasing access to and improving 
the quality of health care and services offered to Native Veterans by 
both agencies; (2) promoting patient-centered collaboration and 
facilitating communication among VA, IHS, AI/AN Veterans, Tribal and 
Urban Indian Health Programs; (3) establishing in consultation with 
Tribes, effective partnerships and sharing agreements in support of AI/
AN Veterans; (4) ensuring appropriate resources are identified and 
available to support programs for AI/AN Veterans; and (5) improving 
health promotion and disease prevention services to AI/AN veterans to 
address community-based wellness.
    To further these goals, the IHS and VA actively collaborate and 
coordinate activities across several broad areas. I will describe our 
activities in these areas along with the most recent accomplishments in 
each one.
Improve Coordination of Care
    IHS and VA staff have been working to improve coordination of care 
for AI/AN Veterans served by IHS, Tribal, or Urban Indian health 
programs and VA. Six training sessions on VA eligibility requirements 
for the IHS, Tribal and Urban Indian health programs have been held to 
improve the ability of frontline patient registration, business office, 
and Contract Health Service personnel to assist AI/AN Veterans access 
VA services. This training focused on how to assist an AI/AN Veteran 
seen in an IHS facility with completing the VA eligibility paperwork 
and how to assist with accessing VA services.
Development of Health Information Technology
    Improving care through the development of health information 
technology, including the sharing of technology and the inter-
operability of systems continues as a part of a long history of active 
collaboration between the IHS and VA around information technology. 
Both agencies continue to actively consult on electronic health record 
(EHR) certification and Meaningful Use requirements. IHS staff is 
meeting regularly with VA and Department of Defense (DOD) 
representatives in planning for the Integrated Electronic Health Record 
(iEHR) and designing the EHR interface and care management functions, 
with an anticipated implementation plan starting in FY 2014. These 
activities will result in the ability of IHS and VA to share medical 
records and better coordinate care for AI/AN Veterans that receive care 
in both health care systems.
Development and Implementation of New Models of Care Using New 
        Technologies
    Enhancing access through the development and implementation of new 
models of care using new technologies is another focus area for IHS and 
VA staff. For example, activities include completion of a summary 
document on the best practices for providing tele-psychiatry services 
to AI/AN veterans, completion of implementation of telemedicine 
services to provide connectivity between the Prescott VHA facility in 
Prescott, AZ and the IHS in Chinle, AZ on the Navajo Reservation, and 
evaluation of an outreach project for homeless veterans.
Improve Efficiency and Effectiveness at the System Level
    IHS and VA are focusing on improving efficiency and effectiveness 
at a system level through sharing of contracts and purchasing 
agreements. Staff is developing pre-approved templates for agreements, 
and the standard policies and common agreement procedures to support 
local collaboration. The MOU also provides opportunities to strengthen 
existing sharing agreements with VA. To illustrate how this supports 
local collaboration, the IHS Tucson Area Leadership staff met with the 
Southern Arizona VA and a local agreement is being developed as a 
result of the national MOU.
Improve the Delivery of Care through Active Sharing of Programs
    This focus area aims to improve the delivery of care through active 
sharing of care process, programs, and services with benefit to those 
served by both IHS and VA. These activities include a focus on Post-
Traumatic Stress Disorder (PTSD) and staffs are currently working on a 
satellite broadcast designed to engage and educate VA providers on 
cultural considerations that may need to be taken into account when 
providing mental health services to AI/AN veterans living in rural 
environments. While each Tribe has its own unique culture, there are 
similarities across Tribes that providers should be aware of when 
providing care to this population. Staff is also focusing on suicide 
prevention and working to develop an AI/AN-sensitive Operation SAVE 
version, a VA gatekeeper training program, for use in Indian country 
this year; staff report 157 Tribal outreach activities provided to 
date.
    IHS and VA staffs have also undertaken Pharmacy collaborations and 
have successfully completed a pilot program between the VA Consolidated 
Mail Outpatient Pharmacy (CMOP) and IHS, with expansion to the 
following sites: Phoenix, AZ; Claremore, OK; and Yakama, WA, and Rapid 
City, SD. In fiscal year 2011, over 19,000 medications were dispensed 
through the CMOP program, and, to date, over 50,000 prescriptions have 
been dispensed within the IHS, through the CMOP program. The IHS, VA, 
and DOD have also partnered to train pharmacy technicians.
    Staffs focusing on Long-Term Care services have increased the 
number of American Indian and Alaska Native Veterans served through the 
VA Home Based Primary Care (HBPC) program with IHS and Tribal Nations 
from 55 in December, 2010 to 234 by September, 2011. There are 
currently 160 AI/AN veterans actively enrolled in this program.
    VA has an ongoing collaboration with Alaska that continues to 
enhance our collaborative activities. The Tribal Veteran Representative 
(TVR) program has trained 47 people on VA eligibility and benefits, and 
to improve coordination of care, support outreach, and co-management of 
patients.
Increase Cultural Awareness and Competent Care
    Attention to cultural awareness and increasing culturally competent 
care for VA and IHS beneficiaries is the focus of IHS and VA staff who 
are developing a three tiered cultural awareness training program, with 
each tier having a different level of intensity and immersion into 
cultural issues.
Training and Workforce Development/Sharing of Staff and Enhanced 
        Recruitment and Retention of Professional Staff
    Increasing capability and improving quality through training and 
workforce development, and increasing access to care through sharing of 
staff along with enhanced recruitment and retention of professional 
staff are also an important focus of collaborations between IHS and VA 
staff. Activities include sharing of educational and training 
opportunities and resources, and specialty services. VA has made 239 
web-based courses and 7 video courses available to IHS. Of these, 124 
have been made available through the Department of Health and Human 
Services' (HHS) Learning Management System. An additional 215 courses 
are currently under review by IHS. In 2012 training programs will 
reside outside of firewalls and therefore be more easily accessible to 
staff from both agencies.
Address Emergency, Disaster, and Pandemic Preparedness and Response
    IHS and VA staff are working together on emergency, disaster, and 
pandemic preparedness and response by sharing contingency planning and 
preparedness efforts, joint development of materials targeting AI/AN 
veterans, and joint exercises and coordination of emergency response. 
Current activities include working with the Federal Emergency 
Management Agency to supply materials for training of Tribal emergency 
response teams.
Development of Joint Implementation Task Force to Identify Strategies 
        and Plans for Accomplishing the Tasks and Aims of the MOU
    The development of a joint implementation task force to identify 
strategies and plans to accomplish the tasks and aims of the agreement 
continues. IHS and VA leadership meet regularly to address the draft 
reimbursement agreement, consultation comments and issues, and regular 
meetings of IHS and VA staff on focus areas previously mentioned.
Collaboration with VA at the IHS Area and Local Levels
    In addition to our collaborative work with VA at the national 
level, I have instructed all of my IHS Area Directors to meet with the 
VA Veterans Integrated Services Networks (VISNs) in their Areas and to 
consult with Tribes on how to better coordinate services at the Area 
and the local levels. We have included this work in partnership with 
the VISNs and Tribes at the Area and local levels to improve the 
coordinated provision of health services to AI/AN Veterans as an 
element in performance contracts.
    Several new collaborative efforts have emerged from these 
partnerships. In Alaska, 47 people in Alaska are trained as Tribal 
Veterans' Representatives to help Alaska Native veterans gain access VA 
health and other benefits. The Area's goal is to train 100 by the end 
of the fiscal year.
    The IHS Areas in the northern plains--the Billings and Aberdeen 
Areas--are also working collaboratively with VA. The Billings Area 
meets regularly with VA to discuss issues related to telemedicine, VA 
eligibility rules and regulations, and Tribal Veteran Representative 
trainings. The Area also coordinates discussions between the Billings 
Area Urban Indian programs and VA because of the large population of 
Native American veterans living in the urban towns of Montana and 
Wyoming that may be eligible for services at the urban clinics. The 
Aberdeen Area continues collaborative efforts to foster strong and 
productive working relationships with VA, such as use of the VA mobile 
MRI. Agreements are currently in place with the VA for Consolidated 
Mail Outpatient Pharmacy Service and Compensated Work Therapy Programs. 
The Area and VA are working on a post-traumatic stress disorder DVD and 
continue to participate in suicide prevention workgroup conference 
calls.
    The Bemidji Area works closely with VISN 11 and 12 outreach workers 
to provide an information session on VA programs to Tribes in Michigan 
and Wisconsin. As a result, Tribal Programs began working with VA 
facilities to coordinate care. The acting Area Director and the 
Behavioral Health Consultant attended the VA Office of Tribal 
Government Relations, Central Region Meeting held in April. Ongoing 
meetings with the three VISN's are planned. A meeting with VISN 23 
Directors is planned for May and there is a pending meeting with the 
Fargo VA to work on coordination of care for beneficiaries of the three 
federal sites. The Cass Lake Pharmacy was invited to present on their 
Medication Reconciliation process as part of the IHS-VA CMOP webinar 
entitled ``Medication Use Crisis'', a joint presentation to VHA and DOD 
personnel on May 18. Cass Lake Pharmacy is also seeking to work with 
the Fargo VA on medication reconciliation for joint beneficiaries. This 
effort is expected to also include the Bemidji Community Based 
Outpatient Clinic (CBOC) and the St. Cloud Veterans Administration 
Medical Center (VAMC). Area Patient Benefits Coordinators were informed 
about the upcoming VA-IHS webinar training on VA Enrollment and 
Eligibility.
    The IHS Areas in the Southwest--the Navajo and the Phoenix Areas, 
are also collaborating with VA on serving American Indian veterans. In 
the Navajo Area, the VA VISN 18 (Southwest) developed video 
connectivity for direct patient care between the Chinle, AZ IHS 
facility and the VA facility in Prescott, Arizona. In the Phoenix Area, 
VA has newly established a Native American Coordinator Position. This 
Coordinator has met with Phoenix IHS Area leadership and has also 
established meetings between one of the VISNs and IHS Service Units 
regarding the VA scope of services.
Summary
    The MOU has facilitated collaboration between IHS, Tribal and Urban 
programs and VA at the national, regional, and local level, with the 
common goal of providing quality access to health care services to our 
AI/AN Veterans. The reimbursement agreement will help increase access 
for AI/AN Veterans. The activities that I have described illustrate a 
range of active and effective areas of collaboration. IHS and VA are 
committed to working in partnership to improve the provision and 
coordination of services for AI/AN Veterans in consultation with 
Tribes. I want to recognize the strong support and commitment of 
Secretary Shinseki as we have worked together to more effectively serve 
our common missions. Our American Indian and Alaska Native Veterans 
deserve our best efforts to honor their service through our 
collaborative activities to improve access to quality health services. 
While we have made significant progress, we understand we have much 
more to do, and both agencies are committed to this important work.
    Mr. Chairman, this concludes my testimony. I will be happy to 
answer any questions that you may have. Thank you.

    The Chairman. Thank you very much, Mr. Grinnell.
    Mr. Gover, please proceed with your statement.

  STATEMENT OF KEVIN GOVER, DIRECTOR, NATIONAL MUSEUM OF THE 
                        AMERICAN INDIAN

    Mr. Gover. Good afternoon, Mr. Chairman.
    We welcome the opportunity to come and discuss the work of 
the National Museum of the American Indian with regard to 
Native veterans.
    As you know, our responsibility at the NMAI is the 
presentation of the history, art and culture of the Native 
peoples of the Americas and Hawaii. It stands to reason that 
because service in the Armed Forces of the United States is so 
deeply embedded in the traditions and history of many of the 
Native American nations that we would spend a considerable 
amount of our time treating the subject.
    A couple of things come to mind about this work. First, you 
should know that one of the most popular exhibitions we have 
created and sent out into the world to go to various venues was 
an exhibition about the Code Talkers of Word Wars I and II. 
That exhibition is still traveling throughout the United 
States. It has been to many reservations but also many non-
Indian communities. It always comes as a surprise to many 
people to see the depth of commitment to service of the Native 
Americana community.
    Second, having grown up in Oklahoma where the 45th Infantry 
was legendary for their service during World War II and many of 
the men who served in that division were American Indians, 
including my grandfather, we got to see firsthand how deeply 
embedded this reverence for service and for our veterans is in 
Native culture in Oklahoma. As I grew older and traveled to 
other parts of the country, I could see that was practically a 
universal thing.
    Much in the way Senator Franken was describing this 
reverence for veterans and the honoring of veterans, it is 
embedded in many elements of contemporary Tribal culture and 
ritual and so, again, it will always be a major part of our 
work at the National Museum of the American Indian.
    I do want to mention a specific statutory authorization 
that the Museum has which is to construct and maintain a 
National Veterans Memorial at the NMAI. It is an usual statute 
in a number of respects in that it specifies a location within 
the structure that was authorized by Congress when it 
established the National Museum of the American Indian, but 
then it goes on to say that fundraising and the conduct of a 
competition for the design of such a memorial would be carried 
out by the National Congress of American Indians.
    NCAI does a great deal of fine work and they have any 
number of other things they need to do. It strikes me as 
somewhat unlikely to make it to the top of NCAI's priority list 
and given that we are literally prohibited from using our own 
resources or from raising funds ourselves for such a memorial, 
it seems unlikely that we are going to be able to construct 
such a memorial within the foreseeable future.
    We invite Congress' attention to that issue and your 
guidance on how we might proceed going forward.
    With that, Mr. Chairman, I thank you again for the 
opportunity to testify today. Thank you for your attention to 
issues affecting Native veterans. I would be happy to answer 
any questions you may have.
    [The prepared statement of Mr. Gover follows:]

  Prepared Statement of Kevin Gover, Director, National Museum of the 
                            American Indian
    Good morning, Mr. Chairman and members of the Committee. I am 
honored to be here today to discuss the work of the Smithsonian 
Institution's National Museum of the American Indian concerning Native 
American veterans. As you might expect, programming, research, and 
exhibitions concerning the contributions of Native American veterans is 
a large part of our work at the NMAI. Service in the Armed Forces of 
the United States is a strong tradition among many Native nations, and 
the acknowledgement of Native veterans has therefore become embedded in 
the cultures, traditions, and histories of many Native communities.
    Our programming at the NMAI has included many events relating to 
Native veterans. Just in the few years since I arrived at the NMAI, we 
have had Veterans' Day and Memorial Day programming relating to Native 
service in the Armed Forces. Our film and video program occasionally 
presents films relating to Native veterans, and we have had several 
authors of books about Native veterans present their work at the 
museum.
    Perhaps our most significant treatment of the subject is the 
traveling exhibition that the NMAI created. It is titled Native Words, 
Native Warriors. The exhibition explores the service of Native American 
communication specialists who used their Native languages to develop 
codes that could not be broken by the enemies of the United States in 
World War I and World War II. Native Words, Native Warriors tells the 
remarkable story of Indian soldiers from more than a dozen tribes who 
used their Native languages in the service of the U.S. military. The 
exhibition was designed to travel to other museums, cultural centers, 
and libraries, and through the Smithsonian Institution's Traveling 
Exhibition Service, it has found many homes and received enthusiastic 
responses from a broad range of audiences.
    As you know, the NMAI has also been authorized by Congress to 
``construct and maintain a National Native American Veterans' 
Memorial.'' Several limitations on that authority make it unlikely that 
we will be able to build such a Memorial. First, the statute requires 
that the Memorial be located ``within the interior structure'' of the 
NMAI's museum on the National Mall. This limits our options in locating 
a permanent Memorial, given the limited space available within the Mall 
museum.
    Second, the statute places a great deal of responsibility on the 
National Congress of American Indians, rather than the NMAI, to develop 
the Memorial. NCAI is authorized by the law ``to hold a competition to 
select the design of the Memorial.'' Further, the statute provides that 
the National Congress of American Indians ``shall be solely responsible 
for acceptance of contributions for, and payment of expenses of, the 
establishment of the Memorial.'' Finally, the statute prohibits any use 
of federal funds to pay for any expense related to the establishment of 
the Memorial.
    Mr. Chairman, the powerful tradition of Native American patriotism 
finds its clearest expression in the service of young Native men and 
women. It is a key component of modern tribal life, and we could not 
present the histories and cultures of Native America without delving 
deeply into this subject. We will continue to do so as opportunities 
arise.
    I would be pleased to answer any questions the Committee might 
have.

    The Chairman. Thank you very much, Mr. Gover.
    Ms. Birdwell, since established last year, the Office of 
Tribal Government Relations has been very active in conducting 
outreach and seeking to best serve Native veterans. Please 
discuss the important role your office would continue to play 
moving forward.
    Ms. Birdwell. Yes, sir, I am happy to.
    Our team at the Office of Tribal Government Relations 
always acknowledge that prior to establishment of the office, 
there were many people within VA who worked hard over the years 
to establish at the local level positive working relationships 
with Tribal governments to reach our veterans in Indian 
country.
    The establishment of the office in many ways strengthens 
and enhances the agency's ability to reach veterans in Indian 
country, to build a relationship with Tribal leaders and really 
ensure that voice is heard in programs and policies implemented 
by the Department.
    We like to say our office does not do per se health care 
benefits or the work of the National Cemetery Administration 
but we work very closely with our colleagues nationwide in each 
one of those organizations to ensure that if there is a 
particular issue, if there is an issue related to training, 
information, technical assistance, that we ensure those subject 
matter experts and leaders are made available to meet with 
Tribal leaders and to meet with those who serve veterans in 
Indian country.
    We also like to say we want to ensure that VA is part of 
the landscape of Indian country, that Tribes know who we are, 
what we offer and how to get to us. That, I think, sort of 
defines the level of our work within VA.
    The Chairman. Thank you very much.
    Mr. Grinnell, your testimony mentions that IHS has 
estimated 45,000 Indian beneficiaries registered as veterans in 
the agency's patient registration system. Is there specific 
outreach to these 45,000 veterans to ensure that they are aware 
of all the services they have earned at both HS and the VA?
    Mr. Grinnell. Yes, Mr. Chairman, there is. One of the 
things we are doing in collaboration with the VA is actually 
training our business office staff. The VA also has a program, 
the Tribal veteran representatives, which helps to further 
provide outreach and education. Recently we have had a number 
of trainings with them, web sessions and so forth, that are not 
only training our staff but also the Tribal Health Program 
staff so that more importantly, first and foremost, they are 
trying to get veterans enrolled in the VA system and identified 
as to what benefits they are eligible for. That close 
coordination allows us to try to maximize the benefits veterans 
can access.
    The Chairman. Thank you very much.
    Mr. Gover, you discussed some of the obstacles in 
constructing the National Native American Veterans Memorial 
authorized by Congress. Is there any way Congress can alleviate 
these obstacles without burdening the taxpayers?
    Mr. Gover. Mr. Chairman, I believe so. Obviously Congress 
and the Administration should review the statute together. If 
the question is sufficient Tribal support for such a memorial, 
I absolutely believe there will be. If, for example, the NMAI 
was authorized to receive contributions for that purpose, just 
from the general level of interest that has been expressed to 
me from a variety of Tribal representatives, I don't have any 
doubt that we would be able to generate private resources to 
construct such a memorial. I think it would be relatively 
expensive but I believe that level of support exists for the 
memorial.
    The Chairman. Thank you.
    Senator Franken, any questions you may have?
    Senator Franken. Yes. Thank you, Mr. Chairman.
    Director Birdwell, you spoke at the top about the issue of 
trust between the VA and the Native community. Mr. Grinnell, 
you talked about the years and decades of work that has been 
done between the Health Service and VA. What is the source of 
this distrust, in your opinion?
    I understand we have this new Memorandum of Understanding 
and we are working on reimbursement to the IHS from the VA. 
Where does the distrust come from and to what extent are this 
Memorandum of Understanding and these kinds of actions 
mitigating that distrust?
    Ms. Birdwell. That is an excellent question. I think that 
some of the areas of mistrust from the VA perspective, maybe 
historically one of the analogies sometimes that I make is that 
when it comes to the VA, over the last five years, VA has 
really ramped up an aggressive effort to really focus on the 
needs of veterans in rural areas.
    A large number of Tribal communities are in very rural 
areas and historically, with VA being more concentrated in 
urban locations, I think that it would be fairly accurate to 
say that maybe VA did not historically reach out to rural 
locations because they were hard to get to, specifically with 
Tribal communities because they were hard to get to, the agency 
didn't speak the language in terms of understanding some of the 
unique cultural issues and it was complicated. Maybe the agency 
wasn't aware of the importance of engaging the voice of Tribal 
leaders to understand what some of the challenges were in 
Tribal communities.
    I think the converse was true that the VA was hard to get 
to, didn't speak the language, understanding the bureaucracy 
and it was complicated. I think in some respects maybe veterans 
had a bad experience with the VA because of lack of 
understanding, lack of engagement and also maybe not 
consistently showing up. Maybe there was mistrust built up over 
time that was also synonymous with mistrust of the Federal 
Government in general.
    That would be what I would say was the basis of some of the 
mistrust. I think also the importance of really understanding 
the VA and the Indian Health Service have a common consumer, 
the Native veteran and to really press through this MOU, which 
is much more specific, the one in 2010 than the one in 2003, to 
really understand how we can join forces and work together to 
build upon each other's expertise where one of us may be 
stronger than the other with respect to understanding the 
unique cultural needs, the importance of engaging the voice of 
Tribal leaders, looking at the infrastructure that may exist 
through the IHS health care system that maybe VA has not gone 
into that market.
    That would be my response to that question.
    Senator Franken. Mr. Grinnell?
    Mr. Grinnell. In terms of the mistrust, some of the 
comments we have received from Tribes and individual patients a 
lot of times has been about the challenges they experience in 
trying to access the system. In some cases, that is both 
systems. A lot of times it is because the location of the VA 
facility may be further away. The IHS facility may be closer 
because many of our facilities are located on the reservation.
    The other challenge is the eligibility requirements which I 
mentioned in my testimony. There is different criteria that 
comes into play both in the VA and the IHS system for certain 
types of service, for example contract health service. You have 
to be a resident, a member of that Tribe, and so forth.
    A lot of times, the feedback we receive from veterans has 
been they feel they are shuffled back and forth between the two 
systems. We feel the MOU will help us to move closer toward our 
mutual goal of trying to address the true needs of our 
veterans.
    Senator Franken. Thank you.
    Mr. Chairman, I know I have gone through my time but 
unfortunately, I am going to have to leave after this panel. I 
was wondering if I could ask one more question of the panel? 
Would that be all right?
    The Chairman. Yes.
    Senator Franken. Thank you, Mr. Chairman.
    Director Birdwell, you did mention one of the barriers was 
that so many Native veterans are in rural areas. As I mentioned 
in my opening statement, I have a piece of legislation I 
introduced with Senator Boozman of Arkansas that addresses 
rural veterans' health care including Native veterans in rural 
areas.
    We are hoping to get action on that bill this year. The 
bill is meant to get VA's Office of Rural Health to plan more 
strategically and therefore use its resources more prudently to 
improve access to health care for rural veterans. My bill 
specifically calls on the Office of Rural Health to include in 
its strategic plan, plans to coordinate care and share 
resources with IHS.
    Ms. Birdwell, can you tell me how your Office of Tribal 
Government Relations works with the Office of Rural Health 
within the VA and the same question for you, Mr. Grinnell. Does 
IHS work the VA's Office of Rural Health?
    Ms. Birdwell. Yes, sir, the Office of Tribal Government 
Relations works very closely with VA's Office of Rural Health. 
The Office of Rural Health is the entity within VA that is 
tasked to work directly with the Indian Health Service related 
to implementation of all of the activities related to the MOU.
    Our Tribal government relations specialists are actively 
engaged in some of the work group activities related to the 
MOU. We meet on a regular weekly, sometimes multiple times in 
one week, basis with the Office of Rural Health. We have four 
Tribal government relations specialists located in various 
places around the country and they are tasked with managing a 
portfolio of relationships with Tribes in their regions.
    They are really our eyes and ears in many ways on the 
ground working directly with Tribes to really assist with 
informing the Office of Rural Health what the unique needs are 
with respect to veterans in Tribal communities.
    ORH, as it is called, in the meantime is doing a fine job 
of launching a number of special projects that affect the 
American and Alaska Natives. For the last two years, ORH has 
expended I think $35 million worth of projects in Tribal 
communities nationwide. We have seen quite an expansion in 
home-based primary care programs, telehelp and telemedicine 
supporting of Tribal veterans, representative training and all 
those efforts are achieved through grants through the Office of 
Rural Health.
    Since our office is tasked with implementing the Tribal 
consultation policies, one of the VA-specific consultation 
topics is how to engage Tribes in activities related to the VA/
IHS MOU, meaning at the national and local levels. Sometimes we 
will meet with Tribal leaders and say we don't hear the good 
news stories, we don't hear the outcomes of the work of some of 
the ORH grants. Our role is serve as that kind of conduit 
between the agency and the Tribes and in this particular 
instance with ORH to build awareness of those activities and 
how to engage Tribes more effectively.
    Senator Franken. Thank you.
    Mr. Grinnell?
    Mr. Grinnell. The Office of Rural Health is the primary 
office within the VA that our area and our clinical staff at 
the service unit community level has been working with the VA 
and the respective hospitals.
    As I mentioned, there have been years of collaboration with 
the VA on various things. Some of the more notable items are 
telemedicine where you are beginning to see greater expansion. 
Our electronic health record and patent management system is 
actually a VA product we have utilized and implemented 
throughout our entire system.
    There are many projects going on locally with lots of 
collaboration and it is going towards trying to bring more 
services from the VA to the local communities to utilize our 
facilities and our staff as well as theirs to try and improve 
access to care.
    Senator Franken. Thank you all.
    Thank you, Mr. Chairman, for your indulgence.
    My apologies to the second panel, I do have to leave now. 
Thank you.
    The Chairman. Thank you very much, Senator Franken.
    I want to thank the first panel very much. I have further 
questions for you that I will put in the record and have you 
respond to them.
    Our schedule has just changed. They have moved up the 
votes, we need to move on. I want to thank you so much for 
being here and helping us with this hearing.
    Thank you.
    Will the second panel please come forward? The second panel 
consists of: Mr. Wayne Burke, Chairman, Pyramid Lake Paiute 
Tribe located in Nixon, Nevada; Lt. Col. Kelly McKaughan, 
Director, Veterans Advocacy, Choctaw Nation in Durant, 
Oklahoma, accompanied by Maj. Nathaniel Cox, Director, Choctaw, 
Global Staffing, Choctaw Nation, in Durant, Oklahoma; Ms. 
Cheryl Causley, Chairperson, National American Indian Housing 
Council located in Washington, D.C.; and Ms. Noelani Kalipi, 
President of the TiLeaf Group in Hilo, HI.
    I want to welcome you all here today. Chairman Burke, will 
you please proceed with your statement?

 STATEMENT OF HON. WAYNE BURKE, CHAIRMAN, PYRAMID LAKE PAIUTE 
                             TRIBE

    Mr. Burke. Good afternoon, Mr. Chairman. I appreciate the 
opportunity and the honor to come before this Committee to give 
testimony this afternoon.
    My name is Wayne Burke, Chairman of the Pyramid Lake Paiute 
Tribe located in the Great Basin area in northern Nevada.
    Our Native people have lived and sustained the life of a 
warrior. Our ancestors and relatives fought and defended our 
Tribal nations to secure food, our homelands and to protect the 
young, the old and our families. That warrior spirit is passed 
on in our songs, our stories, our dances and our traditions.
    Many of our battles against the United States Government, 
along with the massacres perpetrated against the Native 
Nations, are not found in history books or taught in schools, 
but they are passed on through our oral teachings. From the 
young to the old, some stories are never to be told again. As 
with the old people, the younger generations continue to answer 
the call to arms and serve our Tribal and Federal nations 
taking that warrior spirit with them.
    We serve in the Army, the Air Force, the Navy, the Marines 
and the Coast Guard and National Guard. As with all veterans, 
representing all the nations under the United States flag, we 
serve with honor, dignity and the desire to protect, fight and 
to win battles.
    With conflicts and the continued threat of terrorism on 
those who live in all regions and lands of the globe, the 
United States military continues to provide that protection and 
service through our men and women who enlist in the Armed 
Services.
    As our warriors return home, I see the demand and need for 
advocacy and support for our veterans. Cultural traditions and 
beliefs are significant in the manner in which Tribes and 
Native people prepare, sustain, heal and survive war. These 
cultural beliefs and ways of life need to be recognized and 
used to offer and provide more services and resources to Native 
veterans.
    It is estimated that more than 12,000 American Indians 
served in the United States military during World War I. More 
than 44,000 American Indians out of a total Native American 
population of less than 350,000 served with distinction between 
1941 and 1945 in both European and Pacific theaters of war.
    More than 42,000 Native Americans, more than 90 percent of 
them volunteers, fought in Vietnam. Native American 
contributions to the United States military combat continued in 
the 1980s and 1990s as they saw duty in Grenada, Panama, 
Somalia and the Persian Gulf.
    Per population, more Native veterans serve in the United 
States military than any other ethnic group. The Vietnam War 
Memorial has a statute of three soldiers representing the 
white, black and Hispanic. Our Native warriors should stand 
alongside those three statutes as a testimony to our 
contributions and brotherhood with all American soldiers we 
fought alongside.
    The VA must understand and know the population they serve. 
Tribes from the north, the south, the east and the west all 
have distinct traditions and beliefs. The VA is a complex 
system which is intimidating and frustrating for veterans to 
navigate. As a young Marine returning from Africa and being 
discharged shortly after, I was told I could get my teeth 
cleaned 90 days after I discharged and I had some money 
somewhere in the GI bill. Services through the Veterans 
Administration should be transparent and more accessible. 
Veterans need to know what services and resources are available 
to them.
    Educational benefits and college enrollment has become more 
cumbersome, expensive and intimidating. I have spoken to 
veteran representatives from colleges in northern Nevada and 
they have reported the GI bill and accessing those funds has 
become very complex and requires extensive reporting and 
knowledge in obtaining and ensuring college courses meet GI 
bill regulations. Transfer credits and criteria for higher 
education credits is becoming increasing more complicated.
    With the growing number of veterans who have served on 
foreign shores and been exposed to the harmful effects of 
chemical and biological weapons, stress and combat action, we 
are not prepared or have limited resources to provide services 
from documented cases of Post Traumatic Stress Disorder, 
depression, suicide and other emotional mental health issues. 
Many of our reservations are found in extreme rural areas of 
the country where ambulatory and mental health services are 
only available on a very limited basis.
    How does a veteran receive a business or home loan? I have 
gone to the local Small Business Administration and advised 
banks are not approving business loans because of the economic 
development. Natives who reside on trust land or reservations 
such as Pyramid Lake and other reservations across the country 
cannot access loans because banks will not authorize loans to 
Indians who live on Tribal lands. Tribes, in many instances, 
must waive their sovereign immunity rights to receive 
traditional loans from banks.
    Next are the advantages and disadvantages of Indian health 
services. Big Brother is always watching and regulating. As 
Tribal nations we must adhere and conform to the operational 
standards of the Federal agencies which regulate health care 
which includes appropriations, services, resources and most 
importantly, contract health services and paying medical bills. 
When bills and contracted health services are not paid in a 
timely manner, Tribal members are taken to creditors, are 
refused services and wait for authorization from Indian Health 
Services.
    I have had the opportunity to meet with Dr. Roubideaux, 
Director of the Indian Health Service. She so eloquently put it 
``We must hold our veterans harmless from the system.'' The 
Memorandum of Understanding between the Veterans Administration 
and the Indian Health Service was signed in 2010 under the 
authority of the Indian Health Care Improvement Act, 25 U.S.C. 
 1645, 1647 and 38 U.S.C.  523.
    Under the current MOU, what is the charge, what is the 
authority and who is responsible for ensuring that IHS and the 
VA are working in collaboration with Tribal nations and the 
government-to-government trust obligations are being met? The 
first time I saw this MOU was in 2011. Who or what agency is 
ensuring regulation and compliance with the Memorandum of 
Understanding?
    The Chairman. Mr. Burke, will you please summarize your 
statement? You have gone over your time.
    Mr. Burke. Excuse me.
    One last thing, Mr. Chairman. I come from a reservation on 
a street that has broken down fences, rusty cars, rez dogs and 
more importantly, family and children who depend on our 
programs to protect, serve and provide for sustainable Tribal 
nations. My home and my street is the greatest place to live in 
this great land.
    To those who serve and answer the call to arms, I say, 
thank you, God speed and God bless all of us. Dance, pray and 
fight with honor.
    Thank you.
    [The prepared statement of Mr. Burke follows:]

 Prepared Statement of Hon. Wayne Burke, Chairman, Pyramid Lake Paiute 
                                 Tribe
    Our Native people have lived and sustained the life of a warrior; 
our ancestors and relatives fought and defended our tribal nations to 
secure food, homelands, and to protect the young, the old . . . the 
family.
    That warrior spirit is passed on in our songs, our stories, our 
dances, and our traditions. Many of our battles against the United 
States, along with massacres perpetrated against the Native Nations are 
not found in history books or taught in schools, but they are passed on 
through oral teachings. From young to old . . . some stories are to 
never to be told again. As with the old people, the younger generations 
continue to answer the call to arms and serve our tribal and federal 
nations . . . taking that warrior spirit with them. We serve in the 
Army, Air Force, Navy, Marines, Cost Guard, and National Guard. As with 
all veterans, representing all the nations under the United States 
Flag, we serve with honor, dignity and the desire to protect, fight, 
and win battles.
    With conflicts and the continued threat of terrorism on those who 
live in all regions and lands of the globe, the United States military 
will continue to provide that protection and service through our men 
and woman who enlist in the armed forces.
    As our warriors return home, I see the demand and need for advocacy 
and support for our veterans. Cultural traditions and beliefs are a 
significant part in the manner in which tribes and Native people 
prepare, sustain, heal, and survive war. These cultural beliefs and 
ways of life need to be recognized and used to offer and provide more 
services and resources to Native Veterans.
    Per population, more Native Veterans serve in the United States 
Government than any other ethnic group.
Veterans Administration
    The VA must understand and know the population they serve. Tribes 
from the North, South, East, and West all have distinct traditions and 
beliefs. The VA is a complex system which is intimidating and 
frustrating for veterans to navigate. As a young Marine returning from 
Africa, and being discharged shortly after, I was told I could get my 
teeth cleaned 90 days after my discharge, and I had a GI Bill 
somewhere. Services through the VA should be transparent and more 
accessible. Veterans need to know what services and resources are 
available.
Education
    Educational benefits and enrolling into college has become very 
cumbersome, expensive and intimidating. I have spoken to Veterans' 
representatives from colleges in Northern Nevada, and they have 
reported the GI Bill and accessing those funds has become very complex, 
and require extensive reporting and knowledge in obtaining and ensuring 
college courses meet the GI Bill regulations. Transfer credits, and 
criteria for higher education credits is becoming increasingly more 
complicated.
Mental Health Services
    With the growing number of Veterans who have served on foreign 
shores, and have been exposed to the harmful effects of chemical/
biological weapons, stress, and combat action; we are not prepared or 
have limited resources to provide services from documented cases of 
PTSD,depression, suicide, and other emotional/mental health issues. 
Many of our reservations are found in extreme rural areas of the 
country where ambulatory and mental health services are only available 
on a limited schedule.
Business and Mortgage Loans
    How does a Veteran receive a business or home loan? I have gone to 
the local Small Business Administration and I was advised banks are not 
approving business loans because of the economic environment. Natives 
who reside on trust land (Reservations) such as Pyramid Lake and other 
reservations, cannot access loans because banks will not authorize 
loans to Indians who live on tribal lands. Tribes in many instances 
must waive sovereign immunity to receive traditional loans from banks.
Indian Health Services
    The advantage and disadvantage . . .. Big Brother is always 
watching and regulating. As Tribal Nations, we must adhere and conform 
to the operational standards of federal agencies which regulate health 
care, which includes appropriations, services, resources, and most 
importantly contract health services and paying the medical bills. When 
bills and contracted health services are not paid in a timely manner, 
Tribal members are taken to creditors, are refused services, and wait 
for authorization from Indian Health Services. I have had the 
opportunity to meet with Dr. Roubideaux--Director IHS, she so 
eloquently put it: ``We must hold our Veterans harmless from the 
system.''
    The Memorandum of Understanding between the VA and IHS was signed 
in 2010, under the authority: The Indian Health Care Improvement Act, 
25 U.S.C. Section 1645, 1647; 38 U.S.C. Sections 523(a), 6301-6307, 
8153. *
---------------------------------------------------------------------------
    * The information referred to can be found at http://www.ihs.gov/
announcements/documents/3-OD-11-0006.pdf
---------------------------------------------------------------------------
    Under the current MOU, what is the charge, the authority, and who 
is responsible for ensuring the IHS and VA are working in collaboration 
with Tribal Nations, and the government-to- government/trust 
obligations are being met. The first time I had ever heard or seen of 
this MOU was in 2011. Who or what agency is ensuring regulation and 
compliance with the MOU?
Our Elected Tribal Leaders and Government
    The Tribes continue to manage and support their communities through 
existing 638 contracts, Federal grants, and revenue generated 
programming, and economic development. Under continued resolutions, 
regulations, and federal statutes, Tribal governments continue to meet 
the demands of those we serve, or to the best of our abilities.
    I have no doubt in my mind that our Tribal Nations have the ability 
and resources to collaborate and assist the Federal Government and 
Federal agencies in effecting and supporting policies and regulations 
that can support our Veterans.
My Request of This Committee
    Appropriate funding and authorize Veteran liaisons/caseworkers to 
represent and work with Tribal Nations in establishing and providing 
transportation, services/resources, and secure education and training 
for Native Veterans and programs such as the VA, Disabled American 
Veterans, and all regional Veteran Service Offices. These liaisons/
caseworkers would assist all Native Veterans in obtaining, securing, 
and accessing benefits and services. Educating agency staff and 
establishing a network of services and funding for continued services 
and resources.
    I am very grateful for the support of Nevada Senators Harry Reid, 
Dean Heller, and Governor Brian Sandoval in their support and 
acknowledgement of our veteran's issues in Indian Country. I would also 
like to thank Lt. John Hansen (retired) Disabled American Veterans 
Service Officer for the collaboration and services he provides to 
several of the 27 Northern Nevada Tribes, and the work he has done in 
advocating for our Veterans.
In Closing
    I come from a reservation, on a street that has broken down fences, 
rusty cars, rez dogs, and more importantly, families and children who 
depend on our programs to protect, serve, and provide for sustainable 
tribal nations. My home and my street is the greatest place to live in 
this great land.
    To those who serve and answer to the call to arms I say thank you, 
god speed, and god bless all of us. Dance, pray, and fight with honor.
    Attachment
    
    
    

    The Chairman. Thank you so much, Mr. Burke.
    Mr. McKaughan. will you please proceed?

       STATEMENT OF LT. COL. KELLY McKAUGHAN, DIRECTOR, 
    VETERANS ADVOCACY, CHOCTAW NATION; ACCOMPANIED BY MAJ. 
   NATHANIEL COX, DIRECTOR, CHOCTAW GLOBAL STAFFING, CHOCTAW 
                             NATION

    Mr. McKaughan. Good afternoon, Mr. Chairman.
    My name is Kelly McKaughan, Director of the Choctaw Nation 
Veterans Advocacy Program. I have Major Nathaniel Cox with me. 
Chief Pyle and Assistant Chief Batton both send their regrets 
that they were otherwise detained and weren't able to come and 
speak themselves.
    To begin, I want to talk about the Choctaw Nation. We 
talked a while ago about rural areas. The Choctaw Nation covers 
the southeastern most counties of Oklahoma. It is very rural, a 
large area, we have large counties covering over 11,000 square 
miles. The Choctaw Nation has over 250,000 members currently.
    The reason I am here and the reason our program was started 
was Chief Pyle came to me one day and said our veterans aren't 
getting services. They don't know what they are eligible for, 
they don't have people coming to them and they don't like to go 
to outside services such as the VA. Maybe they will come to the 
Choctaw Nation and use their own people.
    Therefore, in 2005, Chief Pyle, along with our Tribal 
council, established our program, the Veterans Advocacy 
Program, to try to assist those people who are being missed. 
Chief Pyle has said many times, we want to get those people who 
are being missed right now. That is why we were established.
    We noticed there was a need for an actual application 
process. If you don't apply to the VA, you don't get 
disability. We try to provide that service to them if they 
don't want to go to the VA. Since our Tribal members have to 
travel so far, sometimes up to four hours, to a VA facility in 
Muskogee, Oklahoma, they are not going to do it. We have 
advocates who go out, meet them at their homes or our senior 
citizen centers. We do disability and compensation claims for 
them, help them get grave markers. Some World War I or II 
veterans never had a grave headstone at all. Those are some of 
the services we provide that were somehow missed.
    Health care is a big deal. The problem is they have to go 
to the health care facility. Again, in rural Oklahoma, it is 
difficult for them to get that far. We can't really assist with 
that. We also provide special events. We have an annual 
Veterans Day celebration where we honor our veterans every year 
which they are very appreciative. We give them a gift, a jacket 
of some kind.
    We have that at our council grounds and have a veterans 
memorial that was old and worn out. We are in the process right 
now of upgrading that memorial, making it more proper for our 
veterans.
    We also have annual events at each center to honor the 
Native veterans. A lot of the old Vietnam veterans didn't get 
recognition they needed, so we try to recognize them and show 
how important they are to us still.
    Our Veterans Advocacy Program is not a recognized service 
organization so a lot of our work is referrals, simply getting 
the veteran to the right person, the VA, the veteran service 
officer. Oklahoma doesn't have counties but has regions. We get 
them there and that way they get the proper help they need.
    Another thing we do for our veterans--it is actually 
serving members now, which I am still a member of the National 
Guard and I just come back from overseas--we actually give care 
packages. We send it out to all Native Americans and any 
servicemember's family which asks, we send it. We have had 
requests to send specific items like handheld radios, some 
specialty knives they have asked for. One big thing was a 
sonogram machine that the military would not provide to this 
unit and we did.
    That is what we are doing to try to help. Pending your 
questions, that is all I have.
    [The prepared statement of Mr. McKaughnan follows:]

  Prepared Statement of Lt. Col. Kelly McKaughan, Director, Veterans 
                        Advocacy, Choctaw Nation




    The Chairman. Thank you so much, Col. McKaughnan.
    Ms. Causley, please proceed with your statement.

 STATEMENT OF CHERYL A. CAUSLEY, CHAIRWOMAN, NATIONAL AMERICAN 
                     INDIAN HOUSING COUNCIL

    Ms. Causley. Good afternoon, Chairman Akaka, Vice Chairman 
Barrasso and distinguished members of the Senate Committee on 
Indian Affairs.
    I would like to thank you for conducting this oversight 
hearing.
    My name is Cheryl Causley. I am an enrolled member and 
Director of Housing for the Bay Mills Tribe of Chippewa 
Indians. I appear before you today in my capacity as Chairwoman 
of the National American Indian Housing Council.
    NAIHC's primary goal is to support Native housing entities 
in their efforts to provide safe, decent, affordable, 
culturally appropriate housing for Native people, including our 
distinguished Native veterans.
    As the members of this Committee know, Native Americans 
represent a small percentage of the U.S. population. Throughout 
history, however, a high percentage of Tribal members have 
volunteered to serve in all branches of the United States 
military. In fact, some Native Americans were serving in the 
American Armed Forces before they were even granted 
citizenship. In times of national need, Native Americans have 
been the first to answer the call and step forward to protect 
this great country that we all call home.
    Our Native American people will never forget PFC Lori Ann 
Piestewa. Lori was a member of the Hopi Tribe who served in 
Iraq and was the first American female soldier to die in 
combat. Her spirit, her memory will always live in the minds 
and hearts of all of our people.
    While our communities show deep respect for our Native 
veterans in combat, it is a sad reality that often when they 
return to our homelands, they face another extraordinary 
challenge in fulfilling one of the most basic needs--they come 
home to find a place to live.
    In 2005, we actually held a news conference in this 
building, in this room and brought two Native veterans who 
recently had returned from tours of duty in Iraq. They provided 
a deeply emotional statement that they returned home to their 
reservations to living conditions in Indian country that were 
worse than those they faced in Iraq.
    As noted in a 2005 Washington Post article, Staff Sergeant 
Julius Tulley from the Navajo Nation shared this statement: ``I 
am not here to bash my Commander in Chief, nor am I here to 
speak out against the military. I am here to say that I have 
gone to war, I have put my life on the line, my brothers put 
their lives on the line. I want to say, look, I have done my 
part, my family has done their part. Now, I want something in 
return.'' His want should have been simple. He wanted a house 
to live in.
    Yesterday, Mr. Tulley shared with us that after seven 
years, his conditions in his home in his community of Blue Gap, 
Arizona have not changed. According to Tulley, at every Native 
veterans' meeting, the issue of housing is still a major 
concern.
    He also shared that he is diagnosed with Post Traumatic 
Stress Disorder and has yet to receive any treatment, even 
though he has made consistent requests over the last seven 
years. He shared, ``I'd like to go. I would still like to go, 
but I think they forgot about me.''
    Tulley's story is common throughout Indian country. 
Unfortunately, with the lack of resources and data, it is very 
difficult for us to measure the true, unmet needs of our Native 
heroes. NIHC strives to work with the leadership of this 
important Committee and Congress to recognize the acute housing 
needs that continue to exist in our Tribal communities and how 
this impacts Native veterans. Let me give you three examples.
    A survey conducted in 11,500 households in the Navajo 
Nation revealed that 2,726 were households that included at 
least one Native American veteran. Severe overcrowding coupled 
with wounded veterans returning home to caretakers has added 
tremendous stress on a community that has continued to 
experience a serious housing shortage.
    American Indians are significantly over-represented among 
the homeless populations in Minnesota. According to two 
separate Minnesota studies, American Indians make up one 
percent of the population but are 11 percent of the off-
reservation homeless adult population. Furthermore, American 
Indians make up 20 percent of the homeless veterans throughout 
Minnesota.
    In Montana, Native Americans make up 6.3 percent of the 
population, but according to the Montana Veterans Foundation 
data, in 2009 Montana had 475 homeless vets, 54 of which were 
Native American. Also in 2009, they had 43 homeless females, 25 
who were veterans, 9 were Native American women.
    Consider these needs against a backdrop that includes the 
following observation from the GAO in a February 2010 report. 
NAHASDA's first appropriation in fiscal year 1998 was $592 
million; the average funding was $633 million between 1998 and 
2009. However, the GAO report underscored that when accounting 
for inflation and constant dollars, the allocation for Indian 
housing has generally decreased since the enactment of NAHASDA.
    The needs in Indian country have not lessened since this 
report. In fact, the Census actually shows that we have an 
increased need with growth in every younger population. The 
Census reported that the American Indian and Alaskan Native 
population increased by 26.7 percent. Our median income was 
roughly $15,000 lower than the rest of the Nation and 
furthermore, 28.4 percent of Natives were in poverty.
    Bottom line, funding for Indian housing has not increased 
while the need in our population and Tribal communities is on 
the rise. The funding trend is stifling not only in housing 
development but economic development, job creation and an 
opportunity to build sustainable communities.
    Our veterans have courageously served our country and 
should not be left behind in their communities, their homelands 
because we lack safe and decent housing.
    Thank you.
    [The prepared statement of Ms. Causley follows:]

Prepared Statement of Cheryl A. Causley, Chairwoman, National American 
                         Indian Housing Council
    Good afternoon Chairman Akaka, Vice Chairman Barrasso, and 
distinguished members of the United States Senate Committee on Indian 
Affairs. Thank you for inviting me to attend today's oversight hearing 
on Programs and Services for Native Veterans. My name is Cheryl Causley 
and I am the Executive Director of the Bay Mills Indian Housing 
Authority. I am an enrolled member of the Bay Mills Indian Community in 
Brimley, Michigan. Today, I appear before you in my capacity as 
Chairwoman of the National American Indian Housing Council (NAIHC). I 
wish to thank the Committee for this opportunity to appear before you 
today to discuss programs for Native Veterans.
    Before I speak directly about the housing programs that affect our 
Native veterans, permit me to remind the Committee about the NAIHC. 
NAIHC is the only national, tribal non-profit organization dedicated 
solely to advancing housing, physical infrastructure, and economic and 
community development in Native American communities throughout the 
United States.
    The NAIHC was foundeded 1974 and has, for 38 years, served its 
members by providing invaluable training and technical assistance (T/
TA); sharing information with Congress about the issues and challenges 
that tribes face in terms of housing, infrastructure, community and 
economic development; and working with key Federal agencies to help 
meet the challenges of improving the housing conditions in tribal 
communities.
    The membership of NAIHC is comprised of 271 Indian Housing Block 
Grant (IHBG) recipients, representing 463 tribes and tribal housing 
organizations. The primary goal of NAIHC is to support Native housing 
entities in their efforts to provide safe, decent, affordable, 
culturally appropriate housing for Native people, including our 
distinguished Native Veterans.
    As the members of the Committee know, Native Americans represent a 
small percentage of the United States population. Throughout history, 
however, a high percentage of tribal members have volunteered to serve 
in all branches of the United States military. Many tribal nations are 
traditional, warrior societies, and this tradition has translated into 
an extraordinarily high level of patriotism in Native America--of 
dedication and commitment to service in the United States armed forces.
    In fact, some Native Americans were serving in the American armed 
forces before they were even granted citizenship. In times of national 
need, Native Americans have been the first to answer the call and step 
forward to protect this great country that we all call home. Yet, 
sadly, Native Veterans often return to their homelands to face 
extraordinary challenges in finding a place to live.
    Our first Americans face some of the worst housing and living 
conditions in the country, and the availability of affordable, 
adequate, and safe housing in Indian Country falls far below that of 
the general U.S. population. Veterans return home to find too few 
housing opportunities and are put on a wait list for tribal housing--a 
list that includes many families who have been waiting many, many years 
to access affordable housing.
    There is an agreement among most members of Congress, HUD, tribal 
leaders, and tribal organizations that there is a severe housing 
shortage in tribal communities; that many homes are, as a result, 
overcrowded; that many of the existing homes are in need of repairs--
some of them substantial; that many homes lack basic amenities that 
many of us take for granted, such as full kitchens and plumbing; and 
that at least 250,000 new housing units are needed in Indian Country.
    These issues are further complicated by the status of Indian lands, 
which are held in trust or restricted-fee status. As a result, private 
financial institutions will generally not recognize tribal homes as 
collateral to make improvements or for individuals to finance new 
homes. Private investment in the real estate market in Indian Country 
is virtually non-existent, with tribes almost entirely dependent on the 
Federal government for financial assistance to meet their growing 
housing needs. The provision of such assistance is consistent with the 
Federal Government's well-established trust responsibility to American 
Indian tribes and Alaska Native villages.
    The Native American Housing Assistance and Self-Determination Act 
(NAHASDA) was enacted to provide tribes with new and creative tools 
necessary to develop culturally appropriate, safe, decent, affordable 
housing. NAIHC and its membership appreciate the investment and 
continuing efforts that this Administration and the Congress have made 
since NAHASDA became law in 1996. However, despite the increase in 
overall spending within the Department of Housing and Urban 
Development, the Administration has proposed level funding for the 
Indian Housing Block Grant (IHBG) at $650 million for FY 2013.
    Were the President's budget proposal to be accepted, it would mark 
the third consecutive year that the funding for Indian housing would be 
flat-lined. We will work with the Congress, including the leadership of 
this important Committee, to recognize the acute housing needs that 
continue to exist in tribal communities and how this impacts Native 
Veterans. Let me give just three examples.
    A recent survey conducted of 11,500 households on the Navajo Nation 
Reservation revealed that 2,726 were households that included at least 
one veteran. Severe overcrowding, coupled with wounded veterans 
returning home to family caretakers, has resulted in a tremendous 
stress on housing needs. We also know that Native veterans have a great 
need for housing assistance in off-reservation and urban areas 
throughout the country.
    American Indians are significantly overrepresented among the 
homeless population in Minnesota, according to studies conducted by the 
Amherst H. Wilder Foundation and the Corporation for Supportive 
Housing's American Indian Supportive Housing Initiative. American 
Indians make up 1 percent of the Minnesota population, but 11 percent 
of the off-reservation homeless adult population. Furthermore, American 
Indians make up 20 percent of the homeless Veterans throughout 
Minnesota according to another Wilder Foundation study.
    In Montana, Native Americans make up 6.3 percent of the population. 
According to the Montana Veterans' Foundation data, in 2009, Montana 
had 475 homeless veterans, 54 of whom were Native American. Also in 
2009, Montana was home to 43 homeless females, 25 of whom were 
veterans. Nine of the 25 were Native American women.
    Consider these needs against a backdrop that includes the following 
observation from the Government Accountability Office (GAO) in their 
Report 10-326, Native American Housing, issued in February 2010 to the 
Senate Banking Committee and the House Committee on Financial Services:

         NAHASDA's first appropriation in fiscal year 1998 was $592 
        million, and average funding was approximately $633 million 
        between 1998 and 2009. The highest level of funding was $691 
        million in 2002, and the lowest was $577 million in 1999. For 
        fiscal year 2009, the program's appropriation was $621 million. 
        However, when accounting for inflation, constant dollars have 
        generally decreased since the enactment of NAHASDA. The highest 
        level of funding in constant dollars was $779 million in 1998, 
        and the lowest was $621 million in 2009.

    The needs in Indian Country have not lessened since this report was 
issued just over two years ago. In fact, the Department of Commerce's 
Bureau of the Census clearly shows that the needs continue to increase 
along with a growing and ever-younger population. In a report prepared 
in November 2011, the Census reported that:

   The nation's American Indian and Alaska Native population 
        increased by 1.1 million between the 2000 Census and 2010 
        Census, or 26.7 percent, while the overall population growth 
        was 9.7 percent;

   The median income of American Indian and Alaska Native 
        households was $35,062 compared with $50,046 for the nation as 
        a whole.

   The percentage of American Indians and Alaska Natives that 
        were in poverty in 2010 was 28.4 percent compared to the 15.3 
        percent for the nation as a whole.

   The percentage of American Indian and Alaska Native 
        householders who owned their own home in 2010 was 54 percent 
        compared with 65 percent of the overall population.

    I wish to conclude this testimony by thanking Chairman Akaka, Vice 
Chairman Barrasso, and all of the members of the Senate Committee on 
Indian Affairs. NAHASDA is not just about constructing houses, it is 
about building tribal communities--communities where health and safety 
are a top priority and where education can thrive. However, the path to 
a self-sustaining economy is not achievable without a robust housing 
sector, and tribal housing conditions cannot be improved without 
adequate funding. Veterans who have so courageously served should not 
be left behind because their communities--there homelands--lack safe 
and decent housing.
    We often here people say, ``thank you for your service.'' Let's 
make sure these words are not hallow. We can best say thank you to our 
veterans by making sure they have a home to return to after serving our 
Nation. I know we can count on you to support our efforts. Together, we 
can continue the important work of building vibrant communities in 
Indian Country.

    The Chairman. Thank you very much.
    Ms. Kalipi, will you please proceed with your statement?

    STATEMENT OF D. NOELANI KALIPI, PRESIDENT, TILEAF GROUP

    Ms. Kalipi. Aloha, Chairman Akaka, Vice Chairman Barrasso 
and distinguished members of the Senate Committee on Indian 
Affairs.
    My name is Noelani Kalipi and I am a Native Hawaiian 
veteran having served on active duty in the United States Army.
    Of the approximately 117,000 veterans living in Hawaii, a 
significant number are Native veterans who were born and raised 
in Hawaii. Like our Native brethren in Indian country and 
Alaska, Native Hawaiians have a cultural and spiritual tie to 
our lands. We seek to live on our land and will find a way to 
survive in our homeland because no matter how challenging the 
economic conditions, no matter how bad or scarce the jobs are, 
our family ties and our relationship to our lands are 
intricately tied to the essence of our being.
    The State of Hawaii depends on imported fossil fuels for 
more than 75 percent of its electricity generation and imports 
85 percent of its food. This means the State of Hawaii 
currently imports 2 million meals per day. We have a serious 
food security and energy security issue in Hawaii and we have a 
wonderful opportunity for Native Hawaiian veterans to lead the 
way in addressing this.
    The Hawaii Veteran to Farmer Pilot Program begins in a week 
and the first 12 participants are Native Hawaiian veterans with 
agricultural leases within the Hawaiian Homelands Trust. 
Participants will receive hands-on training on all aspects of 
farming and participate in an educational curriculum that 
focuses on the business aspects of successful farming 
operations including marketing, accounting and best practices.
    This is a win-win situation where Native Hawaiian veterans 
can lead the way in addressing critical needs in Hawaii while 
incorporating cultural and traditional practices, creating 
jobs, generating revenue and creating additional opportunities 
for economic development and empowerment.
    Mr. Chairman, as a Native Hawaiian and as a veteran, I 
thank you for all you have done over your career to assist and 
empower all veterans but in particular, Native veterans. Your 
insight as a Native veteran has been invaluable in facilitating 
programs in recognition of the Federal trust relationship 
between the United States and its Native peoples.
    Establishment of the VA Native American Direct Home Loan 
Program, for example, serves as an important precedent in 
demonstrating how Federal programs can be modified to provide 
the delivery of benefits and services to Native veterans living 
on trust lands.
    We thank you for all that you have done.
    Mahalo.
    [The prepared statement of Ms. Kalipi follows:]

    Prepared Statement of D. Noelani Kalipi, President, TiLeaf Group
    Aloha Chairman Akaka, Vice-Chairman Barasso and Distinguished 
Members of the Senate Committee on Indian Affairs. Thank you for 
providing me with the opportunity to share information with you about 
the Veteran to Farmer initiative we are implementing on the island of 
Hawaii.
Background
    My name is D. Noelani Kalipi and I am a Native Hawaiian Veteran. I 
work with TiLeaf Group, a native social enterprise. We work with native 
and non-native companies and organizations focused on projects, 
services and programs that contribute to the well-being of native 
communities. A substantial portion of our activity is focused on 
economic development and empowerment in native communities involving 
energy, agricultural and data security initiatives.
    I served on active duty in the United States Army Judge Advocate 
General's Corps (JAGC) where I was stationed at Fort Stewart, Georgia, 
home to the 3d Infantry Division (Mechanized). As a young JAGC 
attorney, I served in a number of positions. I found my experience with 
the Trial Defense Service (TDS) to be the most insightful. As a TDS 
attorney, I represented soldiers facing non-judicial punishment, 
administrative separation, or courts-martial. I learned very quickly 
about the trials and tribulations faced by soldiers and their families 
as they struggled to balance rigorous training and deployment schedules 
with demands and challenges of everyday life. While many military 
members thrive in these conditions, I worked primarily with those who 
encountered difficulties. These experiences served me well in my 
professional career which has led me to work with military members and 
Veterans in various capacities.
Native Veterans
    Native Veterans have a strong tradition of military service despite 
the often tragic circumstances underlying the history between the 
federal government and their native governments. Native Veterans have 
served at the highest rate per capita of any population in the United 
States. According to the Department of Veterans Affairs (VA), studies 
have also shown that Native Veterans suffer disproportionally from the 
consequences of service, including higher rates of disorders related to 
combat exposure.
    According to the U.S. Census Bureau's American Community Survey, 
27, 800 Veterans identified themselves as single-race Native Hawaiian 
and Other Pacific Islanders. Four out of five of these Veterans are 65 
years old or younger. This means we have a relatively young population 
of Native Hawaiian and Pacific Islander Veterans. Additionally, given 
the multicultural population in Hawaii, a large number of Native 
Hawaiians identify themselves in the multi-race category. We therefore 
know that we have a significantly larger population of Native Hawaiian 
Veterans in the United States.
    Of the 117,000 Veterans living in Hawaii, a significant number are 
native Veterans who have been born and raised in Hawaii. Like our 
native brethren in Indian Country and Alaska, Native Hawaiians have a 
cultural and spiritual tie to our lands--we seek to live on our lands 
and will find a way to survive in our homeland because no matter how 
challenging the economic conditions or how scarce the jobs are, our 
family ties and our relationship to the `aina or land, is intricately 
tied to the essence of our being.
Hawaii Island 21st Century Roadmap
    The State of Hawaii is composed of islands in the Pacific Ocean. 
The nearest metropolitan population is located more than 2500 miles 
away. Hawaii depends on imported fossil fuels for more than 75 percent 
of its electricity generation \1\ and imports 85-90 percent \2\ of its 
food. This means that the State of Hawaii currently imports more than 
two million meals per day. If the barges were to be stopped, Hawaii has 
approximately 2-3 weeks of fuel for electricity and 7 days of locally 
grown food.
---------------------------------------------------------------------------
    \1\ Renewable Energy in Hawaii June 2011, Hawaii Economic Issues, 
Economic Report 2011, Department of Business, Economic Development & 
Tourism, June 2011.
    \2\ Food Self-Sufficiency in Hawaii, A Hawaii Department of 
Agriculture White Paper, Hawaii Department of Agriculture, December 
2008.
---------------------------------------------------------------------------
    Energy and food security, therefore, are key priorities for the 
people of Hawaii. The volatility in oil prices impact all aspects of 
commerce in Hawaii as the cost of importing items and the cost of 
electricity are factored into all products and services. These 
additional costs make it very difficult for any Hawaii-based business 
to be competitive with its counterparts on the continent and greatly 
impact the standard of living for individuals living in rural 
communities.
    Given our geographic isolation coupled with our dependence on 
imports for vital needs such as electricity and food, Hawaii is on the 
precipice of a future that can be either very good or very bad. It can 
be very bad if we retain the status quo and fail to proactively address 
our energy and food security challenges.
    On the other hand, Hawaii is blessed to have robust, renewable 
resources that can be utilized for electricity generation. On my island 
of Hawaii, we have geothermal, solar, wind, and hydropower resources 
that can be utilized to generate enough electricity to make our island 
completely energy self-sufficient. We also have abundant water 
resources and fertile soil that can revitalize a once vibrant 
agricultural industry. Whether we change our behavior and utilize these 
natural resources in a manner that meets our needs while preserving 
them for use by future generations is the key to whether we contribute 
to a vibrant, thriving or depressed economic future on our island. 
Native Hawaiians play a vital role in shaping this future.
    Many of us look back to our native kupuna, or elders, for guidance 
on how to move forward. The ancient Native Hawaiians were incredibly 
scientific people. They had identified the stars and constellations and 
used them for navigation across the Pacific Ocean. They had developed a 
calendar that dictated when to fish, when to plant and what to plant, 
so that their subsistence needs were met in abundance while still 
preserving Hawaii's precious natural resources. They had identified 
hundreds of thousands of species of plants and animals and had named, 
categorized and learned how to use them. Native Hawaiians worked 
comprehensively and collaboratively, using complex engineering methods 
to maximize the use of resources such as water for everything from 
agriculture to advanced forms of aquaculture.
    As we look back to move forward, our native communities can see the 
vast opportunities available for the perpetuation of our native 
culture, language, practices, and traditions. We know that our elders 
were not so mired in tradition that they refused innovation. Our 
ancestors were incredibly intelligent and if they were here today, they 
would not hesitate to couple their incredible wisdom with today's 
technology to figure out how to sustain our population and be 
responsible stewards of the environment. As Hawaii is increasingly 
viewed as the ``test bed'' or ``pilot'' for energy and agricultural 
security, our native communities have become much more active and are 
certainly willing to be the ``tip of the spear'' that leads this fight 
for survival.
    TiLeaf Group is just one of many partners involved in developing 
and implementing the Hawai'i Island 21st Century Economy Roadmap, a 
comprehensive plan that seeks to develop a viable, robust, and self-
sufficient economy for Hawaii Island. The Roadmap has been developed by 
Rivertop Solutions, LLC over the past two years with the participation 
of key stakeholders on the island. It includes 29 projects, each with a 
viable business model and plan which allows the project to succeed on 
its own, and more importantly, to support the rest of the projects in 
the roadmap, thereby building a comprehensive, self-sufficient 
infrastructure on the island that yields economic success and community 
empowerment.
Addressing Agricultural Capacity on Hawaii Island
    Many Hawaii farmers are struggling to compete with imported foods 
because of the high price of electricity. On my island of Hawaii, for 
example, we paid an electric rate of 40 cents per kilowatt hour in the 
month of April 2012 in comparison to the national average of 11 cents 
per kilowatt hour. \3\ If we want to increase our agricultural 
capacity, we need to find a way for farmers to be competitive with 
their counterparts on the continent.
---------------------------------------------------------------------------
    \3\ ``April Electric Rates Up on All Islands Except One,'' Star-
Advertiser, April 12, 2012.
---------------------------------------------------------------------------
    A critically important facet of the Hawaii Island 21st Century 
Economy Roadmap is revitalizing Hawaii's agricultural capacity by (1) 
developing processes that lower input and processing costs, (2) 
increasing educational and apprenticeship programs that help transition 
individuals into farming, and (3) generating market demand through the 
commitment of large businesses, organizations, government agencies. It 
is essential that we are able to match market demand with increased 
agricultural capacity to ensure economic growth and to sustain 
progress.
    Richard Ha, a Native Hawaiian Vietnam Veteran who owns and operates 
Hamakua Springs Farm, one of the more successful farming operations on 
Hawaii Island, summarizes the situation succinctly: ``The farmer will 
farm if the farmer can make money. If the farmer cannot make money, the 
farmer cannot farm.'' Given the volatility of oil prices and its 
devastating impact on Hawaii's economy, Mr. Ha has focused on helping 
Hawaii to stabilize its electric generation prices by utilizing 
Hawaii's robust renewable resources. He was motivated to actively help 
his community to address energy and food security following the spike 
in oil prices in 2008 which radically increased the cost of fuel, 
electricity, and fertilizer and caused his farm workers to ask him for 
loans to pay for gas to get to work.
    The first pilot project from the Hawaii Island 21st Century Economy 
Roadmap is the Pu'ukapu Agricultural Community Facility which includes 
an anaerobic digester, post-harvest facility, and certified kitchen. 
The anaerobic digester will process organic waste to produce methane 
which will be utilized to generate electricity and soil amendments 
which will serve as low cost fertilizer. The electricity will power a 
Post-Harvest facility, complete with processing equipment and 
refrigeration. A certified kitchen will also be included in the 
facility to provide for the manufacture of value-added products such as 
sweet potato chips and tomato paste. The facility improves agricultural 
capacity by providing low-cost fertilizer and low-cost electricity 
which enables post-harvest processing by local farmers, which has 
traditionally been cost-prohibitive. Such post-harvest processing 
enables farmers to sell produce to larger markets, including the 
Department of Defense, University of Hawaii at Hilo, grocery stores and 
resorts.
    This facility will be located on the Hawaiian Home Lands trust in 
Waimea, Hawaii. Congress created the Hawaiian Home Lands trust in 1921 
via the Hawaiian Homes Commission Act which set aside approximately 
200,000 acres for residential, agricultural, and pastoral homesteading 
by qualified Native Hawaiians. The trust lands are noncontiguous and 
are located on each of the islands. Each homestead community has a 
homestead community association, composed of lessees and family 
members, with democratically elected leadership.
    The Pu'ukapu Community Agricultural Facility will be owned and 
operated by the Homestead Community Development Corporation (HCDC), a 
statewide nonprofit owned and operated by several homestead community 
associations on Kauai, Oahu, and Hawaii Island. The Waimea Hawaiian 
Homestead Association, which represents the homestead community in 
which this facility is located, will be the lead on managing this 
project for HCDC. Native Hawaiians, therefore, are not only 
participating, but managing and leading the way towards increased 
agricultural capacity and creating economic development and empowerment 
opportunities that simultaneously address food and energy security.
Veteran to Farmer Initiative
    The Hawaii Veteran to Farmer Initiative can address not only 
Hawaii's food security challenges but also the growing food security 
challenges across the nation. The average age of a farmer in Hawaii is 
60 years old and the U.S. average is similar. The United States 
Department of Agriculture has loan programs in place to aid the 
addition of 100,000 new farmers every year because in the next decade, 
half of the current farmers are expected to retire. Rebuilding the 
nation's ability to feed itself is a critical component of the strength 
of our country.
    Young Veterans consistently have higher than average unemployment 
rates. Not only are their unemployment rates higher than average, but 
there are numerous other social and personal welfare indicators where 
Veterans and families of returning Veterans also rank higher than 
average such as substance abuse, homelessness, and domestic violence. 
These figures all show there is a need to better support the transition 
of Veterans from the areas of conflict where they served, back into 
civilian life.
    There is a definite need to introduce a younger generation into 
agriculture careers with most of the U.S. farmers approaching 
retirement. Though only one sixth of the U.S. population is in rural 
communities, nearly 45 percent of the military comes from rural 
communities; so many Veterans have strong background knowledge of 
agriculture. Native Veterans represent the highest proportion of rural 
Veterans. Additionally, in Hawaii, four out of five of the individuals 
who identified themselves as Native Hawaiian or Other Pacific Islander 
Veterans, were under the age of sixty-five, indicating a younger 
population of Veterans.
    Horticulture has been used as a therapy tool for decades. 
Horticulture therapy is a proven method of reducing stress and anxiety, 
improving coping skills and motivation. It also promotes confidence and 
hopefulness among other qualities important for Veterans suffering from 
post-traumatic stress disorder and traumatic brain injuries. In 
addition to providing a path to a career well-suited to re-integrating 
the Veterans, the Hawaii Veteran to Farmer initiative can provide a 
structure that includes routine monitoring by VA certified healthcare 
providers who will have routine contact with program participants, as 
needed, to ensure that treatment for physical and mental health of the 
Veterans and their families is on track.
    The Hawaii Veteran to Farmer initiative provides: (1) a certificate 
level hands-on farming skills training curriculum, (2) classroom-based 
business training, (3) business start-up support, and (4) as-needed 
health monitoring and assessments for Veterans. A key goal of the 
program is to enable Veterans to develop the necessary skills and 
provide opportunities that utilize these skills in farming while 
acknowledging the difficulties many face in transitioning back to 
civilian life after military service. Completion can enable Veterans to 
both create new farm businesses, and to meet the requirements to 
acquire the leases and loans needed to start a farm.
    The Hawaii Veteran to Farmer pilot program supports the Pu'ukapu 
Agricultural Community Facility because it increases the agricultural 
capacity that will be serviced by the facility. The program pilot 
begins in June 2012 and the first 12 participants include homesteaders 
who are Native Hawaiian Veterans and who have been granted agricultural 
leases within the Hawaiian Home Lands trust. The pilot will be 
completed in December 2012.
    Each program participant will be provided the supplies necessary to 
build at least one greenhouse on their property. Participants will 
receive hands-on training on all aspects of farming from building the 
greenhouse to germination, drip-irrigation methods, and harvesting. 
They will also participate in an educational curriculum that focuses on 
the business aspects of successful farming including marketing, 
accounting, and business relations.
    The hands-on training has been developed and will be taught by Mike 
Hodson, a Native Hawaiian homesteader who owns and operates a 
successful organic vegetable farm, WoW Farms, on his agricultural 
homestead. The educational curriculum is being developed in 
collaboration with the University of Hawaii system and agricultural 
industry. Classes for this pilot program will be held at a Native 
Hawaiian educational facility located in the homesteader community, 
thereby making access easy for program participants.
    Each participant in the pilot program has committed to, upon 
completion, ``paying it forward'' by continuing to participate as 
instructors so that the model can grow exponentially. At the end of the 
pilot we will have 12 working farms. If each participant helps even 
just two additional Native Hawaiian Veteran homesteaders with the 
practical hands-on training, there could be 24 additional working farms 
within the next two years in this rural homestead community.
    The pilot program will be used to refine and finalize the 
curriculum and to develop the required documentation to certify the 
program with various federal agencies. At least eight additional 
homestead communities have been identified by the State of Hawaii for 
participation in the program. While the pilot and its initial rollout 
focuses on participation by Native Hawaiian Veterans, non-native 
Veterans who have access to lands for farming or who seek to work on 
farms are eligible to participate. This is truly a community 
empowerment and community economic development model that can grow 
exponentially in a relatively short period to address our food security 
and economic development challenges in our rural communities.
    This program involves many, many stakeholders throughout Hawaii. 
The Roadmap and the Pu'ukapu Agricultural Community Facility involve 
participation by Native Hawaiian leaders, Native Hawaiian 
organizations, State agencies and officials, Federal agencies and 
officials, County agencies and officials, and community-based 
organizations involved in food security, agricultural industry, energy 
security, economic development and workforce training. As we continue 
to progress, more interest is generated and we continue to expand the 
number of partners and collaborators in this project.
    The fact that the tip of this spear to address food and energy 
security is being led by Native Hawaiian Veterans is not only symbolic, 
it just and it is right. This is a win-win situation where Native 
Hawaiian Veterans can lead the way in addressing critical needs in 
Hawaii while incorporating cultural and traditional practices, creating 
jobs, generating revenue, and creating additional opportunities for 
economic development and empowerment.
Conclusion
    Mr. Chairman, as a Native Hawaiian Veteran, I thank you for all 
that you have done over your career to assist and empower Veterans, but 
in particular Native Veterans.
    Your insight as a native Veteran has been invaluable in 
facilitating programs in recognition of the federal trust relationship 
between the United States and its native peoples. The establishment of 
the VA Native American Direct Loan program, for example, helped Native 
American Veterans to utilize the VA loans for homeownership on native 
lands. While there are additional barriers to increased participation 
in the program, the establishment of the VA Native American Direct Loan 
program serves as important precedent in demonstrating how federal 
programs can be modified to support the delivery of benefits and 
services to native Veterans living on native lands.
    The definition of trust lands utilized since 1992 as part of the VA 
Native American Direct Loan program has continued to help native 
communities. The 2008 Farm bill codified this definition of trust lands 
as ``Substantially Underserved Trust Areas'' and authorized certain 
programs within the USDA's Rural Development program to issue low-
interest loans and grants on these lands. This is a vitally important 
tool to economic development and empowerment on native lands. If this 
definition can be expanded to apply to other USDA and federal programs, 
it could greatly incentive private capital to invest in native 
communities and on projects on native lands.
    Your unwavering support for the recognition of the accomplishments 
of native Veterans from the Navajo Code Talkers to the young Hawaiian 
men sent to colonize Baker, Jarvis, and Howland Islands to Medal of 
Honor recipients have served to memorialize the important contributions 
of native Veterans in defending and honoring our nation. We also 
greatly appreciate your efforts as a longstanding member, and as the 
Chairman of, the Senate Committee on Veterans' Affairs, in striving to 
maintain the commitment of the United States to its military members 
and Veterans, but especially the native Veterans.
    As a beneficiary of the Montgomery GI Bill, you truly understand 
its value to Veterans and we applaud your accomplishments in 
strengthening the program to meet the needs of today's Veterans. 
Innovative programs like the Veteran to Farmer initiative can be 
successful because your insight, thereby resulting in economic 
development, community empowerment, jobs and food security in native 
and rural communities.

    The Chairman. Thank you very much.
    I am going to have to wrap up right now, ten minutes ago 
the vote was called but we finished you because we have a 
series of votes that we will be taking. I want to thank you 
again. You are doing community work that is incredible and I 
encourage you, in Hawaiian, [phrase in Hawaiian], that you 
strive for the highest as you continue to work with our Native 
veterans.
    I am looking forward to the next update from the Veterans 
Administration, the Indian Health Service and others about how 
you are working in the spirit of [phrase in Hawaiian], 
collaboration and cooperation as you are doing with health 
services and veterans affairs to maximize the reach of 
resources available to our Native veterans.
    Please remember, the hearing record is open for written 
testimony for two weeks. Your full statements will be placed in 
the record. I have questions that I wanted to ask you that I am 
going to put in the record for you to respond to.
    I want to thank you so much. We tried to move this up so we 
could take more time but they have moved the votes up also. I 
thank you so much for being so patient and for your responses 
today. You have been helpful and we will continue to work 
together to try to bring some things about that can help our 
Native veterans and of course our indigenous peoples.
    Mahalo nui. Thank you very much. Aloha and safe trip home.
    This hearing is adjourned.
    [Whereupon, at 2:07 p.m., the Committee was adjourned.]
                            A P P E N D I X

  Prepared Statement of Hon. Lisa Murkowski, U.S. Senator from Alaska
    Thank you Chairman Akaka and Vice Chair Barrasso, I would like to 
thank you for holding this important and timely hearing on programs and 
services for Native veterans. Last year in June I requested the 
Committee hold a hearing to examine the VA's record of service to 
Native veterans and its progress toward implementing the several tools 
provided by Congress to improve access and quality to VA programs in 
Indian Country, and at last year's Alaska Federation of Natives 
Convention I stayed at the Veteran's listening session until the last 
Alaskan had shared their story.
    This hearing is timely because it comes just before Memorial Day 
and on the heels of the historic signing of a Memorandum of 
Understanding between 14 Alaska Native tribal Healthcare providers and 
the VA. The MOU seeks for the first time to allow rural Alaska veterans 
to receive healthcare benefits at Native health clinics instead of 
hundreds of miles from home. Alaska Native health providers have long 
been concerned that they must subsidize care to rural veterans from 
limited federal Indian Health funds. The agreement was crafted in 
consultation with and facilitated by the Alaska Native Health Board, 
it's something I've been pushing through my Care Closer to Home 
initiative through MILCON appropriations, and I hope that the MOU helps 
the VA reassume its responsibility to veterans.
    Under the agreement, the VA will reimburse the participating Native 
health care entities for the services they provide, and it will also 
allow non-Native veterans to get care at the participating tribal 
health facilities. As our military heroes start to come home, it is 
increasingly important that we renew our commitment to ensure that the 
promises made to our Veterans, particularly our Native Veterans, are 
promises that we honor.
    In November of 2007, during my tenure as Vice-Chair, I presided 
over a field hearing before the Senate Committee on Indian Affairs in 
Anchorage, Alaska. That hearing, about ``Health Care for Alaska Native 
Veterans .'' offered important insights into the concerns voiced by 
Alaska Native and non-Native veterans from across the state. I am proud 
of provisions in the GI bill that authorizes a year of advance 
appropriations for VA healthcare so the VA is able to start the federal 
fiscal year with enough funding. And I am proud of our success in 
getting TRICARE to delay the implementation of their policy requiring 
``drive time waiver'' for retirees living more than 30 minutes or 100 
miles from a base hospital. I will continue to advocate for the needs 
of military children and for mental health services for our veterans, 
to support families because empowering veterans is a key part of 
America's future success.
    Nearly 24,000 American Indians and Alaska Natives are now serving 
as active duty personnel across the Armed Forces, and I'm glad we are 
holding this hearing to discuss issues they will face. Alaska is home 
to over 77,000 veterans. We proudly claim that Alaska is home to more 
veterans as a percentage of our total population than any other State 
in the Nation. We know that over the next five years more than a 
million military service members will return home. As we welcome them 
home as heroes, I encourage employers to recognize them when hiring--
recognize their skills, experience, leadership, and values that will 
help reinvigorate our communities and economy. I am proud to say that 
my personal office employs five current and former military veterans 
from branches of the Army, Navy, Coast Guard, and Marines. I would like 
to take a moment to thank those who have served and who currently 
serve, and their families, as well as pay my respects to the courageous 
men and women who have given the ultimate sacrifice, their lives, 
defending our safety and our liberties.
                                 ______
                                 
 Prepared Statement of Jefferson Keel, President, National Congress of 
                            American Indians



                                 ______
                                 
   Prepared Statement of Papa Ola Lokahi Native Hawaiian Health Board



                                 ______
                                 
   Prepared Statement of Richard Allen Adame, Sergeant First Class, 
       Retired U.S. Army, Prairie Band Potawatomi Nation Veteran



                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
                           Stephanie Birdwell
    Question 1. The 2010 MOU built upon and seeks to improve the 2003 
MOU. Will the VA/IHS MOU need to be updated every few years to best 
serve Native veterans?
    Answer. The VA/IHS MOU will need to be updated every two to three 
years. The Joint Implementation Task Force is charged with this duty 
and ensures the update will take place. The MOU provides the foundation 
of understanding between IHS and VA which defines purpose, priorities 
and specific areas of focus for working together to improve, access, 
quality of care, collaborations, sharing of resources and programs to 
serve American Indian/Alaska Native (AI/AN) Veterans. As 
accomplishments are documented and progress improves, changes and 
adjustments will be made to keep up with the needs of the population 
served.

    Question 2. Can you please discuss the importance of having 
accurate data to properly serve Native veterans? Are there areas where 
you can improve data collection and analysis to better serve Native 
veterans?
    Answer. It is important to maintain up-to-date and accurate data to 
properly serve Native Veterans and meet their needs. The Office of 
Rural Health (ORH) collects data from all Veterans Integrated Service 
Networks twice a year and maintains an inventory of programs, 
activities, and projects. ORH coordinates MOU workgroup activities, 
attends their meetings, and obtains quarterly status updates and 
reports of accomplishments from the workgroup leaders. Also, ORH tracks 
the numbers and types of sharing agreements that advance the goals 
ofand objectives of the MOU between VA and IHS and between VA and 
Tribes. Sharing agreements are developed at local health care 
facilities continuously through the year. A list of the agreements is 
reported to ORH twice a year to track and trend progress in meeting MOU 
goals and objectives. Information communicated to VA leadership is 
utilized to support activities and improve Native Veteran care and 
services.

    Question 3. In your testimony, you discussed the updated VA/IHS 
MOU. Are there mechanisms in place to measure the effectiveness the MOU 
has had and will have in the future?
    Answer. The MOU Metrics Report is used to measure the effectiveness 
of the MOU. At the present time, three metrics have been defined to 
monitor performance progress and success across all MOU workgroups. The 
three distinct metrics are: (1) The number and types of programs 
developed between VA and IHS and between VA and Tribes, (2) The number 
and types of outreach activities provided to help and impact AI/AN 
Veterans, their families, caregivers and communities, and (3) the 
number and types of sharing agreements developed between VA and IHS and 
between VA and tribes. This data will be reported annually. The first 
report will be completed by August 31, 2012 and will be reported to the 
Senate Appropriations Committee, target date September 30, 2012.

    Question 4. In March 2012, Secretary Shinseki assured me that he 
would look into ways to work with Native Hawaiian health care systems 
and Native American Veterans systems to provide services to Native 
Hawaiian Veterans who live in rural parts of Hawaii. To your knowledge, 
has any progress been made on this effort?
    Answer. The VA Pacific Islands Health Care System (VAPIHCS) has 
approximately 45,000 Veterans enrolled throughout our 4.5 million 
square mile Pacific Ocean area of responsibility, including Hawaii 
(Oahu, Maui, Kauai, Big Island, Molokai and Lanai), American Samoa, 
Guam and the Commonwealth of the Northern Mariana Islands (CNMI--
Saipan, Tinian and Rota). These 45,000 enrollees are made up of people 
from many cultures, including Native Hawaiian, other Polynesian, Asian 
and European based cultures.
    In addressing the health care needs of all Veterans in the Pacific, 
VAPIHCS has put forth an effort to establish new and close working 
relationships with the Federally Qualified Health Centers (FQHCs) on 
Maui, Kauai, Big Island, Molokai and Lanai. These FQHCs, while close in 
proximity to our existing Community Based Outpatient Clinics, offer a 
variety of health care services to native Hawaiians including native 
Hawaiian Veterans.
    We have a well established relationship, over many years, with the 
leadership of Papa Ola Lokahi, a consortium of providers that make up 
the Native Hawaiian Health Care (NHHC) Clinic System, throughout 
Hawaii.
    We have an initiative in place with the NHHC System for VA to 
actively enroll Native Hawaii Veterans into VAPIHCS.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. John Barrasso to 
                           Stephanie Birdwell
    Question 1. In 2010, the Indian Health Service and the Department 
of Veterans Affairs established a Memorandum of Understanding outlining 
a plan for coordination, collaboration, and resource sharing. However a 
prior interagency agreement for the same purposes has been in existence 
since 2003. Tribes have contended that no action has been taken by the 
Indian Health Service and the Department of Veteran Affairs to improve 
services, despite the existence of these two agreements. How will the 
2010 Memorandum of Understanding be implemented more effectively than 
the prior agreement?
    Answer. VA/IHS workgroups have been established to accomplish the 
work of the MOU. These workgroups include: Services and Benefits, 
Coordination of Care, Health Information Technology, New Technologies, 
System Level Agreements, Payment and Reimbursement, Sharing of Care 
Processes and Services, Cultural Competency Awareness, Training and 
Recruitment, Emergency and Disaster, and Oversight. Each of these 
workgroups has a defined purpose, goals, objectives and action plans. 
These workgroups are proactively meeting to discuss their purpose, 
goals, objectives and action plans and ways to enhance them. Each 
workgroup has defined membership and leaders. They meet regularly and 
their accomplishments are tracked and reported quarterly to the MOU 
Oversight Workgroup. This information is used to improve care and 
services for Native Veterans.

    Question 2. The 2010 Caregiver and Veterans Omnibus Health Services 
Act allows, in certain circumstances, electronic transfers of health 
records of Indian Veterans between Indian Health Services and VA. This 
Act was intended, in part, to provide seamless health care services to 
these Veterans. What is the status on the implementation of this Act?
    Answer. Section 303 of Public Law (P.L.) 111-163 (Caregivers and 
Veterans Omnibus Health Services Act of 2010) permits VA to carry out 
demonstration projects to examine the feasibility and advisability of 
alternatives to expand care for Veterans in rural areas. The 
demonstration projects could include (1) a partnership between VA and 
the Centers for Medicare and Medicaid Services of the Department of 
Health and Human Services (HHS) at critical access hospitals to 
coordinate care for rural Veterans, (2) a partnership between VA and 
HHS at community health centers to coordinate care for rural Veterans, 
or (3) expanding coordination with IHS to expand care for American 
Indian and Alaska Native (AI/AN) Veterans. VA would be required to 
ensure that the demonstration projects are carried out at facilities 
that are geographically distributed throughout the United States. VA is 
required to submit a report to Congress, no later than 2 years after 
enactment, on the results of the implemented demonstration projects.
    VA has not implemented any new demonstration projects under this 
discretionary authority. However, there are considerable efforts 
underway to improve rural health care under other authority that builds 
on existing agreements with HHS and IHS. For example, VA and IHS have 
established a task force to explore using existing authorities to 
expand coordination between the two agencies. In addition, VA's Office 
of Rural Health (ORH) currently supports a number of projects already 
that involve expanded access and collaborations with other parties, 
including HHS and IHS. ORH activities include funding for Community 
Based Outpatient Clinics; enhancing primary care for women Veterans in 
rural areas; expansion of tele-health services including tele-renal, 
tele-psychiatry, tele-dermatology, tele-mental health, tele-
rehabilitation, tele-amputee, tele-pharmacy, tele-PolyGram and tele-
radiology; expansion of Home-Based Primary Care (HBPC); expansion of 
Outreach Clinics; services to homeless Veterans and expansion of mental 
health services. ORH also funds the pilot program required by section 
403 of P.L. 110-387, the Veterans' Mental Health and Other Care 
Improvements Act of 2008, Project ARCH, or Access Received Closer to 
Home, under which covered health services are provided to covered 
Veterans through qualifying non-VA health care providers. Additionally, 
the Veterans Rural Health Resource Centers (VRHRC) are developing local 
partnerships and innovative programs to address the needs of Veterans 
in rural and highly rural areas. Veterans Integrated Service Networks 
are also sponsoring a number of efforts to increase access for Veterans 
in these areas. VA advised the House and Senate Veterans' Affairs 
Committees of the decision not to develop any new demonstration 
projects under section 303 on May 17, 2012.

    Question 3. A 2010 Department of Labor report, mandated by the 
Veterans Benefits Improvement Act of 2008, found that Native American 
Veterans living on tribal lands were often unaware of employment 
programs available to them. In addition to finding that increased 
awareness of these programs is needed within Native American 
communities, the report also found that increased collaboration is 
needed between the several Federal agencies (Department of the 
Interior, Department of Labor, and Department of Veterans Affairs) that 
maintain employment services programs serving Native American Veterans. 
Among other things, the report recommends consolidating these programs, 
at least to some extent, by creating ``one-stop Veterans helps shops'' 
on Indian reservations. What is your agency doing to address the issues 
highlighted in this report?
    Answer. In an effort to ensure that Native American Indians, 
particularly those living on Indian reservations and in rural areas, 
are aware of services provided by VA's Vocational Rehabilitation and 
Employment (VR&E) benefits, VR&E Service has taken the following steps:

   Collaborate with other offices within VA, such as the Center 
        for Minority Veterans, Benefits Assistance Service, the Office 
        of Tribal Governmental Relations (OTGR), and ORH to promote 
        outreach efforts specifically targeted to Native Americans;

   Attended the first Eastern Region Summit sponsored by OTGR 
        to provide information on VR&E services and build stronger 
        relationships with stakeholders to better serve Veterans and 
        their families;

   Presented information on VR&E benefits and services during 
        the 2012 Consortia of Administrators for Native American 
        Rehabilitation (CANAR) Mid-Year Conference, which was held June 
        17-20, 2012;

   Presented at the following Native American events:

    --VA Alaska Tribal Consultation, May 25, 2012
    --Lincoln Consultation, June 17, 2012; and

   Developed a Memorandum of Understanding between VR&E and the 
        Alaska Consortium of Tribal Vocational Rehabilitation.

    Question 4. What is the status on implementing the recommendations 
in this report, including collaborating with the other Federal agencies 
to create ``one-stop Veterans help shops'' on Indian reservations? If 
these recommendations are not currently being implemented, please 
explain why.
    Answer. The Department of Labor (DOL) is responsible for 
establishing ``One-Stop Career Centers,'' including new locations on 
Indian reservations. VA collaborates with DOL to ensure the ``One-Stop 
Career Centers'' are publicized on VR&E's VetSuccess.gov transition and 
employment Web site as well as VA's eBenefits Web site. VR&E Service 
will also ensure that information regarding ``One-Stop Career Centers'' 
is provided during outreach events with Native American Veterans.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
                           Cheryl A. Causley
    Question 1. Last Congress, we enacted the Indian Veterans Housing 
Opportunity Act to ensure that amounts received by Indian veterans for 
disabilities resulting from military service would not be included in 
calculating family income for housing purposes. Are there other 
barriers Congress can remove to allow greater housing opportunities for 
Native veterans?
    Answer. Indian Country is enormously grateful to this Committee for 
showing your full support and championing the passage of the Indian 
Veterans Housing Opportunity Act of 2010. This law ensures that Indian 
veterans who receive federal disability and survivor benefits are not 
denied support under NAHASDA. The passage of this legislation 
demonstrates that when Congress and Tribes work together we can find 
tangible solutions that will help our Native Veterans.
    As you may recall, this law ensures that Indian veterans who 
receive federal disability and survivor benefits are not denied support 
under NAHASDA. This is good, but it only applies to NAHASDA. We 
understand that similar legislation needs to be passed so that Native 
veterans and their families are eligible to receive housing services 
from the BIA's Housing Improvement Program (HIP). NAIHC is researching 
the issue, but we believe that neither Indian veterans nor their 
families should be denied services through the BIA-HIP because the 
veteran or family is receiving federal disability or survivor benefits.

    Question 2. In your testimony, you cited housing data related to 
Native Veterans only in certain states. Is there a need for more 
comprehensive data related to the housing needs of Native veterans?
    Answer. There is little to no housing information or housing data 
available on Native veterans and there is no funding available to 
collect that housing information or data. Indian Country is in dire 
need of accurate and reflective data to help us build a solid case for 
support, but to also help tribal communities in prioritizing and 
planning housing projects for Native veterans.
    However, there are solutions to this problem. First, provide 
funding to tribes and tribal housing programs to collect information on 
Native veterans. Second, build training and technical assistance 
programs so tribes have the tools necessary to build an appropriate 
database on the scope and needs of Native veterans. Third, develop 
partnerships and collaborations among various agencies at the local, 
regional and national level to share information and data. For example: 
at the local level, the tribal veterans affairs office, local veterans 
organizations and tribal housing authorities can come together to share 
information and data on Veterans in their community--often these 
offices and programs are separate; and at the national level, the 
federal agencies need to build interagency working groups to 
collaborate services for Native veterans. The Department of Veterans 
Affairs and HUD should have joint agreements to share information and 
data, and create initiatives to fund and support tribes in this effort.

    Question 3. Ten years ago, the GAO released a report identifying 
barriers for Native American veterans seeking to use the Native 
American Veterans Direct Home Loan Program. To your knowledge, have 
those barriers been removed and are Native American veterans utilizing 
the program at a greater rate?
    Answer. The VA Direct Home Loan Program has the potential to be an 
important tool for housing development in Indian Country. The program 
has, however, been underutilized as noted in the August 2002 GAO report 
on Native American Housing.
    Barriers that remain are as follows:

   Insufficient income or credit history to qualify Native 
        Veterans for the direct loan.

   Lack of infrastructure on tribal land, especially in more 
        remote reservation locations, and land availability for those 
        tribes that have insufficient ``buildable'' land.

   Difficulty in securing a clear title for home site leasing 
        purposes on tribal land.

    There have been notable improvements. The loan limits have 
increased to $417,000--when the 2002 GAO report was issued, the maximum 
loan was $80,000. Also, the Department of Veterans Affairs is making a 
concerted effort to get information about the Direct Loan Program to 
tribes, tribal housing entities, and tribal members. I was pleased to 
see that Ms. Stephanie Birdwell, the VA's Director of Tribal Government 
Relations, appeared before the Committee to testify on behalf of the 
VA. Stephanie has worked with NAIHC and the National Congress for 
Americans Indians to make sure that VA Direct Loan Program training 
sessions take place during our annual meetings. She has also worked 
diligently with other national Indian organizations to ensure that the 
VA's tribal programs are available and that needed technical assistance 
is conducted to ensure access to the VA programs.
                                 ______
                                 
Response to Written Questions Submitted by Hon. John Barrasso to Cheryl 
                               A. Causley
    Question 1. In 2002, the Government Accountability Office released 
a report identifying several issues affecting the use of the Native 
American Veterans Direct Home Loan Program. These issues included, 
among others, land fractionation-where multiple interests in a tract of 
land make mortgaging difficult, if not impossible. In addition, a 2006 
report by the Department of Veterans Affairs found that Native American 
veterans are less likely to own their own homes than veterans in 
general. Do you think there has been improvement in addressing any of 
these problems identified in either report?
    Answer. As has been stated in our response to Chairman Akaka's 
questions, there has been an improvement in the way the Department of 
Veterans Affairs administers the Native American Direct Loan program, 
especially the increase in the loan limits, and in VA's notable 
outreach to tribes and tribal organizations. However, Federal agencies 
could greatly improve access to housing programs with better 
coordination and communication among themselves. There are multiple 
Federal programs for housing assistance. A February 2012 General 
Accountability Office (GAO) report identified 51 areas where programs 
could be more effective in providing housing services , including the 
areas of affordable housing (low income), green building, and housing 
counseling programs. Tribes and their housing departments are keenly 
aware that some programs within HUD, USDA, and the Veterans 
Administration often serve the same purposes yet rarely coordinate 
their programs or administrative requirements.

    Question 1a. How should the issues identified in these reports be 
addressed?
    Answer. There are two primary areas that need to be considered when 
addressing the issues identified in these reports. The first is the 
need for data and the second is the need for infrastructure development 
in tribal areas.
    Tribes need guidance on the nature of the data required by Congress 
and the Administration. Tribes consistently hear the refrain, ``you 
need to give us more data!'' However, tribes rarely receive guidance on 
what kinds of data are actually useful to policy makers and 
Administration officials. In the absence of such guidance, there is no 
consistency to the data that is collected and reported across the 
country. Meaningful data must be focused and consistent across the 
board, and data should center on building a robust, reliable, and 
representative quantification of the tribal housing conditions and 
needs. It is noteworthy that twenty years ago the final report of the 
National Commission on American Indian, Alaska Native and Native 
Hawaiian Housing, the Commission explained that, ``Various agencies 
have presented testimony establishing the current housing needs for 
Native Americans at somewhere near 100,000 units of new housing. Almost 
no specific information exists that would profile, tribe by tribe, the 
typical family waiting for assistance.'' We now estimate that there are 
250,000 units needed in Indian Country, and still, the Federal 
government has not found nor identified a means by which to provide 
this information.
    Sound physical infrastructure is vital for housing to be an engine 
of economic development. Challenges to physical infrastructure 
development include access to capital and financing, conflicting 
statutory and regulatory provisions, and a need for comprehensive 
planning. HUD does not collect grantees' infrastructure plans nor does 
it measure their investments in infrastructure for affordable homes 
funded by the Indian Housing Block Grant program (See GAO Report 
February 2010). There is an acute need for sanitation-related 
infrastructure for Indian housing in general, and the GAO survey 
indicated a significant need for sanitation infrastructure for HUD 
assisted housing. Nothing in Indian County compares to the tax base 
available to municipal, county, and State governments. There are 
limited examples of tribes and tribal communities developing a revenue 
stream through taxation and providing basic community development and 
infrastructure. Bonding and other methods to raise capital are 
desperately needed for infrastructure development.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
                             Randy Grinnell
    Question 1. Your testimony covers many areas in which the IHS and 
VA collaborate and coordinate services. For a Native veteran seeking 
healthcare services, is there a one-stop shop available at IHS?
    Answer. If an American Indian or Alaska Native (AI/AN) Veteran is 
eligible for IHS, they can go to the nearest IHS facility for 
healthcare services. If their need for services exceeds local capacity, 
referral to the VA or private sector may be required.

    Question 2. Will the VA/IHS MOU need to be updated every few years 
to best serve Native veterans?
    Answer. The 2010 MOU provides a framework for a broad range of IHS-
VA collaborations which is national in scope, with implementation 
requiring local adaptation. As new opportunities present themselves, 
updates to the existing MOU may be appropriate. The VA/IHS MOU will 
also be reviewed on an annual basis by both agencies.

    Question 3. Can you please discuss the importance of having 
accurate data to properly serve Native veterans? Are there areas where 
you can improve data collection and analysis to better serve Native 
veterans?
    Answer. Accurate data is important to properly serve Native 
Veterans. Many AI/AN Veterans are eligible for health care services 
from both the Veterans Health Administration (VHA) and the Indian 
Health Service (IHS). Having accurate data helps IHS and VHA provide 
quality healthcare services that are comprehensive, coordinated and 
continuous. Exchanging data with the VA will improve data accuracy and 
therefore services to AI/AN Veterans. For example, IHS meets regularly 
with VA and DOD in planning for the Integrated Electronic Health Record 
(iEHR); VA, DOD, and IHS staffs are designing the EHR interface and 
care management functions. These activities will result in the ability 
of IHS and VA to share medical records with appropriate privacy 
protections and better coordinate care for American Indians and Alaska 
Native Veterans that receive care in both health care systems.

    Question 4. Are there mechanisms in place to measure the 
effectiveness the MOU has had and will have in the future?
    Answer. The IHS/VA MOU sets forth five mutual goals for serving AI/
AN Veterans. These goals include: (1) increasing access to and 
improving the quality of health care and services offered to Native 
Veterans by both agencies; (2) promoting patient-centered collaboration 
and facilitating communication among VA, IHS, AI/AN Veterans, Tribal 
and Urban Indian Health Programs; (3) establishing, in consultation 
with Tribes, effective partnerships and sharing agreements in support 
of AI/AN Veterans; (4) ensuring appropriate resources are identified 
and available to support programs for AI/AN Veterans; and (5) improving 
health promotion and disease prevention services to AI/AN Veterans to 
address community-based wellness. VA and IHS staff are working together 
to support these goals and have established action items and target 
dates for deliverables. Where appropriate, VA and IHS staff also 
document outreach activities resulting from the MOU partnerships and 
the number of AI/AN Veterans impacted by such activities. IHS Senior 
leaders are required in their performance evaluations to describe 
measurable activities and accomplishments that promote implementation 
of the VA-IHS MOU each year.
                                 ______
                                 
Response to Written Questions Submitted by Hon. John Barrasso to Randy 
                                Grinnell
    Question 1. In 2010, the Indian Health Service and the Department 
of Veterans Affairs established a Memorandum of Understanding outlining 
a plan for coordination, collaboration, and resource sharing. However, 
a prior interagency agreement for the same purposes has been in 
existence since 2003. Tribes have contended that no action has been 
taken by your agency to improve services despite the existence of these 
two agreements. How will the 2010 Memorandum of Understanding be 
implemented more effectively that the prior agreement?
    Answer. The IHS/VA MOU sets forth five mutual goals for serving AI/
AN Veterans, as outlined above. To further these goals, IHS and VA 
staff actively collaborate and coordinate activities targeted at the 
twelve strategic objectives. These strategic objectives include: (1) to 
increase access to services and benefits of IHS and VA; (2) to improve 
coordination of care, including co-management, for AI/AN Veterans 
served by both IHS, Tribal, or Urban Indian health programs and VA; (3) 
to improve care through the development of health information 
technology; (4) to enhance access through the development and 
implementation of new modules of care using new technologies; (5) to 
improve efficiency and effectiveness of both VA and IHS at a system 
level; (6) to increase availability of services, in accordance with 
law, by the development of payment and reimbursement policies and 
mechanisms; (7) to improve the delivery of care through active sharing 
of care process, programs, and services; (8) to increase cultural 
awareness and culturally competent care for VA and IHS beneficiaries; 
(9) to increase capability and improve quality through training and 
workforce development; (10) to increase access to care through sharing 
of staff and enhanced recruitment and retention of professional staff; 
(11) to address emergency, disaster, and pandemic preparedness and 
response; and (12) to accomplish the broad and ambitious goals of this 
agreement through the development of a joint implementation taskforce. 
Following the release of the MOU in November, 2010, the IHS Director 
instructed each of the IHS Area Directors to meet with their regional 
VA counterparts on how to better coordinate services between IHS and 
the VA under the MOU in their respective regions and their progress is 
measured in their annual performance evaluations.

    Question 2. The 2010 Caregiver and Veterans Omnibus Health Services 
Act allows, in certain circumstances, electronic transfers of health 
records of Indian Veterans between Indian Health Service and the 
Department of Veterans Affairs with appropriate privacy protections. 
This Act was intended, in part, to provide seamless health care 
services to these Veterans. What is the status on the implementation of 
this Act?
    Answer. Since the VA-IHS 2010 MOU, VA and IHS staff have been 
working on twelve strategic objectives to improve AI/AN Veteran's 
health services and care. Strategic objectives 3 and 4 highlight 
efforts to improve health care services:

        Strategic Objective 3: Health Information Technology
        Purpose: Development of Health Information Technology
        Major Tasks: Share technology; interoperability of systems; 
        develop processes to share information on development of 
        applications and technologies; and develop standard language 
        for inclusion in sharing agreements to support this 
        collaboration.

    Accomplishments:

   Consultation on EHR Certification and Meaningful Use: the 
        agencies continue to actively consult on EHR Certification and 
        Meaningful Use requirements.

   ICD-10 Development and Implementation: staff have met to 
        design system changes to VistA and Resource & Patient 
        Management System (RPMS) in preparation for transition to ICD-
        10.

   Bar Code Medication Administration: staff have met to define 
        scope, support agreement, and needs to leverage VA experience 
        with Bar Code Medication Administration in support of potential 
        use in IHS and Tribal hospitals.

   VA-DOD EHR: IHS meets regularly with VA and DOD in planning 
        for the Integrated Electronic Health Record (iEHR); VA, DOD, 
        and IHS staffs are designing the EHR interface and care 
        management functions. These activities will result in the 
        ability of IHS and VA to share medical records with appropriate 
        privacy protections and better coordinate care for American 
        Indians and Alaska Native Veterans that receive care in both 
        health care systems.

   Both agencies will be participating in health information 
        exchange through the Nationwide Health Information Network 
        (NwHIN). NwHIN is a group of federal agencies and private 
        organizations that have come together to securely exchange 
        electronic health information. NwHIN ``onboarding'' (process to 
        join the Exchange) is underway in IHS and should be complete 
        for all federal facilities by the summer of 2013. Through NwHIN 
        Connect, IHS and Tribal providers will be able to download 
        (``pull'') summary of care documents for any VA patient (or, 
        for that matter, any patient whose private sector provider 
        participates in Health Information Exchange (HIE)), and vice 
        versa. Also, as part of Meaningful Use, IHS will be adopting 
        the Direct Exchange protocols, which will allow IHS providers 
        to deliver patient records to any trusted entity such as a VA 
        hospital or provider. This solution is scheduled for 
        implementation in 2014.

        Strategic Area 4: Implementation of New Technologies
        Purpose: Development and implementation of new models of care 
        using new technologies.
        Major Tasks: Tele-health services; mobile communication 
        technologies; enhanced telecommunications infrastructure; share 
        training programs to support these models of care; and share 
        knowledge gained from testing new models.

    Accomplishments:
   Completed best practices for providing telepsychiatry 
        services to AI/AN Veterans.

   Established videoconferencing connectivity between Prescott 
        VA and the IHS Chinle facility to implement telemedicine 
        services, connection made Aug. 2011.

   Coordination of network-to-network connectivity for 
        videoconferencing with Work Group 3--Health Information 
        Technology.

   Explored mVET program (a VA program that targets prevention 
        of acute crises which lead to death among homeless Veterans) 
        within the context of the MOU collaborative (Work Group 4--to 
        enhance access through the development and implementation of 
        new models of care using new technologies), to provide homeless 
        vets with a smart phone with ``life-line'' apps.

                                  
