[Senate Hearing 112-703]
[From the U.S. Government Publishing Office]
S. Hrg. 112-703
VA'S COLLABORATION WITH INDIAN HEALTH SERVICE: IMPROVING ACCESS TO CARE
FOR NATIVE AMERICAN VETERANS BY MAXIMIZING THE EFFECTIVE USE OF FEDERAL
FUNDS AND SERVICES
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HEARING
before a
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE
ONE HUNDRED TWELFTH CONGRESS
SECOND SESSION
__________
SPECIAL HEARING
AUGUST 30, 2011--RAPID CITY, SD
__________
Printed for the use of the Committee on Appropriations
Available via the World Wide Web: http://www.gpo.gov/fdsys/browse/
committee.action?chamber=senate&committee=appropriations
__________
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COMMITTEE ON APPROPRIATIONS
DANIEL K. INOUYE, Hawaii, Chairman
PATRICK J. LEAHY, Vermont THAD COCHRAN, Mississippi
TOM HARKIN, Iowa MITCH McCONNELL, Kentucky
BARBARA A. MIKULSKI, Maryland RICHARD C. SHELBY, Alabama
HERB KOHL, Wisconsin KAY BAILEY HUTCHISON, Texas
PATTY MURRAY, Washington LAMAR ALEXANDER, Tennessee
DIANNE FEINSTEIN, California SUSAN COLLINS, Maine
RICHARD J. DURBIN, Illinois LISA MURKOWSKI, Alaska
TIM JOHNSON, South Dakota LINDSEY GRAHAM, South Carolina
MARY L. LANDRIEU, Louisiana MARK KIRK, Illinois
JACK REED, Rhode Island DANIEL COATS, Indiana
FRANK R. LAUTENBERG, New Jersey ROY BLUNT, Missouri
BEN NELSON, Nebraska JERRY MORAN, Kansas
MARK PRYOR, Arkansas JOHN HOEVEN, North Dakota
JON TESTER, Montana RON JOHNSON, Wisconsin
SHERROD BROWN, Ohio
Charles J. Houy, Staff Director
Bruce Evans, Minority Staff Director
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Subcommittee on Military Construction and Veterans Affairs, and Related
Agencies
TIM JOHNSON, South Dakota, Chairman
DANIEL K. INOUYE, Hawaii MARK KIRK, Illinois
MARY L. LANDRIEU, Louisiana KAY BAILEY HUTCHISON, Texas
PATTY MURRAY, Washington MITCH McCONNELL, Kentucky
JACK REED, Rhode Island LISA MURKOWSKI, Alaska
BEN NELSON, Nebraska ROY BLUNT, Missouri
MARK PRYOR, Arkansas JOHN HOEVEN, North Dakota
JON TESTER, Montana DANIEL COATS, Indiana
THAD COCHRAN, Mississippi
(ex officio)
Professional Staff
Christina Evans
Chad Schulken
Michael Bain
Dennis Balkham (Minority)
D'Ann Lettieri (Minority)
Administrative Support
Rachel Meyer
Courtney Stevens (Minority)
C O N T E N T S
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Page
Opening Statement of Senator Tim Johnson......................... 1
Statement of Robert L. Jesse, M.D., Ph.D., Principal Deputy Under
Secretary for Health, Veterans Health Administration,
Department of Veterans Affairs................................. 2
Prepared Statement of........................................ 3
Funding for Rural and Native American Veterans................... 4
Indian Health Service Partnership................................ 5
South Dakota Projects and Initiatives............................ 6
Statement of Randy Grinnell, M.P.H., Deputy Director, Indian
Health Service................................................. 7
Prepared Statement of........................................ 9
American Indian/Alaska Native Veterans Dual Use of Indian Health
Service and Veterans Health Administration..................... 9
Department of Health and Human Services/Indian Health Service-
Department of Veterans Affairs/Veterans Health Administration
Memoranda of Understanding..................................... 10
Indian Health Service-Veterans Health Administration
Collaborations................................................. 10
Area Director Meetings With Veterans Integrated Service Network.. 10
Sharing Facilities............................................... 11
Telemedicine..................................................... 11
Outreach (Tribal Veteran Representatives)........................ 11
Health Information Technology.................................... 11
VistA Imaging.................................................... 11
Bar Code Medication Administration............................... 12
Meaningful Use................................................... 12
Alaska Area Indian Health Service-Veterans Health Administration
Health Information Technology Collaborations................... 12
Consolidated Mail Outpatient Pharmacy............................ 12
Future Opportunities of Partnership.............................. 13
Statement of Stephanie Elaine Birdwell, Director, Office of
Tribal Government Relations, Department of Veterans Affairs.... 13
Prepared Statement of........................................ 14
Outreach and Consultation........................................ 15
Increase Access to Healthcare and Sustainable Economic
Opportunities.................................................. 15
Indian Health Service and Department of Veterans Affairs
Coordination................................................... 18
Payment and Reimbursement........................................ 19
Telemedicine..................................................... 20
Mental Health Telehealth......................................... 23
Tribal Consultation Sessions..................................... 23
Outreach......................................................... 24
Tribal Veteran Representative Program............................ 25
Nondepartmental Witnesses........................................ 27
Statement of Don Loudner, National Commander, National American
Indian Veterans................................................ 27
Statement of Iva Good Voice Flute, Air Force Veteran, Oglala
Sioux Tribe.................................................... 31
Material Submitted Subsequent to the Hearing..................... 35
Prepared Statement of the Cheyenne River Sioux Tribe............. 35
Prepared Statement of Geri Opsal, Tribal Veterans Service Officer
for the Sisseton Wahpeton Oyate, Lake Traverse Reservation..... 36
Letter From the Standing Rock Sioux Tribe........................ 38
VA'S COLLABORATION WITH INDIAN HEALTH SERVICE: IMPROVING ACCESS TO CARE
FOR NATIVE AMERICAN VETERANS BY MAXIMIZING THE EFFECTIVE USE OF FEDERAL
FUNDS AND SERVICES
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TUESDAY, AUGUST 30, 2011
U.S. Senate,
Subcommittee on Military Construction and Veterans
Affairs, and Related Agencies,
Committee on Appropriations,
Rapid City, SD.
The subcommittee met at 10 a.m., at the Journey Museum, 222
New York Street, Rapid City, South Dakota, Hon. Tim Johnson
(chairman) presiding.
Present: Senator Johnson.
opening statement of senator tim johnson
Senator Johnson. Good morning. This hearing will come to
order.
I welcome everyone to Rapid City today to discuss
collaboration between the Department of Veterans Affairs (VA)
and the Indian Health Service (IHS).
Present today are councilmen from Crow Creek Tribe, Oglala
Tribe, and the chairman of the Rosebud Tribe.
Our first panel today will be Dr. Robert Jesse, Principal
Deputy Under Secretary for Health, Veterans Health
Administration (VHA); Randy Grinnell, Deputy Director of the
IHS; and Stephanie Elaine Birdwell, Director of the Office of
Tribal Government Relations (OTGR) at the VA.
Welcome, and I look forward to your testimony today.
IHS and the VA have very unique responsibilities, but often
overlap in their roles of providing care to Native American
vets. Today's hearing is aimed at determining how the two
departments plan to work together to deliver services in a more
efficient manner.
The budget climate we face today means that the Federal
Government is going to be asked to do more with less. The VA
and IHS will need to be more innovative and collaborative than
ever in order to provide services in a very demanding
environment. In particular, the VA and IHS need to be more
proactive in their efforts to ensure that Native American vets
receive the care that they have earned through their service in
the Armed Forces.
Native American vets face unique challenges in receiving VA
benefits due to a number of factors, including a lack of access
on tribal lands and an often confusing maze of bureaucratic
hurdles leaving vets unsure of whether they should be receiving
care through the IHS or the VA.
I am hopeful that today's hearing will provide a better
understanding of how both departments plan to address these
problems. I am especially interested in how the VA and the IHS
plan to leverage technology to bring services closer to where
these vets live.
With that said, again I welcome you to South Dakota. Thank
you for coming, and I look forward to your testimony.
Dr. Jesse, please proceed.
STATEMENT OF ROBERT L. JESSE, M.D., Ph.D., PRINCIPAL
DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS
HEALTH ADMINISTRATION, DEPARTMENT OF
VETERANS AFFAIRS
Dr. Jesse. Thank you, Senator.
Good morning, Mr. Chairman. First, thank you for inviting
me and Ms. Birdwell, the Director of the OTGR, to discuss the
collaboration between the VHA and the IHS on improving access
to care for Native American veterans by maximizing the use of
Federal funds and services.
I am accompanied today also by Mary Beth Skupien, who is
the Director of the VHA Office of Rural Health, and Janet
Murphy, who is the Director of the VA Midwest Healthcare
Network, which is Network 23, providing services in South
Dakota, North Dakota, Iowa, and Minnesota, Nebraska, and
portions of Illinois, Kansas, Missouri, Wisconsin, and Wyoming.
Increasing access for veterans is one of Secretary
Shinseki's top priorities and has several components
immediately relevant to the Native American and rural veterans.
On a national level, VA is investing more than $270 million to
improve access and quality care services to rural and highly
rural veterans, including $43 million in telehealth.
As of August 1, 2011, we are now operating 16 active
telehealth programs for Native American, Alaska Native, and
Pacific Island veterans. We continue to look for more
opportunities to extend our reach in delivering quality
healthcare so that Native American veterans in remote areas can
have the same access to healthcare from national experts as
their urban counterparts.
In October 2010, the VA and IHS signed a new memorandum of
understanding (MOU). Its principal goals are for VA and the IHS
to provide patient-centered collaborations in consultation with
tribes at regional and local levels. These efforts are already
paying dividends.
For example, last October, we initiated a pilot program
here in Rapid City, South Dakota, to promote the safety and
cost effectiveness of providing prescription refills by mail
for veterans and other IHS patients. This program will enhance
prescription delivery to federally recognized tribes and about
2 million Native Americans.
Similarly, VA collaborates with IHS and tribal governments
to expand home-based primary care, including a number of local
initiatives to improve access and outreach for Native Americans
in South Dakota. The VA Black Hills Healthcare System, to name
one example, maintains a robust noninstitutional purchased care
program that offers eligible veterans in-home care when travel
for healthcare is not possible or would be made difficult.
In addition, the Wagner, Watertown, Spirit Lake, Sioux
City, and Aberdeen clinics are planning information fairs and
open houses to inform veterans of available services and
benefits, to enroll eligible veterans so that they may access
these hard-earned benefits.
The Sioux Falls VA Healthcare System holds monthly phone
conferences with the IHS Aberdeen area office so IHS can
determine the potential areas of resource sharing, including
services for radiology, audiology, laboratory, physical
therapy, and patient transportation.
Through local agreements, VA and IHS share technical
training, informatics, and electronic health records (EHRs).
VA's contract clinics at Mission, Winner, Eagle Butte, Faith,
Pierre, and Isabel now serve veterans from Lakota, Nakota, and
Dakota tribes in South and North Dakota. VA provides
transportation support to the South Dakota tribes at Rosebud,
Standing Rock, Cheyenne River, and Pine Ridge Reservations. And
VA provides pharmacy mail order services for tribes in South
Dakota.
In April 2010, VA opened the Wagner community-based
outreach clinic (CBOC), the first CBOC built on tribal land for
a variety of primary and mental healthcare. The Wagner CBOC
also hosts a home-based primary care team, which helps Native
Americans remain in their homes and avoid frequent
rehospitalizations or emergency room visits for chronic
conditions.
Our Readjustment Counseling Service Mobile Vet Center
Program provides early access to returning combat veterans via
outreach at a variety of military and community events, and
today we want just to acknowledge and thank them for showing up
here. And they are parked outside the museum so that veterans
can access our services.
And Mr. Chairman, we understand the unique difficulties
Native Americans face when accessing care. We are committed to
working to improve that access in partnership with IHS. We are
introducing VA providers to traditional healing practices so
that they can work to integrate these practices as adjuncts to
Western medicine.
prepared statement
And finally, I just really want to thank you personally for
your support and that of the subcommittee and the Congress for
securing VA resources that we need to deliver better, more
accessible care to Native Americans. As you know, there has
been a book written about the VA called ``The Best Care
Anywhere''. It is in its second edition. And we think we
strongly believe that the title of that next book should be
``The Best Care Everywhere'', and VA is committed to providing
that.
So thank you again, and I am prepared to answer any
questions.
[The statement follows:]
Prepared Statement of Robert L. Jesse
Good Morning, Mr. Chairman. Thank you for inviting me to discuss
the collaboration between the Department of Veterans Affairs (VA) and
the Indian Health Service (IHS) on improving access to care for Native
American veterans by maximizing the use of Federal funds and services.
I am accompanied today by Mary Beth Skupien, Director, Veterans Health
Administration's (VHA's) Office of Rural Health, and Ms. Janet Murphy,
Director of the VA Midwest Health Care Network (Veterans Integrated
Service Network (VISN) 23), which provides services to veterans in
South Dakota, North Dakota, Iowa, Minnesota, Nebraska, and portions of
Illinois, Kansas, Missouri, Wisconsin, and Wyoming.
Native American veterans face many of the same challenges as
veterans living in rural and highly rural areas, such as geographic
distance from healthcare facilities and a shortage of skilled community
providers. Native American veterans also face unique challenges of
their own, such as higher morbidity for certain conditions and the need
for culturally appropriate care. Earlier this year, VA established an
Office of Tribal Government Relations, which is working in close
cooperation with VHA's Office of Rural Health (ORH), specifically to
serve as an advocate within the Department for Native American veterans
and help VA improve healthcare access and services for Native American
veterans. Increasing access for veterans is one of the Secretary's top
priorities for the Department and has several components immediately
relevant to Native American and rural veterans--it means bringing care
closer to home, sometimes even into the veteran's home; increasing the
quality of the care we deliver; and providing veteran-centered care in
a time and manner that is convenient to our veterans.
My testimony will begin by reviewing VA's plans in fiscal years
2011 and 2012 for continued support of ORH projects and other rural
health initiatives. I will then focus on VA's memorandum of
understanding (MOU) with IHS and our continually evolving partnership.
My statement will conclude with a discussion of VA's efforts in South
Dakota to ensure veterans, particularly Native American veterans,
receive the care and benefits they have earned.
funding for rural and native american veterans
With the funding provided by the Congress in fiscal year 2011, VA
will invest more than $270 million to improve the access and quality of
healthcare services to rural and highly rural veterans, including $43
million in telehealth programs. Telehealth involves the use of
information technology to deliver services when the patient and
healthcare provider are separated by geographic distance. We have seen
a 20-percent increase in the use of telehealth services by veterans
living in rural and highly rural areas between fiscal year 2008 and
fiscal year 2010. VA-supported telehealth programs offer specialty
services, including mental health, dermatology, amputee care, pharmacy,
polytrauma, radiology, and others. As of August 1, 2011, VA operates 16
active telehealth programs for Native American, Alaska Native, and
Pacific Island veterans. Telehealth can reduce the need for travel by
patients and providers, but it does not replace the need for face-to-
face care delivery. We continue to look for more opportunities to
extend our reach in delivering quality healthcare. We are exploring the
use of wireless technologies, mobile resources, and more accessible
facilities so that Native American and rural veterans in remote areas
can have the same access to healthcare from national experts as their
urban counterparts.
Other ORH-managed programs include Project Access Received Closer
to Home, a pilot program authorizing the use of contractual agreements
with non-VA providers to deliver care closer to home and three veterans
rural health resource centers, which function as field-based clinical
laboratories and serve as rural health experts for all VISNs. ORH also
supports continuing projects and initiatives, including:
--More than $70 million to support 52 rural community-based
outpatient clinics (CBOC);
--Almost $26 million in home-based primary care at 21 sites;
--$1.5 million to support treatment for substance use disorders;
--Nearly $5 million to end homelessness among rural veterans
including funds to promote outreach, prevent homelessness among
at-risk veterans, distribute emergency housing vouchers, and
support grant and per diem programs. ORH-funded programs in
Sioux Falls and nationally are demonstrating improved
collaboration within the community to address homelessness in
rural areas and have a demonstrable impact on preventing
homelessness. These efforts also improve the quality of life
and functioning for veterans served and reduce the frequency of
visits by veterans within the primary care setting.
--More than $3 million to enhance transportation options for veterans
in rural and highly rural areas; and
--$91.2 million to sustain 76 additional rural health projects, such
as mobile health clinics, case management and mental health
services, geriatric care, non-institutional care, and other
specialty services.
VA is addressing mental healthcare needs of rural veterans through
ORH's support of the Mental Health Intensive Case Management program.
This allows VA to hire staff to provide case management services to
veterans with severe mental illness. This program has demonstrated its
success in preventing homelessness and helping patients to set goals to
improve their quality of life and reintegrate into the community.
VA operates a fleet of 50 mobile vet centers that provide early
access to returning combat veterans via outreach to a variety of
military and community events including demobilization activities. The
vehicles are also extending vet center outreach to more rural
communities that are isolated from existing VA services. The vehicles
consistently provide services to Native American reservations and are
staffed with veterans who understand firsthand the needs of these
communities.
The VA Black Hills Health Care System (Hot Springs campus) is
serving almost 300 veterans in 13 counties within a 60-mile radius of
the facility, including much of the Pine Ridge Reservation, through a
full home-based primary care (HBPC) team. Further enhancements are
planned for fiscal year 2012 to provide HBPC and in-home skilled care
for veterans in the southwestern portion of South Dakota, including
previously unreached parts of the Pine Ridge Reservation. A second
program is VA's Medical Foster Home, which matches veterans who are
unable to remain in their homes with people in the community who are
willing to care for them. This is a new program that is currently being
marketed to veterans and the community, and we anticipate we will begin
admitting veterans to the program later this year.
In fiscal year 2012, VA will continue to support many of the same
projects as in fiscal year 2011, and we look forward to initiating
further measures to increase access to care for rural, highly rural,
and Native American veterans. In fiscal year 2012, ORH will again
support increased access to care by funding telehealth service
projects, such as tele-mental health, tele-retinal care, tele-pharmacy,
tele-radiology, tele-rehabilitation, tele-dermatology, and other
innovative telehealth services. We will conduct outreach and marketing
efforts to encourage veterans who need these services to access them.
We will also support greater community collaboration and access to
specialty services, and we will promote education programs, including
healthcare provider training to teach providers how to care for the
unique needs of rural and highly rural veterans, as we enhance our
recruitment and retention efforts for providers in rural areas.
indian health service partnership
Complementing our national efforts, VA and IHS signed a new MOU on
October 1, 2010. In contrast to a February 2003 MOU, this current
agreement includes more areas of focus and is more specific concerning
the obligations of each party to coordinate the delivery of care for
Native American veterans. The memorandum's principal goals are for VA
and IHS to promote patient-centered collaborations in consultation with
tribes at the regional and local levels. Although national in scope,
the MOU provides the necessary flexibility to tailor programs through
local implementation. We believe that by bringing together the
strengths and resources of each organization, we will improve the
health status of American Indian and Alaska Native veterans.
We also recognize that interagency agreements are critical to our
joint efforts. VA and IHS continue to work through payment and
reimbursement policies and practices, including working to resolve
legal questions resulting from new provisions in Public Law 111-148,
the Patient Protection and Affordable Care Act.
Another primary goal of the MOU is to promote the health of our
veterans through disease prevention and community-based wellness
programs. Through cultural awareness and culturally competent care,
sharing staff and training programs, and collaborating on issues such
as care for post-traumatic stress disorder (PTSD), suicide prevention,
pharmacy management, and long-term care, we can deliver the care Native
American veterans need.
VA and IHS have established 14 workgroups to develop specific
recommendations and action items related to the MOU. The workgroups are
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. We have made
significant progress in many of these areas, and will continue to
monitor progress through weekly meetings and quarterly updates to
leadership on the remaining items.
The efforts of VA and IHS are already paying dividends. For
example, last October, we initiated a pilot program in Rapid City,
South Dakota, to improve the safety and cost effectiveness of providing
prescription refills by mail for veterans and other IHS patients. This
program will enhance prescription delivery to federally recognized
tribes and about 1.9 million Native Americans. Based on initial
reports, both veterans and staff are very pleased with the arrangement,
which has reduced the amount of time it takes to transfer medication
from VA to veterans and improved the ability of veterans to adhere to
their treatment regimens.
Similarly, VA has several collaborative projects with IHS and
tribal governments to expand home-based primary care to Native American
and rural veterans. In fiscal year 2011, VA supported these programs in
11 States, including two locations in South Dakota (Rosebud and Pine
Ridge). Hospice and Palliative Care has also received support from VA's
ORH to partner with IHS so that all veterans will have reliable access
to these services from a knowledgeable and skilled workforce.
south dakota projects and initiatives
In addition to these collaborative efforts between VA and IHS, the
Department is also supporting a number of local initiatives to improve
access and outreach for Native American veterans in South Dakota. To
this end, VA obligated approximately $4 million in fiscal year 2011 to
expand telehealth, audiology, home-based primary care, mental
healthcare, and medical foster homes. When we are unable to deliver
care ourselves, VA Black Hills Health Care System maintains a robust
non-institutional purchased care program. This service offers eligible
veterans in-home care when travel for healthcare is not possible or
would create a significant hardship. VA Black Hills Health Care System
purchases home hospice, skilled nursing, skilled services, homemaker/
home health aide, and adult home day care services for more than 1,000
rural veterans.
For mental healthcare, two sites offer Compensated Work Therapy in
the State of South Dakota--the Cheyenee River Miniconjou Lakota
Reservation and the Pine Ridge Oglala Lakota Reservation. VA's
Compensated Work Therapy programs provide paid vocational
rehabilitation models designed to return veterans with mental health
conditions to the highest level of functioning, living, and working in
their communities. VHA program staff work collaboratively and
cooperatively with tribal government leadership for reservation-based
programming. VA also has established mental health specialty clinics
for Native veterans. For example, the Rosebud clinic offers tele-
psychiatry, and the Standing Rock facility offers tele-psychiatry and
live clinics for mental health conditions. Cultural outreach and other
services include a residential alcohol and PTSD program with a VA sweat
lodge at the Hot Springs clinic of the VA Black Hills Health Care
System. Native Americans use the sweat lodge as a spiritual place for
healing to be able to send prayers and thoughts to the Creator and
grandfathers through the use of meditation, song, and prayers. A sweat
lodge is a dome-shaped structure made of 28 willow branches, which
represent the 28 ribs of the sacred buffalo, covered by canvas or other
materials to hold in the heat and uses the heat and steam from the
heated rocks for spiritual cleansing.
Several additional efforts are underway to increase Native
Americans' access to care in South Dakota. For example, the Wagner,
Watertown, Spirit Lake, Sioux City, and Aberdeen clinics are planning
information fairs and open houses to inform veterans of services and
benefits they may be eligible for and to enroll them if needed. The
Sioux Falls VA Health Care System holds monthly phone conferences with
the IHS Aberdeen area office so the IHS can determine potential areas
of resource sharing, including services for radiology, audiology,
laboratory, physical therapy, dietetics, telehealth, outreach, and
patient transportation. We are also developing plans to use video-
teleconferencing to provide tele-mental health services to veterans in
the Sisseton area through an agreement between VA and IHS.
VA provides office space and serves as a regional information
technical support center for the Aberdeen Area Office of IHS. VA and
IHS share technical training, informatics, and electronic health
records through local agreements. VA Hot Springs provides IHS' Pine
Ridge Hospital with information resource management consultation and
other services such as use of a General Services Administration
vehicle, phone line costs, and parts exchange-purchase. VA's contract
clinic at Mission serves veterans from Lower Brule and Sioux tribes,
and the Winner VA CBOC located on the Rosebud Reservation serves
veterans from Lower Brule, Rosebud, and Yankton Sioux tribes, Eagle
Butte, Faith, and Winner. VA provides transportation support to the
South Dakota tribes at Rosebud, Standing Rock, Cheyenne River, and Pine
Ridge Reservations, and VA provides pharmacy mail order services for
tribes in South Dakota.
In April 2010, VA opened the Wagner CBOC which is located on tribal
land provided through an agreement with the Yankton Sioux Tribe and
Aberdeen area IHS and is the first CBOC built on tribal land for the
sole purpose of providing VA primary and mental healthcare. The Wagner
CBOC hosts an HBPC team, which helps veterans remain in their homes and
avoid frequent re-hospitalization or emergency room visits for chronic
conditions. Similarly, care coordination/home telehealth services are
also provided at this facility.
conclusion
Mr. Chairman, we understand the unique difficulties faced by Native
American and rural veterans in accessing care, and we are committed to
working to improve access to care. We are introducing VA providers to
traditional healing practices and the unique practices of local tribes
to help them understand how these practices may be integrated as
adjuncts to traditional care. We greatly appreciate your support, and
the Congress' support, in securing the resources VA needs to deliver
better, more accessible care to all of America's veterans. This
concludes my prepared statement. I am prepared to answer your questions
at this time.
Senator Johnson. Thank you, Dr. Jesse.
Mr. Grinnell, please proceed.
STATEMENT OF RANDY GRINNELL, M.P.H., DEPUTY DIRECTOR,
INDIAN HEALTH SERVICE
Mr. Grinnell. Good morning, Senator Johnson.
I am Randy Grinnell, Deputy Director of IHS. I am
accompanied today by Rick Sorenson from the Aberdeen area
office. Pleased to have this opportunity to testify on the IHS/
VA collaboration.
IHS has a unique role in the Department of Health and Human
Services because it is a healthcare system established to meet
the Federal trust responsibility to provide healthcare to
American Indians and Alaska Natives. Our mission is to raise
the physical, mental, social, and spiritual health of American
Indian and Alaska Natives to the highest level.
IHS provides comprehensive healthcare services to
approximately 1.9 million American Indian and Alaska Natives
through a network of hospitals, health centers, and clinics
located in 35 States, many of them in rural and remote areas
where access is a challenge. We also provide care through the
private sector, through Contract Health Service (CHS), for
those types of services that are not available directly.
In 2006, a joint VA/IHS study was initiated to review dual
use of the two systems. The findings of the study indicated
that veterans using the VHA are similar to other veterans with
similar medical conditions, such as post-traumatic stress
disorder (PTSD), hypertension, and diabetes. The review also
found that dual users are more likely to receive primary care
from IHS and general medical diagnostics and medical healthcare
from the VHA, and they are likely to receive complex healthcare
services from both systems.
Many of the American Indian and Alaska Native veterans are
eligible for healthcare services from both IHS and VHA. We
estimate within our patient registration system that we have
got approximately 45,000 who are identified as veterans in our
system. Many of them live in rural areas as well and have
trouble accessing direct facilities, and therefore, they are
dependent upon our urban Indian health programs where they are
located in 34 cities.
IHS also pays for referred care outside the system for
veterans if they meet the CHS program rules and regulations.
The VHA is considered an alternate resource, along with
Medicare, Medicaid, and private insurance in accordance with
our CHS regulations.
The MOU that Dr. Jesse talked about was recently signed in
2010. He identified the five mutual goals of that, which I will
talk about briefly. It was to improve access to care and
services; improve communication between the VA, tribes, and
IHS; encourage partnerships and sharing agreements between the
three entities; also to ensure appropriate support for programs
that serve American Indian and Alaska Native veterans; and also
to improve access to health promotion and disease prevention
services.
The principal focus of both of these agreements is to
provide optimal healthcare to American Indian and Alaska Native
veterans. Examples include allowing VHA staff to utilize IHS
and tribal facilities to provide services, opportunities that
IHS providers take advantage of through the VA for clinical
skills training and education.
Dr. Jesse also talked about the traditional healing, where
we have been working with the VHA to bring that approach into
their delivery system. Dr. Jesse also talked about the VHA
home-based primary care project. Right now, there are 13
collaborative projects in States in New York, North Carolina,
Oklahoma, Oregon, New Mexico, California, Mississippi, and
Minnesota, as well as the Rosebud and Pine Ridge Reservations
here in South Dakota.
One of the other examples includes increasing mental health
services by locating VHA social workers in healthcare
facilities on both the Navajo and the Hopi reservations in the
Southwest.
Dr. Jesse also talked about the Wagner service unit, where
the VA has opened a community-based outpatient clinic. Services
are being shared there, include audiology, include lab, include
dietary and radiology.
On the Navajo reservation, an agreement is currently in
place with the Prescott VA that allows IHS office space for VA
PTSD counselors. Also there is work underway with Prescott to
increase services by allowing more space so that they can
provide services directly to Navajo veterans.
In Montana, there are currently telepsychiatry mental
health services provided at each of the service units
throughout the Montana area. It is an example of success and a
way of reaching those remote locations and providing needed
services.
Another example is in Alaska. Since 1995, there has been
the Alaska Federal Healthcare Partnership, which brought
Federal and tribal entities together to increase access of
services both in the rural areas and the remote areas of
Alaska, but also to bring the technology advancements that the
VA has brought to healthcare and take advantage of it.
There are more than 100 telemedicine equipment carts that
are now in rural locations throughout Alaska, and they also
have deployed digital imaging radiology services to more than
51 Federal and tribal facilities across Alaska.
I would like to also point out that the IHS and the VHA
have a long history of partnering for many decades, especially
in the health information technology arena. The IHS Resource
and Patient Management System (RPMS) is actually a system that
was built and designed by the VA. IHS uses that in place. Many
of the tribes also take advantage of that.
And Dr. Jesse mentioned about the VistA, the VistA system
that they function with as well. The EHR that IHS currently has
is one that came out of the RPMS system. It is in place now.
The RPMS EHR is in place in more than 300 IHS tribal and urban
facilities.
There are other projects underway with the VA that will
increase our utilization of their technology, and one of the
results of that is that the IHS EHR has been certified for
meaningful use, which is one of the new requirements under the
Affordable Care Act.
Dr. Jesse also talked about the Consolidated Mail
Outpatient Pharmacy (CMOP) project. IHS is working with them.
One of the pilots is right here in Rapid City. To date, we have
had more than 20,000 prescriptions that have been filled
through that project. It has allowed two of our pharmacists at
our IHS facility to focus on providing direct patient care,
which we feel is a tremendous outcome.
Also both staff and patients have been extremely satisfied
with this new service. So IHS and VA are pursuing utilizing the
CMOP throughout the entire system.
So we are committed. IHS is very committed to working with
the VHA to improve access to services for American Indian and
Alaska Native veterans.
PREPARED STATEMENT
That concludes my remarks today, Senator, and I am happy to
answer any questions.
[The statement follows:]
Prepared Statement of Randy Grinnell
Mr. Chairman and members of the subcommittee: Good morning. I am
Randy Grinnell, the Deputy Director of the Indian Health Service (IHS).
I am pleased to have the opportunity to testify on the IHS/Department
of Veterans Affairs (VA) collaboration.
The IHS plays a unique role in the Department of Health and Human
Services (HHS) because it is a healthcare system that was established
to meet the Federal trust responsibility to provide healthcare to
American Indians and Alaska Natives (AIs/ANs). The mission of the IHS
is to raise the physical, mental, social, and spiritual health of AIs/
ANs to the highest level. The IHS provides comprehensive health service
delivery to approximately 1.9 million AIs/ANs through hospitals, health
centers, and clinics located in 35 States, often representing the only
source of healthcare 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 healthcare from private providers through the
Contract Health Services (CHS) 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 healthcare programs. IHS
accomplishes a wide array of clinical, preventive, and public health
objectives within a single system for AIs/ANs.
american indian/alaska native veterans dual use of indian health
service and veterans health administration
In 2006, a joint Veterans Health Administration (VHA)-IHS study was
initiated to review dual use of the two systems by AI/AN veterans. The
findings of this study indicate that AI/AN veterans using the VHA are
demographically similar to other VHA users with similar medical
conditions, such as post-traumatic stress disorder (PTSD),
hypertension, and diabetes. The review found that dual users are more
likely to receive primary care from IHS, and general medical diagnostic
services and mental healthcare from the VHA. They are likely to be
receiving complex care from both VHA and IHS.
Many AI/AN veterans are eligible for healthcare services from both
IHS and VHA. IHS has an estimated 45,000 Indian beneficiaries
registered as veterans in the agency's patient registration system.
Some AI/AN veterans who live in urban locations do not have geographic
access to care in IHS facilities on or near reservations and must use
the local systems of care or Urban Indian Health Programs (UIHP) where
they are available. In some of these locations the UIHPs provide
limited direct care and assist these patients in accessing VHA and
other services in the local area. AI/AN veterans residing on
reservations in some cases are not easily able to access VHA health
facilities and services.
IHS recognizes that the complexity of IHS-CHS program and VHA
eligibility requirements can make it difficult for AI/AN veterans to
access care. IHS pays for the care referred outside of IHS for AIs/ANs
including veterans if all the CHS program rules and regulations are
met. For the AI/AN veteran, the VHA is an alternate resource along with
Medicare, Medicaid, and private insurance in accordance with the CHS
regulations.
department of health and human services/indian health service-
department of veterans affairs/veterans health administration memoranda
of understanding
A memorandum of understanding (MOU) between the HHS/IHS and the VA/
VHA was signed in 2003 to encourage cooperation and resource-sharing
between the two Departments. The 2003 MOU outlined joint goals and
objectives for ongoing collaboration between VA and HHS to be
implemented primarily by IHS and VHA. The MOU advanced our common goal
of delivering quality healthcare services to and improving the health
of the 383,000 veterans who identified as AIs/ANs within the VHA
system, a portion of which are served by IHS. The HHS/IHS and the VA
entered into this MOU to further their respective missions, to serve
AI/AN veterans who comprise a segment of the larger beneficiary
population for which they are individually responsible.
Tribes stressed the need to improve collaboration and coordination
of services for veterans eligible for both the VA and IHS services. The
IHS Director met with VA Secretary Shinseki in May 2010, and they
agreed to update the 2003 VA-IHS MOU to improve collaboration and
coordination of services for AI/AN veterans. The updated MOU was signed
in October 2010 and a consultation on implementation of the MOU was
initiated with tribes in November, 2010. Tribal leaders identified
priorities for implementation and the VA and IHS are working on
improvements to better coordinate care, services and benefits, State-
level agreements, implementation of new technologies, payment and
reimbursement, health information technology, training, and cultural
competency. IHS area directors are already working locally in some
areas with the VHA and tribes to make improvements specific to the
unique needs of veterans in the IHS area and local levels.
The MOU identifies five mutual goals to:
--Improve beneficiary access to healthcare and services;
--Improve communication among the VA, AI/AN veterans and tribal
governments with IHS assistance;
--Encourage partnerships and sharing agreements among VHA, IHS, and
tribal governments in support of AI/AN veterans;
--Ensure the availability of appropriate support for programs serving
AI/AN veterans; and
--Improve access to health promotion and disease prevention services
for AI/AN veterans.
indian health service-veterans health administration collaborations
The principal focus of the interagency communication and
cooperation is to provide optimal healthcare for the AI/AN veterans who
rely on the IHS and/or VHA for their medical needs. Together, we strive
to achieve multiple goals outlined by the MOU by developing projects
that, for example, improve access to VHA services by allowing VHA staff
to utilize Indian health facilities for providing healthcare to AI/AN
veterans while the joint working relationship expands opportunities for
professional development of clinical skills by IHS providers. IHS'
experience with the use of traditional healing in its system became a
model for the VHA when it began incorporating traditional approaches to
healing for AI/AN veterans.
area director meetings with veterans integrated service network
Other collaborations that meet the goals of the MOU range from
expansion of access to VHA home-based primary care for AI/AN veterans
through the collaboration with IHS and tribal health facilities to the
improvement of interagency partnership on health information and the
use of tele-health modalities. The home-based primary care program
expansion will increase availability of services for AI/AN veterans
with complex chronic disease and disability through 13 collaborative
projects located in States including New York, North Carolina,
Oklahoma, Oregon, New Mexico, California, Mississippi, and Minnesota
and two locations in South Dakota (Rosebud and Pine Ridge). In 2010,
this collaboration resulted in a five-fold (11 to 55 veterans) increase
in the number of AI/AN veterans served by home-based primary care. In
Arizona, the IHS and the VHA are working together to increase mental
health services by locating VHA social workers in IHS health facilities
on the Navajo and Hopi reservations.
sharing facilities
The Wagner IHS facility recently opened a VA community-based
outpatient clinic (CBOC). IHS has an audiology booth in the facility
and the VA has an audiologist they can send to the facility to see both
VA and service unit patients. Both agencies are also sharing lab
services, the service unit provides onsite lower level lab services to
the VA while the VA provides some higher level lab services at an
alternate location. The service unit is developing the capacity to
provide radiology services to the CBOC. The service unit also provides
onsite dietary services to the CBOC patients.
The Navajo Area IHS (NAIHS) is currently working on an approval for
the Prescott VA providers to be allowed space in an IHS facility to
increase access to VA services for veterans on the Navajo Nation. The
NAIHS already has an agreement with Prescott VA that allows office
space for a PTSD counselor in an IHS facility to provide counseling and
increase access to services. The NAIHS is also working with Veterans
Integrated Service Network (VISN) 18 to develop an IHS-VA task force to
address specific issues to these organizations.
telemedicine
In Montana, the Billings Area IHS and the VHA Montana Healthcare
System (VHAMHCS) have ongoing collaborative efforts such as tele-
psychiatry established at each service unit to facilitate VHA mental
health services for AI/AN veterans. Because of the geographic
remoteness and difficulty in accessing transportation to a VHA
facility, this service greatly benefits the AI/AN veterans. The
Billings Area IHS and VHAMHCS have formalized a PTSD protocol that is
utilized by the service units and Fort Harrison. Among the protocol
elements, the VHA has created a position designated as a tribal
outreach worker (TOW) who works on-site to actively seek and educate
veterans who may benefit from the services provided through tele-
psychiatry clinics. Each service unit has a designated VHA liaison to
help the AI/AN veterans needing medical services as well as working
with the TOW and local tribal veteran representative (TVR). As the
primary IHS contact, they can provide information, assistance, and
guidance on VHA services and health benefits to AI/AN veterans. To
distinguish the different roles and responsibilities, the TVRs function
as an arm of the VA program with the IHS providing and coordinating the
medical care for the AI/AN veteran. These collaborative efforts are
reviewed on an on-going basis in efforts to address patient-related
issues, improve services, outreach, and rural initiatives, and to
assist AI/AN veterans to utilize both the IHS and VHA systems.
outreach (tribal veteran representatives)
VA's development and use of the TVR program has been and is
critical to addressing issues related to communicating about and
reducing barriers to VHA services and to the IHS-CHS program for AI/AN
veterans through coordinated training on benefits and eligibility
issues for each of the two programs.
health information technology
The IHS and VHA have a long history of working jointly on health
information technology that dates back to the early 1980s. The Resource
and Patient Management System (RPMS) is the IHS' comprehensive health
information system that is derived from and evolved alongside the VHA's
acclaimed VistA system. IHS/tribal/UIHP (I/T/U) facilities use many
components of VistA along with IHS-developed components that address
the population and public health mission of IHS.
The model for the RPMS electronic health record (EHR) is the
Computerized Patient Record System, the EHR component of VistA. Since
its release in 2005, the RPMS EHR has been deployed to more than 300 I/
T/U healthcare facilities nationwide. IHS continues to leverage VHA
healthcare software development by adapting it for our use where
possible.
vista imaging
Another important example of IT sharing between VHA and IHS is
VistA Imaging (VI), the VHA's Food and Drug Administration-certified
system for capture, storage and viewing of diagnostic images and
scanned documents. VI provides the multimedia component of both
agencies' EHR systems, and has now been deployed to more than 90 I/T/U
facilities across the country. This deployment would not have been
possible without interagency agreements that have allowed VHA staff and
contractors to provide implementation support and help desk services to
our facilities. The VHA's VI program is critical to IHS.
bar code medication administration
Like VI, the VHA Bar Code Medication Administration (BCMA) system
is an integral component of modern hospital practice. BCMA ensures that
the right patients are receiving the right doses of the right
medications in the inpatient setting. The IHS, in cooperation with the
VHA Bar Code Resource Office, is just beginning a joint effort to
deploy BCMA in IHS and interested tribal hospitals. This effort will be
modeled after the successful VI collaboration previously described.
meaningful use
The Meaningful Use Initiative authorized by the HITECH Act of 2009
has given the IHS an opportunity to materially assist the VHA with an
important effort. In April 2011, the IHS became the first Government
agency to have its health information system certified according to the
requirements for Meaningful Use. The VHA is seeking to certify the
VistA system in 2012, and has reached out to IHS staff for consultation
on how we addressed the various certification criteria. Our staff is
more than willing to do so, as IHS has greatly benefited from so many
VHA innovations in health information technology for more than two
decades.
alaska area indian health service-veterans health administration health
information technology collaborations
The Alaska Area IHS has partnered with the VHA since 1995 via the
Alaska Federal Health Care Partnership (AFHCP) which includes IHS/
tribal, VHA, Army, Air Force, and Coast Guard partners. The AFHCP
office's primary responsibility is to coordinate initiatives between
the partners that result in increased quality and access to Federal
beneficiaries, or an overall cost savings to the Federal Government.
Current initiatives in the Alaska Area IHS include:
--joint training offerings;
--a neurosurgery contract services agreement;
--a perinatology contract services agreement;
--tele-radiology;
--sleep studies;
--home tele-health monitoring;
--partner staffing needs assessment;
--emergency planning and preparedness; and
--tele-behavioral health.
Past projects of AFHCP include the Alaska Federal Health Care
Access Network (AFHCAN) which deployed network capability (backbone)
along with hundreds of telemedicine equipment carts, the Teleradiology
Project, deploying digital imaging radiology services to 51 federally
and tribally managed IHS-funded facilities, video teleconferencing
equipment to promote administrative and clinical consults, as well as
an IT partnership bridge (``Raven Bridge''), allowing Federal and
tribal partners to connect to each other.
The AFHCP frequently shares workload data during its investigations
of possible joint services analyses; a recent example is a study for
joint-agency tele-dermatology and tele-rheumatology contracts. One of
the AFHCP committees is the Partnership Telehealth & Technology
Committee (PT&T) which brings together information technology staff to
discuss partner organization needs, identify potential telehealth and
technology applications to meet those needs, and find avenues for
shared technology resources. PT&T members and their clinical champions
will monitor patient results and gather feedback on the use of new
technologies to improve clinical outcomes and access to care.
consolidated mail outpatient pharmacy
The Consolidated Mail Outpatient Pharmacy (CMOP) is a VHA program
that consolidates and automates the mailing of prescriptions and
refills to veterans across the country, relieving workload from
pharmacy staff at VHA facilities. The VHA has permitted IHS to use the
CMOP facility at Leavenworth, Kansas to provide prescription mail-out
services for IHS beneficiaries. The pilot has been going on for more
than a year, right here in Rapid City. More than 21,000 prescriptions
have been processed through the IHS CMOP to date, allowing two full-
time pharmacists to move from the pharmacy into the clinic where they
can provide direct patient care services, (i.e., anti-coagulant clinic)
and improve access to care. The program has improved patient safety by
reducing medication errors, and has improved both patient and staff
satisfaction. IHS use of the CMOP facilities will centralize routine
prescription filling and increase pharmacy collections, and will
greatly reduce travel time for patients. In addition, it will enable
pharmacy staff to focus on patient counseling, adverse drug event
prevention, and primary care.
future opportunities of partnership
Local IHS-VHA efforts to improve access and develop formal
partnerships have increased since 2003. IHS will continue joint efforts
on issues related to access to healthcare for AI/AN veterans. We are
committed to working on these issues, within the IHS, as well as with
the VA and the VHA. AI/AN Native communities have always honored their
veterans and we are committed to improving the health services they
utilize and the quality of their lives.
Mr. Chairman, this concludes my testimony. I appreciate the
opportunity to appear before you to discuss the collaboration between
the HHS through the IHS and the VA through the VHA. I will be happy to
answer any questions that you may have. Thank you.
Senator Johnson. Thank you, Mr. Grinnell.
Ms. Birdwell.
STATEMENT OF STEPHANIE ELAINE BIRDWELL, DIRECTOR,
OFFICE OF TRIBAL GOVERNMENT RELATIONS,
DEPARTMENT OF VETERANS AFFAIRS
Ms. Birdwell. Good morning, Chairman Johnson. Thank you for
inviting me to discuss VA outreach to tribal governments.
On November 5, 2009, President Obama signed the Memorandum
on Tribal Consultation, pronouncing tribal consultations a
critical ingredient of a sound and productive Federal/tribal
partnership. As part of the strategy to realize the President's
vision of regular and meaningful consultation and collaboration
with tribal officials, VA created the OTGR, and I was appointed
as Director of this office earlier this year.
Guided by the tribal consultation policy signed by
Secretary Shinseki in February 2011, the office was created to
develop partnerships with American Indian and Alaska Native
tribal governments for the purpose of enhancing access to
services and benefits for Native veterans.
We must maintain lasting bonds with tribal leaders and
Native veterans. Meaningful consultation is absolutely vital if
we are to effectively address the unique needs of this
population.
VA's OTGR serves as an entry point for American Indian and
Alaska Native tribal government concerns. With an estimated
383,000 Native American veterans and 565 federally recognized
tribes, 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. We
believe the best way to create lasting bonds of trust is to
meet with tribal leaders and their communities. VA has held
listening sessions in Bethel, Alaska; Billings, Montana; and
Bismarck, North Dakota. I am excited to hear from local tribal
leaders and veterans right here in Rapid City and Kyle, South
Dakota.
The office 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.
While we are in the communities, we are aiding and training
Native American veterans. For example, VA staff have trained
tribal veteran representatives (TVRs) in Montana and Alaska and
provided technical assistance to Native American veterans
seeking home loans during a recent gathering of Northwest
tribal leaders and veterans in Spokane, Washington.
We can leverage these opportunities to increase Native
American enrollment in VA's healthcare system, educate veterans
about benefits for which they may be eligible, and connect them
with online resources, such as eBenefits and My HealtheVet.
VA's goal of creating a bond of trust with American Indian
and Alaska Native tribal governments is not an end, in and of
itself. This bond should lead to improved access to benefits
and services, as well as economic sustainability for veterans
in Indian Country.
My office is working with the VHA to enhance access to
healthcare in several ways. We are facilitating technical
assistance and the sharing of best practices with the IHS as
part of our effort to implement the MOU between the VA and IHS.
Our 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 tribes' perspectives on
practices that will improve access to care.
After OTGR was created, we worked with various stakeholders
within VA to draft a vision statement. We see a future where we
consistently demonstrate our commitment to Native American
veterans by being culturally competent, respecting the unique
sovereign status of tribes, and reaching out to veterans in
their communities.
As an enrolled member of the Cherokee Nation of Oklahoma
with more than 15 years 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.
PREPARED STATEMENT
Thank you for the opportunity to discuss the work VA is
doing to reach out to Native American veterans and tribal
leaders. I look forward to answering any questions you may
have.
[The statement follows:]
Prepared Statement of Stephanie Elaine Birdwell
introduction
Good Morning, Chairman Johnson and members of the subcommittee:
Thank you for inviting me to discuss Department of Veterans Affairs
(VA) outreach to tribal governments.
On November 5, 2009, President Obama signed the Memorandum on
Tribal Consultation pronouncing tribal consultations ``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 (OTGR). I was hired
as the Director of this office earlier this year. The fiscal year 2012
budget request includes $800,000 to support the establishment of this
new office.
Guided by the 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
for the purpose of enhancing access to services and benefits for Native
veterans. We must maintain lasting bonds with tribal leaders and Native
American veterans. Meaningful consultation is absolutely vital if we
are to effectively address the unique needs of this population.
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 more than 15 years 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.
outreach and consultation
VA's OTGR serves as an entry point for American Indian and Alaskan
Native tribal government concerns. With an estimated 383,000 Native
American veterans and 565 federally recognized tribal entities, 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.
Listening certainly includes receiving communications from tribal
leaders 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 Bethel,
Alaska; Billings, Montana; and Bismarck, North Dakota. I am excited to
hear from local tribal leaders and veterans right here in Rapid City,
South Dakota. OTGR has participated in conferences in Arizona, Montana,
Idaho, Texas, Wisconsin, Oklahoma, and Washington. We have 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. 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. We will maintain an aggressive outreach schedule
to increase the number of American Indian and Alaska Native tribal
governments with which we are building relationships.
While we are 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 American veterans seeking home loans during a recent
gathering of Northwest tribal leaders and veterans in Spokane,
Washington. Our outreach provides a unique opportunity to deliver
technical information to Native American veterans. We can leverage
these opportunities to increase Native American veteran enrollment in
VA's healthcare 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
Veterans Affairs is committed to conducting meaningful consultation
with tribes; this means transforming words into action. We plan to
facilitate five tribal consultation sessions in 2012 at different
locations across the country. 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.
increase access to healthcare and sustainable economic opportunities
OTGR's goal of creating a bond of trust with American Indian and
Alaska Native tribal governments is not an end in itself. This bond
should lead to improved access to benefits and services as well as
economic sustainability for veterans in Indian Country.
OTGR is working with the Veterans Health Administration (VHA) to
enhance access to healthcare in several ways. First, OTGR is
facilitating technical assistance and the sharing of best practices
with the Indian Health Service (IHS) as part of our effort to implement
the memorandum of understanding (MOU) between VHA and IHS. VHA's Office
of Rural Health has made great strides in supporting the delivery of
care to rural veterans across the country. OTGR's role is to ensure
tribal concerns are heard and considered. To this end, OTGR will hold
annual listening sessions in addition to formal consultation to obtain
recommendations, hear local priorities, and advocate the tribes'
perspectives on practices that will improve access to care. In
addition, OTGR is working with VHA to realize opportunities to
integrate new media and other communication tools to promote innovative
technologies that bring care to rural communities.
Mental healthcare is a critical component of overall healthcare,
and Native American veterans often face unique challenges in accessing
appropriate mental healthcare. To promote better mental healthcare in
this population, VA has undertaken several initiatives. In Alaska, we
are exploring a partnership with the South East Alaska Regional Health
Consortium to provide mental health compensation and pension
examinations. OTGR has worked closely with VHA to identify similar best
practices and to explore options for exporting them. Currently, as part
of the implementation of the VA/IHS MOU on enhancing services to Native
American veterans, several new initiatives are being implemented.
Guidance on outreach and education to tribes about VA/IHS post-
traumatic stress disorder (PTSD) services will involve further
disseminating training materials created by VA, designed to make
initial connections with and provide information to tribal governments
about VA services.
The training has been used extensively in the Western States (e.g.,
Montana, Idaho), and a current project will focus on Eastern areas,
including those in Veterans Integrated Service Network (VISN) 6, with
tribes such as the Lumpee, and in VISN 1. VA staff and tribal groups
will expand the original training materials with information that
describes local VISN 6 facility services. Information also will be
associated with significant symbols of the local tribes. There will
also be another satellite broadcast/DVD to support this planned
outreach effort. In addition, the National Center for PTSD Web site,
(www.ncptsd.va.gov) has the video: ``Wounded Spirits, Ailing Hearts:
PTSD in Native American Veterans,'' created in 2000 with versions for
clinicians and general audiences (http://www.ptsd.va.gov/public/videos/
wounded-spirits-ailing-hearts-vets.asp).
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. 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.
In addition to working with VHA to increase access to care, we are
also working with the Veterans Benefits Administration to address
systemic economic issues within tribal communities. We 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 we believe deserves special attention is the Native
American Direct Loan Program (NADL), a vital tool in VA's efforts to
provide permanent housing options for Native American veterans. NADL is
available for Native American veterans and their spouses to purchase,
construct, or improve a home on trust land or to refinance an existing
NADL at a lower interest rate. OTGR is increasing VA's efforts in
Indian Country and Alaska to educate eligible veterans about this
important program. Our goal to make sure every eligible veteran
understands the value the NADL benefit as a long-term housing solution.
OTGR will also work with tribal leaders to address memorial issues.
VA's first grant to establish a veterans cemetery on tribal trust land,
as authorized in Public Law 109-461, was approved by the Secretary of
Veterans Affairs on August 15, 2011. The amount of the grant,
$6,948,365, is for the Rosebud Sioux Tribe, and the cemetery will be
located in White River, South Dakota. This grant will fund the
construction of a main entrance, an administration building, a
maintenance facility, roads, an assembly area, a committal shelter,
preplaced crypts, cremains burial areas, memorial areas, columbaria,
landscaping, a memorial walkway, and supporting infrastructure. The
project will provide services to approximately 4,036 unserved Rosebud
Sioux Tribe veterans and their families. The project will develop
approximately 14.40 acres. The construction will include 600 pre-placed
crypts, 544 cremains gravesites, and 32 columbarium niches. The
cemetery will provide improved service for veterans and their families
of the Rosebud Sioux Tribe. The nearest VA national cemetery is Hot
Springs National which is closed and 169 miles away in Hot Springs,
South Dakota. The proposed cemetery will be near Mission, South Dakota
on the Rosebud Indian Reservation.
We 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 the point of completion. We do not promise that every
recommendation we receive will be adopted, but we do commit to ensuring
tribal leaders' and veterans' voices are heard and considered. Our
success will be not only be measured by the frequency of our contact
with federally recognized tribes, but also by utilization rates for
benefits and programs and healthcare enrollment by eligible Native
American veterans. A stronger relationship between the tribes and VA
will lead to better results and outcomes for Native American veterans.
conclusion
After OTGR was created, we worked with the various stakeholders
within VA to draft a vision statement. 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 a relationship 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 work VA is doing to
reach out to Native American veterans and tribal leaders. I look
forward to answering any questions you may have.
Senator Johnson. Thank you, Ms. Birdwell.
Too often I hear stories from Native American vets that
they show up at IHS facilities only to be told that they should
be going to the VA and that there is no patient coordination
occurring. The new MOU is supposed to address this issue and
break down these barriers.
Mr. Grinnell, can you describe in detail how this MOU will
increase patient coordination between the IHS and VA?
Specifically, if a vet shows up at an IHS facility with a
service-connected disability, will they be treated at IHS or be
told to go to the VA?
Mr. Grinnell. Thank you for your question, Senator.
That is probably one of the most challenging aspects of
what we are trying to improve on. A good example is that when I
mentioned in my opening comments that the VHA is considered an
alternate resource for IHS, per our CHS regulations. So any
time that a veteran does access our system and they have to be
referred out for care, then we have to exhaust all other
opportunities before it qualifies for CHS.
To begin to address that, one of the things that the IHS
and the VHA are doing is training both the IHS staff, as well
as the VHA staff in terms of what services are available and
also understanding the eight categories that the veterans have
to be eligible for for consideration. Trainings have already
taken place in a number of the service units where our staff is
being trained so that they fully understand. And our goal at
the end is so that the veteran itself is not being shuffled
back and forth between the two systems, but there is good
coordination of care.
Further things that we are talking about is how we can
hopefully do case management of that individual patient between
both systems so that they don't feel like that they are being
passed off from one system to the other.
INDIAN HEALTH SERVICE AND DEPARTMENT OF VETERANS AFFAIRS COORDINATION
Senator Johnson. Dr. Jesse, the VA has a good track record
of coordination with DOD health facilities. But it seems that
coordination with the IHS has been difficult. From the VA's
perspective, how do you believe the MOU will give Native
American vets better access to VA services and break down these
bureaucratic barriers?
Dr. Jesse. Thank you, Senator.
I think there are several aspects to answering that
question. First is the simple matter of coordinating the
information related to healthcare. So that what a given
patient's issues are, are then visible to both the VA and the
IHS. With a shared electronic record, that is increasingly
easier to do.
Second is that both the IHS and the VA are actively
implementing, I guess as a common collective term, new models
of care, moving from a single-provider model into a team-based
model of care, with a heavy emphasis on care coordination.
This, I think, will allow for that level of coordination which
occurs in any one of those services to be much more visible to
the other in times when that is needed because it is not
dependent on a single provider.
Another piece I think is the great commitment that VA has
made and is sharing, I guess is the best way to say that, in
terms of telehealth with IHS. By combining these resources, IHS
has been extremely accommodating in providing outlets for
telehealth on the reservations so that we can get a lot of the
care that would normally require people to go somewhere for
high-level care. This includes, very importantly, mental
healthcare, but also much of the subspecialty care, for
instance, in cardiology or any number of the other
subspecialties that can be managed through telehealth. It very
much minimizes the need to have people travel long distances
for what would be simple appointments.
We can't do procedures by telehealth but certainly can
determine when procedures are needed and where the best place
for people to go when they are needed without having to have
multiple visits prior to that. I think there is already, at the
early stage of the deployment of telehealth, modalities through
American healthcare with VA collaborating with IHS. We are very
much moving this whole initiative forward.
There are some challenges, to be sure. The technology is
rapidly evolving. Teaching providers how to use it is at times
challenging. Although, interestingly, our fear was that
patients would be less accepting and have to get used to it,
and my sense is that is not the case. You can correct me if I
am wrong, but the patients love it. It allows them to speak to
the people they need to speak to without having long delays for
appointments and long travel times to do this.
The whole notion of how healthcare is going to be delivered
through team-based care and the use of telehealth and these
other modalities is very important.
One other thing I will just mention is that to my mind, one
of my personal interests is, how do we get patients, veterans,
and patients in the IHS, invested in their own health in ways
that they can take greater control in managing it? Part of that
is by having them be able to interact with their personal
health records, so that the health record is not a mystery that
lives in the provider's office, but something they can engage
with on a relatively routine basis.
VA has started this with My HealtheVet. There has been a
lot of press recently about an innovation that we have been
rolling out called the Blue Button, which allows patients who
use My HealtheVet to actually download substantive parts of
their records. Probably, I am guessing, within the year, it
will be the entire medical record that can live in their
possession, and they can have it with them.
There will never be a question about what has been done,
what prior lab results, what prior tests were done. And with
all of these things, VA is rolling these out in collaboration
with IHS and distributing this into the rural and highly rural
populations.
PAYMENT AND REIMBURSEMENT
Senator Johnson. Dr. Jesse, in your testimony, you
mentioned that the VA and IHS are still working through payment
and reimbursement policies. When do you believe these will be
worked out?
Dr. Jesse. I think that is actually a pretty simple
question to answer because our respective Secretaries have made
it very plain to staff that they expect this to be worked out
by the end of the calendar year. We have been given marching
orders from the Secretaries to get this resolved, to do it
quickly, and get it right.
Their timeline is end of the calendar year.
Senator Johnson. Mr. Grinnell, how do you see the work with
other private hospitals proceeding, and is it true that the
Native American saying that ``you better get sick through June
or it is all over with'' still holds true?
Mr. Grinnell. The statement about ``don't get sick after
June'' referred to--within the CHS program, there is one aspect
that is referred to as the Catastrophic Health Emergency Fund
account, and that account is centrally managed, and it is a
reimbursement program to a local hospital or CHS program
whenever they have a high-cost case.
And those are first come, first serve. It starts on October
1, and the funding that we receive, it is there until it is
exhausted. At this point, we have got $48 million that we have
in that particular account.
In the past, before we had the increases which have--and
over the last 5 years, that account has more than doubled. And
so, we are able to go beyond May. This year, it looks like we
are going to get into September before that account is
exhausted, which is tremendous progress from prior years.
We had a real nice increase in 2010. We had a $100 million
program increase in CHS that every CHS program benefited from
across the country, including an increase in the CHEF account.
We see great progress. We have been in contact with pretty much
all the CHS programs across the system. They have more
resources this year and are able to provide more referrals than
they have in the past, but we still feel like that the need is
more than we have funding for at this point.
Based on our estimates so far, we estimate that we receive
almost $800 million a year in CHS overall. We estimate, based
on the information from our locations and from some tribes,
that the need is an additional $860 million more than the $800
million.
So we still have a long ways to go to where we feel like
that we will be fully funded to be able to pay for all of our
referred care.
Senator Johnson. Mr. Grinnell, was that bump up in the
income available as a result of the stimulus?
Mr. Grinnell. No. It had to do with the President's budget
in 2010, and actually, President Obama approved that budget and
moved it forward as his first act against our budget. So the
stimulus did not provide any CHS funding.
TELEMEDICINE
Senator Johnson. Telemedicine offers great promise in
closing the gap in services in remote areas and lowering
healthcare costs. My biggest concern with telemedicine has been
the lack of technology infrastructure in highly rural areas,
such as access to broadband.
Dr. Jesse, as you highlighted in your testimony, the VA has
been moving more aggressively in its use of telemedicine. Can
you please describe a bit more how the VA envisions
telemedicine being deployed? For example, are these
applications located only at IHS facilities, or is the VA
planning to implement home-based solutions as well?
And how does the VA plan to overcome the lack of
infrastructure in highly rural areas and on reservations as it
deploys new technology?
Dr. Jesse. Our chief information officer, Mr. Roger Baker,
says that what keeps him awake at night is bandwidth. So I will
put that on the table first, and then I will come back and
answer the other issues you brought up.
It is an issue. I think the wisdom of the Federal
Government is in understanding the value of the Internet in all
we do in this country, not just healthcare, but in education,
in banking, in communication, and social networking, all the
things that are really changing the fabric of American life.
The commitment to get broadband access into rural and
highly rural areas is, I think, an important statement on
behalf of the Government that we need this. It is certainly not
something the VA can do on its own, but I do think that our
commitment to making this an integral part of healthcare
certainly drives the imperative to do so, more so than some of
the other needs for broadband.
We will push very hard to ensure that we have the ability
to leverage our technologies through broadband access and with
the understanding that this is a shared commitment on the part
of the Federal, State, and local governments as well. It may
take some time, but I think this will get done.
In terms of the technologies being used, telehealth is a
very broad statement, and there are a number of different
categories that we look at. For instance, we can talk about
telehealth as a provider in one place and a patient in another
place so that, when we have a primary care clinic--which I had
the honor and pleasure of visiting in the CBOC in town this
morning--we can have an extensive primary care capability in
that facility. If there is a question for a cardiologist or a
pulmonologist, then having ability to contact somebody, say, in
Minneapolis or anywhere else in the country to provide almost
an instant referral, or consultation, is one methodology.
Another is the ability to communicate with patients in
their homes. We have a program, which is probably, at this
point, the widest deployment of home telehealth, which we call
CCHT, Coordinating Care Home Telehealth. This is where we have
a telehealth communication box in the patient's home that can
do some basic things like hook up to a blood pressure cuff, to
a scale, or to a rhythm strip, and which provides vital
information for caring for patients with multiple chronic
disease, in particular heart failure and hypertension.
Because rather than showing up once a month or once every 3
months for an appointment and checking blood pressure, we can
actually see the blood pressure every day. Then if it is going
outside of bounds, we have triggers, and we can reach out to
the patient to intervene.
I am a cardiologist by training. This is extremely
important for heart failure because patients can self-manage
heart failure if they have that information and particularly if
they have a little help. We have been able to markedly reduce
admissions for patients with heart failure by being able to
communicate with them in their home.
Now that is interesting because, more and more, we are
finding people who don't have land lines in their homes, and
these things are dependent on land lines. How do you then begin
to move a lot of this to a much more ubiquitous platform like
the smartphone?
I think that capability is moving forward very quickly.
Even things like the PTSD Coach, which is an iPhone app, have
been a great demonstration that you can leverage the simple
telecommunications platforms that people have to improve their
health in many novel ways, most of which we probably haven't
even thought of yet.
We do a lot of things that require ongoing monitoring, and
I will use an example of that which is teleretinal imaging in
diabetic patients. It is really important that we monitor the
consequences of that disease, and looking at the retina is a
view to the inside of the body in many respects. It speaks to
the microvascular state, but also to the catastrophic
consequences of diabetes, which is blindness.
You can't have an ophthalmologist or an optometrist
everywhere. But we can take those images, store them in the
local record, and forward them off where they can be read, and
that way the results come back locally so we can monitor for
vision changes over time.
We have teleradiology. So, for instance, you can have a CAT
scanner in a facility without the advanced radiology capability
to read them if that image can get forwarded to somewhere where
you do have that capability. This is becoming increasingly
important in the management of several complex diseases, where
we can get a tech in to do the scan, but we can't have the
radiologist available.
In fact, VA now has a series of teleradiology reading
centers which actually expands the time throughout the day
where we can have studies accurately read. Likewise, you can do
the same thing with electrocardiograms and any number of other
tests.
We all get very nervous about dermatology, and it is often
difficult to discern what are bad lesions from what are ones
that are okay. But we have teledermatology where in the clinic
they can take an image, and it can go across the country to a
dermatologist who can look at it and make a determination that
this is benign or, no, this is something we need to follow.
There are a lot of different parts of this that are
complex. Probably the most interesting is the ability to do
consultation in a way that actually increases the education of
the primary care provider. There are projects that we are
standing up as part of the patient line care team to bring
specialty care into that mix through a project called SCAN--
Specialty Care Access Now--that gives real-time consultative
capability in a way that actually educates the provider.
And when we talk about telehealth--I am sorry, it is a
rambling answer--but there are a broad number of modalities.
The capabilities of some require a lot of bandwidth, for
instance, moving big images around. But frankly, a lot of them
don't, including what we to date have investment in, which is
home telehealth, where we have the ability to reach in the
patient's home on a daily basis to watch their weight, and
their blood pressure, with a simple phone line.
Senator Johnson. Mr. Grinnell, how do you see telemedicine
being deployed and utilized in Native lands? And please comment
on the lack of infrastructure in these areas.
Mr. Grinnell. You mentioned earlier about the questions
about the stimulus and the funding that came through the
American Recovery and Reinvestment Act. The IHS did receive $85
million that was targeted to help us to make improvements to
the RPMS system. It was also to look at how we can expand
telemedicine opportunities.
As Dr. Jesse indicated as well, many of our locations in
remote areas have issues with bandwidth. And so, our ability to
expand telemedicine to some of those locations is going to be
challenged until the bandwidth is made more available. IHS is
looking at every opportunity and looking specifically with the
VA to expand as many telemedicine opportunities as we can.
Dr. Jesse also talked about the diabetic care specific to
eye care. We have a very active telemedicine program with
teleophthalmology, where we got a number of IHS and travel
sites that actually have optometrists or other staff that take
images of the eye, and then they are sent via telemedicine to
an ophthalmology center where they are actually read. And then
they are followed up with the necessary procedure.
So we have lots of challenges. And some of them really get
down to the bandwidth and the ability of that local facility to
have the capability.
Different than what Dr. Jesse talked about, we have not
looked into going to providing home health through
telemedicine. But right now, we have got more than 600
facilities that we have still got to get connected and improve
access to some of these services that he talked about.
A couple of the other ones that we are looking into as well
is teleradiology. We have got some areas now that have area-
wide contracts where they don't have a radiologist on staff,
but they have got a radiology service that they contracted
with. They take the images, store them, and then send them
forward, get the readings that come back to our direct
providers, and then they do the follow-up care.
So we still have a lot of work to do. We definitely are
counting on our partnership with the VA to help us to move that
forward.
MENTAL HEALTH TELEHEALTH
Senator Johnson. I understand that the Sisseton IHS health
center is partnering with the Sioux City CBOC to offer mental
health telehealth. One day a month, vets in Sisseton can meet
with a psychologist in Sioux City.
Dr. Jesse, can you speak to this partnership? How did this
come to be? Is it meeting demand? Are there similar telehealth
collaborations in the State and throughout the country?
Dr. Jesse. With your indulgence, I will ask Jan Murphy to
speak to that because I think she can give you the detail you
need.
Ms. Murphy. Sure. Thank you for the question.
There are a number of these kinds of collaborations that we
are very anxious to do. I am surprised to hear about Sioux City
because we hear more about Wagner. But we are able to put a
telemedicine unit either in the IHS clinic or we can have one
in our clinic, and the two go back and forth.
Sometimes we send the actual practitioners back and forth,
too. So, really, with this sharing agreement, this is really
very easy to do.
The technology, if you have the bandwidth, is quite simple
and quite successful to be able to do that. So that is an easy
one, actually.
TRIBAL CONSULTATION SESSIONS
Senator Johnson. Ms. Birdwell, in the Senate appropriations
bill for fiscal year 2012, we have included $800,000 as
requested to support the establishment of your office. In your
testimony, you highlighted the critical need to build trust
between the VA and the tribes through meaningful consultation.
The VA is funded to conduct five tribal consultation
sessions this year. How many of these sessions have been
conducted to date, or are these the first of these sessions?
Can you briefly describe what these sessions will include and
how they will help shape future VA policy?
Ms. Birdwell. Yes, Senator, thank you for that question.
The five consultation sessions will be scheduled during
fiscal year 2012. There have been currently no formal
consultation sessions held, although we did hold three
listening sessions in Bethel, Billings, and Bismarck.
The purpose of the consultation sessions are really to
engage the voice and the perspective of the tribes with respect
to understanding regulations, grants, funding opportunities,
and need for services that VA offers that may impact tribal
communities and Native American veterans.
The sessions really seek to engage the voice and
perspectives of the tribes in informing how VA does business in
Indian Country and delivers services and resources. Something
that is important to note is that there have been a number of
very dedicated leaders and employees within VA for many years
who have worked and reached out to tribes, tribal leaders, and
Native veterans.
The cemetery that is coming up, that is online in Rosebud,
the national cemetery is the effort of many years of
collaborative hard work with the tribal leadership, and that is
something that we are excited to see hopefully expand
throughout Indian Country.
It is really the goal of our office to put a face with
respect to engaging in Government-to-government relations with
tribal leaders. As Dr. Jesse mentioned, it is very important
that when we are doing business with tribes and we are reaching
our vets in rural areas that we get this right. And really,
this is an opportunity for VA to formally engage the voice of
the tribes in setting policy as we move forward and getting it
right and being informed in the work that we do.
We are talking about the possibility for expanding and
sharing best practices and increasing sharing agreements. These
consultation sessions and engaging the voice and perspectives
of the tribes, hopefully, will result in that.
And not just from the perspective of increasing access to
healthcare, but also increasing access to benefits, all of the
resources that our veterans have earned through their service,
we would like to see that result from these sessions.
OUTREACH
Senator Johnson. One major concern that I have has been
outreach to educate vets on reservations as to what benefits
they are entitled. Ms. Birdwell, outside of the consultation
sessions and listening sessions, what specific outreach plans
are in place to better educate Native American vets of the
benefits available to them?
Ms. Birdwell. Senator, a particular one that is very much
on our front burner is Alaska. Alaska has a rural outreach
coordinator that is working very closely with VA. When the
rural outreach coordinator or when our tribal government
relations specialist will be going out and meeting with tribal
leaders or conducting any listening sessions in Indian Country,
they will always be teaming up with representatives from across
VA through VHA, through the Veterans Benefits Administration
(VBA), and even the National Cemetery Administration (NCA).
The approach is to have a coordinated approach in reaching
out to Indian Country and really informing, educating, and
providing onsite technical assistance with respect to benefits
and resources that are available through the VA. We are
partners, and our role is to enhance the role of VA with
respect to reaching out to Indian Country. It is critical that
we have those relationships internal to the organization, as
well as with our external stakeholders. It is a combined
effort.
I have to say that Alaska is something that we have just
recently worked on in a strategic outreach plan to reach rural
Native veterans. That plan is going to be implemented,
hopefully, this fall and throughout fiscal year 2012.
We have also had contact from veterans in the Northwest and
tribal leaders and also veterans in the Southwest and tribal
leaders seeking technical assistance for how to bring about the
MOU, and how to see that the MOU in action is as robust as they
would like it to be. That involves coordinating technical
assistance with our partners at the local level, within the
VBA, VHA, and the NCA.
One of the focuses of our office is to promote economic
sustainability in Indian Country within veterans. In other
words, by veterans are eligible for post 9/11 GI bill, the
Native American direct home loan program, compensation and
pension benefits.
Our vision is to see that if there is a veteran in Indian
Country, that veteran is at least aware of all of the benefits
and can access all of the benefits and resources available with
VA through their service. That is a goal and part of the
mission of our office.
TRIBAL VETERAN REPRESENTATIVE PROGRAM
Senator Johnson. The Tribal Veteran Representative Program
was mentioned in testimony today. Dr. Jesse and Ms. Birdwell,
can you elaborate on this program. Does the VA plan to expand
this program in fiscal year 2012?
Ms. Birdwell. Senator, I will be happy to respond to that.
The Tribal Veteran Representative Program was started as a best
practice and has expanded to Alaska. It was started as a best
practice in Montana and is now--the TVRs, as they are called,
in rural areas, because it is often the case in tribal
communities there may be a lack of a local resource or
connection with respect to veteran services and resources.
TVRs are brought together by the VA on an annual basis, and
they are provided training into all of the resources that are
available through VA. There are even State representatives
present. Basically, all of the resources that are available to
veterans, the TVRs are trained in and made aware of them.
The TVRs then go back home to their local community, and
they become a local resource for vets. So, if a vet comes in
and asks questions about benefits, the TVR knows where to
direct and how to assist that veteran in moving forward with
any kind of claims that they may want to or need to pursue.
Healthcare, grants, or information that tribal governments may
need to know about, that TVR is a resource.
There are definitely plans of expanding that program. What
is also important with respect to sharing resources are that
there are some tribal locations that may not have a TVR
presence, and there are some tribal locations that actually
have their own tribal veterans affairs department. Some States
actually have tribal veteran service officers.
And it is interesting because those tribal veteran service
officers have asked about the TVR training and have said they
would really like to see it expanded locally so that they can
also avail themselves of that TVR training.
We are very excited to see that as a best practice. There
is definitely a strong interest and a need to expand that, and
we look forward to doing that in 2012. Strategically, we would
probably be doing that in a way that would be consistent with,
moving from the Northwest to the Great Plains to the Southwest
and on to the Midwest. It is something that we would probably
host with regional trainings and then ideally make it so that
they are held at as local a level as we possibly can hold them.
Senator Johnson. Dr. Jesse, did you have anything to add?
Dr. Jesse. Yes, sir. I would just like to amplify something
Ms. Birdwell said, and that is that healthcare, in and of
itself, will flounder--by whatever VHA does or IHS does--
without the strong support of the broader social needs of
patients. That support includes education, housing, and a host
of things.
I think the elegance of the VA is that we have the
capability to provide much of those needed services so that the
healthcare side of things can truly flourish. It is vital in
order for us to do that, in addition to supporting IHS, we need
veterans to get enrolled. Because it is not just access to the
healthcare system, it is access to this broader base of very
needed and very hard-earned support.
It is very much our interest and important to us that the
veterans are aware of how to get enrolled and are aware of
this. We are strongly supportive of all these initiatives and
are working with the IHS in order that we can identify the
Native Americans who are eligible for VA benefits and get them
enrolled. I think it is important to note that it is their
choice of which of those benefits they wish to access, but the
first step is the access into the system.
If I may just go back to the first question you asked me
about the MOU and the deadline on that? I just want to be very
clear that IHS and VA are committed to making this work.
There are some challenges in the law reconciling parts of
title 38 legislation with the Affordable Care Act, but it is
not either party being recalcitrant or creating a problem. We
just have to get this reconciled. We are anxious to make it
work and are working hard and diligently to do so.
Senator Johnson. Thank you for your testimony. The
witnesses may now be excused.
Thank you.
Dr. Jesse. Thank you, sir. Appreciate it.
NONDEPARTMENTAL WITNESSES
Senator Johnson. I would now like to welcome our second
panel of witnesses. I am honored to have two South Dakotans
testify today--Don Loudner and Iva Good Voice Flute.
Mr. Loudner served 32 years in the Army and is a veteran of
the Korean war. He is a member of the Dakota Sioux Nation and
has been a tireless advocate for Native American vets,
particularly in his role as the national commander of the
National American Indian Veterans, Inc.
Iva Good Voice Flute is a Air Force vet, having served here
in South Dakota at Ellsworth Air Force Base. She is a member of
the Oglala Sioux Tribe. Ms. Good Voice Flute is a strong
advocate for female vets and in March of this year received
designation as the Oglala Sioux Tribe's women's tribal vets
representative.
Thank you both for being here today.
Mr. Loudner, would you begin?
STATEMENT OF DON LOUDNER, NATIONAL COMMANDER, NATIONAL
AMERICAN INDIAN VETERANS
Mr. Loudner. Good morning. Yes, I have with me one of my
regional commanders that has North Dakota, South Dakota,
Nebraska. His name is Peter Lengkeek. He is a member of the
Crow Creek Tribal Council. He is here with me.
And we also have in our audience some of our tribal veteran
service officers. I am glad they are here, and I hope that they
speak up to ask these questions that were not answered to them.
Don't be afraid of these people. I mean, they are human like
all of us.
And this is the time to get them straightened out. Because
you know, as well as I know, that the services that they are
talking about are not being completed for us veterans.
Senator Johnson. We need a lot of straightening out.
Mr. Loudner. I want to thank you, Senator Johnson, for
holding this important hearing. The last hearing that I can
remember that was held for American Indian veterans with
congressional people was back in the Nixon administration. And
it is a hearing that should have been held long before.
Hopefully, we can have more.
Holding this important hearing to discuss the degree of
cooperation that currently exists between the IHS and the VA to
provide quality care to our American Indian veterans and the
Alaska Native veterans and ways to improve the agencies'
working relationship.
As you can imagine, American Indians, Alaska Native
veterans have many problems in common with other veterans. But
because of their geographic remoteness, weak tribal economies,
and a host of related pathologies, face challenges that are, in
many ways, unique. I believe that the members that share with
you, Senator Johnson, are aware of the valor and the service of
American Indian/Alaska Native veterans to this country and that
they have served in the highest proportion than any other
ethnic group in the United States.
You may also be aware that the lack of healthcare to these
veterans upon returning home is nearly to the point of being
unacceptable, considering for what they have done protecting
our homeland. Especially with the event of the Afghanistan and
Iraqi wars, the number of veterans returning with injuries,
disabilities--physical and emotional--has increased largely.
And as we have learned from the past wars and conflicts,
the need for treatment of these warriors may not be revealed
for several years after these men and women have returned home.
The primary healthcare provider to tribal communities,
including American Indian/Alaska Native veterans, is the IHS,
which has always been woefully underfunded. Many veterans have
sought healthcare from VHA hospitals because that is an option
and their right.
In an attempt to stretch their healthcare dollars, both IHS
and the VA hospitals have denied services to our veterans,
insisting that they go to the other agency for treatment. These
proud veterans, who in some instances use their last dollars to
travel long distances to either facility, deserve better
treatment.
I thought the days of transferring responsibility from one
agency to the other were over when this MOU, between the IHS
and the VA hospitals, was signed. It is my understanding that
the issue is still with us, and it is my hope that this hearing
will be a step forward in finally resolving this situation to
prevent more veterans from additional suffering.
In my capacity as national commander, I am in constant
contact with these men and women in the States of Arizona,
California, Colorado, Montana, New Mexico, Oregon, South
Dakota, Wisconsin, Washington, and others. In fact, we just
returned home within the last 10 days from a strong visit to
the Alaska Natives up there, and I will send you a written
report of what we just found out up there that needs immediate
attention.
Senator Johnson. Please do.
Mr. Loudner. Since 2004, the National American Indian
Veterans has hosted three national conferences, the most recent
taking place in March 2009. I know that has been a couple of
years ago, but it takes money to hold them, and we are working
with our own dollars to do those. It was held at the Morongo
Convention Center in California. We had more than 500 American
Indian veterans from throughout the West and Southwest and
Midwest in attendance.
The National American Indian Veterans has the support of
the National Congress of the American Indians, the National
Association of State Directors--and I want to just elaborate a
little something there. My chief of staff, Joey Strickland, is
the only American Indian that serves, in all 50 States, as a
Secretary of Veterans Affairs, and now he is in Arizona.
There he serves for all veterans in the State of Arizona.
Although his job is to support all of Arizona's 600,000
veterans, Arizona is home to 21 federally recognized Indian
tribes, and American Indian veterans regularly attend his
commission meetings. As a result of these meetings, he relays
to me the concerns, issues, and needs regarding the lack of
proper medical care delivered through the VA and Indian
veterans residing on Indian lands.
I just wanted to stress just a little bit about the Navajo
Nation. I heard them talk about it. The Navajo Nation
reservation is roughly the size of West Virginia. And on that
reservation, there are more than 12,000 veterans living today.
To date, the Disabled American Veterans (DAV) has rejected
repeated calls to locate a permanent community-based outpatient
clinic within that reservation. They are claiming the number of
veterans will not support it. The fact is the numbers will not
support a CBOC at the Navajo reservation because the
reservation is divided into three Veterans Integrated Service
Networks (VISNs).
Given this division, the VA cannot count the number of
veterans to justify the clinic. It is precisely this type of
bureaucratic red tape which results in inaction and,
ultimately, inferior or a complete lack of medical care to
American Indian veterans.
Recently, just recently, the VA's Office of
Intergovernmental Affairs--I say recently, but about 1 year. It
has been more than 1 year ago. The director of VISN 18 and
others visited the Navajo reservation and witnessed for
themselves the urgent need for additional healthcare
facilities.
They graciously called on the director of VA from Arizona,
who is a Choctaw Indian, for his input, which he, of course,
provided. The reality is that I have seen numerous visits over
the years throughout Navajo, the Pine Ridge Indian Reservation,
and other Indian reservations with little or no follow-up by
the Federal officials.
When an American Indian veteran will get to the VA medical
center in Prescott, Arizona; or Albuquerque, New Mexico; or
Sioux Falls, South Dakota; or Fort Meade, the medical care is
excellent. But few, if any, of the veterans cannot overcome the
vast distances to use such facilities. The distances are vast,
and transportation is not always available.
As a result, many of the American Indian veterans' efforts
to obtain care at IHS facilities fail because they are
veterans. In this regard, the MOU that was entered in 2003 by
the VA and the IHS has been ineffective because the level of
cooperation is nowhere near where it needs to be for the
benefit of American Indians.
I bring that up because I brought this to the attention of
Secretary Shinseki when you brought him out here, and we met
with him out at Fort Meade. I told him we needed to revisit
that, and we need to make it more effective with the use of
American Indian veterans' input.
Today, we have that new MOU signed. No American Indian
veterans' input whatsoever in it. So, you know, my personal
thought in talking with some of the tribal officials and the
American Indian veterans is why--if not, then why do we need a
CBOC on an Indian reservation?
Why not use our IHS to provide all these services that they
are providing to our Indian veterans today and have the VA
reimburse them back for those services--for the doctors, the
nurses, the facility, administrative services, pharmacy, and so
on, so forth? Those monies can go to help the IHS hospitals for
other services that are needed.
And I turned in my statement to you, Senator, and I said I
wasn't going to go through it all. But there are some things
that I would like to bring up on that. I would like to conclude
on that now, and I would answer any questions on it.
But it has been brought to my attention from some of the
veterans here in South Dakota, which you asked me to respond
on, that the VA is putting many of our American Indian veterans
on the payee system. I don't know if you are aware of that?
But the people that brought that to my attention are very
upset about that because the payee is being paid out of his
benefits. And he said that now he is getting around one-half of
what he was getting from the VA because the other one-half is
going to pay the payee for his travels to visit him and condemn
him from going back to the reservations to attend the American
Indian functions, such as pow-wows and stuff, visiting his
relations.
When I first talked with Secretary Shinseki, I told him
that most of our American Indian veterans, especially in South
Dakota, are very elderly. We have World War II veterans still
alive. But with them having to ride or rent a car or take the
family car or if they have DAV vans are available to go to Fort
Meade or go to Sioux Falls, it is a great distance to travel,
and they are unable to make those long distance travels.
You know, you talk about elderly. At one time when I was
growing up--you know Vern Ashley like I do. Vern Ashley is
World War II Air Corps veteran. He never went to the VA, to my
knowledge, for help, although he needs it. Today, he is 96
years old, 97 years old, needs hearing aids, and he is too
proud to go ask for them. But he needs them. He told me that he
couldn't go there.
But today, you talk about elderly, I served during the
Korean war in 1950. My gray hair is here because I am 80 years
old, and I am proud to have served my country. There were 12 of
us cousins that volunteered and went into the service. They all
returned home.
Off-reservation American Indian veterans; that was brought
to my attention. When they go back to the IHS facility back on
the reservation, because they are working off the reservation--
their families are growing up off the reservation, going to
public schools--when they go back to IHS facilities, they are
being denied services yet today.
I asked one of the veterans from Sisseton to come today,
and he couldn't make it. At least I don't see him here anyway,
but he said he was going to try. To tell his story on how he
was treated when he was having a heart attack at the IHS
facility.
Burial flags. That is one of the NCA's--I am on that board,
and the next meeting, I am going to bring that out again.
But burial flags are not able to be gotten by a lot of
American Indian veterans because they are human like everybody
else. They either lost it or delayed it or something, but they
can't get that flag from the post offices unless they have that
DD-214 or the discharge papers or something to prove that they
are a veteran. And when you die, they have got only so many
days to be buried, and they need that flag.
I know when I served on the South Dakota Veterans
Commission, I served on that for more than 20 years, and we
were told that the headstones, some of the headstones were
being held hostage by some of the funeral directors because of
lack of payment for the burial, when they ordered the stone. We
need to change that.
We have our own tribal veteran service officers, and there
is no reason in the world why those headstones can't be shipped
directly back to that tribe itself, to the tribal veteran
service officer.
Senator Johnson. Don, will you please wrap it up? And let
us go to Ms. Good Voice Flute, and then I will ask you some
questions.
Mr. Loudner. Okay. Thank you. Thank you.
Senator Johnson. Ms. Good Voice Flute.
STATEMENT OF IVA GOOD VOICE FLUTE, AIR FORCE VETERAN,
OGLALA SIOUX TRIBE
Ms. Good Voice Flute. Good morning, Senator Johnson. Thank
you for allowing me this opportunity to be here today.
Good morning, ladies and gentlemen, to the various agencies
that are represented here to come together for our Native
American veterans.
I would like to recognize our tribal president, John Yellow
Bird Steele, who is in the audience. And also our fifth member,
Mr. Myron Pourier, is over here on my left.
And thank you to the many Native American veterans who have
appeared here today for this hearing.
I would like to begin by sharing two stories from veterans
that I have visited with regarding the service that they did
not receive from IHS and the VA.
``Iva, I wish I had never let our Indian Health Service
know that I am a veteran. They sent me to the VA hospital right
away, only to find out that the VA hospital did not have the
doctors I needed to address my female medical problems.''
To this day, this woman veteran will never visit a VA
hospital again. And she finished in the conversation with me,
``Iva, I am a Lakota first.''
Senator Johnson. Could you pull the microphone up closer to
you?
Ms. Good Voice Flute. Okay. And the other story I have is
from a Marine Corps veteran. He traveled to the IHS, and he was
told that he needed to update his contact information. He came
there for a dislocated shoulder.
And IHS told him that they could not provide services for
him because he is a veteran and that he had to utilize other
resources that he may qualify for. So he traveled to a VA
hospital, and then the hospital tells him that his income is
too high to qualify for their services. But if he writes
``zero'' for an income, the VA can take his vital readings. And
if he returns for medical treatment, he will have to pay for
it.
He never returned to the VA after that initial visit. He
thought he deserved those VA services because he is a veteran.
These tribal-enrolled, honorably discharged veterans
fulfilled their commitment in serving our country, but
experienced the cruelest of ironies when two agencies, the VA
and IHS, tell them we cannot help you, although based on the
facts that you are members of a tribe with whom the Federal
Government has treaties with, and you did serve in our
country's military.
Why was this MOU created between the VA and IHS when it
only hurts our veterans when it is supposed to help them? And
these two agencies have proven that they did not
collaboratively, effectively work toward the common goal of
meeting our veterans' healthcare needs.
I have never agreed to this MOU, and once again, my
personal thoughts on this are that I feel that it is a
situation with the intentions of one agency to be profit-making
in nature and the other agency to become cost efficient by not
providing services to one particular group of people.
I believe that our Federal Government has a fiduciary
responsibility in obligating funds to our Native American
veterans' healthcare, to bring everyone together to
troubleshoot the problems of this MOU, and resolve the problems
that have existed since its inception in 2003.
And in closing, we deserve quality healthcare, and we must
all work together to make this happen for the generation of
veterans now and our younger generation of veterans, who need
to be encouraged to utilize the services meant for us.
Senator Johnson. Thank you.
Ms. Good Voice Flute and Mr. Loudner, I will pose this
question to both of you. In what specific areas do you see a
need for improved collaboration between VA and IHS? In your
opinion, going forward, where do the VA and IHS need to be
focusing their efforts to ensure Native American vets receive
appropriate healthcare?
Ms. Good Voice Flute. First of all, I would like to comment
on the services that the VA provides, that there be more
medical care for our women veterans. And not just Native
American women veterans, but all women veterans, and then to
make these services more visibly available to where we are
aware.
And my question is whose responsibility will that be on
behalf of the VA to make us aware that there are doctors for
our unique special needs?
Mr. Loudner. Thank you, Senator Johnson.
I think what needs to be done is we need to try to work
together. There are a lot of us out there trying to do the same
thing, but we are going in different ways. But our American
Indian veterans deserve to be given the opportunity to decide,
because of their age and stuff, where they want to have their
treatment done.
If an elderly American Indian veteran knows that IHS
facilities has the capability of helping him, he should be
allowed to go there. And if IHS doesn't have the capabilities,
there should be a way to get him to the VA facilities, whether
it be Fort Meade or Sioux Falls.
Right now, some of them are saying that they have to beg,
borrow, and steal to try to get someone to take them there. A
lot of them don't have a VA vehicle. I am proud to say that
with a lot of arguing and everything, we finally got a new van
back in Crow Creek delivered back there last Friday. So they
have the capability.
But those are some of the things that they are bringing to
our attention.
Senator Johnson. It is important that the VA communicate
with the tribes, and I appreciate the creation of the OTGR. As
Ms. Birdwell highlighted in her testimony, the office is
focused on meaningful outreach with tribal officials.
How do you think the VA can improve communication and
outreach to Native American vets, Mr. Loudner and Ms. Good
Voice Flute?
Mr. Loudner. Let me start on that. Thanks for the question,
Senator.
I personally went and met with Stephanie Birdwell in her
office and volunteered to work with her in any way that she has
seen possible for me to work with in providing input that is
coming back to me as the national commander from all over the
United States. To this day, she has never returned any calls or
even asked me to talk to her.
So I think what she needs to do is see the importance of
our national organization, which is called upon by you people,
Senator Johnson, in Washington to testify on behalf of the
American Indian veterans. There can be only one veteran
organization to do that, and that is our organization.
So I feel that they need to start working with us, both VA
and IHS, so that we can get that brought to your attention in
the Congress.
Senator Johnson. Ms. Good Voice Flute.
Ms. Good Voice Flute. Yes, Senator Johnson.
I believe that the VA can improve communication with the
tribes by being more of a visible presence. I keep going back
to that. And I also must add that there be a healthy balance of
being more culturally sensitive and not so much as a clinical
approach to our problems.
Have a liaison within the tribe to work with the VA to
where we can bring both worlds together to benefit the needs of
the veterans. So that is how I believe that there can be more
communication is for the VA to have a more visible presence on
the reservations.
Senator Johnson. Speaking of female vets, the VA is having
to undergo a culture change from a department designed to treat
male vets to one that has a growing female vet population.
Ms. Good Voice Flute, in your opinion, what steps do you
think the VA needs to take to better meet the unique needs of
female vets?
Ms. Good Voice Flute. What I think, first of all, the VA
needs to do in the hospitals is have more doctors available for
our medical needs, and second is make us aware that there will
be these medical needs that will be met for the medical needs
that we have.
I think the VA overall and IHS need to work together to
meet the needs of the women veterans because, since my
separation from the military and being home on the reservation,
women veterans are very reluctant to come forward and tell the
service providers what they need. And a lot of it, I believe,
is trust issues.
Senator Johnson. Are there enough OB/GYNs to go around?
Ms. Good Voice Flute. No, I don't think there are. I do not
think so, Senator.
Senator Johnson. Yes. I want to thank everyone for
attending today's hearing, especially those who have traveled
from out of town to be here. I believe it is important for both
the VA and IHS to appear together routinely to update everyone
on how a more collaborative partnership will enhance services
for Native American vets.
As a reminder, Ms. Birdwell will be conducting a listening
session today at 3 p.m. at the Pejuta Haka College Center in
Kyle, South Dakota, on the Pine Ridge Indian Reservation.
CONCLUSION OF HEARING
Senator Johnson. Again, thank you to everyone, and I look
forward to continuing this dialogue as the VA and IHS move
forward, creating a meaningful partnership.
This hearing is concluded. Thank you.
[Whereupon, at 11 a.m., Tuesday, August 30, the
subcommittee was recessed, to reconvene subject to the call of
the Chair.]
MATERIAL SUBMITTED SUBSEQUENT TO THE HEARING
[Clerk's Note.--The following testimony was received
subsequent to the hearing for inclusion in the record.]
Prepared Statement of the Cheyenne River Sioux Tribe
executive resolution no. e-360-2011-cr
WHEREAS, the Cheyenne River Sioux Tribe of South Dakota is an
unincorporated tribe of Indians, having accepted the
provision of the act of June 18, 1934, (48 Stat. 984); and
WHEREAS, the Tribe \1\ in order to establish its tribal organizations,
to conserve its tribal property, to develop its common
resources, and to promote the general welfare of its
people, has ordained and established a Constitution and By-
Laws; and
---------------------------------------------------------------------------
\1\ Cheyenne River Sioux Tribe, Cheyenne River Reservation, Act of
March 2, 1889, Section 4, 25 Stat. 888 (reservation boundaries).
---------------------------------------------------------------------------
WHEREAS, the Tribal Council has authority pursuant to article IV,
Section 1(a) of the Tribal Constitution ``[t]o enter into
negotiations with the Federal, State, and local Governments
on behalf of the tribe.'' Id.; and
WHEREAS, the Cheyenne River Sioux Tribe is the successor in interest to
four of the historic bands of the Great Sioux Nation
(Titonwan Lakota Oceti Sakowin/Seven Council Fires of the
Teton or Prairie-dwelling Nation of Friends or Allies),
i.e., Mnicoujou (Plants-by-the-Water), ltazipco (Without
Bows), Siha Sapa (Blackfoot) and Oohenumpa (Two Kettles or
Boilings) signatory to the Fort Laramie Treaties of 1851
(11 Stat. 749) and 1868 (15 Stat. 635); and
WHEREAS, as a stipulation of the Fort Laramie Treaty of 1868 health
care is right provided to enrolled members of the Cheyenne
River Sioux Tribe (15 Stat. 635); and
WHEREAS, American Indian Servicemen and women have the highest record
of service per capita of all the ethnic groups in America;
and
WHEREAS, American Indian people have participated with distinction in
United States military actions for more than 200 years,
their courage, determination, and fighting spirit were
recognized by American military leaders as early as the
18th century; and
WHEREAS, American Indian people have served in all our nation's wars
despite the fact that we were not granted citizenship until
1924; and
WHEREAS, American Indian veterans face unique challenges when it comes
to equal access to care and navigating the VA and IHS
systems; and
WHEREAS, the Memorandum of Understanding (MOU) Between the Department
of Veterans Affairs and Indian Health Service is difficult
to understand and makes no provision for payments made on
behalf of American Indians between the said two Federal
governmental agencies; and
WHEREAS, upon their service to the United States military the
Department of Veterans Affairs became the payer of first
resort; and
WHEREAS, American Indian people have access to the healthcare via the
Department of Health and Human Service office of Indian
Health Service (IHS), IHS becomes the payer of last resort,
as their service to the U.S. Armed Services supersedes the
initial obligation of IHS to enrolled members of Federally
Recognized Tribes; and
WHEREAS, the Cheyenne River Service Unit, Indian Health Service,
Contract Health in Eagle Butte, SD, acted in good faith in
preparing and issuing payment vouchers for 15 veterans of
the Cheyenne River Sioux Tribe to the Department of
Veterans Affairs, Black Hills Health Care System (BHHCS);
and
WHEREAS, the BHHCS have denied the payments citing no ``Sharing
Agreement'' between the Department of Veterans Affairs and
the Indian Health Service; and
WHEREAS, the Cheyenne River Sioux Tribe hereby recommends and fully
endorses a Sharing Agreement between the Cheyenne River
Service Unit, Indian Health Service, Contract Health in
Eagle Butte, SD; now
THEREFORE BE IT RESOLVED, that the Cheyenne River Sioux Tribal Council
hereby calls upon South Dakota Senator Tim Johnson,
Chairman, Subcommittee on Military Construction and
Veterans Affairs Appropriations Subcommittee, support a
Sharing Agreement; and
BE IT FURTHER RESOLVED, that this resolution be transmitted to the
South Dakota Congressional delegation;\2\ and
---------------------------------------------------------------------------
\2\ [Addressed to U.S. Senator Tim Johnson, U.S. Senator John
Thune, and U.S. Representative Kristi Noem.]
---------------------------------------------------------------------------
BE IT FURTHER RESOLVED, that the Cheyenne River Sioux Tribal Chairman
is authorized to take all necessary and appropriate actions
for the implementation of this Resolution; and
BE IT FINALLY RESOLVED, that nothing in this Resolution diminishes,
divests, alters, or otherwise affects any inherent, treaty,
statutory, or other rights of the Cheyenne River Sioux
Tribe over the property or activities described herein. The
Cheyenne River Sioux Tribe expressly retains all rights and
authority over the property and activities described
herein, including but not limited to legislative,
regulatory, adjudicatory, and taxing powers.
certification
This is to certify that the foregoing Executive Resolution has been
reviewed and approved by the Executive Committee, acting under the
Executive Authority and in the best interest of the Cheyenne River
Sioux Tribe this 29th day of August, 2011 in Eagle Butte, South Dakota.
Kevin C. Keckler,
Chairman, Tribal Chairman.
Ev Ann White Feather,
Tribal Secretary.
Benita Clark,
Tribal Treasurer.
______
Prepared Statement of Geri Opsal, Tribal Veterans Service Officer for
the Sisseton Wahpeton Oyate, Lake Traverse Reservation
Chairman Johnson and members of the Subcommittee on Military
Construction and Veterans Affairs, and Related Agencies: Good morning,
I am Geri Opsal, tribal veterans service officer (TVSO) for the
Sisseton Wahpeton Oyate located on the Lake Traverse Reservation.
I want to thank you for inviting us to attend this very important
meeting, and since our schedules conflicted due to the annual
certification school of the TVSOs and county veterans service officers,
we are unable to attend. We do want to provide some comments regarding
this important issue of improving access to care for Native American
veterans in maximizing the effective use of Federal funds and services.
The Sisseton Wahpeton Oyate is comprised of more than 12,941 tribal
members. Of those tribal members, we have a veteran roster that goes
back to the scout to present--we have more than 1,250 tribal members
that are veterans. Each year we have of our members going off to serve.
We have more than 80-plus tribal member veterans that have served in
the Desert Era War from 1990 to present. We have tribal members
stationed across the United States and also overseas fighting the fight
for our country.
Our Tribal Veterans Service Office has met many times with our
Indian Health Service (IHS) regarding our veterans utilizing IHS verses
having to travel and use the Department of Veterans Affairs (VA).
Although progress has been made in the following areas, there are other
areas we have concern about and wish to resolve.
The following areas that we have had success with are:
Pharmacy.--Veterans can bring their prescriptions to the pharmacy
and our pharmacist will call directly to the VA and confirm.
Our veterans are able to get the prescriptions filled locally
at IHS rather than traveling to get refills, etc.
Walk-In Clinic, Optometry, Dental-Pharmacy.--Our veterans are
able to utilize IHS for their medical needs. They don't have to
travel if they chose not to but should they need referral to a
specialist they are required to then go to the VA and have the
referral done through them.
Co-Pays.--IHS will pay for the veterans co-pays they accumulate
at the VA, but they do require that either the veteran or
myself contact Tami Seiber, contract health specialist, and
notify her of the appointment ahead of time. We've had a couple
of veterans that had their income tax refund withheld due to
nonpayment. One went and appealed this and had about 90 percent
of it returned to him. The co-pays that aren't covered by IHS
are the prescription co-pays and this they say is due to the
fact the prescription can be filled by IHS. A prescription has
two meds--one is covered; one is not. One you can get through
the VA and one through IHS, a simple Rx that takes days to fill
as someone has to run back and forth determining the least
cost-effective way to get this filled. Why isn't their brochure
geared for the Native American veteran notifying them to of
what extent their services are covered through the VA and IHS.
We have found out by trial and error as each case comes up why
are we pieced out the information as we seek it?
The following areas of concern for us that we would like help to
resolve are:
Electronic Records.--If possible to have IHS doctors as well as
VA doctor's access electronically each others records/labs/
notes on the veteran. This will help eliminate duplicate care
and often times our veterans after going to the VA for their
appointment or even after discharge from a hospitalization will
go to the IHS and ask the doctor to explain the procedure or
any questions. They sometimes are so happy to get discharged
and get home they don't ask questions until they get back to
the reservation and they have all the follow-up questions.
Co-pays being returned or not paid in a timely manner, the
veteran getting sent to collections, or either getting their
income tax taken. How are we able to correct any negative
credit rating they may get as a result? And is their any way to
flag the tribal member veteran's record so the VA automatically
bills the IHS first rather than sending it to the patient's
address and expecting them to take or forward to IHS. Co-pays
for prescriptions should be covered as well. How is the veteran
to know that they only get co-pays for appointments?
Solution.--We have a memorandum of understanding (MOU). This says
the VA and the IHS are working together for the benefit of the veteran.
Have the MOU give the VA authority (a new policy) that when a Native
American veteran utilizes the VA, the VA is given authority to document
under the financial part that the veteran is IHS-eligible; no co-pays.
This will eliminate co-pays for office visits, medications, or
referrals to specialty doctors. Right now, our biggest problem for our
veterans is navigating the VA and IHS issue. The sharing of electronic
records would come in handy with this process as well. Who's going to
pay; hurry-up-and-wait game for referrals and getting bills because
they didn't know they could take their Rx to IHS if they carry the
meds; if they don't carry them they will order them and still no co-pay
for the patient.
We feel as a tribal member, first, and veteran, second, that we are
protected under treaty rights. We are considered ``dual eligible''.
Theoretically, being dual-eligible has caused more trouble for us due
to trying to navigate the system which we have difficulty
understanding. The Snyder Act of 1921 (25 U.S.C. 13) and the Indian
Health Care Improvement Act (25 U.S.C. 1601) of 1976 provide specific
legislative authority for the Congress to appropriate funds
specifically for the healthcare of Indian people. In addition, we also
have treaty rights to Federal healthcare services through the
Department of Health and Human Services. The Federal trust to uphold
the treaty responsibility for healthcare is first, and being a veteran
is secondary to our healthcare process--moreso, when the tribal member
is also a veteran, as they took the oath to fight for our freedom. We
as veterans have heard the term from IHS that they are the ``payor of
last resort'', and, as such, the use of alternative resources is
required when such resources are available and accessible to the
individual. We are required to go to the VA for any referrals;
otherwise, IHS will not cover it. Dual eligibility which has us going
between the IHS and the VA, and we try and keep our records straight.
Mr. Chairman, this concludes my statement. Thank you for this
opportunity to discuss the unique challenges when it comes to access to
care and navigating the VA and IHS. We will be happy to answer any
questions and consult on this process and perhaps if you have another
meeting in the future we can attend along with our tribal secretary of
the Sisseton Wahpeton Oyate; Ms. Winfield Rondell who is a Marine Corps
veteran as well as one of our tribal executives.
______
Letter From the Standing Rock Sioux Tribe \1\
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\1\ Charles W. Murphy, Chairman; Mike Faith, Vice Chairman; and
Adele M. White, Secretary:
Tribal Council (At Large).--Jesse ``Jay'' Taken Alive; Ronald C.
Brownotter; Avis Little Eagle; Dave Archambault II; Joseph McNeil Jr.;
and Jesse McLaughlin.
Tribal Council (Districts).--Sharon Two Bears, Cannonball
District; Henry Harrison, Long Soldier District; Duane Claymore,
Wakpala District; Kerby St. John, Kenel District; Errol D. Cross Ghost,
Bear Soldier District; Milton Brown Otter, Rock Creek District; Frank
Jamerson Jr., Running Antelope District; and Samuel B. Harrison,
Porcupine District.
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August 26, 2011.
Hon. Tim Johnson,
Chairman, Subcommittee on Military Construction and Veterans Affairs,
and Related Agencies, Committee on Appropriations,
Washington, DC.
Most Honorable Senator Tim Johnson: We are in receipt of your
letter and are most honored to be invited to the hearing to be held in
Rapid City, SD on August 30, 2011.
We are grateful for the opportunity to express our concerns
regarding the collaboration with the Indian Health Services and the
Department of Veterans Affairs. The following are our primary concerns
for the Standing Rock Sioux Tribal veterans.
I. Standing Rock veterans would like to have x-rays, labs,
pharmacy, referrals, and all primary care provided at the local level.
II. Standing Rock veterans would like to have a day set aside for
their care. One day scheduled for veterans to come in and see a doctor.
These visits would then be put into their charts at the Veterans
Hospital that they have been assigned to.
III. Technological access to the Department of Veterans Affairs
medical records would allow for all medical and pharmaceutical visits
to be viewed by the veteran's primary care physician. This would also
eliminate the duplication of services and medications given to the
veteran.
IV. Veterans would like the Indian Health Services and the
Department of Veterans Affairs to have better communications so the
veterans get the best care available. Such as getting veterans
stabilized at the Indian Health Services and then transported to the VA
for care.
V. Veterans on the Standing Rock Reservation travel 300+ miles to
get to their primary care provider. Services here would eliminate the
travel time for our veterans.
Thank you for your interest in our veterans on the Standing Rock
Sioux Tribal reservation.
Charles W. Murphy,
Chairman and Vietnam
Veteran.
Wenelle F. Clown,
Tribal Veterans Service
Office.
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