[Senate Hearing 112-806]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 112-806

 
                      HEALING IN INDIAN COUNTRY: 
                 ENSURING ACCESS TO QUALITY HEALTH CARE

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

                                HEARING

                               before the

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             SECOND SESSION

                               __________

                           (CROW AGENCY, MT)

                               __________

                             AUGUST 8, 2012

                               __________

                                     
                                     

            Printed for the use of the Committee on Finance




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                          COMMITTEE ON FINANCE

                     MAX BAUCUS, Montana, Chairman

JOHN D. ROCKEFELLER IV, West         ORRIN G. HATCH, Utah
Virginia                             CHUCK GRASSLEY, Iowa
KENT CONRAD, North Dakota            OLYMPIA J. SNOWE, Maine
JEFF BINGAMAN, New Mexico            JON KYL, Arizona
JOHN F. KERRY, Massachusetts         MIKE CRAPO, Idaho
RON WYDEN, Oregon                    PAT ROBERTS, Kansas
CHARLES E. SCHUMER, New York         MICHAEL B. ENZI, Wyoming
DEBBIE STABENOW, Michigan            JOHN CORNYN, Texas
MARIA CANTWELL, Washington           TOM COBURN, Oklahoma
BILL NELSON, Florida                 JOHN THUNE, South Dakota
ROBERT MENENDEZ, New Jersey          RICHARD BURR, North Carolina
THOMAS R. CARPER, Delaware
BENJAMIN L. CARDIN, Maryland

                    Russell Sullivan, Staff Director

               Chris Campbell, Republican Staff Director

                                  (ii)
?



                            C O N T E N T S

                               __________

                           OPENING STATEMENT

                                                                   Page
Baucus, Hon. Max, a U.S. Senator from Montana, chairman, 
  Committee on Finance...........................................     1

                               WITNESSES

Black Eagle, Hon. Cedric, Chairman, Crow Nation, Crow Agency, MT.     4
Pretty On Top, Henry, Cabinet Head, Crow Agency Health and Human 
  Services, Crow Agency, MT......................................     6
McSwain, Robert G., M.P.A., Deputy Director for Management 
  Operations, Indian Health Service, Rockville, MD...............    11

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Baucus, Hon. Max:
    Opening statement............................................     1
    Prepared statement...........................................    37
Black Eagle, Hon. Cedric:
    Testimony....................................................     4
    Prepared statement with attachments..........................    39
McSwain, Robert G., M.P.A.:
    Testimony....................................................    11
    Prepared statement...........................................    49
Pretty On Top, Henry:
    Testimony....................................................     6
    Prepared statement...........................................    57

                             Communications

Center for Fiscal Equity.........................................    65
National Indian Health Board.....................................    67

                                 (iii)


   HEALING IN INDIAN COUNTRY: ENSURING ACCESS TO QUALITY HEALTH CARE

                              ----------                              


                       WEDNESDAY, AUGUST 8, 2012

                                       U.S. Senate,
                                      Committee on Finance,
                                                   Crow Agency, MT.
    The hearing was convened, pursuant to notice, at 11 a.m., 
in the Crow-Northern Cheyenne Hospital, Crow Agency, MT, Hon. 
Max Baucus (chairman of the committee) presiding.
    Present: Democratic Staff: Kelly Whitener, Professional 
Staff; and Richard Litsey, Counsel and Senior Advisor for 
Indian Affairs.
    The Chairman. The Senate Finance Committee field hearing at 
Crow Agency, MT will come to order.
    This is a standard Finance Committee hearing. We have field 
hearings like this one on occasion, just trying to help, 
especially during some of the recess periods, to get around the 
country, hold hearings, and learn a lot more about what we 
should be doing and maybe not doing in Washington, DC. This is 
one of those hearings, so thank you very, very much for letting 
me attend.
    I know that the surrounding wild fires are working pretty 
heavily in the hearts and minds of many of the folks here 
today. Some of you are probably victims, some of you are 
related to those who are victims and their families, and you 
are all in our thoughts and prayers.
    I want to thank you before we begin, though, and just say 
that we have something more important before we begin, and that 
is the flag ceremony. So let me just stop here and hold the 
ceremony. Thank you.
    [Whereupon, the flag ceremony commenced.]
    Mr. Jefferson. Senator Baucus, staff, and all the guests, 
welcome to Crow Agency. Once again, if you will bear with me, I 
will say a prayer.
    [Whereupon, Mr. Jefferson performed the invocation.]

   OPENING STATEMENT OF HON. MAX BAUCUS, A U.S. SENATOR FROM 
            MONTANA, CHAIRMAN, COMMITTEE ON FINANCE

    The Chairman. Thank you all very much for the flag ceremony 
and prayer; it was very appropriate. Thank you.
    There is a Crow proverb that teaches us, ``People's eyes 
can say words that the tongue cannot pronounce.''
    A hospital should be a place of healing and relief, but 
here at the Crow-Northern Cheyenne Hospital, far too many eyes 
tell a story of pain, frustration, and disappointment. Stories 
like the one I heard from a man who was denied his medication 
without any explanation or alternative treatment--medication he 
needed to treat rheumatoid arthritis, a condition that, when 
left untreated, can lead to increased risk of heart attacks and 
even death.
    After months of inquiries at the Indian Health Service, his 
family learned that the problem stemmed from a failure to 
communicate among the doctors, the hospital, and the 
pharmacist. The patient had done everything right and still 
could not get the medication the doctor prescribed. I know that 
this patient is not alone.
    The American Indians and Alaskan Natives have a life 
expectancy that is about 5 years shorter than that of the 
general population. Access to quality health care can help the 
folks live longer, but it is increasingly difficult to provide 
this kind of care with shortages as high as 20 percent for IHS 
doctors and 15 percent for nurses and dentists.
    And health is not just physical. Native Americans and 
Alaska Natives are more likely to die from alcohol-related 
diseases or commit suicide than any other racial group, and yet 
here, at this hospital, there are only three mental health 
providers.
    The flooding last year lead to evacuations, damaged more 
than 50 homes, and left people without clean water for months. 
The physical damage is apparent, but the psychological effects 
often go unrecognized.
    Imagine being uprooted from your home, unsure when you will 
be able to return. When you turn to the hospital for help, you 
are told you are going to have to wait months to see a 
clinician, if at all. Imagine losing a child to suicide and 
being unable to get any professional help. Many of you do not 
have to use your imaginations at all. You have lived through 
it.
    Many also know all too well that one in three American 
Indian women have been raped in their lifetimes, twice the 
national average. Each one of those numbers is a mother, a 
daughter, a sister, or a friend. That is why I fought hard to 
include language in the Violence Against Women Act, which 
passed the Senate but has not yet passed the House, to give 
tribes more power to prosecute sexual predators. I am hopeful 
that the House will act soon.
    So, I was shocked to hear stories of staff at this very 
hospital refusing to conduct full sexual assault examinations 
or provide rape kits to victims. It is appalling enough to deny 
much-needed care to the victims who have already suffered 
severe trauma. And these refusals also make it harder to build 
evidence to prosecute those who perpetrated these crimes and 
prevent them from hurting more women in the future.
    The problems are serious, they demand serious solutions, 
and that is why we are here today.
    We made important progress when we passed the health reform 
law, known as The Affordable Care Act. That law also made the 
Indian Health Care Improvement Act permanent, which is a big 
win for tribal health care. The law gives the IHS the authority 
to expand tribal mental and behavioral health services. It 
provides financial incentives to help the tribes recruit and 
retain clinicians. American Indians will also have access to 
many other benefits in the law if they choose to purchase 
private insurance plans in the insurance exchanges. I would 
like to hear from any of you today as we continue to implement 
these programs.
    Of course, none of what we have done, or hope to do, can be 
accomplished without sufficient resources. The administration 
requested about $4 billion for the Indian Health Service in 
this last budget. That would be an increase of about $116 
million.
    Third-party reimbursements and mandatory appropriations for 
the special Indian diabetes program bring the total to about 
$5.5 billion. A significant chunk of that money will go toward 
Contract Health Services, otherwise known as referrals, that 
purchase care from outside providers when the IHS is unable to 
meet the patients' needs. In 2010, the funding shortfalls and 
insufficient resources led to nearly 220,000 denials for 
Contract Health Services. Every one of those denials means a 
patient goes without care, so this funding is needed.
    Still, referrals do not help us provide higher quality care 
at reservation hospitals like this one. The Crow people and the 
Northern Cheyenne people deserve to be able to use this 
hospital that was built for them. Many want services here; they 
do not want to have to go someplace else to get them.
    In 2010, the Centers for Medicare and Medicaid Services 
conducted a survey of this hospital and issued a 900-page plan. 
Many solutions lie in that plan, so we need to understand what 
is being done to implement the plan, and what more is needed.
    This is not going to be easy. It is not going to happen 
overnight. But just as the eyes in this room tell a story of 
pain and disappointment, they also tell a story of 
determination and hope.
    Each one of you is here because you care. You want to see a 
change, and you are part of the solution. There will be a sheet 
here distributed later where you can submit testimony on your 
way out, and I urge you to use it. The more people who 
participate, the better. Give us your ideas; they all are going 
to be read. You may agree with some things that somebody said, 
and you may disagree with something somebody said. I just urge 
you to take advantage of the situation and just say what you 
think.
    Our goal is to begin a new era of providing not only 
affordable health care, but quality health care. Health care 
that can change the vicious cycles American Indians suffer 
from. So let us begin our journey today together, learn from 
what we hear, and think creatively. Like I said earlier, do not 
be afraid to throw out ideas; we are here to make things 
happen. It is not going to be easy, but we are here to make 
things happen. We have no alternative but to keep thinking 
positively, constructively, and moving forward, and that is 
what we are going to do.
    [The prepared statement of Chairman Baucus appears in the 
appendix.]
    The Chairman. Okay, let me begin. I am very honored to have 
Chairman Cedric Black Eagle, the Chairman of the Crow Nation, 
here today. Chairman Black Eagle and I have worked on many 
matters, water rights, et cetera, and others.
    I just want to thank you, Chairman, for all you have done, 
and I would love to hear from you on this subject.

             STATEMENT OF HON. CEDRIC BLACK EAGLE, 
             CHAIRMAN, CROW NATION, CROW AGENCY, MT

    Mr. Black Eagle. Thank you. Thank you, Senator Baucus, in 
your position today as chairman. I will call you Chairman 
Baucus, and, members of the staff of the Senate Finance 
Committee, welcome to the Crow Reservation, as well the home of 
the Apsaalooke Nation, also known as the Crow Tribe of Indians. 
And we want to thank you for this opportunity to share the 
views and concerns of the Crow Nation on the Indian Health 
Service and the current state of health care on the Crow Indian 
Reservation.
    We are here in the Crow-Northern Cheyenne Hospital. It is 
an impressive facility, and many good people work very hard 
here. We absolutely must acknowledge the staff who keep this 
hospital running and deal with many challenges due to 
insufficient funding and challenges of location in the rural 
reservation community.
    The Crow people are entitled to receive medical care here 
and in other Indian Health Service facilities. It is our right 
as a treaty tribe to be healed within these walls. However, the 
healing should take place, as well as preventative care that 
has been compromised and elusive for many people of the tribes. 
The reality is that many tribal members are unable to obtain 
health care here because of inadequate staffing and programs 
and services that are no longer offered. There are many 
problems that require concern and consistent attention and 
work.
    A CMS survey was recently conducted in September of 2010. 
The CMS conducted a survey on the Crow-Northern Cheyenne 
Hospital, and confirmed and documented what the Crow Tribe 
conveyed to Dr. Roubideaux in our initial meetings with her on 
August 25, 2010, both physical plant issues as well as internal 
management policies and accountability failures. Through the 
survey, CMS found and documented a number of significant 
shortcomings in the facility.
    And, because you are chairman of the Finance Committee, we 
have budget issues that we are very concerned about. There are 
several items needed for the Crow Service Unit, which funding 
is currently not available within our budget, including an 
upgrade for the outdated phone system for the hospital and 
clinics--$35,000 would be required to replace it. The hospital 
and clinics need approximately $2 million in upgrades for 
medical equipment. We currently receive $130,000 for medical 
equipment and replacement equipment, which barely makes a dent 
in the need. Replacing the existing dental operatory records to 
digital, which would cost $500,000, would enable the dental 
clinic to use EHR.
    We currently have $2.7 million in deficiencies for the 
hospital and clinics, which include various building 
deficiencies that need to be addressed.
    The Indian Health Care Improvement Act, as permanently 
reauthorized through the Affordable Care Act, authorized the 
Indian Health Service to operate dialysis services; however, 
there is no funding provided for these programs. We currently 
transport our tribal members who receive dialysis 3 times a 
week to either Billings or Sheridan, distances averaging from 
30 to 70 miles or more each way, over roads that are often 
nearly impassable during the harsh Montana winters. As you 
know, funding for dialysis on-site at Crow Agency would improve 
the quality of life and long-term prognosis of these patients.
    Emergency room services are basically unfunded. This puts 
an additional demand of approximately $5 million on the Crow 
Service Unit budget. Because Crow is a Critical Access 
Hospital, meaning that the ER cannot turn anyone away for ER 
services, this is an additional burden on the budget that is 
already insufficient to meet the health needs of the Crow 
Tribe.
    The Catastrophic Health Emergency Fund is another area 
where additional funds are needed. This fund provides for 
accidents and serious medical emergencies where the costs are 
unforeseeable. However, there are shortfalls each year which 
are then deducted from the Service Unit's budget. According to 
figures provided by the Billings area office, in fiscal year 
2010, unfunded CHEF costs were $135,000; in fiscal year 2011, 
the unfunded CHEF costs were $1,033,462; and in fiscal year 
2012, the unfunded costs to date have been $319,000.
    Population increases place higher demand on services and 
providers that are available. The facility needs repair and 
upgrades as it ages. The Service Unit has consistently operated 
on a shortfall of around $2 million each year, which is then 
made up from the following year's 3rd-party collections.
    Community concerns. The community members bring a wide 
variety of issues, and some you have already mentioned, but one 
of the most consistent issues is the perception that the 
providers do not listen, and do not treat them with respect. A 
communication barrier may exist because of cultural 
differences. This can be alleviated with appropriate training, 
which the Crow Tribe can and has begun to assist with. However, 
there may be deeper-seated issues than simple lack of cultural 
sensitivity. When multiple patients consistently are not given 
routine tests and screenings, are repeatedly sent home with 
aspirin or ibuprofen, and finally go to off-
reservation facilities to be admitted immediately and treated 
for life-threatening conditions within hours after being sent 
home from the Crow Hospital, something is wrong. There is more 
than a simple breakdown in communication.
    There is also concern about the continued closure of the OB 
delivery services. We have a hospital. Crow people should be 
able to give birth on their own reservation. The limitation of 
inpatient services is also an ongoing concern. We should have 
the hospital up and running and fully staffed so tribal members 
can receive treatment here rather than being sent off 
reservation, which is time-consuming and financially difficult 
for many families.
    In conclusion, in short, there is much work to be done, but 
there are good foundations that can be built on to bring 
quality patient care back to the Crow people.
    And I also want to say that, you know we generally want to 
hear good things, and there are a lot of good things to report 
back in terms of how the hospital has been improving from, let 
us say, a year ago. And so the consistency of health care and 
the improvements that we have been seeing, there is still a 
ways to go, but I can say that improvements are beginning, and 
we would like to assist from the tribal side, as much as we 
can, to do all we can to help this hospital continue to bring 
back the programs that were here before. Thank you.
    [The prepared statement of Mr. Black Eagle appears in the 
appendix.]
    The Chairman. Thank you, Mr. Chairman, very much. And now 
we will hear from Henry Pretty On Top, Cabinet Head for Crow 
Agency Health and Human Services. Henry, go ahead.

  STATEMENT OF HENRY PRETTY ON TOP, CABINET HEAD, CROW AGENCY 
           HEALTH AND HUMAN SERVICES, CROW AGENCY, MT

    Mr. Pretty On Top. Good morning. It is still morning here 
in Montana.
    The Chairman. Yes it is.
    Mr. Pretty On Top. I want to extend my personal welcome to 
you, Senator Baucus, and members of your staff and entourage, 
and welcome back to Montana. But more specifically, welcome to 
Crow country, which we believe is the best place on earth.
    The Chairman. Nobody is going to dispute that.
    Mr. Pretty On Top. Okay, I am glad you agree.
    The Chairman. Well, there may be others in other parts of 
Montana who might not agree, but it is all great.
    Mr. Pretty On Top. But we are from Montana.
    The Chairman. Right.
    Mr. Pretty On Top. So that is all that matters right now.
    The Chairman. Right.
    Mr. Pretty On Top. You have my written testimony on record, 
and in my comments I will make reference to notes and to 
consultations that I have had with the Chairman and also with 
the legal department. I believe I can be much more effective if 
I speak from experience and being in the trenches with people.
    I want to first off say that I and we, the Crow people, 
appreciate the fact that we have this facility, in view of the 
ongoing difficulties in health care nationwide, and even 
worldwide. And I want to go on record as saying that we are 
extremely fortunate to have a facility such as this.
    I am a former employee of IHS. We moved in here in 1995; 
construction began on this building in the early '90s. And you 
had to have seen the old hospital, which is the tribal building 
right now. Compared to this facility, it is just a world of 
difference, day and night.
    As with any organism or any life being, we go through an 
evolutionary process, experience a lot of difficulties, 
changes. So it is with this organization also.
    I was a social worker, I still am; I consider myself a 
social worker. I worked for this hospital, and I worked over at 
Lame Deer, and then I retired 3 years ago. And the Honorable 
Chairman offered me a position with the Tribal Health 
Department, and I said, well, hell, I will do it. And I did it, 
not out of a sense of idealism, but a sense of reality. I felt 
that I could be a strong advocate, a strong voice for my 
people, the Crow people.
    I began that process of advocating for Crow people, and I 
do it daily. And even if I were not in this capacity that I am 
now in as the tribal representative, I would still do it, and I 
still intend to do it. Somebody has to speak for the people, 
and I will do that. Even if they have to drag me off, I guess. 
But it is that important to me, health care.
    In the 3 years that I have been with the Health Department 
as Health and Human Services Cabinet Head--I know that is an 
awesome-sounding title, and I am a little bit self-conscious 
about that title, but it is just my social roots; I speak for 
the people.
    Our work and our performance has been predicated on Dr. 
Yvette Roubideaux's stated philosophies, and I would like to 
reiterate them right now. She came on board pretty much about 
the same time that I did, maybe a little bit earlier than 
myself. But our department has taken to heart and to soul and 
into mind what Dr. Roubideaux said. We take those words to mean 
that she means what she said.
    Her goals, her statements were, number one, to renew and 
strengthen our partnership with tribes; to reform the Indian 
Health Service; to improve the quality of and access to care; 
and, finally, to make all other work accountable, transparent, 
fair, and inclusive. Those are, in my mind, in my estimation, 
powerful, actionable, attainable statements and goals.
    So consequently we, the Tribal Health Department, have 
operated on those premises. And to this point, I personally 
deeply appreciate your personal attention to the Crow 
Reservation, the Crow people, to conduct this hearing in this 
facility on Crow land.
    Reference has already been made to some of the issues: CMS, 
funding. If I were to elaborate on some of those points, it 
would be repetitious and time-consuming. But plain and simple, 
we need money, we need funds. And, as you listen to us and as 
you devise strategy getting back to Washington, we want to be 
an integral part of that process. We want to be partners, as 
Dr. Roubideaux intends, and we want to help reform IHS. It is a 
system, unfortunately, in disrepair. And I do not say that with 
any animosity; I say that with all reality. As we help repair 
the organization, we hope and we intend to improve the quality 
of health care and access, our access to health care. You know, 
being an old-timer like yourself, age just wears away the 
strength. I am in that position right now. I require not 
constant care, but, you know, I am not young anymore.
    The Chairman. You look very young.
    Mr. Pretty On Top. Thank you. And that is one of the 
reasons I say that I appreciate the fact that we have this 
facility, and we do have dedicated, committed health care 
providers.
    But, as with any organization, as I mentioned, there are 
problems and difficulties. And we have to pay attention to 
that. Give us more money.
    To give you a specific example, we need an ambulance 
service that is based out of this facility. It used to be that 
we had that ambulance service here. Now, directly connected to 
the current situation, you mentioned Contract Health Services 
funding earlier. The current ambulance service that we have is 
based out of Hardin, and that situation has ramifications of 
all that we are saying today.
    The bulk, the huge majority of money for that ambulance 
service comes out of Contract Health Services money that was 
budgeted for this facility. Unfortunately, when that contract 
was negotiated, the tribe had absolutely no input into that 
contract. This is another instance of somebody deciding for me 
what I need, somebody deciding or determining that they know 
more about what I need than I know myself.
    In any case, one of our plans eventually is to bring the 
ambulance service back, and it is doable. We will do it. But 
right now that chunk of money that was intended for patient 
care is taken out of here, and it is operating out of Hardin. 
Not only that, but the current ambulance service serves all 
people, non-Indians as well. Again, I do want to repeat for the 
record that my understanding, my knowledge, is that that money 
was budgeted for Contract Health Services for this service 
unit.
    Other issues have been mentioned quickly, and I do not want 
to take up a lot of time, but----
    The Chairman. Go ahead, say what you think.
    Mr. Pretty On Top. All right.
    The Chairman. That is why we are here.
    Mr. Pretty On Top. I am concerned that you might be on a 
schedule to get back to DC.
    The Chairman. Do not worry about it; no, no, I am home.
    Mr. Pretty On Top. Good, stay home.
    The Chairman. You bet.
    Mr. Pretty On Top. For a while.
    The Chairman. You got that right.
    Mr. Pretty On Top. How long have you been in DC?
    The Chairman. You mean how long have I had this job?
    Mr. Pretty On Top. Yes.
    The Chairman. A good number of years.
    Mr. Pretty On Top. Get back here while you can still do a 
lot of things physically, enjoy the mountains, enjoy the 
country.
    The Chairman. I will. The day before yesterday I hiked, not 
here, I hiked Glacier Park. And 2 days before that I hiked up 
in--what mountain range is it that I tried? Well, I tried to 
climb a mountain called Mount Wilson, but I am getting a little 
older and did not quite make it. It is outside of Big Sky.
    Mr. Pretty On Top. Well, if you can still do some of those 
things, do it. Get back here more often than--sometimes I 
question what goes on in DC, you know?
    The Chairman. I get home around every other weekend.
    Mr. Pretty On Top. That is good.
    Anyway, going on. A mention was made of the behavorial 
health services, and that is a topic near and dear to my heart, 
because that is my profession. And I do not do it anymore, none 
of the clinical stuff anymore, but people still come approach 
me and ask me if they can see me. And I say, well, you know, it 
is not like it used to be, because I do not do that stuff 
anymore; I should not say ``stuff.''
    But it was not work to me, it was something that I needed 
to give back. And that is not idealistic. A lot of us who grew 
up and lived on the reservation, we went through a lot of 
difficult times. And what I did not know and what I did not 
experience--I try to help young people with opportunities.
    When I was in that field, Mr. Jefferson and myself, our 
Vice Chairman, also a licensed professional, we used to work in 
the same department, so he knows of what I speak.
    But we do need money; we do need additional funding. There 
was a time when the department here had six full-time mental 
health professionals, three clinical social workers, and three 
psychologists. Now it is down to three. Those three people are 
expected to serve the entire geographic area of the Crow 
Reservation, about 8,000, 9,000 people. And we have two 
outlying clinics, and I do not know what the coverage is right 
now for the behavioral health, the problems of domestic 
violence, drug and alcohol abuse behavior, school behavior, 
young people, the current prevalence of obesity.
    All of these problems, some I probably have not mentioned, 
all afflict the Crow Tribe. So we do need money, funding, for 
additional mental health professionals.
    That brings to mind--I do want to share this with you--
getting to the accounting practice methods of IHS. Several 
years ago when I was still working in this department, we were 
at full staff. One of our psychologists left for a different 
job. And it was fully budgeted for six people plus the medical 
clerk. I said, good, we can hire somebody else; we can hire 
another worker. So we got the process started, and about a 
month later we were notified by the area office, you guys are 
in the hole, in the red in terms of personnel. And I said, how 
can that be? We are budgeted for those full time. No, you are--
I think at the time he said, you are $45,000 in the red for 
that particular personnel. And I asked, and to this day I have 
never gotten a reasonable response, why we can be fully 
budgeted, somebody leaves, and we can be in the red. But I 
guess that is not for me to question. I guess it is, it really 
is.
    But a couple of the major afflictions, health conditions, 
diabetes--the special diabetes program for Indians is coming up 
for renewal. We need your help in pushing that, renewing it, 
because diabetes is running rampant in Indian country. It used 
to be much more so down in the southwest, but now it is 
afflicting us too. So that particular initiative, we ask, we 
request that you promote, push, finagle, whatever, to keep that 
alive, to re-fund it, and to keep it going.
    OB, you know, that is costing a lot of money. We want that 
facility, that department opened up again. We have been 
meeting--I do not want to paint a negative picture; I will 
dwell on the positive components that are going on right now. 
As Mr. Chairman Black Eagle alluded to, there has been some 
significant progress made. Namely in hiring Mr. Old Elk--
Clayton Old Elk is currently the chief executive officer of the 
hospital here. And he brings to us, and he brought to us, long 
experience in IHS and administration. So that has been an 
accomplishment that we have fought for, advocated for, and now 
we have one of our own who is administrator of this hospital. 
And the administrative officer position right now is being 
handled by the Chairman's son who is detailed with us. That is 
an accomplishment. But it is a beginning. It is only a 
beginning.
    I would like to also share with you one situation. You 
know, in our pharmacy department, there is a qualified pro 
individual for the pharmacy supervisor position, and for 
whatever reason, this and that, I do not know the ins and outs 
of it, the details, but that person has been passed over twice, 
I believe, Heather, is it?
    Ms. White Man Runs Him. Yes.
    Mr. Pretty On Top. Yes, that needs to be looked at, you 
know. This is one of our own who has the credentials, who has 
the experience, and, for whatever reason, she is not hired. But 
this is a movement that eventually in the future I would like 
to see, God willing, if I live long enough, to see Crow M.D.s 
on staff here. This is one of the initiatives that I am 
pushing, establishing educational curriculum for college.
    The Chairman. There is none now?
    Mr. Pretty On Top. None here, but that is something that we 
would like to put in place and have the young people pick up.
    The Chairman. Okay, I appreciate that.
    Mr. Pretty On Top. Okay.
    The Chairman. Thank you.
    Mr. Pretty On Top. All right. I have taken up a lot of 
time, but again I----
    The Chairman. It is very important; I learned a lot. Thank 
you.
    Mr. Pretty On Top. Yes. What else? Staff shortages; that 
seems to be a chronic difficulty here. We need to devise an 
approach to deal with that. Mr. Chairman alluded to that 
earlier too.
    Cultural sensitivity. We are human beings, the Crow people. 
We experience the same emotions, the same likes and dislikes, 
we are afflicted by absolutely everything medical and social 
and emotional and spiritual just as everybody else. We are no 
different. And I know that, a lot of times, non-Indians come 
here probably with preconceived notions. I am not being 
judgmental--that is a fact, that is real. You know, we need to 
put into place a mechanism that attracts professionals and that 
will retain professionals here.
    We as Crow people are very hospitable. Our doors are open. 
But we are--we do welcome non-Crows, you know, but they need to 
take the time, and I guess we need to do something to let them 
know that, hey, come get to know me. But we have to devise 
something that will retain M.D.s, nurses, those who want to be 
here and who will stay here.
    You know, in my long experience here and over in Lame Deer, 
it was really interesting, working with Crow people, and over 
in Northern Cheyenne when I worked there. I lived there for 5 
years, lived in the community. And, after about a couple years, 
I was working with a man, and he came into my office, and he 
said, ``Hey, I want to ask you something before we even get 
started.'' ``Sure, if I can answer it, I will.'' He says, ``How 
long are you going to stay?'' He said, ``First of all, why are 
you, Crow, coming over here and helping Cheyennes?'' I said, 
``Well, you know, number one, I have to be someplace, and 
number two, this is what I want to do.'' And I said, ``I will 
go anywhere that people will take me.''
    And his second question was, ``How long are you going to 
stay?'' I said, ``I do not know; I do not have a time limit. I 
have not set a time limit.'' And I asked him, ``Why do you ask 
me that?'' And he said, ``You know, one of our problems here,'' 
he said, ``people like yourself and non-Indians have come here, 
we trust and respect and accept certain people, non-Indians, 
you know, because we like them, and then they pick up and 
leave.'' And he said that really makes a difference. And I 
said, ``I cannot tell you when I will leave.'' But that has 
stuck with me. The same thing occurs here too.
    The Chairman. I know.
    Mr. Pretty On Top. So that is an area that, with additional 
funding, with money, we can create, again, a mechanism to 
retain individuals committed to people; you know, make it 
attractive here, add to their enthusiasm, add to their desire 
to be here.
    But I know that Mr. McSwain is chomping at the bit here.
    The Chairman. I am waiting to hear from him too, but 
thanks. I do appreciate it.
    Mr. Pretty On Top. But I will conclude and say, I do 
appreciate you being here, and your staff being here. And we 
are meeting with Mr. Old Elk regularly, which I say again, is a 
positive. We are also meeting with Area Director Conway on a 
monthly basis to talk about issues, topics, initiatives, and 
whatnot; we are doing that consistently and regularly.
    But there is still a lot to be done. And, as you push for a 
lot of money for us, we will do a lot more. Sad to say, but, 
you know, money talks, and that is the reality of the world.
    The Chairman. Yes it is.
    Mr. Pretty On Top. Thank you very much.
    The Chairman. Okay, thanks very much.
    Mr. Pretty On Top. Thank you.
    [The prepared statement of Mr. Pretty On Top appears in the 
appendix.]
    The Chairman. Now we will hear from Bob McSwain, Deputy 
Director for Management Operations for the Indian Health 
Service. And, Mr. McSwain, thanks so much for being here.

  STATEMENT OF ROBERT G. McSWAIN, M.P.A., DEPUTY DIRECTOR FOR 
  MANAGEMENT OPERATIONS, INDIAN HEALTH SERVICE, ROCKVILLE, MD

    Mr. McSwain. You are welcome.
    Thank you, Mr. Chairman and members of the committee, 
certainly tribal leaders Chairman Black Eagle and Cabinet Head 
Pretty On Top.
    First of all, I am pleased and honored to be here, quite 
frankly, and to have the opportunity to testify before the 
Senate Finance Committee on operations of the Crow-Northern 
Cheyenne IHS Hospital.
    I had the fortunate opportunity to actually walk through 
the facility and spend an hour or so with Mr. Old Elk and Mr. 
Conway and Diane Wetsit. What I found is everything that my 
predecessors here have said, and that is that the staff are 
really committed. They are doing multiple jobs. They are 
working hard, they are committed to the community, they are 
committed to the patients, and some of the numbers that they 
are sharing with me is something that I will certainly talk 
with Mr. Conway and Mr. Old Elk about.
    I am going to summarize my statement; I am not going to go 
into my talking points on it, because I think the most 
important thing to talk about is the fact that Mr. Old Elk, 
since he has arrived, what, 4\1/2\ months ago, has really begun 
to turn around the very essence of what we are talking about, 
which is staffing. And the way you turn that around is with 
leadership; you turn that around with leadership at the very 
key levels.
    I will state for the record that, for example, he has hired 
certainly a clinical director, he has hired a director of 
nursing, and a business office manager. The business office 
manager is so crucial because, as we know, collections and 
reimbursements are the lifeblood for Indian Health Service 
systems across the country. In fact that, in many cases, really 
keeps the program afloat. And I want to say that that was a 
great set of priorities that the new CEO has engaged in.
    He is also considering positions for an administrative 
officer, a very critical position, and the chief financial 
officer position. The jobs are closed--I mean the idea is that 
we are filling in a complete team that he will lead. And the 
selection that I was struck by was the pharmacy office, and the 
fact that a selection has been made--the person is going to 
report the 1st of October, and you will begin to, again, have 
leadership in those particular components that can be available 
to provide the recruitment and actually work on filling the 
vacancies.
    There are a number of vacancies, and there are certainly 
challenges to that effect. And I will say that the Northern 
Plains Human Resources--and for purposes of everyone's 
information, we have broken the country up into five regions 
across Indian Health Service, and the northern plains region is 
comprised of Billings, Aberdeen, and Bemidji. And it just so 
happens that the Director of the northern plains regional 
center is actually in Billings and working very closely with 
Mr. Conway, and of course Mr. Old Elk and all of the other 
folks in the Billings area, to reduce the numbers.
    I will say that our target that the Director has been 
watching has reduced the hiring time to 80 days per the OPM 
guidelines. Actually, Billings has reduced it to 60 days. Now 
what that means is, obviously, we are getting people hired 
faster, but now we have to make sure that the quality of people 
we bring on is equally to the point. And as was mentioned 
earlier, he has established monthly meetings with the two 
tribes and the respective tribal health officials, a weekly 
governing body meeting. So there is a lot of communication, 
there is a lot of accountability that is being built in, as we 
move forward. And the action plan that has been put in place 
actually begins to lay a template for further improvements.
    And clearly, you know, we certainly have an Area Director, 
and I just want to say publically that Mr. Conway was due to 
retire in March, I think it was March or February, but the idea 
was, he decided that, when Mr. Old Elk came on board, he would 
stay here until Mr. Old Elk was actually in place and able to 
be supported and beginning to get those other positions filled. 
And I envy Mr. Conway retiring, because I probably could have 
retired a few years ago myself. But the fact is that he is 
committed to doing this to make sure that the response to the 
Crow-Northern Cheyenne Hospital is made.
    And of course the whole notion of the governing body is 
crucial to any health system, and that is where we are at. 
Effective collaboration between IHS and the two tribes, as Mr. 
Pretty On Top talked about, is Dr. Roubideaux's number-one 
priority, to increase the effectiveness of the tribal IHS 
partnership. And it is crucial to ensuring that the shared 
goals are met. We are grateful for the commitment the Crow 
Nation and the Northern Cheyenne Tribe have made to focus on 
the challenges facing the Billings area. And we look forward to 
solutions, and I see them actually coming very quickly. And we 
will continue to make improvements, with a core being staffing.
    And this is not unusual to the Crow. We have this across 
Indian Health Service; we are struggling. Where we operate is 
in rural areas and where people are turned out of medical 
schools, and professionals schools tend to want to work in 
urban centers. We want them out here, and so we are using as 
many of those incentives to get people moving along. And I 
believe that, even with the progress we have made thus far, 
there is no question that we have a long way to go. We have 
some additional challenges, but I feel very confident that Mr. 
Old Elk, in his position, and the staff and team he is putting 
together, will enable that to parlay into filling those 
vacancies in the native areas.
    I cannot leave my opening remarks until I say that the 
numbers were just really striking for me, the numbers of ER 
visits. Because of the situation of the Crow-Northern Cheyenne 
Hospital, the fact is that last year they saw 240 patients in 
ER. The average for any other hospital in the region is 5 per 
month. So they are operating at about 20 a month. And so you 
can see its value to the people it serves, but also, because 
they are people who--maybe it is an accident out on the 
highway, so the first place they come for care is here. And so 
I offer that as another striking example of how critical this 
particular facility is for this part of the region.
    With that, Mr. Chairman, thank you for your long-standing 
commitment on behalf of Dr. Roubideaux, your commitment to 
improve Indian health in the Billings area and throughout the 
Indian Health Service, and finally for the opportunity to 
testify. Thank you.
    The Chairman. Thank you, Mr. McSwain.
    [The prepared statement of Mr. McSwain appears in the 
appendix.]
    The Chairman. I have to ask the three of you some 
questions. And I would urge the audience to, as I said earlier, 
thinking about it, submit some ideas later on.
    I am also going to be asking those in the audience who want 
to stand up and speak to do so. Say anything that is on your 
mind. You may agree with something that is said, you may 
disagree with something that is said, but I am going to try to 
be as effective as I can, but it may be a bit unorthodox in how 
we do all this; I will just do my best.
    Okay. To me it comes down to, it just seems anyway, that 
there are certain basic services that can be performed here 
that perhaps cannot be performed elsewhere. Let us just take 
some specialty services like some very special neurosurgery 
that is not expected to be here, I am guessing, and probably a 
place like Billings or someplace else. But there is a lot that 
can and should be here, a lot that can and should be done. So I 
would like you, and others who want to, to speak up.
    Mr. Old Elk, right, you are the CEO? You are the top guy 
here. If anybody wants to, chime in here. So I am going to 
ask--the first question is going to be, what kinds of services 
should be provided here at this hospital that perhaps cannot be 
provided, or should be provided but you do not have the 
resources, what specialty services? What are the basics that 
should be provided here? What good health care should be 
provided here? Let us just go down the list. Anybody.
    Mr. McSwain. First of all, it is a hospital, so you have to 
be able to provide care for inpatient.
    The Chairman. What kind of care?
    Mr. McSwain. Basic hospital inpatient care. And surgery, 
obviously, is critical.
    The Chairman. There is no surgery here now?
    Mr. McSwain. I do not believe so, there is some light 
surgery, but it is----
    Audience Speaker. Outpatient.
    Mr. McSwain. There is outpatient surgery, but if you have 
to have the patient recover----
    The Chairman. I know, but why is there no inpatient surgery 
here?
    Mr. McSwain. You do outpatient surgery.
    The Chairman. I know, but I am talking about inpatient. Why 
no inpatient surgery?
    Audience Speaker. Because of the cost.
    The Chairman. Cost?
    Mr. McSwain. Yes, cost.
    The Chairman. Because you just cannot afford it, is that 
the reason? Stand up if you want.
    Audience Speaker. Yes.
    The Chairman. Okay. Any other services?
    Mr. Black Eagle. I guess we talked about it earlier, and 
because of the dramatic increase in our population, there are 
13,000--over 13,000 Crows, and approximately 8,000 of those 
Crows live on the Crow Reservation. And the influx that this 
hospital receives is quite a bit.
    And of that population, there is a high rate of diabetes 
that occurs. And so aside from, you know, the in-service/out-
service surgeries that should be required, the dialysis program 
should be provided here. Even a mobile dialysis would be 
beneficial----
    The Chairman. Right.
    Mr. Black Eagle [continuing]. Because a lot of our elder 
people are still at home, and they have to drive miles to get 
here----
    The Chairman. Right, we talked about that earlier.
    Mr. Black Eagle [continuing]. Or even to get to Sheridan.
    The Chairman. Right, right.
    Mr. Black Eagle. So that is one.
    The Chairman. Can appendectomies be performed here? If 
someone has appendicitis and has to have their appendix taken 
out?
    Mr. Black Eagle. No.
    The Chairman. No appendectomy? No gallbladder removal? No 
general surgery?
    Mr. Pretty On Top. Senator, I really wanted to--at one 
point I forgot to mention dialysis; Chairman Black Eagle had 
brought that up. We used to have that service here.
    The Chairman. Dialysis?
    Mr. Pretty On Top. Yes.
    The Chairman. Right.
    Mr. Pretty On Top. And with the increasing number of 
patients, I just wanted to say, the request that we have been 
hearing over and over from the community is, please bring that 
program back and operate it out of here. And I do not know the 
particulars and details about the Health Care Improvement Act, 
but I understand that dialysis is addressed in that, and that 
perhaps now IHS can contribute in some way monetarily or 
resource-wise or whatever; but we do need to bring that service 
back.
    The Chairman. Yes.
    Mr. Pretty On Top. That is something we want back here.
    The Chairman. That is a good act, and it goes back to 
earlier points you mentioned. It is money, it is dollars. If 
that is basically an authorization for lots of great services, 
it should be available, but it just comes back to dollars.
    What about OB-GYN care and delivery of babies here? I am 
sure you would like to get that back, too.
    Mr. McSwain. Well, that is huge. I think the staffing is--
you have two docs now. You need four.
    Mr. Old Elk. Two.
    Mr. McSwain. So it becomes a staffing issue as to how much 
you actually take on. But OB is clearly needed, because 
otherwise they are having to travel great distances for the 
care.
    The Chairman. How long ago was there OB care here?
    Ms. White Man Runs Him. Before the flood.
    The Chairman. Sorry?
    Ms. White Man Runs Him. Before the flood.
    The Chairman. Before?
    Ms. White Man Runs Him. Before the flood.
    Mr. Old Elk. May of 2011 when we had the flood and had to 
close it down, but now we are talking about October 1st to open 
it up again.
    The Chairman. So you are looking to reopen it October 1st. 
That is good.
    Mr. Old Elk. Yes.
    The Chairman. And you have the doctors to open it up?
    Mr. Old Elk. Yes.
    The Chairman. That CMS study--some of you just addressed 
what parts of that you think are accurate and some of their 
complaints and what is not accurate. And help me start to 
address the parts that are accurate versus the ones that might 
not be accurate.
    Who wants to take a crack at that?
    Mr. Pretty On Top. Can I quickly just lead into that?
    The Chairman. Yes.
    Mr. Pretty On Top. And I will just leave it up to people 
with more knowledge about that.
    The CMS survey, there was a big scare back when it came 
out. Word spread that the hospital was going to close down; 
people were very concerned about that. And then the tribe, our 
knowledge, our information was that IHS came up with a 
corrective action plan which was accepted by CMS in DC. And, 
what, that is going on 2 years now, and we still do not know 
what the office in Washington, DC is going to do. So that is 
where we are as a tribe. Correct, Heather?
    Ms. White Man Runs Him. Yes.
    The Chairman. Yes, that is a good question. Where is that 
action at?
    Mr. McSwain. I would expect that Mr. Old Elk could answer 
that.
    The Chairman. But I understand it is something IHS is 
addressing.
    Mr. McSwain. Right.
    The Chairman. The CMS survey.
    Mr. McSwain. We have a plan that was actually an action 
plan that was submitted to CMS. And, if you know CMS, if it is 
not acceptable, they will take actions. They will take actions 
such as removing your conditions of participation, which means 
you cannot bill Medicare. That has not occurred.
    So they have accepted the plan. And moving forward----
    The Chairman. Who has accepted the plan?
    Mr. McSwain. The CMS, the Centers for Medicare and Medicaid 
Services.
    The Chairman. The IHS plan?
    Mr. McSwain. Yes. They have come out, done the survey, and 
then we have submitted an action plan, just as we are always 
asked to do.
    And it is when they accept the action plan that, if we 
complete those actions, then we have addressed their findings.
    The Chairman. At what stage are you in on that?
    Mr. Jefferson. We are in the second year.
    Mr. McSwain. The second year, but I mean, how far down the 
list are we?
    Mr. Jefferson. The plan of correction addressing the 
deficiencies----
    The Chairman. Okay. Let us go through the main 
deficiencies. What are they that are being addressed?
    Do you want to come up too and get a microphone up here? 
You seem to be the guy who has some of the answers. Thank you.
    Mr. Old Elk. The CMS identified a number of deficiencies 
for the ``conditions of participation'' is what it is called; 
some of those things that are outlined. And there are many, 
many things that are provided in there, such as the quality of 
services that are provided here, and the equipment that we use 
at the facility--how all of these pieces of equipment are used, 
how they are maintained, if they are sanitary. Basically things 
like that: housekeeping and sanitation and infection control. 
There are many, many things that they have listed on there.
    I have only been here 4 months. I am not really familiar 
with the report itself, but I know the area has made 
significant progress in addressing these deficiencies that are 
outlined and identified. And we have a plan of correction for 
each of these deficiencies that we are addressing. It is an 
ongoing thing. We have our area supporting us 100 percent, and 
they have monthly conference calls with CMS.
    The Chairman. Right. Number one, one of them is equipment, 
sanitary requirements for equipment that need to be addressed. 
Am I correct in understanding that that is one of the 
deficiencies that was suggested?
    I am trying to get a sense of what two or three or four of 
the basic deficiencies are so we can then start working on 
them. So the first one was sanitary equipment? Was that it?
    Mr. Old Elk. Well, I am just outlining the type of things 
that they look for.
    The Chairman. Yes.
    Mr. Old Elk. And I mentioned equipment, because we make do 
with what we have.
    The Chairman. Right.
    Mr. Old Elk. And sometimes we do not have the equipment, so 
we do without.
    The Chairman. Right.
    Mr. Old Elk. And the equipment that we have needs to be up 
to standards; state-of-the-art, if you will.
    The Chairman. But one is inadequate equipment. Is that one 
of the deficiencies?
    Mr. Old Elk. What?
    The Chairman. Inadequate equipment or insufficient or 
improper equipment?
    Mr. Old Elk. I would say it is outdated.
    The Chairman. Outdated equipment. Okay, that is one. What 
else? What other deficiencies?
    Mr. Old Elk. They have 90 pages of deficiencies that are 
listed----
    The Chairman. Right.
    Mr. Old Elk. I think 97.
    The Chairman. Yes.
    Mr. McSwain. Fundamentally, Mr. Chairman, it is by 
staffing, and it is by staffing by department. And so, if you 
are not meeting the staffing levels to do the necessary quality 
of care, quality care checks, and the protocols that you are 
necessarily going through, a lot of it has to do with governing 
boards, and governing boards follow up on activities. So it is 
the oversight, it is the documentation. If they see 
documentation lacking, there may be in-service training 
requirements for providers.
    These are consistent findings that we found across all the 
CMS folks, and they use this rubric called ``conditions of 
participation'' that sets criteria as to how you are staffed, 
how you are providing care, how you are documenting the care, 
and what are the outcomes; not just medical errors, but 
prescription errors. So there are a lot of these criteria that 
they are looking at.
    I do not have the actual report, but I know that it did 
occur, and it did occur not just in Crow, but several 
facilities across the northern plains.
    The Chairman. Right.
    Mr. McSwain. And every one of them addressed the 
deficiencies.
    The Chairman. Right. But the CMS report was for all Indian 
country, or is it----
    Mr. McSwain. No, they just do it by facility.
    The Chairman. By facility.
    Mr. McSwain. Yes.
    The Chairman. Okay. Well obviously, the thing that makes 
sense, to me anyway, is to try to figure out what the major 
issues are and just identify them and then figure out how to 
address them. And, in figuring out how to address them, there 
have to be some standards or some benchmarks, some follow-up, 
some way of knowing the degree to which we are actually 
addressing them. Like one very minor issue is turnover. As I 
understand, there have been ten CEOs in 10 years. Well, if it 
turns out there is one CEO in 10 years, that is progress. The 
same thing in staffing; if there is less turnover in staffing, 
that is progress. We need to put numbers next to it. Let us 
say, this number of docs here, and see how many more docs are 
here in a year or two. Let us find out in a year or two from 
now, are there more docs or not? Is there a dialysis center 
here? Let us find out in a year or two. Is there an OB-GYN? Can 
you deliver babies here or not? I mean, it just seems to me 
there are a lot of categories that are not so little that you 
can look at to measure the progress. You said, follow up a year 
from now and see where we are.
    Everybody is trying to help everybody out here, believe me. 
It is a mutual effort to try to get better health care for Crow 
people and Northern Cheyenne people. That is what this is 
really all about. And I know a lot of it is resources, believe 
me, I know that, and we struggle back there to get more 
resources. And I do not want to get too far down this road, but 
there are some people back there who just do not want to spend 
many dollars on Indian health care. I do not want to name them, 
but they are there. And it kind of depends who gets elected 
back there as to whether resources are going to be provided or 
not. I mentioned the President suggested $116 million in 
addition, but that has to get enacted by Congress. And with 
some of the people back there in Washington these days, it is 
kind of hard to get some of that.
    So we just have to deal with that and try to persuade them 
to appropriate, try to get the right people elected in the 
first place, and try to deal with what we have, given the 
dollars that we do have. There are lots of ways to skin a cat. 
There are ways to get dollars from here, dollars from there, 
and maybe a doc here, I am just--I really need to know what the 
major problems are. I guess the deficiencies are in the CMS 
report. And the second thing is, what your thoughts are on how 
we start to address those problems, and I will do my best to 
try to help out.
    So equipment, that is one; turnover, that is another. Is 
that correct?
    Mr. Old Elk. Yes.
    The Chairman. And I will ask you the same question Henry 
Pretty On Top was asked: tell us how long you plan to stay.
    Mr. Old Elk. Well, I am from here, so I am here to stay 
forever, for good.
    The Chairman. So you plan to stay a while?
    Mr. Old Elk. That is right.
    The Chairman. That is good to hear.
    Mr. McSwain. Mr. Chairman, while you are thinking about 
that question, what occurs to me, what I discovered is that the 
staffing is so critical because it does two things: one, if you 
can increase staffing, you can increase billing, and billing 
then produces another form of revenue stream, not just 
appropriations, but billing and collecting.
    The other thing that is happening is--certainly on the CMS 
survey--what happens with us is that, in this particular 
facility, when we try to operate an ER, we will steal people 
from the hospital itself to staff the ER. And then along comes 
CMS and says, are those folks adequately trained to do 24/7 ER? 
And the answer is ``no.''
    So it is a matter of getting staff on board so you can have 
actually specialized trained trauma docs as opposed to taking a 
family practice doc out who might have delivered a baby that 
afternoon to pull duty at night in the ER. That is the 
challenge; if you can get staffing up with qualified staffing 
by department, you can actually begin to see a different 
revenue stream. But that is happening right now, and it is how 
Mr. Old Elk is building his business plan as he goes forward.
    The Chairman. Sure.
    Mr. Pretty On Top. Mr. Chairman, really quickly.
    The Chairman. Yes.
    Mr. Pretty On Top. I apologize for butting in, but I take 
this opportunity seriously.
    The CMS issue is an area where we can put into practice 
what Dr. Roubideaux says about partnership.
    We want to be a part of the solution. We want to help. Tell 
us about the CMS survey, where we are, what they are saying. 
The tribe can help. We want to help. We do not want to be at 
each other's throats with IHS. Staffing, hiring, we want to be 
a part of that process here in the hospital. You know, we are 
the people IHS is serving. I am a customer of you guys.
    The Chairman. Yes, if you want to sit down, let us get 
together and work this out.
    Mr. Pretty On Top. Yes. But you talk about the partnership, 
let us sit down and do it instead of just talking about it.
    The Chairman. Okay. Where would you like to see more 
partnership?
    Mr. Pretty On Top. Everything.
    The Chairman. Give us one example, one or two.
    Mr. Pretty On Top. Staffing, hiring. We want to be a part 
of the process, and we want our voices to be heard.
    I will give you an example of what happened a while back. 
The AO position several years ago, Mr. Vice Chairman and myself 
were part of the interview process. I think the CEO for the 
tribe, Mr. Half, was part of the interview process.
    We interviewed along with IHS representatives, and we kept 
everybody informed. We interviewed, what, about four or five 
people, didn't we, Calvin?
    Mr. Jefferson. Yes.
    Mr. Pretty On Top. And it boiled down to three who showed 
up personally. And we, the group, the committee, came up with 
one recommendation, and we thought it was the unanimous 
decision, the unanimous choice for one individual, one Crow 
man, and that was the tribe's recommendation.
    The Chairman. Right.
    Mr. Pretty On Top. And the next day we found out that they 
hired somebody else.
    The Chairman. IHS did?
    Mr. Pretty On Top. Right.
    The Chairman. And did they tell you why?
    Mr. Pretty On Top. I would still like to know why.
    Mr. McSwain. I did not sign the cert; no, I defer to----
    The Chairman. Well, but this is an important question.
    Mr. McSwain. This is an important point.
    If you are going to involve tribal leaders in the selection 
process, you should give them feedback----
    The Chairman. Yes.
    Mr. McSwain [continuing]. As to why you make the decisions.
    The Chairman. Sure. And did you ask him why?
    Mr. Pretty On Top. We did, but unless somebody got a 
sufficient answer, I never got it. Calvin, did you?
    Mr. Jefferson. Never.
    Mr. Pretty On Top. Oliver, did you get an answer?
    Mr. Half. No.
    Mr. Pretty On Top. Heather, did you get an answer?
    Ms. White Man Runs Him. No. What we were told is, it was 
just a formality to include the tribe in the processes, and we 
were pretty upset when we----
    The Chairman. They basically were telling you it was not 
real?
    Ms. White Man Runs Him. We did not have any decision-
making power, that is right.
    The Chairman. Well, what about other positions or other 
similar instances? Are there other instances where you, the 
tribe, have made the determination or would like to make the 
decision, but were overruled by IHS or dictated--I can maybe 
get a better word--or told by IHS what the decision is going to 
be after you really were consulted? Are there other areas?
    Mr. Pretty On Top. I think this really was the first and 
only time that we actually participated in that process. And we 
do not pretend to say that we want to hire--that is officially 
an IHS function. But just the fact of participation and having 
our opinion and our voice heard after reviewing applicants, 
interviewing them, and what we consider as the best fit for any 
position, then we would like to believe that our voice has 
credibility.
    The Chairman. Yes. At what level of IHS were you working 
with?
    Mr. Pretty On Top. Service Unit and Area.
    The Chairman. So ``Area'' is Billings.
    Mr. Pretty On Top. Was Area involved in that?
    Mr. Old Elk. I thought so.
    Mr. Pretty On Top. Yes.
    Mr. Half. Yes, they were.
    The Chairman. So who was, sorry? I have to learn here.
    Mr. Pretty On Top. These gentlemen here can elaborate more 
on the situation.
    Mr. Half. Some of the HR personnel were available who----
    The Chairman. Where is that? In Billings?
    Mr. Half. We had meetings here, and we had some meetings at 
Billings, and we made our request, and a majority of the 
meetings were in that green room, in that one room.
    The Chairman. Right.
    Mr. Half. And we had HR out of Billings that we met with, 
and we voiced our concern, and we even wrote letters and 
everything for that particular AO position that time. So we 
never got a response on the outcome.
    The Chairman. Are there other instances coming up in the 
future where you would like, as a tribe, to make the 
determination, but where there might be conflict with IHS, and 
IHS might be making decisions irrespective of what you might be 
thinking? Are there other decisions coming up down the road 
over the next months or a year or two, positions to be filled 
or services to be provided or something?
    Obviously, what I am trying to get at is to try to figure 
out some way so both sides are talking a lot better than they 
have been.
    Mr. Pretty On Top. Well, currently, right now, Mr. Old Elk 
is in the process of considering hiring a CFO and an AO, and we 
would certainly like to be a part of that process.
    Mr. Half. Excuse me.
    The Chairman. Yes.
    Mr. Half. I guess the bottom line is that we want our very 
own people who are qualified and have the credentials. You 
know, just like everybody said, we want them to occupy those 
positions that are available so that we know they will be here. 
This guy, Mr. Old Elk, he is old now, and he is not going 
anywhere. That is what I hear.
    The Chairman. You are going to make sure of that. Right?
    So what about this, Mr. McSwain? It kind of sounds like, in 
some sense, a lot of folks are just getting stuffed, just not 
being listened to.
    Mr. McSwain. I would not speak for Mr. Old Elk, but I 
believe that it is certainly a reasonable request.
    And the other part of it--and I think Mr. Pretty On Top did 
not talk about the fourth thing, which is transparency, in that 
there has to be that feedback.
    The Chairman. Right.
    Mr. McSwain. Recognizing that the authority, and, again, it 
was very correct, it is an inherent authority to appoint a 
Federal employee, and that does not happen at Crow, it happens 
at the regional personnel office. That is where the authority 
rests, and so that is probably where the disconnect may have 
occurred. But the feedback should have come from the selecting 
official, because the selecting official is the actual 
appointing authority who will look at a cert. If there is a 
check mark next to a name, that is a green light for the 
appointing authority to go ahead, offer the job, and make the 
appointment.
    Now, there is a lot that can happen before then, and that 
is the selection process. And whether or not those particular 
entities, such as the AO or any of the other positions that the 
tribe feels really interested in--I mean obviously they may not 
want to get involved in hiring housekeeping or maintenance or 
floor nurses; I do not know. But at least the key positions 
that really affect the overall operation of a hospital would be 
fair areas for consultation, bearing in mind that that process 
has to be an exchange, so that, when the selection is 
ultimately made, that is all communicated back. Bear in mind, 
too, the selection process in a Federal personnel system is a 
selection. It is not really final until the appointing 
authority does say, okay, this person can be appointed to this 
position. There may be some other things that occur, but that 
needs to be fed back if that particular person is not 
appointed.
    For example, if per chance, all of a sudden, somebody pops 
up on the OIG exclusion list, you are not supposed to hire 
those people. And we do not see that until the selecting 
official's decision is made. But those are the processes. But I 
think the most focus should be on the selection, and when, in 
the case of Mr. Old Elk, when he actually is going to sign the 
cert.
    The Chairman. Yes.
    Mr. McSwain. He selects somebody. How he does that is where 
the discussion should occur.
    The Chairman. What about if some people feel that there is 
insufficient examination in the ER of women who are sexually 
assaulted? It is not sufficient. It has not been done as much 
as it should. At least I have heard that charge. Does anybody 
want to address that?
    Mr. McSwain. My first response is, trained personnel. You 
need to have SANE and SART folks trained, Sexual Assault Nurse 
Examiners, Sexual Assault Response Teams, for example. I would 
defer to Mr. Old Elk if he--I know you are relatively new; I do 
not know if you have had any cases. But how that particular 
activity occurs--I know where you are going with the Tribal 
Order Act and the whole requirement that we actually assist. 
And I know that--I do not know if the kits are here, but maybe 
you can respond to that.
    Ms. Johnson. Can I make a comment?
    The Chairman. Yes, sure, I would like that. I like 
comments.
    Ms. Johnson. Okay. When we talk about funding, the budget 
that started this whole facility, the one budget that was left 
out was ER. There was no funding allowed for ER.
    The Chairman. That is when the facility was built?
    Ms. Johnson. When the facility was built in '94, '95. And 
so the entire budget for the hospital has had to carry that 
added burden.
    The Chairman. Why was ER not included? That seems pretty 
obvious to me.
    Ms. Johnson. That was before I was born. That was before my 
time, so I do not know why in the world they left that out, but 
that came to our attention. And so the burden is being carried. 
And so, therefore, we do not have sufficient staffing and 
people who would be adequately trained to--and the first place 
people go when they have that kind of an incident is the ER, 
and so that is why we do not have adequate personnel in that 
area.
    And then I just have two things I wanted to add. When it 
comes to finances----
    The Chairman. I am sorry, could you give your name, please?
    Ms. Johnson. Leanne Johnson.
    The Chairman. Okay.
    Ms. Johnson. And I am currently the Tribal Health Director. 
I am the Commission Corps Officer assigned to the tribe, and I 
have been there for 2 years so far.
    The Chairman. Thank you.
    Ms. Johnson. And the two things I just wanted you to think 
about as you go back and think about finances is that, first, 
we are inadequately funded at 50-some percent. And nothing says 
that IHS is the only one to provide us health services. There 
are other government entities such as NIH, CDC, other 
government entities, that could provide those health services, 
that could possibly meet that 100 percent if they were allowed 
to and brought in to meet that insufficient need. That would be 
really helpful, or just an idea I am throwing out there.
    The other one is also funding, possibly, for insurance for 
every tribal member. If there was any funding at all in a very 
good insurance that tribal members could have access to, to 
then get their health care----
    The Chairman. Now, are you talking about health care other 
than and in addition to IHS care?
    Ms. Johnson. Yes. They are not getting it here.
    The Chairman. Because IHS covers services that are provided 
here.
    Ms. Johnson. They cover services, but, as you well know, it 
is not 100 percent. There are no specialty services. And to 
also meet that 100 percent, if insurance was provided for every 
tribal member, they could go out and get the health care.
    The Chairman. Yes. Well, this raises a very, very difficult 
question. When Congress passed the health care bill, one big 
question was, what do we do about Indian health care? And most 
people felt at the time, well, IHS is just separate, we will 
just--we will not include the Native Americans within the 
health care bill, except to the degree that when Montana and/or 
the Feds set up exchanges, then anybody, including persons on 
or off reservation, can apply for health insurance under these 
exchanges, which are to go into effect in 2014. And there are 
credits, tax credits for those who are unable to afford to buy 
health insurance.
    But other than that, it is just--there is a big problem 
there. And I asked my staff frankly many, many times, what are 
we doing about the Native Americans in this health care bill? I 
could not get much traction because the other members of the 
Senate and the House just did not really--the president 
either--did not want to deal with Indian health, that whole 
part of the health care reform, in part because the Native 
Americans did not want to be included, because the tribes want 
to have their own health service, and IHS wanted to have its 
own health service. And there is just a conflict there with the 
two together.
    But I grant you are right, just as the Affordable Care Act 
does provide much more coverage, much more insurance for many, 
many more people, it should also include Native Americans to 
the same degree it includes everybody else, and I think it 
basically does. But still, as you say, it has to be insurance 
for specialized services that are not otherwise provided for 
here. I am no expert on that part.
    So are there any specialized services that Native Americans 
have covered, even though they are not covered by the actual 
hospital here? What if somebody here requires a service that is 
not provided here, like the appendectomy, as I mentioned 
earlier, so that person goes to Billings, and the appendectomy 
is performed there. To what degree does IHS pay that bill?
    Ms. White Crane. Can I say something?
    The Chairman. I am just asking the question. I do not know.
    Ms. White Crane. Can I say something?
    The Chairman. Yes.
    Ms. White Crane. I had my gallbladder removed, and I came 
here to Crow Hospital to try to get it removed. And I could not 
get it done here at Crow, even though they did have the 
facility to do it. I ended up having to do it in Billings at 
Billings Clinic. Now I am stuck with a $10,000 bill when it 
could have been done here.
    The Chairman. So that is the answer to the question.
    Ms. White Crane. Yes.
    The Chairman. IHS does not cover the gallbladder.
    Ms. White Crane. Yes, they did not do it. And we come from 
Billings, we ride the bus. Okay, we stand in line here. And the 
first ten people here are supposed to be seen. Well, they are 
not being seen, so everybody ends up going to the emergency 
room, and there is only one doctor back there; like right now 
it is full back there. So everybody needs to come together to 
help us as patients here.
    And as far as everybody wants money for this and wants 
money for that, it is about us people getting health care. And 
you guys are fighting, maybe you need to work together, because 
people like us, we are getting stuck with bills in Billings 
when it could be done here.
    The Chairman. If you had--I am just trying to get 
information here. If there were a surgeon here who could 
provide just basic general surgery--removal of a gallbladder is 
not that difficult.
    Ms. White Crane. No, it is not.
    The Chairman. And so, if there were a surgeon here who--why 
isn't there? Is it all money? But let me ask it this way: If 
there were a surgeon here who did gallbladder removal, then it 
is my understanding that that bill would be paid. You would not 
be charged if that service were provided here; is that correct?
    Ms. White Crane. It seems like it should be.
    The Chairman. I see heads nodding in the back indicating it 
is probably correct. Thank you.
    Well, that is all the more reason we need services here.
    Mr. McSwain. Well, you have hit on a fundamental question, 
and that is what you can provide here that you do not have to 
refer out.
    But I think it is important to point out that patients who 
wind up needing a gallbladder removed, unless they are 
referred, because, as you know, we have had CHS--our Contract 
Health Services hearings--about why it is we have to manage the 
way we do, and that is that we want to make sure there is a 
continuity of care--we are not an insurance company. So, if a 
patient is referred out and there is an authorization, we pay 
the bill. But if they simply just walk into a facility and they 
are not authorized--I have seen enough of the appeals that come 
in asking for payment, and, if it was not authorized, or if it 
was not priority--there is a set of regulations that govern the 
Contract Health Services program. And that is, you know, 
obviously, if you can provide the care here, you do not have to 
go and buy it.
    The biggest problem I know that Mr. Old Elk will face is, 
if he wants to put in surgery, he has to have some additional 
backup if anything goes wrong. And then, if you have to rush a 
patient out of here who has had a bad surgery that they 
discovered when they went in, then you have to transport them--
--
    The Chairman. Well, that would be authorized.
    Mr. McSwain. Yes, that would be authorized. But then, when 
you talk about, can we provide some of those services, it is 
just how much backup support really do you have in the facility 
to be able to support those services. Surgery is one, 
certainly, OB is another. Any time you get into the secondary 
services, you are going to have to have enough support to 
respond to a situation.
    The Chairman. Let me ask this lady here, though, what she 
did.
    Audience Speaker. She stepped out.
    The Chairman. Oh, she is gone. I was wondering where she 
tried to get her gallbladder removed. She could not get it done 
here if she wanted to----
    Mr. McSwain. No.
    The Chairman [continuing]. Because you do not provide it 
here. She had to get her gallbladder removed, and she is a 
member of the tribe presumably. So why was that not authorized?
    Mr. McSwain. I guess the other question, I would imagine, 
is, is she in the Contract Health Services delivery area?
    Mr. Old Elk. Yes, she is.
    Mr. McSwain. And if she is----
    Mr. Old Elk. There is an appeals process.
    Mr. McSwain [continuing]. There is a process.
    The Chairman. That would seem pretty automatic to me. If 
she is in the area and the service is not provided here, it 
seems to me that is an automatic authorization.
    Mr. Old Elk. Yes.
    Mr. McSwain. Well, if it is an emergency, yes, because----
    The Chairman. Sorry?
    Mr. McSwain. Because, really, as you heard us testify, the 
fact is that we are hovering at the life and limb level of care 
because of the CHS budget level. But with the increases, the 
40-percent increases from CHS, now we are talking about doing 
some prevention, paying for colonoscopies and the like. So the 
situation, this particular case, I would have to see it and 
look it at it.
    The Chairman. Sorry. Are we at life and limb position here 
now?
    Mr. McSwain. No. We were.
    The Chairman. Until when?
    Mr. McSwain. Until probably 2010. And then there was the 
big increase in 2010, and then we have had a series of 
increases since then. Because of the tribal priority on 
Contract Health Services, the Indian Health Service asked for 
increases in the Contract Health Services budget because we buy 
more care.
    The Chairman. Okay. Are any doctors in the audience here? 
Any M.D.s? Anybody? Are there any PAs, any other providers in 
the audience? Nurses, are there any nurses in the audience? 
Okay, we have one nurse.
    Ms. Wetsit. I did have a couple more back there; I do not 
know if they left.
    The Chairman. Okay. Your thoughts about all this. Let us 
talk about how some people provide services to patients. What 
are your thoughts about all this?
    Ms. Wetsit. My name is Diane Wetsit. I am the lady who took 
Mr. McSwain around and gave him the interview and the tour of 
the building.
    The Chairman. Yes.
    Ms. Wetsit. I have been listening to the comments. I have 
served here for the last 12 years. And I have watched in those 
12 years a number of leaders, like what the tribe just talked 
about, the various CEOs come and go.
    When Mr. Old Elk came on board, we were functioning over in 
Administration with myself and others as acting this and acting 
that, and acting over various times in the interim of our 
leadership. And it is very hard to maintain any kind of 
continuity of services when you have such a fluctuation in your 
leadership and your management teams.
    And so, with Mr. Old Elk coming on board, and us knowing 
that he is a permanent resident, and the chance of him going 
anywhere probably pretty minimal, that has raised the morale of 
this facility probably 10-fold, knowing that we have someone 
and we are going to have some stable leadership here.
    And what Mr. McSwain has talked about, as far as in the 
short period of time, the types of things that have been 
happening, one of them that is the key to this whole process to 
me is, you cannot provide health care if you do not have 
medical providers.
    The Chairman. Yes.
    Ms. Wetsit. And when we started moving toward various 
chains of leadership, and then we got hit with the flood, that 
really brought our health care system to its knees. And we, in 
that process, like what they have talked about, we stopped 
inpatient services, we stopped surgery, we stopped OB services, 
and we were down to having one provider to provide outpatient 
services, but usually we--10 years ago, we used to average 180 
patients in our outpatient area. We are lucky if we even hit 80 
to 90 patients in a day, because we do not have the health care 
providers.
    The other part is nurses. We have an extremely high vacancy 
rate in our nursing positions. If we start our OB services like 
what we are projecting to do, we are scrambling to try to 
figure out--we have two OB permanent providers here, and we 
need a minimum of four OB providers to provide accurate OB 
services. We have four OB nurses. We need eight. So where are 
we going to get these additional services? It is more than 
likely we are going to have to use money we do not have to 
contract those services.
    So that is just one portion. And when we do the OB 
services, we need to have surgery services. That is a given 
with the CMS accreditation standards. And so, you start looking 
at--it just goes from one to another, to this and to that with 
additional resources that we do not currently have.
    We have made the commitment to the tribe that we are going 
to have OB services. And our clinical director, Dr. Bates, who 
is not here, is working very hard toward recruiting additional 
providers. And he does have some--we are starting to work on 
that process, but definitely not moving fast enough. For the 
lady who stood here and said she needed to have gallbladder 
surgery, she is just one of so many others whom we are turning 
away because we do not have a surgeon.
    We had a surgeon here. He was a commissioned officer, and 
he retired on us. And that was last year, April. And he retired 
just when we went into the flood situation. So, for us to have 
surgery, definitely it would be great if we had a surgeon whom 
we could recruit.
    So we have identified a number of different issues and are 
slowly working with the governing body. And people such as 
myself are coming forward with our ideas, corrective actions, 
things that worked previously. But we took a very hard hit when 
we went through that flood, and then we lost a number of 
providers--not only medical providers, but we lost nurses as 
well, because we were not able to provide services. We did not 
have running water; I mean, there are a whole bunch of things 
that happened during that process.
    And so we have lost a number of, not only just services, 
but positions, providers, whatever. And we have--we are slowly 
working toward action plans to help address those issues. But 
again, as I am saying, it is not fast enough for everybody.
    The Chairman. All right. Thank you very much.
    Mr. Pretty On Top. Really quickly.
    The Chairman. Yes?
    Mr. Pretty On Top. Really quickly. You know, everything is 
connected here. The flood was a benchmark, devastating, 
catastrophic event, but the problems were there before the 
flood. That has to be on record also.
    The Chairman. All right. I have some ideas, but before I 
talk about that, other thoughts? Who wants to contribute here?
    Yes, sir.
    Mr. Half. Oliver Half, CEO of the Crow Tribe.
    I gave Richard my business card there, and I wrote on there 
we have a lot of veterans who are returning, starting from 
Desert Storm, Iraq, Iran, all the way down to Korea and so 
forth. We have an MOU in place for the VA to come over, and 
that would help facilitate some of the medical issues that 
occured in combat. And at one point I had been in contact with 
someone at the VA, Buck Richardson, you probably know Buck 
Richardson. Anyway, during our contacts and meetings, we had 
set some standards for PTSD counseling, some for bipolar issues 
due to combat.
    The Chairman. Right.
    Mr. Half. And we had made contact with the Sheridan VA, 
with Miles City, with Helena, and we were trying to bring some 
of the medical doctors over here to help the Crow hospital at 
one point. And then it fizzled out for some reason. But that is 
still there. So, I would like to----
    The Chairman. What docs is it? Is it VA doctors or what?
    Mr. Half. VA doctors, VA specialists; they were willing to 
come over here to help. They were even willing to bring a CAT 
scan, a portable CAT scan, within their rounds between Helena 
and Wyoming, and I thought that would have helped out over here 
if we could have utilized that for some of the patients here. 
But that did not work out, I do not know why. Maybe it was 
because we did not make our assertion for that service, I do 
not know.
    So I was wondering if we can maybe look into that.
    The Chairman. This is----
    Mr. Half. We do have a lot of insurance. And I was kind of 
hoping that Senator Tester was here, because I have had talks 
with him probably about 3 times.
    The Chairman. Yes. He has a representative here, so at some 
point she wants to read a statement. He is here in spirit.
    I would like other thoughts before I say something.
    Yes?
    Mr. Not Afraid. Welcome, Senator Baucus. Always a pleasure. 
Leroy Not Afraid, member of the Crow legislative branch, and 
also I am the Chairman of the Health and Human Services 
Committee. I represent the Apsaalooke or Lodge Grass District.
    I think one of the things that has not been mentioned today 
is dental care. I believe at this time, and I--my condolences 
to the CEO for the mess he came into; I mean, he has only been 
here 4\1/2\ months, and the wheels are turning. But, as stated 
earlier, we have a long ways to go.
    I believe at this time, for dental care, a lot of children 
and elderly have to wait for the October 1st fiscal year date 
for Contract Health Services to make referrals to specialists 
in Billings, because the money is gone; it is in the red. And 
the only way that folks can be treated in dental is through 
emergency care, extraction; there is hardly any preventive 
maintenance.
    I believe the dental department is down to one dentist, 
last I heard. One for the adults and one for children, when I 
believe earlier this year they had up to three dentists for the 
adults. So I believe that is an area of neglect.
    My other comment would be, Senator, the lady--I was in line 
with her this morning, my wife and I; we were in line with her. 
She was ahead of us by two persons. We stood in line since 6:30 
this morning, and by the time 8 o'clock rolled around and we 
were trying to see the IHS because of our own health, my 
childrens' health issues and my wife's, we were turned away; 
and that was this morning. The issues are very real. I mean, 
standing in line for an hour and a half and not having our 
treaty obligations by the United States being upheld is a 
problem.
    Now, my wife and I are fortunate to have health insurance, 
so now we have to take our business elsewhere. We want to keep 
our money here, but now we have to exercise our option to go to 
Hardin or Billings. It has always been my intent to keep our 
dollars here, but, if the doctors are not available on the 
immediate or on the short term, then we just--and we are not 
alone in this story. Our constituents are turned away on a 
daily basis. And I know our CEO is working hard to bring our 
doctor back, but it is a very real situation this Wednesday.
    Thank you, Senator.
    The Chairman. Thank you. I regret that there were no 
doctors here whom we could talk to; that would have been very 
helpful.
    Yes, sir.
    Mr. Kingfisher. My name is Quentin Kingfisher. I come from 
the Northern Cheyenne tribe.
    Some of our patient accounts are used to help fund the 
hospital here, and I just want to underscore everything that 
has been said here. But I just want to say that we want to be 
able to have a certain amount of certainty that our people are 
going to be served here continuously in addition to the 
problems that we are trying to solve here. And I want to offer 
my prayers to that end, that we will be able to come up with a 
workable solution that will help not only our people, because, 
in this conversation here, it is all about this tribe. But we 
do not want to be ignored as well, and our voice needs to be 
heard today. And I thank you for inviting us, and I will 
contact our people, and we will get a statement together too. 
Thank you.
    The Chairman. You are very, very welcome. Thank you.
    Mr. Black Eagle. Senator?
    The Chairman. Yes.
    Mr. Black Eagle. Senator Baucus, I would like to make a 
comment after listening to everybody's comments. You know, it 
all boils down to, I believe as a general comment, inadequate 
funding for Indian country in general, not just Crow-Northern 
Cheyenne, but across Indian country.
    Quite often in appropriations, we are put into a cookie-
cutter type of appropriation for Indian country. And one of the 
unique--every tribe is unique, and we are too. And you know, 
all of the treaties with the United States were mostly military 
up until Acts of Congress after May 7, 1868, when we ceded a 
lot of the 38 million acres of Wyoming and from Bozeman this 
way to make sure that Montana had the territory. And now a lot 
of ranchers and farmers enjoy that part of the country.
    And for those reasons and other reasons, and the treaties 
that we signed with the United States, there are obligations by 
the United States to provide that health care. And the 
inadequacy of funding comes from that, and we are probably--
native American people in this country, the first Americans, 
are categorized under the Interior Department, which is, as you 
know, the wildlife and parks, the national parks.
    When you look at that--I often look at that, because we are 
part of that. And I often wonder why we are designated under 
fish and wildlife in this country, when we should be under the 
State Department. And so, just a thought about when 
appropriations are set aside for Native Americans, it should be 
the State Department, because we have treaty obligations and we 
have made it possible for this country to become the United 
States.
    The Chairman. Yes, there is no doubt that that is true.
    Okay. I am going to have to say, the one point I want to 
make here is there is an election coming up, and some 
candidates for public office are more inclined to agree with 
you than some others. I need not say any more, except, vote for 
people whom you think will work for you more than people who 
are not going to work for you. You have to make that decision, 
whom you think is going to work more for you. And it is very 
important that you do that. You can only lead a horse to water. 
We are talking about appropriations here. You want to lead that 
horse to drink the right water and appropriate some dollars.
    All right. Before we wrap up here, though, I have something 
else that I want to suggest here. We have to find some 
solutions, and I am not sure just exactly what the best 
approach is, so here is what I am suggesting. I would like the 
tribe to come up with a list of three or four or five 
categories that need to be addressed. Maybe it is dialysis, 
maybe it is OB-GYN; I do not know what it is, but four, five, 
six things. Maybe it is a process issue, like consultation on a 
certain number of areas. Then I would like IHS to do the same 
thing. Where does the IHS think it can make improvements? I 
would like both to try; IHS to reference that CMS survey and 
identify which recommendations you think make sense, are 
appropriate, and which ones may be off-base. And I would like 
to get that from you, say, what is today? This is the 8th or 
9th of August, something like that; let us say it is a couple 
months. Is that fair? Two months?
    Mr. Pretty On Top. Fine.
    Mr. Black Eagle. Yes.
    The Chairman. This is August.
    Mr. Pretty On Top. Before elections?
    The Chairman. Before the elections? No, it does not make 
much difference to me about that. But let us say by the end of 
November, November 30th.
    And then I am going to look at that--and I want you also to 
be thinking about benchmarks. Like what criteria we can agree 
to use to indicate what will make it a success here. That is, 
how many doctors are there here today, and is the number of 
doctors a good sort of benchmark say a year from now. If we 
have three or four doctors today, is that right, maybe let us 
see how many doctors we have one year from now. If we have how 
many nurses, let us see how many nurses we have a year from 
now. Get these various categories that will be good health 
indicators; doctors and nurses is one. What do we have--
dialysis might be another--a year from now?
    Mr. Black Eagle. Dental?
    The Chairman. Dental could be another.
    Mr. Jefferson. Behavioral health?
    The Chairman. Behavioral and mental health. We need some 
criteria here like how many patients we have seen, so that a 
year from now we can benchmark it and see what progress we have 
made in each of these areas.
    And, in developing these lists, I would like you to work 
with me and my staff, and we can talk about this every month to 
make sure we are doing all this.
    This is the area of follow-up and making sure we are 
actually doing something, not just talking.
    Yes, do you have an idea?
    Ms. Schildt. Yes. Actually I am an IHS certified trainer. 
My name is Sandy Schildt. I am from the Blackfeet Reservation. 
And I wanted to come to this because--thank God for Facebook. I 
saw this was happening, so I drove down last night. And my 
thing is, I have been writing reports assessing our Indian 
hospitals and clinics, whether it is tribal or IHS. And, when I 
send in my reports to the Area Director, there is no effective 
response. So I am just saying I really, truly believe our 
tribes need to get more involved, because we are losing, and 
there is no one to protect us. I sent the same letter to Dr. 
Roubideaux, to President Obama, to the Center for Indian 
Affairs; and it is hard to reach people. And so, it is just a 
big battle. It is bad with a lot of issues, but health care is 
a major one.
    So we actually face the same problems as the Crow and the 
Northern Cheyenne, and I would just like to say, I hope we get 
to start having more input. And like what you guys want to do, 
Mr. Pretty On Top, I really believe we need more input, because 
I have been writing letters since 2008. No effective response, 
period.
    The Chairman. Right.
    Ms. Schildt. And so I just--I drove down here from 
Browning. I am glad to sit here and listen, because it is the 
same issues.
    The Chairman. I was going to ask that question. How is 
Browning? I want to ask you that question: is it any different 
from Crow?
    Ms. Schildt. No, it is the same exact issues. Of course we 
have a pill epidemic. We have major problems, and the lack of 
funding.
    And actually in the letter I wrote to the Area Director 
were the solutions that were at our fingertips. So I do not 
understand why it is not acted on. That is why I think we need 
the tribes to become involved in that.
    The Chairman. Right.
    Ms. Schildt. And it is at our fingertips; there is no 
reason it should go on for another 5 years.
    The Chairman. Well, I thank you for that. There is no 
question in my mind that tribes should become much more 
involved in decisions made by, not just IHS, but other agencies 
that affect the Native Americans.
    The BIA for example, I just think a lot more should be 
delegated to the tribes. Tribes should make a lot more 
decisions themselves, be much more fully consulted, because 
they know what is going on. You know, they are here, the 
agencies are there, so we need much more of that.
    And what I would like you to do, Mr. Chairman, Ms.--I am 
sorry, I did not get your name.
    Ms. Schildt. Sandy.
    The Chairman. Sandy----
    Ms. Schildt. Schildt.
    The Chairman. Oh, Cheyenne. You are correct in asking IHS 
for something, and, if you do not get a response, let me know 
so we can----
    Ms. Schildt. Actually, I wrote your office twice with the 
same letter. I wrote to the Governor, I wrote to International 
Affairs, I wrote to Congress. I wrote to every chain of command 
to make a difference, because, you know, I hear ``lack of 
funding'' a lot.
    The Chairman. Yes.
    Ms. Schildt. That is so true. But the reason we have lack 
of funding is, if we had the solutions that I was writing--I 
was trained in IHS, why do we ignore that?
    The Chairman. Right.
    Ms. Schildt. So how do I reach you?
    The Chairman. How do you reach me? I will tell you right 
now.
    Ms. Schildt. Okay, good. Thank you for listening. And I am 
sorry; I did not want to embarrass you.
    The Chairman. That's okay.
    Ms. Schildt. It is just--I am just trying to get the point 
across.
    The Chairman. I admire you for driving all the way down 
here from Browning to come here to this.
    Ms. Schildt. It is a long drive.
    The Chairman. That says a lot; that is a long distance.
    Okay. Here is the best way to reach me; there are two ways, 
a lot of ways. One is just to call me up, and I will give you 
my telephone number.
    Ms. Schildt. Can I ask you, are you going to come to all 
reservations? Like, will you be coming to Blackfeet Country 
or----
    The Chairman. No, I do not have other tribes on my schedule 
at this point.
    Here is another way to reach me: I'll give you my personal, 
private e-mail. It is not my office e-mail, it is my personal, 
private e-mail; it goes only to me.
    If you write to that e-mail address, and you get no 
response, there is only one person to blame, me, because that 
goes only to me. Now when I get e-mails, I will respond, but I 
may also have somebody like Richard or Kelly get back to you.
    But I encourage all of you: do not forget, you are all my 
employers. I am just a hired hand; I work for all of you. So it 
is important that you tell me what you need and what you want 
so I can do a better job. And I try to do as good as I can 
anyway, but I can still do an even better job the more I hear 
from you.
    And I know this is tough--resources, money, it is a huge 
part of this. I will do what I can. But I think we may be able 
to better work on some of these resource issues the more we 
also work on these criteria, these benchmarks, and these 
categories.
    Another category is obesity. I mean, there is diabetes. I 
am sure that is going to be something: number of diabetics 
treated, and trying to get it down. That is probably another 
category we are going to have to work on.
    But I am serious about this. Let's get going here. And I 
think a lot of people otherwise are kind of cynical. Well gee, 
we had this nice hearing, all this and that, and not much 
really happens. Well I am determined something is going to 
happen, but I might be leaning on you guys and gals. I will 
make it happen. Okay?
    I would like Richard to stand, Richard and Kelly, quickly. 
You all know Richard; Richard is one of our top guys. And Kelly 
is one of my health care people. So kind of get to know them; 
they are really good.
    Okay. Now I also--Rachel, do you want to say something for 
Jon?
    Ms. Court. Yes, thank you.
    The Chairman. This is Rachel Court, everybody, who works 
for our Senator, Jon Tester.
    Ms. Court. Thank you. Thank you, Senator Baucus.
    I am Regional Director out of Billings. And I know most of 
you, growing up in Hardin, and so it is nice to be here in Crow 
Country, as always, for me.
    And this is just a message from Jon. I know you are hungry, 
so I am going to hurry up and say it and be done.
    He says, ``Thank you for inviting me to share a few words, 
and thank you for bringing attention to an important issue that 
we all work on: health care access in Indian country. Indian 
country has unique challenges when it comes to health care. 
That is why I have twice brought folks from Washington to 
Montana to talk specifically about improving health care for 
Montana's Native population, both on and off the reservation. 
That is why I have voted for the Affordable Care Act that 
permanently reauthorizes the Indian Health Care Improvement 
Act, a bill that I was proud to cosponsor. That landmark bill 
modernizes services delivery in Indian country, expands funding 
for IHS, and brings Native American health care closer in line 
with the rest of the country. I will continue working to 
improve access to care in Indian country until everyone has 
access to quality health care. Thanks again, and please keep in 
touch. Respectfully, your Senator, Jon Tester.''
    The Chairman. Thank you, Rachel. Thank you, Jon, for that 
statement.
    Now what I am doing here with the Crow is also going to be 
the same with the Blackfeet and all Montana tribes. So now I 
have to figure out a way to get to them so they do the same as 
you. But you will do the same for all, right?
    Mr. McSwain. Right.
    The Chairman. Okay, all Montana tribes.
    Mr. McSwain. True.
    Ms. Schildt. So----
    The Chairman. And I--sorry.
    Ms. Schildt. So how soon will the tribes start working to 
make decisions on selections with IHS?
    The Chairman. Well----
    Ms. Schildt. What is the first step? What do we have to do 
so it does not go on?
    The Chairman. First of all--well, two things. First I want 
the list from each of the tribes. And, if selection is one of 
the most important matters, then that tribe will put that on 
the list.
    But in addition, things are going to come up from time to 
time that are not anticipated, and we will just have to deal 
with those, like selection. It may not be on the list, but 
there is a selection issue. We will just have to deal with it.
    But I am asking you first for the list--not a long list, no 
more than a half-dozen items; obviously the most important 
half-dozen items.
    And then you, Mr. McSwain, I would just ask you to do the 
same. From your perspective, what better health care is needed, 
and what needs to be done. That would be great too.
    So by November 30th, and what is the best address?
    Ms. O'Loughlin. We can send a follow-up letter.
    The Chairman. Well, we will send a follow-up letter to Mr. 
Chairman and Mr. McSwain and to the other tribes, and follow up 
on it.
    This is going to be--we are going to make a difference 
here. Okay, I have nothing else to add.
    Does anybody else want to say something in response to 
something that was said? Did somebody say anything outrageous 
that needs to be addressed?
    Mr. Black Eagle. Just maybe some closing remarks.
    The Chairman. Okay, thank you, Mr. Chairman.
    Mr. Black Eagle. Thank you, Senator Baucus, for taking the 
time to be here and also the guests who are here. And I also 
want to thank IHS, the CEO and AOO and the rest of the staff 
who are here who made it possible to have this Senate hearing 
here. And, again, we are really honored.
    The Chairman. You bet, Mr. Chairman. Everything is teamwork 
and partnership. Nothing of consequence is ever accomplished by 
somebody trying to do something alone. It is all teamwork, it 
is all partnership, and we are all here working together. And I 
just urge us to keep open minds, keep working. We are going to 
make some headway here.
    Thank you, everybody.
    Audience Speaker. Hello?
    The Chairman. The hearing is adjourned.
    Audience Speaker. Can I say something before you leave?
    The Chairman. Oh yes, sure. Go ahead. I am sorry, I did not 
see you.
    Audience Speaker. I am from the Northern Cheyenne 
Reservation.
    The Chairman. Yes.
    Audience Speaker. And it seems none of the representatives 
from the clinic are here, but anyway I think the ladies' clinic 
needs to be addressed in terms of their decisions. I personally 
do not go there because of the quality of--I mean the medical 
professionals who deal with patients in Lame Deer. It is like, 
when people go there for medical reasons, they have to stay 
there, as the one gentleman says, all day long. And then some 
of them just leave. And also on the basis of diagnoses, they do 
not seem to have physicians there who specialize in certain 
areas like they do on the outside, like some people specialize 
in certain fields. It is just more like they are country 
doctors with a black bag with aspirins and Tylenol and such.
    But maybe, somewhere along the line, they can address the 
Lame Deer IHS, because a lot of people have gone there who have 
been misdiagnosed by giving them painkillers, which eventually 
led to, I hate to say it, but a lot of people have died from 
being misdiagnosed.
    The Chairman. Yes, it happens.
    Audience Speaker. So I was wondering, something along the 
line of just IHS----
    The Chairman. Another thought I had is, frankly, this is 
long-term, but trying to help figure out ways to get local kids 
excited about pursuing a medical career. Maybe a doctor, maybe 
a nurse, maybe something so they are more likely to want to, 
after they receive their training, come back and live here. And 
what I just suggest is that the tribes--it is a presumptuous 
suggestion--maybe some way put in place incentives in school to 
get kids interested in medicine. Again, it could be a nurse, or 
physician's assistant, or maybe a doctor, just something so 
they go away for training, and, boy, they can hardly wait to 
come back home and serve the people.
    Audience Speaker. Maybe with all this talk about the 
funding, they can have funding to hire qualified physicians so 
there will not be all these problems.
    The Chairman. Okay. Thanks everybody for taking the time. 
We are going to work together. Use that address, that telephone 
number, and work together. Thank you, everybody.
    The hearing is adjourned.
    [Whereupon, at 1:30 p.m., the hearing was concluded.]


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