[Senate Hearing 113-327]
[From the U.S. Government Publishing Office]






                                                        S. Hrg. 113-327

      THE PRESIDENT'S FISCAL YEAR 2015 BUDGET FOR TRIBAL PROGRAMS

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

                                HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 26, 2014

                               __________

         Printed for the use of the Committee on Indian Affairs





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                      COMMITTEE ON INDIAN AFFAIRS

                     JON TESTER, Montana, Chairman
                 JOHN BARRASSO, Wyoming, Vice Chairman
TIM JOHNSON, South Dakota            JOHN McCAIN, Arizona
MARIA CANTWELL, Washington           LISA MURKOWSKI, Alaska
TOM UDALL, New Mexico                JOHN HOEVEN, North Dakota
AL FRANKEN, Minnesota                MIKE CRAPO, Idaho
MARK BEGICH, Alaska                  DEB FISCHER, Nebraska
BRIAN SCHATZ, Hawaii
HEIDI HEITKAMP, North Dakota
        Mary J. Pavel, Majority Staff Director and Chief Counsel
              Rhonda Harjo, Minority Deputy Chief Counsel





















                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on March 26, 2014...................................     1
Statement of Senator Barrasso....................................    22
Statement of Senator Begich......................................    19
Statement of Senator Johnson.....................................    14
Statement of Senator Murkowski...................................    24
Statement of Senator Tester......................................     1
Statement of Senator Udall.......................................    16
    Prepared statement...........................................    17

                               Witnesses

Joseph, Jr., Hon. Andrew, Member-At-Large/Portland Area 
  Representative, National Indian Health Board; Chair, Northwest 
  Portland Area Indian Health Board..............................    64
    Prepared statement...........................................    65
Payment, Aaron, Midwest Area Vice President, National Congress of 
  American Indians; Chairman, Sault Ste. Marie Tribe of Chippewa 
  Indians........................................................    32
    Prepared statement...........................................    35
Roubideaux, Hon. Yvette, M.D., M.P.H., Acting Director, Indian 
  Health Service, U.S. Department of Health and Human Services...     8
    Prepared statement...........................................     9
Washburn, Hon. Kevin, Assistant Secretary--Indian Affairs, U.S. 
  Department of the Interior.....................................     2
    Prepared statement...........................................     4

                                Appendix

National Indian Child Welfare Association (NICWA), prepared 
  statement......................................................    87
National Indian Education Association (NIEA), prepared statement.    92
Native Hawaiian Education Council, prepared statement............    85
Patterson, Hon. Brian, President, United South and Eastern 
  Tribes, Inc., prepared statement...............................    78
Yazzie, Albert A., President, Crystal Boarding School Board of 
  Education, prepared statement..................................    77

 
      THE PRESIDENT'S FISCAL YEAR 2015 BUDGET FOR TRIBAL PROGRAMS

                              ----------                              


                       WEDNESDAY, MARCH 26, 2014


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:56 p.m. in room 
628, Dirksen Senate Office Building, Hon. Jon Tester, 
Chairman of the Committee, presiding.

             OPENING STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    The Chairman. We will call this hearing to order on the 
President's Fiscal Year 2015 Budget for Tribal Programs.
    I want to welcome the two witnesses for this panel and also 
the witnesses for the next panel.
    We will be holding this Oversight Committee while there are 
votes happening on the Floor right now. I honestly do not know 
how that will impact the membership attending this hearing but 
we will have questions as we move forward.
    The President's request for Indian Affairs and the 
Department of Interior is $2.6 billion, an increase of $33.6 
million over fiscal year 2014. The Indian Health Service budget 
was increased by $199 million to $4.6 billion.
    Although these proposed increases are encouraging, we must 
also acknowledge that these are harsh financial times. Tribes 
have not recovered from sequestration which resulted in across 
the board cuts to all Federal programs, including those 
affecting tribes and nowhere was this more devastating than the 
Indian Health Service where due to sequestration, continuing 
resolutions and a 16-day government shutdown, health care to 
Indian people was jeopardized.
    That is why today and next week, the Committee is going to 
talk about securing advanced appropriations for the Indian 
Health Service. The delivery of health care to Indian people 
should not be threatened because those of us who serve in 
Washington cannot get our act together, prepare, and pass a 
budget.
    There is a bill now pending in Committee, S. 1570, that 
would provide advance funding for the Indian Health Service. 
This bill is tailored after a bill Congress enacted to advance 
funding for the Veterans Administration system in 2009. I look 
forward to working with my colleagues on both sides of the 
aisle and the Administration on making this initiative a 
reality.
    Despite the budgetary constraints that we face, there are 
some positive highlights in the President's fiscal year 2015 
budget request. The Committee is pleased that the 
Administration finally understands the legal obligation to 
fully fund contract support costs for both the Indian Health 
Service and the Bureau of Indian Affairs.
    I am particularly encouraged by the $11 million increase 
for social services and job training to support an initiative 
to provide a comprehensive and integrated approach to address 
violence, poverty and substance abuse in Indian Country.
    As we learned from Dr. Costello, who testified at our early 
childhood development hearing last month, we can either pay now 
or we pay later, but we are going to pay. I think it is much 
wiser to invest in preventive services today than pay for a 
lifetime of treatment and remedial assistance later.
    However, there are some areas that may not be receiving the 
attention they deserve. For tribal communities to thrive now 
and into the future, there must be economic development 
opportunities and an educated workforce.
    My colleagues and I have heard in numerous Committee 
meetings of the poor conditions at many of the BIA schools. Yet 
again, the BIA has only requested enough funding to do the site 
development to construct one of three schools that remain on 
the 2004 school construction list. In addition to that list, 
there are another 60 schools considered in poor condition.
    Finally, I am very concerned with the Administration's 
request for drinking water and sanitation construction. There 
is more than a $3 billion backlog in drinking water and 
sanitation construction needs in Indian Country. However, 
across all Federal agencies, including the EPA, the 
Administration is only requesting $173 million to address 
drinking water and sanitation needs in Indian Country.
    Senator Barrasso obviously is not here. When he gets here, 
opening statements will certainly be open to him. I am going to 
move with the panel.
    On our first panel is the Honorable Kevin Washburn, 
Assistant Secretary, Indians Affairs, U.S. Department of the 
Interior and the Honorable Yvette Roubideaux, Acting Director, 
Indian Health Service, U.S. Department of Health and Human 
Services.
    Your entire written testimony will be made a part of the 
record. I would ask that you be as close to five minutes as you 
possibly can. That way, there will be enough time for me to ask 
questions.
    With that, we will start with you, Secretary Washburn.

          STATEMENT OF HON. KEVIN WASHBURN, ASSISTANT 
       SECRETARY--INDIAN AFFAIRS, U.S. DEPARTMENT OF THE 
                            INTERIOR

    Mr. Washburn. Thank you, Chairman Tester.
    Let me say the Secretary very much enjoyed her recent visit 
to Montana. I heard wonderful stories about it.
    The Chairman. Don't believe them.
    [Laughter.]
    Mr. Washburn. It is really important for her to get 
firsthand experience and she really enjoyed it.
    The Chairman. It was a great trip and we appreciate the 
time she spent in Montana visiting Indian Country, water 
projects, conservation projects and energy projects around the 
State of Montana. Thank you.
    Mr. Washburn. Larry Roberts is with me, the Deputy 
Assistant Secretary who was on that trip and Pam Hayes, another 
Deputy Assistant Secretary. Two Deputy Assistant Secretaries 
are useless unless you have three so we have Tommy Thompson 
here as well. They come in threes, so we are well staffed.
    The Chairman. We appreciate them.
    Mr. Washburn. The budget that we propose for Indian Affairs 
this year is best characterized as a responsible budget. We 
understand there is not dancing in the streets, but we also 
understand there are serious budget caps here on the Hill with 
the Murray-Ryan budget cap. We have promised to live within 
that so the budget we propose fits within the Murray-Ryan cap.
    It includes the $33 million increase, new money, for Indian 
Affairs and also $42 million, new money, for fire in the 
Department's overall budget. There is a nice increase for 
tribes in this budget even though it is a very flat budget year 
and a very strict fiscal environment.
    We do propose to fully fund contract support costs. We know 
that contract support costs are necessary for tribes to be able 
to really perform under their self governance compacts and 
their self determination contracts, so we have fully funded 
them for fiscal year 2014 and propose full funding for fiscal 
year 2015. We are grateful for the leadership of this Committee 
on that issue.
    We also propose a new approach to social services which you 
recognized in your opening statement. The Tiwahe Initiative 
which is sort of a double entendre, the idea is that we need to 
be serving families.
    Tiwahe is the Lakota word for family. The idea is we need 
to be bringing our services together more around serving 
families rather than leaving them in silos serving individuals. 
That program will help with social services.
    We have social workers running from crisis to crisis in 
Indian Country. In part through people on this Committee, 
Senators Hoeven and Heitkamp, we have seen some of the serious 
problems that these social workers face when they are under 
staffed and overworked.
    That money will basically go in large measure to provide 
more money for social workers to help get ahead of problems 
instead of being reactive all the time and just going from 
crisis to crisis.
    That is one of our initiatives we really think can improve 
things. We can all work together within the BIA and function 
more like a family ourselves. We think that will be an 
improvement.
    As part of that initiative, we have asked for funding for a 
housing improvement program, something we have talked about 
zeroing out in the past but we heard from tribes that is a real 
important part of their social services. We heard loud and 
clear they want us to keep the funding for the housing 
improvement program so we have asked for funding for that for 
fiscal year 2015.
    We have several other programs. One of them is somewhat 
involved with the Tiwahe Initiative is we have embarked on a 
program that would continue into 2015 that will reduce 
recidivism in Indian Country.
    Our chief law enforcement officer with the BIA tells me 
that we have several people in Indian Country who are serving 
life sentences a couple of days at a time because they 
committed some very minor offense and they get locked up for a 
couple of days and get out only to commit another offense soon 
thereafter.
    We are going to work on trying to reduce recidivism in 
Indian Country and especially try to provide services to people 
suffering those kinds of issues.
    Those are two of the biggest things, contract support costs 
and the Tiwahe Initiative. We have some modest increases in 
other areas. It is a fairly flat budget though. We are trying 
to improve but we are also trying to stay within the Murray-
Ryan cap.
    The Obama Administration has worked very hard to improve 
the Nation's commitment to Indian Country and we do think this 
budget continues that commitment. We thank you, Senator Tester, 
and this Committee for being such an important ally in that 
mission.
    Thank you very much.
    [The prepared statement of Mr. Washburn follows:]

Prepared Statement of Hon. Kevin Washburn, Assistant Secretary--Indian 
                Affairs, U.S. Department of the Interior
    Good afternoon, Chairman Tester, Vice Chairman Barrasso, and 
members of the Committee. Thank you for the opportunity to provide a 
statement on behalf of the Department of the Interior (Department) on 
the President's Budget Request for Fiscal Year (FY) 2015 that was 
presented to Congress on March 4, 2014. The FY 2015 budget request for 
Indian Affairs programs within the Department totals $2.6 billion, 
which is $33.6 million more than the FY 2014 enacted level.
    As the Assistant Secretary for Indian Affairs, I have the 
responsibility to oversee the numerous programs within the Bureau of 
Indian Affairs (BIA) and the Bureau of Indian Education (BIE), along 
with other programs within the immediate Office of the Assistant 
Secretary for Indian Affairs. The Office of the Assistant Secretary for 
Indian Affairs, BIA, and BIE programs expend over 90 percent of 
appropriated funds at the local level. Of this amount, over 62 percent 
of the appropriations are provided directly to Tribes and tribal 
organizations through grants, contracts, and compacts for Tribes to 
operate government programs and schools. In sum, tribal self-
determination and self-governance programs have eclipsed direct service 
by the BIA and BIE to Indian people. Indian Affairs' programs serve the 
more than 2.0 million American Indian and Alaska Natives living on or 
near Indian reservations.
    The FY 2015 President's Request supports continuing efforts to 
advance self-governance and self-determination, promote efficient and 
effective governance, prudently manage tribal natural resources, build 
stronger economies and self-sufficiency and maintain safer Indian 
communities. In November 2013, President Obama hosted the fifth annual 
White House Tribal Nations Conference. The event included thirteen 
Cabinet members and dozens of senior Administration officials who met 
with representatives from the 566 federally recognized Tribes on a wide 
range of issues including advancing the Nation to Nation relationship, 
economic development, housing, excellence in education, energy, 
infrastructure, law enforcement, cultural protection, natural 
resources, and Native American youth.
    Our funding priorities are guided, in part, by careful coordination 
with Tribes through a regional-to-national planning process through the 
Tribal Interior Budget Council. In addition, input from tribal leaders 
gained since the first White House Tribal Nations Conference has helped 
guide the Administration's priorities and decisionmaking processes. 
These and other sources of tribal input have informed legislative and 
programmatic initiatives and funding priorities in the 2015 budget, 
including full funding for contract support costs.
    To insure the continued success of tribal self-determination and 
self-governance, the 2015 President's budget request proposes to 
continue full funding for contract support costs. It includes a request 
for $251.0 million, an increase of $4.0 million above the 2014 enacted 
level. Based on the most recent analysis, the requested amount will 
fully fund the estimated 2015 contract support need. The availability 
of contract support cost funding is a key factor in tribal decisions to 
assume responsibility for operating Federal programs, furthering tribal 
self-determination and self-governance. The Interior Department fully 
funded estimated contract support costs in 2014. The Bureau of Indian 
Affairs will continue to consult with Tribes to develop streamlined 
mechanisms and a long-term approach to advancing these shared goals.
    To further enhance the Nation-to-Nation relationship, Indian 
Affairs is continuing its comprehensive look at the regulations 
addressing how Indian groups apply for and receive Federal recognition 
as an Indian Tribe. The Department is reviewing comments recently 
received and plans to proceed with a proposed rule for publication in 
the Federal Register. After another round of consultations and a formal 
comment period, Indian Affairs plans to publish the final rule in 2014 
or early 2015. In addition, the 2015 budget proposes language to 
clarify the Department's authority to take Indian land into trust and 
amend the Indian Reorganization Act of 1934, thereby reducing 
significant delays in processing land into trust applications
Supporting Indian Families and Protecting Indian Country
    Supporting Indian families and ensuring public safety are top 
priorities for the President and tribal leaders. As part of the 
President's commitment to protect and promote the development of 
prosperous tribal communities, BIA proposes the Tiwahe Initiative, a 
new effort to support community and cultural awareness in Indian 
Country. Child abuse and neglect are serious and persistent problems 
among Indian populations in the United States. The impact of child 
maltreatment in many Indian communities has been devastating. It has 
disrupted extended family support networks and broken up families 
through placements outside the community.
    Children living in poverty are far more likely to be exposed to 
violence and psychological trauma, both at home and in the surrounding 
community. Indian communities are plagued by high rates of poverty, 
substance abuse, suicide, and violent crime. The U.S. Census Bureau 
recently reported that between the years 2007 and 2011, 23.9 percent of 
the American Indian and Alaska Native population lived in poverty; a 
figure that exceeded the national poverty rate of 14.3 percent.
    The 2015 budget includes a comprehensive and integrated approach to 
the interrelated problems of poverty, violence, and substance abuse 
faced by Indian communities. The proposed increase of $11.6 million for 
social services, child welfare and job training programs will support 
the initiative by providing culturally appropriate services with the 
goal of empowering individuals and families through health promotion, 
family stability, and strengthening tribal communities as a whole. In 
its initial phase, the Tiwahe Initiative will expand BIA's capacity in 
current programs that address Indian children and family issues and job 
training needs.
    To promote public safety and community resilience in Indian 
communities, the 2015 budget maintains resources to build on recent 
successes in reducing violent crime and implements a new goal to lower 
repeat incarceration in Indian Country. The goal of the pilot program 
is to lower rates of repeat incarceration at the three targeted 
reservations of Red Lake, Ute Mountain, and Duck Valley by a total of 
three percent by September 30, 2015. To achieve this goal, BIA will 
implement a comprehensive ``alternatives to incarceration'' strategy, 
that seeks to address underlying causes of repeat offenses, including 
substance abuse and social services needs, by utilizing alternative 
courts, increased treatment opportunities, probation programs, and 
interagency and intergovernmental partnerships with tribal, Federal, 
and State stakeholders.
Supporting Sustainable Stewardship of Trust Resources
    The BIA's trust programs assist Tribes in the management, 
development, and protection of Indian trust land and natural resources 
on 55 million surface acres and 57 million acres of subsurface mineral 
estates. These programs assist tribal landowners in optimizing the 
sustainable stewardship and use of resources, providing many benefits 
such as revenue, jobs, and the protection of cultural, spiritual, and 
traditional resources.
    Taking land into trust is one of the most important functions 
Interior undertakes on behalf of Indian Tribes. Homelands are essential 
to the health, safety, social, cultural, and economic welfare of tribal 
governments. In 2013, Interior acquired 32,148 acres of land in trust 
on behalf of Indian Tribes and individuals and approved 438 fee-to-
trust applications. The Administration has set an ambitious goal of 
placing more than 500,000 acres of land into trust by the end of the 
Obama Administration. To that end, BIA has processed more than 1,500 
land-into-trust applications, accepting more than 240,500 acres in 
trust on behalf of Tribes since 2009. To put that in context, that 
figure equals more than 375 square miles. The BIA intends to build on 
this progress to meet or exceed the 500,000 acre goal.
    The BIA is striving to increase the economic utilization of Indian 
lands. In addition to implementing the Helping Expedite Responsible 
Tribal Homeownership Act provisions for tribal leasing approval, Indian 
Affairs continues to implement other new Federal leasing regulations 
finalized in early 2013. The updated regulations encourage and 
accelerate economic development in Indian Country. The revised 
regulations reformed the former antiquated, one-size-fits-all Federal 
surface leasing regulations for Tribes and individual Indians. The rule 
defines specific processes, with enforceable timelines, through which 
BIA must review leases and permits. The regulation establishes 
separate, simplified processes for residential, business, and renewable 
energy development, so that, for example, a lease for a single family 
home is distinguished from a large solar energy project.
    The 2015 budget will continue funding resource stewardship with 
expanded science and technical support started in 2014, including 
research, analysis, and technical support activities for the 
development of alternative and conventional energy sources, sustainable 
management of natural resources such as land, water, oceans, endangered 
and invasive species, and climate adaptation and resilience. In 
addition, the Indian Affairs budget proposes $35.7 million for Indian 
land and water settlements in the 2015 budget, which is equal to the 
2014 enacted level.
Advancing Indian Education
    Native American youth are the most precious resource of any Tribe, 
and educating our youth is vital to the well-being of Indian Country. 
The 2015 budget request for the Bureau of Indian Education is $794.4 
million, $5.6 million above the 2014 enacted level. Included within 
this funding request are programs that will advance the Department's 
continuing commitment to American Indian education.
    A thriving educational system for American Indian students is 
essential for the long-term health and vitality of Native American 
communities and is a critical component of the broader initiative to 
strengthen tribal communities. In 2013, Secretary Jewell and Secretary 
of Education Arne Duncan convened an American Indian Education Study 
Group to address needed reforms to American Indian elementary and 
secondary education and seek higher levels of academic achievement.
    The Study Group is overseen by myself, as Assistant Secretary for 
Indian Affairs, and includes representatives from BIE, Department of 
Education, leading academics, and Department of Defense educational 
system. Foundational issues the group is evaluating include: the 
creation of a relevant curriculum; the need for retention and 
recruitment of effective teachers; the application of appropriate 
teaching practices; and addressing the student achievement gap. The 
work will be done in concert with President Obama's initiative to 
support tribal self-determination. The group has traveled the Country 
to listen to BIE and tribal school employees, parents, and students 
directly impacted by the BIE system. They will conduct tribal 
consultations to gather tribal views and input on recommendations for 
improving educational outcomes in schools. The President's budget 
proposes to include Indian education in the Opportunity, Growth and 
Security Fund. The Fund would support incentives to promote 
improvements in educational outcomes at schools funded through the 
Bureau of Indian Education.
Land Buy-Back Program for Tribal Nations
    Throughout 2013, the Land Buy-Back Program continued to implement 
the land consolidation portion of the Cobell Settlement Agreement. In 
the Settlement, $1.9 billion was set aside to consolidate fractionated 
ownership of land interests held in trust or restricted status across 
Indian Country. Under the terms of the Settlement, the Department of 
the Interior has until November 2022 to expend the funding to acquire 
fractional interests at fair market value from willing sellers. 
Fractionation has been identified as a key impediment to economic 
development and is a significant factor in the complexity and cost of 
managing the Indian Trust. Lands acquired through the program will 
remain in trust or restricted status and are immediately consolidated 
for beneficial use by the tribal nation with jurisdiction. Some of the 
beneficial uses of consolidated land include energy development, 
farming, cultural preservation, and timbering.
    In December 2013, the Department made initial purchase offers for 
fractional interests at three locations: Pine Ridge Reservation, Makah 
Indian Reservation, and Rosebud Reservation. In 2014, the Land Buy-Back 
Program has extended offers to additional individual owners with 
fractional interests at these locations and will send offers to owners 
at other locations. Purchasing interests at fair market value from 
willing sellers ultimately strengthens tribal sovereignty by increasing 
tribal land bases. As a result of Buy-Back offers, tens of thousands of 
acres have been consolidated and millions of dollars in payments have 
gone to willing sellers. The program is focusing on the most 
fractionated locations and using a detailed mass appraisal method where 
feasible to achieve the most cost-effective acquisition of fractional 
interests.
Other Bureau funding in the Department
    As this Committee is aware, all the departments within the 
Executive Branch of our Federal Government potentially have at least 
one or more bureaus or programs that provide funding in support of 
Native Americans and Tribes. The Department of the Interior 
(Department) is no different. The Department's FY 2015 budget includes 
$612 million for programs in other bureaus, not in Indian Affairs, in 
support of Native Americans and Tribes. This reflects an increase of 
$42 million or 7.4 percent from 2014 enacted levels. When added 
together with the Indian Affairs budget, the total request for Indian 
programs is $3.2 billion. This is an increase of $76 million or 2.5 
percent over 2014 enacted levels.
    Listed below are a few highlights of the programs outside the 
Indian Affairs budget that support Tribes and American Indians and 
Alaska natives, these include:

   Wildland Fire: The Wildland Fire budget includes $200.1 
        million for emergency and non-emergency Fire Programs. The 
        Tribal initiative includes additional $52. 3 million in funds 
        for Fire Preparedness, Fuel Management, and the Resilient 
        landscapes program.. Funds will support contract support costs, 
        workforce development, firefighter and support personnel, and 
        to maintain veteran crews0.

   The Bureau of Land Management (BLM) budget includes $16.9 
        million for programs such as Alaska conveyance, oil and gas, 
        and coal and other minerals to support Native Americans.

   The Fish and Wildlife Service (FWS) budget includes $10.7 
        million for a wide-range of activities including fish hatchery 
        maintenance and Tribal Wildlife Grants.

   The National Park Service (NPS) budget includes $13.5 
        million for Native American programs including grants for 
        Historic Preservation Fund and the Native American Grave 
        Protection programs.

   The United States Geological Service (USGS) budget includes 
        $7.6 million for Tribal Science Partnerships which includes an 
        increase of $2.8 million for Tribal Science Partnerships.

   The Office of Surface Mining (OSM) budget includes $2.1 
        million for programs with Crow, Hopi, and Navajo tribes.

   The Office of the Special Trustee (OST) includes $139.0 
        million for programs that manage Indian funds held in trust by 
        the Federal Government.

   The Office of Natural Resources Revenue (ONRR) budget 
        includes $35.0 million for the management of royalty assets 
        from Indian trust properties, an increase of $1.0 million.

   The Bureau of Reclamation (BOR) budget includes $186.5 
        million for Native American programs including $112.0 million 
        for Indian Water Rights Settlements.

Conclusion
    This FY 2015 budget supports the Administration's objectives to 
strengthen tribal nations through economic development, protect Indian 
communities through public safety and justice programs and social 
services, improve Indian education to secure the long-term health and 
vitality of Indian Country, and improve the government-to-government 
relationship between tribal nations and the United States. The 2015 
budget request maintains the President's commitment to meet our 
obligations to tribal nations while exercising fiscal responsibility 
and improving government operations and efficiency.
    Chairman Tester and Members of the Committee, thank you for the 
opportunity to appear before you today. I am happy to answer any 
questions you may have.

    The Chairman. Thank you for your testimony, Secretary 
Washburn.
    Dr. Roubideaux, you are up.

          STATEMENT OF HON. YVETTE ROUBIDEAUX, M.D., 
M.P.H., ACTING DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT 
                  OF HEALTH AND HUMAN SERVICES

    Dr. Roubideaux. Thank you and good afternoon, Chairman 
Tester.
    I am Dr. Yvette Roubideaux, the Acting Director of the 
Indian Health Service. I am pleased to provide testimony today 
on the President's fiscal year 2015 budget request for the 
Indian Health Service.
    The President's fiscal year 2015 budget request in 
discretionary budget authority for the IHS is $4.6 billion, an 
increase of $200 million or a 4.5 percent increase.
    The request includes priority increases for medical 
inflation, staffing and operation of four newly constructed 
facilities, an increase for the Purchased/Referred Care 
Program, formerly the Contract Health Services Program, pay 
costs, funding for five new tribes, funding to restore 
reductions made in 2014 to fund priorities and full funding for 
the estimated need for contract support costs in fiscal year 
2015.
    We are very happy about this proposal and the outcome in 
2014. We thank you for your partnership on this issue and I am 
glad we were all able to work together to make sure we could 
advocate and get the tribal priorities enacted.
    The budget proposal also includes health care facilities 
construction funding to complete construction on the Kayenta, 
Ft. Yuma and Northern California Youth Regional Treatment 
Center and funds to continue construction on the Gila River 
Southeast Arizona facility.
    The President's fiscal year 2015 budget request also 
includes an Opportunity, Growth, and Security government-wide 
initiative that proposes an additional $200 million for IHS 
health care facilities construction.
    The fiscal year 2015 budget also includes legislative 
proposals to reauthorize the Special Diabetes Program for 
Indians for an additional three years, to establish authority 
for Medicare-like rates for non-hospital and physician/non-
physician services and to provide a tax exemption for the 
Indian Health Service Health Professions Scholarship and Health 
Profession Loan Repayment Programs.
    The IHS budget is critical to our progress in accomplishing 
our agency priorities, reforms and improvements. If this 
proposed budget is enacted, the IHS appropriations will have 
increased 38 percent since 2008, so thank you for your 
partnership.
    Appropriations increases received in the past six fiscal 
years are making a substantial difference in the quality and 
quantity of health care we are able to provide American Indians 
and Alaska Natives. We are grateful that IHS remains a top 
budget priority.
    The budget request was developed after formal tribal budget 
formulation process and incorporates tribal budget priorities. 
Tribal consultation is a priority of President Obama who has 
expressed a commitment to honoring treaty rights and making 
tribal consultation a priority.
    In order to continue our commitment to tribal consultation, 
I plan to personally conduct listening sessions in all IHS 
areas this year to hear views from tribes on how we can 
continue to make progress in agency reforms. I do believe I am 
holding a listening session next week in Montana.
    IHS has made improvements in a number of areas detailed in 
my written testimony. One of those areas is contract support 
costs. In addition to working with tribes on a long term 
solution for contract support costs or CSC appropriations, we 
have also made substantial progress on settling past CSC 
claims.
    We heard input from Congress and tribes to accelerate the 
settlement process and our recent dedicated increase in 
resources and staff is making a difference. IHS has analyzers 
in the process of analyzing over 550 claims and since Ramah, 
IHS has made settlement offers on over 200 claims from 31 
tribes. The total settlement amount to date for 104 claims that 
have been formally settled or are in the process of settlement 
totals over $133 million.
    IHS is committed to fair, consistent, and speedy resolution 
of claims through settlement wherever possible.
    In summary, we are working hard and in partnership with 
Congress and tribes to change and improve the Indian Health 
Service through our reform efforts. We really thank you for 
your support and partnership.
    The increases IHS has received in the budget over the past 
few years are making a difference but we know we still have 
much more to do. We look forward to working with you on the 
President's fiscal year 2015 budget request to help continue or 
progress in changing and improving the Indian Health Service.
    Thank you and I am happy to answer questions.
    [The prepared statement of Dr. Roubideaux follows:]

  Prepared Statement of Hon. Yvette Roubideaux, M.D., M.P.H., Acting 
 Director, Indian Health Service, U.S. Department of Health and Human 
                                Services
    Good morning Chairman Tester, Vice Chairman Barrasso, and Members 
of the Committee. I am Dr. Yvette Roubideaux, Acting Director of the 
Indian Health Service. I am pleased to provide testimony on the 
President's Fiscal Year (FY) 2015 Budget request for the Indian Health 
Service (IHS), and to update you on our progress in addressing our 
agency mission to raise the physical, mental, social, and spiritual 
health of American Indians and Alaska Natives (AI/ANs) to the highest 
level.
Indian Health System
    IHS is an agency within the Department of Health and Human Services 
(HHS) that provides a comprehensive health service delivery system for 
approximately 2.1 million American Indians and Alaska Natives (AI/ANs) 
from 566 federally recognized Tribes in 35 states. The IHS system 
consists of 12 Area offices, which are further divided into 168 Service 
Units that provide care at the local level. Health services are 
provided directly by the IHS, through tribally contracted and operated 
health programs, through services purchased from private providers, and 
through urban Indian health programs.
President's FY 2015 Budget Request
    The President's FY 2015 Budget request in discretionary budget 
authority for the IHS is $4.6 billion; an increase of $200 million, or 
4.5 percent, over the FY 2014 enacted funding level.
    The request includes priority increases: $63 million for medical 
inflation, $70.8 million to staff and operate four newly constructed 
health facilities, $15.4 million for a general program increase for the 
Purchased/Referred Care (PRC) program (formerly known as Contract 
Health Services) that results in a total increase of $50.5 million when 
added to the $32.5 million for medical inflation for PRC and a program 
increase of $2.6 million for New Tribes, $2.5 million for pay increases 
for federal and Tribal health program staff, $8 million for five new 
Tribes, $10 million to restore funding reductions made in FY 2014 to 
fund priorities, and $29.8 million for contract support costs (CSC), 
primarily for the estimated need for new and expanded contracts. The 
budget proposal also includes $85 million for health care facility 
construction to complete construction and the staff quarters for the 
Kayenta, AZ facility, begin and complete construction of the Fort Yuma, 
AZ facility, continue construction of the Gila River Southeast, AZ 
facility, and complete construction of the Northern California Youth 
Regional Treatment Center.
    The President's FY 2015 Budget request also includes an 
Opportunity, Growth and Security government-wide initiative to grow the 
economy and create opportunities. For IHS, the initiative includes an 
additional $200 million to continue progress in constructing facilities 
on the IHS Health Care Facilities Construction priority list.
    At the Program Level, the budget also estimates $1.2 billion in 
third party collections in FY 2015 that includes an estimated increase 
in Medicaid reimbursements of $22 million compared to FY 2014, which is 
anticipated to result from additional enrollees as the Affordable Care 
Act continues to be implemented. The Program Level funding also 
includes $39 million in estimated reimbursements from the Department of 
Veterans Affairs.
    The FY 2015 President's budget also includes legislative proposals 
to reauthorize the Special Diabetes Program for Indians for an 
additional three years, to establish authority for Medicare-Like Rates 
for non-hospital and physician/non-physician services for Indian Health 
Service, Tribal and Urban Indian Health Programs, and to provide a tax 
exemption for the Indian Health Service Health Professions Scholarship 
and Health Profession Loan Repayment Programs similar to the National 
Health Service Corps programs.
IHS--Continued Progress
    Over the past few years, we have been working to change and improve 
the IHS. The IHS budget is critical to our progress in accomplishing 
our agency priorities and improvements. If this proposed budget is 
enacted, IHS appropriations will have increased by 38 percent since FY 
2008. The appropriations increases received in the past six fiscal 
years are making a substantial difference in the quantity and quality 
of healthcare we are able to provide to AI/ANs. IHS remains a top 
Administration priority. In the President's FY 2015 Budget request the 
HHS discretionary budget overall decreased while IHS' budget increased.
    IHS has made considerable progress in addressing our Agency 
priorities and reforms and the budget increases have been critical to 
this progress. Tribal consultation is fundamental to our Agency reform 
activities. This budget request was developed after a formal Tribal 
budget formulation process and incorporates Tribal budget priorities. 
Tribal consultation is a priority of President Obama, who has expressed 
a commitment to honoring treaty rights and making tribal consultation a 
priority. In order to continue our commitment to Tribal consultation, I 
plan to personally conduct listening sessions in all IHS Areas this 
year to hear views from Tribes on how we can continue to make progress 
on Agency reforms.
    Tribal consultation helps us focus on budget priorities. For 
example, funding for the Purchased/Referred Care (PRC) program, 
formerly called the Contract Health Service program, is a top budget 
priority of IHS and Tribes and has increased by 60 percent since 2008. 
This increased funding is making a difference. Four years ago, most 
programs were funding only Medical Priority 1, or ``life or limb'' 
referrals. In FY 2013, 15 out of 66 Federal PRC programs were able to 
fund referrals beyond Medical Priority 1. This means these programs are 
paying for more than just life or limb care and more patients are 
accessing the health services they need, including preventive services 
such as mammograms and colonoscopies. The increased PRC funding also 
means that the IHS Catastrophic Health Emergency Fund (CHEF), which 
used to run out of funding for high cost cases in June, now is able to 
fund cases through August.
    In this budget request, the Administration demonstrates its 
commitment to self-determination by continuing its FY 2014 commitment 
to fully fund the estimated amount of CSC for FY 2015. Of particular 
importance for the FY 2015 budget is Tribal consultation on a long term 
solution for funding CSC, as requested in the Explanatory Statement 
accompanying the Consolidated Appropriations Act of 2014. The 
Explanatory Statement requested the Department of the Interior and IHS 
consult with Tribes and work with Congress and the Office of Management 
and Budget on long term accounting, budget, and legislative strategies. 
IHS will be engaging Tribes in multiple forums over the next several 
months to develop strategies for the long term CSC solution. A workplan 
on the plan for consultation is under development and will be submitted 
to Congress as requested.
    Related to this is IHS' work to resolve all past claims for 
underpayment of CSC. IHS has heard the request from Tribes and Congress 
to accelerate the rate at which the Agency is resolving past claims. As 
a result, IHS has devoted additional resources and staff to resolving 
claims for unpaid CSC with a primary focus on speedy resolution through 
settlement whenever possible. IHS must analyze each claim individually 
and comply with the multi-step process required by the Contract 
Disputes Act. IHS is working to resolve the claims expeditiously and 
also believes that the Agency and Tribes working together to resolve 
the claims will have the most benefit for our ongoing relationship. IHS 
is also improving internal business practices related to the CSC claims 
settlement process. IHS is also consistently reviewing methods to 
enhance collaboration and streamline the process, and has offered an 
alternative claim resolution process that is less burdensome for Tribes 
but still is fair and consistent for all Tribes.
    This work is showing results. As of March 18, 2014, IHS has 
analyzed, or is in the process of analyzing, over 550 claims. Since 
Ramah and as of March 18, 2014, IHS has made settlement offers on over 
200 claims for 31 Tribes. Of those claims, 34 claims have been formally 
settled with five Tribes, and an additional 68 offers have been 
accepted by eight Tribes and are in the process of settlement. This is 
a considerable increase from the three settled claims reported as of 
November 2013. The total settlement amount for claims that have been 
formally settled, or are in the process of settlement, totals over $133 
million. Our goal is to resolve the majority of currently pending 
claims with Tribes that are amenable to settlement and to extend 
settlement offers to all Tribes by the end of calendar year 2014. I 
personally have experienced the recent increased pace of our settlement 
process since I now receive emails almost every day from Agency 
attorneys requesting approval of settlement offers.
    IHS is also continuing its work to reform the IHS. We are now 
focused on implementation and outreach activities to ensure that our 
patients benefit from the Affordable Care Act. We want every patient 
who visits our facilities to get education and assistance primarily 
from the business office, which is a place where every patient spends 
some time in our facilities. All of our sites have been working hard to 
educate our patients on the Affordable Care Act provisions.
    We have also been working with national and regional Tribal 
organizations to conduct outreach and education on the benefits of the 
Affordable Care Act. Our partners include the National Congress of 
American Indians, the National Indian Health Board, the National 
Council of Urban Indian Health, and the Self-Governance Communication 
and Education organization.
    Our internal reform efforts are focused on improving the way we do 
business and how we lead and manage our staff. Overall, we have 
implemented many improvements. To improve the way we do business, we 
are working with HHS and our Area Directors to improve how we manage 
and plan our budgets and improve our financial management. We are 
working to make our business practices more consistent and effective 
throughout the system. We are also working on program integrity and 
responding to recommendations from oversight agencies to ensure we are 
effective and using federal resources wisely.
    We are also working on strategies to improve recruitment and 
retention, which are big issues at all of our sites. This includes 
working on specific activities to make the hiring process more 
efficient and proactive, and less time-consuming. We need to make sure 
the way we do business is not causing us to lose the opportunity to 
hire and keep quality staff.
    We are also continuing work on our priority of improving the 
quality of and access to care for our patients. We have emphasized the 
importance of customer service, and we are also working on a number of 
initiatives to help improve the quality of care and promote healthy 
Indian communities.
    One of the most important of these is our Improving Patient Care, 
or IPC, program. The IPC is our patient-centered medical home 
initiative that is designed to improve the coordination of care for 
patients. This is about making changes that will result in measurable 
improvements in patient-centered care, including reduced waiting times, 
more access to appointments, and improvements in the quality of care. 
The patient-centered medical home is a big focus of the changing health 
care system in the United States.
    We plan to expand this initiative throughout the entire IHS 
system--currently we have 127 sites. Many of these sites are doing 
really outstanding work, including reducing waiting times, improving 
no-show rates, and arranging the system so that patients can see the 
same providers each time they come to the clinic, which results in 
better coordination of care.
    A few other initiatives are also helping us improve the quality of 
care. The Special Diabetes Program for Indians (SDPI) is continuing its 
successful activities. In partnership with our communities, we can 
prevent and treat diabetes in Indian country with innovative and 
culturally appropriate activities. Our 2011 SDPI Report to Congress 
clearly shows that the SDPI programs have done an incredible job of 
implementing activities to prevent and treat diabetes in the 
communities we serve. The data in the congressional report shows that 
the SDPI programs have dramatically increased access to diabetes 
treatment and prevention services. For example, access to diabetes 
clinics has increased from 31 percent to 71 percent of grant programs 
from the 1997 baseline before SDPI funding to 2010. Based on local 
needs and priorities, the SDPI grant programs have implemented proven 
interventions to address the diabetes epidemic, often where few 
resources existed before.
    The most important impact of these combined and sustained clinical 
improvements is seen in the dramatic drop in the rate of end stage 
renal disease (ESRD) in American Indian and Alaska Native people with 
diabetes when compared with other racial and ethnic groups in the U.S.
    Between 1995 and 2011, the incident rate of ESRD in American Indian 
and Alaska Native people with diabetes fell by nearly 39 percent--a 
greater decline than for any other racial or ethnic group. Given that 
the Medicare cost per year for one patient on hemodialysis was $82,285 
in 2009, this reduction in the rate of new cases of ESRD means a 
decrease in the number of patients who would have required dialysis--
translating into millions of dollars in cost savings for Medicare, IHS, 
and other third-party payers, as well as improved quality of life for 
patients who do not need dialysis.
    Diabetes health outcomes have also improved significantly in 
American Indian and Alaska Native communities since the inception of 
the SDPI. One of the most important improvements has been a 10 percent 
reduction in the average Hemoglobin A1C levels of American Indians and 
Alaska Natives with diagnosed diabetes. Improved blood sugar control 
contributes to reductions in complications from diabetes. This FY 2015 
President's Budget request includes a proposal to reauthorize the SDPI 
for another 3 years to maintain and build upon this important progress.
    We are also focusing on behavioral health issues, which Tribes have 
identified as a top priority. IHS is making progress on implementing 
its recently released National Behavioral Health Strategic Plan and its 
National Suicide Prevention Plan. And the evaluation data from our 
Methamphetamine and Suicide Prevention and Domestic Violence Prevention 
initiatives show very promising results as the programs are 
implementing evidence-based strategies.
    IHS has a lead role in the First Lady's Let's Move! in Indian 
Country initiative, which includes our IHS Baby-Friendly Hospital 
initiative and a collaboration with the Notah Begay III Foundation 
involving activities to prevent childhood obesity. We are promoting 
breastfeeding in all IHS hospitals because it has been shown that 
breastfeeding can reduce childhood obesity. We are also encouraging all 
tribally-managed hospitals to join us in this effort.
    We have also established a new hospital consortium to work on 
improving quality and maintaining accreditation requirements in our 
hospitals. We plan to establish a system-wide business approach to 
accreditation.
    We are meeting regularly with the Department of Veterans Affairs 
(VA) to implement activities to better coordinate care for American 
Indian and Alaska Native veterans who are eligible for both VA and IHS 
care. We have also implemented the VA-IHS national reimbursement 
agreement at all federal facilities and are billing and receiving 
reimbursements from the VA for direct care provided to American Indian 
and Alaska Native veterans.
    We have accomplished a great deal as we work to meet our 
priorities, and this is reflected in our Government Performance and 
Results Act (GPRA) measures. In FY 2011, for the first time ever, we 
met all of our clinical GPRA measurement goals. In FY 2012, we did 
great again. And the results are now in for 2013, and once again, we 
met all of our clinical targets. We are very proud of all the IHS and 
tribal sites that worked so hard to make improvements in the quality of 
the health care that we deliver. Our focus on improving the quality of 
care, along with more accountability system-wide, is making a 
difference. But we know that we still have much more to do.
    In summary, we are working hard and in partnership with Tribes to 
change and improve the IHS through our reform efforts, and we thank you 
for your support and partnership. The increases IHS has received in its 
budget over the past few years are making a difference, and we look 
forward to working with you on the President's FY 2015 Budget request 
to help continue progress. Although we are in a challenging fiscal 
environment, the work of the past few years has clearly established 
that by working together, our efforts can change and improve the IHS to 
ensure that our AI/AN patients and communities receive the quality 
health care that they need and deserve.
    Thank you and I am happy to answer questions.

    The Chairman. Thank you both for your testimony. We very 
much appreciate it. Thank you for the work that you do.
    I will start with you, Kevin. If I'm the only one here, we 
will probably ask questions for a while. Then you can take a 
break and we will go to Dr. Roubideaux.
    This year's budget, as already pointed out, has a 1.2 
percent increase over last year's enacted levels. There is a 
chart up there that you can see of the Interior allocations. I 
am not saying the National Park Service should not get 22.2 
percent, because our national parks are in disrepair. I am not 
saying that the BLM should not get 6.1 percent because the BLM 
needs resources to be able to do their job.
    What I am saying and what you know much better than I is 
the challenges out there in Indian Country across this country. 
Their increase is almost at the bottom, yet we have so many 
challenges out there.
    I don't know how your life works. I don't know if you come 
in and say we need a 5, 10, or 20 percent increase over last 
year and they just whittle you down and keep whittling you down 
until you get to 1.2 percent or if you come in at zero and hope 
they give you 1.2 percent. The chart is not right, it says 1.5 
percent. It is 1.2 percent, lower than that.
    How do we get budgets that will work? I know you have to 
shed the best light you can on this budget but this needs some 
work. Give me an idea of what you are up against? Who do we 
need to talk to? Who do I need to get Senator Udall or Senator 
Johnson to talk to so we can get some of these figures up so 
the people and the agencies can do the job? It will help morale 
and help folks on the ground.
    Mr. Washburn. You put these charts up and they look pretty 
bad. I feel there are some apples and oranges going on in these 
charts.
    I won't quibble with it too much except to say I think we 
would provide different data and it would look a bit different 
the way we would present it. For example, over the last five 
years, in the Obama Administration you would find the 
President's budget request for Indian Affairs has been higher 
than for any other agency at the department.
    If you pick out one year, you can cherry pick figures and 
make it look bad. You are also comparing tiny budgets to big 
budgets. Our overall budget is about $11 billion at the 
Department of Interior. Ours is $2.6 billion, so it is a big 
chunk of that. Some of these offices are tiny offices that $1 
million can make a 10 percent swing in the office if it is a 
$10 million office.
    I guess we would quibble with this but the question is how 
do we come up with these budgets. We work really hard and the 
Secretary made a real commitment this year and really went to 
bat for the Indian Affairs budget. Compared to the really big 
budgets at the Department of Interior, we did okay.
    If you compared apples to apples, I think you would find we 
didn't get the request the National Park Service got for their 
centennial year. There is a special occasion this year for them 
next year and there is also this Opportunity Growth and 
Security Initiative built into these numbers that you have 
presented.
    We didn't quantify our request for that initiative. It is 
in there. We have a request for Indian education in that 
initiative but we didn't put a number figure. We kind of got 
shellacked here because we didn't attach a number to the 
Opportunity Growth and Security Initiative which is the 
President's way of saying if we do get more money than the 
Murray-Ryan caps provide, we are going to put a significant 
amount into Indian education.
    I am not sure this graph is entirely fair.
    The Chairman. That is a fair statement but here is what we 
will argue. When you talk about this Administration putting in 
record amounts of money, especially compared to previous 
administrations, that is apples and oranges too because the 
previous administrations haven't exactly been stellar when it 
comes to Indian Country.
    I would just say this. It comes down to things within these 
programs and we can go down the list and you can pick any line 
item and say it is deficient. Honestly, you might be able to do 
that with the other budgets also but in this case because of 
the trust responsibility we have and treaty responsibilities we 
have, it is different.
    I know where your heart is. I just think we need to figure 
out how we can work together to make this happen.
    The only other question I have is I know OMB plays a role 
in all this budgetary stuff. Sometimes they are the hammer that 
pares back things. I would like your honest assessment. Does 
OMB know about the trust responsibilities and treaty rights 
that this country has for Indian Country?
    Mr. Washburn. Mr. Chairman, they have actually learned a 
lot. I have to say they have really been much more engaged with 
tribes over the last few years. I think they really have gotten 
onboard and gotten much more engaged with tribes.
    I think it might be fair to say they are sort of the adults 
in the room who say hold on a second, we have to meet these 
Murray-Ryan budget caps so we cannot give you everything you 
dream of; we have to pare it back a little bit, but they do 
have sense of the trust responsibility and have been learning a 
lot.
    The Chairman. I appreciate that.
    We are going to do something a little different. I am going 
to go down the line. I want seven minutes on the clock for 
questioning because I think there are two people here who are 
pretty important to everyone on this Committee.
    I will start with you, Senator Johnson. You can do it with 
an opening statement or go right into questions, whatever you 
prefer.
    Senator Johnson. I will give my opening statement for the 
record.

                STATEMENT OF HON. TIM JOHNSON, 
                 U.S. SENATOR FROM SOUTH DAKOTA

    Senator Johnson. Mr. Washburn, I appreciate the BIA is 
focusing on reducing repeat incarceration in Native 
communities. However, tribes are still struggling with the lack 
of infrastructure.
    Tribal law enforcement and agencies need detention centers 
that are not falling apart and tribal courts need integrated 
courts for drug and mental health issues. How is the Department 
planning on addressing this infrastructure issue?
    Mr. Washburn. Thank you, Senator Johnson. We have increased 
our funding request for detention facilities in Indian Country. 
We have 96 existing detention facilities. As Chairman Tester 
said in the beginning we have about 180 schools. I don't like 
those numbers. I wish we had a lot more schools than detention 
centers. The fact is we don't take care of either one of them 
enough.
    In the fiscal year 2014 budget, we had a $14 million 
increase for detention facilities and because we just got our 
operating plan finalized about a month ago, that money is just 
now to a place where we can use it. That money is continued 
into the fiscal year 2015 budget request so there will be more 
money available.
    We fund the detention programs at about 55 percent of need. 
That is not enough. Many of the poorest tribes cannot afford to 
come up with the other 45 percent. This is going to be an 
ongoing challenge for us but we are working hard to meet it.
    Senator Johnson. Too often I hear from South Dakota BIA 
funded tribal schools that they much continually use ISEP funds 
to pay the heating and electrical bills. Can you please explain 
why the President's budget does little to alleviate the burden 
of administrative costs, facilities operations, and maintenance 
costs?
    Mr. Washburn. You are asking that question at a very 
stressful time for tribes and for the Administration. The cost 
of propane this winter was a serious problem in your State and 
that really ate into those funds.
    We pay for our maintenance program out of the same funds, 
we pay for our electric bills and the propane bills. If you use 
up all your money on propane, it doesn't leave a lot for 
maintenance and repairs and that sort of thing. That has been a 
real challenge to all of us.
    We hope that is a one year problem and that the costs will 
not repeat themselves. We have also worked on other strategies 
of trying to pay in advance for propane so that we are paying a 
more flat rate rather than dealing with the ups and downs in 
the market. We are exploring ways to deal with those problems.
    It is a tough fiscal environment. We are trying to do a lot 
with a little amount of money.
    Senator Johnson. The expense of propane exacerbates things. 
This issue has long been in existence, the use of ISEP funds 
for overhead.
    Dr. Roubideaux, you noted the dramatic increase in funding 
for the Purchased Referred Care Program. However, in a recent 
GAO study, this program was given poor marks on the handling of 
medical claims. Recently a South Dakota dialysis clinic 
reported to me that the business has thousands of dollars of 
unpaid claims and a number of patients were left to foot the 
bill because their life-sustaining dialysis treatments were not 
a high medical priority.
    Can you please address how IHS will improve both the claims 
process and approval of referred patient services?
    Dr. Roubideaux. Thank you for that question. We will have 
our staff connect with yours about that particular provider and 
that particular issue.
    The Purchase and Referred Care Program, how we pay for 
referrals, we have been working very hard to try to improve our 
ability to process and pay for those referrals and have been 
working on education with outside providers on eligibility, 
looking at our billing process and the GAO report you mentioned 
looked at how we are measuring our progress. We are 
implementing recommendations from that report.
    We want to do everything we can to make sure we can pay or 
authorize referrals in the quickest time possible. We 
definitely want to work with you on this issue.
    Senator Johnson. The Sanitation Facilities Construction 
Program provides critical water supply and disposal for 
individual homeowners and projects.
    As Chairman of the Banking, Housing, and Urban Affairs 
Committee, it is important to me to find solutions to our 
critical housing needs. With a tremendous need for water 
systems in Indian Country, how will IHS continue to work with 
tribes and other agencies to address the need for this critical 
infrastructure without a budgetary increase?
    Dr. Roubideaux. We are very interested in finding solutions 
in this area because you are correct, there is an incredible 
need.
    One of the things we have done in the past year is signed 
an interagency memorandum of understanding with other Federal 
agencies to try to leverage other resources and look at what 
legal or regulatory things might be getting in our way. That 
MOU is with EPA, HUD, DOI and the Department of Agriculture.
    That will help us make sure we can look for some creative 
solutions to this very significant challenge.
    Senator Johnson. I yield back.
    The Chairman. Senator Udall?

                 STATEMENT OF HON. TOM UDALL, 
                  U.S. SENATOR FROM NEW MEXICO

    Senator Udall. Thank you very much, Chairman Tester. I 
really appreciate being here with you as our new Chairman.
    I want to completely identify with the frustration of the 
Chair and the passion he spoke of in terms of the budgets and 
looking at these charts. He has outlined something and I would 
adopt his comments.
    In addition, I would point out it has been absolutely 
devastating, the long terms effects sequestration has had on 
Indian Country. Dr. Roubideaux, the IHS was the only direct 
medical service agency that was subject to full sequestration 
cuts. Medicare, Medicaid, children's health insurance, veterans 
affairs, all were either exempt or received a smaller cut of 2 
percent.
    According to your testimony in April 2013, you estimated 
that the reduction would include 3,000 in-patient admissions, 
804 out-patient visits and this was a painful, unnecessary, 
arbitrary cut to communities that can ill afford them.
    I am not going to go on and on. I will put the statement in 
the record because I want to ask you questions on BIE.
    It is important we get the figures out there. BIE schools 
lost $42.2 million as a result of sequestration. This had to be 
absorbed by 183 already underfunded schools.
    Tribal Head Start programs lost $11.9 million as a result 
of sequestration, impacting 25,000 children in 26 States.
    The Bureau of Indian Affairs, Office of Public Safety had 
an $18.3 million sequestration cut and I could go on and on. I 
know you both know and understand this very well. I would be 
interested as we proceed with the hearing how these cuts are 
going to affect us in terms of moving forward.
    [The prepared statement of Senator Udall follows:

   Prepared Statement of Hon. Tom Udall, U.S. Senator from New Mexico
    I would first like to thank Chairman Tester and Vice Chairman 
Barrasso for holding this important hearing. I am glad to see my friend 
Assistant Secretary for Indian Affairs, Kevin Washburn, here today. I 
look forward to hearing from him, as I do the rest of this 
distinguished panel, as we discuss the President's FY 2015 budget and 
the impact on Indian communities.
    I'd like to begin by addressing the devastating and long-term 
effects sequestration have had on Indian Country. The IHS was the only 
direct medical service agency that was subject to full sequestration 
cuts. Medicare, Medicaid, Children's Health Insurance Program, and 
Veteran's Affairs were all either exempt, or received a smaller cut of 
2 percent. According to her testimony in April 2013, Dr. Roubideaux 
estimated that reduction would include 3,000 inpatient admissions and 
804,000 outpatient visits. This was a painful, unnecessary, arbitrary 
cut to communities that can ill-afford them.
    The BIE schools lost $42.2 m as a result of sequestration. This had 
to be absorbed by the 183 already underfunded schools. Tribal Head 
Start programs lost $11.9 million as a result of sequestration, 
impacting 25,000 children in 26 states. The Bureau of Indian Affairs 
Office of Public Safety had a $18.3 sequestration cut. The Indian 
Housing Block grant program was cut $34.5m by sequestration. And the 
cuts continued. I will be interested in hearing how these cuts affect 
programs moving forward.
    Contract support costs are a vital part of tribal self-
determination and self-governance. I think everyone here can 
confidently acknowledge the positive outcomes that have resulted from 
tribes having the option to contract and carry out their own services. 
Unfortunately, funding for contract support costs has consistently 
fallen short, and I look forward to addressing with Dr. Roubideaux the 
steps being taken to address the underpayments, in addition to hearing 
from Mr. Washburn how the budget will try to anticipate these costs.
    I look forward to working with my colleagues on this Committee to 
help address the long-standing issues facing Indian country. I am 
encouraged by the administration steps to take seriously our 
responsibilities to Tribes, and look forward to hearing how the 
President's budget reflects that commitment.

    Senator Udall. Let me ask a couple questions. Dr. 
Roubideaux, I appreciated your testimony about the work the 
Indian Health Service is doing to address outstanding claims 
for contract support costs. As you noted, these have real 
impacts on tribes, including tribes in New Mexico. However, 
while you have reported considerable progress overall, your 
agency has stated that of the 93 claims, zero have been settled 
and 81 are still pending.
    What will you do to work with me and the Committee to 
ensure that tribes receive the settlements they are entitled?
    Dr. Roubideaux. We are absolutely committed to working with 
you to try to resolve these past claims for contract support 
costs as quickly as possible.
    If you look at the claims in New Mexico, I think since we 
sent you information, I think in my in-box a settlement offer 
to one of the tribes popped up and I approved it. We will see 
how that negotiation goes. We have also completed four analyses 
and have 15 claims on the priority list for New Mexico.
    We are working very hard and know that tribes need this 
funding, they know it is owed to them and we want to work very 
hard to resolve these claims. We are working hard. The numbers 
are changing on a daily basis, so I am glad to be able to give 
you a little update.
    Senator Udall. I hope you will update us and keep us 
apprized because as you have said, these contract support costs 
are absolutely crucial for self determination and for the 
tribes to be able to move forward with the things they believe 
are important to them.
    We have an Indian center in Gallup called the Gallup Indian 
Medical Center. It has long been on the list. It is a facility 
that needs to be renovated, if not replaced. At this time, how 
is the IHS creatively thinking to advance the management of 
facilities and construction to update or improve or replace 
these outdated facilities and what other sources of funding, 
what greater use of Tele-health or emerging models of care are 
you contemplating to address this concern now and in the 
future?
    Dr. Roubideaux. We are absolutely trying to do everything 
we can to address the health facility construction needs in 
Indian Country and they are enormous. The current priority 
list, which Gallup Indian Medical Center is on, has $2.1 
billion of construction left on it.
    In addition to our President's budget, the Opportunity 
Security and Growth Initiative has the $200 million increase 
for health facilities construction. We do hope that gets good 
consideration.
    We do a lot of creative things. The average age of our 
facilities is 20-30 years, so we do things like save our third 
party collections. Gallup Indian Medical Center was very 
innovative and was able to build an entire outpatient center 
doing that.
    We look at leasing sites, we look at other innovative 
things like modular construction, and we look at what kinds of 
repairs we can make. Tele-health is an area that really does 
help us expand services without having to do construction. New 
Mexico leads in that with several programs that are happening 
and help get services to rural areas.
    In terms of delivery models, I think there is a lot of 
change with the changing health care delivery system. We are 
working on our Improving Patient Care Initiative which looks at 
reorganizing the clinic to make sure patients waiting times go 
down and there is more availability of appointments, with more 
of a team approach to care. In some cases, that involves 
reorganizing the actual space in the clinic to be more 
efficient.
    We are working on some of those things, but we know funding 
is the quicker answer and we are working on that as well.
    Senator Udall. Thank you.
    Assistant Secretary Washburn, you heard me talk a bit about 
the impacts of sequestration. Moving forward and coming up with 
your budget, what are you trying to do, as best you can, to 
fill the holes and make a difference in terms of the cuts that 
have happened and how we are going to move forward to deal with 
what has happened in the past?
    Mr. Washburn. You are right, a lot of the tribes are still 
feeling the sequestration because we did not backfill the five 
percent that got cut. First of all, we paid full contract 
support costs in the 2014 year when we did get funding, so we 
couldn't backfill the five percent because we had other 
purposes for that money suddenly.
    We did a few other things we felt were important in the law 
enforcement area and a little bit in education. We are doing 
the best we can and tribes are frustrated and struggling. We 
are in tight fiscal times. As long as we are in tight fiscal 
times, it is going to be hard to get out of this.
    Hopefully with the economy improving, we won't get another 
sequestration, we will get past the Murray-Ryan budget caps and 
go back to regular order where we can ask for what we need 
rather than trying to live and fit into really tight caps. We 
are working hard on that. I just came from two days of budget 
meetings with tribes and they are really feeling the pinch.
    Senator Udall. Thank you very much. I know you are both 
working very hard to try to remedy some of this.
    Thank you and I yield back.
    The Chairman. Senator Begich.

                STATEMENT OF HON. MARK BEGICH, 
                    U.S. SENATOR FROM ALASKA

    Senator Begich. Thank you, Mr. Chairman.
    Thank you both for being here today and thanks for the work 
that you do for Indian Country and Alaska Native communities 
throughout my State.
    As you know, we have the most remote parts of the country 
and some of the most difficult challenges be they from health 
care to education to infrastructure and many other things. 
Thank you all very much for being here.
    Dr. Roubideaux, thank you for your work at the Indian 
Health Service. I know at times we have pushed back quite a bit 
here and I am trying to get some resolution. Let me follow up 
quickly on the data point you were sharing with Senator Udall.
    I would love to see you submit something to the Committee 
with regards to how many cases are still pending overall, how 
many are being actively pursued for resolution and how many are 
still kind of out there getting scheduled and what those time 
schedules would be.
    If you could answer that now, it would be great. If you can 
submit something, that would be even better. If you can answer 
that, I also have some additional questions in regards to the 
past claims issues.
    Dr. Roubideaux. For contract support past claims, we have 
heard from Congress and tribes that they wanted us to 
accelerate the claims process, so we committed additional 
resources and staff.
    Currently, there are 1,200 claims pending but we have about 
550 of those in analysis or the analysis is done. We have 
actually made offers on over 200 claims from 31 tribes. The 
total amount of claims that either there have been offers 
formally settled or accepted and in the process of settlement 
is about $133 million worth.
    Our progress definitely over the past couple of months has 
increased and we are working hard to continue that increase 
because we know it is important that we settle those as quickly 
as possible.
    Senator Begich. Do you think you would be able to give to 
the Committee, with the numbers remaining in the process, what 
that schedule would look like timewise? It doesn't have to be 
specific but you expect another x amount of cases settled in x 
amount of time. Is that something you could tell me now or 
submit to the Committee so that we have a good sense of how 
that progress will move?
    Dr. Roubideaux. We would like to work with you and give you 
frequent updates on that. It is hard to estimate because some 
of the cases are in Federal court.
    Senator Begich. Yes, and some are more complicated.
    Dr. Roubideaux. Some are more complicated and the 
negotiations are in process. The one thing we can control is 
getting settlement offers out to the tribes. That is our 
primary goal right now, as soon as possible to get settlement 
offers out to the tribes.
    Senator Begich. That is the 550 where you have done an 
analysis. From that 550, 200 of those are in motion or have 
been resolved and the remaining amount are ones you could make 
offers to at some point because now you have an understanding 
of where the parameters are. Is that a fair statement?
    Dr. Roubideaux. Yes. We have worked collaboratively with 
the tribal lawyers on this and have negotiated. I am really 
seeing progress in my email inbox every day or offers that I 
approved. I approved one while I was waiting for the hearing.
    Senator Begich. Let's stop the hearing and you continue to 
approve a few more.
    Dr. Roubideaux. We are seeing the numbers go up like that, 
so I am pretty confident we can make significant progress this 
year.
    Senator Begich. That is very good.
    As you know, I have had regrets about this initiative and 
sometimes I know you felt too aggressive from me maybe, but 
this is important. It is contract provided services and we need 
to settle them so we can move forward.
    The next question I have, which I think is a great 
statement, 2014 and 2015, and now the 2015 budget has full 
funding of contract support services. We greatly appreciate 
that. I want to make sure that at some point you will put 
together a more detailed plan of how you can maintain that.
    One of the big concerns people have is maintaining that may 
mean other services get squeezed within the overall Interior 
budget and/or within budgets like BIA and others. I don't know 
if you are planning to submit something to the Congress or the 
Administration, but this is something I would be very 
interested in.
    Now you have two years under your belt, one year and moving 
to two years, hopefully, and that piece of the puzzle, it is 
very important that it's sustainable, long-term and full 
funding. Is that something you could provide at some point, 
your plan of action?
    Dr. Roubideaux. Yes, sir. The Consolidated Appropriations 
Act of 2014 required a work plan to be submitted within 120 
days. That is due in May. We are very interested in working 
with all of you on the long term solution for contract support 
costs, to be able to determine the more predictable amounts and 
that would work in the overall budget formulation with other 
priorities.
    Senator Begich. In May when you submit that, is that to us 
and the Administration or is it the Administration first and 
then to us?
    Dr. Roubideaux. Yes. It goes through our clearance and then 
goes to Congress. We are happy to discuss it with you before we 
develop the plan. It is a plan for consultation on the issue 
because we want to develop this in consultation with the 
tribes.
    Senator Begich. Perfect. May is 30 some days away.
    Dr. Roubideaux. Yes.
    Senator Begich. Also, as you know, I am a lead sponsor on 
the advance appropriations bill for Indian Health Services 
which I know about a year ago we asked for the position you 
would have on that. Do you have any new information you can 
share? Do you support that legislation or does the 
Administration have a position? Can you give me your thoughts 
on that?
    Dr. Roubideaux. We are very happy to work with this 
Committee on this issue. We know it is a top tribal priority. 
It would be so good to have more predictable and stable funding 
levels.
    Senator Begich. Can I take that as you are supportive of 
the concept in the legislation and we could talk about the 
details?
    Dr. Roubideaux. We just saw the legislation and are now 
reviewing it. We are talking with the VA to see their 
experiences. We are hoping to have more definitive information 
for you.
    Senator Begich. I would love that soon. I know we have done 
it with the VA very successfully. I actually have a bill for 
the VA also to finish out their discretionary advanced funding. 
Between VA and Indian Health Service, it would make a huge 
difference long term.
    I know we have done it on the medical side of VA. I 
supported that when I first came in. Now I have the bill for VA 
on discretionary and also now Indian Health Services. I would 
love your thoughts on that.
    I have some other things I will submit for the record. If I 
could jump very quickly to Mr. Washburn, we have talked about 
public safety issues. Based on conversations we have had 
publicly and privately, there is always great stress on your 
budget but tell me your thoughts on how we are going to go 
after the issue based on the report.
    We had a hearing here in regards to the report done on the 
needs not only in Alaska but across the country in public 
safety and how we can get these more unified and also how and 
what you need to be successful.
    I can tell you in Alaska, the incarceration rate with the 
Alaska Native population is double the population percent which 
is unacceptable. As you know, I have a bill which I think in a 
week along with other bills, we will be doing a hearing on. I 
would love to hear your thoughts on what you think we need to 
be doing. Obviously we are not doing enough. I don't mean that 
in a negative way but we just are not.
    Mr. Washburn. Senator Begich, thank you for your leadership 
on the contract support cost issue. You have made a difference 
there and it has been helpful.
    The law enforcement issues are important. I think we have 
increased funding over the Obama Administration. That is the 
area where we probably have already increased funding the most 
in our budget or it is close to it. It is one of the highest 
priorities. I just came out of two days of budget meetings with 
tribes, including the Alaska region, where law enforcement, 
once again, was one of the highest priorities.
    It is no small challenge to try to start funding 229 Native 
villages and 109 tribes in California in addition to the ones 
we are already under funding. During really tight fiscal times 
like we are in, I am not sure if we can make a big impact on 
that.
    Senator Begich. It is a resource issue.
    Mr. Washburn. It is a resource issue and requires changing 
our paradigm about how we do this stuff because in Public Law 
280, States like yours, we just don't fund very much law 
enforcement. That is a problem. Those tribes have public safety 
issues as well.
    Senator Begich. Serious issues.
    Mr. Washburn. Absolutely.
    Senator Begich. I know I am out of time, Mr. Chairman, but 
I will submit other questions for the record if that is okay.
    The Chairman. Absolutely. Thank you.
    Senator Barrasso, we appreciate your being here. We 
appreciate your courtesy for the previous ones.

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

    Senator Barrasso. Thank you, Mr. Chairman, for holding this 
hearing on the President's Fiscal Year 2015 budget request for 
tribal programs.
    We all recognize the Federal Government has important 
responsibilities in Indian Country. Public safety, education 
and health care are just a few. Carrying out the 
responsibilities requires money and as I have stated before, 
priorities and spending will receive increasing scrutiny, 
especially with the enormous Federal deficit.
    Agencies are called upon to find a more efficient manner of 
operating and promoting economic development, especially and 
particularly for Indian communities. Earlier this month, I 
introduced S. 2132, the Indian Tribal Energy Development and 
Self Determination Act Amendments for 2014.
    This bill is going to streamline the bureaucracy of Indian 
energy resource development and in turn facilitate long term 
job development and economic growth.
    Secretary Washburn, I have a couple of things.
    In reading the testimony from both you as well as from Dr. 
Roubideaux, you highlight several behavioral health initiatives 
as top priorities, appropriately. The Bureau of Indian Affairs 
proposes a new family initiative to address violence and 
substance abuse within Indian communities related to what 
Senator Begich talked about in terms of crime.
    How is your agency coordinating with tribes and the Indian 
Health Service to effectively implement these interrelated 
initiatives?
    Mr. Washburn. Our Tiwahe Initiative, our family initiative, 
is a request for the fiscal year 2015 budget which we do not 
have yet. Let me say we have already started planning in the 
hope we will have it funded and it will require coordination.
    So far it is an initiative in concept. We have not had 
lengthy conversations with our partners in IHS and elsewhere 
about that but that is certainly something we need to do. We 
need to take a much more holistic attitude towards these 
problems.
    Senator Barrasso. I appreciate your efforts and direction.
    I mentioned the energy bill I introduced again this 
session. Your written testimony notes that the Bureau of Land 
Management is requesting $16.9 million for programs such as oil 
and gas to support Native Americans.
    The Bureau of Land Management also requested a $6,500 fee 
for submitting an application for a permit to drill for energy. 
The Bureau of Land Management has stated in recent budget 
justifications that this fee is to offset the application 
processing costs.
    I am looking for an explanation in detail of what makes up 
those processing costs for the applications for a permit to 
drill?
    Mr. Washburn. Thank you for your leadership on Indian 
energy issues. We know you are concerned about those and have 
been a constructive partner on those issues.
    I can't tell you what all the specific costs are. We 
probably need to get someone from BLM to do that better. I will 
tell you there has always been frustration about how slow we 
are to issue our APDs at BLM. The good news about those costs 
is they go to offset the costs so that BLM can process more of 
those. That is a good thing because it requires the people who 
want to drill to bear the cost of the drilling, the processing 
costs and the government.
    I am not sure exactly what each of those costs is but we 
work very closely with BLM on processing these APDs. We have a 
part to play and they have a role to play as well. That is one 
reason why, Mr. Chairman, those figures you put up on the board 
where you say BLM is funded higher than BIA, some of the BLM 
money actually benefits Indian tribes also. That happens and 
that is why some of those figures aren't so obvious.
    We would be happy to get back to you with a clearer answer 
exactly accounting for those figures.
    Senator Barrasso. I'd appreciate it.
    Dr. Roubideaux, we talked a little bit in the past about 
the cost to construct all facilities on the current Indian 
Health Care Facility Priority List. It is over a billion 
dollars. I think in your testimony was it was $1.2 billion. I'm 
sorry, over $2 billion, I can't read my own writing.
    I have also emphasized to you a number of times that the 
primary health care facility on the Wind River Reservation in 
Wyoming is nearly 140 years old. We have only been a State in 
Wyoming for 124 years. It was there before we became a State.
    It would astonish everyone in this room, I would imagine, 
to know that the facility is not even on the priority list. We 
are talking about a priority list of $2.1 billion and it has 
not even made it to the priority list yet.
    The last time I asked, you said you would be happy to work 
with us. I just what to know what has happened since we last 
visited? Have you personally worked with the Wyoming tribes to 
develop a plan and a timeline for addressing their facility 
needs?
    Dr. Roubideaux. We address the facility needs in a number 
of ways. The first is the list which by law we have to address 
all of those facilities but we do have other ways to address 
health care facilities construction. I know Wind River has been 
interested in the joint venture program.
    The good news I have to share today is that we are 
approving the last three agreements from the last round of 
applicants. Wind River is one of them. We can move forward with 
that joint venture agreement.
    We also plan to open a new round of applications for joint 
venture later this year. We are trying to look at other 
innovative ideas in addition to trying to fund the Health Care 
Facilities Construction List and trying to move forward on some 
of these other programs.
    Senator Barrasso. Hopefully we can continue to work 
together on this because it continues to be an issue of concern 
for many.
    Thank you, Mr. Chairman.
    The Chairman. Senator Murkowski.

               STATEMENT OF HON. LISA MURKOWSKI, 
                    U.S. SENATOR FROM ALASKA

    Senator Murkowski. Thank you, Mr. Chairman.
    Welcome to you both, Mr. Washburn and Dr. Roubideaux. Thank 
you for all that you do.
    From a budgetary perspective today, I am going to focus my 
questions on some of the programs that really have impact on 
our tribal governments and our village clinics. These are the 
small and needy tribes account at BIA and the Village Built 
Clinic Lease Program at IHS.
    We have clearly seen the benefit of these programs but 
considering these programs keep the village governments, and 
the village clinics open, it is important we pay attention to 
them as priorities.
    Oftentimes they get kind of swept under with all of the 
other big things we are dealing with. I appreciate the 
discussion you have had with Chairman Tester as well as Senator 
Begich on contract support costs and the advances we have made 
which were long and hard fought but I think we are on the right 
track. I agree with Senator Begich, we need to make sure that 
it continues on that track.
    I am also very curious, Dr. Roubideaux, to hear greater 
clarity from the Administration in terms of our request on the 
advance appropriations. That is an area where I look at the 
trust responsibility we have to our Native people which is akin 
to our obligation to our veterans.
    If we can provide greater certainty to our veterans, if we 
can assure that during times of furloughs and cutbacks that 
they don't see that reduction, I would certainly like to think 
that we can afford the same to our Native people as well. I 
would be curious to hear your response to that.
    Mr. Washburn, on the small and needy tribes issue, the BIA 
budget justification describes the background behind the small 
and needy tribes account, the initiative that was advanced in 
the early 1990s. It was the 1994 Joint Tribal Advisory Task 
Force on BIA Reorganization that made the recommendation to 
provide the small tribes with a base of $160,000 and in that, 
the recommendation for Alaska tribes was $200,000 as a base. Of 
course we know that this has never been met.
    You always feel you have to make a special case but we 
know, you know, both of you, that the costs in rural Alaska are 
tremendously high. Utility bills are eight to nine times higher 
than they are in the lower 48. In Noatak, in the northwest 
Arctic area, they are looking at energy costs of 87 cents a 
kilowatt hour as compared to about 11-11.5 cents in other parts 
of the lower 48.
    The cost to keep the lights on and the cost to heat a 
building is extraordinarily expensive for our tribes. Given the 
minimum amount of funding they receive, it is not penciling. 
Our tribal populations are growing. We have seen a 19 percent 
increase in the Bering Strait region in the past ten years.
    Population has gone up, costs are going up and yet, the 
assistance for our small and needy tribes has not moved. I 
guess the question to you, Mr. Washburn, is given what we have 
seen within BIA necessary budget increases for public safety 
and school operations, and I am not complaining about it, we 
know these programs are not eligible for our Alaska tribes.
    Can you give me any kind of commitment or assurance that we 
might see a base funding level to Alaska tribal governments of 
the $200,000 that was recommended in that report? What is the 
future of this?
    Mr. Washburn. I am relatively new to this issue, so I guess 
I would like to take it back and respond to you in writing.
    We do have a Small and Needy Tribes Program. It sounds like 
you are saying we have a shortfall that we don't provide 
$200,000 to each of the Native villages in Alaska. My 
understanding is we only have about five tribes in the lower 48 
still involved in the Small and Needy Program because the base 
of $160,000 has been eclipsed by the regular funding.
    The idea behind the Small and Needy Program was it sort of 
provided a base funding in case your ordinary funding didn't 
rise to $200,000 or $160,000 in the lower 48. We can look at 
that. We can look to see what the shortfall is and talk to you 
more about that and try to figure out what is the shortfall and 
what is needed to solve that. With 229 Alaska Native villages 
and $200,000 for each, we are talking real money.
    Senator Murkowski. We are talking real money. I clearly 
understand and appreciate this. I also appreciate your 
willingness to take a look at it if you are not familiar with 
it. Again, some of the programs available for our tribes in the 
lower 48 through BIA are simply not available to the Alaska 
tribes.
    If we are going to treat all of our Native people on some 
level of funding parody, I think this is an area we need to be 
looking at. If you are willing to explore it with your staff 
and mine sitting down, I would certainly welcome that.
    Mr. Washburn. We would be happy to.
    Senator Murkowski. Dr. Roubideaux, we have had good 
opportunity to talk about the success we have seen with our 
dental health aid therapy program in our tribal communities. I 
think it is something we point to as a source of pride, an 
innovative way to be able to provide for oral health care needs 
of our Native people in areas where we are not going to see 
dentists out there on a regular basis.
    I have been pleased with how we have built that forward. It 
is important that we continue to see the support of the DHAT 
program in the budget process in order to see these 
improvements in access to the care.
    The other program that we follow closely, on which you and 
I have had a conversation, that is essential to delivering 
basic health services in our remote Native communities is the 
Village Built Clinic Lease Program. The Indian Health Care 
Improvement Act mandates that IHS develop and operate the 
community health aid program of which the funding for the VBCs, 
these leases are essential. The Village Built Clinic Program 
that really helps keep our health clinic doors open.
    Going back to the rising costs that we see directly related 
to energy that impacts our utilities, VBCs only cover 55 
percent of clinic operating costs. IHS has not increased the 
lease rental since 1989. I know we have had a chance to talk 
about it before. In previous conversations, you indicated this 
was something you would like to look into to gain a better 
understanding.
    I really think we are in a situation and I hear from so 
many of our tribes that they just don't know where to turn. It 
would appear that some of our more remote communities are just 
kind of forgotten. I cannot forget them, will not forget them.
    My question to you with both these programs is, the Dental 
Health Aid Therapy Program and the Village Built Clinic, what 
are you doing to address both of them within the context of 
this budget we have before us?
    Dr. Roubideaux. We definitely see the success of the Dental 
Health Aid Program in Alaska. We actually posted on my 
director's blog a very positive position paper showing our 
support for that program. In terms of the budget formulation 
process, we definitely want to continue to work with you on 
that and also on the Village Built Program.
    As I think about all the programs in Alaska are 638 and 
there is the ability to rebudget their programs. We are 
proposing an increase in medical inflation in 2015. I wonder if 
maybe that kind of increase gives tribes the flexibility to put 
funds into different areas they might have a need.
    We are interested in talking with you more and working with 
you. I know a work group has been formed in Alaska and I 
believe there is some new information they want to share on the 
needs related to village built clinics. We are definitely 
willing to continue to work on this issue with you.
    Senator Murkowski. My time has expired so I will be very 
quick. Are you saying that contained within your fiscal year 
2015 budget, you think you have funding flexibility with this 
inflation factor or not?
    Dr. Roubideaux. Because the tribes manage the programs 
under the ISDA contracts and compacts, they can rebudget and 
reprogram however they want. As we look at the increases in the 
budget, we are proposing a $63 million increase in medical 
inflation. It is really up to the tribes how they use those 
funds. That might be a way to address some of these needs.
    Senator Murkowski. It is not necessarily taking it from 
another budget category where we are arm wrestling with 
somebody else?
    Dr. Roubideaux. This is on top of. In particular, we have 
talked about the hospitals and clinics line item and the 
medical inflation increase does include increased funding for 
the hospitals and clinics line item. Under the ISDA, tribes are 
able to rebudget funds however they want.
    Senator Murkowski. Is there anything separate for VBCs, for 
the village built clinics?
    Dr. Roubideaux. There hasn't ever been a separate line item 
for village built clinics in the budget. There was conference 
language that mentioned it many years ago, but it really can be 
in the hospital and clinic line item and any funds could be 
used towards leases in that particular line item. That is part 
of the great thing about tribal management, the flexibility 
with ISDA.
    The challenge, of course, is there are many other 
priorities and each tribe makes decisions about what they need 
to fund. We are hoping that this increase in medical inflation, 
once it gets to the local level, each tribe can make choices 
about how they allocate those funds.
    Senator Murkowski. I would be interested in learning a bit 
more about that. I recognize we can have very successful, 
innovative programs like the DHAT Program and have these 
programs like VBC that have been critical in maintaining these 
clinics but we have to make sure that we have the funds in the 
budget to allow for that going forward.
    As you gain more information from some of our tribes on 
this and we can better understand what is going on within the 
medical inflation account, perhaps we can build on that.
    Thank you, Mr. Chairman. Thank you for the additional time.
    The Chairman. Absolutely. Thank you, Senator Murkowski. I 
appreciate your line of questioning.
    Secretary Washburn, over the last month and a half I have 
toured most of the reservations, some of them twice. I will 
tell you they have some great new facilities I can think of 
across Highline 3, as a matter of fact, that have facilities 
that are brand new that aren't open and they are done. They are 
not open because they don't have staffing.
    I was wondering how your department works with other 
Federal partners, DOJ, the Indian Health Service, the 
Department of Education, to ensure that operations and 
maintenance expenses are being fully funded for these new 
facilities because it is really frustrating that we have 
literally state of the art facilities that are either partially 
open or not open at all.
    Mr. Washburn. To the extent those are detention facilities, 
we fund our existing detention facilities at 55 percent of 
need, which is not adequate. Tribes are frustrated by that. We 
increased our funding in the operating plan we just finished 
for fiscal year 2014. We increased the fund by $14.3 million 
for new facilities that have come on line.
    If we used all of that $14 million for the new facilities, 
including one at Ft. Peck, we would be funding those facilities 
at 88 percent of need but meanwhile, our existing facilities 
would be at 55 percent of need.
    We are trying to figure out a more fair way to allocate 
that money. We may very well be spreading around that money a 
little bit more to not just include the six newest facilities 
but some of the other relatively new ones like the ones you are 
talking about that have come online in the last few years.
    That will not be 100 percent of need for staffing but it 
will be much closer to what the tribes need.
    The Chairman. The bottom line in almost every other 
question I have asked, you understand this and I know you get 
it, right now there just aren't the resources there to open 
these facilities. I am not going to say it is almost criminal 
because it is criminal because in a lot of these cases, we have 
criminals walking the streets because they don't have a 
facility to put them in.
    Ft. Peck's water system and the O&M associated with this is 
a BIA obligation. You know the BIA and the tribe negotiated the 
amount of money that is required to operate this project and 
that the tribes executed the Indian Self Determination Act 
contract based on those negotiations.
    The BIA only requested $750,000 for the operation, 
maintenance and repair of the water project that provides water 
to frankly most of the folks on the Ft. Peck Reservation. Why 
is BIA having so much trouble determining the cost of 
operation, the cost of repair and maintenance of this project?
    Mr. Washburn. Chairman Tester, I am not sure why that is. 
Last year I think we over funded the project for operation and 
maintenance. Because of that, this year we lessened that 
amount. We are committed to funding it at the proper amount 
going forward, but we were trying to average out for the last 
two years basically so we get to the right amount.
    We do want to see that project with the right amount now 
that it is finished so it can continue going forward. We will 
certainly work with you when it comes to the fiscal year 2016 
budget formulation to get it right. We hope it averages out for 
fiscal years 2014 and 2015.
    The Chairman. Which brings up another issue, an issue we 
tend to create around here, not you, and that deals with 
government shutdowns and reserve accounts. What is your 
perspective on reserve accounts as they apply to government 
shutdowns?
    Mr. Washburn. The government shutdown is the best reason I 
see to having tribes running these programs because they can 
keep operating even if the Federal Government is shutdown but 
they have to have the money to do so. We need to create 
flexibility in the system to ensure they can do so.
    The Chairman. I would hope we can figure out what the 
amount is supposed to be and get it there. Quite frankly, if I 
was running the water system right now, seeing what I saw last 
fall, I wouldn't deplete my reserve account either.
    I want to talk a little bit about education and I will move 
on to Dr. Roubideaux because I know she doesn't want to get 
left out of this conversation.
    Secretary Jewel testified before this Committee that Indian 
education is an embarrassment. We have looked at the budget and 
I am curious to know, Secretary Washburn, what you think is in 
this budget that would change that perception?
    Mr. Washburn. Thank you for asking the question. I do have 
the BIA Director, a new permanent BIA Director, Monty Roessel, 
here with me today.
    We are studying Indian education really hard right now. 
Secretary Arne Duncan is very interested in this and of course 
Secretary Jewel. She knew when she made that statement, she 
needed to do something about it, so I have clear marching 
orders.
    We have a study group working on this. I notice you put up 
some charts about the Department of Defense education.
    The Chairman. It's right there.
    Mr. Washburn. It's right there.
    The Chairman. That is not apples and oranges.
    Mr. Washburn. No, that is not apples and oranges. That 
makes we think maybe we should move the BIA back into the War 
Department because they are funding their schools well in the 
Department of Defense.
    One of the things I mentioned early on was the President 
has proposed we are going to live within the Murray-Ryan budget 
caps, but if there are new revenues, we have already projected 
how we would spend those new revenues. One of the areas is for 
Indian education.
    We have a study group. I know study group doesn't sound 
like a big deal. You can certainly put together a study group 
at any time but we are really committed to doing something with 
Indian education once the study group comes up with 
recommendations.
    The White House has been engaged in this and two Cabinet 
Secretaries and Mr. Roessel, the Director. I am confident we 
are going to be moving forward with some real improvements in 
Indian education.
    The Chairman. I appreciate that. Do you agree that Indian 
education is a trust responsibility?
    Mr. Washburn. It certainly is. It is in some of the 
treaties. Some of the treaties include words about education.
    The Chairman. You answered that correctly. Thank you.
    Do you think the OMB understands that education is a trust 
responsibility?
    Mr. Washburn. Yes. I know in theory they think it is a 
trust responsibility.
    The Chairman. I think it is really important. Secretary 
Jewel thinks it is important, the Secretary of Education thinks 
it is important, and I would dare say I absolutely do and I 
think a vast majority of people on this Committee agree when it 
comes to getting people out of poverty, this is the best way to 
get it done. There is a lot of poverty in Indian Country.
    Thank you very much. I appreciate your testimony. I have 
some other questions for the record.
    Dr. Roubideaux, correct me if I am wrong, there are about 
1,500 claims out there for contract services, correct?
    Dr. Roubideaux. It depends on who you ask, but the running 
tally of total claims is over 1,300, probably over 1,400. The 
pending ones now are about 1,200 and some.
    The Chairman. Let's use the smaller number, let's say it is 
1,200. There have been about 200 claim offers to tribes of that 
1,200, correct?
    Dr. Roubideaux. Yes.
    The Chairman. How long have we been working on this?
    Dr. Roubideaux. We have been working on this since the 
Ramah decision came down which was in June 2013.
    The Chairman. June 2013, so we are about nine months in?
    Dr. Roubideaux. Yes.
    The Chairman. How many of those 200 claims that have been 
offered, not counting the ones on your blackberry today, have 
been settled?
    Dr. Roubideaux. Of the 200 claims, we have 41 claims 
formally settled with tribes, 68 offers accepted by tribes but 
they are in process, so it is about 104 settled. That is $133 
million worth.
    The Chairman. How many settled out of the 200?
    Dr. Roubideaux. 104.
    The Chairman. 104 have been settled out of the 200. Did you 
say the process started in June 2013 or June 2012?
    Dr. Roubideaux. I'm blanking right now, so I will get back 
to you but we have been working very hard on it for so long, I 
can't remember.
    The Chairman. I will just tell you this. We had this 
conversation in my office before and I know you guys are 
working hard to get it done, but in the overall scheme of 
things, with 1,200 claims, potentially more than that, 104 have 
been settled, 200 have been offered, the reason I am hearing 
from tribes and the reason many people on this Committee are 
hearing from tribes is because they are frustrated that it is 
not moving faster.
    I would tell you that we have to figure out how to move the 
ball forward. We just have to figure it out because it is not 
going to get easier for me or for you if this doesn't move 
quicker.
    I want to talk about Indian health care and sanitation 
facilities. I think the Ranking Member talked about it from an 
Indian health care facility standpoint. I want to talk about it 
from both because this Administration has reported that there 
is a $10 billion backlog for health care facility and 
sanitation facility construction, yet the request is $150 
million. I know those are all big numbers but $150 million of 
$10 billion is 1.5 percent.
    Talk to me. We are it even keeping up with inflation and 
inflation is pretty low.
    Dr. Roubideaux. I hear your frustration on this. We are 
frustrated as well. These are difficult budget times and with 
available funds, we are not able to fund all tribal priorities 
but we do believe these are extremely important priorities.
    That is why trying to use the Opportunities Growth and 
Security Initiative to get more construction funds for health 
facilities could help us. That is why we are collaborating with 
other agencies to leverage other funds to try to see if we can 
make some progress. It is an enormous need and we are very much 
interested in working with you on this.
    The Chairman. I could go down the same list of questions I 
did with Secretary Washburn but I won't. I will tell you if you 
look at this backlog, we are talking about backlogs in health 
care facilities construction and talking about sanitation 
facilities construction. There is no way we are going to get 
our arms around the health impacts of these two deficiencies.
    I dare say that we are running way, way more than $150 
million in additional expenses because we are this far behind 
on these two arenas.
    When we talk to OMB in all these things, I just think it is 
very, very important that we talk about what is happening on 
the ground because it is really important. This quality of 
life, this is health care, this is the ability to go to school, 
this is the ability to get educated. We need to fix it.
    Eighteen million dollars for health care education in this 
budget request, as I alluded in my opening comments, we can 
invest now in a lot of these things or we can invest later. I 
can tell you on a lot of the reservations in Montana, and I am 
learning more about it since I have gotten this position around 
the country, we are seeing unemployment rates through the roof 
and we are seeing a shortage of nurses and an incredible 
shortage of doctors.
    It would seem to me that this is just an incredible 
opportunity, with the challenges that are out there, to make 
some investments, whether it is through tribal college, which 
would be my first choice, or some other arena to help push 
Native American people into health care to take care of their 
own.
    They are good paying jobs, there is a huge need out there. 
The question is, when you go to OMB, the President, Sally 
Jewel, or whoever it may be, what are we talking about when it 
comes to investment in health care education? Have we talked 
about it? It is a priority but it doesn't seem to be a priority 
when it comes to money.
    Dr. Roubideaux. It is definitely a priority to our agency 
because we know there is a great need. Our fiscal year 2015 
budget proposal includes the medical inflation which could be 
used to hire more providers. We also have the proposal to 
exempt our scholarship and loan repayment programs from 
taxation which would allow us to give more awards which would 
allow us to be able to improve the pipeline.
    We are definitely interested in working with you on this in 
the budget formulation process.
    The Chairman. I will make a statement and we will get to 
the next panel. I appreciate your patience, I appreciate your 
testimony and I appreciate your willingness to sit here and 
answer questions over a budget.
    When Byron Dorgan was Chairman of this Committee, we had 
the same conversation with different people sitting in your 
chairs. I would just say that when we look at budgets for 
Indian Country, we need to look at it from the standpoint of 
what challenges are out there and what needs are out there and 
if we are doing anything to close the gap.
    I will be honest. If you just took health care, if you just 
took the facilities budget, or if you just took loan 
forgiveness or this $18 million for health education or 
whatever it might be, my daughter happens to be a nurse. It is 
a good job. There is a lot of opportunity out there to take 
care of folks.
    I also live in a small town in rural America, frontier 
America, and I know how hard it is to get people off 
reservations to come and work there. We have a tremendous 
opportunity. Whether it is your department, your agency, Health 
and Human Services and Secretary Sebelius or OMB, we need to 
try to get across this message.
    All you have to do is step into Indian Country. Some of 
them who have the resources are doing a great job but those who 
don't have the resources, it is not good. It is just not good.
    We have some other questions for the record that we will 
put in for you, Dr. Roubideaux, as well as Secretary Washburn. 
Once again, I want to thank you for your testimony and we will 
be visiting as we move forward on budget issues and everything 
else.
    Thank you for your service to the country.
    We will start with the next panel. The next panel consists 
of the Honorable Aaron Payment, Midwest Area Vice President, 
National Congress of American Indians and Chairman, Sault Ste. 
Marie Tribe of Chippewa Indians of Sault Ste. Marie, Michigan.
    Mr. Payment was elected October 16, 2013 to serve a two 
year term as Midwest Area Vice President of the National 
Congress of American Indians. His resume is good and 
impressive. It is good to have you here and look forward to 
your testimony.
    Then we have the Honorable Andrew Joseph, Jr., Member-at-
Large and Portland Area Representative, National Indian Health 
Board here in Washington and Chair, Northwest Portland Area 
Indian Health Board in Portland, Oregon.
    Andrew Joseph, Jr. was elected in March 2013 as Member-at-
Large and Portland Area Representative of the National Indian 
Health Board. Andrew also has a very impressive resume which I 
could go through but their testimony is more important than the 
accolades at this point in time.
    I would say thank you very much for being here. Before you 
give your testimony, I very much value it and I appreciate you 
taking the time to tell us what is going on from your 
perspective.
    As with the previous presenters, we are going to give you 
five minutes but your entire written testimony will be made a 
part of the record. It might just be you and I on question and 
answer but maybe someone will show up again.
    At any rate, we will start with you, Mr. Payment, and then 
go to Mr. Joseph.

 STATEMENT OF HON. AARON PAYMENT, MIDWEST AREA VICE PRESIDENT, 
  NATIONAL CONGRESS OF AMERICAN INDIANS; CHAIRMAN, SAULT STE. 
                    MARIE TRIBE OF CHIPPEWA 
                            INDIANS

    Mr. Payment. Good day. My name is Aaron Payment. I am 
Chairperson of the Sioux Tribe.
    As Congress considers the fiscal year 2015 budget and 
beyond, tribal leaders call on Congress to ensure that the 
promises made to Indian Country are honored in the Federal 
budget. Please remember just as we do not have the discretion 
to renege on our millions of acres of land cessation, we ask 
that you no longer exercise your trust obligation as 
discretionary.
    With accumulated impacts of level funding, budget cuts and 
sequestration in some cases amounting to up to 30 percent cuts 
since the Clinton era, the continued trust obligation of the 
Federal Government is threatened. These cuts feel very much 
like an abrogation of the treaty and trust obligations.
    NCAI's President Cladoosby would remind you this is your 
duty, you are our trustee. Please serve with honor and put the 
trust in trustee. When people ask why honor such antiquated 
documents like Indian treaties, I remind them that they are 
pursuant to the U.S. Constitution and judicial decisions and 
remember the Constitution is older.
    My written testimony calls for the equitable funding for 
tribal governments across the board and then addresses specific 
proposals in the Administration's fiscal year 2015 budget, 
including the Bureau of Indian Affairs, Indian Health Services, 
Natural Resources and Environment, Education and Public Safety 
and Justice.
    NCAI, in collaboration with national, regional and issue 
specific tribal organizations has developed comprehensive 
recommendations included in the fiscal year 2015 Indian Country 
budget request. We request for the document to be entered into 
the record.
    For the remainder of my time, I would like to hit a few 
highlights to sound the clarion call for equitable funding for 
tribes.
    Even with the inroads and understanding of trust 
obligation, Indian Country continues to experience what the 
U.S. Commission on Civil Rights in 2002 called the ``quiet 
crisis of Federal funding and unmet needs.''
    The Indian Health Service is currently funded to meet only 
about 56 percent of the need despite being the primary provider 
of health care for many tribal communities. In 2002, IHS per 
capita expenditures for patient health services were just 
$2,896 compared to $7,535 per person for health care spending 
nationally. This is a disparity of nearly the magnitude of 
three times.
    For my tribe, for 66 percent of the citizens not residing 
near our health care delivery system, their health needs remain 
unmet. The response, intended or not, to access Medicaid fails 
to recognize the trust obligation, besides hundreds of 
thousands of tribal citizens across the country live in States 
where Medicaid expansion simply did not occur.
    Please restore leftover 2013 IHS budget cuts due to 
sequestration. We lost ground. The rural nature of our health 
care system, so far my tribe lost six providers just since last 
fall due to the shutdown and sequestration. I fear this will be 
even more devastating if special diabetes is not renewed and 
one year is the least of what we are looking for.
    Due to these losses, we desperately ask Congress to move 
our funding from discretionary to non-discretionary and support 
advance funding to further avoid losing ground.
    We ask that Congress fully fund contract support and 
reinstate sequestration losses. Again, fully funding contract 
support is mandated by the Supreme Court in the Ramah case. 
However, fully funding contract support but cutting other areas 
appears like a sleight of hand or punishment.
    We support the President's request for $251 million to 
fully fund contract support but please don't cut services to 
IHS or infrastructure to do so. Otherwise, we will experience a 
net loss.
    To give you the importance of health care in our community, 
life expectancy for American Indians and Alaska Natives is 4.1 
years less than it is for the general population. In my family, 
our life expectancy is 60 years, with one exception. How many 
years would you have left? I have 12 if we live the expectancy.
    We support the BIA's increase of at least $33.8 million or 
1.4 percent above the fiscal year 2014 enacted level. However, 
with congressional mandate to fully fund contract support, this 
will mean inevitable cuts to Indian programs and essential BIA 
infrastructure. After a year of sequester cuts, now making do 
with sequestration is an impossible burden to place on the BIA.
    With Interior budgets, some budgets are projected to 
increase up to 22 percent. Ours is really the least of it. Ours 
is the very least. A joke was made the other day, maybe Indians 
should move to the national parks. However, that is to a good 
idea either because the Navajo haven't been able to move 
forward some of their housing development because they are 
located in national parks, so that is really not the solution.
    We have the highest dropout rate of any racial ethnic 
population in this country. This has not increased in the last 
ten years. We need greater effort in Indian education. Impact 
aid is critically important because 90 percent of our kids go 
to public schools and depend on the funding that comes from 
impact aid. I hope there are questions so we can flush that out 
later.
    I have much, much more that I could address but I think I 
am out of time. There is a lot more in my written testimony. I 
hope that you lots and lots of questions for me.
    Thank you.
    [The prepared statement of Mr. Payment follows:]

Prepared Statement of Hon. Aaron Payment, Midwest Area Vice President, 
National Congress of American Indians; Chairman, Sault Ste. Marie Tribe 
                          of Chippewa Indians


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    The Chairman. Thank you, Mr. Payment.
    Mr. Joseph, you are up.

STATEMENT OF HON. ANDREW JOSEPH, JR., MEMBER-AT-LARGE/PORTLAND 
                 AREA REPRESENTATIVE, NATIONAL 
             INDIAN HEALTH BOARD; CHAIR, NORTHWEST 
               PORTLAND AREA INDIAN HEALTH BOARD

    Mr. Joseph. Good afternoon, Chairman Tester.
    I thank you for holding this important hearing on the 
fiscal year 2015 budget.
    On behalf of the National Indian Health Board and the 566 
federally-recognized tribes we serve, I submit this testimony.
    My name is Andrew Joseph, Jr. I am an at-large executive 
committee member of the National Indian Health Board. I also 
serve as the Chair of the Northwest Portland Area Indian Health 
Board and as tribal co-chair to the National Tribal Budget Work 
Formulation Work Group.
    First, I would like to thank the Committee for the work it 
has done to advance health care priorities for our people. In 
fact, due to the help of many members of this Committee, we 
were able to change the mind of the Administration on contract 
support costs. For this and all you have done and continue to 
do for the first people of this country, thank you.
    Despite important changes in health care funding we have 
achieved over the last several years, we still experience many 
disparities. I look back home to my tribe and see us burying 
too many people. It is tough to be here at meetings in 
Washington and see three or four of our people have passed by 
the time I get home. This has to stop. The Federal Government 
has not fulfilled its promise and our people continue to 
suffer.
    Considering the level of funding appropriated to IHS, these 
statistics are not surprising. In 2013, the IHS per capita 
expenditure for patient health services was $2,800 compared to 
almost $8,000 per person for health care spending nationally. 
The first people of this Nation should not be last when it 
comes to help. Let's change that now.
    For fiscal year 2015, NIHB echoes the recommendations for 
the Tribal Budget Formulation Work Group and recommends $5.3 
billion for IHS overall. This request would allow the funding 
of current services and include program expansion increases in 
several key areas including Purchased/Referred Care hospitals 
and clinics, mental health, alcohol and substance abuse.
    These programs represent the core of IHS work and areas of 
most critical need to our people. You will see in NIHB's 
written testimony greater details about each priority.
    We also ask that sequestration cuts from fiscal years 2013 
and 2014 be fully restored. Congress did not provide enough 
funding to fund contract support costs and restore the 
sequestration or provide increases in the other crucial service 
areas. Some accounts even received cuts beyond the fiscal year 
2013 sequestration level in fiscal 2014. This, combined with 
medical inflation and additional staffing costs has not really 
allowed these budgets to move forward. We are once again losing 
ground in addressing health disparities suffered by our people.
    I would also like to support several policy changes that 
would enable our IHS budget to be used in a better way. NIHB 
strongly supports Medicare-like rates for IHS Purchase/Referred 
Care. In 2003, Congress enacted legislation to require hospital 
providers to only pay Medicare-like rates when billing IHS 
through the Purchase/Referred Care Program, but non-hospital 
providers do not have this requirement.
    We also echo the recommendation of the GAO who said that 
reimbursements for providers should be capped at Medicare-like 
rates.
    Advance appropriations for IHS would allow tribally 
operated IHS programs to know what kind of funding they have a 
year in advance. This would mean that we could not only save 
the administration cost but would also be able to provide a 
better compendium of care for our people.
    Finally, we support the immediate renewal of the Special 
Diabetes Program for Indians. This is saving lives and taxpayer 
dollars and must be renewed now.
    You will see additional policy recommendations detailed in 
our written testimony. Thank you again for this opportunity to 
testify before the Committee today and for all the work you do 
to support Indian health.
    I am happy to answer any questions you might have.
    [The prepared statement of Mr. Joseph follows:]

Prepared Statement of Hon. Andrew Joseph, Jr., Member-At-Large/Portland 
  Area Representative, National Indian Health Board; Chair, Northwest 
                   Portland Area Indian Health Board
    Chairman Tester, Vice Chairman Barrasso, and Members of the 
Committee, thank you for holding this important hearing on the FY 2015 
President's Budget Request. On behalf of the National Indian Health 
Board and the 566 federally-recognized Tribes we serve, I submit this 
testimony.
    First, I would like to start by thanking the members of this 
committee for their dogged determination in advocating for the rights 
of American Indian and Alaska Native (AI/AN) peoples. Consistently, 
this committee has been willing and ready to stand up for the trust 
obligations the Federal Government has toward American Indians and 
Alaska Natives. The United States assumed this responsibility through a 
series of treaties with Tribes, exchanging compensation and benefits 
for Tribal land and peace. The Snyder Act of 1921 (25 USC 13) 
legislatively affirmed this trust responsibility. To facilitate 
upholding its responsibility, the Federal Government created the Indian 
Health Service (IHS) and tasked the agency with providing health 
services to AI/ANs. Since its creation in 1955, IHS has worked to 
fulfill the federal promise to provide health care to Native people.
    In passing the Affordable Care Act, Congress also reauthorized and 
made permanent the Indian Health Care Improvement Act (IHCIA). In 
renewing the IHCIA, Congress reaffirmed the duty of the Federal 
Government to American Indians and Alaska Natives, declaring that ``it 
is the policy of this Nation, in fulfillment of its special trust 
responsibilities and legal obligations to Indians--to ensure the 
highest possible health status for Indians and urban Indians and to 
provide all resources necessary to effect that policy.''
Health Discrepancies for American Indians and Alaska Natives
    Despite these promises, the health of AI/ANs continues to fall far 
short of the health status of all other Americans. The AI/AN life 
expectancy is 4.1 years less than the rate for the U.S. all races 
population. AI/ANs suffer disproportionally from a variety of diseases. 
According to IHS data from 2005-2007, AI/AN people die at higher rates 
than other Americans from alcoholism (552 percent higher), diabetes 
(182 percent higher), unintentional injuries (138 percent higher), 
homicide (83 percent higher) and suicide (74 percent higher). 
Additionally, AI/ANs suffer from higher mortality rates from cervical 
cancer (1.2 times higher); pneumonia/influenza (1.4 times higher); and 
maternal deaths (1.4 times higher).
    Devastating health risks from historical trauma, poverty and a lack 
of adequate treatment resources also continue to plague Tribal 
communities. According to IHS data, 39 percent of AI/AN women 
experience intimate partner violence, which is the highest rate of any 
ethnic group in the United States. One in three women in AI/AN 
communities will be sexually assaulted in her lifetime. AI/ANs suffer 
at higher rates from psychological distress; feelings of sadness, 
hopelessness and worthlessness; feelings of nervousness or restlessness 
and suicide. Additionally, public health risks due to alcohol and 
substance abuse are sadly widespread in many Tribal communities, 
leading to other health disparities such as poverty, mental illness, 
and increased mortality from liver disease, unintentional injuries and 
suicide. Dental health concerns also continue to affect AI/ANs at 
higher rates than other Americans. Ninety percent of AI/AN children 
suffer from dental caries by the age of eight, compared with 50 percent 
for the same age in the US all races population. Our children ages 2 to 
5 have an average of six decayed teeth, when children in the U.S. all 
races population have only one.
    Clearly, more must be done to alleviate these health risks for our 
people and to fulfill the trust obligations to AI/ANs. When considering 
the level of funding appropriated to IHS, these statistics are not 
surprising. In 2013, the IHS per capita expenditures for patient health 
services were just $2,849, compared to $7,717 per person for health 
care spending nationally. Despite the historic increases that Congress 
has given to the IHS budget over the last several years, funding 
discrepancies unambiguously remain. The First People of this nation 
should not be last when it comes to health. Let's change that now.


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Sequestration in FY 2013 and the FY 2014 Budget
    As the Committee is well aware, the IHS budget lost $220 million 
due to sequestration in FY 2013. This, combined with the two week long 
government shutdown at the start of FY 2014 was devastating many Tribal 
health programs. Many sites cut patient visits, furloughed staff and 
delayed or denied needed medical procedures. The tragedy of 
sequestration in Indian Country was a clear denial of the federal trust 
responsibility to Tribes and our communities became, yet again, an 
unfortunate victim of unrelated political battles in Washington. As 
then Senate Committee on Indian Affairs Chairwoman Maria Cantwell 
stated on November 14, 2013, ``Our country's financial troubles are not 
really stemming from our obligations to Indian Country, and frankly, 
we're not doing a good job in fulfilling those obligations.''
    The Congress, in the FY 2014 budget did make a commitment to 
replace some of the funding lost due to sequestration in the previous 
year. However, due to priorities outlined by Congress and the rightful 
funding of Contract Support Costs, the IHS was not able to alleviate 
sequestration across most accounts and provided only nominal increases 
for those where the funding was restored. Some accounts even received 
cuts beyond the FY 2013 sequestration level in FY 2014. This, combined 
with medical inflation and additional staffing costs, have not really 
allowed these budgets to move forward. Despite receiving these urgently 
needed increases, we are once again losing ground in addressing health 
disparities suffered by our people.
    For FY 2015, Congress, at a bare minimum must truly restore these 
sequestration cuts, and adjust for inflation and population growth. 
Otherwise, our people will continue to experience some of the worst 
health disparities in the nation and continue to experience loss of 
lives due to sequestration cuts. To that end, Tribes also request that 
Congress enact legislation to exempt IHS and all programs serving 
Indian Country from any future sequestration. While discretionary 
spending is not facing sequestration in FY 2015, we urge this committee 
to continue to advocate with your colleagues in Congress to create a 
permanent, full exemption from sequestration, as well as rescissions, 
for Tribal programs for FY 2016 and beyond.
FY 2015 President's Budget Request
    NIHB echoes the recommendations of the Tribal Budget Formulation 
Workgroup for FY 2015. The Tribal Budget request continues to be full 
funding of the Total Tribal Needs base budget of 28.7 Billion dollars 
over a 12 year period. This includes amounts for personal health 
services, wrap-around community health services and facility capital 
investments. However, for FY 2015, Tribes request total funding amount 
of $5.3 billion. This request would enable the funding of current 
services and include program expansion increases in several key areas 
including purchased/referred care; hospitals and clinics; mental health 
and alcohol and substance abuse.
    The NIHB and Tribes believe that the President's FY 2015 request a 
positive step forward for Indian Country. The President's overall 
proposal restores the cuts caused by sequestration and the cuts made in 
the FY 2014 IHS operating plan. NIHB commends the Administration for 
including a $63 million increase to account for medical inflation and 
an additional $2.6 million for pay cost increases at both the IHS and 
Tribal level. However, other challenges still remain in the federal 
budget, such as a long-term solution on Contract Support Costs when a 
long-term commitment is required; increased funding for Purchased/
Referred Care (formerly Contract Health Services); increase for Mental 
Health care, screenings and services; and alcohol and substance abuse.
Contract Support Costs
    Importantly, the FY 2015 budget request also fully funds Contract 
Support Costs (CSC) in accordance with the U.S. Supreme Court decision 
in Salazar v. Ramah Navajo Chapter. The request includes a $30 million 
increase in order to fund the increases requested for the IHS in FY 
2015. This represents a historic shift in a decades-long battle. As you 
recall, in FY 2014, the Administration proposed capping CSC for 
individual contracts, which Indian Country unanimously pointed out was 
a violation of both the federal trust responsibility and the principles 
of Ramah decision. Congress rejected this proposal in FY 2014 and 
provided a pathway for the Administration to fund CSC in FY 2014. NIHB 
would like to again, thank this committee for the work it did to not 
only elevate the issue, but also to change the position of the 
Administration.
    However, as noted above, this CSC funding obligation should not 
have been achieved at the expense of other Tribal programs. It is 
unfair to force Tribes to choose between increased services and funding 
of costs already owed to us to operate our programs. Funding CSC at the 
expense of other direct services is a continuation of the injustice, 
and is simply ``robbing Peter to pay Paul.'' The increases provided in 
the FY 2014 budget to fund CSC only restored obligations to the Federal 
Government has already made to Tribes, and did not provide a true 
increase to the overall budget in terms of real health dollars.
    NIHB is encouraged by statements that the Administration recently 
made that it wants to continue to find a long-term solution for funding 
CSC. We urge Congress and the Administration to work together with 
Tribes in order to ensure that funding for CSC can be maintained 
without making sacrifices to other areas of the budget.
Purchased/Referred Care
    Over the last several years both Congress and the Administration 
have heard the call of Tribes to increase funding for Purchased/
Referred Care (PRC) (formerly called Contract Health Services). 
Purchased/Referred Care dollars fund for IHS patients health care 
services that cannot be directly provided by an IHS or Tribal health 
facility. These dollars have historically been so scarce that many 
health programs run out of funding by June 1 of the fiscal year. This 
dearth of funding creates an emergency ``life or limb'' scenario 
(Priority I) where an amputation will be paid for when the preventative 
care that could prevent the amputation will not--or where painkillers 
will be paid for when orthopedic surgery is needed. This has to stop. 
Tribes are grateful that since FY 2009 PRC has increased by $244.1 
million, or 38 percent. Before sequestration, some clinics were 
actually able to start treating cases that were nonlife threatening 
(Priority II). In FY 2015, the President's request includes an $18 
million increase for PRC. However, funding is so short for this program 
that Tribes have requested $1.1 billion for PRC in FY 2015, which is 
$22 million above the FY 2014 enacted level and $17 million above the 
FY 2015 request. At current levels (and especially after 
sequestration), the IHS budget typically only covers Priority I or 
``Life or Limb'' referrals. Through lack of funding and de-prioritizing 
preventative opportunities, this cycle creates increased costs for 
needed health care by increasing costs to the Purchased/Referred Care 
programs specifically, and to the IHS health delivery system overall.
Medicare Like Rates for PRC
    In addition to providing additional funding for PRC, one common-
sense solution to enable these funds to go further is for Congress to 
enact legislation that would require that PRC reimbursements to 
nonhospital providers are made at ``Medicare Like Rates.'' In 2003, 
Congress amended the Medicare law to authorize the Secretary of Health 
and Human Services to establish a rate cap on the amount hospitals may 
charge IHS and Tribal health programs for care purchased from hospitals 
under the PRC program. However, hospital services represent only a 
fraction of the services provided through the PRC system. The IHS PRC 
program may be the only Federal Government entity that does so; neither 
the Veterans' Administration nor the Department of Defense pay full 
billed charges for health care from outside providers.
    On April 11, 2013, the Government Accountability Office (GAO) 
issued a report that concluded ``Congress should consider imposing a 
cap on payments for physician and other nonhospital services made 
through IHS's CHS program that is consistent with the rate paid by 
other federal agencies.'' We agree: these savings would result in IHS 
being able to provide approximately 253,000 additional physician 
services annually. This number will even be greater when you consider 
Tribally-run programs, which means that total savings are more likely 
to be around $100 million annually. NIHB and Tribes encourage Congress 
to swiftly enact the legislative change to make PRC subject to Medicare 
Like Rates.
Hospitals and Clinics
    In FY 2015, Tribes request $2.1 billion for Hospitals and Clinics 
(H&C) in order to better provide health services for 2.1 million AI/
ANs. This represents an increase of $297 million, or 16 percent over 
the FY 2014 enacted level. H&C includes medical and surgical inpatient 
care, routine and emergency ambulatory care, and other medical support 
services. H&C funds also support community health initiatives targeting 
health conditions disproportionately affecting AI/ANs, such as 
specialized programs for diabetes, maternal and child health, women's 
health, and elder health.
    The services provided by H&C are constantly being challenged by 
many factors including inflation, population growth and an increased 
rates of chronic diseases. Additionally, IHS/Tribal/Urban-managed 
facilities often have great difficulty in recruiting and retaining 
medical staff meaning due to remote locations and funding difficulties. 
If the health status of AI/ANs is ever going to improve, Congress must 
prioritize this core program now.
Mental Health
    For FY 2015, NIHB recommends $130 million for mental health 
services. This represents a $52.7 million increase over the FY 2014 
enacted level. As noted above, American Indians and Alaska Natives 
suffer from a high incidence of mental health disorder, illnesses and 
suicide rates; in fact, suicide is the second leading cause of death 
for AI/AN children and youth. Failure to treat mental health conditions 
and providing appropriate and timely interventions and care, 
effectively results in community-wide public health risks both on and 
off reservations for AI/ANs. For example, the Navajo Area suicide rate 
that is four times greater than the US all races rate for youth aged 5-
14. In 2010, in one town with a population of only 8,000, there were 15 
suicides. Sadly, many communities throughout Indian Country also 
experience this tragic story. The trauma and emotional injury stemming 
from a suicide in Tribal communities impacts elders, mothers and 
fathers, sons and daughters, friends and destabilizes the cultural and 
community fabric of our Nations. Our young people in Indian Country 
often experience a life filled with a variety of social problems such 
as substance abuse and poverty, and envision a future without promise 
or hope for a better life. For the sake of the next Seven Generations, 
we must all work together to find a serious, comprehensive solution to 
end this disturbing epidemic.
    Treating these issues among AI/ANs must utilize a comprehensive 
approach that targets early intervention and engages all aspects of 
life. Services that IHS currently provides, when resources are 
available, include comprehensive outpatient mental health treatment, 
crisis response services, prevention programming, collaborative 
treatment planning with alcohol and substance abuse treatment 
providers, group therapies, and traditional healing methodologies, in 
addition to other evidence-based approaches to mental health treatment. 
Overall, these solutions are more reactive than they are proactive. 
Services generally not available at IHS or Tribally-operated 
facilities, but instead must be procured through third party contracts, 
include inpatient and residential treatment services, group homes, and 
independent living centers.
    One of the most critical problems Tribal communities face is the 
recruitment and retention of qualified fulltime psychiatrists and 
psychiatric nurse practitioners. This is one of the many reasons NIHB 
supports a legislative fix that would enable IHS Student Loan Repayment 
Program and Health Professions Scholarship Program to have tax exempt 
status. It would enable IHS to fund an addition 105 new repayment 
awards to combat the 1,550 vacancies for health care professionals in 
the IHS system. In the House of Representatives (H.R. 3391), bipartisan 
legislation has been introduced to address this concern. We urge the 
members of this committee to introduce a Senate companion bill to H.R. 
3391 and swiftly pass it out of committee.
    NIHB also urges this committee to seriously investigate the 
contributing factors to mental health and work with Tribes, federal 
agencies and other stakeholders to find a real solution to this 
difficult problem.
Alcohol and Substance Abuse
    Closely linked with mental health issues are chronic problems 
stemming not only from historical trauma, but from emotional injuries 
related to domestic violence as well as alcohol and substance abuse in 
Tribal communities. As mentioned above, AI/ANs are consistently 
overrepresented in statistics relating to alcohol and substance abuse 
disorders, leading to widespread health issues for individuals, 
families and even entire communities.
    For FY 2015, we recommend $236 million for Alcohol and Substance 
Abuse, or $50 million above the FY 2014 enacted level and $43 million 
above the FY 2015 President's request. IHS programs and Tribally 
operated alcohol and substance abuse programs employ a variety of 
treatment modalities consistent with evidenced-based approaches to 
address substance abuse disorders and addictions through individual and 
group counseling, peer support, and inpatient and residential 
placement. However, it is essential that treatment approaches also 
include traditional healing techniques designed to improve outcomes and 
to tie services provided back to valuable cultural practices and the 
individual AI/AN's spiritual journey.
    IHS funding supports the operation of adult and youth residential 
facilities and placement contracts with third party agencies, but 
limited funding often results in placement decisions based on the 
availability of alternate resources and the providers' clinical 
recommendations. IHS-funded alcohol and substance abuse programs 
continue to focus on integrating primary care, mental health and 
substance abuse services, and the exploration and development of 
partnerships and alliances with other community stakeholders.
    Again, treatment for alcohol and substance abuse must be approached 
from a community-wide perspective and integrate not only health 
programs, but also Tribal justice, and education initiatives. 
Communities in Indian Country experience these tragic issues due to a 
large and complex list of contributing factors, so approaches to solve 
these problems must also address all aspects of society.
Fund IHCIA New Authorities
    The adoption of the Patient Protection and Affordable Care Act 
(ACA) (P.L. 110-148) in 2010 was historic for Tribes in many ways. Most 
importantly, it renewed the Indian Health Care Improvement Act (IHCIA). 
The effort to renew IHCIA took 10 years and represents a true victory 
for Indian health. The Act updates and modernizes health delivery 
services, such as cancer screenings, home and community based services 
and long-term care for the elderly and disabled. It also establishes a 
continuum of care through integrated behavioral health programs (both 
prevention and treatment) to address alcohol/substance abuse problems 
and the social service and mental health needs of Indian people.
    However, many of these provisions remain unfunded, which again, 
represents another failure to follow through on promises to our people. 
All provisions of the IHCIA are critcal to advancing the health care of 
American Indian and Alaska Native people and should be implemented 
immediately. Adequate funding for the implementation of these long 
awaited provisions is needed now. Tribes recommend funding of $300 
million in order to fully implement IHCIA in FY 2015.
Definition of Indian in the Affordable Act
    As NIHB testified previously, we urge Congress to enact a 
legislative ``fix'' for the Definition of Indian in the Affordable Care 
Act. The ``Definitions of Indian'' in the ACA are not consistent with 
the definitions already used by the Indian Health Service (IHS), 
Medicaid and the Children's Health Insurance Plan (CHIP) for services 
provided to American Indians and Alaska Natives. The ACA definitions, 
which currently require that a person is a member of a federally 
recognized Tribe or an Alaska Native Claims Settlement Act (ANCSA) 
corporation, are narrower than those used by IHS, Medicaid and CHIP, 
thereby excluding a sizeable population of AI/ANs that the ACA was 
intended to benefit and protect. Unless the definition of Indian in the 
ACA is changed, many AI/ANs will not be eligible for the special 
protections and benefits intended for them in the law.
    NIHB requests that the committee use all methods at its disposal to 
resolve this issue. On October 16, 2013, Senator Mark Begich (D-AK) 
introduced S. 1575 which would address this issue. NIHB encourages the 
committee to swiftly consider and favorably report S. 1575 to ensure 
that all AI/ANs are eligible for the benefits intended for them in the 
ACA.
Other Policy Recommendations
    The Administration's FY 2015 Budget Request Contains three 
legislative policy provisions: (1) Provide Tax Exempt Status for the 
Indian Health Service Health Professions Scholarship Program and the 
Health Professions Loan Repayment Program; (2) Renew the Special 
Diabetes Program for Indians at $150 million for three years. NIHB 
supports these legislative priorities, in addition to Advance 
Appropriations for the Indian Health Service.
Renewal of the Special Diabetes Program for Indians
    As part of the Balanced Budget Act of 1997, Congress established 
the Special Diabetes Program for Indians (SDPI) to address the growing 
epidemic of Type II diabetes in American Indian and Alaska Native (AI/
AN) communities. The Special Diabetes Program for Type 1 Diabetes (SDP) 
was established at the same time to address the serious limitations in 
Type 1 diabetes research resources. Together, these programs have 
become the nation's most strategic, successful and comprehensive effort 
to combat diabetes. SDPI is transforming lives and changing the 
diabetes landscape in America.
    According to the Centers for Disease Control and Prevention (CDC), 
AI/AN adults have the highest ageadjusted prevalence rate of diagnosed 
diabetes compared to other major racial and ethnic groups at 16.1 
percent. By comparison, this is almost twice the rate for the total 
U.S. adult population. Some regions of Indian Country have diabetes 
rates as high as 33.5 percent, with specific communities having Type II 
diabetes reach a level as high as 60 percent.
    Today, SDPI is funded at a level of $150 million per year and 
supports 404 diabetes treatment and prevention programs in 35 states. 
With funding for this critical program set to expire on September 30, 
2014, Tribes are requesting a renewal of this program of $200 million/
year for 5 years. While we understand an increase in funds during this 
budgetary environment is difficult, SDPI has been level-funded since 
2002. This represents an effective decrease. Calculating for inflation, 
$150 million in 2002 would be about $115 million in 2014--or 23 percent 
less. In order to keep the momentum of this important program alive, it 
is critical that Congress continue to invest in SDPI, which will save 
millions in preventative care over the long term. When taking into 
account additional Tribes that have gained federal recognition since 
2002, the dollars are even scarcer.
    NIHB wishes to express its gratitude for the work that members of 
this committee have done so far to support renewal of SDPI. With the 
deadline of September 30th in mind, I urge you to support a multi-year 
reauthorization of the SDPI by March 31st of this year. We have a 
critical opportunity to see the program renewed by March 31, when 
Congress must renew the Medicare Extender legislation--and that 
legislative vehicle is typically the legislative vehicle for SDPI 
renewals. Without an immediate, long-term reauthorization, critical 
infrastructure that the Tribes have built to address the Diabetes 
epidemic in Indian Country has greatly contributed to the success of 
SDPI. A delay in renewal will mean loss of SDPI staff--loss of jobs--
that will severely impact tribal health: both in terms of patient 
health and community economic health. Also, because SDPI is a grant 
program, the Indian Health Service requires four months to advertise 
and complete the grant process--so please actively shepherd through the 
reauthorization of SDPI by March 31, 2014.
Support for Advance Appropriations
    In addition to the policy recommendations outlined by the 
Administration, NIHB would like to reiterate its support for Advance 
Appropriations for the Indian Health Service. On October 10, 2013, 
Senator Lisa Murkowski (R-AK) introduced legislation, S. 1570, to 
provide advance appropriations for the IHS. While this measure will not 
solve the complex budget issues at IHS, it will be an important first-
step in ensuring that AI/ANs receive the health care they deserve. 
Advance appropriations would allow Indian health programs to 
effectively and efficiently manage budgets, coordinate care, and 
improve health quality outcomes for AI/ANs. The need for advance 
appropriations was no more obvious during the Federal Government 
shutdown at the start FY 2014. Many Tribal health programs were forced 
to furlough employees, close their clinics and deny services during 
this period.
    This change in the appropriations schedule will help the Federal 
Government meet its trust obligation to Tribal governments and bring 
parity to the federal health care system. Adopting advance 
appropriations for IHS would result in the ability for health 
administrators to continue treating patients without wondering if--or 
when--they would have the necessary funding. Additionally, IHS 
administrators would not waste valuable resources, time and energy re-
allocating their budget each time Congress passed a continuing 
resolution.
    At the Department of Health and Human Services Budget FY 2016 
Tribal Budget Consultation on March 7, 2014, agency officials noted 
that they are seriously considering this issue with the Office of 
Management and Budget. They are also engaged in conversations with the 
Veterans' Administration to learn how they implemented advance 
appropriations when they received this status in 2010. NIHB is highly 
encouraged by these statements and urges this Committee to quickly 
consider S. 1570 and report the bill favorably to ensure that Tribes 
can move forward to a more stable funding mechanism.
Conclusion
    On behalf of the National Indian Health Board and the 566 federally 
recognized Tribes we serve, thank you to the Committee for holding this 
important hearing on the FY 2015 budget. While we have made important 
gains in the IHS funding budget over the last several years, the 
scourge of sequestration has eliminated much of that progress. Tribal 
communities still continue to suffer greatly from chronic public health 
risks exacerbated by grossly underfunded health services in Indian 
Country.
    For FY 2015, Tribes are requesting:

        1) Begin implementation of a plan to achieve a Needs Based 
        Budget for IHS at 28.7 billion.

        2) Fund IHS at $5.3 billion for FY 2015.

        3) Restore Cuts/Shortfalls in FY2013-15 resulting from 
        sequestration, inadequate increases to cover Congressionally 
        mandated budget categories, and no provision for inflation for 
        Continuing Services & Binding Obligations and advocate that 
        Tribes and Tribal programs be permanently exempted from any 
        future sequestration.

        4) Provide an additional $300 million to implement the 
        provisions authorized in the Indian Health Care Improvement Act 
        (IHCIA).

    State and local governments have the power to tax in order to fund 
government services. Tribes do not have that option. In many remote 
Tribal communities, economic development is also unfeasible. Tribal 
governments depend more heavily on Federal Government sources, thereby 
making the need to fund Tribal programs at a sustainable level even 
greater. It is a matter of justice and equity--failure to prioritize an 
IHS budget that makes a meaningful investment in the health of AI/ANs 
is a violation of the federal trust responsibility and denial of the 
sacrifices that our people have made to this country.
    Thank you for the opportunity to offer this testimony.

    The Chairman. Thank you, Mr. Joseph. I appreciate your 
testimony.
    I appreciate both your testimonies and both of you taking 
time from your busy schedules to be here today to advocate for 
causes I know you both feel are very, very important. I feel 
the same.
    I will start with you, Mr. Payment. With the President's 
fiscal year 2015 budget request for $2.6 million for Indian 
Affairs at the Department of Interior, my understanding from 
your testimony is that the NCAI full budget request is, at 
almost every line item in the Indian Affairs budget, 
underfunded.
    NCAI testimony mentions an across the board $139 million 
increase, knowing that there are unmet needs for basically all 
the Indian Affairs programs. Is an across the board increase 
the best place to start or would it be better to start with 
specific programs and if so, could you prioritize a few of 
those?
    Mr. Payment. I would say we have a critical need with law 
enforcement right now. We do have a detention center and it 
actually covers its own costs. We are able to use the revenue 
from the detention center but have been doing that for the last 
couple of years, so that fund is almost gone.
    We have used that to make up for the Federal Government not 
adequately funding our law enforcement and conservation. In 
about a year that fund will be depleted and it then will 
compete with our other self governance funds.
    We have a very rural area like a lot of tribes, so our law 
enforcement is minimally covered right now. We just signed a 
couple years ago the permanent settlement of our treaty rights, 
so the conservation portion of that is going to increase. I am 
not sure how we are going to cover that, so law enforcement 
would be one.
    Education is critical. I am working on my doctorate in 
education. We have a 50 percent dropout rate. The solution is 
not only in the BIE. Ninety percent of our kids don't go to 
school in Indian schools. We do have a tribal school in my 
community and we just got the highest MEAP scores in the 
region, higher than the local schools. When we do it, we do it 
right.
    We can't abandon those who attend public schools because 
there needs to be a focused attention there. How does impact 
aid benefit communities? A friend of mine is a superintendent 
of a school that serves about 50 percent Native American 
children. They are underfunded.
    With the cuts that happened last year, the funding to 
impact aid happened in the middle of the school year so they 
didn't have time to adjust. When cuts happen to public schools, 
to impact aid, it impacts the highest need people because that 
is the first thing cut. Our people happen to be the highest 
need people. The connection with impact aid is there.
    Social welfare, we need a new commitment in social welfare, 
especially with mixed messages coming from the Supreme Court in 
Indian child welfare. We need much, much more resources in 
Indian child welfare. Juvenile placements in detention, we need 
direct funding for that.
    The last one I will say is suicides. We have a very high 
rate of suicide in our community. We need direct funding from 
SAMHSA to tribes. We need to skip the State compacting process 
and come directly to the tribes because I think we know best 
how to serve our people and meet those needs.
    The Chairman. A very good point.
    I am going to cut to another area that has to do with 
consultation. When I go around the State and around the country 
as far as that goes, there is an understanding that Indian 
Affairs does a reasonable job in consultation. Other 
departments, not so much.
    I don't want to be critical of them because, quite frankly, 
they don't deal with Native American issues all the time and 
consultation is a different way of doing business than they are 
used to.
    I want your input or NCAI's input. We will start with the 
two biggies, the Department of Interior and the Office of 
Management and Budget. Do they give sufficient opportunity to 
talk about the resources for programs?
    Mr. Payment. I would say that the Obama Administration 
especially consultation has been a priority for many Federal 
agencies. What is consultation? It is not completely and 
universally understood how it should actually happen. There are 
some templates that suggest how it should happen.
    I would say there is definitely a need to educate OMB to 
carry forward the trust obligation and to understand and 
appreciate it better. I think something is lost in the 
translation when it gets to OMB. I think more work is needed 
there.
    NCAI has requested that a Native American desk be 
established in the OMB so they better understand so the 
translation from the President's office and from Congress' 
commitment make its way to the OMB.
    I think the problem is systemic and it is much bigger. I 
think with creation of the White House Counsel and in fact, 
this week the Midwest Alliance of Sovereign Tribes passed a 
resolution which I drafted calling for some infrastructure that 
will go along with the commitment and asking the White House 
Counsel to put in place some consultation and maybe an advisory 
council of tribal leaders across the country to advise the 
White House Counsel.
    I think the silo problem of the different departments and 
OMB being kind of over here leads to lack of communication. The 
problems that happened with IHS not being exempted from 
sequestration is a perfect example of that.
    The Chairman. I would just say this. I don't like to point 
fingers without a few pointing back to us but Congress hasn't 
been particularly helpful on a lot of these issues too. I would 
just say to both of you if there are things we can do to help 
with consultation, getting input to people who need to have 
input, please let us know so we can try to help facilitate.
    You make good decisions based on good information. Let's 
just put it that way. If you don't have good information, you 
aren't going to make good decisions.
    I want to go to you for a second, Mr. Joseph, on IHS 
staffing. The Northwest Portland Area Indian Health Board has 
often had concerns about staffing levels in the region's Indian 
Health Service facilities. I am aware this is not just a 
problem in that region. Have you seen any change in staffing of 
facilities in Indian Country? Has it been static? Has it gotten 
better or has it gotten worse?
    Mr. Joseph. Right now, my tribe has declared a state of 
emergency for staffing. It is an IHS Federal service unit. The 
Portland Board and the California Rural Indian Health Board 
have a joint resolution on staffing needs. A lot of our tribes 
have built their own facilities, we couldn't wait for the 
government. We are kind of like the Wind River Tribe that was 
talked about earlier.
    We built our clinics. Two of the four were written into the 
master plan by IHS. We still have the staffing from I'd say the 
1950's or maybe before then. The Affordable Health Care Act is 
an excellent bill, I helped write it, but tribes like mine that 
have poor staffing or low staffing are not able to take 
advantage of all of the good language written in that bill.
    I believe every tribe needs to look at facilities and 
staffing across the country. I am really grateful for the ones 
that get it because they get the full deal, they get the 
facilities, staffing and then they get to take advantage. Some 
tribes have been waiting as long. If we could have staffing, it 
would be helpful.
    I took my son to the dentist, he had an emergency a couple 
of weeks ago, and there is only one dentist. We have one we 
brought back from retirement and he comes in part-time. I was 
waiting for my son and an elder came in and asked if he could 
get an appointment. He was told, give me your name and number 
and we will call you maybe in two or three months. There is 
about a six month waiting time for an actual appointment. 
Staffing is a big need.
    The reason why Portland is opposed to staffing is because 
they that increase right off the top of the budget and it 
affects the overall medical part of health that IHS has to 
provide. Based on last year's 2013 budget when we did get 
sequestered, there was $53 million that went into staff two new 
facilities and that was taken right off the top of the 
increase. The real medical increase wasn't as high as the 
Senate thought it would be.
    Like I said, I am grateful there are tribes who got it but 
the rest of us kind of suffered from it.
    The Chairman. In your opinion, is the problem with staffing 
budgetary or is it lack of availability of professionals for 
IHS?
    Mr. Joseph. It kind of hits on the question you asked Aaron 
about OMB. We have been submitting our budget and asking for 
what we really need for quite a few years now. The real need 
for the IHS budget is $28.1 billion. We are stuck at the $4 
billion level.
    When I first started working on the budget 11 years ago, I 
was wishing they would just round off the number to $3 billion. 
We were really struggling then. Our population and the cost of 
providing medical health has gone way up.
    The Chairman. For sure.
    You both talked about advance funding. I would just say the 
Veterans Administration already has advance funding. You 
probably know that. You Native Americans serve at a higher rate 
than other minority in this country. We have some questions 
that we are going to talk to Dr. Roubideaux about.
    I want to tell you guys since you are part of organizations 
that one of the ways the Veterans Administration got advance 
funding was because all the groups out there wanted it. I think 
it would be an incredible plus for Indian Country if we got 
advance funding. I think it is possible to get done. In fact, I 
have a bill to do that, a piece of legislation to do exactly 
that.
    I think it is going to take some real force from Indian 
Country to get it done, to get in there and talk about how 
important it is and how it can help in a very big way. I think 
if everyone gets on the same sheet and is very focused, it can 
happen. Anything short of that is going to be very difficult.
    I would thank you very much for your testimony. We have a 
few more but this hearing has gone two hours which is a little 
longer than I anticipated but there were some good questions 
here today.
    I want to thank all witnesses for their testimony, the two 
of you included. It is great to hear the information not only 
from the Administration but the folks out on the ground. Once 
again, this testimony shows the agencies and the tribes are 
resourceful but you can't get blood out of a turnip. We need to 
make sure we do what we can do here and through the 
Appropriations Committee to try to plus up this budget. It 
needs to be.
    I know there is always a lot of interest in this testimony. 
I think the fact we had the folks here even though I can tell 
you right now I missed three meetings while this hearing was 
going on so everyone else is in that same boat, no disrespect.
    This hearing record will remain open for two weeks for any 
additional comments that anyone may add to it.
    Once again, gentlemen, thank you for your testimony.
    This hearing is adjourned.
    [Whereupon, at 5:45 p.m., the Committee was adjourned.]






                            A P P E N D I X

  Prepared Statement of Albert A. Yazzie, President, Crystal Boarding 
                       School Board of Education


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



                                 ______
                                 
Prepared Statement of Hon. Brian Patterson, President, United South and 
                          Eastern Tribes, Inc.
Introduction.
    Chairman Tester, Vice Chairman Barrasso and members of the 
Committee, my name is Brian Patterson. I serve as president of the 
United South and Eastern Tribes, Inc. (USET), as well as on the Men's 
Council of the Oneida Nation of New York. Thank you for this 
opportunity to provide written testimony regarding the budget 
priorities of USET.
    USET is an inter-tribal organization representing 26 federally 
recognized Tribes from Texas across to Florida and up to Maine. The 
USET Tribes are within the Eastern Region of the Bureau of Indian 
Affairs (BIA), covering a large expanse of land compared to other BIA 
Regions. Due to this large geographic area, the Tribes in the Eastern 
Region have great diversity. From an economic standpoint, some of our 
Tribes have highly developed economies, while others remain mired in 
poverty. All of our Tribes, however, look to the United States to live 
up to its trust responsibility, to support Tribal sovereignty, and to 
work with us on a government-to-government basis, especially on a 
matter as central to the trust responsibility as Federal budget policy.
The Role of this Committee--Defending American Values, such as the 
        Trust Responsibility
    The role of this Committee, or that of any of the Congressional 
committee, is ultimately not about dividing up money and power, but 
rather determining, deciding and defending American values. For 
example, under budget sequestration the Veterans Administration's 
hospital system was exempt. That demonstrates a great American value--
fulfilling the commitment to honor our obligations to those who put 
their lives on the line to defend American freedom. However, it is not 
an American value that the Indian Health Service was not exempted, 
putting the life, health and well-being of generations of Native 
peoples at risk in a system that already strains to deliver basic 
healthcare. This Committee can and should demand that the IHS be funded 
in a manner consistent with an important American value--our Nation's 
commitment to its First Peoples.
    Similarly, the sequestration exempted many low-income programs 
(e.g., Child Care Entitlement to States; Child Health Insurance Fund; 
Family Support Programs and Temporary Assistance for Needy Families) 
demonstrating the great American value that we will leave nobody behind 
when it comes to basic needs. And yet, the sequestration applied fully 
to virtually all Federal Indian programs, even though many Native 
communities suffer the worst social and economic statistics in the 
country, largely due to Federal action and policies in place over the 
last two hundred years. The application of sequestration to Native 
programs was not an American value. Federal budget problems should not 
be addressed on the back of Native peoples. USET respectfully asks that 
this Committee support funding increases for Federal Indian programs 
that consistently exceed the relevant rate of inflation in order to 
achieve real progress in closing the services gap for Natives. As 
described below, Federal Indian program should not be deemed 
discretionary, but rather mandatory.
The Constitution, Indian Tribes, Treaties and the Laws of the United 
        States
    From the earliest days of the United States, the Founders 
recognized the importance of America's relationship with Native nations 
and Native peoples. They wove important references to those 
relationships into the Constitution (e.g., Art. I, Section 8, Cl. 3 
(Indian Commerce Clause); Article II, Section 2, Cl. 2 (Treaty Clause).
    Natives influenced the Founders in the development of the 
Constitution as recognized by the 100th Congress, when the Senate and 
the House passed a concurrent resolution acknowledging the ``historical 
debt'' the United States owes to Indian tribes.

         [O]n the occasion of the 200th Anniversary of the signing of 
        the United States Constitution, acknowledges the historical 
        debt which this Republic of the United States of America owes 
        to the Iroquois Confederacy and other Indian Nations for their 
        demonstration of enlightened, democratic principles of 
        government and their example of a free association of 
        independent Indian nations;. . .

    S. Con. Res. 76, 100th Congress. One has only to walk the halls of 
the Capitol to see many works of art and sculpture that depict the 
central role that Native nations have played in the development of 
America's national identity. Not depicted on the walls of the Capitol 
are the many injustices that Native peoples have suffered as a result 
of Federal policy, including Federal actions that sought to erode 
Native territories, learning, and cultures. Out of those injustices, 
and from other legal sources, there has arisen a Federal trust 
obligation to support Native governments and Native peoples.
    The Indian provisions in the Constitution were given immediate life 
in treaties that the United States entered into with Indian nations 
beginning with the Treaty with the Delaware in 1778 and continuing 
through another 373 treaties. Additionally, in the first decades of the 
United States, numerous laws were enacted addressing the details of the 
Federal-Tribal relationship (e.g., Trade and Intercourse Acts of 1790, 
1793, 1796, 1799, 1802, and 1834), even as the Federal courts defined 
the Federal Government's trust obligation to Indian nations (e.g., 
Cherokee Nation v. Georgia (1831)). Notwithstanding this Constitutional 
foundation, the Federal Government engaged in many actions that 
betrayed the treaties and trust obligation to Indian nations, such as 
the seizure of Indian lands and the forced assimilation efforts of the 
Indian boarding school system. Fortunately, American greatness has led 
to more enlightened policies since the boarding school era, reflected 
in a host of laws that support tribal sovereignty and are critical to 
the vitality and well-being of tribal communities. Regrettably, these 
laws are rarely funded to the level necessary to achieve their intended 
purposes.
    Because of this history, the Trust obligation of the Federal 
Government to Native peoples, as reflected in the Federal budget, is 
fundamentally different from ordinary discretionary spending and should 
be considered mandatory in nature. As a 1977 U.S. Congress/American 
Indian Policy Review Commission Report stated:

         The purpose behind the trust is and always has been to ensure 
        the survival and welfare of Indian tribes and people. This 
        includes an obligation to provide those services required to 
        protect and enhance Indian lands, resources, and 
        selfgovernment, and also includes those economic and social 
        programs that are necessary to raise the standard of living and 
        social well-being of the Indian people to a level comparable to 
        the non-Indian society.

The World has its Eyes upon the United States and its Leadership--the 
        United Nations Declaration on the Rights of Indigenous Peoples
    As a sovereign nation, the United States exercises jurisdiction 
within its boundaries. However, the United States is also part of a 
community of nations that has come together through the United Nations 
to develop common principles for the benefit of all mankind. These 
principles are used to place a light on those in the international 
community who do not live up to international human rights standards.
    With regard to Indigenous peoples, the United Nations has adopted 
the Declaration on the Rights of Indigenous Peoples (UNDRIP). With 
regard to the improvement of the economic and social conditions of 
Indigenous peoples, Article 21(2) provides: ``States shall take 
effective measures, and, where appropriate, special measures to ensure 
continuing improvement of their economic and social conditions.'' 
Further, Article 38 provides that: ``States, in consultation and 
cooperation with indigenous peoples, shall take the appropriate 
measures, including legislative measures, to achieve the ends of this 
Declaration.'' Those ends include advances in well-being of Indigenous 
peoples in the social, economic, cultural, political, environmental, 
and other areas. One of the primary mechanisms or ``effective measure'' 
that States routinely use to address such problems is funding to 
achieve UNDRIP's standards, which Article 43 summarizes as: ``. . . the 
minimum standards for the survival, dignity and well-being of the 
indigenous peoples of the world.'' Federal Indian program funding 
should also be measured against international standards.
The Spectre of Sequestration Remains
    The budget sequestration of FY 2013 was devastating to Federal 
Indian programs and to the tribal communities they serve. While 
Congress has provided an alternative budget structure for FY 2014 and 
FY 2015, sequestration could be re-imposed in FY 2016. Although this 
may seem early to raise this concern, USET urges the Committee to 
educate other members of the Senate that the application of 
sequestration to Indian programs violates the trust responsibility, 
does not make economic sense, and should not be countenanced going 
forward. For example, when some Federal health programs were rightfully 
exempted from sequestration, it was morally wrong that the Indian 
Health Service was not. That should not happen again.
Contract Support Costs--Robbing Peter to Pay Paul
    Congress provided that the Indian Health Service and the Bureau of 
Indian Affairs must pay the full amount of contract support costs in FY 
2014, as they are contractually obligated to do anyway! However, 
Congress, while fully funding CSC in FY14, did so principally through 
restoration of pre-sequestration funding. This meant that fully funding 
CSC was at the expense of other Federal Indian programs.
    Full funding for CSC must not come with a penalty--namely, a 
reduction in program funding or effective permanent sequestration of 
Indian program funds. That result would have the same devastating 
effect on our service delivery as the failure to fully fund CSC. Yet 
Congress, in the Joint Explanatory Statement accompanying the FY 2014 
Consolidated Appropriations Act, noted that ``since [CSC] fall under 
discretionary spending, they have the potential to impact all other 
programs funded under the Interior and Environment Appropriations bill, 
including other equally important tribal programs.'' Moreover, without 
any permanent measure to ensure full funding, payment of CSC remains 
subject to agency ``discretion'' from year to year, even though tribes 
are legally entitled to payment under the ISDEAA. Noting these ongoing 
conflicts of law, Congress directed the agencies to consult with tribes 
on a permanent solution.
    In our view, there is a logical permanent solution which Congress 
is empowered to implement: CSC should be appropriated as a mandatory 
entitlement. The full payment of CSC is not discretionary; it is a 
legal obligation, affirmed twice by the U.S. Supreme Court. Yet the 
budget authority for CSC is currently provided and controlled through 
appropriation acts--as if it were a discretionary program. The solution 
then is to bring the appropriations process in line with the statutory 
requirements and to recognize CSC for what it is: a mandatory 
entitlement, not a discretionary program. We therefore strongly urge 
the Congress to move to appropriate funding for CSC on a mandatory 
basis.
    Additionally, the settlement of past CSC claims continues to move 
at an unacceptable slow pace. The settlement of past CSC claims must be 
prioritized and resolved expeditiously.
Fundamental Philosophical Flaw in the Tribal Interior Budget Council 
        (TBIC) Format
    The Tribal/Interior Budget Council (TIBC) was established to allow 
Tribes and Tribal organizations to work with Interior officials in the 
formulation of the Indian Affairs and Office of the Special Trustee 
(OST) annual budget requests and performance plans in the spirit of the 
President's Government-to-Government consultation and collaboration 
policy.
    However, TBIC is structured in a fashion that results in a warping 
of Tribal views. Federal representatives to TBIC urge Tribal leaders to 
prioritize areas of need, a virtually impossible task for many Tribal 
communities where deficiencies are found in all areas of development 
and social need. Although this is pointed out, Federal officials 
respond that in the absence of Tribal guidance the officials themselves 
will set the priorities. At that point Tribal leaders, reluctantly, 
attempt to prioritize the needs of their communities.
    While we understand that the budget planning process pushes Federal 
officials to in turn push Tribal officials to establish a limited 
number of priorities, setting such priorities should not be used 
against important Tribal interests. For example, when a Tribal leader 
brings up a ``non-prioritized'' need, Federal officials should not use 
as an excuse for not supporting that need that Tribal leaders did not 
prioritize it. One example of this is education funding. Education 
funding did not make it on a recent ``priority'' list. When Federal 
officials were questioned by Congress about education funding, they 
said it was not a Tribal priority. That is a misuse of this process. 
Essentially, the TBIC process is being used in a way that allows 
Federal officials to affirmatively argue against a particular need even 
though that was never the Tribal intent. The Committee should provide 
corrective guidance to Interior on this point.
    The bottom line: while the Federal-Tribal Nation relationship is 
understood to be ``special'' and ``unique'', the budget process 
currently utilized does not allow for the United States to fulfill its 
fiduciary trust responsibilities and obligations. The process needs to 
move away from a ``needs based'' understanding to a ``fulfilling 
obligations'' understanding. A significant part of the challenge is in 
the reality that OMB approaches this budgeting process no different 
than any other area; resulting in an expressed disrespect for the 
uniqueness of the sacred federal fiduciary responsibilities and 
obligations.
Advancing the Appropriations Process by Providing for Advance 
        Appropriations
    Advance appropriations are enacted a year before the funds become 
available, thus allowing the federal agency knowledge of its funding 
level a year in advance. The advance appropriations process does not 
put additional pressure on the appropriations subcommittees' 
allocations. For instance, if FY 2015 IHS advance appropriations were 
included in the FY 2014 Interior, Environment, and Related Agencies 
Appropriations Act, those advance appropriations would not be counted 
against the FY 2014 Interior Appropriations Subcommittee allocation but 
rather would be counted against its FY 2015 allocation. For the first 
year of advance appropriations Congress would enact two years of IHS 
funds, and thereafter revert to appropriations one year at a time.
    Veterans organizations advocated for years for Congress to provide 
the Veterans Administration (VA) with advance appropriations, noting 
that chronically late funding negatively affected their ability to 
properly plan and manage its resources, including recruitment and 
retention of medical personnel. In 2009 Congress responded by 
authorizing advance appropriations for the VA medical accounts. Like 
the VA, the IHS and tribal organizations provide direct, federally-
funded health care services to a specific population.
    Just like the VA, the IHS has been very adversely affected by 
recurrent delays in the passage of appropriations bills and by Federal 
Government shutdowns. Advance appropriations would dramatically reduce, 
if not eliminate, this problem.
    For example, if IHS was receiving funding on an advance 
appropriations schedule, its FY 2014 appropriations would have been 
enacted as part of a FY 2013 appropriations act and the IHS and tribal 
health care providers would not have entered FY 2014 with no knowledge 
of what amount of funding to expect. Instead, the IHS had to furlough 
some employees and had others working on an unpaid status. Tribal 
health care providers were similarly affected.
    Enactment of legislation authorizing advance appropriations is the 
first step in actually realizing such funding. The Budget Resolution, 
while not having the effect of law, lists particular programs which may 
have advance appropriations. In order for IHS advance appropriations to 
not be subject to a point of order, the IHS Services and the IHS 
Facilities accounts should be included on that list in the Budget 
Resolution.
Medicare-Like Rate Caps--Stretching Precious Federal Health Care 
        Dollars
    As this Committee fully understands, the unmet health needs of 
American Indians and Alaska Natives are severe and the health status of 
American Indians and Alaska Natives is far below that of the general 
population of the United States, resulting in an average life 
expectancy for American Indians and Alaska Natives 4.1 years less than 
that for the U.S. all races population.
    The Indian Health Service and Tribal Purchased/Referred Care 
programs purchase primary and specialty care services from private 
health care providers when those services are not available at Indian 
Health Service or Tribal health facilities. However, Purchased/Referred 
Care funds have been insufficient to ensure access to care for American 
Indians and Alaska Natives, resulting in rationed care and diagnosis 
and treatment delays that lead to the need for more intensive and 
expensive treatment, further reducing already scarce Purchased/Referred 
Care funds.
    In 2003, Congress amended XVIII of the Social Security Act to 
require Medicareparticipating hospitals to accept patients referred 
from the Indian Health Service and Tribal Purchased/Referred Care 
programs and to accept payment at no more than Medicare rates--the 
Medicare-Like Rate cap--for the services provided. However, the 
Medicare-Like Rate cap only applies to hospital services, and does not 
apply to other types of Medicare-participating providers and suppliers.
    Unlike other federal health care programs, the IHS and Tribal 
Purchased/Referred Care programs routinely continue to pay full billed 
charges for non-hospital services, resulting in needless waste of 
scarce federal Purchased/Referred Care funds. Because Purchased/
Referred programs continue to pay full billed charges for non-hospital 
services, in many cases the Indian Health Service may only treat the 
most desperate ``Life'' or ``Limb'' cases, leading to many undesirable 
health outcomes for American Indians and Alaska Natives, and ultimately 
increasing costs to the Purchased/Referred Care programs.
    In the near future, legislation will be introduced to provide for 
the application of the Medicare-Like Rate cap to all IHS Medicare-
participating providers and suppliers. In April 2013, GAO recommended 
that Congress enact such legislation, and HHS concurred in that 
recommendation. USET urges this Committee to strongly endorse such 
legislation and support its rapid advancement.
Carcieri Fix
    This Committee has strongly supported Carcieri fix language over 
the last several years. In doing so, this Committee has sought to 
overturn the unjust Supreme Court decision in Carcieri v. Salazar, 
which has led to two classes of Tribes--those that can take land into 
trust and build up their communities and those that cannot. Further, 
this holding has severely hampered economic development in Indian 
Country and created a public safety risk through jurisdictional 
confusion. President Obama has requested this Fix in his budget and 
USET asks that this Committee elevate the urgency to resolve this 
injustice and once again take up the fight for fair and equal treatment 
of all Tribal nations and advance a Carcieri fix. In an era of Tribal 
Nation rebuilding and the pursuit of economic success and prosperity, 
the confusion and chaos that has resulted from this SCOTUS decision 
serves as one of our most significant barriers and challenges to this 
pursuit.
Support Tribal Sovereignty in the Area of Taxation
    With Federal budget restrictions in place for years to come, Tribal 
tax rights become more important, both for Tribal economic success and 
as a matter of sovereignty.
    USET calls upon Congress to ensure that federal tax law treats 
Indian Tribes in a manner consistent with their governmental status, as 
reflected under the U.S. Constitution and numerous federal laws, 
treaties and federal court decisions. Indian Tribes have a governmental 
structure, and have the power and responsibility to enact civil and 
criminal laws regulating the conduct and affairs of their members and 
reservations. They operate and fund courts of law, police forces and 
fire departments. They provide a broad range of governmental services 
to their citizens, including education, transportation, public 
utilities, health, economic assistance, and domestic and social 
programs. Like states and local governments, Tribes--as political 
bodies--are not subject to income tax under the Code. The non-taxable 
status of Tribal governments is a matter of governmental fairness and 
parity. Improvements to the Tax Code are also vitally needed to align 
federal tax policy with the critical federal policy objectives of 
Tribal self-determination, Tribal economic growth and self-sufficiency 
and the promotion of strong Tribal governments on equal footing with 
other sovereigns within the federal system. Tax policy fairness toward 
Tribal governments and the promotion of economic growth are of central 
importance in Indian Country. Tribal governments must stimulate 
reservation-based economic growth to generate the level of revenue 
needed to deliver vital programs and services within their territories. 
While Tribal governments carry out responsibilities in their 
communities that are similar in many respects to those of states and 
local governments; Tribal governments are not able to rely on a robust 
tax base for revenue. Instead, Tribal governments rely on revenue 
generated from economic development to meet and supplement vital 
programs and services. This makes clear that Congress must create 
reliable and effective federal tax policy to firmly support Tribal 
governance while protecting the ability of Tribes to generate and 
retain the full use of Tribal revenue.
    Tribal governments also have responsibilities that are distinct 
from those of other sovereigns. Tribes and their elected 
representatives have the added responsibility of ensuring they have the 
revenue needed to fulfill responsibilities to maintain Tribal language, 
culture, and ceremonies. Preservation and restoration of Tribal culture 
remains a significant federal policy objective.
    We ask that this Committee be supportive of this effort as we work 
on addressing the larger budget picture for all of Indian Country.
Fair Funding for Newly Recognized Tribes
    Federal recognition obligates the government to provide for the 
health and welfare of Tribal nations. Yet, two recently recognized 
Tribes in the Nashville Area, the Shinnecock and Tonawanda Nations are 
forced to operate without the appropriated funds for health care 
services to which they are legally entitled. This has gone on for 
several years, in spite of previous requests for funding from the IHS. 
While other Tribes have access to their apportionment of IHS dollars, 
these Tribes have only a small amount of ``bridge'' funding through the 
Purchased and Referred Care program, access to which was only given in 
February of 2013.
    USET was pleased to learn that IHS has, once again, requested 
funding for these Tribes and that the Administration acknowledged their 
obligation to the Tribes and proposed $8 million in the FY 2015 
President's Budget Request for five newly recognized or restored Tribes 
in the California and Nashville Areas. However, as the Congressional 
Justification reveals, the Administration has requested only $4.2 
million and $1.7 million for Shinnecock and Tonawanda, respectively. 
These levels are far below those formulated and requested by the 
Nashville Area IHS Office in previous years: $6.2 million in 2012 for 
Shinnecock and $2.6 million in 2010 for Tonawanda. Adjusting for 
inflation, IHS' FY 2015 funding requests for Shinnecock and Tonawanda 
are markedly insufficient.
    This Administration and Congress must deliver on the promise made 
to these ``new'' Tribes and provide new appropriations that will allow 
for parity with other Indian health programs nationally. We urge the 
Committee to advocate for funding for new Tribes at a level reflective 
of their true need.
Definition of ``Indian''--Support the Indian Definition of ``Indian''!
    USET joins other Tribes and Tribal Organizations in calling for a 
fix to inconsistencies in the definition of ``Indian'' in the 
Affordable Care Act (ACA). While we believe the intent of Congress was 
to allow all IHS beneficiaries access to the special benefits and 
protections reserved for American Indians and Alaska Natives (AI/AN) in 
the ACA, the ACA has been interpreted to limit access to only enrolled 
Tribal members and Alaska Native Claims Settlement Act Shareholders. 
The result is an uneven and unfair application of the law to IHS' 
patients, including those served by facilities in the Nashville Area--
USET's area-and confusion across Indian Country. In addition to a fix 
through regulation, USET fully supports passage of S. 1575, which would 
streamline the definitions of Indian in the ACA to reflect the 
statutory definition of Indian used to determine eligibility for IHS 
services. While the Committee works to favorably report S. 1575, we ask 
that Congress clarify its intent to the Department of Health and Human 
Services (HHS) that the special benefits and protections for AI/ANs in 
the ACA are intended to apply all IHS beneficiaries. As millions of 
Americans begin to experience the benefits of the ACA, the Committee 
should use all methods at its disposal to ensure that all AI/AN receive 
the benefits Congress intended for them.
Health Information Technology--Renew Funding for FY 2015 for the 
        Successful Nashville Area Program
    Due in part to congressional reporting requirements like the 
Government Performance and Results Act (GPRA) and improving efficiency 
in health care delivery, Health Information Technology (HIT) is an 
ongoing need throughout Indian Country. The Indian Health Service 
Resource Patient Management System (RPMS) Electronic Health Record 
(EHR) is a data system designed to meet the varying needs of the IHS 
and Tribal hospitals and clinics. The goal of RPMS EHR is to provide 
meaningful and rapid access to information for direct support of health 
care delivery and resource management. Although HIT has advanced to 
make it easier for IHS/Tribes/Urban (I/T/U) programs to report on the 
quality of health care they deliver to their beneficiaries, additional 
advancement is needed to modernize the I/T/U systems to be at par with 
other health care delivery systems across the United States.
    The IHS has been providing USET with funding to assist Tribes in 
taking full advantage of their RPMS systems in an attempt to increase 
GPRA reporting. For FY15, USET was disappointed to learn that IHS does 
not plan to renew funding for the GPRA program in the Nashville Area. 
These funds have been vital to the success of USET Tribes, and the IHS 
in meeting health indicators that are reported to Congress each year. 
Over time, this data has shown the efficacy of increased funding to the 
Indian Health Service. We urge Congress to consider additional funds to 
assist I/T/U in advancing their HIT needs.
Inflation and the Budget for Federal Indian Programs
    In evaluating whether the Federal budget fulfills the Trust 
responsibility, USET believes that it is critical to take into account 
the effects of inflation. From FY 2002 through FY 2008, despite annual 
increases, after taking into account the effect of inflation, most 
Federal domestic programs, including the Indian programs, saw a 
purchase power decrease of approximately 14 percent. The large budget 
increase in FY 2009, including ARRA funding, was approximately enough 
to make up for this effective cut and bring the purchase power of 
Indian programs back to FY 2002 levels, but in the intervening 12 
years, Indian country needs have grown substantially. And, of course, 
the FY 2002 levels were inadequate to address the needs of Indian 
country or to fulfill the Federal Government's trust obligation.
    Further, with regard to inflation, the rate the Federal Government 
uses does not accurately reflect true levels of inflation. In the FY15 
President's Budget Request, IHS requested $34 million for inflation. 
This reflects a blanket rate of 3.6 percent for medical inflation and 
1.5 percent for non-medical identified by OMB, the same they used last 
year, and is earmarked for increases in Purchased/Referred Care 
(formerly CHS). However, the Consumer Price Index (CPI) contains 
different rates that correspond to different parts of the IHS delivery 
system. Inpatient hospital care is at 4.3 percent and outpatient is at 
3.8 percent. Inflation for various line items in the IHS budget, H&C, 
PRC, Mental Health, etc. should be calculated based on relevant 
components in the CPI.
    In a very real way, the budget of the United States government 
reflects the values of the American people. Courtesy of the National 
Congress of American Indians (NCAI), set forth below is a chart that 
depicts the percentage of the Federal budget dedicated to funding the 
BIA. As you can see, as a percentage of the overall budget, the BIA 
budget has declined from .115 percent in FY 1995 to .075 percent 
(correcting chart typo) in FY 2011, approximately a one-third decline 
as a percentage of the overall budget (despite a small bump up in FY 
2010). Below that chart is another which demonstrates that over the 
last ten years, when funding increases have come to the Department of 
the Interior they have been greater for other major agencies within the 
Department than for the Bureau of Indian Affairs.


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Conclusion
    USET recognizes that in challenging times, all Americans must be 
called upon to sacrifice for the common good of all. USET suggests, 
however, that when it comes to sacrificing for the good of all 
Americans, the historic record demonstrates that nobody has sacrificed 
more than Native Americans. We ask that this Committee support and 
advocate for a budget based on American values that reflects the trust 
responsibility and fair dealing for Indian Tribes.
                                 ______
                                 
      Prepared Statement of the Native Hawaiian Education Council
    Aloha Chairman Tester and members of the Senate Committee on Indian 
Affairs,
    Mahalo, thank you, for allowing us an opportunity to submit 
comments at your oversight hearing on the President's FY 2015 Budget.
    We are seeking continued funding at pre-sequestration levels for 
the Native Hawaiian Education Program (NHEP) that targets the Native 
Hawaiian student population. The NHEP is an important part of 
fulfilling the trust relationship between the U.S. and Native 
Hawaiians, and it helps to improve the educational status of Native 
Hawaiians. It is an important element in the Native community's effort 
to control its education programs and policies and to achieve 
educational parity. NHEP aims to close the education achievement gap 
between Native Hawaiians and the general population, and also functions 
to fulfill the trust relationship between the United States and Native 
Hawaiians, the indigenous people of a once sovereign nation. During the 
time of their own sovereignty in the kingdom of Hawai`i, Native 
Hawaiians had a higher rate of literacy than citizens of the United 
States. The educational achievement gap has occurred during the 
intervening years since the loss of Native Hawaiian sovereignty, so 
that today Native Hawaiians are among the most disadvantaged groups in 
the state.
The NHEP Works
    NHEP has been effective over the years in meeting the goals of the 
program. For example, NHEA has been instrumental in preserving and 
protecting the Native Hawaiian language through funding projects that 
are designed to address the use of the Native Hawaiian language in 
instruction, one of the priorities named in the NHEA. The number of 
speakers nearly doubled in 18 years from 8,872 speakers in 1990 to 
16,864 in 2008 (Source: OHA Data Book 2011 Tables 4.19 and 4.44)
    The NHEP has funded programs that incorporate culture and 
indigenous teaching practices in the classroom that leads to better 
outcomes for Native Hawaiian students. An example is the improvement in 
the graduation rates for Native Hawaiians and math and reading scores. 
Graduation rates for Native Hawaiians between 2002 and 2010 rose from 
70 percent to 72.2 percent (Sources: Kamehameha Schools' Native 
Hawaiian Education Assessment Update 2009, Fig. 9 and HI DOE 2005-06 to 
2009-10).
    Similarly, math and reading scores have risen for Native Hawaiians. 
The percent of Native Hawaiians scoring ``Proficient or Above `` from 
2007 to 2012 rose from 27 percent to 49 percent in math and from 41 
percent to 62 percent in reading (Source: Hawaii DOE Longitudinal Data 
System ).
    School attendance rates in schools with student populations that 
are over 50 percent Native Hawaiian have increased from 90.1 percent in 
the 2000-01 school year to 91.3 percent in the 2011-12 school year 
(Source: Kamehameha Schools' draft Ka Huaka`i update, p. 58)
The Need Still Exists
    In spite of the gains that Native Hawaiians have made 
educationally, the need for innovative programs to assist Native 
Hawaiians to improve their academic performance still exists, since 
Native Hawaiians have not yet attained parity with the rest of the 
students in the state.
    Timely high school graduation rates for students in the state rose 
from 77 percent to 79.6 percent in the same time period that it rose 
from 70 percent to 72.2 percent for Native Hawaiians (Sources: 
Kamehameha Schools' Native Hawaiian Education Assessment Update 2009, 
Fig. 9 and HI DOE 2005-06 to 2009-10).
    Native Hawaiians still lag behind the rest of the state in academic 
performance; however the gap between the Native Hawaiians and others is 
decreasing. From 2007 to 2012 the increase in the percentage of Native 
Hawaiians scoring ``Proficient or Above'' in math rose 22 percentage 
points, while the increase for the state during the same time period 
was 21 percentage points. The increase for Native Hawaiians in reading 
was even more dramatic during that time period, increasing 21 
percentage points compared to the state increase of only 11 percentage 
points. Unfortunately those gains were not enough to bring Native 
Hawaiians to parity. In 2012 Native Hawaiians were still 10 points 
behind the state in the percentage scoring ``Proficient or Above'' in 
math and nine points behind in the percentage scoring ``Proficient or 
Above'' in reading.

                   Percent Scoring Proficient or Above
------------------------------------------------------------------------
                                            2007       2012      Change
------------------------------------------------------------------------
Native Hawaiians     Math..............        27%        49%         22
State Totals         Math..............        38%        59%         21
                     Difference........        -11        -10
Native Hawaiians     Reading...........        41%        62%         21
State Totals         Reading...........        60%        71%         11
                     Difference........        -19         -9
------------------------------------------------------------------------
Source: Hawaii DOE Longitudinal Data System

    In the area of Native Hawaiian language immersion, although the 
gains have been tremendous, the nearly 17,000 speakers in 2008 only 
represents 6 percent of the approximately 290,000 Native Hawaiians in 
Hawai`i (2010 U.S. Census).
Appropriations Request
    The pre-sequestration appropriations level for the NHEP was $34 
million. Sequestration reduced the amount by $2 million to $32 million, 
which is the amount entered into the President's budget. For such a 
small program as the NHEP, the $2 million reduction makes a significant 
negative impact on the program. We would like to continue to make gains 
in the educational achievement of Native Hawaiians, and request the 
pre-sequestration level of $34 million so that we don't lose the 
momentum of improvement.
    NHEP funds programs to help improve the educational attainment of 
Native Hawaiians in ways that are linguistically and culturally aligned 
to the needs of our Native students and communities in Hawai`i. 
Improving education, particularly for the most depressed groups, 
eventually leads to cost savings over time through decreased 
incarceration, poor health, and public assistance.(Barnett, W. S., & 
Ackerman, D. J. 2006. Costs, benefits, and the long-term effects of 
early care and education programs: Cautions and recommendations for 
community developers. Journal of the Community Development Society, 
37(2), 86-100.) Academic achievement is also correlated with positive 
economic outcomes. (Belfield, C. 2008, June. The economic investments 
of early education in Hawaii. Issue Brief. Flushing, NY: Queen's 
College, City University of New York.)
    Please help us sustain the NHEP to its pre-sequestration level in 
order to continue the educational gains that have taken this program 
years to accomplish.
                                 ______
                                 
  Prepared Statement of the National Indian Child Welfare Association 
                                (NICWA)


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                                 ______
                                 
   Prepared Statement of National Indian Education Association (NIEA)
    The National Indian Education Association (NIEA) appreciates the 
work of the Senate Committee on Indian Affairs for making education a 
priority. As the Committee works with appropriators and the 
Administration, we request this written testimony be submitted into the 
record, so Native education stakeholders are represented. NIEA was 
incorporated in 1970 and is the most representative Native education 
organization in the United States. NIEA's mission is to advance 
comprehensive and equal educational opportunities for American Indian, 
Alaska Native, and Native Hawaiian students. NIEA supports tribal 
sovereignty over education as well as strengthening traditional Native 
cultures and values that enable Native learners to become contributing 
members of their communities. As the most inclusive Native education 
organization, NIEA membership consists of tribal leaders, educators, 
students, researchers, and education stakeholders from all 50 states. 
From communities in Hawaii, to tribal reservations across the 
continental U.S., to villages in Alaska and urban communities in major 
cities, NIEA has the most reach of any Native education organization in 
the country.
The State of Native Education
    Native education is in a state of emergency. Native students lag 
behind their peers on every educational indicator, from academic 
achievement to high school and college graduation rates. Just over 50 
percent of Native students are graduating high school, compared to 
nearly 80 percent for the majority population nationally. Further, only 
one in four Native high school graduates who took the ACT scored at the 
college-ready level in math and only one-third in reading 
comprehension, as compared to more than half for white graduates. 
Increasingly alarming, only 40 percent of Native college enrollees in 
2004 actually graduated college with a bachelor's degree by 2010. 
Nearly 62 percent of the majority students graduated. For Native 
students to succeed in college and careers, they must have a strong 
education foundation that also meets their local needs and strengthens 
their linguistic and cultural identity.
Uphold the Trust Responsibility
    The federal government has a trust relationship with tribes 
established through treaties, federal law, and U.S. Supreme Court 
decisions. This relationship includes a fiduciary obligation to provide 
parity in access and equal resources to American Indian and Alaska 
Native students. National fiscal and policy concerns should not be 
addressed by decreasing funds and investment to Native students or the 
programs that serve them.
    Native education is one of the most effective and efficient 
investments the federal government can make. Unfortunately, historical 
funding trends illustrate that the federal government is abandoning its 
trust responsibility by decreasing federal funds to Native-serving 
programs by more than half in the last 30 years. Sequestration only 
exacerbated those shortfalls. As tribes and Native communities work 
with Congress to increase their role and responsibility in 
administering education, federal support should increase for tribal 
governments and Native education institutions to repair the damage 
caused by shrinking budgets.
Fiscal Year 2014 Funding Requests
    While FY 2014 funding increases over sequestration levels are 
welcome, funding continues to be insufficient for effectively and 
equally serving Native students. Until the federal government fully 
appropriates funding to bridge the educational attainment gap among 
Native and non-Native students, the trust responsibility will be 
undermined. The federal government should fund Native education 
programs at the levels below as the programmatic requests detail the 
minimum appropriations needed to maintain a system that is already 
struggling and underfunded. Further, NIEA supports the budget requests 
of the National Congress of American Indians and the American Indian 
Higher Education Consortium.
Department of Education--Labor, Health and Human Services and Education 
                          Appropriations Bill
Title I, Part A Local Education Agency Grants
    Provide $25 billion for Title I, Part A. An increase of $10.6 
billion.

   Title I of the Elementary and Secondary Education Act 
        provides critical financial assistance to local educational 
        agencies and schools with high percentages of children from 
        low-income families that ensure all children meet challenging 
        state academic standards.

   Currently, there are over 600,000 Native students across the 
        country with nearly 93 percent of those students attending non-
        federal institutions, such as traditional public schools in 
        rural and urban locations.

   A drastic increase in funding to counter annual inflation 
        and sequestration, as well as match the amount appropriated 
        under the American Reinvestment and Recovery Act, is necessary 
        to meet the needs of Native students and students from low-
        income families.

State-Tribal Education Partnership (STEP) Program
    Provide $5 million. An increase of $3 million.

   Congress appropriated roughly $2 million dollars for the 
        STEP program to five participating tribes in FY 2012 and FY 
        2013 under the Tribal Education Department appropriations.

   In order for this program to continue to succeed and thrive, 
        it must receive its own line and authorization of 
        appropriations in FY 2015.

   Collaboration between tribal education agencies and state 
        educational agencies is crucial to developing the tribal 
        capacity to assume the roles, responsibilities, and 
        accountability of Native education departments and increasing 
        self-governance over Native education.

Impact Aid
   Provide $2 billion for Impact Aid, under ESEA Title VIII. An 
        increase of $711 million.

   Impact Aid provides direct payments to public school 
        districts as reimbursement for the loss of traditional property 
        taxes due to a federal presence or activity, including the 
        existence of an Indian reservation.

   With nearly 93 percent of Native students enrolling in 
        public schools, Impact Aid provides essential funding for 
        schools serving Native students.

   Funding for Impact Aid must not be less than this requested 
        amount.

Title VII (Indian Education Formula Grants)
    Provide $198 million under ESEA Title VII, Part A. An increase of 
$76 million.

   This grant funding is designed to supplement the regular 
        school program and assist Native students so they have the 
        opportunity to achieve the same educational standards and 
        attain parity with their non-Native peers.

   Title VII funds support early-childhood andfamily programs, 
        academic enrichment programs, curriculum development, 
        professional development, and culturally-related activities.

   Title VII programs were maintained at the 2013 sequestration 
        level of $124 million.

   While these levels are higher than what would have been 
        incurred under another year of sequestration, current funding 
        results in inadequate support for critical culturally-relevant 
        educational services.

Native Hawaiian Education Program
    Provide $35 million under ESEA Title VII, Part B. An increase of $3 
million.

   This program funds the development of curricula and 
        education programs that address the education needs of Native 
        Hawaiian students to help bring equity this Native population.

   The Native Hawaiian Education program empowers innovative 
        culturally appropriate programs to enhance the quality of 
        education for Native Hawaiians. When establishing the Native 
        Hawaiian Education Program, Congress acknowledged the trust 
        relationship between the Native Hawaiian people and the United 
        States.

   These programs strengthen the Native Hawaiian culture and 
        improve educational attainment, both of which are correlated 
        with positive economic outcomes.

   Native Hawaiian-serving programs under Title VII were also 
        maintained at the 2013 sequestration level, reducing much-
        needed services to Native students.

Alaska Native Education Equity Assistance Program
    Provide $35 million under ESEA Title VII, Part C. An increase of $4 
million.

   This assistance program funds the development of curricula 
        and education programs that address the unique educational 
        needs of Alaska Native students, as well as the development and 
        operation of student enrichment programs in science and 
        mathematics.

   This funding is crucial to closing the gap between Alaska 
        Native students and their non-Native peers.

   Other eligible activities include professional development 
        for educators, activities carried out through Even Start 
        programs and Head Start programs, family literacy services, and 
        dropout prevention programs.

   Alaska Native-serving programs under Title VII were also 
        maintained at the 2013 sequestration level, reducing much-
        needed services to Native students.

Tribal Colleges and Universities: Supporting Financially Disadvantaged 
        Students
    Provide $60 million ($30 million in discretionary funding and $30 
million in mandatory funding) for Title III-A grants under the Higher 
Education Act for Tribal Colleges and Universities. An increase of 
$35.5 million.

   Titles III and V of the Higher Education Act, known as Aid 
        for Institutional Development programs, support institutions 
        with a large proportion of financially disadvantaged students 
        and low cost-per-student expenditures.

   Tribal Colleges and Universities (TCUs) clearly fit this 
        definition. The nation's 37 TCUs serve Native and non-Native 
        students in some of the most impoverished areas in the nation.

   Congress recognized the TCUs as emergent institutions, and 
        as such, authorized a separate section of Title III (Part A, 
        Sec. 316) specifically to address their needs.

   Additionally, a separate section (Sec. 317) was created to 
        address similar needs of Alaska Native and Native Hawaiian 
        institutions. Sixty million should be provided ($30 million 
        discretionary/appropriations and $30 million in mandatory 
        funding under SAFRA) in FY 2015 to continue to fund grants to 
        these vital institutions.

Tribal Colleges and Universities: Adult/Basic Education
    Provide $8 million for American Indian Adult/Basic Education at 
Tribal Colleges and Universities, from existing funds appropriated for 
state block grant funding. An increase of $8 million.

   Despite an absence of dedicated funding, TCUs must find ways 
        to continue to provide basic adult education classes for those 
        American Indians that the present K-12 Indian education system 
        has failed.

   At TCUs, the number of students in need of remedial 
        education before embarking on their degree programs is 
        substantial.

   There is a wide-ranging need for basic adult education and 
        literacy programs and TCUs need adequate funding to support the 
        ever increasing demand for basic adult education and 
        remediation program services.

Tribally Controlled Post-Secondary Career and Technical Institutions
    Provide $8.2 million for postsecondary career and technical 
institutions program funds under Carl Perkins Technical and Career 
Education Act. An increase of $.5 million.

   Section 117 of the Carl Perkins Career and Technical 
        Education Improvement Act authorizes funding for operations at 
        tribally-controlled postsecondary career and technical 
        institutions.

   Vocational education/training programs are very expensive to 
        conduct, but are vital to preparing a future workforce that 
        will operate safely and efficiently contributing greatly to the 
        global economy.

   Currently, two TCUs participate in this funding program: 
        United Tribes Technical College in Bismarck, North Dakota, and 
        Navajo Technical College in Crownpoint, New Mexico. The TCUs 
        urge Congress to appropriate $8.5 million for Sec. 117 of the 
        Act.

Native American-Serving, non-Tribal Institutions (Higher Education Act 
        Title III-F)
    Provide $10 million for non-tribal, Native-serving institutions of 
higher education. An increase of $7 million.

   As the primary federal funding for Native-serving, non-
        tribal institutions of higher education, the current 
        appropriation of $5 million is insufficient.

   With nearly 100 institutions potentially qualifying as 
        Native-serving, non-tribal institutions, this strains the small 
        amount of available funding.

   To ease the high-level of competition between Native-serving 
        schools, increasing the funding will provide the opportunity 
        for more Native-serving institutions to better serve their 
        students and increase graduation rates among Native students.

 Department of Education and Department of the Interior--Labor, Health 
  and Human Services and Education Appropriations Bill, and Interior--
                    Environment Appropriations Bill
Tribal Education Departments
    Provide $10 million to fund Tribal Education Departments. An 
increase of $5 million, collectively.

   Five million dollars should be appropriated to the 
        Department of the Interior, and $5 million should be 
        appropriated to the Department of Education to support tribal 
        education departments (TEDs).

   This funding assists TEDs, who are uniquely situated at the 
        local level to implement innovative education programs that 
        improve Native education.

   Because they are administered by tribes, TEDs are best 
        equipped to deliver education programs tailored to improve 
        education parity for Natives.

   TEDs would use this much-needed funding to develop academic 
        standards, assess student progress, and create math and science 
        programs that require high academic standards for students in 
        tribal, public, and Bureau of Indian Education schools.

   Tribes utilizing self-governance over education have been 
        very successful because they better understand the 
        circumstances of their populations and can develop initiatives 
        that meet local needs.

 Department of the Interior--Interior--Environment Appropriations Bill
School Construction and Repair
    Provide $263.4 million for Bureau of Indian Education (BIE) school 
construction and repair. An increase of $153.3 million.

   This funding category includes school construction, 
        facilities improvement and repair, and replacement school 
        construction.

   Schools operating within the BIE system are woefully 
        outdated and in some cases, dangerous for student and staff.

   Currently more than 60 BIE schools are rated in ``poor'' 
        condition, which puts Native students at an unfair 
        disadvantage.

Johnson O'Malley
    Provide $42 million for full funding. An increase of $27 million.

   The Johnson O'Malley program has provided grants to 
        supplement basic student needs since 1934.

   It is currently being used across the country in innovative 
        ways to assist with the unique cultural and scholastic needs of 
        Native students.

   Current funding provides less than $76 per student, which 
        are often the only source through which Native students--
        including those in public schools--can engage in basic 
        activities expected of all American students.

   $95 per student was the allocation of JOM funding per 
        student in 1995.

Student Transportation
    Provide $73 million for student transportation in the BIE system. 
An increase of $20 million.

   BIE schools incur significant costs in transporting Native 
        students to and from school.

   These costs are considerably higher than most school systems 
        due to the often-rural location of BIE facilities.

   Poor road conditions that link the BIE-funded schools 
        increase vehicle maintenance costs.

   These high costs often lead to funding shortfalls, which 
        then must either go unpaid or funded by diverting funds from 
        other education programs.

Tribal Grant Support Costs
    Provide $73 million for tribal grant support costs for tribally-
operated schools. An increase of $26 million.

   Tribal Grant Support Costs fund the administrative costs of 
        existing tribally-operated schools.

   The current funding levels only pays 65 percent of the 
        current need and must not be reduced in the upcoming budget 
        cycle.

   This funding also help tribes expand self-governance and 
        tribal control over education programs by allocating monies for 
        administrative costs such as accounting, payroll, and other 
        legal requirements.

   Schools must divert critical teaching and learning funding 
        to cover any shortfalls in operational costs.

Facilities Operations
    Provide $109 million for BIE facilities operations. An increase of 
$50 million.

   BIE schools use this funding for costs such as electricity, 
        heating fuels, communications, GSA vehicle rentals, custodial 
        services, and other vital operating expenses.

   For years, schools have only received roughly 50 percent of 
        funding needed for these expenses. This shortfall is 
        unacceptable as costs continue to rise for vital services.

Facilities Maintenance
    Provide $76 million for BIE facilities maintenance. An increase of 
$25 million.

   BIE schools use this funding for the preventative and 
        routine upkeep, as well as for unscheduled maintenance of 
        school buildings, grounds, and utility systems.

   Underfunding of maintenance continues to be an issue as 
        buildings are in poor conditions and cannot maintain proper 
        standards.

Indian School Equalization Program (ISEP)
    Provide $431 million for the Indian School Equalization Program. An 
increase of $35 million.

   These funds provide the core budget account for BIE 
        elementary and secondary schools by covering teacher salaries, 
        aides, principals, and other personnel.

   ISEP funds are often reallocated to cover the program cuts 
        in other areas of education.

   ISEP must have adequate funding to ensure all program needs 
        are fulfilled and must not be reduced to provide funds for new 
        initiatives that have not been vetted by tribes.

Juvenile Detention Education
    Reinstate $620,000 for juvenile detention education in BIA-funded 
facilities.

   These critical funds were eliminated for FY 2012.

   This essential funding was used to provide educational 
        services to detained and incarcerated youth at 24 BIA-funded 
        juvenile detention facilities.

   One of the best methods to rehabilitate individuals is 
        through education.

   Eliminating this program creates additional costs by 
        increasing the rate of repeat offenders.

Tribal Colleges and Universities' Institutional Operations
    Provide $94.3 million for Titles I and II under the Tribally 
Controlled Colleges and Universities Assistance Act. An increase of $30 
million.

   Title I: To fully fund Title I of the Tribally Controlled 
        Colleges and Universities Assistance Act of 1978 (Tribal 
        College Act), which provides day-to-day operating funds for 26 
        TCUs, would require $77.3 million.

      Since the Act was first funded in 1981, the number of 
        TCUs has more than quadrupled and enrollments have increased by 
        more than 325 percent.

      Title I TCUs receive $5,665 per Indian student toward 
        their institutional operating budgets. Accounting for 
        inflation, the program's funding level is more than $1,500 less 
        per Indian student than it was under the program's initial FY 
        1981 appropriation, which was $2,831 per Indian student.

      Despite the constraints of the current economy, Congress 
        has an obligation to make these critical institutions whole now 
        rather than continuing to make hollow promises for the future.

   Title II: Dine College has indicated a need for $17 million 
        to operate its multiple campuses and education sites located on 
        the Navajo Nation.

   Five other TCUs receive institutional operating funds 
        through the annual Department of the Interior Appropriation 
        measure, under separate various authorities.

   To support the basic day-to-day operating budgets of these 
        TCUs, NIEA requests the following:

      $9.3 million for institutional operations of tribally-
        chartered career and technical institutions under Title V of 
        the Tribally Controlled Colleges and Universities Assistance 
        Act of 1978;

      $4.8 million in a one-time payment to allow the 
        institutions to be forward funded;

      Adequate funds for continued and expanded operations of 
        Haskell Indian Nations University in Kansas and Southwestern 
        Indian Polytechnic Institute in New Mexico under the Snyder Act 
        of 1921; and

      $27.7 million for a one-time appropriation, equal to 75 
        percent of the current combined funding of the institutional 
        operations grants of those TCUs not funded under Titles I or II 
        of the Tribally Controlled Colleges and Universities Assistance 
        Act of 1978, necessary to transition these programs to be 
        forward funded.

Forward Fund Remaining Five Tribal Colleges and Universities
    Provide a One-Time Appropriation of $22 million to forward fund 
five TCUs.

   All other TCUs are able to plan multi-year budgets and start 
        each school year with predictable funding for operations. 
        Forward funding these remaining five institutions is necessary 
        for Haskell Indian Nations University; Southwestern Indian 
        Polytechnic Institute; Institute of American Indian Arts; 
        Navajo Technical University; and United Tribes Technical 
        College.

   These five tribal colleges, which are the only education 
        institutions funded through the BIE that are not forward 
        funded, have received no new operating funds and were in danger 
        of closing their doors to the thousands of Native students they 
        serve during the October 2013 federal government shutdown.

Institute of American Indian Arts (IAIA) and Center for Lifelong 
        Education
    Provide $13.3 million to the Center & Museum under the American 
Indian, Alaska Native, and Native Hawaiian Culture and Art Development 
Act. An increase of $5.3 million.

   IAIA is the only four-year degree fine arts institution 
        devoted to the study of contemporary Native American and Alaska 
        Native arts.

   IAIA has graduated more than 3 ,800 students from federally-
        recognized tribes and beyond. Of the $13.3 million requested, 
        provide $9.3 million, with an additional one-time payment of $4 
        million to allow for forward funding.

Haskell Indian Nations University (HINU) and Southwestern Indian 
        Polytechnic (SIPI)
    Provide $36.9 million to HINU and SIPI under the Snyder Act. An 
increase of $19.4 million.

   As the first TCUs, these institutions are funded separately 
        from the other institutions and require additional funding 
        considerations.

   Appropriations of $14.3 million to HINU and $8.5 million to 
        SIPI are necessary to ensure adequate services are provided to 
        Native students.

   A one-time payment of $13.2 million would help forward fund 
        the institutions.

       Department of Agriculture--Agriculture Appropriations Bill
1994 Extension Program
    Provide $6 million for the 1994 Extension Grants Program. An 
increase of $2.1 million.

   The 1994 Extension Program is designed to complement, not 
        duplicate, the federally recognized tribe extension program 
        (FRTEP). Ironically, the 1994 Institutions--tribal colleges and 
        universities--are the only members of the land grant system 
        that are not eligible to compete for these grant dollars.

   The 1994 Extension Program activities include: outreach to 
        at-risk youth; business skills development for local 
        agriculture entrepreneurs; Native plant restoration and 
        horticulture projects; environmental analysis and water quality 
        projects; and nutrition projects aimed at addressing health 
        disparities, such as high rates of diabetes among Native 
        populations.

   Ten years ago, while the 1994 Extension Program suffered a 
        13 percent cut in appropriated funding, the 1862 and 1890 
        extension programs were reduced by just 0.59 percent. In the 
        years since, the 1994 Extension Programs has been struggling to 
        recovered lost funds and opportunities. It is time that 
        Congress adequately invests in the extension programs 
        benefiting our reservation communities.

1994 Institutions Research Grants
    Provide $3 million for the 1994 Research Grants Program. An 
increase of $1.2 million.

   The 1994 Research Grants Program allows TCUs to partner with 
        communities in research areas such as agriculture marketing, 
        renewable energy, nutrition and health, Native plants and 
        horticulture, water quality, and land management.

   These research areas are of increasing importance as tribal 
        economies and tribes' efforts to address pressing challenges 
        depend on access to quality data and evidence.

   Challenges include the disproportionate impacts of climate 
        change on tribal lands and people, as well as the impact of 
        poor economic conditions.

   TCUs need and deserve a level of funding that will increase 
        their capacity for further developing and conducting research 
        and to strengthen education and sustainable economic 
        development important to their tribal communities.

   In FY 2013, the program was cut a further 7.6 percent by 
        sequestration to only $1.664 million.

Educational Equity Grant Program
    Provide $6 million to the Educational Equity Grant Program for 1994 
land-grant institutions. An increase of $2.7 million.

   The Education Equity Grant Program assists TCU land-grants 
        to establish academic programs within the field of agriculture 
        that explore areas such as natural resource management, 
        nutrition, environmental science, horticulture, sustainable 
        development, and forestry.

   The funding requested will help in preparing to address 
        issues of climate change and its impact on agriculture, 
        ecosystems, and natural resources focusing on remote 
        reservation communities.

   This investment will support TCU efforts to provide 
        increased nutrition education to their reservation communities, 
        who experience diabetes and other health issues at rates far 
        greater than the national average.

   In FY 2013, the program was cut a further 7.6 percent by 
        sequestration to only $3.081 million.

The 1994 Native American Institutions Endowment Fund
    Provide a $136 million endowed payment into the 1994 Institutions 
Native American Endowment Fund. An increase of $124 million.

   The Native American Institutions Endowment Fund, managed by 
        the US Treasury, provides funds to TCU land-grant institutions 
        through dissemination of the annual interest yield. Although 
        Congress has made regular contributions to the corpus of the 
        endowment, the latest interest yield shared by the 32 eligible 
        1994 institutions amounted to just $4.5 million.

   These funds assist in strengthening academic programs, 
        including agriculture curricula development, faculty 
        development, instructional delivery, and experiential learning.

   Funds are also used to enhance student recruitment and 
        retention in the agricultural sciences, as well as to address 
        the ongoing need for improved facilities at the 1994 land-grant 
        institutions.

   The 1994 institutions request that a payment of $136 million 
        be made, which would essentially double the principle amount 
        funded for the 1994 Native American Institutions Endowment.

   Since only the annual interest yield is distributed to the 
        1994 land-grant institutions, only the interest on the Fund-and 
        not the appropriated payment amount-is scored as budget outlay, 
        yet the additional interest available to the TCUs, will yield 
        get dividends in community-based programs.

Essential Community Facilities at Tribal Colleges and Universities 
        Grant Program
    Provide $10 million for the TCU Essential Community Facilities 
Grant Program. An increase of $6.9 million.

   The USDA-Rural Development program provides grants for 
        Essential Community Facilities at TCUs funds the ever-growing 
        need for construction, improvement, and maintenance of TCU 
        facilities, such as advanced science laboratories, computer 
        labs, student housing, day care centers, and community service 
        facilities.

   Although the situation has improved at many TCUs over the 
        past several years, some institutions still operate partially 
        in temporary and inadequate buildings.

   Few TCUs have dormitories, even fewer have student health 
        centers, and only a handful of TCUs have full research 
        laboratories.

   The 1994 land-grant institutions need a commitment of $5 
        million each year for the next five fiscal years to support 
        construction, improvement, and maintenance of TCU facilities.

   Department of Health and Human Services--Labor, Health and Human 
                Services--Education Appropriations Bill
Head Start
    Provide $9.6 billion in total funding for Head Start, which 
includes Indian Head Start. An increase of $1 billion.

   Head Start has been and continues to play an instrumental 
        role in Native education.

   In 2012, Head Start funds provided early education to over 
        24,000 Native children.

   This vital program combines education, health, and family 
        services to model traditional Native education, which accounts 
        for its success rate.

   Current funding dollars provide less for Native populations 
        as inflation and fiscal constraints increase.

   It is now conventional wisdom that there is a return of at 
        least $7 for every single dollar invested in Head Start

   Congress should increase funds to Head Start and Early Head 
        Start to ensure Indian Head Start can reach more tribal 
        communities and help more Native people by triggering the 
        Indian special expansion funding provisions (after a full Cost 
        of Living Allowance has been paid to all Head Start programs).

   The definition of ``expansion'' for funding purposes should 
        include not only new positions, but also the establishment of 
        new programs in unserved Indian communities, as well as quality 
        improvements (e.g., increased staffing, professional 
        development, transportation equipment, computer technology/web 
        access, facility renovations and repair, etc.).

   Expansion should also include going from part-day to full-
        day, from home-based to center-based, full year services and 
        from Head Start to Early Head Start.

Native Languages Preservation (Esther Martinez Program Grants)
    Provide $12 million for Native language preservation with $5 
million designated to fund the Esther Martinez Language Programs. An 
increase of $3 million.

   Native language grant programs are essential to revitalizing 
        Native languages and cultures, many of which are at risk of 
        disappearing in the next decades.

   With adequate funding, Esther Martinez Program Grants 
        support and strengthen Native American language immersion 
        programs.

   In addition to protecting Native languages, these immersion 
        programs have been shown to promote higher academic success for 
        participating students in comparison to their Native peers who 
        do not participate.

   The federal budget should include $12 million as part of the 
        appropriation to the Administration for Native Americans for 
        Native language preservation activities.

   The appropriation should include $5 million designated to 
        support Esther Martinez Language Programs' Native language 
        immersion initiatives, as they have demonstrated success in 
        supporting Native language revitalization.

  Department Of Housing And Urban Development (HUD)--Transportation, 
           Housing and Urban Development Appropriations Bill
HUD-University Partnership Program for Tribal Colleges and Universities
    Provide $5.5 million to the HUD-University Partnership Program for 
TCUs. An increase of $5.5 million.

   Executive Order 13592, ``Improving American Indian and 
        Alaska Native Educational Opportunities and Strengthening 
        Tribal Colleges and Universities,'' holds federal agencies 
        accountable for developing plans to integrate TCUs into their 
        programs.

   TCUs work with tribes and communities to address all aspects 
        of reservation life, including the continuum of education, 
        housing, economic development, health promotion, law 
        enforcement training, and crime prevention.

   Likewise, federal agencies need to work with TCUs. To 
        achieve results, Congress needs to hold the Administration 
        accountable for strengthening the TCUs, including their 
        physical plants and that they are routinely included as full 
        partners in all existing and potential federal higher education 
        programs.

   The HUD-TCU competitive grants program, administered by the 
        Office of University Partnerships, is an excellent place to 
        start.

   This competitive grants program has enabled TCUs to expand 
        their roles and efficacy in addressing development and 
        revitalization needs within their respective communities.

   National Science Foundation (NSF)--Commerce, Justice, and Science 
                          Appropriations Bill
Education and Human Resources (EHR)
    Provide at least $13.3 million to the Tribal Colleges and 
Universities Program. An increase of $1 million.An increase of $1 
million.
   In FY 2009, NSF awarded $4.2 billion in science and 
        engineering (SE) funding to the nation's institutions of higher 
        education, and TCUs only received $10.5 million, or one-quarter 
        of one percent of this funding.An increase of $1 million.
   Among other minority serving institutions, NSF awarded 
        $144.2 million in SE funding to 174 historically black colleges 
        and universities and Hispanic serving institutions, averaging 
        $828,545 per institution, while 29 TCUs received an average of 
        only $362,000 per institution.An increase of $1 million.
   This disproportionate distribution trend must be addressed 
        in FY 2015.An increase of $1 million.
Conclusion
    NIEA appreciates the continued support of this Committee and we 
look forward to working closely with its members under the leadership 
of Chairman Tester and Ranking Member Barrasso. We share your 
commitment to Native education and want to strengthen our partnership 
with you to ensure programs serving Native communities are as efficient 
and effective as possible.

                                  [all]
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