[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]


  H.R. 5406, HELPING ENSURE ACCOUNTABILITY, LEADERSHIP, AND TRUST IN 
                TRIBAL HEALTHCARE ACT, ``HEALTTH ACT''

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

                          LEGISLATIVE HEARING

                               BEFORE THE

                  SUBCOMMITTEE ON INDIAN, INSULAR AND
                         ALASKA NATIVE AFFAIRS

                                 OF THE

                     COMMITTEE ON NATURAL RESOURCES
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                         Tuesday, July 12, 2016

                               __________

                           Serial No. 114-50

                               __________

       Printed for the use of the Committee on Natural Resources


         Available via the World Wide Web: http://www.fdsys.gov
                                   or
          Committee address: http://naturalresources.house.gov
          
                    
          
          
 [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]  
 
                               ___________
                               
                               
                        U.S. GOVERNMENT PUBLISHING OFFICE
20-919 PDF                       WASHINGTON : 2016                        
 
 ________________________________________________________________________________________
 For sale by the Superintendent of Documents, U.S. Government Publishing Office, 
 http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,
 U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free).
 E-mail, [email protected].  

 
 
 
 
      

                     COMMITTEE ON NATURAL RESOURCES

                        ROB BISHOP, UT, Chairman
            RAUL M. GRIJALVA, AZ, Ranking Democratic Member

Don Young, AK                        Grace F. Napolitano, CA
Louie Gohmert, TX                    Madeleine Z. Bordallo, GU
Doug Lamborn, CO                     Jim Costa, CA
Robert J. Wittman, VA                Gregorio Kilili Camacho Sablan, 
John Fleming, LA                         CNMI
Tom McClintock, CA                   Niki Tsongas, MA
Glenn Thompson, PA                   Pedro R. Pierluisi, PR
Cynthia M. Lummis, WY                Jared Huffman, CA
Dan Benishek, MI                     Raul Ruiz, CA
Jeff Duncan, SC                      Alan S. Lowenthal, CA
Paul A. Gosar, AZ                    Matt Cartwright, PA
Raul R. Labrador, ID                 Donald S. Beyer, Jr., VA
Doug LaMalfa, CA                     Norma J. Torres, CA
Jeff Denham, CA                      Debbie Dingell, MI
Paul Cook, CA                        Ruben Gallego, AZ
Bruce Westerman, AR                  Lois Capps, CA
Garret Graves, LA                    Jared Polis, CO
Dan Newhouse, WA                     Wm. Lacy Clay, MO
Ryan K. Zinke, MT
Jody B. Hice, GA
Aumua Amata Coleman Radewagen, AS
Thomas MacArthur, NJ
Alexander X. Mooney, WV
Cresent Hardy, NV
Darin LaHood, IL

                       Jason Knox, Chief of Staff
                      Lisa Pittman, Chief Counsel
                David Watkins, Democratic Staff Director
                  Sarah Lim, Democratic Chief Counsel
                                 ------                                

       SUBCOMMITTEE ON INDIAN, INSULAR AND ALASKA NATIVE AFFAIRS

                        DON YOUNG, AK, Chairman
                RAUL RUIZ, CA, Ranking Democratic Member

Dan Benishek, MI                     Madeleine Z. Bordallo, GU
Paul A. Gosar, AZ                    Gregorio Kilili Camacho Sablan, 
Doug LaMalfa, CA                         CNMI
Jeff Denham, CA                      Pedro R. Pierluisi, PR
Paul Cook, CA                        Norma J. Torres, CA
Aumua Amata Coleman Radewagen, AS    Raul M. Grijalva, AZ, ex officio
Rob Bishop, UT, ex officio

                              ----------
                              
                              
                              
                                CONTENTS
                                                              
                                
                             ------------                              
                                                                   Page

Hearing held on Tuesday, July 12, 2016...........................     1

Statement of Members:
    Noem, Hon. Kristi L., a Representative in Congress from the 
      State of South Dakota......................................     5
        Prepared statement of....................................     7
    Ruiz, Hon. Raul, a Representative in Congress from the State 
      of California..............................................     3
        Prepared statement of....................................     4
    Young, Hon. Don, a Representative in Congress from the State 
      of Alaska..................................................     1
        Prepared statement of....................................     2

Statement of Witnesses:
    Bohlen, Stacy, Executive Director, National Indian Health 
      Board, Washington, DC......................................    38
        Prepared statement of....................................    40
    Church, Jerilyn, Chief Executive Officer, Great Plains Tribal 
      Chairmen's Health Board, Rapid City, South Dakota..........    46
        Prepared statement of....................................    48
    Kitcheyan, Victoria, Treasurer, Winnebago Tribe of Nebraska, 
      Winnebago, Nebraska........................................    32
        Prepared statement of....................................    34
    Miller, Hon. Vernon, Chairman, Omaha Tribe of Nebraska, Macy, 
      Nebraska...................................................    26
        Prepared statement of....................................    28
    Shield, Hon. William Bear, Chairman, Rosebud Sioux Tribal 
      Health Board, Rosebud, South Dakota........................    23
        Prepared statement of....................................    25
    Smith, Mary, Principal Deputy Director, Indian Health 
      Service, U.S. Department of Health and Human Services, 
      Rockville, Maryland........................................    14
        Prepared statement of....................................    16
        Questions submitted for the record.......................    22

Additional Materials Submitted for the Record:
    Avera Health, Deb Fischer-Clemens, Sr. Vice President, 
      Prepared statement of......................................    58
    Confederated Tribes of the Colville Reservation, Hon. Michael 
      Marchand, Chairman, Prepared statement of..................    58
    Oglala Sioux Tribe, John Yellow Bird Steele, President, 
      Prepared statement of......................................    60
    South Dakota Organization of Healthcare Association, Scott A. 
      Duke, CEO, Prepared statement of...........................    68
    United South and Eastern Tribes Sovereignty Protection Fund 
      and Self-Governance Communication and Education Tribal 
      Consortium, Prepared statement of..........................    69
                                     


 
   LEGISLATIVE HEARING ON H.R. 5406, TO AMEND THE INDIAN HEALTH CARE 
 IMPROVEMENT ACT TO IMPROVE ACCESS TO TRIBAL HEALTH CARE BY PROVIDING 
  FOR SYSTEMIC INDIAN HEALTH SERVICE WORKFORCE AND FUNDING ALLOCATION 
   REFORMS, AND FOR OTHER PURPOSES, ``HELPING ENSURE ACCOUNTABILITY, 
  LEADERSHIP, AND TRUST IN TRIBAL HEALTHCARE ACT,'' OR ``HEALTTH ACT''

                              ----------                              


                         Tuesday, July 12, 2016

                     U.S. House of Representatives

       Subcommittee on Indian, Insular and Alaska Native Affairs

                     Committee on Natural Resources

                             Washington, DC

                              ----------                              

    The subcommittee met, pursuant to notice, at 2:04 p.m., in 
room 1334, Longworth House Office Building, Hon. Don Young 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Young, Benishek, Gosar, LaMalfa; 
Ruiz, Bordallo, and Sablan.
    Also present: Representative Noem.
    Mr. Young. The Subcommittee on Indian, Insular and Alaska 
Native Affairs will come to order.
    The subcommittee is meeting today to hear testimony on the 
following bill: H.R. 5406 from Congressman Kristi Noem to amend 
the Indian Health Care Improvement Act to improve access to 
tribal health care by providing for systematic Indian Health 
Service workforce and funding allocation reforms, and other 
purposes, or the ``Helping Ensure Accountability, Leadership, 
and Trust in Tribal Healthcare Act.''
    Under Committee Rules, opening statements will be issued by 
myself and the Ranking Member. This will allow us time to hear 
from our witnesses. Therefore, I ask unanimous consent that all 
other Members who have opening statements be made part of the 
record if they are submitted to the Subcommittee Clerk by 5:00 
p.m. today, or at the close of the hearing, whichever comes 
first.
    And I ask unanimous consent that the gentlewoman from South 
Dakota, Mrs. Noem, be allowed to join us at the dais to be 
recognized and participate in today's hearing. Hearing no 
objection, so ordered.

STATEMENT OF HON. DON YOUNG, A REPRESENTATIVE IN CONGRESS FROM 
                      THE STATE OF ALASKA

    Mr. Young. We are here today to take testimony on a bill 
intended to address a severe problem in Indian Country. 
Adequate health care is one of the most important issues to 
American Indians and Alaska Natives. However, the Indian Health 
System (IHS) direct care system is deficient, inadequate, and 
simply fails in areas of the country that need help the most.
    In 2010, a Senate investigation report brought to light 
some very severe problems plaguing 1 of the 12 regions in the 
Indian Health Care Service, the Great Plains region. After the 
report was released, the agency repeatedly assured Congress 
that issues were being addressed. Then, roughly a year ago, the 
same IHS region experienced a termination of a provider 
agreement with Centers for Medicare and Medicaid Services (CMS) 
at the Winnebago IHS hospital located in Winnebago, Nebraska. 
CMS found repeated deficiencies at the hospital ``had caused 
actual harm and is likely to cause more harm'' to persons 
seeking examination or treatment.
    Since 2015, CMS has found deficiencies in other hospitals 
in the Great Plains region. Emergency department services have 
been diverted to hospitals that are 45 miles away. This leaves 
some tribes asking not `if,' but `when' other hospitals may 
lose CMS provider agreements.
    H.R. 5406, the Healthcare Act, is intended to make reforms 
to the Indian Health Service to help their broken system. This 
bill does not fix every problem in IHS; however, it is a step 
in the right direction for Indian County.
    And again, I would like to thank the sponsor of the bill 
for being here today, and she will be one of our witnesses.
    Before we turn to our witness, though, I want to 
acknowledge a group of students that I understand are here in 
the audience, who are part of the NCAI's Health Fellowship 
program, which I had the privilege of speaking to in Spokane, 
all of which are looking to pursue careers in the health field. 
I am encouraged by your interest, as I think many here in this 
room are, and I recognize you will play a role in the future of 
health care in Indian Country.
    So, if you are a student, would you raise your hands, 
please? That is not bad. One, two, three, four, five--five? 
Where are the rest of you? Six? OK. Anyway, welcome to the 
healthcare field and this hearing, by the way.
    [The prepared statement of Mr. Young follows:]
  Prepared Statement of the Hon. Don Young, Chairman, Subcommittee on 
               Indian, Insular and Alaska Native Affairs
    We are here today to take testimony on a bill intended to address a 
severe problem in Indian Country. Adequate healthcare is one of the 
most important issues to American Indians and Alaska Natives; however 
the IHS direct care system is deficient, inadequate, and is simply 
failing areas of the country that need help the most.
    In 2010, a Senate investigation report brought to light some very 
severe problems plaguing 1 of the 12 regions of the Indian Health 
Service, The Great Plains region. After the report was released, the 
agency repeatedly assured Congress that issues were being addressed. 
Then, roughly a year ago, the same IHS region experienced the 
termination of a provider agreement with Centers for Medicare and 
Medicaid Services at the Winnebago IHS hospital located in Winnebago, 
Nebraska. CMS found that repeated deficiencies at the hospital ``had 
caused actual harm and is likely to cause harm'' to persons seeking 
examination or treatment.
    Since 2015, CMS has found deficiencies in other hospitals in the 
Great Plains region. Emergency Department services have been diverted 
to hospitals that are 45 miles away. This leaves some tribes asking not 
``if'' but ``when'' other hospitals may lose CMS provider agreements.
    H.R. 5406, the HEALTTH Act, is intended to make reforms to the 
Indian Health Service to help a broken system. This bill does not fix 
every problem in the IHS; however, it is a step in the right direction 
for Indian Country.
    I want to thank the Sponsor of the bill and our witnesses for being 
here today.
    But before we turn to our witnesses, I want to acknowledge a group 
of students here in the audience who are part of NCAI's Health 
Fellowship program--all of which are looking to pursue careers in the 
health field. I am encouraged by your interest and I think many here in 
this room and elsewhere recognize you will play a role in the future of 
healthcare in Indian Country.

                                 ______
                                 

    Mr. Young. With that, I will turn to the Ranking Member for 
his opening statement.

STATEMENT OF HON. RAUL RUIZ, A REPRESENTATIVE IN CONGRESS FROM 
                    THE STATE OF CALIFORNIA

    Dr. Ruiz. Thank you, Mr. Chairman. I also want to 
congratulate the students and encourage you to continue to 
reach your dreams and your goals, with a passion and compassion 
that you have, to serve in healthcare capacity. I am an 
emergency physician, and I have been in your shoes. I can tell 
you that it is doable, it is absolutely doable, and you can do 
it.
    I also want to thank Congresswoman Noem for being here and 
discussing your bill, and to thank our other witnesses for 
taking the time to testify. We are here to talk about one 
thing, and that is health care in Indian Country. This is a 
chance to not only hear about the current issues at the Indian 
Health Services facilities and proposed solutions to address 
them, but to also take a hard look at the future of health care 
in Indian Country.
    Where do we want to be when it comes to our trust 
responsibility to ensure the health and well-being of our 
Native brothers and sisters? We do know where we have been, and 
the results speak for themselves. American Indian and Alaska 
Native people have long experienced a desperate health status 
when compared with other Americans, including a lower life 
expectancy and a disproportionate disease burden.
    American Indians and Alaska Natives born today have a life 
expectancy that is 4.4 years less than the rest of the U.S. 
population. American Indians and Alaska Natives continue to die 
at a higher rate than other Americans in many categories, 
including chronic liver disease and cirrhosis, diabetes, 
unintentional injuries, assault, homicide, suicide, and chronic 
lower respiratory diseases.
    There are many reasons for these health disparities, and we 
know that one of the contributing factors is the adequacy of 
the Indian health care delivery system. A recent GAO study 
found that the IHS has never conducted an agency-wide oversight 
on the timeliness of their care. Even the facilities that do 
attempt to track wait times are hampered by an outdated 
electronic health record system.
    We all agree on the seriousness of the deficiencies 
outlined by CMS in their survey of the four Great Plains area 
hospitals and the effects they have had on the communities they 
serve. I am saddened and angry to hear about the victims of 
those deficiencies. And while this is just the Great Plains 
area, I know that we will probably hear many of the same 
stories from other service units in other areas; this is not 
unique to the Great Plains area.
    We cannot provide competent, quality health care to Native 
American and Alaska Natives when we allow this inadequate level 
of facilities, management, and care. There are long-standing 
systemic issues at IHS that must be addressed, whether 
regulatory and legislatively, and the entire system needs to be 
brought into the 21st century.
    This includes an investment in infrastructure and 
information technology. It includes recruitment and retention 
of high-quality medical professionals and administrators, 
starting from grade school all the way to residency and 
fellowship training. And it includes the ability for tribes to 
control their own destinies through self-governance, while 
guaranteeing that the Federal Government lives up to its end of 
the bargain.
    This is the vision I see for the future of Native health 
care and the IHS, and I think many of my colleagues, both in 
Congress and the healthcare industry, would agree with me. I 
appreciate the effort that Acting Director Mary Smith has put 
forth in an attempt to address the current issues at these 
Great Plain area hospitals, and to establish a more proactive 
approach through mock surveys and other measures to prevent 
these issues from cropping up at other service units.
    I want to thank our colleague, Rep. Noem, for shining a 
light on the concerns at IHS, and bringing this legislation 
forward. I agree with some of the proposals--in fact, most--in 
H.R. 5406, and I disagree with others. The fact is that we need 
to start talking about permanent solutions that comprehensively 
address long-standing issues at IHS. And I also think we need 
to seriously talk about finally adequately funding IHS, which 
includes exempting IHS and its programs from sequestration.
    It strikes me as hypocritical to complain about the level 
of service that is provided, and then turn around and 
consistently under-fund the very agency responsible for 
providing it. And I know you agree with me, as well.
    There are actual lives in the balance, and they deserve 
better; we can do better as a community and as a country. In 
the end, I know that we all want the same thing. Everybody on 
this dais, everybody in the audience, we all want the same 
thing, the best healthcare system for our Native American 
communities.
    So, I want to yield back my time and thank you, Mr. 
Chairman, for addressing some of these issues in the past, and 
bringing this to light now.
    [The prepared statement of Dr. Ruiz follows:]
 Prepared Statement of Hon. Raul Ruiz, Ranking Member, Subcommittee on 
               Indian, Insular and Alaska Native Affairs
    Thank you, Mr. Chairman. I want to thank our witnesses for taking 
the time to testify today. We are here today to talk about one thing--
Healthcare in Indian Country.
    This is a chance to not only hear about current issues at IHS 
facilities and proposed solutions to address them, but to also take a 
hard look at the future of healthcare in Indian Country.
    Where do we want to be when it comes to our trust responsibility to 
ensure the health and well-being of our Native brothers and sisters? We 
do know where we have been, and the results speak for themselves. 
American Indian and Alaska Native people have long experienced a 
disparate health status when compared with other Americans, including a 
lower life expectancy and a disproportionate disease burden.
    American Indians and Alaska Natives born today have a life 
expectancy that is 4.4 years less than the U.S. all races population. 
American Indians and Alaska Natives continue to die at higher rates 
than other Americans in many categories, including chronic liver 
disease and cirrhosis, diabetes, unintentional injuries, assault, 
homicide, suicide, and chronic lower respiratory diseases.
    There are many reasons for these health disparities, and we know 
that one of the contributing factors is the adequacy of the Indian 
health care delivery system. A recent GAO study found that the IHS has 
not ever conducted any agency-wide oversight on the timelines of their 
care. Even the facilities that do attempt to track wait times are 
hampered by an outdated electronic health record system.
    We all agree on the seriousness of the deficiencies outlined by CMS 
in their survey of the four Great Plains area hospitals, and the 
effects they have had on the communities they serve. Like us all, I am 
saddened and angry to hear about the victims of those deficiencies. And 
while this is just the Great Plains area, I fear that we could probably 
hear many of the same stories from other service units in other areas.
    We cannot provide competent, quality healthcare to Native American 
and Alaska Natives when we allow this inadequate level of facilities, 
management and care. There are long-standing systemic issues at IHS 
that must be addressed, whether regulatory and legislatively, and the 
entire system needs to be brought into the 21st century.
    This includes an investment in infrastructure and information 
technology. It includes recruitment and retention of high quality 
medical professionals and administrators. And it includes the ability 
for tribes to control their own destinies through self-governance, 
while guaranteeing that the Federal Government lives up to its end of 
the bargain.
    This is the vision I see for the future of Native healthcare and 
the IHS, and I think many of my colleagues, both in Congress and the 
healthcare industry, would agree with me. I appreciate the effort that 
Acting Director Mary Smith has put forth in an attempt to address the 
current issues at these Great Plain area hospitals, and to establish a 
more proactive approach through mock surveys and other measures to 
prevent these issues from cropping up at other service units.
    I want to thank our colleague, Rep. Noem, for shining a light on 
the concerns at IHS, and bringing this legislation forward. I agree 
with some of the proposals in H.R. 5406, and I disagree with others. 
The fact is that we need to start talking about permanent solutions 
that comprehensively address the long-standing issues at IHS. And I 
also think we need to seriously talk about finally adequately funding 
IHS, which includes exempting IHS and its programs from sequestration.
    It strikes me as hypocritical to complain about the level of 
service that is provided, and then turn around and consistently 
underfund the very agency responsible for providing it.
    There are actual lives in the balance, and they deserve better. We 
can do better. In the end, I know that we all want the same thing--the 
absolute best heath care system for our Native peoples.
    Thank you, Mr. Chairman, and I yield back.

                                 ______
                                 

    Mr. Young. I thank the gentleman, and one thing that I want 
to make clear--in Alaska, I believe--I may be wrong--the IHS 
role with contracting is only with the Native organizations, 
and it works very well, and I think we ought to look at that. 
We have probably the best Native healthcare system in the 
United States right now. I am a little proud of that, and I 
should be.
    So, our first witness, Congresswoman Noem, you are up. 
Thank you for your bill, and thank you for taking the time to 
be here. We gladly look forward to your testimony.

STATEMENT OF HON. KRISTI L. NOEM, A REPRESENTATIVE IN CONGRESS 
                 FROM THE STATE OF SOUTH DAKOTA

    Mrs. Noem. Thank you, Chairman Young and Ranking Member 
Ruiz, and the members of the subcommittee. I appreciate you 
having this hearing today and inviting me to testify in support 
of my bipartisan bill, H.R. 5406. Maybe by the end of this 
committee hearing, I will have you on board, as well, 
Representative Ruiz, with all parts of the bill.
    This bill is called the Helping Ensure Accountability, 
Leadership, and Trust in Tribal Healthcare, the HEALTTH Act. 
And I want to thank today's witnesses who have traveled a long 
way to be with us. Mr. Bear Shield and Ms. Church, who are here 
from my home state of South Dakota; we have Mr. Miller and Mrs. 
Kitcheyan, who are here from Nebraska. And thanks also to Ms. 
Bohlen and Ms. Smith for being here today to add their 
perspective.
    I don't want to make any mistakes today in telling you 
clearly we are here because of a crisis. The Indian Health 
Service is beyond broken. Fixing it is literally a matter of 
life and death. Nowhere is this truer than in the Great Plains 
region. The Great Plains service area is home to some of 
America's most remote and most impoverished tribal communities. 
Unemployment rates, substance abuse rates, and suicide rates 
are far above national averages. In fact, many of the 
unemployment rates in these areas are 80 to 90 percent.
    At the center of it all is a healthcare system so deficient 
that providers are offering care with expired licenses. Their 
surgical instruments are being washed by hand. Opioids and 
other drugs are being stolen by the thousands, and premature 
babies are being born on hospital bathroom floors with no 
physician present.
    Last year, CMS terminated its accreditation of the 
Winnebago Hospital in Nebraska, which serves the Omaha and the 
Winnebago Tribes. CMS then cited the Rosebud, Pine Ridge, and 
Sioux San Hospitals in South Dakota. In Rosebud, the situation 
is by far the worst. Without warning, IHS closed the facility's 
emergency room and diverted patients to hospitals located over 
50 miles away. In the 7 months that the ER has been closed, 
five babies have been born in ambulances, and nine people have 
died in transit to these other hospitals. So, literally, we are 
talking life and death.
    I want everybody to think of this perspective, too, because 
I think it is important to know--IHS is a subset under HHS, as 
is CMS. CMS actually refused to reimburse the kind of care that 
was being delivered at IHS facilities, both under the same 
umbrella of HHS, which tells you--we have one Federal agency 
pointing out how terrible of a job another Federal agency is 
doing--literally, every single day it is important that we 
recognize how terrible this situation is.
    In the years since the 2010 Senate Indian Affairs Committee 
report that outlined many of the most shocking problems, the 
IHS has promised again and again to make changes. But it has 
failed to do so, even at the most basic levels. If you thumb 
through the past IHS budget requests, you will find the same 
promises copied and pasted from one year to the next. This is 
the very definition of status quo.
    What has changed is the funding. Congress has delivered 
funding increases to IHS almost every year since the Senate 
report, bringing the annual IHS budget almost $1 billion over 
2010 levels. Yet the situation is just as bad as it has ever 
been. So, we know for a fact that money alone is not going to 
fix the problem.
    The HEALTTH Act reforms an agency that is desperately in 
need of an overhaul. Many tribes are considering self-
governance, which you indicated, Mr. Chairman, works well in 
Alaska. But for a number of reasons, many of my tribes are not 
quite ready to administer a hospital when they are so 
impoverished and lack so many resources. They want to 
eventually end up there, though, that is the goal.
    My bill creates a pilot project in which hospitals can be 
controlled by tribal-led boards, rather than IHS. This new 
model will give tribes more control over their hospitals, and 
equip them with the expertise that they need for self-
governance. The IHS's chief obstacle in the Great Plains is 
staffing. To improve recruitment and retention, my bill extends 
the agency student loan repayment program to administrators, as 
well as medical staff, and makes this financial support tax-
free, like other government programs that are already out there 
designed to attract providers to under-served areas. This will 
make the repayment program a more valuable tool to recruit more 
competent administrative and medical staff.
    We also require cultural competency training to ensure that 
IHS employees understand the people that they are serving. We 
ask the agency to report their wait times, and we eliminate 
barriers that currently prevent medical and dental providers 
from being able to volunteer at IHS facilities. And finally, 
the HEALTTH Act reforms the purchased referred care program, 
which currently operates under an unfair funding allocation 
formula. My bill would require that IHS update this formula and 
ensure that the money is getting to those people who need it 
the most.
    As I said before, I believe IHS should get out of the 
hospital business. I think they are terrible at it. My bill 
takes us a step in that direction, under this pilot program. We 
have received widespread support, including from the Rosebud 
Sioux Tribe, the National Indian Health Board, all the major 
health systems in South Dakota, and national and state health 
organizations. But we are not done.
    I look forward to a robust discussion today, and I welcome 
all of the input from the subcommittee, the witnesses, and the 
tribes across the country.
    Chairman Young, Ranking Member Ruiz, and members of the 
committee, thank you for allowing me to testify today. I truly 
thank you for your commitment to improving tribal health care. 
With that, I will yield back.
    [The prepared statement of Mrs. Noem follows:]
  Prepared Statement of the Hon. Kristi L. Noem, a Representative in 
                Congress from the State of South Dakota
    Chairman Young, Ranking Member Ruiz, and members of the 
subcommittee, thank you for inviting me to testify in support of my 
bipartisan bill, H.R. 5406, the Helping Ensure Accountability, 
Leadership, and Trust in Tribal Healthcare--or HEALTTH Act.
    I thank today's witnesses, especially Mr. Bear Shield and Ms. 
Church, who traveled from my home state of South Dakota, and Mr. Miller 
and Ms. Kitcheyan, who are here from Nebraska. Thanks also to Ms. 
Bohlen and Ms. Smith for being here today.
    We are here today because of a crisis. The Indian Health Service is 
beyond broken, and fixing it is literally a matter of life and death. 
Nowhere is this truer than in the Great Plains. The Great Plains 
service area is home to some of America's most remote and impoverished 
communities. Unemployment rates, substance abuse rates, and suicide 
rates are above national averages. At the center of it all is a 
healthcare system so deficient that providers are offering care with 
expired licenses, surgical instruments are being washed by hand, 
opioids and other drugs are being stolen by the thousands, and 
premature babies are being born on hospital bathroom floors with no 
physician present.
    Last year, CMS terminated its accreditation of the Winnebago 
hospital in Nebraska, which serves the Omaha and Winnebago Tribes. CMS 
then cited the Rosebud, Pine Ridge, and Sioux San hospitals in South 
Dakota. In Rosebud, the situation is particularly dire. Without 
warning, the IHS closed the facility's emergency room, diverting 
patients to hospitals located over 50 miles away. In the 7 months the 
ER has been diverted, five babies have been born in ambulances while in 
transit to these other hospitals, and nine people have died.
    In the years since a 2010 Senate Indian Affairs Committee report 
that outlined many of the most shocking problems, the IHS has promised 
time and again to make changes. But it has failed to do so at even the 
most basic levels. If you thumb through past IHS budget requests, you 
will find the same promises copied and pasted from one year to the 
next. This is the very definition of status quo.
    What has changed is funding. Congress has delivered funding 
increases to the IHS almost every year since the Senate report, 
bringing the annual IHS budget almost $1 billion over 2010 levels, and 
yet, the situation is as bad as it has ever been. Money alone will not 
fix the problems.
    The HEALTTH Act reforms an agency in desperate need of change.
    Many tribes are considering self-governance, but for a number of 
reasons, aren't yet ready to administer a hospital. My bill creates a 
pilot project in which hospitals can be controlled by tribal-led 
boards, rather than IHS. This new model would give tribes unprecedented 
control over their hospitals, and equip them with the expertise needed 
for self-governance.
    The IHS's chief obstacle in the Great Plains is staffing. To 
improve recruitment and retention, my bill extends the agency's student 
loan repayment program to administrators as well as medical staff and 
makes that financial support tax-free, like other government programs 
designed to attract providers to underserved areas. This will make the 
repayment program a more valuable tool to recruit more competent 
administrative and medical staff.
    We also require cultural competency training to ensure IHS 
employees understand the people they serve. We ask the agency to report 
wait times. And we eliminate barriers that currently prevent medical 
and dental providers from volunteering at IHS facilities.
    Finally, the HEALTTH Act reforms the Purchased/Referred Care 
program, which currently operates under an unfair funding allocation 
formula. My bill would require the IHS to update this formula and 
ensure the money is getting to people who need it most.
    As I have said before, I believe the IHS should get out of the 
hospital business, and my bill is a step in that direction.
    We have received widespread support, including from the Rosebud 
Sioux Tribe, the National Indian Health Board, all the major health 
systems in South Dakota, and national and state health associations. 
But we're not done. I look forward to a robust discussion today and I 
welcome input from the subcommittee, the witnesses, and tribes across 
the country.
    Chairman Young and Ranking Member Ruiz, thank you again for 
inviting me to testify. I thank you for your commitment to improving 
tribal healthcare. Because this is such a critical issue for my 
constituents in South Dakota, I respectfully request that the members 
of the subcommittee allow me to join them on the dais for the remainder 
of the hearing.

                                 ______
                                 

    Mr. Young. Thank you, Congresswoman. Ranking Member, do you 
have any questions?
    Just out of curiosity, did you write this bill, or did you 
have help from the people directly affected?
    Mrs. Noem. We had help from many of the tribes that are 
impacted directly. We even got technical assistance from IHS 
originally. The thing that has been the most frustrating for me 
is that, as you will hear in the testimony today of the IHS's 
Acting Director, they have some criticisms of our bill, which 
we have been waiting weeks now for more technical assistance.
    So, some of the criticisms that you will hear in testimony 
today I think are unwarranted, when we did consult with them in 
drafting the legislation. Our tribes are very happy with the 
legislation, and recognize that these needed reforms have to be 
put in place as soon as possible. Every day that emergency 
department is closed down and services are diverted, their 
people are dying. IHS doesn't recognize the emergency situation 
we have on our hands.
    Mr. Young. You just led an opening to me, Kristi. We did 
not get their testimony until last night at 8:00.
    Mrs. Noem. I know.
    Mr. Young. I have checked it over, and if I really wanted 
to be nasty, I would have the Senate testimony and this 
testimony, and there are just some words that have been 
transferred.
    Mrs. Noem. Except for the criticisms of this bill.
    Mr. Young. That is right.
    Mrs. Noem. That was added on at the end. The rest of it was 
identical.
    Mr. Young. That is right. And I am just saying that is a 
no-no, so thank you for your legislation.
    Mr. Benishek.
    Dr. Benishek. Well, I want to thank Mrs. Noem for bringing 
this to my attention. I, frankly, was not aware of the severity 
of the problem. And looking over the briefing here, it is just 
remarkable what has been going on. How can there be any defense 
of this action? I don't know, and I think your legislation is 
long overdue. I can't wait to hear from the tribal people.
    So, this hospital is run by the IHS, is that the story?
    Mrs. Noem. Our hospitals in the Great Plains region, except 
for one--but all the ones in South Dakota are run by direct 
service, which means IHS Federal employees deliver the health 
care in these facilities. Other tribes in other parts of the 
country operate under a 638, which means that they do not have 
Federal employees running it, but they receive the funds to run 
the facilities.
    But for us, I think we are in such a tragic situation 
because we have IHS running these facilities, and you will hear 
stories from the tribal members today that you would not 
believe could happen in America. The quality of health care 
that is being delivered in my tribal communities is third-world 
health care, and it should not be happening in this country, 
especially when the Federal Government is responsible for 
providing health care to them.
    Under our treaty obligations--these are treaty tribes that 
we need to honor by treating them with the respect they deserve 
and the health care that we have promised them, and we are 
failing.
    And the agency is slow-walking fixes. They will tell you in 
the testimony today that they have the authority to do some of 
the things in the bill. Well, the tribal members will tell you 
if they have had the authority to do this all along, then shame 
on them because they should have been doing it. Our legislation 
is making sure that they follow through on delivering the kind 
of health care that our tribes deserve.
    Dr. Benishek. Thank you. I yield back.
    Mr. Young. Mr. Gosar.
    Dr. Gosar. Sure. One of the things the Office of IHS is 
supposed to work in consultation with the tribes, and that is 
foremost and inadequate in that discovery. We have seen the 
638. In fact, in Arizona we have seen the 638 take off. I mean 
the Navajos were one of the first ones to use the 638. There 
were some complications, granted, but I am hoping there is a 
way that what we can do is teach the tribes to take that onus 
and the transitional factor, so that they have more of the 
leadership role in that application to health care, but also 
have the accountability, as well.
    So, from that standpoint, I applaud your efforts in that 
regard. There will be some things that I will have some 
concerns about, because I want the same type of care from 
auxiliaries. That has to be mandated differently.
    My one question for you is--did you have any input from the 
Pew Foundation?
    Mrs. Noem. Not that I am aware of, but I will request from 
my staff and clarify later with you if we did.
    Dr. Gosar. I appreciate it. Thanks.
    Dr. Benishek. Will you yield for a minute?
    Dr. Gosar. I will yield to the gentleman from Michigan.
    Dr. Benishek. I thought of another question.
    Mrs. Noem. Sure.
    Dr. Benishek. Do you know how much the IHS was spending on 
this hospital?
    Mrs. Noem. One of the problems that we have had with IHS is 
we cannot get the exact dollar amounts that flow to the Great 
Plains region and what actually meets the tribes. The tribes 
will testify to you that they believe a lot of the dollars 
disappear at the regional center in Aberdeen, that it never 
quite flows down to the people or actually results in delivered 
health care to the people.
    So, the purchased referred care that I reform within my 
bill, that money runs out by June every year. In fact, it is 
common knowledge and there is a saying in Indian Country in 
South Dakota, ``Don't get sick after June,'' because if you get 
sick after June, you are just not going to receive care, you 
will be----
    Dr. Benishek. This hospital that was closed down, the IHS 
ran it, but you don't really know how much money they spent 
there per patient, or the total amount, or any of those 
numbers. That is all, like----
    Mrs. Noem. Exactly.
    Dr. Benishek. All right, thank you. I yield back.
    Dr. Gosar. I am going to reclaim my time, because Dr. 
Benishek actually gave me another question.
    One of the things that would--and I mean this is not my 
first rodeo with problems with IHS and application to the 
tribes. Part of the reason is credentialing. And dentistry is 
also a big issue within the tribes. IHS refused to have a core 
central credentialing protocol in which those that want to 
volunteer for extended periods of time can do so. I hope that 
is a real prominent aspect of this bill.
    Mrs. Noem. It is.
    Dr. Gosar. I will spend a little more time with that. 
Credentialing is a problem. And I would alert the tribes to 
tell them that, once again, the consultation process--IHS has 
to function on consultation with a tribe. So, I would beg that 
the tribes become very affluent and forceful in that regard, to 
have transparency and have them answer directly to them, 
because that is the way it is supposed to function; and 
Congress should back that.
    Mrs. Noem. Representative Gosar, I wholeheartedly agree 
with you. My tribes will tell you that they feel as though no 
consultation happens and that virtually they are left out of 
the decisionmaking process, they are informed when something 
has already been implemented. When we do have problems with 
employees, they are shuffled around to other positions, nobody 
is ever fired.
    The consultation piece is one of the biggest complaints 
that I hear out of my tribes.
    Dr. Gosar. Yes, and I once again would re-acknowledge the 
point that there are some 638s out there that are becoming very 
sophisticated in application, not just for tribal members, but 
off tribal. In Flagstaff, there are some outreach clinics that 
are associated with the 638s, so there is a lot of possibility 
that actually works within this.
    I appreciate the gentlelady's interest and----
    Mrs. Noem. Well, my tribes would like to get there, they 
just do not have the resources to get there tomorrow. That is 
their goal.
    Mr. Young. I am going to use my prerogative, Mr. Ruiz.
    Dr. Ruiz. Thank you, Mr. Chairman.
    Congresswoman Noem, I just want to give a warning that 
there is no one size that fits all in Indian Country. There are 
a lot of dynamics and complexities within the different 
regions, within the different tribes. There is a difference 
between rural health and urban health. There is a difference 
within the states, of course. So, sometimes IHS can work within 
a certain region, within a certain population. Perhaps, in 
Great Plains, it is not working with the big hospital model, 
however there have been partnerships with hospitals with IHS 
and local tribes working together.
    So, I think that this is not a one-size-fits-all or this 
one particular bill is going to fix the entire IHS. We should 
be flexible in understanding the local unique dynamics within 
the different regions and the different types of health care 
and the different types of risk factors that exist in those.
    The other thing is that we should really focus on making 
sure that there are incentives for recruitment. I know this 
bill has some of those, and also prevent the disincentives for 
retention, because there are some barriers that are unique in 
Indian Country in terms of trying to get, as you mentioned, 
administrators, doctors, and nurses to serve there that we need 
to address. So, I think it is important that we keep those 
things in mind and I thank you for your attempt in doing that.
    Mrs. Noem. Thank you. I think that is why you will see that 
the bill is drafted as a pilot program for the Great Plains 
region, because we know that we face a different situation than 
other regions in the country. This is specifically to test this 
kind of implementation process in our region, where the 
situation is so terrible.
    And also, one of the challenges that we face is the vacancy 
rates of positions of nurses, doctors, and administration 
officials. That is why, in the bill, we try to address that 
through provisions that will help us recruit, but also allow 
individuals to stay in these communities, become a part of the 
community, and maybe even train members of the community, so 
that they continue to better their lifestyle and livelihood, as 
well. Thank you.
    Mr. Young. Mr. LaMalfa.
    Mr. LaMalfa. Thank you, Mr. Chairman. Mrs. Noem, you 
mentioned a pretty horrific situation there. I wasn't sure if 
you said that was at Rosebud on the ER closure?
    Mrs. Noem. Yes, for 7 months the emergency department has 
been closed.
    Mr. LaMalfa. And it is still closed?
    Mrs. Noem. Yes.
    Mr. LaMalfa. All right. What was the condition of why they 
chose to close it? Was it the right decision to close it?
    Mrs. Noem. Well, what created the situation was CMS coming 
in and saying they would no longer reimburse for services 
provided in that emergency department because of conditions 
that were occurring there. And what IHS identified and has 
fixed, some of it was construction, some of it was adding new 
technology or new medical devices, lack of staff.
    But they also put new security measures in on protecting 
their drugs and----
    Mr. LaMalfa. Some of that was done, or was being done----
    Mrs. Noem. That has been done. Then they contracted the 
emergency department out to a staffing agency that has been 
hiring and trying to fill positions before they reopen.
    I have been told for weeks that it will reopen soon. But 
every time I have asked IHS, ``When will this emergency 
department open because lives depend on it,'' I have never 
gotten an answer.
    I understand that CMS is there today conducting a survey; 
so potentially that is coming soon, and that should be the 
final step before it reopens. The problem I have had is it has 
taken them 7 months to get their act together, to get it done, 
hire staff, and that I never once was given a date on when this 
emergency department would reopen--and I don't believe my 
tribes were ever given any kind of an indication. Even if we 
asked them today, I am not sure they would tell us what day it 
would open.
    But what we need to realize is that we are transporting 
people across very rural areas of South Dakota, and they are 
dying in ambulances on the way there----
    Mr. LaMalfa. You said five baby deliveries and nine 
deaths----
    Mrs. Noem. Nine deaths.
    Mr. LaMalfa [continuing]. They could attribute to maybe 
lack of timing?
    Mrs. Noem. Lack of care when they needed it.
    Mr. LaMalfa. And was actual closure really necessary, or 
could they have restaffed a little ongoing? I mean shutting 
something completely down----
    Mrs. Noem. It was a dangerous situation.
    Mr. LaMalfa [continuing]. Versus trying to do something in 
a couple weeks that would take care of this cleanliness issue, 
or get one--I mean it would seem like with the cost involved to 
the community in its convenience or proximity, or whatever you 
would call it, that is a pretty big cost.
    Mrs. Noem. That is a great question for the Acting 
Director.
    Mr. LaMalfa. The next panel? OK. In the bill, how do you 
feel about the allocation formula and capping being placed on 
the PRC. How is that going to play out?
    Mrs. Noem. The PRC funding formula does not currently work, 
because my tribes run out of money by June. So, for the rest of 
the year, they cannot get care. Unless they are dying on the 
table, they might get care. But other than that, those 
reimbursements or payments are not made to other facilities 
that are providing care to Natives that IHS should be doing.
    Mr. LaMalfa. Because there is a fund somewhere that runs 
out by June instead of it being properly funded?
    Mrs. Noem. Yes.
    Mr. LaMalfa. Or is there a higher cost involved or 
something that is blowing up the fund, or what?
    Mrs. Noem. Yes. What my legislation does is that it 
reimburses at Medicare rates, so that it stretches the dollars 
farther, so that they are not paying astronomical rates to 
other providers to take care of Native Americans.
    And then also what it does is it allocates the formula 
according to need. Some tribes are getting more dollars than 
what they can really utilize and have plenty of money to make 
it through the year. My tribes run out by June because it has 
never been changed according to population. As population grows 
in these tribes, I am just asking IHS to redo this formula to 
make sure that needs are being met.
    Mr. LaMalfa. Are you getting any pushback on the Medicare 
cap?
    Mrs. Noem. I have not.
    Mr. LaMalfa. OK. So maybe smooth sailing?
    Mrs. Noem. I am sure there is somebody that is unhappy with 
it, but it certainly will help my tribes receive care for more 
months out of the year.
    Mr. LaMalfa. And it is probably commensurate with a lot of 
other medical facilities that maybe are not as tribe-oriented.
    Mrs. Noem. Well, my medical facilities that are providing 
care to Native Americans today that are not getting paid for 
that, they are doing it as charity care, sure, they would like 
to get something.
    Mr. LaMalfa. Yes, well, certainly. OK. Very good. Thank you 
for your testimony.
    Mr. Young. I have been informed there are no other 
questions at this time. We want to hear from the other 
witnesses, is that correct?
    We thank you Congresswoman, very much so, and thanks for 
bringing this bill forward. We will have Mary Smith, Principal 
Deputy Director, Indian Health Service; the Honorable William 
Bear Shield, Chairman of the Rosebud Sioux Tribal Health Board; 
Ms. Victoria Kitcheyan--I have to say that, Victoria, because 
it is not Ketchikan; it is very nearly Ketchikan, though, I can 
tell you that, so you know--a city in Alaska; and the Honorable 
Vernon Miller, take the witness stand, please.
    Which one? Two more? OK. Jerilyn Church and Stacy Bohlen. I 
think most of you recognize or have testified before. You have 
5 minutes. I am pretty lenient if you are making good 
presentation. I have to say that because if you start rambling 
I will enforce the 5-minute rule. So, just keep that in mind.
    But I try to give you time. I have never liked the 5-minute 
rule. But it is because of time. And, unfortunately, you cannot 
present your real case in 5 minutes, nor can we ask questions 
in 5 minutes. But because of time we can't.
    And Ms. Mary, I have to say that we are not picking on you, 
we are picking on the system. This is not new. This has been 
going on for years, and we are just trying to ensure--the 
congresswoman is trying to arrive at a solution, and we are 
willing to listen to all sides of this issue and see if we 
can't get something done for those that have not been served.
    So, Ms. Mary, you are up.

  STATEMENT OF MARY SMITH, PRINCIPAL DEPUTY DIRECTOR, INDIAN 
 HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
                      ROCKVILLE, MARYLAND

    Ms. Smith. Thank you. Good afternoon, Chairman Young, 
Ranking Member Ruiz, and members of the committee. I want to 
thank you all for the invitation to join you today to testify 
on H.R. 5406, the Helping Ensure Accountability, Leadership, 
and Trust in Tribal Healthcare Act.
    And, Mr. Chairman, I do want to apologize personally on the 
timing of the testimony. I am sorry.
    Mr. Chairman, I appreciate and thank you and the committee 
for your leadership in elevating the importance of delivering 
quality care at the Indian Health Service. I would also like to 
thank Representative Noem for her partnership and for focusing 
attention on the critical needs of health care for Native 
Americans, and for her participation at the recent field 
hearing in Rapid City, South Dakota. Finally, I would like to 
thank my fellow witnesses for all their work and partnership in 
this important area.
    All of us share the goals reflected in this legislation: 
driving accountability, strengthening the workforce, and 
improving the quality of care for the Native American 
communities we serve. I think, while we are sitting on 
different sides of the table, I think we are all on the same 
side. We all want to improve the quality of health care for 
Native Americans.
    While the Administration has some concerns with some of the 
provisions in the bill as drafted, we look forward to working 
with the committee to improve the bill as it moves through the 
legislative process.
    At the outset, I want to thank the many dedicated staff and 
providers we have at IHS. They work under difficult conditions 
to deliver care in some of the poorest and most remote areas of 
our country. Nonetheless, IHS faces severe operational and 
staffing challenges, challenges not unlike those shared by 
other healthcare systems that provide care in rural 
communities, such as nursing and provider shortages. And, 
unfortunately, these challenges did not occur overnight. They 
are long-standing and systemic.
    Over the past several years, IHS has encountered challenges 
with a number of our direct service facilities in the Great 
Plains area. And more recently, these long-standing challenges 
have gained attention from Congress, including this committee. 
We welcome this attention and momentum that it creates for 
lasting quality improvements for these facilities because we 
are on the front lines of medical care in some of the most 
remote parts of our country.
    To underscore, our challenges are daunting. But I am 
committed, along with the rest of the team at IHS, and with the 
support of the Department of Health and Human Services, to 
creating a culture of quality, leadership, and accountability. 
Since I was asked to lead IHS just a few months ago, I have 
moved aggressively toward this goal, meeting with tribal 
leaders to hear their concerns firsthand, visiting facilities, 
and launching agreements to make improvements in the IHS 
delivery system that will be sustainable over time.
    One area of focus is staffing and the retention of 
qualified staff. Across the system, IHS is committed to 
supporting staff with the necessary resources and tools to 
perform their jobs. For example, IHS is ensuring that living 
quarters are allocated efficiently to support the retention of 
health professionals, as a lack of housing is a serious barrier 
to recruitment. Retaining dedicated IHS staff members is 
important and essential for the continuity of operations. This 
year we began executing an aggressive strategy to improve the 
quality of care at IHS, and we are focusing on a 5-point 
strategy.
    First, we are focusing on assessment. We are taking a close 
look at the quality of care delivered through our direct-
service hospitals. We are beginning a system-wide mock survey 
initiative for all 27 IHS hospitals to assess compliance with 
Medicare and readiness for re-accreditation.
    Second, we are immediately strengthening service delivery. 
IHS is working diligently to stem local staff shortages and 
build a pipeline for staff training and deployment. Already 
more than 60 clinicians from the U.S. Public Health Service 
Commissioned Corps have deployed to hospitals in the Great 
Plains. We are expanding our outpatient hours and we are using 
telehealth to bring hard-to-find specialty care right to the 
patient.
    Third, we are strengthening IHS management. We are 
assessing a number of staffing and management office options, 
including finding innovative ways to compete and retain talent.
    Fourth, we are infusing quality expertise. We recently 
joined a hospital engagement network to reach across all 27 IHS 
hospitals and share strategies on how to reduce avoidable re-
admissions and hospital-acquired infections. We are bringing in 
experts from different parts of HHS to consult with IHS 
hospitals to ensure that our improvements are real and 
measurable.
    Fifth, we are engaging local resources. Some of the most 
helpful expertise and effective leadership are the tribal 
communities we work with daily. We are committed to 
strengthening these relationships and engaging further with 
partners from the community like local and regional healthcare 
systems, local colleges and universities, and the leadership of 
our direct-service hospitals.
    At IHS, we are committed to making meaningful and 
measurable progress to improve the health and well-being of all 
American Indians and Alaska Natives. It is not business as 
usual. It is not simply pointing out the challenges, but 
focusing on solutions and about how we all have been entrusted 
with providing access to health care for Native people, and how 
we can work together to tackle these issues to make sustainable 
improvements so that we can move forward toward solving the 
long-standing systemic issues and deliver the quality of care 
that our patients deserve.
    Thank you, Mr. Chairman.
    [The prepared statement of Ms. Smith follows:]
  Prepared Statement of Mary Smith, Principal Deputy Director, Indian 
                             Health Service
                              introduction
    Good afternoon, Chairman Young, Ranking Member Ruiz, and members of 
the committee. Thank you for the invitation to join you today to 
testify on H.R. 5406, the Helping Ensure Accountability, Leadership, 
and Trust in Tribal Healthcare Act (HEALTTH Act). We would like to 
start by thanking you and the committee for your leadership and for 
elevating the importance of delivering quality care through the Indian 
Health Service. I would also like to thank Representative Noem for her 
leadership and partnership in focusing attention on the critical needs 
of health care for Native Americans. This committee, IHS, and HHS share 
common goals of providing consistent, quality health care to the 
American Indian and Alaska Native communities. The Administration has 
concerns with some provisions in H.R. 5406 as drafted and looks forward 
to working with the committee to improve the bill as it moves through 
the legislative process.
    Earlier this year, we strengthened and refocused our resources 
within the IHS as part of an aggressive strategy to improve the overall 
quality of care in the Great Plains area, and across the country. IHS 
is working to instill a culture of quality care, leadership, and 
accountability across the agency. We are committed to hearing directly 
from you and the communities we serve to focus sharply on how to best 
improve access to quality health care and, most importantly, improve 
the health status of American Indian and Alaska Native families and 
communities.
    To be clear, the acute problems we are seeing right now are largely 
tied to chronic, long-standing issues, often spanning decades. 
Recognizing that, the focus of our work this year is to move 
aggressively to develop both systemic changes even while we're 
addressing immediate, short-term needs. We have significant efforts 
underway on both fronts.
    It is not business as usual at IHS. Under my leadership, IHS is 
changing the way it approaches long-standing challenges. We are working 
to transform the process by which we recruit and retain staff; to 
create an organizational structure that supports sustained improvement 
and accountability; and to strengthen our financial management 
infrastructure.
    To ensure that dependable, quality care is delivered consistently 
across IHS facilities, 3 months ago, Secretary Burwell created the 
Executive Council on Quality Care and asked Acting Deputy Secretary 
Wakefield to lead it. This Council includes senior executives from 
across HHS and draws on expertise from across the Department. We have 
some of HHS's top managers, clinicians, and program experts taking a 
fresh look at long-standing obstacles like workforce supply, housing, 
challenges to delivering quality of care, and addressing key operations 
issues. The Council provides the framework to ensure that we are 
leveraging all the resources we can on behalf of tribal communities and 
the patients we serve.
    IHS, in conjunction with the work of this Council, for the past 3 
months, has been engaging our work through a five-prong strategy to 
address these challenges--many of the same obstacles like sufficient 
workforce, human resources issues, and care quality, that this 
legislation seeks to address. With this strategy, IHS and the 
Department are working to (1) surface issues so that we can work to 
resolve them; (2) improve service delivery; (3) strengthen IHS Area 
management; (4) infuse quality expertise; and (5) engage with local 
resources.
Surfacing Issues
    First, we are assessing and surfacing issues so that we can work to 
resolve them. We are taking a very close look at the quality of care 
delivered through direct-service hospitals at IHS facilities across the 
Great Plains area as well as throughout Indian Country. We want to 
affirm and support facilities that are delivering quality care and work 
closely with facilities that need improvement. It is important that IHS 
leadership from Headquarters to Area offices to our service units work 
closely with both tribal leadership and direct service hospitals in a 
transparent way that encourages open information exchange about 
improvement opportunities. We know from decades of experience across 
the health care continuum, that problems that are not acknowledged and 
fixed put patients at risk. For the past 20 years, health care systems 
across the Nation have been embracing new models of improvement, and we 
are working to embrace those models through the assets of IHS and other 
HHS operating divisions.
    For example, IHS has begun a system-wide mock survey initiative at 
all 27 of its hospitals to assess compliance with the Centers for 
Medicare and Medicaid Services (CMS) Conditions of Participation and 
readiness for re-accreditation. These mock surveys will be conducted by 
survey teams from outside each respective area to reduce potential 
bias. The new mock survey initiative is being coordinated through the 
IHS Quality Consortium as a unified effort to reinforce standardization 
of processes. We are beginning in the Great Plains area with 
assessments and, when appropriate, interventions through the provision 
of on-site assistance to hospital staff. Although some direct service 
hospitals currently conduct self-assessments, IHS is standardizing and 
improving this process so that direct-service hospitals receive a 
consistent assessment within the next few months and performance data 
is centrally tracked, not just at individual facilities but across all 
facilities.
    Through this and other targeted strategies, IHS will move from 
being reactive to proactive in identifying and addressing performance 
issues early. Our first efforts were piloted May 10, 2016, at the 
Rosebud Hospital, and we will continue to do quality surveys at all 
direct service hospitals, excluding those that have been surveyed in 
the past year or are scheduled to be formally surveyed through other 
mechanisms during this time frame. When our survey teams identify 
problems, we will work swiftly to address these local problems and work 
to put systems changes in place to resolve the problems. Additionally, 
best practices that are identified will be shared across IHS 
facilities.
    Another example of surfacing and addressing problems is IHS' 
enhanced drug testing interim policy. This policy was released on June 
6, 2016, and it focuses on drug testing based on reasonable suspicion. 
The interim policy provides guidance to supervisors and managers on 
drug testing based on a reasonable suspicion of drug use. This effort 
was informed by tribal leaders' calls for additional IHS administrative 
actions in this area.
Improve Service Delivery
    Second, we are working to improve service delivery by focusing on 
workforce and clinical support infrastructure.
Workforce
    The IHS continues to face significant workforce challenges with a 
chronic shortage of health care providers. While we have taken 
immediate steps to address some local shortages, and are in the process 
of adding more, such as telemedicine, these long-standing challenges 
require bolstering and expanding the training and deployment pipelines 
and full use of innovative approaches to delivering care. In the near-
term, with Secretary Burwell, Deputy Secretary Wakefield, and the U.S. 
Surgeon General's support, over 60 Commissioned Corps clinicians have 
been deployed for temporary placements into the Great Plains hospitals 
with CMS findings. In addition, the National Institutes for Health 
(NIH) and the Health Resources and Services Administration (HRSA) have 
been helping IHS deploy strategies they have used to recruit 
applicants. IHS is also revising job announcements and deploying more 
comprehensive recruitment plans around key positions, in an effort to 
recruit a greater number of qualified candidates. IHS is utilizing 
Title 38 pay increases for high-demand Emergency Department clinicians 
and has established eligibility for payment of relocation expenses for 
GS-12 and lower graded clinical positions. However, even with these and 
a number of other strategies that have been utilized during the past 
few months or that are in development right now, there is still much 
more work that needs to be done to attract and retain an adequate 
health care workforce. Some of these changes may require legislative 
action. In addition, we are working with Office of Personnel Management 
(OPM), the Office of Management and Budget (OMB), and other affected 
agencies to explore ways to enhance our current flexibilities. We are 
also are combining efforts that leverage collaboration between tribal, 
public, and private academic institutions.
    One of the most challenging areas to support is the availability of 
emergency services, particularly in the Great Plains area. Because of 
this, on May 17, 2016, IHS initiated a new strategy through a contract 
award to provide both emergency department staffing and operations 
support and management services at three hospitals: Rosebud Hospital 
and Pine Ridge Hospital in South Dakota and Omaha Winnebago Hospital in 
Nebraska. This contractor will provide health care in these hospital 
emergency rooms while IHS reviews the administrative and clinical 
operations of its facilities across the region to develop long-term 
solutions. IHS's leadership both in the hospitals and at headquarters 
have direct oversight of this contractor and is responsible for holding 
this contractor accountable for providing consistent quality health 
care. However, because this is a new approach to Emergency Department 
staffing and management combined, a team of clinicians and attorneys, 
as well as the CEOs of the facilities, are tracking this initiative 
weekly to ensure that performance expectations are met.
    As part of a longer-term strategy, we are re-examining the 
scholarship and loan repayments program to make sure that we are 
maximizing their impact as well as introducing new strategies as well. 
We are working with the Peace Corps' Global Health Services program 
that fields clinicians to areas of critical workforce needs and most 
immediately, we are building communication channels about service to 
Indian Country to returning volunteers. By the end of last month, for 
example, 60 returning volunteers learned about opportunities to work in 
IHS direct service hospitals even as we are engaging other longer-term 
communication strategies with the broader Global Health Services 
program. Additionally, the U.S. Public Health Service Commissioned 
Corps has prioritized assignment of new officers to IHS with a 
particular focus on the Great Plains area.
    On a related front, on June 1, IHS proposed to expand its Community 
Health Aide Program. Partnership and collaboration are part of our 
ongoing work to deliver quality health care to patients. Increased 
access to care is a top priority, which is why IHS is engaging in 
consultation with tribal leaders on this expanded effort. Community 
health aides are proven partners, and this important proposed change 
would bring more health workers directly into American Indian and 
Alaska Native communities.
Infrastructure
    In addition to addressing workforce challenges, the IHS is trying 
to lessen the loads on our emergency departments by establishing 
alternative avenues of care, such as urgent care clinics and telehealth 
services. IHS is working aggressively to reopen the Rosebud Emergency 
Department as soon as possible. In the meantime, in order to fill the 
temporary gap, the IHS has re-purposed existing ambulatory care space 
into an Urgent Care clinic staffed with emergency department and 
ambulatory providers. Given the types of illnesses that individuals 
present with to the Rosebud Emergency Department, the Urgent Care 
clinic can manage the majority of non-emergent care needs.
    Specialty services like behavioral health, cardiology, and diabetes 
care can be difficult to find in rural areas. IHS will also be using 
telehealth contracts to bring specialty services into the communities 
where individuals live so they do not need to travel. IHS issued a 
Telemedicine Request for Proposal on May 5, 2016. Proposals were 
originally due June 6, 2016; however, at the request of prospective 
offerors who needed more time to prepare comprehensive proposals, IHS 
extended the deadline to respond by 30 days.
Strengthening Area Management
    Third, we are working to strengthen area management. While we 
support the workforce at each hospital, we are taking a broader view to 
strengthen Great Plains area management through the temporary 
deployment of high-quality managers from within other areas of IHS as 
well as deploying HHS experts to both IHS headquarters and the field to 
assist with finance, contracting, and management functions. IHS also 
established a Human Resources (HR) Steering Committee, which provides 
oversight and guidance on the implementation of system-wide HR 
improvements in IHS.
    As part of these efforts, Rear Admiral Kevin Meeks spent 3 months 
leading the Area Office, and he continues to support the Great Plains 
area in order to provide continuity of leadership. Captain Chris 
Buchanan joined the Great Plains area leadership team in May and is 
serving as the Acting Director of the Great Plains Area Office. Captain 
Buchanan has extensive expertise working with complex health systems 
which are IHS directly operated facilities as well as tribally managed 
programs. In the longer term, the IHS is actively looking to find the 
best possible candidate for the Great Plains Area Director position. We 
have taken steps to attract as broad a pool of well-qualified 
candidates as possible. We have also implemented a stronger search 
committee process for recruiting highly qualified managers and 
executives. This committee is charged with candidate outreach, 
assessment, and vetting. IHS is also more widely advertising vacancies 
through Federal, state, and non-profit partners, and is actively 
seeking additional venues to help attract a broad and diverse applicant 
pool. Additionally, going forward, we have expanded tribal 
participation in filling vacant Area Director positions and members of 
a tribe from each area will, for the first time, play a role in these 
search committees at the outset of the hiring process on these key 
positions.
    Finally, IHS recently announced it is conducting a 90-day 
consultation with tribal leaders to discuss the organization and 
operation of the Great Plains Area Office, to, in partnership with the 
tribes, identify new approaches to better support patients and tribal 
community health in the area. The first telephonic consultation was 
held on June 22, and the first in-person consultation will be held in 
Rapid City later this week on July 15.
Infusing Quality Expertise
    Fourth, we are infusing substantial quality expertise into 
informing and improving care quality in direct service facilities. In 
partnership with CMS, we have launched a Hospital Engagement Network 
(HEN) to provide evidence-based efforts in quality improvement. As we 
announced on May 13, 2016, this HEN is now available to all IHS direct 
service facilities and focuses on quality improvement methods intended 
to reduce avoidable readmissions and hospital acquired conditions (e.g. 
central line blood infections, pressure ulcers, falls, etc.). Hospitals 
in the network share successful practices and lessons learned to 
accelerate learning and change.
    The HEN will prioritize working with the three Great Plains area 
hospitals and is currently working with each hospital to schedule on-
site meetings.
    Additionally, we are bringing in targeted quality improvement 
assistance through CMS' Quality Improvement Organization (QIO) 
infrastructure. Among other support and training functions, QIOs assist 
with root cause analysis of identified problems, assist with the 
development of improvement plans, establish baseline data, and monitor 
data to ensure improvement plans are successful and sustained over 
time. Also through Secretary Burwell's Executive Council on Quality 
Care, HHS is deploying quality experts, as needed, from throughout the 
Department to consult with and help our IHS direct-service hospitals 
that are currently out of compliance with CMS Conditions of 
Participation and to monitor progress as the facilities come into 
compliance.
Engaging Local Resources
    And fifth, we aim to engage more robustly with local resources. We 
know that, in addition to our strong partnerships with tribes and their 
leadership, local academic and health systems organizations can be 
valuable sources of expertise and partnership. We intend to strengthen 
our relationships with local and regional health care systems, local 
colleges and universities and tribal colleges, direct-service hospital 
leadership and tribal leadership to build stronger academic pipelines 
and health care connections to ensure we are working collaboratively 
and effectively to produce health related workers and health care 
services.
    We also recognize that the health of communities is tied to the 
economic health of communities. Rates of unemployment and poverty 
matter. Consequently, we are committed to advancing the success of 
small businesses in tribal communities. The Department's Office of 
Small and Disadvantaged Business Utilization, in collaboration with the 
U.S. Small Business Administration, is working to coordinate meetings 
with tribal leaders and small businesses owned by Native Americans, 
Indian tribes, and the Native American community at large.
    Our team plans to have these meetings in or near the 12 Indian 
Health Service Area Offices and the events will focus on how to 
effectively pursue contract opportunities with HHS, IHS, and other 
Federal agencies.
                           strengthening ihs
    We have been working to address challenges using new approaches on 
our end. First, we appreciate the authority we already have to use the 
pay flexibilities under chapter 74 of title 38. We are working with 
OPM, OMB, and other affected agencies to explore ways to enhance our 
current authorities to provide more tools to recruit and retain high-
quality staff.
    Second, we are seeking tax treatment, similar to the treatment 
provided to recipients of National Health Service Corps (NHSC) and 
Armed Forces Health Professions scholarships. Currently, IHS loan 
repayment/scholarship awards are taxable, reducing their value. In 
contrast, participants in the NHSC scholarship program and Armed Forces 
Health Professions may exclude scholarship amounts used for qualifying 
expenses from income, and participants in the NHSC loan repayment 
program may exclude NHSC loan repayment amounts paid on their behalf 
from income. We recommend adopting the Administration's Fiscal Year 
2017 Budget proposal which would conform the tax treatment of IHS 
repayments/scholarships to the tax treatment for NHSC and Armed Forces 
Health Professions repayments/scholarships.
    Third, the Indian Health Care Improvement Act requires employees 
who receive IHS scholarships or loan repayments to provide clinical 
services on a full-time basis. However, the Affordable Care Act permits 
certain NHSC loan repayment and scholarship recipients to satisfy their 
service obligations through half-time clinical practice for double the 
amount of time or, for NHSC loan repayment recipients, to accept half 
the loan repayment award amount in exchange for a 2-year service 
obligation. We would like similar flexibility in order to attract 
health care professionals who may not be able to work full-time to 
fulfill their service obligations.
    Being able to access resources is key to amplifying our work. It is 
critically important that we receive the funding the President 
requested in his Fiscal Year (FY) 2017 Budget, which includes: an 
increase of $159 million above FY 2016 to fund medical inflation, pay 
costs, and accommodate population growth for direct health care 
services; an increase of $20 million for health information technology 
to fund the development, modernization, and enhancement of IHS' 
critical health information technology systems; $2 million to create a 
new program which will focus on reducing medical errors that adversely 
affect patients; and $12 million specifically for staff quarters at 
current facilities, in addition to staff quarters associated with new 
facilities.
H.R. 5406
    H.R. 5406 addresses three broad areas and the paragraphs below 
include our feedback on various sections of the bill.
Title I--Expanding Authorities and Improving Access to Care
    Section 101 of the bill would establish a 7-year pilot project for 
long-term contracts to fully staff three hospitals. This is a concept 
IHS is exploring through our sources sought notice for at least two 
hospitals in the Great Plains that includes the option of contracting 
out the top senior management of the facility or the option to contract 
out the entire hospital. This section of the bill presents a third way 
between the current two methods of providing care through IHS funding, 
either full direct service or full self-governance.
    IHS supports a tribe's decision to receive services directly from 
IHS or to contract under the Indian Self-Determination and Education 
Assistance Act (ISDEAA). However, the agency is concerned that this 
provision while not impacting the right of a tribe to contract under 
ISDEAA would not absolve IHS from contractual liability to the private 
sector contractor for up to 7 years. While IHS has the current 
authority to contract out both the management and staffing of an entire 
hospital, IHS is concerned with the language in this section that IHS 
could be expected to fund both a private sector contractor and an 
ISDEAA tribal contractor, using the same source of funding. We suggest 
language be added to clarify that, in this situation, a tribe would 
take over the contract, not be paid in addition. Finally, IHS would be 
open to further discussing a long-term pilot, and associated funding 
needs, with the impacted tribes and the committee.
    Subsection (d) establishes governance boards for the selected 
hospitals made up of representatives from IHS, tribes, and experts in 
health care administration. IHS is concerned that such boards vest 
authority in individuals (elected tribal officials and other health 
care experts) who would not be accountable to IHS or the Secretary, who 
would retain the legal responsibility for running the hospitals. Tribes 
who want to assume full responsibility for the operation of their 
hospitals already have this authority under the ISDEAA. Instead, 
creation of an Advisory Board could ensure that tribes have input into 
hospital operations and access to information about how the hospital is 
operated. Advisory boards could also bring in the perspective of 
outside health experts, benefiting both IHS and tribes.
    Section 102 would expand IHS's authorities under chapter 74 of 
title 38 to help IHS offer more flexible and competitive benefits to 
recruit employees. IHS appreciates the authority we already have to use 
the pay flexibilities under chapter 74 of title 38. We are working with 
OPM, OMB, and other affected agencies to explore ways to enhance our 
current authorities to provide more tools to recruit and retain high-
quality staff.
    Section 103 addresses IHS authority to remove or demote employees. 
The specific provisions on removing or demoting an employee appear 
unnecessary as IHS already has authorities to implement adverse 
employment actions as contemplated by this section. While IHS already 
has these authorities, in an effort to bolster effective leadership and 
management accountability in addressing employee issues, we have taken 
the following actions during the past few months: issued a new drug 
testing policy based on reasonable suspicion; established that a new 
performance requirement focused on providing quality health-care be 
added to all applicable performance plans during the mid-year 
performance reviews; started providing Employee Relations and Labor 
Relations training to our managers beginning with the IHS Senior Staff; 
and issued policy guidance and expectations on reporting of any 
suspected fraud, waste, and abuse, and Whistleblower protection rights 
to all IHS employees. In addition, the Department of Justice (DOJ) 
advised us that it has serious constitutional concerns with the 
procedures in section 103, which appear to derive from section 707 of 
the Veterans Access, Choice, and Accountability Act of 2014, codified 
at 38 U.S.C. Sec. 713. The Attorney General notified Congress in a 
recent letter that DOJ could not defend section 707 in litigation 
challenging that provision on Appointments Clause grounds. Section 103 
could present similar concerns if enacted in its present form.
    Finally, we believe there may be technical issues with some of the 
bill's language pertaining to applicability to the U.S. Public Health 
Service (USPHS) Commissioned Corps, and definitions and references to 
current personnel practices. We would be happy to provide any technical 
comments.
    On expedited appeals, revoking Federal employee protections could 
lead to the unintended consequence of making IHS a less desirable place 
to work and thus compound staffing problems.
    Section 104 requires IHS to develop and implement standards to 
measure the timeliness of care at direct-service IHS facilities. IHS 
believes this provision is unnecessary as IHS already is cascading 
annual Senior Executive Service performance standards that specifically 
address improving access to patient care by establishing accountability 
for all senior managers to implement at least two activities to improve 
wait times and access to quality health care for patients that are 
based on enhanced implementation of current quality initiatives or new 
quality initiatives and that have measurable goals, measures, and 
outcomes, and requiring improvements to be documented at Headquarters, 
Area Office and facility levels. In addition, IHS is developing a 
quality framework that will take action on timeliness of care and 
provide data analytics.
Title II--Indian Health Service Recruitment and Workforce
    Section 201 would provide tax treatment, similar to the treatment 
provided to recipients of NHSC and Armed Forces Health Professions 
scholarships, to allow scholarship funds for qualified tuition and 
related expenses received under the Indian Health Services Health 
Professions Scholarships to be excluded from gross income under Section 
117(c)(2) of the Internal Revenue Code (IRC) and to allow participants 
in the IHS Loan Repayment Program to exclude from gross income student 
loan amounts that are forgiven by the IHS Loan Repayment program under 
Section 108(f)(4) of the IRC. IHS appreciates the inclusion of this 
provision as it was requested as part of the President's FY 2017 Budget 
request.
    Section 202 includes health care management or health care 
executive positions as eligible professions for loan repayment awards, 
including non-clinical service obligations. Management expertise is 
very important in a health system as large as IHS.
    Section 203 adds specific requirements for implementation of annual 
mandatory cultural competency training programs for IHS employees, 
locum tenens providers, and other contracted employees engaged in 
direct patient care. Cultural competency in the IHS workforce is 
essential to the provision of quality care.
    Section 204 addresses relocation reimbursement. IHS currently has 
ability to provide payment of relocation expenses. This section appears 
to combine payment of relocation expenses and relocation incentives. 
IHS already has the authority to pay Relocation expenses included in 5 
CFR part 572 and in accordance with the Federal Travel Regulations, 
Chapter 302, Relocation Allowances. The authorized allowances are 
outlined in Chapter 302. We would like the opportunity to better 
understand why payments of 50-75 percent of an employee's salary would 
be required under this section of the bill.
    IHS also has the authority to pay relocation incentives under 5 CFR 
part 575--Recruitment, Relocation, and Retention (3Rs) Incentives. To 
help with difficult-to-fill positions, agencies may authorize an 
incentive of up to 25 percent of an employee's annual rate of basic pay 
times the number of years in a service agreement, which could amount to 
an incentive of as much as 100 percent of an annual salary for 4 years 
of service. Only OPM can authorize incentive payments above 25 percent 
based on a critical agency need so that larger incentives may be 
approved for shorter service obligations. Relocation incentives also 
can be paid in addition to providing reimbursement of relocation 
expenses. We would be happy to provide any technical comments in 
coordination with OPM.
    Section 205, which permits a limited waiver of Indian preference, 
is more restrictive than current law. Impacted Indian tribes and tribal 
organizations are already permitted to waive Indian preference laws 
with respect to personnel actions pursuant to 25 U.S.C. 
Sec. 472a(c)(1). Current waiver authority is unconditional, unlike 
section 205, which requires the IHS service unit to have a personnel 
vacancy rate of at least 20 percent.
    Section 206 requires a Service-wide centralized credentialing 
system to credential licensed health professionals who seek to 
volunteer at a Service facility. IHS shares the goal of this section to 
streamline and standardize credentialing across the entire IHS system. 
IHS is exploring options for either installing an enterprise IT system 
for tracking credentialing and privileging across IHS or for 
contracting out the credentialing function to a third party. It appears 
the intent of the bill is for the Secretary to establish a separate and 
different credentialing system for volunteers. IHS's preference is to 
pursue the implementation of a single credentialing system for the 
entire agency, which would include volunteers.
Title III--Purchase/Referred Care Program Reforms
    Section 301 is similar to our Final Rule Medicare-like Rate payment 
for non-IHS, Tribal, or Urban (non-ITU) physician and other health care 
professional services associated with either outpatient or inpatient 
care provided at non-ITU facilities. If the intent of the legislation 
is to codify this regulation, we suggest using the language of the 
regulation, as there are a number of subtle changes that could 
drastically impact the meaning and implementation. However, if the 
intent is reinforcement of the rule then drafters could consider 
codified enforcement mechanisms, such as civil monetary penalties.
    Section 302 requires that the Secretary promulgate regulations to 
develop and implement a revised distribution formula for the purchase/
referred care program (PRC). To the extent that this provision is 
optional for 638 contractors and not optional for direct service 
tribes, this proposed legislation will provide incentives for tribes to 
enter into 638 contracts to run their own PRC programs and essentially 
cause a race to contract for PRC in order to avoid a revised 
distribution formula. The Federal Government's legal responsibility is 
to all AI/ANs, regardless of whether the services are provided directly 
or through a 638 contractor. The direct service tribes have a right to 
contract under the ISDEAA, but they also have a right not to do so and 
there is no basis in the law to penalize them for choosing to stay a 
direct service tribe.
                               conclusion
    IHS and HHS are committed to making meaningful and measurable 
progress in the way that IHS delivers care and to ensuring that this 
progress is sustainable over time. We have already taken significant 
steps, but there is much more work ahead, including the intense work 
underway to strengthen and stabilize the hospitals in South Dakota and 
Nebraska. We look forward to addressing those challenges and making 
lasting progress in close partnership with you. We look forward to 
working with the committee on this legislation as it moves through the 
legislative process. Thank you, and we are happy to take your 
questions.

                                 ______
                                 

 Questions Submitted for the Record by the Hon. Don Young to Ms. Mary 
     Smith, Principal Deputy Director, Indian Health Service, U.S. 
                Department of Health and Human Services

Ms. Smith did not submit responses to the Committee by the appropriate 
deadline for inclusion in the printed record.

    Question 1. Section 121 of the Indian Health Care Improvement 
Reauthorization and Extension Act of 2009, enacted into law as part of 
P.L. 111-148, required the Secretary of the Department of Health and 
Human Services to submit to Congress a report on the current health 
status and resource deficiencies of the Indian Health Service for each 
service unit, including newly recognized or acknowledged tribes.

    Has the Department finalized this report? If not, when can Congress 
expect to receive the report?
    Question 2. 25 U.S.C. Sec. 1680h includes the authorization the 
Indian Health Service to establish joint venture projects under which 
tribes or tribal organizations would acquire, construct, or renovate a 
health care facility.

    a.  For direct service tribes that have not any health facilities 
constructed under either the health care facility priority system or 
the Joint Venture Construction Program, does any way exist for those 
tribes to renegotiate or bring current their facility staffing ratios 
within the Indian Health Service system?

    b.  For Joint Venture Construction Program solicitations dating 
back to 2009, please provide for each the solicitation information that 
identifies:

     the tribes that submitted applications;

     the applications that progressed beyond the initial round 
            of review and the level of review they progressed to before 
            being denied, and

     the applications that Indian Health Service ultimately 
            selected.

                                 ______
                                 

    Mr. Young. Thank you, Mary.
    The Honorable William Bear Shield, Chairman, Rosebud Sioux 
Tribal Health Board.

STATEMENT OF HON. WILLIAM BEAR SHIELD, CHAIRMAN, ROSEBUD SIOUX 
           TRIBAL HEALTH BOARD, ROSEBUD, SOUTH DAKOTA

    Mr. Bear Shield. Greetings, Chairman Young and Ranking 
Member Ruiz. I would also like to acknowledge our South Dakota 
Congresswoman, Kristi Noem, and offer the gratitude and support 
of the Rosebud Sioux Tribe for her crafting and introducing 
H.R. 5406, the Helping Ensure Accountability, Leadership, and 
Trust in Tribal Healthcare Act.
    My name is William Bear Shield, and I am a Council 
Representative for the Rosebud Sioux Tribe, representing the 
Milks Camp Community, 1 of our 20 communities. I am also the 
Chairman of our Health Board, the Vice-Chairman of the Great 
Plains Tribal Chairman's Health Board, and the Chairman of the 
Unified Tribal Health Board for the Sioux San Hospital in Rapid 
City, South Dakota, which consists of the Cheyenne River, 
Oglala and Rosebud Sioux Tribes as members of the governing 
body.
    Sioux San also provides health care to tribal members from 
all Sioux Tribes and from over 200 federally recognized tribes.
    For over the past 2 years, basic health care has declined 
to an all-time low at the Winnebago, Omaha, Rosebud, Pine 
Ridge, and Sioux San IHS facilities, as reported by the tribes 
and confirmed by CMS, that has caused the deaths of tribal 
members and created other life-threatening issues.
    While Director Smith and other IHS officials seem to view 
the current and ongoing diversion of the emergency room in 
Rosebud with rose-colored glasses, nine tribal members have 
died in ambulances and five babies have been born in ambulances 
while being transported more than 50 miles or, in some 
instances, up to a 2-hour one-way trip to other off-reservation 
hospitals, since December 5, 2015 over the past 7 months.
    This cries for an investigation by someone other than IHS. 
Let me repeat: nine tribal members have died while riding in 
ambulances, and five babies have been born in ambulances while 
being transported over 50 miles to other hospitals.
    Let's highlight another less-than-rosy fact, that Indian 
Health Service official that suggested that two babies being 
born on the bathroom floor at the Rosebud IHS hospital in 8 
years was ``not doing too badly'' was the choice of Director 
Smith to be the Chief Medical Officer of the Great Plains 
region. No tribal leaders were consulted. Rosebud certainly was 
not. And, that official clearly has disdain for our people and 
should work elsewhere.
    The Rosebud Sioux Tribe signed a treaty of peace with the 
United States and promised no more wars between our nations. I 
bring this to your attention because our treaty is different 
than others in that it specifically addressed our health care. 
By 1982 there were 360 federally recognized tribes in Alaska 
that Natives recognized, and even then funding was not provided 
fairly by treaty, land base, and population, nor fully.
    Since Congress passed the Indian Gaming Regulatory Act, or 
IGRA, in 1988, the number of federally recognized tribes has 
increased to 567. As of today, 209 additional tribes have been 
federally recognized. Of those, none have even a fraction of 
our land base or population.
    We do not object to Congress recognizing other tribes, but 
we do want a fair formula to address health care needs in 
accordance with our treaties, land base, and populations. IHS 
has reported about 67 percent of the IHS budget is administered 
by 114 tribes, primarily through the authority provided to them 
under the Indian Self-Determination and Education Assistance 
Act, leaving approximately 37 percent for the remaining 453 
tribes, which, in many cases, are large land-based and large 
population tribes.
    Quite simply, the U.S. Government must live up to its 
obligations. That means acceptable and quality health care. 
That means reform, and with reform, additional Federal funding. 
We recognize this is an authorization bill, but at heart this 
is an appropriation issue. Congress must not walk away from the 
obligation to fully fund these treaty and trust 
responsibilities. A purely private-sector solution is simply 
not appropriate.
    Another challenging issue we wanted to raise before the 
committee is the tribal employer mandate of the Affordable Care 
Act, which we oppose along with other large land-based tribes. 
This law will result in over $2 million in fines from the 
Internal Revenue Service annually, for just the Rosebud Sioux 
Tribe alone. We will have to cut elder and youth programs, 
social assistance for low to no-income tribal members, and let 
go tribal members who work for the Rosebud Sioux Tribe. 
Congress needs to fix this law now.
    As of this moment, the Rosebud Sioux Tribe, through its 
economic arm, which is the Rosebud Economic Development 
Corporation, or REDCo, is working with Avera Hospital in Sioux 
Falls, South Dakota, to contract the key management positions 
of the Indian Health Service hospital by utilizing our 8a 
Native program, and asking IHS to issue a sole-source contract 
to us. By doing so, this follows the spirit of Section 833, the 
Service Hospital Long-Term Contract 9 Pilot Program in the 
proposed legislation. As of this date, IHS has not responded to 
our request.
    These are only some of the examples of why we support this 
bill, and we ask that IHS justify the funding formula that it 
is currently using and why the South Dakota and Great Plains 
area tribes' budgets are far below that of small land-based and 
large population-based tribes.
    We support direction of the legislation and look forward to 
working with members of this committee and your staff as you 
move forward to a legislative markup. We urge that you work to 
reform and move robust funding.
    Last, I would again express appreciation for the leadership 
of Congresswoman Noem for introducing this legislation and to 
Chairman Young and Ranking Member Ruiz for holding today's 
hearing. Thank you.
    [The prepared statement of Mr. Bear Shield follows:]
  Prepared Statement of William Bear Shield, Chairman, Rosebud Sioux 
                          Tribal Health Board
                                opening
    Greetings Chairman Young and Ranking Member Ruiz. I would also like 
to acknowledge our South Dakota Congresswoman Kristi Noem and offer the 
gratitude and support of the Rosebud Sioux Tribe for her crafting and 
introducing H.R. 5406 the ``Helping Ensure Accountability, Leadership, 
and Trust in Tribal Healthcare Act.''
    My name is William (Willie) Bear Shield and I am a Council 
Representative for the Rosebud Sioux Tribe representing the Milks Camp 
Community, 1 of our 20 communities. I am also the Chairman of our 
Health Board, the Vice-Chairman of the Great Plains Tribal Chairman's 
Health Board, and the Chairman of the Unified Tribal Health Board for 
the Sioux San Hospital in Rapid City South Dakota which consist the 
Cheyenne River, Oglala and Rosebud Sioux Tribes as members of the 
governing body. Sioux San provides health care to tribal members from 
all Sioux Tribes and from over 200 federally recognized tribes.
                                problems
    For over the past 2 years basic health care has declined to an all-
time low at the Winnebago-Omaha, Rosebud, Pine Ridge and Sioux San IHS 
facilities as reported by the tribes and confirmed by CMS that has 
caused the death of tribal members and created other life threatening 
issues.
    While Director Smith and other IHS officials seem to view the 
current and ongoing diversion of the Rosebud Emergency Room with rose-
colored glasses, nine tribal members have died in ambulances and five 
babies have been born in ambulances while being transported more than 
50 miles (up to a 2-hour one-way trip) to other off reservation 
hospitals since December 5, 2015--over the last 7 months. This cries 
out for an investigation--by someone other than IHS. Let me repeat--
nine tribal members have died while riding in ambulances and five 
babies have been born in ambulances while being transported over 50 
miles to other hospitals.
    And, let us highlight another less than rosy fact. The IHS official 
that suggested that two babies being born on the bathroom floor at the 
Rosebud IHS Hospital in 8 years was not doing too badly--was the choice 
of Director Smith to be the Chief Medical Officer of the Great Plains 
Region. No tribal leaders were consulted--Rosebud certainly was not. 
That official clearly has disdain for our people and should work 
elsewhere.
    The Rosebud Sioux Tribe signed a treaty of peace with the United 
States and promised no more wars between our Nations. I bring this to 
your attention because our treaty is different than others, in that it 
specifically addressed our health care. By 1982, there were 360 
federally recognized tribes and Alaska Natives recognized and even then 
funding was not provided fairly by treaty, land base and population, 
nor fully. Since Congress passed the Indian Gaming Regulatory Act 
(IGRA) in 1988, the number of federally recognized tribes has increased 
to 567, so as of today 209 additional tribes have been federally 
recognized and of those none have even a fraction of our land base or 
population.
    We do not object to Congress recognizing other tribes, but we do 
want a fair formula to address health care needs in accordance with our 
treaties, land base and populations.
    IHS has reported about 67 percent of the IHS budget is administered 
by 114 tribes primarily through the authority provided to them under 
the Indian Self Determination and Education Assistance Act, leaving 
approximately 37 percent for the remaining 453 tribes, which in many 
cases are large land-based and large population tribes. Quite simply, 
the U.S. Government must live up to its obligations--that means 
acceptable, quality health care. That means reform, and with reform, 
additional Federal funding. We recognize this is an authorization bill, 
but at heart this is an appropriation issue. Congress must not walk 
away from the obligation to fully fund these Treaty and Trust 
responsibilities. A purely private sector solution simply is not 
appropriate.
                            a sideline issue
    Another challenging issue we wanted to raise before the committee 
is the Tribal Employer Mandate of the Affordable Care Act which we 
oppose, along with other large land based tribes.
    This law will result in over $2 million in fines from the Internal 
Revenue Service annually for just the Rosebud Sioux Tribe. We will have 
to cut elder and youth programs, social assistance for low to no income 
tribal members--and fire (let go) tribal members who work for the 
Rosebud Sioux Tribe. Congress need to fix this law now.
                               solutions
    As of this moment the Rosebud Sioux Tribe through its economic arm 
(Rosebud Economic Development Corporation, REDCO) is working with the 
Avera Hospital in Sioux Falls, SD to contract the key management 
positions of the IHS Hospital by utilizing our 8a Native program and 
asking IHS to issue a sole source contract to us and by doing so 
follows the spirit of ``SEC. 833. SERVICE HOSPITAL LONG-TERM CONTRACT 9 
PILOT PROGRAM in the proposed legislation. As of this date IHS has not 
responded to our request. These are only some of the examples of why we 
support this bill and ask that IHS justify its funding formula that it 
is currently using and why the South Dakota and Great Plains Area 
Tribes' budget is far below that of small land-based and large 
population-based tribes.
                    work with committee and wrap up
    We support the direction of the legislation and look forward to 
working with members of the committee and your staff as you move toward 
a legislative markup. We urge that you work to pair reform with more 
robust funding.
    Last, I would again express appreciation for the leadership of 
Congresswoman Noem for introducing this legislation and to Chairman 
Young and Ranking Member Ruiz for holding today's hearing.

                                 ______
                                 

    Mr. Young. Thank you, Mr. Bear.
    Now we are going to Mr. Miller.

   STATEMENT OF HON. VERNON MILLER, CHAIRMAN, OMAHA TRIBE OF 
                    NEBRASKA, MACY, NEBRASKA

    Mr. Miller. Thank you, Chairman Young, Ranking Member Ruiz, 
and members of the subcommittee. I want to thank you for 
inviting me here to testify regarding Representative Noem's 
H.R. 5406, HEALTTH Act. Also, I wanted to further discuss with 
you the immediate need for substantive and effective change on 
delivery of healthcare services by the IHS.
    My name is Vernon Miller, and I am Chairman of the Omaha 
Tribe of Nebraska. The Omaha Tribe is located in the northeast 
corner of Nebraska, right along the Nebraska and Iowa border. 
Our facility is the Omaha Winnebago Hospital, which is a 
facility that is utilized by both the Winnebago Tribes and the 
Omaha Tribes within Nebraska. A week from today, it will be a 
full year since CMS came into our facility and determined that 
our healthcare services were not adequate for our tribal 
members, and for tribal members from other tribes, as well.
    What this is indicative of is 1 full year of an 
acknowledgment by an HHS agency that that hospital does not 
provide adequate care. And it is not an acknowledgment from a 
year, but it is years of inadequate health care that CMS has 
finally made that designation a year ago. It was not the only 
facility within the Great Plains region that does not have that 
certification, so as a result of that we are going to be seeing 
some pretty big impacts of that financially from the hospital 
being able to operate and further even function.
    The stories from the Omaha Winnebago Hospital and other IHS 
facilities in the Pine Ridge and Rosebud Reservations sound 
like scenes from the third-world countries because they are. 
Our members routinely seek to avoid the hospital because of its 
poor services, but often end up there because of an emergency, 
and we do not have the resources or the means to go elsewhere. 
I am a prime example. I was born in the late seventies, and 
even back then my family chose to have me born in Pender, 
Nebraska, rather than that facility. So that is an indicative 
example almost four decades of inadequate services that I am a 
proof of, by not being born in that facility. And that is only 
10 miles from where I live.
    With the emergency rooms, we have constantly talked about 
the failures that are within existence within those facilities. 
Within the Omaha Tribe, we have several committee members who 
do utilize the ER as a result of not being able to utilize it 
elsewhere, and we have numerous stories that we could share. I 
can go on and on, but I will refrain from doing that.
    Within our own tribe, we have a dialysis facility as well 
as a nursing home where we provide long-term healthcare 
services. As a tribe, we have made it a designation to avoid 
the hospital and so we use our own tribal resources to divert 
the facility and go directly to the Sioux City, Iowa facility 
or even to Ottawa, Iowa, which is over 30 miles away from our 
community, to have our health care and ER services met.
    I want to thank the subcommittee for having this important 
hearing on this critical issue. I also want to give particular 
thanks to Representative Noem for introducing this Act, and for 
spearheading this initiative to really take a hard-hitting look 
at the health care being provided within the Great Plains area 
and, more specifically, within the Omaha and Winnebago 
Hospital, how that really is indicative of the designation it 
does deserve.
    I want to talk about some of the issues within the HEALTTH 
Act. With long-term contract pilot program, it would create 
that 7-year program and the Omaha Tribe is definitely 
interested in pursuing that option. The Omaha Tribe supports 
the concept of blending tribal and IHS governance within the 
private operation of direct-service hospitals. Within the 
hospital itself, the governing board is a group of individuals 
who sit in Aberdeen, South Dakota, which is about 4 hours away, 
and through a video monitor, they make decisions based on the 
health care and the policies that are provided from that 
facility.
    As a result of that, the Chairman from the Winnebago Tribe 
and I do sit in those meetings, but there is no one there from 
the community that is able to provide that feedback, provide 
that narrative that is needed to these individuals, and they 
are the same governing board for the rest of the IHS hospitals 
within the Great Plains region.
    So, there definitely needs to be some reform in how the 
governing process is actually provided, because as a community 
member and as a tribal leader, we are directly in the field 
where tribe members come to and bring their complaints and 
bring their concerns to, and that input is not adequately 
provided, because we are pretty much just sitting there and 
listening to their concerns, and we cannot really take action.
    I also want to talk about the recycling problem that we 
have been having with the contractor that has been identified 
and has been awarded a contract for 4 years, but they are using 
it for 1 year in our facility. AB Contracting Services has been 
providing the ER staffing needs, and their whole staff--IHS 
cannot hire anybody to work there. As a result of that, you see 
a lot of these issues with our hospital, the Omaha Winnebago 
Hospital, and the loss of that CMS certification.
    And, as a result of that, the bid was announced. 
Unfortunately, AB Contracting was the contractor that got it 
again, so we are recycling this problem. I can tell you today 
of two examples last week, two more examples from the weeks 
before, of constant inadequate health care that is being 
provided in that facility. And unfortunately, like I said, the 
problem has just been recycling, and I would not be surprised 
if CMS came in and found those same issues today that were 
existent a year ago when that certification was taken away.
    I also want to talk about the need to really monitor that 
contractor, because now they are expanded to nursing, and that 
is really a concern within that facility for the inpatient 
beds, as well as the ER.
    I do want to also mention the expanded hiring authority. 
The Omaha Tribe supports this initiative. We recommend the 
subcommittee work with Representative Noem to locate 
authorities that will put IHS's process at the front of the 
pack, and not just a small step ahead.
    In regards to the removal and demotion of employees, the 
tribe supports provisions enabling the Secretary of HHS to more 
easily remove or demote employees. We recommend that language 
be added to this section that any cost for litigation----
    Mr. Young. I don't want to cut you off, you are doing well, 
but we have a vote on.
    [The prepared statement of Mr. Miller follows:]
  Prepared Statement of the Honorable Vernon Miller, Chairman, Omaha 
                           Tribe of Nebraska
    Chairman Young, Ranking Member Ruiz, and members of the 
subcommittee, thank you for inviting me here to testify regarding 
Representative Noem's H.R. 5406, the Helping Ensure Accountability, 
Leadership, and Trust in Tribal Healthcare Act (the HEALTTH Act), and 
to discuss with you the immediate need for substantive and effective 
change in the delivery of healthcare services by the Indian Health 
Service, particularly in the Great Plains area. My name is Vernon 
Miller, and I am the Chairman of the Omaha Tribe of Nebraska. I am part 
of the Thunder Clan and the former Business Teacher at 
Umonhon (Omaha) Nation Public Schools on the 
Omaha Tribal Reservation in Macy, Nebraska.
    The Omaha Tribe is located in the northeastern corner of Nebraska 
and, along with our neighbors in the Winnebago Tribe, we receive 
healthcare services from the Indian Health Service at the Omaha/
Winnebago Hospital located in Winnebago, Nebraska. In just a week from 
today, it will have been a full year since the Centers for Medicare and 
Medicaid Services (CMS) ceased payment for services at the hospital 
because the facility failed to provide for patient safety, failed to 
combat negligence that resulted in injuries and deaths, and failed to 
provide adequate care to patients. For us in the Omaha Tribe and our 
members, the IHS has failed to live up to its treaty and trust 
obligations to furnish healthcare and failed to treat us with respect 
and decency.
    The stories from the Omaha/Winnebago Hospital and other IHS 
facilities serving the Pine Ridge and Rosebud Reservations sound like 
scenes from Third World countries, not the American heartland. Our 
members routinely seek to avoid the hospital because of its poor 
services, but often end up there because of an emergency or they do not 
have the means to go elsewhere. But, the emergency rooms at these 
hospitals are renowned for their failures. In the Omaha/Winnebago 
Hospital, the emergency room staff received one of our tribe's members 
who was complaining of severe back pain. The hospital sent him home, 
and later left a single voicemail with the man telling him his kidneys 
were failing. The hospital attempted no further contact, and the man 
died at a relative's house 2 days later. Another one of our tribal 
members, a pregnant woman, came to the hospital only to be discharged 
after the staff could not find a heartbeat for her baby. They told her 
to drive herself to Sioux City to another hospital to receive care. 
We've heard stories from our neighbors in South Dakota that their IHS 
facilities have gone 6 months without sterilization machines so their 
workers were hand washing medical equipment. We have heard stories of 
women giving birth on the floor of IHS facilities' bathrooms and people 
dying of heart attacks with no intervention from staff.
    In 2010, Senator Dorgan and the Senate Indian Affairs Committee 
reported on the Great Plains region's failures. Unfortunately, the 
problems identified in the Dorgan Report have only gotten worse, and 
the care our tribal members receive still does not meet minimum 
standards of quality.
    We thank the subcommittee for having this important hearing on this 
critical issue. We would also like to give particular thanks to 
Representative Noem for introducing the HEALTTH Act. The HEALTTH Act is 
a critically important piece of legislation that we hope will empower 
the Secretary to begin to address the fundamental structural issues 
that have plagued the IHS in the Great Plains area for far too long. 
The Omaha Tribe strongly supports it, and urges this committee to 
consider it favorably.
    The issues facing the IHS are not only structural in nature 
however. The IHS continues to suffer from inadequate funding, and many 
of the problems it faces stem from the fact that it has always been 
funded at only a fraction of need. The average spending for an IHS 
patient is only 25 percent of that for an average Medicare beneficiary. 
Even if the IHS had no structural issues, the lack of adequate funding 
would still result in inadequate care. While the HEALTTH Act provides 
important and needed reforms for the IHS, we are concerned that without 
additional funding true reform is unlikely to be realized. The problems 
with the Great Plains area require a two-pronged solution: structural 
reform and adequate funding. One cannot succeed without the other.
    We thus urge you to consider providing additional funding as well. 
One important change you can make right away is to ensure that the IHS 
will be held harmless in the event of a sequestration or a government 
shutdown, just as the Veterans Affairs' health facilities are (through 
provisions like advanced appropriations and exceptions in shutdown 
orders). It is unacceptable for our members' health care to get wrapped 
up in these battles.
                            the healtth act
    The Omaha Tribe generally supports the HEALTTH Act and the reforms 
at IHS it seeks to achieve. We offer the following comments on specific 
aspects of the bill, and urge the committee to consider it favorably.
Long-Term Contract Pilot Program
    H.R. 5406 would create a 7-year contracting pilot program ``to test 
the viability and advisability of entering into long-term contracts for 
the operation of eligible Service hospitals with governance structures 
that include tribal input.'' For the pilot program, the Secretary of 
Health and Human Services would be required to select three direct-
service IHS hospitals in rural areas, with the permission of the tribes 
served by those hospitals, and, in consultation with those tribes, to 
create a governing board for each hospital that includes IHS, hospital, 
tribal, and expert health care administration and delivery 
representatives.
    The Omaha Tribe supports the concept of blending tribal and IHS 
governance with private operation of direct service hospitals. The IHS 
has proven unable to operate the services it provides, so--as long as 
private contractors are able to handle the job--we are not opposed to 
the IHS contracting with another entity to fulfill its treaty and trust 
obligations so long as IHS and the United States retain ultimate 
responsibility. We hope the subcommittee agrees that, though this 
provision calls for a long-term contract, the intent is not to lock the 
IHS and the tribes into a contract if the contractor fails. Language 
clarifying that intent in a report may be helpful. We also want to 
ensure that tribally run programs through self-governance that operate 
in our hospitals (like some programs at the Omaha/Winnebago facility) 
that are working are not subject to takeover in these contracts. We 
also support a strong tribal role in the governance of hospitals under 
this pilot program, including having say in the selection of the 
contractor and the hiring and placement of key leadership positions.
    We note that the IHS must not be allowed to ``recycle'' problem 
contractors. The IHS has hired ``AB Staffing'' to fill the gap in its 
services at our hospital and those at Pine Ridge and Rosebud. This 
company was already providing services when CMS terminated payment at 
the Omaha/Winnebago Hospital, and now their role has been expanded to 
include nursing. IHS must look farther afield, including within the 
Great Plains region, to find providers with expertise in rural health 
care delivery.
Expanded Hiring Authority
    The House bill would permit the Secretary to choose to waive civil 
service requirements for employees providing healthcare delivery, and 
to instead exercise statutory and regulatory personnel authorities 
utilized by the Veterans Health Administration. This option would not 
apply with respect to senior executive service positions and positions 
that do not involve health care responsibilities.
    The tribe supports the efforts to streamline and speed hiring. 
Vacancies in health care provisions plague service delivery. However, 
we believe vacancies in leadership cause similar problems, and believe 
these provisions should be expanded to include leadership positions 
even if those are not in service delivery. Further, we would like to 
see the provisions of S. 2953 requiring consultation with tribes 
located in the service area included in this legislation.
    We do have some concern about using the Veterans Health 
Administration's personnel provisions for streamlined hiring. Just 2 
weeks ago, Representative Wenstrup introduced legislation to reform the 
hiring process at the VA, calling the process ``lengthy and 
inefficient.'' Congressman O'Rourke and Congresswoman Stefanik have 
other legislation aimed at improving the process to increase access to 
doctors. The Commission on Care's final report of June 30, 2016 
recommends many changes to the VA's hiring process. We recommend that 
this subcommittee work with Representative Noem to locate authority 
that will put IHS' process at the front of the pack, not just a small 
step ahead.
Removal and Demotion of Employees
    The tribe supports the provisions enabling the Secretary of HHS to 
more easily remove or demote employees.
    Some staff and providers are doing fantastic work with few 
resources to provide what they can to our people. But, those good 
workers are cut off at the knees by employees who are unwilling to work 
or fulfill their duties. The IHS's answer to this is often to transfer 
the employees or put them on lengthy paid leave. The problem will not 
be solved by shipping it elsewhere or shutting it out.
    We note that some have raised due process concerns about a process 
that will result in more rapid firing or demotion. We urge the 
subcommittee and Representative Noem to ensure this authority will not 
result in lengthy, unwinnable litigation by the IHS, or a practice of 
the IHS paying settlements to fired employees to avoid such litigation. 
We recommend that language be added to this section that any costs for 
litigation arising from these personnel practices and payments 
resulting to lost cases or settlements be taken from somewhere other 
than IHS program or services funds, and from either Departmental 
administrative funds or the Judgment Fund. We cannot afford services 
money being diverted for legal settlements.
Timeliness of Care
    H.R. 5406 includes provisions in response to long wait times for 
services at IHS facilities. Section 104 of the bill would require the 
IHS to promulgate regulations establishing standards to measure 
timeliness of the provision of health care services at IHS facilities 
and to develop a process for IHS facilities to submit data under those 
standards to the Secretary. The Omaha Tribe supports these provisions.
Student Loan Provisions
    As an employment incentive, the bill would exclude payments made by 
the IHS student loan repayment program from taxable income, and permit 
health administration employees to participate in the IHS student loan 
repayment program by adding health care management and administration 
degrees to the list of eligible degrees for the program. It would also 
permit part-time employees to participate in the program, with a longer 
time commitment. The Omaha Tribe supports these provisions.
Cultural Competency Program
    The bill would require the IHS, in consultation with tribal 
representatives, to develop and implement a mandatory cultural 
competency training program in each Service area for all employees, 
locum tenens providers, and contracted employees whose jobs require 
regular direct patient access. Participation in the cultural competency 
training program would be mandatory for all employees on an annual 
basis. The Omaha Tribe supports these provisions.
Relocation Reimbursement
    The bill would permit the Secretary to provide between 50 percent 
and 75 percent of base pay for relocation reimbursement to IHS 
employees who relocate to serve in a different capacity or position 
within the IHS, if they relocate to a rural or medically underserved 
area to fill a position that has not been filled by a full-time non-
contractor for at least 6 months, or if the relocation is to fill a 
hospital management or administration position. The Omaha Tribe 
supports these provisions provided that relocation costs do not 
adversely affect the provision of health care services.
Medical Volunteer Credentialing
    The bill would require the IHS to implement a uniform credentialing 
system to credential licensed health professionals who seek to 
volunteer at an IHS facility. The bill would permit the Secretary to 
consult with public and private medical provider associations in 
developing the credentialing system. The bill summary states that the 
purpose of this provision is to ``centralize its licensed health 
professional volunteer credentialing procedures at the agency level 
rather than the facility level to reduce the paperwork burden on 
licensed health professionals who wish to volunteer at IHS direct-
service facilities.'' The Omaha Tribe supports these provisions for the 
IHS, but is concerned that the provisions apply equally to tribally 
operated programs, who are already empowered to do their own 
credentialing of volunteer medical providers. This provision would be 
strengthened by limiting its applicability to the IHS only.
Waiver of Indian Preference Laws
    H.R. 5406 would permit waiver of Indian preference laws. The House 
bill would permit the Secretary to waive Indian preference laws with 
respect to a personnel action if it relates to (1) a facility that has 
a personnel vacancy rate of at least 20 percent, or (2) a former IHS or 
tribal employee who was removed or demoted from that former employment 
for misconduct that occurred within the previous 5 years. In order to 
exercise that authority, the Secretary would be required to first 
obtain a written request or resolution from an Indian tribe located 
within the Service unit.
    Indian Preference is critically important to the Omaha Tribe, 
though we support providing the IHS with some flexibility as 
contemplated here. We recommend that the provision be amended to 
require that a waiver only be operative if the IHS gets a written 
request or resolution from all Indian tribes located in the Service 
unit, not just one. Further, the waiver of preference should be limited 
in nature, and not provide a blanket lifting of preference. Adding a 
provision that the IHS present a limited staffing plan or action to 
which the waiver applies would help avoid the IHS treating requests or 
resolutions as long-lasting without the tribes' intent that they be.
Financial Stability Reports
    The bill would require the Comptroller General, within 1 year, to 
submit a report to Congress on the financial stability of IHS hospitals 
and facilities that have experienced sanction or threat of sanction by 
the Centers for Medicare and Medicaid Services, including any revenues 
lost as a result and recommendations for legislative action. The Omaha 
Tribe supports these provisions.
                               conclusion
    On behalf of my tribe, I thank the subcommittee and Representative 
Noem for their efforts to improve the IHS and the quality of care for 
Native people in the Great Plains. If there is any way I or my tribe 
can further assist with these efforts, please do not hesitate to 
contact me.

                                 ______
                                 

    Mr. Young. I am going to suggest that you go ahead and 
testify. It is going to be an hour before we get back here. I 
guess that is the way we will run it. Eleven votes will be an 
hour, at least. I hate to do that to the witnesses. This shows 
you how we run this silly place, I can tell you that right now. 
It is not good.
    Why don't you take over while I am gone--no, no, OK.
    Mrs. Noem, would that be OK with you, to just come back?
    Mrs. Noem. If the committee members would come back, I 
think that the witnesses have really compelling testimony, and 
I think it would be beneficial, as this legislation moves 
forward.
    Mr. Young. Yes, I----
    Mrs. Noem. So if you will come back, and if they don't mind 
staying for an hour----
    Mr. Sablan. Mr. Chairman?
    Mr. Young. Yes?
    Mrs. Noem. Go get a coffee.
    Mr. Sablan. I have just one question to Ms. Smith, if I 
may, please.
    Mr. Young. Well, go ahead----
    Mr. Sablan. I will make it short.
    Mr. Young. You don't vote, so----
    Mr. Sablan. Yes, yes, I know.
    Ms. Smith, how prevalent is this problem throughout Native 
American communities?
    Ms. Smith. Thank you. I think we have challenges throughout 
the system. Some of them are for any rural healthcare provider 
and some are unique to IHS in tribal communities.
    Mr. Young. OK. We will recess now. And I do apologize to 
you guys. It is not correct, but that is the way this system 
works right now.
    [Recess.]
    Mr. Young. The witnesses can all take the stand, and again 
I do apologize. Ms. Kitcheyan, you can go ahead and testify.

STATEMENT OF VICTORIA KITCHEYAN, TREASURER, WINNEBAGO TRIBE OF 
                 NEBRASKA, WINNEBAGO, NEBRASKA

    Ms. Kitcheyan. Good afternoon, Chairman and members of the 
committee. My name is Victoria Kitcheyan, and I am a member of 
the Winnebago Tribe of Nebraska. I serve as the Tribal 
Treasurer on the Tribal Council, and I want to thank you for 
holding this hearing on this piece of legislation that is the 
logical first step in adjusting the systematic changes that 
need to be made that are present. They have been allowed to go 
on for far too long. We think that the findings in Winnebago 
are so profound that only a long-term plan that implements 
organizational change with the financial resources to match are 
going to make any concrete changes to the crisis.
    The Winnebago Tribe, as background information, is located 
in northeast Nebraska. We have a 13-bed inpatient IHS facility 
with a clinic and an ER department. That facility serves the 
Ponca, Winnebago, and Omaha Tribes, as well as many individual 
Indians from other tribes living in the area. So, collectively, 
it has a patient load of about 10,000 patients. Those are 
10,000 patients that deserve quality health care.
    Since at least 2007, Winnebago Hospital has been operating 
with demonstrated deficiencies that have been so numerous and 
so disturbing that in 2015 we actually became the first 
federally operated facility--and, to our knowledge, the only 
one--to lose our Medicaid and Medicare reimbursement 
certification. And to this day we still are without that 
certification.
    Those findings go back to 2007, but have continued through 
the years. In 2011, there was a re-certification and more 
findings were uncovered. My Aunt Debbie was a victim of those 
deficiencies. She was over-medicated, left unsupervised, and 
died. She died in that hospital, and we questioned the 
circumstances surrounding that. And before all these CMS 
findings had come to light, we had no answers. We questioned 
how long she laid on the floor. We questioned the 
documentation. We questioned the cold-blooded nurses that 
covered up the incident.
    Debbie's story and countless others need to be told. This 
example of sub-standard care and numerous documented CMS 
findings are indicative of the Federal Government's loose 
commitment to its trust responsibility.
    When some of the findings became public, IHS publicly 
committed to fixing those deficiencies, but just 2 years later 
in 2014, we had four more unnecessary deaths identified by CMS. 
In April 2014, a 35-year-old man died of cardiac arrest because 
the nurses did not know how to call a code blue or operate a 
crash cart. A female died because they could not load her on 
the medivac. A 17-year-old female died because they could not 
administer a dopamine drip. These things are happening at a 
place of healing, a place that is supposed to be there for the 
people, yet their health and safety is in jeopardy.
    A fourth survey was conducted in 2014, and it had been 
cited that the facility had caused actual harm and was likely 
to cause harm to all individuals that come to the hospital for 
examination and/or treatment of a medical condition. Keep in 
mind that when CMS comes, they only sample a small portion of 
the record so we will never know how many people died 
unnecessarily. We will never know how many people were 
misdiagnosed.
    It is these changes that need to be made, and it is these 
changes that led up to our certification termination. 
Throughout this period, IHS assured the tribe that these things 
were being corrected, yet we were still terminated in July of 
2015. We have heard reports for years from tribal members of 
the notorious reputation, and we go there, as well, so we know 
how bad it is. But until CMS came in, our complaints fell on 
deaf ears. CMS was able to provide an independent, verifiable 
documentation of what was going on. The sister agency put their 
foot down.
    After these five deaths occurred, we asked the central 
office, ``What happens with unusual circumstances? What happens 
with questionable death? '' And we found that there is no 
procedure to look into these. When we pressed the issue 
further, it is the governing body, which is non-existent. 
Governance was also cited by CMS. So, you have a governing body 
made up of non-medical professionals overseeing the actions of 
the physicians, the nurses, and the anesthesiologist.
    It is important to note also that Winnebago Hospital has 
become a short-term stop for a number of IHS contractors. These 
physicians coming in many times are not Federal employees, they 
are private contractors who rotate in and out of the facility 
for 2 to 3 weeks at a time. They are heavily counting on the 
nursing staff to provide that continuity of care. And with the 
nursing staff being under-trained and cited in the reports, 
even if we had the best physician, how are they going to be 
supported by a poor nursing staff with a poor attitude?
    Many of these things have been cited in multiple reports. 
Finally, in 2015, after the certification had already been 
lost, IHS commissioned their own consultant, and they came up 
with 97 deficiencies at that hospital that had not even been 
identified by CMS.
    With that, they came up with a corrective action plan. The 
tribe has been working hand in hand with IHS to ensure those 
deficiencies are corrected, but the tribe has no real way of 
measuring if that mark has been met. That nurse watched a 
video; does that mean she can operate a crash cart? Things like 
that, we really have no control over that process.
    It is clear that management, recruitment, transparency, and 
also accountability are major issues. A full year has passed 
and we are still without a full-time CEO, we are still without 
a full-time director. We have acting administrators coming in. 
Without consistent leadership, it is very hard to have 
consistent health care.
    Mr. Chairman, these are the reasons why we support this 
bill. I must say that we encourage you to pass this 
legislation, but I implore you do not abandon us after this. It 
is going to take a team effort, additional resources, and 
consistent congressional oversight. And, furthermore, we have 
10,000 people back at home who need their hope restored. You 
cannot bring back those lost lives, but we can honor them by 
passing this legislation and fully supporting it. But until 
those systematic changes are made within the IHS system, 
Winnebago Hospital will continue to be the only place where you 
can legally kill an Indian.
    My family has experienced this, countless families in my 
community have experienced this, and the trauma is so deep that 
it is beyond repair. It is going to take something outside of 
the scope of what IHS is accustomed to doing, that culture 
ingrained in them of self-preservation. We need to restore the 
patient care, the quality.
    [The prepared statement of Ms. Kitcheyan follows:]
Prepared Statement of Victoria Kitcheyan, Treasurer, Winnebago Tribe of 
                                Nebraska
    Good afternoon Mr. Chairman and members of the subcommittee, my 
name is Victoria Kitcheyan. I am a member of the Winnebago Tribe of 
Nebraska and I currently serve as Treasurer of the Winnebago Tribal 
Council. Thank you for holding this hearing on this very important 
piece of legislation which presents a logical first step toward 
addressing systemic problems in the IHS system which have been allowed 
to continue for far too long. I say first step because, as my testimony 
will document, the problems in the current IHS system at Winnebago are 
so profound that only a long-term plan, which implements organizational 
changes and comes with additional financial resources, is required to 
make real concrete changes in our current situation. In order to help 
you understand my point, allow me to provide you with some background 
information.
    The Winnebago Tribe is located in rural northeast Nebraska. The 
tribe is served by a thirteen (13) bed Indian Health Service (IHS) 
operated hospital, clinic and emergency room located on our 
Reservation. This hospital provides services to members of the 
Winnebago, Omaha, Ponca and Santee Sioux Tribes. It also provides 
services to a number of individual Indians from other tribes who reside 
in the area. Collectively, the hospital has a current service 
population of approximately 10,000 people.
    Since at least 2007, the Winnebago IHS Hospital has been operating 
with demonstrated deficiencies which should not exist at any hospital 
in the United States. The CMS deficiencies that have been uncovered are 
so numerous and so life threatening that in July of 2015, the IHS 
operated hospital in Winnebago became what is, to the best of our 
knowledge, the only federally operated hospital ever to lose its 
Medicare/Medicaid Certification.

    Here is a synopsis of the events that led to this decision:

    In 2011, CMS conducted a re-certification survey of the hospital 
and detailed serious deficiencies in nine areas, including Nursing and 
Emergency Services. My wonderful aunt, Debra Free, was one of the 
victims of those deficiencies. She died in the Winnebago Hospital in 
2011 when she was overmedicated, left unsupervised and fell from her 
bed in the inpatient area. After her death, a nurse at the hospital 
told my family that Debra had fallen during the night. She said that 
nurses from the emergency room had to be called to the inpatient ward 
to get Debra back into bed because there was inadequate staff and 
inadequate equipment on the in-patient floor to address that emergency.
    While the hospital insisted that they did everything possible to 
revive her and save her life, we question just how long she remained on 
the floor and what actually happened. Among those questioning was 
Debra's sister, Shelly, who was a nurse at the hospital during that 
period. Unfortunately, my Aunt Shelly was not on duty when this 
occurred, but she did know enough from her professional training to 
question the circumstances of the death.
    When my Aunt Shelly and the family requested to see the charts to 
determine what actually happened, we were met with immediate 
resistance. First, my mother, also Debra's sister, was told she was not 
authorized to request the chart. Then my grandmother, Aunt Debra's own 
mother, Lydia Whitebeaver, submitted a request and was denied the 
information. In fact, the whole family and the attorney that we were 
forced to hire were all told that the chart was ``in the hands of the 
Aberdeen Area Office's attorneys'' and was not available to us.
    Because she demanded answers to our very reasonable questions, my 
Aunt Shelly was retaliated against in the worst way. As an IHS employed 
nurse at the hospital she was regularly intimidated by her supervisors 
and colleagues, and generally treated in the most horrific way by the 
Director of Nursing and her cronies. One of those nurses even reported 
Shelly to the State Licensing Board. Thank goodness the State Licensing 
Board's Members saw that report for what it was and dismissed the 
inquiry almost immediately, but this is a prime example of why we have 
been unable to get the proof of these incidents before the CMS Reports 
were released. Fear of retaliation within the IHS system is real. One 
former IHS employee of the hospital has said that those employees who 
threaten to speak out are regularly reminded to ``remember who you work 
for.''
    My aunt, Debra Free, left behind a 9-year-old daughter and a loving 
family. She should not have been allowed to die like this. Her story 
and those of countless others need to be told. This example of 
substandard care and the numerous other examples documented by the CMS 
Reports are indicative of the Federal Government's loose commitment to 
upholding its Federal trust responsibility. The Great Plains Service 
Area is in a state of emergency and the patients who seek care at the 
Winnebago Service Unit are in jeopardy as we speak!
    My ancestors made many sacrifices so that our people's livelihood 
would continue. As a tribal member and tribal leader, it is my 
responsibility to carry their efforts forward to protect my people. 
Neither the Winnebago Tribe, nor I, will stand idle as Indian Health 
Service kills our people, patient by patient.
    In addition to my aunt's case, the 2011 CMS Report also found that 
during that year: patients who were suicidal were released without 
adequate protection; that a number of patients who sought care were 
sent home without being seen, or with just a nurse's visit, were never 
documented in any electronic medical records; that out of twenty-two 
(22) patient files surveyed by CMS, four (4) of those patients were not 
provided with an examination which was sufficient enough to determine 
if an emergency existed, and that at least one of those patients 
suffered an undiagnosed stroke and was sent home from the emergency 
room without any follow-up care whatsoever.
    When some of the findings of the CMS 2011 Report became public, in 
early 2012, former IHS Director Roubideaux publicly promised 
improvements. While some minor issues were addressed, many other things 
got worse. In just the past 2 years, four additional potentially 
unnecessary patient deaths and numerous additional deficiencies have 
been cited and documented by CMS. These incidents and reports include:

     April 2014. A 35-year-old male tribal member died of 
            cardiac arrest. CMS found that the Winnebago Hospital's 
            lack of equipment, staff knowledge, staff supervision and 
            training contributed to his death. Specifically, the 
            nursing staff did not know how to call a Code Blue, were 
            unfamiliar with and unable to operate the crash cart 
            equipment, and failed to assure that the cart contained all 
            the necessary equipment. CMS concluded in its report that 
            conditions at the hospital ``pose an immediate and serious 
            threat'' mandating a termination of the hospital's CMS 
            certification unless they were corrected immediately.

     May 2014. A second CMS survey found that a number of the 
            conditions which pose immediate jeopardy to patients had 
            not been corrected, and that the hospital was out of 
            compliance with CMS Conditions of Participation for Nursing 
            Service.

     June 2014. A female patient died from cardiac arrest while 
            in the care of the hospital. This time the death occurred 
            when the staff was unable to correctly board her on the 
            medivac helicopter. The conditions leading to the 
            unnecessary death are documented in the July 2014 CMS 
            report. This young woman was employed by the Tribe's Health 
            Department and played an active role in the lives of many 
            youth, who often referred to her as ``Mother Goose.''

     July 2014. A 17-year-old female patient died from cardiac 
            arrest because the nursing staff did not know how to 
            administer the dopamine drip ordered by the doctor. CMS 
            also documented this event in detail in its July 2014 
            report and found that numerous nursing deficiencies 
            remained uncorrected. This resulted in the issuance of a 
            continuing Immediate Jeopardy citation for the hospital on 
            the Condition of Participation for Nursing Services.

     August 2014. In its fourth survey conducted in 2014, CMS 
            concluded that failure to provide appropriate medical 
            screening or stabilizing treatment ``had caused actual harm 
            and is likely to cause harm to all individuals that come to 
            the hospital for examination and/or treatment of a medical 
            condition.''

     September 2014. CMS survey jurisdiction over the Winnebago 
            IHS hospital was transferred from the Kansas City regional 
            office to Region VI in Dallas, TX, when IHS attempted to 
            forum shop the next CMS review, but in November 2014, that 
            new CMS office identified more than 25 deficiencies.

     January 2015. Another death occurred when a man was sent 
            home from the Emergency Department with severe back pain. A 
            practitioner later left him a voicemail after discovering, 
            too late, that his lab reports showed critical lab values. 
            The call advised him to return in 2 days. The patient died 
            at home from renal failure before the 2 days were up. This 
            situation is documented in the May 2015 CMS report.

     May 2015. CMS conducted another follow-up survey. In 
            addition to documenting the January 2015 death noted above, 
            the report states that seven CMS Conditions of 
            Participation and EMTALA requirements were found out of 
            compliance at the hospital.

     July 2015. CMS terminated the Winnebago IHS Hospital 
            provider agreement. CMS stated that the hospital ``no 
            longer meets the requirements for participation in the 
            Medicare program because of deficiencies that represent an 
            immediate jeopardy to patient health and safety.''

    Keep in mind that the deaths and findings cited by CMS are only the 
ones that have been documented by CMS. When CMS conducts a survey, only 
a small sampling of patient records are reviewed. We have no way of 
knowing how many more unnecessary deaths and misdiagnosis have occurred 
at the hands of IHS personnel. There is also no way that we can portray 
the tremendous pain and loss that has been suffered by our families and 
our community in these few pages. These things are happening not only 
in Winnebago, but they are also happening in Rosebud, Pine Ridge and 
Rapid City. Our people are devastated, angry and demanding change.
    The totality of these circumstances finally led CMS to notify the 
Indian Health Service in April of 2015 that it was pulling its 
certification of the Winnebago IHS Hospital, unless substantial changes 
were made. Changes were not made and CMS terminated that certification 
on July 23, 2015.
    Throughout this period the IHS assured the Winnebago Tribal Council 
that the CMS findings, most of which were never provided to the 
Winnebago Tribe at least in their totality, were being addressed. In 
fact, less than 2 weeks before CMS actually pulled the Certification, 
the IHS Regional Director was still telling the Tribal Council that IHS 
was talking to its lawyers and planning an appeal. There was in fact no 
basis for an appeal and, 1 year later, the hospital remains without a 
permanent qualified CEO and is still not ready to submit an application 
to CMS for recertification.
    When the termination happened and the Winnebago Tribe and its 
attorneys asked to see a copy of the latest CMS report, they were told 
by the IHS Regional Office that it needed to be reviewed for privacy 
concerns before it could be released to us. We finally obtained a copy 
and also learned that the CMS oversight of Winnebago IHS Hospital was 
transferred from Kansas City to the Dallas Office. When we asked one 
CMS employee why this transfer had occurred, he was fairly quick to 
suggest that, in his opinion, this was forum shopping. Whether there is 
any truth to this or not, this transfer of CMS oversight certainly 
raises questions.
    While the Winnebago Tribe had heard and reported stories of these 
atrocities for years, the CMS reports have provided independent 
verifiable documentation of what was really going on. What we have 
learned since then is equally disturbing.
    When we asked former Acting Director McSwain about the professional 
medical review that the IHS had engaged in after each of these five 
deaths occurred, and what role the Central Office played in those 
reviews, we were shocked to learn that the IHS does not appear to have 
an established procedure for dealing with questionable deaths or other 
unusual events that occur in its hospital. In fact, if there was ever a 
professional peer review of any of those five incidents of questionable 
death, we can't find it!
    When we pushed harder on this issue we were told that this review 
should have been conducted by the ``Governing Body'' of the hospital. 
This basically means that a body, composed largely of other IHS 
employees who are not doctors or other medical professionals, were 
supposed to review the actions of the physicians, nurses and 
anesthesiologists in the emergency room. The end result, however, is 
that--to the best of our knowledge--no one was fired, no one was 
reprimanded, no one was suspended pending a medical investigation and 
no one was reported to the licensing board. This is outrageous!
    The Governing Body for the Winnebago IHS Hospital has also 
basically been non-functional. The area of governance was cited 
numerous times in the CMS reports. The Governing Body is comprised 
primarily of IHS management officials, many of whom are from the 
regional office and have no direct personal knowledge of the community, 
the facility, the staff or the patients served by the hospital. And 
while there is supposed to be a voting seat on the board from the two 
primary tribes served by the hospital, we have found that the tribal 
representatives are not afforded access to all of the same information 
as other members of the board, or the information is not timely. 
Furthermore, training has been inadequate and there is no regular 
meeting schedule for the Governing Body.
    It is also important to note that the Winnebago IHS Hospital has 
become a short-term stop for a number of IHS contractors. Many of the 
doctors who take care of our needs are not Federal employees, they are 
private contractors who rotate in and out of our facility. This forces 
even the best of those physicians to rely heavily on the nursing staff 
who remain at the facility, many of whom have been found by CMS to be 
seriously undertrained. Most recently, the IHS advertised to find one 
contractor to operate the Emergency Departments at three hospitals in 
the Great Plains region, including Winnebago. The contractor selected 
by IHS is one of the same problem contractors that has been around for 
years and that was working at Winnebago during the period of review by 
CMS. This action was supposedly taken to help improve the quality of 
services but it was done without consultation with the tribes and not 
only did we end up with one of the same companies that failed us in the 
past, the few permanent providers who did work in the Emergency 
Department were forced to either leave or transfer to other positions.
    In the fall of 2015, the IHS hired an outside consultant to perform 
its own review of the facility. This review was conducted applying 
standard Federal and state medical standards. During this review, this 
independent consultant found 97 deficiencies, many of which were never 
uncovered, or at least never reported, by CMS. The IHS consultant 
helped to develop a corrective action plan for the Winnebago facility, 
and the hospital staff is still continuing to work on implementation of 
this plan. This is obviously necessary, but the process is slow and it 
is difficult to trust that checking an item off a list is getting us 
the real change that we need to see or that those changes will be 
sustained.
    It is clear that management, recruitment, accountability and 
transparency are all major issues that need to be addressed. One full 
year has passed since the CMS certification was terminated at 
Winnebago--and 1 year later, the CEO position at the hospital and the 
Director of the Regional Office are still being held by individuals 
detailed from other IHS positions for 30 or 60 days at a time. Real 
change and the rebuilding of this organization cannot happen without 
permanent qualified personnel and the funding necessary to carry out 
the mission.
    Mr. Chairman, these are the reasons that the Winnebago Tribe 
supports the immediate passage of this legislation. But, I must state 
clearly and bluntly, that while everything in this bill is needed, this 
legislation alone will not solve our problem. Proper training of 
hospital staff costs money, new equipment costs money, and recruitment, 
under these circumstances is also going to cost money. So, while I 
encourage you to pass this legislation, please do so as an initial 
first step. I implore you not to abandon us after this bill is passed 
because correcting this situation is going to require a team effort, 
additional resources, and consistent congressional oversight of IHS 
activity.
    Thank you again for allowing me to testify, I will be happy to 
answer any questions you may have.

                                 ______
                                 

    Mr. Young. Thank you, ma'am. We have another witness, I 
believe. Is that Ms. Bohlen?
    Ms. Bohlen. Yes, sir.
    Mr. Young. Ms. Bohlen, you are welcome. Sorry you got 
caught in a lock-down. Come on in.

STATEMENT OF STACY BOHLEN, EXECUTIVE DIRECTOR, NATIONAL INDIAN 
                  HEALTH BOARD, WASHINGTON, DC

    Ms. Bohlen. Thank you, sir. My name is Stacy Bohlen. I am 
the Executive Director of the National Indian Health Board in 
Washington, DC. I am also an enrolled member of the Sault St. 
Marie Tribe of Chippewa Indians, and on behalf of the National 
Indian Health Board, thank you for allowing us to be here 
today.
    Our organization was founded in 1972 by the federally 
recognized tribes, both American Indian and Alaska Native, to 
ensure that the Federal Government upholds its trust 
responsibility and honors the treaties of our people for the 
provision of health care. We also support the sovereignty and 
self-governance, self-determination of the tribes.
    On behalf of the 567 federally recognized tribes, I am 
honored to be here today. Of course, the hearing today is on 
the proposed legislation that we have had a quick review of 
today--the legislation attempting to address long-standing 
tribal concerns about the Indian Health Service and outlining 
how to move forward with better staffing practices, improving 
timeliness of service, increasing cultural competency, and 
reforming the purchase-referred care system, these are needed 
changes.
    The National Indian Health Board would just like to ensure 
that in the review of this legislation, and as it moves forward 
in a bipartisan manner, that it is recognized that the 
legislation is amending the Indian Health Care Improvement Act 
that is the foundation of the delivery of health care to all 
American Indians and Alaska Natives in the United States.
    We want to make sure that there is a national voice and 
presence forming, reviewing, and imparting opinion and 
knowledge into the system of creating what the final bill will 
look like.
    The solutions that we are looking at, we believe that there 
are five key areas to improving the Indian Health System. But I 
want to start with saying that the Number-one thing that the 
Indian Health System could benefit from is implementing 
standard business practices.
    Medicine is a business. In the United States of America, 
health systems are a business. There are standard business 
practices, there are standard accountability practices, and 
quality improvement measures, patient advocacy, and so forth 
that are done throughout this country that work very well. And 
we believe that the Indian Health Service, especially through 
some of the provisions that are allowed in the Indian Health 
Care Improvement Act, has the authority to do innovative work. 
And some of these innovations are the things that I just 
mentioned.
    There needs to be structural and administrative reform, 
quality assurance, recruitment and retention of qualified 
medical and administrative personnel, increase in medical 
literacy and medical health knowledge among American Indians 
and Alaska Natives, as well, and greater investment in our 
systems, our recruitment and retention systems that start in 
kindergarten to grow a cadre of American Indian and Alaska 
Native health professionals who will serve their own 
communities or our tribal communities.
    We know that there are unique challenges to delivering 
health care in any rural setting. However, there are unique 
challenges to the Indian Health System. As the Chairman knows 
from Alaska, we are talking about incredibly rural and remote 
areas in some cases. And certainly with the Great Plains, while 
it is not Kotzebue, it is very remote for Americans, and it is 
a place where something as simple as a housing shortage for 
healthcare providers and teachers can keep the tribes from 
having the kind of healthcare professionals they have.
    There is a chronic lack of funding that the IHS has been 
experiencing for some time. Even now, it is only funded below 
50 percent of need. With that is the reality that the tribes 
fought for years for the Indian Health Care Improvement Act to 
be reauthorized. Congress was with us. We finally achieved 
that. And only about 40 to 60 percent of that Act has been 
implemented because of a lack of funding.
    I want to call attention also to a voice in this system 
that can be very, very beneficial. Today, three American Indian 
physicians are with us in the hearing room. They are an 
emergency physician, a primary care physician, and an OB/GYN. 
They are from the Association of American Indian Physicians. 
Organizations like that, and the professions and the people 
they represent, have an additive value to the voice and the 
consideration of what we are trying to do to improve the Indian 
Health System.
    I could talk more about purchase-referred care and some of 
the other provisions, but I see that I am just about out of 
time. So, the National Indian Health Board does support 
Congresswoman Noem's legislation, and we look forward to 
working with her, Congress, and the tribes to forming it into a 
solution that works for all of Indian Country. Thank you.

    [The prepared statement of Ms. Bohlen follows:]
  Prepared Statement of Stacy A. Bohlen, Executive Director, National 
                          Indian Health Board
    Good afternoon, my name is Stacy Bohlen, and I am the Executive 
Director of the National Indian Health Board (NIHB). Chairman Young, 
Vice Chairwoman Coleman Radewagen, and members of the subcommittee, 
thank you for holding this important hearing on the Helping Ensure 
Accountability, Leadership, and Trust in Tribal Healthcare (HEALTTH) 
Act.
    The National Health Board (NIHB) is a 501(c)3 not for profit, 
charitable organization providing health care advocacy services, 
facilitating tribal budget consultation and providing timely 
information and other services to tribal governments. Whether tribes 
operate their own health care delivery systems through contracting and 
compacting or receive health care directly from the Indian Health 
Service (IHS), NIHB is their advocate. Because the NIHB serves all 
federally recognized tribes, it is important that the work of the NIHB 
reflect the unity and diversity of tribal values and opinions in an 
accurate, fair, and culturally sensitive manner. It is our mission to 
be the one voice affirming and empowering American Indian and Alaska 
Native (AI/AN) peoples to protect and improve health and reduce the 
health disparities our people face. I appreciate the opportunity to 
provide this testimony before the Subcommittee on Indian, Insular and 
Alaska Native Affairs today. I am here today to offer the national 
perspective of all 567 federally recognized Indian tribes.
    This hearing today, and the proposed legislation we are here to 
discuss, have arisen because of long-standing, systemic issues within 
the IHS that have led to crisis situations--especially, in the Great 
Plains Service Area. In the last year, several hospitals in this region 
have lost, (or received threats of revocation) their ability to bill 
Centers for Medicare and Medicaid Services (CMS) due to the failure of 
federally run sites to comply with basic safety and regulatory 
procedures. However, many of the issues now coming to light are not new 
to American Indian and Alaska Natives that rely on the Indian Health 
Service as their primary source of health care and health information. 
At least 5 years ago, then-Senator Dorgan released a report exposing 
the chronic mismanagement occurring at both the IHS regional (Area 
Office) level and the Headquarters level of the Agency. A 2011 report 
by a separate U.S. Department of Health and Human Services (HHS) task 
force specifically noted that: ``. . . the lack of an agency-wide, 
systematic approach makes it virtually impossible to hold managers and 
staff accountable for performance and to correct problems before they 
reach crisis proportions.''
    Now that we are in such crises situations, there must be two 
separate courses of action taken. First and foremost, immediate 
corrective action must be taken to rectify the closing and cutting of 
IHS services so there are no more unnecessary deaths of our people, not 
just in the Great Plains area, but at the national level as well. Once 
the crisis is stabilized, we must then address the fundamental and 
systemic issues that have been occurring within the Agency for decades. 
These reforms may start in the Great Plains area; but they must be 
implemented nationally in order for all American Indians and Alaska 
Natives to have access to safe, reliable and quality health care.
    The HEALTTH Act (H.R. 5406), proposed by Representative Kristi 
Noem, is attempting to address long-standing tribal concerns about the 
IHS, and outlining how to move forward with better staffing practices, 
improving the timeliness of services, increasing cultural competency 
and reforming the Purchased/Referred Care program. The spirit and 
intent of this legislation is clearly aimed at responding to the call 
of tribal leaders, patients and the families of those who have had 
adverse experiences within the IHS system. The National Indian Health 
Board stands ready to work with the committee as the bill is shaped and 
formed through a tribally engaged and informed process.
    Many of the provisions within this bill will provide the IHS with 
the authorizations they need to improve the quality of health care 
services delivered at IHS facilities. However, especially because this 
legislation proposes to amend the Indian Health Care Improvement Act 
(IHCIA), it is the position of the National Indian Health Board that 
the bill must be vetted further with a process similar to that utilized 
during the IHCIA reauthorization. During the years that Indian Country 
and Congress worked to achieve the reauthorization of IHCIA, the NIHB 
facilitated a tribal leader led committee. Furthermore, it is the hope 
of the NIHB that this legislation, and the similar Senate bill (S. 
2953), the IHS Accountability Act of 2016, are the keys that this 
Congress needs to move into an era where the Indian Health Service can 
be fully funded at the level of need year after year. While the 
provisions in these bills that will improve transparency, 
accountability, and administrative functions are absolutely necessary, 
increased funding to carry out health care services in parity with the 
general U.S. population is just as, if not more so, necessary to erase 
the severe health disparities experienced in tribal communities.

                      federal trust responsibility

    The Federal trust responsibility for health is a sacred promise, 
grounded in law and honor, which our ancestors made with the United 
States. In exchange for land and peaceful co-existence, American 
Indians and Alaska Natives were promised access to certain 
remunerations, including health care. Since the earliest days of the 
Republic, all branches of the Federal Government have acknowledged the 
Nation's obligations to the tribes and the special trust relationship 
between the United States and American Indians and Alaska Natives. The 
Snyder Act of 1921 (25 U.S.C. Sec. 13) further affirmed this trust 
responsibility, as numerous other documents, pieces of legislation, and 
court cases have. As part of upholding its responsibility, the Federal 
Government created the Indian Health Service and tasked the Agency with 
providing health services to AI/ANs. Since its creation in 1955, IHS 
has worked to provide health care to Native people. As recently as 
2010, when Congress renewed the Indian Health Care Improvement Act, it 
was legislatively affirmed that, ``it is the policy of this Nation, to 
ensure the highest possible health status for Indians . . . and to 
provide all resources necessary to effect that policy.''

                              disparities

    While some statistics have improved for American Indians and Alaska 
Natives over the years, they are still alarming and not improving fast 
enough. Across almost all diseases, American Indians and Alaska Native 
are at greater risk than other Americans. For example, American Indians 
and Alaska Natives are 520 percent more likely to suffer from alcohol-
related deaths; 207 percent greater to die in motor vehicle crashes; 
and 177 percent more likely to die from complications due to diabetes. 
Most recently, a report has come out reporting that American Indian and 
Alaska Natives are disproportionately affected by the hepatitis C virus 
(HCV). Furthermore, Natives have the highest HCV-related mortality rate 
of any U.S. racial or ethnic group--resulting in 324 deaths in 2013. 
And, most devastatingly to our tribal communities, suicide rates are 
nearly 50 percent higher in American Indian and Alaska Natives compared 
to non-Hispanic whites.
    Although the statistics highlight the severity of the problem, 
behind each statistic is the story of an individual, a family and a 
community lacking access to adequate behavioral health and health care 
services or traditional healing practices, and traditional family 
models that have been interrupted by historically traumatic events. 
Devastating risks from historical trauma, poverty, and a lack of 
adequate treatment resources continue to plague tribal communities. 
American Indians and Alaska Natives have a life expectancy 4.8 years 
less than other Americans. But in some areas, it is even lower. For 
instance, in South Dakota, for white residents the median age is 81, 
compared to only 58 for American Indians.

                           structural reform

    There are unique challenges to delivering health care in any rural 
area, including provider shortages, isolation, long travel distances, 
scarcity of specialty care, and under-resourced infrastructure. 
However, there are successful rural health systems operating all around 
the country that are able to deliver especially innovative and locally 
responsive care. A pressing need and opportunity exists within the 
Indian Health Service, and its many rural, geographically isolated 
hospitals and clinics, to reform the structure in its administrative 
oversight of Service Units and Area offices.
    The HEALTTH Act would provide one unique approach to rethinking the 
way current IHS federally run and tribally run facilities are 
structured. The Act would provide authority to the Agency to conduct a 
pilot program for a ``third way'' of health care delivery--in addition 
to Direct Service and Self-Governance. The NIHB supports piloting this 
proposed program, as it would create joint hospital boards consisting 
of IHS, tribal representatives, hospital administration experts and 
private contractors. The proposed program is written in a way that 
honors tribal sovereignty by placing decisionmaking authority in tribal 
leadership and providing resources to prepare tribes to take on self-
governance of their clinics and/or hospitals if that is what they 
choose.
    We believe that rather than reinventing a health system out of 
whole cloth, or reform around the edges of a system desperately in need 
of dramatic and deep reforms, IHS should aspire to achieve parity with 
mainstream, successful medical and health systems. The long-term 
contract pilot program would be a good start to improving 
administrative oversight and, hopefully, lead to strengthened 
partnerships between the tribes; the IHS Area and Service Unit 
employees; and the private healthcare providers within the region. 
However, other elements absolutely necessary to such an aspiration are 
dramatic increases in the current funding levels and the adoption of 
standard and generally accepted business practices. NIHB believes that 
creating partnerships with mainstream and private entities will help 
IHS improve operations and systems and perhaps provide a learning 
laboratory for system-wide reform.

                           quality assurance

    Many reports attribute the deplorable quality of care at IHS-
operated facilities to poor agency management at all levels. We know 
that hiring decisions are often lengthy, and poor performing employees 
at both the Service Unit, clinic and hospital administration and 
Headquarters are not terminated, but rather moved to other positions 
within IHS--often to a position of equal or higher responsibility 
level. The cyclical chronic lack of funding and mismanagement of funds 
also means that managers are often doing more than one job, and 
managerial oversight of medical conditions is compromised. In addition 
to the staffing and accountability provisions included in the newly 
proposed legislation we are discussing here today, attention must be 
directed at improving the quality of care provided at federally run IHS 
facilities. This can be done by strengthening agency-wide standards for 
hiring qualified individuals who are capable of fulfilling the role as 
expected and improving the timeliness of care.

    On April 28, 2016, the Government Accountability Office (GAO) 
released a report on patient wait times at the Indian Health Service 
(IHS). As part of this report, GAO found that ``IHS has not conducted 
any systematic, agency-wide oversight of the timeliness of primary care 
provided in its federally operated facilities.'' The report further 
found that the electronic health record system used by IHS does not 
``provide complete information on patient wait times,'' making it 
harder for staff to track the wait times. The GAO recommended that IHS 
``(1) communicate specific agency-wide standards for patient wait 
times, and (2) monitor patient wait times in its federally operated 
facilities, and ensure corrective actions are taken when standards are 
not met.'' The NIHB supports these recommendations and applauds the 
HEALTTH Act for including provisions that would do just that.

    Quality would also be increased through implementing and nurturing 
a culture and practice of continuous quality improvement, management 
and supervisory training and setting performance benchmarks that are 
reviewed twice-yearly. If employees are not performing, generally 
accepted management practices and principals must be in place, 
respected and consistently upheld. The HEALTTH Act does include 
provisions that would expand the hiring authority of IHS to that of 
other Federal medical care services like the U.S. Department of 
Veterans Affairs, as well as provide expanded authorities to fire or 
demote underperforming employees. However, before IHS is given greater 
authority to remove problem employees, the NIHB would like remind 
Congress that there are procedures already in place to remove problem 
employees; the real question is whether IHS is using those authorities. 
We recommend that this committee request a report from IHS documenting 
the number of times it has exercised its authority to do just that.

                 recruiting and retention of personnel

    Title II--the Indian Health Service Recruitment and Workforce of 
the HEALTTH Act would greatly strengthen the Agency's ability to 
recruit qualified health professionals by excluding the IHS student 
loan repayment program from gross income payments, essentially making 
the scholarship payments tax free. The Agency has asked for years to 
have similar authorizations as the National Health Service Corps, in 
order to recruit qualified health professionals to work in Indian 
Country. Additionally, we are pleased to see the list of degrees that 
qualify for the loan repayment program would be expanded to include 
health administrators. One of the inherent flaws in the Indian Health 
System is the lack of qualified hospital administrators and lack of 
basic business acumen in the management, leadership and operation of 
health systems. This provision within the bill will help to recruit, 
retain and fund students to enter Masters of Business Administration, 
Hospital Administration and related professions necessary to achieving 
and sustaining meaningful reforms in the IHS system.

    While we understand that it can be challenging to recruit medical 
professionals and health administrators to remote areas, it is critical 
that IHS, and other related agencies within HHS, employ all tools at 
their disposal to do so. Although there are strong provisions within 
this bill to improve recruitment practices, there is little that would 
help with chronic retention issues that we see in all IHS Service 
Areas--especially in our more remote tribal communities. We have long 
heard from healthcare professionals on isolated reservations that a 
lack of housing and quality education are barriers to long-term tenure 
at Indian health facilities. To rectify this, there will need to be 
further collaboration among the tribes, government agencies such as HHS 
and the U.S. Department of Housing and Urban Development (HUD), and 
Congress to make investments in housing so that people working in IHS 
facilities have adequate living quarters available. It is also critical 
to provide support for schools so that the families of medical 
providers will have access to adequate educational opportunities.

    Many policymakers do not realize that the system the United States 
employs to train medical residents, as well as dentists and some 
nurses, is through an entitlement program, Graduate Medical Education, 
within Medicare. The GME program exceeds $15 billion annually. Congress 
capped the number of residency training positions in the United States 
as part of the Omnibus Budget Reconciliation Act of 1997. Since 1997, 
several legislative amendments and changes have occurred to make slight 
increases and variances on the resident limit; however, the medical 
specialties remain highly motivated to increase the number of residency 
training positions within their various colleges and academies. One 
potential opportunity to increase the number of physicians serving in 
Indian Country is to set aside a certain number of new residency 
training positions for those willing to serve in Indian Country. The 
number of years of service in Indian Country following completion of 
residency training would be equal to the number of years the resident 
took to complete the residency. In states like Connecticut, where 
residency training positions are approximately $155,000 per resident 
per year, that is an astonishing incentive to complete service to 
Indian Country. Likewise, since most of the GME funding is in Indirect 
Medical Education expenses--paid directly to the training institution, 
perhaps a similar incentive could attach to the training institute if 
the resident does not fulfill the commitment. Further, there are very 
limited numbers of residency training programs in IHS facilities--and 
exceptions to the caps on new residency positions include rural or 
medically underserved communities or if a residency training program 
has never before existed in the training center. The Secretary of HHS 
has the authority to approve such growth: indeed, is this not the very 
definition of Indian Country?

    Tribes and the NIHB also advocate that a long-term solution to 
addressing American Indian and Alaska Native health disparities lies in 
investing in our youth. We can improve the future of the Indian health 
care workforce by developing a culturally and linguistically competent 
workforce of Native health professionals and administrators. We know 
that AI/AN providers are more likely to remain in their own communities 
long-term and to provide culturally appropriate care. Therefore, 
Congress and the IHS should prioritize resources and relationship 
building with academic institutions and national health professional 
organizations to engage Native youth in cultivating interest and 
capability in pursuing medical and health professions.

                     purchased/referred care reform

    In addition to the direct healthcare services provided by the 
Indian Health Service, eligible American Indians and Alaska Natives can 
also access healthcare services by non-IHS providers through the 
Purchased/Referred Care Program (PRC). PRC funds are used to supplement 
and complement other health care resources available to eligible Indian 
people. The funding for PRC is distributed among the 12 IHS Service 
Areas through a formula that was created through consultation with the 
Director's Workgroup on Purchased/Referred Care and Tribal 
consultation. Regional and national priorities were taken into account 
when the formula was created and the section of the HEALTTH Act that 
requires the IHS to develop and implement a new allocation formula 
within three (3) years, needs to be further consulted on with tribes 
all across the Nation. The National IHS Tribal Budget Formulation 
Workgroup, reported to the Secretary of the HHS on June 20, 2016, that 
``a major concern for tribal leadership is that PRC policies have not 
been updated in years. The current policies were written during a time 
when the IHS had to restrict access to services by creating limits to 
eligibility and scope of services provided. Tribes have asked the IHS 
to update these policies and bring them up to today's standard of 
quality care in order to have a better picture of what the true funding 
need is for PRC services. The truth is that these needs have been 
understated for at least 40 years.'' The HEALTTH Act provides a good 
opportunity for the Agency to continue working with tribes and the 
Director's Workgroup to assess and improve the program and allocation 
formula.

    As with the rest of the IHS budget, PRC funds have not kept pace 
with the health needs of tribal members, the cost of health care and 
the growth of tribal populations. As a result, PRC funds, which are 
managed by the IHS, are typically reserved for emergency and specialty 
services based on a priority schedule developed by the IHS. However, 
self-governance tribes are able to develop their own priority 
schedules, so the provision within the HEALTTH Act that would freeze 
the funding level of facilities who have achieved Priority Level III-V 
for a 3-year transition period, could disparately impact self-
governance tribes and would be a disincentive for high performing 
facilities. An alternative solution may be to allow IHS facilities or 
Service Units the same flexibility as tribally operated facilities for 
developing their own, locally responsive priority schedules.

    Furthermore, the provision of the HEALTTH Act that codifies the 
recent IHS Purchased/Referred Care Final Rule that was published on 
March 21, 2016, needs to take into account some of the tribal concerns 
with the final rules. While the rules were created with tribal 
consultation and input, some concerns remain such as private providers 
refusing to see AI/AN patients that utilize PRC funds, that 
implementing PRC rates will increase the volume of services being 
sought and decrease the quality and length of visits, and that the 
software systems needed to calculate payment rates are too costly for 
the already underfunded Federal and tribal run health facilities.

                               conclusion

    In conclusion, the NIHB overall supports the recent efforts made by 
both the Indian Health Service and Congress to address long-standing 
issues that our people have faced for far too long. Since issues have 
come to light in the Great Plains Service Area in the past year, the 
IHS has sought new leadership and pursued innovative policies and 
programs. Most recently, the IHS issued a new policy on opioid 
prescribing that is the first of its kind for a government agency that 
provides direct medical care. Additionally, law makers have been 
engaged with tribes across the country and, very much so, with the 
tribes of the Great Plains region.

    Finally, because this legislation seeks to amend the Indian Health 
Care Improvement Act, the National Indian Health Board would like to 
take this opportunity to remind the committee that the Indian Health 
Care Improvement Reauthorization and Extension Act (S. 1790, enacted in 
H.R. 3590) permanently reauthorized and made several amendments to the 
Indian Health Care Improvement Act (IHCIA). Numerous provisions of S. 
1790 have not yet been fully implemented. Below is a summary of the 
progress in implementing these provisions. The strides we have already 
made to achieve quality improvement will remain unfulfilled and 
continued or future efforts will not be successful without full funding 
and implementation of these important authorizations for improved 
Indian health.

[GRAPHIC] [TIFF OMITTED] T0919.001

.eps[GRAPHIC] [TIFF OMITTED] T0919.002

.eps[GRAPHIC] [TIFF OMITTED] T0919.003


                                 .eps__
                                 

    Mr. Young. If I may, the Indian Health Care Act that was in 
the Obamacare Act was my bill. It was written by Senator 
Hirono. It took her 15 years to get that done. It is the only 
good thing in the whole Obamacare package, by the way. I want 
you to be aware of that.
    And I will say we have not done our job, but we have done 
pretty good. We are asking for a 5 percent increase, $5.1 
billion, this year. May not be enough, but I was interested in 
what you had to say about management, and we will talk about 
that later.
    Ms. Church, I am glad you made it back. I am sorry if 
anything happened.

  STATEMENT OF JERILYN CHURCH, CHIEF EXECUTIVE OFFICER, GREAT 
PLAINS TRIBAL CHAIRMEN'S HEALTH BOARD, RAPID CITY, SOUTH DAKOTA

    Ms. Church. Good afternoon, Honorable Representative Young, 
Ranking Member Ruiz, and members of the committee. And thank 
you, Representative Noem, for your time and your commitment to 
address the serious quality of care concerns in our region.
    My name is Jerilyn Church, and I am a member of the 
Cheyenne River Sioux Tribe. I was born and raised on the 
Cheyenne River Reservation. I received my primary care through 
IHS growing up, and I choose to receive my care from IHS today.
    I also serve as the Chief Executive Officer for the Great 
Plains Tribal Chairman's Health Board. We are a non-profit 
tribal organization that serves as a vehicle for appointed 
tribal leaders who are consulted within HHS, including IHS. 
These representatives represent the 18 tribes in North Dakota, 
South Dakota, Nebraska, and Iowa. We provide public health 
messaging and support to our tribal health departments, 
technical assistance to tribal leaders on topics of health care 
advocacy, provide training and education opportunities, and 
provide epidemiologic technical assistance, including disease 
surveillance, and increasing tribal capacity to develop data 
products and assist with other emerging health priorities.
    In addition to my written testimony, for your consideration 
I appreciate the opportunity to summarize some of my insights 
and recommendations, which I hope will serve to strengthen the 
intent of this Act.
    Under Title I, one of the most promising opportunities that 
I see is the opportunity to create an alternative delivery of 
care system. The health board's leadership is in early 
discussions with many tribes and tribal health authorities 
regarding the opportunities and feasibilities of tribes 
assuming their programs under the self-determination authority. 
But resources are needed to explore alternative delivery 
systems and establish models that ensure healthy financial 
systems. We do not want our tribes to assume programs that are 
broken and assume failing programs.
    We believe that the pilot project that is recommended under 
Title I needs to stay under the authority of tribes. But the 
private sector has a lot to offer. They are experts in delivery 
of care, and their contractual involvement should be to provide 
management, mentorship in order for tribes to build their own 
capacity, rather than providing the direct operational role.
    Title I is also designed to provide consistency and parity 
between the authorities of the VA and IHS, but I would also 
advocate that that would include protection of IHS funding from 
sequestration.
    Many of the recommendations outlined in Title II serve to 
address Indian Health Service recruitment and workforce needs 
in the Great Plains. However, many of the preference laws are 
imperative to tribal self-determination efforts and developing 
capacity of tribal health programs. So, I don't know that a 
statutory change to Indian preference is necessary, however, 
there needs to be ability for tribes and the IHS to exercise 
flexibility when it is appropriate, and case by case.
    For example, when a position is advertised within IHS, how 
the Indian preference is currently interpreted is that those 
that meet the criteria for Indian preference are raised to the 
top, as they should be, for consideration and for interviews. 
However, those applicants that do not meet Indian preference 
criteria are not included in that pool.
    So, if it is determined that candidates that meet Indian 
preference do not have the qualifications or the experience for 
the position, IHS goes back and then they have to re-advertise, 
and anybody that is worth their salt who may not make Indian 
preference criteria probably has moved on to other 
opportunities. That is an example of where that interpretation 
could be changed to where we look at all candidates, but still 
exercise Indian preference.
    Expanding scholarship opportunities under Title II is a 
positive step, but there are many punitive measures for poor 
performance under Title II, which is important for 
accountability. I think an even more proactive and effective 
approach would be to also invest in advanced education and 
training for the many committed, high-performing staff who are 
members of our communities and who have dedicated their lives 
to serving our tribal members. I think they get forgotten and 
overlooked, especially in a time of crisis.
    Title III attempts to address many of the shortfalls of the 
purchased and referred care program. One of the greatest 
opportunities that IHS has to improve the PRC program is to 
implement the authority under the Indian Health Care 
Improvement Act to recognize North Dakota and South Dakota as 
one contract support service delivery area.
    Currently, IHS continues to operate under the old system 
that limits care to a limited service delivery area, impeding 
access and coverage of tribal members who need specialty care 
that is not available at their local service units.
    And while I understand this committee does not have 
appropriation authority, I would be remiss if I did not stress 
the importance of funding fundamental change of the IHS. To 
implement law without adequate funding is paramount to 
continued failure. There are several other authorities under 
the Indian Health Care Improvement Act that, if funded, would 
greatly improve the quality of service and care.
    I thank you today for your time.
    [The prepared statement of Ms. Church follows:]
 Prepared Statement of Jerilyn Church, Chief Executive Officer, Great 
                 Plains Tribal Chairmen's Health Board
    Good afternoon Chairman Young, Ranking Member Ruiz, and members of 
the committee. Thank you, Representative Noem for your time and 
commitment to address the serious quality of care concerns in the Great 
Plains Area Indian Health Service.
    My name is Jerilyn LeBeau Church; I am a member of the Cheyenne 
River Sioux Tribe, I was born and raised on Cheyenne River, received my 
primary care through IHS growing up and I choose to receive my care 
from IHS today.
    I also serve as the Chief Executive Officer for the Great Plains 
Tribal Chairmen's Health Board. We are a non-profit tribal organization 
that serves as a vehicle for appointed tribal leaders who consultation 
with HHS, including the IHS, who represent the 18 tribes in North 
Dakota, South Dakota, Nebraska and Iowa. We provide public health 
messaging and support to our tribal health departments, technical 
assistance to tribal leaders on topics of healthcare advocacy, provide 
training and educational opportunities and provide epidemiologic 
technical assistance, including disease surveillance, increasing tribal 
capacity to develop data products and assist with other emerging health 
priorities.
    In addition to a detailed written testimony for your consideration, 
I appreciate the opportunity to summarize my insights and 
recommendations which I hope serve to strengthen the intent of H.R. 
5406.
    Title I--``Expanding Authorities and Improving Access to Care'' 
provides a promising opportunity to create an alternative delivery of 
care. GPTCHB leadership is in early discussions with tribal health 
authorities regarding the opportunities and feasibility of tribes 
assuming and successfully implementing their health programs through 
the self-determination authority. Resources are needed to explore 
alternative delivery systems and to establish models that ensure 
healthy financial systems. Under any pilot project, the tribe must 
remain the primary authority to preserve the ``IHS'' provider status. 
Private Health Systems are experts in the delivery care, and their 
contractual involvement should be to provide management mentorship to 
build capacity rather than providing a direct operational role.
    Title I is also designed to provide consistency and parity between 
the authorities of the VA and IHS, I would also advocate that that 
would include protection of IHS funding from sequestration.
    Many of the recommendations outlined in Title II will serve to 
address Indian Health Service Recruitment and Workforce needs in the 
Great Plains. However, Indian Preference Laws are imperative to Tribal 
Self-Determination efforts and developing the capacity of tribal health 
programs. Rather than a statutory change to Indian Preference, tribes 
should have sole authority to exercise regulatory flexibility when 
appropriate and on a case-by-case basis.
    Expanding scholarship opportunities under Title II are a positive 
step. However, much of the focus on under Title II are punitive 
measures for poor performance which is important for accountability. A 
more proactive and effective approach would be to also invest in 
advanced education and training of the many committed high performing 
staff who are members of our communities and who dedicated their lives 
to serving our tribal members.
    Title III attempts to address the many shortfalls of the Purchased 
and Referred Care Program. One of the greatest opportunities that IHS 
has to improve the PRC program is to implement the authority under the 
Indian Healthcare Improvement Act to recognize North Dakota and South 
Dakota as one Contract Support Service Delivery Area. Currently, IHS 
continues to operate under the old system that limits care to a limited 
service delivery area, impeding access to and coverage of tribal 
members who need specialty care that is not available at their local 
service units.
    While I understand this committee does not have allocation 
authority, I would be remiss if I didn't stress the importance of 
funding a fundamental change of the IHS. To implement the law without 
adequate funding is paramount to continued failure. There are several 
other authorities under the Indian Healthcare Improvement Act if funded 
would greatly improve the quality of service and care.

                                 ______
                                 

    Mr. Young. Thank you, Ms. Church. Good testimony, and I 
will have some questions, but Ms. Kristi, I want to let you go 
first, it is your bill. If you have questions--they are all in 
support of it, so be careful. Don't ruin that, you know? No, go 
ahead.
    Mrs. Noem. Thank you, Mr. Chairman, I appreciate that. I 
wanted to speak specifically with Chairman Bear Shield because 
I know you have stayed and actually might be missing a flight 
to stay here and testify on this bill, because it is so 
important to your tribe.
    The Rosebud Emergency Department has now been diverted for 
7 months. I am pleased that we are here today to the point that 
CMS is now re-surveying the emergency department. But according 
to the recent article in the Argus Leader, in Sioux Falls nine 
people have died in ambulances on their way to the hospital. Do 
you confirm these numbers? You have said that in your testimony 
today.
    Mr. Bear Shield. Yes, I just spoke with our ambulance 
service director this morning, and there were nine deaths.
    Mrs. Noem. Did they believe that those deaths could have 
been preventable, if the emergency department had been open?
    Mr. Bear Shield. I guess they happened during the 
diversion. We can't say yes, they could have been, but we can't 
say just the opposite of that. So, our tribe looks at it as 
being a part of the diversion of the ER.
    Mrs. Noem. Well, I think that if there is going to be an 
investigation, which you also talked about in your testimony, 
part of that should be on whether those were preventable. And I 
believe that it should be done by an unbiased entity like the 
HHS Inspector General. Is that what you were recommending when 
you were talking in your testimony?
    Mr. Bear Shield. Yes, exactly, somebody from a different 
agency.
    Mrs. Noem. OK, I appreciate that.
    Ms. Smith, will you commit to join me in asking for the HHS 
Inspector General to investigate those nine deaths?
    Ms. Smith. Yes, Congresswoman, I will.
    Mrs. Noem. OK. I appreciate that very much, because that is 
really why we have an emergency situation on our hands. I 
appreciate you being willing to do that.
    And the HEALTTH Act also provides authorities for IHS to 
discipline and fire under-performing employees. One of the 
things I have heard over the last several years is, oftentimes, 
when we have a problem with somebody who is providing care or 
within administration of IHS, they are removed and then they 
are just rehired somewhere else. They are not necessarily ever 
punished, there are no consequences for not doing their job 
properly. I have heard this since I have been in office and 
have been trying to get to the bottom of it. I have that 
addressed in my legislation, yet in your testimony you say that 
that is not needed, you already have those authorities.
    So, I would like to know why that has not been done. I have 
not heard of a single person being fired from IHS because of 
the poor care that has been delivered in the facilities in the 
Great Plains region. I have heard of people being moved, and we 
have had leadership moved, but we have not had anybody pay any 
consequences.
    So, when you say it is not necessary in my bill, obviously, 
for the last couple of decades that we have had this situation 
going on, and since I have become aware of it, since I have 
come into office in the last few years, as we have been able to 
get all the tribes on the same page and pushing, and then we 
have had this crisis situation, now that I have it addressed in 
my bill you say it is not necessary. Tell me why nothing has 
been done.
    Ms. Smith. Thank you, Congresswoman Noem. I appreciate the 
efforts, and I think that at IHS we are committed to providing 
high-quality care. And to the extent that someone is not 
meeting that standard, there should be accountability. And you 
know, in cases that are warranted, people should be 
disciplined.
    Mrs. Noem. Has anybody been disciplined or fired?
    Ms. Smith. Yes, people have been disciplined.
    Mrs. Noem. Could you get me those names and information?
    Ms. Smith. I am happy to talk to you separately about 
personnel matters.
    Mrs. Noem. Nobody fired? Do you think anybody has been 
fired, removed from IHS employment?
    Mr. Young. Will the gentlelady yield?
    Mrs. Noem. Yes.
    Mr. Young. I think under the personnel laws, you cannot 
fire anybody. It is like the VA.
    Mrs. Noem. Well, we are asking for the same provisions that 
the VA has recently received and changes that----
    Mr. Young. OK. See, but that----
    Mrs. Noem. That is what we are asking.
    Mr. Young [continuing]. Has to be in your legislation.
    Mrs. Noem. Yes. But you indicated in your testimony that it 
wasn't necessary to have those provisions, so that is why I 
want to know if that is in place. We can talk about that 
offline, but I also want it dealt with, too.
    You also say that about my requirements for dealing with 
wait times. Mr. Bear Shield, do people wait a long time in the 
hospital for appointments and for emergency room treatment when 
it is open?
    Mr. Bear Shield. Oh, yes. They have for many years. Yes.
    Mrs. Noem. And again, Ms. Smith, you say that it is not 
necessary for us to require you to assess that and fix that 
problem because you already have those authorities. How come it 
hasn't been done before? How come it hasn't been fixed before?
    Ms. Smith. I have only been in the job for a few months, 
but we are working aggressively on that. It is a very important 
issue. I totally agree with you, Congresswoman.
    And two things I can tell you that we are doing--well, 
actually three things. One, in all the senior executive service 
performance measures they are supposed to account for two 
concrete measures on wait times. We are implementing things at 
different facilities. One thing that has worked is that leaving 
same-day appointments open so there is flexibility for people 
to see that, and then third, we are going to be working on 
coming up with different models to address the wait times. And 
then, obviously, fourth, one of the issues that ties into that 
is having full staffing. We are working on a number of 
recruitment tools. So again, I appreciate your efforts on this 
important issue.
    Mrs. Noem. I can appreciate the fact that you have only 
been in your position a few months; but unfortunately, for 
years we have watched this revolving door happen. And you may 
not be here long-term in this position, somebody else may come 
in and they may not be--that is why we are trying to get 
certainty in health care here, because we look at the situation 
we are at today, and people are dying.
    So having somebody say, ``You don't need to do that, we are 
going to fix it,'' we have heard that for years, and that is 
why we need--I am sorry, Mr. Chairman. I will yield back.
    Mr. Young. You can hang around again. I just want to 
recognize the Ranking Member.
    Dr. Ruiz. Thank you.
    Ms. Bohlen, I understand that many of the proposals 
instituted in the permanent reauthorization of the Indian 
Health Care Improvement Act are still being implemented at the 
Indian Health Services. In your written testimony, you supplied 
us with a breakdown of that progress. In your opinion, will the 
proposals in the HEALTTH Act complement that effort?
    Ms. Bohlen. In the legislation we are talking about today? 
I think it would complement it, yes. But I also think that 
there is a level of funding that is not available. If you look 
at the percentages of the programs that were authorized in the 
Indian Health Care Improvement Act that have not been 
implemented, it matches, kind of tracks side by side with, the 
level of funding that is not there.
    Of course, it is true that Congress, led by this House of 
Representatives, has done an excellent job of increasing 
funding to the Indian Health Service over the past several 
years, and that is to be lauded, especially in the budgetary 
environment we----
    Dr. Ruiz. Are the fundings targeted specifically for this 
problem, or are there fundings for other problems but not this 
one?
    Ms. Bohlen. I am not the one who can speak to that. The 
Indian Health Service would know best where those monies are 
being targeted.
    Dr. Ruiz. OK. And you mentioned that an avenue for 
recruitment for physicians could be through the GME program by 
setting aside a certain number of residency training positions 
for those who choose to serve in Indian Country. Can you 
further explain to us how this could help alleviate the 
problems with recruitment? And what do you need to make this 
goal a reality?
    Ms. Bohlen. Thank you for asking that question, because 
that is an exciting opportunity.
    In the Omnibus Budget Reconciliation Act of 1997, Congress 
put caps on the number of graduate residency training positions 
that could exist in the United States for the first time since 
the program was implemented in 1965. And the important thing to 
understand is that the graduate medical education program of 
this country is an entitlement program through Medicare, 
somewhat through Medicaid. There is a direct medical education 
expense and an indirect medical education expense.
    In a residency position that could be reimbursed, like at 
the University of Michigan, I believe it is about $160,000 per 
resident per year. Maybe $110,000 of that goes into the 
institution to pay the indirect expenses to build that 
residency program, to have the physicians to do the training, 
and so forth. Yet, in Indian Country, I just learned of a 
successful program at the Choctaw Nation of Oklahoma. They are 
experimenting with this, and they are being very successful.
    But where the money goes to build institution and build 
these residents is where all or substantially all of----
    Dr. Ruiz. I think the point here is that a physician is 
most likely going to practice where they are from originally 
and they have a family member, and where they last trained. So, 
if we want more physicians in the recruitment process in under-
served communities like in reservations, then we need to take 
students from the reservation, put them in a program, and then 
have them trained, their last location of training in the 
reservation and practicing community health.
    I think that is a pipeline program that I have developed 
with my Future Physician Leaders program in the most under-
served area in Southern California, and I think it is important 
that when we look at a system of recruitment that is 
comprehensive, that grabs him from the high school, puts him 
into a pipeline program, and sends him back into the community 
for training.
    Ms. Smith, so we have heard from tribal nations, including 
the ones before us today, that Indian Health Service regional 
leadership has not properly informed the DC IHS leadership 
about problems and deficiencies. What are you doing from the 
top to proactively manage and monitor the different regions and 
their facilities?
    Ms. Smith. Thank you, Congressman, for asking that 
question. We are working aggressively on new reporting methods 
from all the areas on finances, HR, and other communication 
methods. And it is important that--I think the one thing that 
is a priority for me is that there is oversight over all the 
areas, and that people recognize that we are all one IHS, and 
we are all working together for the common goal of providing 
access to health care for Native people. And we will----
    Dr. Ruiz. What are your plans on holding the management 
accountable for consistently implementing these new procedures 
and using best practices that are shared amongst the different 
management?
    Ms. Smith. We are working on holding people accountable. 
One example that has recently been done is there is a new 
performance standard in all the performance reviews which is 
holding people accountable for maintaining the conditions of 
participation with the Centers for Medicare and Medicaid 
Services.
    We are also doing training on practices for managers, so 
that they know how to document incidents, and that training has 
already started with senior staff, and it is going to go down 
to all the staff.
    But I will also say, in addition to holding people 
accountable, it is very important that we are also working on a 
culture where people feel free that they must report issues. 
They cannot hide them. They need to present the issue and a 
solution, and we all need to work together. We are also working 
on measures in that regard.
    Mr. Young. Mr. Benishek.
    Dr. Benishek. Thank you, Mr. Chairman.
    Ms. Smith, how long have you been on the job?
    Ms. Smith. I think it is a little over 3 months.
    Dr. Benishek. So you are just new to all this, and this 
huge problem that we have here, the Indian Health Service.
    Frankly, Mrs. Noem was right, this sounds very much like 
the VA, you know, government-run healthcare. Sometimes it does 
not work.
    There are 27 health facilities that the Indian Health Care 
Service--is that the number that I heard? Is that correct?
    Ms. Smith. That is the number of our hospitals. We have 
over 160 clinics, as well, that we run.
    Dr. Benishek. OK. How many of the hospitals have you been 
to?
    Ms. Smith. How many hospitals have I been to?
    Dr. Benishek. Yes.
    Ms. Smith. I have been to four of them.
    Dr. Benishek. Have you been to the one that they are 
talking about here that had the emergency room closed?
    Ms. Smith. I have been to every hospital that we are 
talking about today. I have been to Omaha Winnebago, Rosebud, 
Pine Ridge, and Sioux San.
    Dr. Benishek. Are these places inspected by JCAHO?
    Ms. Smith. I think that, prior to my arrival, the 
accrediting body that was being used in the Great Plains and is 
currently being used is DNV.
    Dr. Benishek. What is that?
    Ms. Smith. DNV, Doss Veritas----
    Dr. Benishek. I don't know. The 99 percent of hospitals in 
the country are certified by JCAHO. It is a foundation--or it 
is a non-profit founded by the American College of Surgeons, of 
which I am a member, to inspect hospitals because the types of 
things that we have seen here I find pretty amazing that have 
actually occurred in a hospital in America.
    I just find it very disconcerting to even hear that this 
stuff is going on. Mrs. Noem's testimony earlier today was 
unbelievable. And, I know you have only been on the job for 3 
months, but this is a huge issue. And frankly, I am not sure 
that political appointees is the way this should be done. There 
should be a long-term management of this with a regular board, 
just like proposed for the VA. All right? We should not have 
political appointees coming in every 2 weeks or 2 months and 
then be responsible for an organization that they don't really 
understand how it all works.
    I mean, you are a manager, but you have a pretty important 
job here, billions of dollars in funding, health care, people 
are dying, and we do not have a good answer for it.
    So, I think that this is a good step for making things 
move, but having political appointments, there should be a 
body, a board of directors that is appointed by the President 
and Congress. There should be a CEO so that there is continuity 
and skill involved in this management process. The way this is 
being done is a disaster.
    Mrs. Noem kind of gets to it, but what do you have to say 
about my idea there, Ms. Smith?
    Ms. Smith. Well, Congressman, I agree that this is a 
serious situation and a lot of this is just unacceptable. And I 
certainly agree with you that one of the key things that makes 
a facility successful is continuity of leadership, strong 
leadership, and strong governing board organization.
    Dr. Benishek. All right, good. Well, I have one more 
question, and that is--you have a balance sheet for every 
facility so that you know how much you are spending and how 
much money is coming in so that there is an accountability as 
to how much money is being spent on administration, on 
supplies, per facility? Do you do that kind of accounting? They 
don't do that at the VA very well.
    Ms. Smith. Congressman, thank you so much for asking that. 
That is actually one of the things we are implementing on the 
finances. We are wanting to get reports from the areas----
    Dr. Benishek. So you don't do that now; is that the answer? 
You are going to start doing that? Is that what you are telling 
me?
    Ms. Smith. I have been there for a couple months, and we 
will start doing that. We have already put the process into 
place.
    Dr. Benishek. All right. My----
    Mr. Young. No, you have 49 seconds.
    Dr. Benishek. Yes, that is what I thought. I thought I 
heard you knock----
    Mr. Young. No, I am a little nervous. I have to go out and 
testify in another committee; you are going to take over here 
in a minute.
    Dr. Benishek. These are the kind of things that it is 
pretty amazing for people in the healthcare field to actually 
listen to, the fact that you are not even taking care of the 
numbers like that, and yet you are running a multi-billion 
dollar operation. You see what I am saying? Because a regular 
hospital could never operate that way. They know exactly how 
much money is coming in, they know actually where it is going. 
And you don't.
    And we talk about funding levels. Well, the efficient 
spending of the taxpayer dollar is a pretty important thing. 
And it doesn't seem to me that this agency is actually doing 
that. So, I think I will yield back. Thank you.
    Mr. Young. Thank you. And you will take over the Chair in a 
moment here. I have to go down and testify.
    One thing I would like to suggest. Chief Bear, you 
mentioned something about the tribes and the potential fines 
would be $2 million if you don't participate in the Obamacare 
bill?
    Mr. Bear Shield. It is cheaper for us to pay the fine than 
it is to pay nearly $400,000 a month in insurance fees for our 
tribal employees.
    Mr. Young. But that is still taking, what you said, about 
$2 million a year out of your cash-flow that could be used for 
other purposes?
    Mr. Bear Shield. Exactly. And if you understand, in 
listening to the questions from the committee earlier, there 
needs to be some education, I feel. And that will be an ongoing 
process. Just remember the population that we are talking about 
with these facilities are historically in the top five poorest 
counties in the Nation; so that is where we are at in the Great 
Plains area.
    Mr. Young. One of my biggest problems personally is that we 
are doing a pretty good job in Alaska. And the IHS is 
supporting it financially, but they are not running them. I 
believe in that self-determination concept, and you do a much 
better job. And I encourage you--I know what you have said, you 
do not have the ability right now. And I don't know how we do 
it, but the sooner we can get the government out of it and let 
you run it, I think it would be a lot better off.
    Ms. Smith, I want to thank you. I am going to have to let 
Mr. Benishek take over this deal in a minute. This has not been 
comfortable for you. And I want to ask you--you have been here 
3 months--to use this committee; don't listen to your boss. We 
are really the boss, because like Mrs. Noem said, this has been 
going on. It is not just you, or not just this Administration. 
This has been going on, and it is a very discouraging thing. I 
have walked through some very interesting places in my life, 
including some quicksand areas, and you try to get out of it, 
and the more you struggle, the bigger you get into it, and 
pretty soon nobody is paying any attention because you are 
already under the quicksand.
    And we need to help. I mean you need help.
    Ms. Smith. Yes.
    Mr. Young. We cannot do this by ourselves. I want to move 
this legislation.
    Mrs. Noem. Mr. Chairman?
    Mr. Young. Yes.
    Mrs. Noem. Over here.
    Mr. Young. Yes.
    Mrs. Noem. Can I just ask you for a favor? The bill that 
Mr. Bear Shield was talking about is one that penalizes tribal 
businesses for not complying with the Obamacare mandate, which 
our tribal businesses should not be bound to. In Obamacare, it 
exempted tribal members from the mandate. Our tribal businesses 
employ tribal members, so they are penalizing our tribal 
businesses in our tribes for not covering people in insurance 
that the government is responsible to cover their insurance and 
health care costs. That is how crazy that thing is. That is 
another bill that I need your help getting done, too, that is 
devastating.
    Mr. Young. Well, I----
    Mrs. Noem. It has passed through Ways and Means, and we 
need to get it across the House Floor.
    Mr. Young. Well, let's do that. And the second thing I can 
tell you, respectfully, that if I was the Chief of those 
tribes, I wouldn't do it and would tell the government to go 
suck an egg.
    I can say that because I probably would not go to jail. But 
the reality is that is inappropriate, because that was the 
intent, that you were not to have to pay this. And now they are 
making you. That is a challenge all over the Nation, as far as 
the American Indian and Alaska Natives go. And that is 
something to work on.
    Mr. Benishek, would you please take the Chair? I want to 
thank the witnesses for your input. I like the idea of a 
business platform, run it right. I don't believe it has been 
run right. And unfortunately, over the years, it has probably 
gotten a little rotten. No disrespect, that is probably what 
has happened. It is a natural phenomenon.
    So, with this bill and the help of Ms. Smith, we will be 
able to try to solve some of these problems, try to get health 
care to those constituents. We can hear all the sad stories we 
want, we just do not want it to happen again. What happened 
yesterday is yesterday. What is going to happen tomorrow is 
what we have a role in trying to do.
    So, Mr. Benishek, would you take the Chair? All right. 
Behave yourself, too.
    Dr. Benishek [presiding]. Mr. Ruiz, do you have any 
questions?
    Mrs. Noem, do you have any further questions?
    Mrs. Noem. Just one, if you don't mind.
    Ms. Smith, I know we have talked about the fact that it has 
not been on your watch that a lot of this happened, but this is 
one instance in which I want to explain to you why there is so 
much concern and why there is legislation here today, is 
because last year, in discussion with IHS officials, my staff 
expressed concern--and Mr. Bear Shield referenced this incident 
before, as well--but we talked about CMS findings at Rosebud, 
pointing out a baby was born on the floor, comparing it to the 
2010 Senate report, where something like that had happened, as 
well. And the IHS's Chief Medical Officer had said, ``Well, if 
you have two babies hitting the floor in 8 years, that is 
pretty good.'' And I understand that now that individual has 
been moved and made Acting Chief Medical Officer of the Great 
Plains.
    So, that is the fundamental question that I have--how are 
we supposed to trust this person to care for people when he 
makes statements like that? I would have removed the individual 
for a statement like that. But now they are the Acting Chief 
Medical Officer of this entire region. How can I trust them 
with the safety and care of the 122,000 tribal members in the 
Great Plains?
    When was he moved to Acting Chief Medical Officer of the 
Great Plains? When did that happen?
    Ms. Smith. Thank you, Congresswoman, and I will just say 
that those comments are unacceptable. And that was made clear 
that it was unacceptable. I believe that the individual in 
question has publicly apologized for those comments.
    So, I certainly agree that our tribal patients and partners 
need to have respect and rapport with medical staff at each of 
our facilities. That is very important to us. And I am happy to 
talk with you any time and with any of the people here about 
any issues they have with people, because I think one of the 
fundamental things is the quality of health care that you have.
    Mrs. Noem. Do you know when that person was moved into that 
position?
    Ms. Smith. I believe it was probably about a month ago.
    Mrs. Noem. So, that was on your watch.
    Ms. Smith. Yes. And, like I said, the person in question 
has publicly apologized. I know that she is committed to caring 
for the patients. And to explain the decision, there was no 
Chief Medical Officer in the Great Plains, and there was no 
full-time person. As I have said at this hearing, we have very 
serious recruitment and retention problems. We have lots of 
vacancies.
    And I can tell you that, personally, I am committed to 
quality health care in the Great Plains. I spend a lot of time 
working on that. I know we don't move as fast as people would 
like. We are not moving as fast as I would like. And I think, 
from my perspective, that it was important to have a full-time 
Chief Medical Officer there. So that was the basis of the 
thinking for that.
    And like I said, if there are issues, I am happy to further 
discuss. But I did feel that it was important to have a Chief 
Medical Officer full time in the Great Plains to try to assist 
our patients there.
    Mrs. Noem. One last thing, Ms. Bohlen, your staff was 
incredibly helpful to us as we drafted this legislation, so I 
appreciate that.
    I know I don't have much time, but can you please tell me a 
little bit about your alternate idea for the PRC transition 
provision in the bill? You have an alternate idea?
    Ms. Bohlen. I am trying to think of what our alternate idea 
is.
    Mrs. Noem. Well, that's all right. If you don't--but I did 
think that you had another idea for how we could transition the 
PRC provision in the bill.
    I want to just maybe leave this discussion so that 
everybody knows our hope is to continue to work on this bill. I 
am not married to this bill exactly the way that it is. I want 
to pass a bill that fixes problems and that everybody can get 
behind and recognize is a huge change that was needed in IHS 
and meets the needs of the tribes in the Great Plains region. 
And I think it is time to think outside of the box, and it is 
time for everybody to get on board, because I am not going to 
quit. So, we need to get on board, and we all need to pull the 
same direction and fix the problems that we have.
    And with that, Mr. Chairman, I yield back.
    Dr. Benishek. All right. Thank you, Mrs. Noem. I have one 
more question, because we are talking about this funding issue, 
and it always comes to funding. We want to be sure that the 
funding is appropriately spent, and apparently the IHS entered 
into an $80 million settlement with the employee unions for 
overtime-related claims at the IHS-operated facilities. Were 
any of the funds that were used to pay these claims staffing 
monies? Do you know anything about that?
    Ms. Smith. The settlement was entered into before I took 
this position, but my understanding is that the settlement was 
over back pay for people who do provide care at these 
facilities.
    Dr. Benishek. Well, the information that I have says that 
the funding was not paid out of a judgment fund, it came out of 
the staffing fund, directly from the money that would go to 
staff these facilities. And there is a separate judgment fund--
would you look into that for me, please, and find out what the 
story is with that?
    Ms. Smith. We are happy to get back to you, Congressman.
    Dr. Benishek. All right. That was the last question that I 
had.
    So, thank you, Ms. Smith. You know, this is not that easy. 
And I have a lot of experience in the VA Committee with very 
similar issues. We have sincere, newly appointed people in the 
Department who have to explain bad behavior for a long time. 
And that is, unfortunately, your job here today. And we need 
sincere people to actually change the way things happen, and 
not come here to tell us how hard you are working to make a 
change, and then nothing happens. I am used to that, I am used 
to the Administration people coming to me and saying, ``We 
really want to fix it,'' but then, over the course of years, 
nothing changes.
    That is what we are all frustrated about. These people out 
here have a bad hospital and nobody seems to be responsible. 
And you are telling them, ``Well, we are doing the best we 
can,'' and that does not work any more.
    So, anyway, I am sorry about all the comments, but I want 
to thank the witnesses today for your valuable testimony, and 
for the Members for their questions.
    The members of the committee may have some additional 
questions for the witnesses, and we will ask you to respond to 
these in writing.
    Under Committee Rule 4(h), the hearing record will be open 
for 10 business days for these responses.
    If there are no further questions, then, without objection, 
the committee stands adjourned.
    [Whereupon, at 5:25 p.m., the subcommittee was adjourned.]

            [ADDITIONAL MATERIALS SUBMITTED FOR THE RECORD]

Prepared Statement of Deb Fischer-Clemens, Senior Vice President, Avera 
                                 Health
    Good afternoon Chairman Young and members of the Subcommittee on 
Indian, Insular and Alaska Native Affairs. Avera, the health ministry 
of the Benedictine and Presentation Sisters, is a regional partnership 
of health professionals who share support services to maintain 
excellent care at more than 300 locations in 100 communities throughout 
eastern South Dakota and surrounding states. On behalf of our health 
care providers in hospitals, post-acute centers, clinics, Avera Health 
appreciates the opportunity to submit a statement of record for 
Congresswoman Kristi Noem's bill, the Helping Ensure Accountability, 
Leadership, and Trust in Tribal Healthcare (HEALTTH) Act of 2016 (H.R. 
5406).
    Avera greatly appreciates the Congresswoman's work to improve 
health care for Native Americans and believe the proposed legislation 
contains many needed steps.

    After reviewing the HEALTTH Act, Avera would suggest the following 
concerns be addressed in an amendment to the legislation:

    The Indian Health Service relies on a number of manual processes 
for Purchased Referred Care (PRC) service authorization, claims 
processing and payment functions. It would be to the benefit of PRC 
beneficiaries and health care providers if the IHS would bring its 
administrative transactions up to the standards specified by the Health 
Insurance Portability and Accountability Act (HIPAA) and as implemented 
by Medicare, Medicaid and private sector health care insurers, 
administrators and providers. Extended processing time frames due to 
manual processes, and the potential for lost records directly 
jeopardize an individual's access to needed health care and/or 
unanticipated medical expenses. Additionally, it means providers are at 
risk for non-payment or delayed payment for authorized services.
    In short, though these technology updates would cost money, they 
are important to improve the referral and billing process.
    Thank you again for considering this input and allowing Avera 
Health to provide feedback on the HEALTTH Act.

                                 ______
                                 

Prepared Statement of the Hon. Michael Marchand, Chairman, Confederated 
                   Tribes of the Colville Reservation
    The Confederated Tribes of the Colville Reservation (``Colville 
Tribes'' or the ``CCT'') appreciates the opportunity to provide this 
statement on H.R. 5406, the ``Helping Ensure Accountability, 
Leadership, and Trust in Tribal Healthcare Act'' (``HEALTTH Act''). The 
CCT would like to express its thanks to Congresswoman Noem for 
introducing this important bill that will address long-standing issues 
with the Indian Health Service (``IHS''), both in the Great Plains and 
in other IHS regions.
    The CCT is one of six direct service tribes in the IHS's Portland 
Area. The Portland Area oversees 43 Indian tribes in the states of 
Washington, Oregon, and Idaho. Similar to the tribes in the Great 
Plains, the CCT has struggled with chronically low staffing levels in 
its IHS-operated facilities. In the CCT's case, the lack of staff is 
primarily the result of the absence of a mechanism for tribes that have 
not been fortunate enough to construct a new health care facility 
through the IHS system to bring their staffing levels current. Like the 
Great Plains, some is also attributable to the challenges of attracting 
qualified health professionals to work in rural areas.
    This statement provides background on these issues and three 
recommendations on how they can be addressed in the HEALTTH Act. The 
CCT believes the HEALTTH Act, particularly its provisions relating to 
staff recruitment and re-examining Purchased-Referred Care funds 
distribution, is a needed and overdue fresh look at these long-standing 
issues.
                   background on the colville tribes
    Although now considered a single Indian tribe, the Confederated 
Tribes of the Colville Reservation is, as the name states, a 
confederation of 12 aboriginal tribes and bands from across the plateau 
region of the Northwest and extending into Canada. The present-day 
Colville Reservation is approximately 1.4 million acres and occupies a 
geographic area in north central Washington State that is slightly 
larger than the state of Delaware. The CCT has more than 9,500 enrolled 
members, about half of whom live on the Colville Reservation. In terms 
of both land base and tribal membership, the Colville Tribes is one of 
the largest Indian tribes in the Pacific Northwest.
    Most of the Colville Reservation is rural timberland and rangeland 
and most residents live in one of four communities on the Reservation: 
Nespelem, Omak, Keller, and Inchelium. These communities are separated 
by significant drive times.
          facility needs and historically low staffing levels
    Like other Indian tribes with large service delivery areas, the 
Colville Tribes face a health care delivery crisis. The CCT's original 
clinic in Nespelem, was built by the U.S. Department of War in the 
1920s and was converted into an IHS facility in the late 1930s. From 
the information that we have been able to obtain from IHS, the staffing 
ratios at the Colville IHS Service Unit were established when the 
Nespelem clinic went into service in the 1930s. While funding levels 
have increased incrementally with IHS's base budget in the intervening 
decades, the initial staffing ratios have not changed.
    The only way for direct service tribes like the CCT to bring 
staffing levels current under the IHS system is to construct a new 
facility under the IHS system. There are currently two ways to 
accomplish this. The first is the priority list system, which has been 
in effect since the early 1990s and provides funding for construction 
of the facilities included on the list as well as 80 percent of the 
annual staffing costs. The second is the joint venture (JV) program, 
which requires an Indian tribe to pay the entire up-front cost of 
construction of a facility in exchange for IHS providing a portion of 
the annual staffing costs. The priority list has been closed since the 
early 1990s and the JV program is extraordinarily competitive and has 
been funded only sporadically during the past decade. Unless a facility 
is built under either of these two programs, IHS will not update the 
staffing ratios for a given IHS service unit.
    The CCT sought in the 1980s and the early 1990s to replace the 
Nespelem facility with a new facility through the IHS priority list 
system. We understand that at one point, the CCT's request for a new 
clinic in Nespelem was near the top of the priority list but was 
removed because of concerns that the facility was a historical site. 
None of the more than 40 tribes in the IHS Portland Area, of which the 
CCT is a part, have ever had a facility constructed under the priority 
list system.
    Because the CCT's need for a new facility in Nespelem was so great 
and the priority list had been closed, the CCT was ultimately forced to 
take matters into its own hands and construct a new Nespelem facility 
primarily using tribal funds. Since the facility was not on the 
priority list and the CCT was not selected for the JV program, IHS did 
not provide any additional staff or otherwise update the antiquated 
staffing ratios for the Colville Service Unit. This means that, despite 
paying to construct our own facilities, we continue in a sometimes 
futile effort to provide modern health delivery to approximately 5,000 
tribal citizens using 1930s staffing ratios.
    In response to a congressional inquiry, in 2013 IHS calculated that 
the Colville Service Unit had less than one-third of the required 
number of clinical staff and only one-quarter of the required number of 
dental staff. Later that year, on December 17, 2013, the CCT adopted a 
resolution declaring a state of emergency in response to the continued 
lack of healthcare provided by the IHS and vacancies that threatened 
delivery of healthcare on the Colville Reservation altogether.
    The CCT has been doing everything it can to find creative ways to 
address these issues. For example, we are currently examining the 
feasibility of deploying Dental Health Aide Therapists (DHATs) to help 
bridge the gap in oral health care on the Colville Reservation. The 
lack of available dentists in Omak (the largest population center on 
the Reservation) sometimes forces those residents to drive nearly 3 
hours to Inchelium for dental services. The CCT is encouraged by the 
IHS's recent overtures to Indian country to expand the use of DHATs and 
is fully supportive of this effort.
   recommendations to address staffing inequities in the healtth act
    The CCT has three recommendations on how the HEALTTH Act could 
address the CCT and other similarly situated tribes' staffing issues. 
The first would be to provide direction for IHS to provide some pathway 
for tribes that self-funded and constructed their own health facilities 
outside the IHS system to obtain staffing packages, whether short term 
or permanent. Lack of adequate staffing not only means fewer health 
care providers and longer wait times for our tribal members, it also 
means that we are unable to maximize third party reimbursements because 
of lack of administrative support. The limited number of providers are 
not able to see as many patients, which negatively impacts the CCT's 
service population and, by domino effect, the Purchased-Referred Care 
funds allocated to the Colville Service Unit.
    Although permanent staffing would be desired, even shorter term 
staffing would be beneficial. With the 2010 reauthorization of the 
Indian Health Care Improvement Act, more opportunities exist for tribes 
to generate additional revenue to pay for staff through third party 
reimbursements. Providing even a short-term infusion of staff to tribes 
in this situation would empower those tribes to make these 
reimbursements and staff self-sustaining.
    Another benefit of providing a path forward for tribes to update 
staffing levels is that it would allow for increased preventative care, 
which would reduce the need for Purchased-Referred Care by ensuring 
that minor health conditions do not become severe.
    Another recommendation the CCT would like to explore would be to 
direct IHS to prioritize or provide some enhanced consideration to 
tribes that are currently operating under historic staffing levels when 
IHS allocates any increases that Congress may provide to IHS for 
staffing. If implemented, this would provide some equity to those 
tribes that have been operating under antiquated historic staffing 
levels.
    Finally, the CCT would also like to see Congress direct IHS to 
consult with Indian country and provide information to Congress on 
those IHS service units that are operating under historic staffing 
levels. Such information could include the volume of third party 
reimbursements between service units with low staffing levels compared 
to those with updated staffing ratios, impact on patient care, and 
other considerations.
    The CCT looks forward to working with Congresswoman Noem, this 
committee, and the other committees of jurisdiction on these issues and 
assisting in advancing the HEALTTH Act to House approval.

                                 ______
                                 

Prepared Statement of John Yellow Bird Steele, President, Oglala Sioux 
                                 Tribe
    My name is John Yellow Bird Steele and I serve as the President of 
the Oglala Sioux Tribal Council. The Oglala Sioux Tribe is pleased to 
see that Congress and this subcommittee recognizes the urgent need for 
action to address the current Indian health care crisis in the Great 
Plains region and throughout the Country. I appreciate the opportunity 
to submit this testimony on behalf of the Oglala Sioux Tribe to provide 
the subcommittee with the tribe's views on H.R. 5406, the Helping 
Ensure Accountability, Leadership, and Trust in Tribal Healthcare 
(HEALTTH) Act.
                       the urgent need for action
    The United States owes a trust duty to all tribes and a specific 
treaty obligation to the Oglala Sioux Tribe to ensure the health and 
well-being of our Indian people. In the Sioux Treaty of 1868 (known as 
the Fort Laramie Treaty), the Great Sioux Nation and the United States 
agreed on a quid pro quo: by the terms of the treaty, the United States 
promised to provide certain benefits and annuities to the Sioux Bands 
each year, including health care services, in exchange for the right to 
occupy vast areas of Sioux territory. The IHS is tasked with carrying 
out this duty by providing quality health care services in our 
communities, though the responsibility belongs to the U.S. Federal 
Government as a whole. The evidence is clear that the IHS--and as a 
result, the United States--is failing at that task.
    Congressional action is sorely needed to address this very serious 
emergency. As it stands, the Pine Ridge Hospital is not a functioning 
facility that is capable of meeting even the basic health care needs of 
our community. On top of the mismanagement problems that have been well 
highlighted by government reports, witness testimonies, and even news 
reports, our hospital facility is only utilizing a portion of our 
inpatient beds, and our intensive care unit is not even operational due 
to funding, staffing, and equipment shortages and despite the high 
level of unmet health care needs on our reservation. This situation is 
unacceptable; falls far short of the Federal Government's treaty 
obligations to our tribe; and must be addressed.
    The Oglala Sioux Tribe appreciates the ongoing efforts of this 
subcommittee to hold the IHS--and indeed the Federal Government as a 
whole--accountable to deliver on the promise of quality health care for 
our people. We believe that H.R. 5406 would take important steps to 
implement needed reforms, and we would like to comment on the specific 
provisions of the bill and offer our suggestions to strengthen the bill 
and its impact even further.
Sec. 101: Service hospital long-term contracting pilot program
    H.R. 5406 would create a 7-year contracting pilot program ``to test 
the viability and advisability of entering into long-term contracts for 
the operation of eligible Service hospitals with governance structures 
that include tribal input.'' The pilot program is also designed as ``an 
alternative to full direct-service and full self-governance, with an 
emphasis on preparing tribes for self-governance.''
    The Oglala Sioux Tribe is not opposed to the consideration of new 
and innovative ideas to address deep-rooted and systemic problems, 
including long-term contracting. Fundamentally, the Oglala Sioux Tribe 
simply wants a health care system that works and that results in the 
best possible health outcomes for our communities. The tribe also 
appreciates efforts to provide an alternative to full direct service 
and full self-governance. However, we emphasize that the trust and 
treaty responsibility to provide health care to our tribal people 
belongs to the U.S. Federal Government and cannot itself be contracted 
out or privatized. Accordingly, the Federal Government must always 
remain ultimately responsible and accountable for Indian health 
programs. With respect to the pilot program proposal, that means that 
the contracts and governing board for each hospital must be structured 
in such a way that the IHS is not relieved of its ultimate 
responsibility of ensuring quality healthcare for our people. Private 
involvement should be geared toward capacity-building and systems 
improvement so that direct service tribes are better served and tribes 
that eventually choose to contract under the ISDEAA do not inherit a 
dysfunctional and ineffective system. Further, in addition to 
leveraging private sector expertise, the Federal Government must commit 
to providing Federal resources at the full level of need in order to 
make tribal self-governance a meaningful option for tribes. With these 
caveats, the tribe supports the proposed pilot project in H.R. 5406.
Sec. 102: Expanded hiring authority for the Indian Health Service
    We are also happy to see that H.R. 5406 seeks to address the need 
to improve and streamline the hiring process within the IHS. H.R. 5406 
would allow the Secretary to utilize, in place of the civil service 
requirements, VA hiring authorities with respect to positions involving 
direct patient services or services incident to direct patient-care 
services. The IHS has represented that it already has the ability to 
exercise at least some of these authorities, and it is not clear to the 
tribe that these authorities have permitted the VA itself to succeed in 
resolving the recruitment problems it has faced. Moreover, the bill as 
currently drafted focuses primarily on recruitment and less on 
retention, which is equally important. Thus, further consideration 
should be given to whether the VA authorities are the best substitute 
for current IHS authorities, and additional measures may be necessary 
to make a meaningful impact on IHS recruitment and retention.
    There are many factors that contribute to the hiring and retention 
challenges faced by the IHS in the Great Plains area and elsewhere, 
including mismanagement, uncompetitive salaries, unattractive and 
underequipped facilities, the rural and isolated location of our 
facilities combined with the economically depressed character of our 
communities, and the lack of housing and other infrastructure. As one 
example, the Oglala Sioux Tribe is in serious need of housing for its 
health care professionals given the shortage of housing options in the 
vicinity of our hospital and clinics--an issue that directly impacts 
our ability to attract and retain health care professionals and 
administrators.\1\
---------------------------------------------------------------------------
    \1\ The Pine Ridge Hospital has 450 positions but only 104 housing 
units. Likewise, the Kyle Health Center has 86 positions but only 20 
housing units; the Wanblee Health Center has 35 positions but only 5 
housing units; and the LaCreek District Clinic has 6 positions but no 
housing units. There are few alternative housing options within a 
reasonable distance of any of these facilities, so staff housing 
specifically associated with IHS facilities is critical.
---------------------------------------------------------------------------
    The Oglala Sioux Tribe believes that meaningful improvement in 
recruitment and retention at the IHS depends in large part on resolving 
these interwoven issues. We agree with other testimony that 
collaboration between the tribes, the IHS, and other Federal agencies--
including the U.S. Department of Housing and Urban Development, the 
Bureau of Indian Affairs, the Bureau of Indian Education, the U.S. 
Department of Education, and the U.S. Treasury Department, among 
others--is needed to ensure that attractive housing, education, and 
economic opportunities are available to health care professionals 
considering employment with the IHS in our communities, and to their 
families. It is exceedingly difficult to attract and retain qualified 
professionals while asking them to forego quality education for their 
children or meaningful employment prospects for their spouse. The tribe 
also supports efforts to recruit and train a Native health care 
workforce, so that we can staff our health care facilities with tribal 
members who already have strong ties with and commitments to our 
communities.
    Funding for facilities and equipment also impacts recruitment and 
retention. Competent, qualified staff do not want to work in a facility 
where they lack the tools necessary to do their job or where their job 
is made harder (or even impossible) by a lack of resources. But the 
Pine Ridge Service Unit has documented a need for, among other things: 
fetal monitoring systems, telemetry systems, surgery lights, a nurse 
call system, dental chairs and equipment, and IV pumps, to name a few. 
Equipment needs are so dire that, as one example, earlier this year we 
were told that the hospital was waiting for one of its IV Service Unit 
Pumps to finally stop working so they could take parts from it to fix 
another one. Some of this equipment is critical and could mean the 
difference between life or death in a patient emergency, but there is 
no additional funding for equipment purchases. Additionally, the 
facility is inadequate to handle the hospital's user population.\2\ 
Even so, not all of the existing space is even being utilized because 
we lack the necessary staff and equipment. Very few health care or 
management professionals would want to work in such an environment, 
even with loan repayment and other incentives, and these realities have 
a very real impact on IHS recruitment efforts.
---------------------------------------------------------------------------
    \2\ The IHS Service Unit profile shows that the Service Unit 
currently services a user population of 51,227 in a space designed for 
a user population of 22,000.
---------------------------------------------------------------------------
    Additionally, the tribe feels strongly that key IHS hiring 
decisions ought to be made with tribal consultation. A bill to reform 
the IHS currently pending in the Senate, S. 2953, would require the 
Secretary to consult with Indian tribes located in the service area 
before hiring or transferring senior executives or top managers, and we 
believe a similar provision would be appropriate in H.R. 5406.
Sec. 103: Removal or demotion of employees
    Poor management practices and the ``recycling'' or shuffling of 
problem employees has been a long-standing problem within the Great 
Plains area, as has the use of administrative leave in lieu of more 
appropriate action like demotion and firing. H.R. 5406 seeks to address 
this mismanagement problem by enhancing the Secretary's authority to 
hire, fire, demote, and reward employees based on performance; by 
limiting the use of paid administrative leave; and by requiring 
expedited review of removal and demotion decisions.
    The Oglala Sioux Tribe generally supports these reforms, and 
emphasizes the importance of qualified and accountable leadership 
within the IHS and the Department of Health and Human Services, as well 
as strong ongoing congressional oversight, to ensure that these 
authorities are appropriately used to fulfill the United States' trust 
responsibility to provide our tribal members with quality health care. 
Indeed, as the IHS points out in its own testimony, authorities and 
procedures already exist to remove problem employees, but they have not 
been used in a consistent or effective manner.
    We support the enhanced authorities in H.R. 5406, and recommend 
that the IHS develop a policy for how it is to use these and existing 
authorities. Such policy should be developed in consultation with 
tribes and congressional committees of jurisdiction. This would help to 
ensure that existing and expanded authorities are utilized as intended 
by Congress and to the benefit of tribes with meaningful results.
    IHS testified that removal of employee protections could impact 
recruitment by making IHS a less desirable place to work. Our view is 
that most employees want a well-thought out policy that is objectively 
and consistently applied, not an ad hoc, subjective modus operandi.
    We also agree with other testimony that any reform measures 
relating to adverse action against employees should be carefully vetted 
for constitutional due process concerns to avoid the prospect of 
copious, lengthy, or costly litigation against the IHS, and that these 
provisions should specify that the costs of such litigation and any 
resulting settlements be paid from sources other than IHS program or 
service funds, such as the United States Judgment Fund.
    Finally, the tribe supports the use of mandatory random drug 
testing for all IHS employees as a key accountability measure. 
Representative Noem recently introduced H.R. 5437 to implement such a 
program, and we suggest that the provisions of H.R. 5437 be 
incorporated into H.R. 5406 to require random drug testing not just for 
IHS management, but for all IHS employees. We understand that the VA 
uses pre-employment drug testing as well as random employee drug 
testing in its facilities, and the same should be true of the IHS. 
Health professionals should not be reporting for duty while under the 
influence of illegal substances.
Sec. 104: Improving timeliness of care
    Long wait times are a major barrier to care at IHS facilities 
within the Great Plains area and a serious problem at the Pine Ridge 
Hospital, where emergency patients wait for hours and sometimes leave 
without ever being seen. H.R. 5406 would require the IHS to promulgate 
regulations establishing standards to measure timeliness of the 
provision of health care services at IHS facilities and to develop a 
process for IHS facilities to submit data under those standards to the 
Secretary. However, the draft bill stops short of requiring any 
particular action in response to those reports. The tribe suggests that 
the bill be amended to require negotiated rulemaking and to specify 
that the topics to be addressed in the negotiated rulemakings include 
follow-up steps to be taken by the IHS, in consultation with affected 
tribes, to reduce patient wait times in response to the reported data 
wherever possible.
Sec. 201: Exclusion from gross income for payments made under Indian 
        Health Service Loan Repayment Program
    The tribe supports this proposal, which was requested by the IHS in 
the Administration's Fiscal Year 2017 Budget request and would bring 
the Indian Health Service loan repayment program into parity with the 
National Health Service Corps and Armed Forces Health Professions 
scholarship programs with respect to income tax treatment.
Sec. 202: Clarifying that certain degrees qualify individuals for 
        eligibility in the Indian Health Service Loan Repayment Program
    The tribe supports this proposal as a means of improving the IHS's 
ability to attract health care management and executive professionals. 
The IHS has long struggled to attract and retain qualified management 
personnel.
Sec. 203: Cultural competency programs
    The tribe supports the bill's provision to require cultural 
competency training in each service area for all employees.
Sec. 204: Relocation reimbursement
    The tribe supports the use of relocation reimbursement and 
incentives to attract high-quality employees to the IHS, provided 
funding is not diverted from needed health services. The IHS has 
testified that it already has authority to provide relocation 
reimbursement and incentives, again pointing to the need for 
accountable IHS leadership and strong congressional oversight, as well 
as adequate funding, to ensure that existing authorities are 
appropriately utilized.
Sec. 205: Authority to waive Indian preference laws
    The tribe appreciates the intent behind this provision to provide 
greater hiring flexibility while leaving the ultimate decision to waive 
Indian preference laws to the impacted tribe. Any provision seeking to 
waive Indian preference should be carefully crafted and fully vetted as 
Indian preference is an important tool that has been used to strengthen 
the Indian health care system and build tribal capacity. Furthermore, 
we note that similar authority already exists under 25 U.S.C. 
Sec. 472a(c)(1).
Sec. 206: Streamlining medical volunteer credentialing process
    The tribe supports the creation of a centralized credentialing 
system within the IHS to credential volunteer health professionals at 
direct-service IHS facilities.
Sec. 301: Codification of limitation on charges for health care 
        professional services and non-hospital-based care
    The tribe appreciates efforts to improve the Purchased/Referred 
Care (``PRC'') program. The PRC program is designed to ensure access to 
primary and specialty health care services that the IHS is unable to 
provide in its own facilities and must purchase from outside providers. 
Funding for the PRC program is so limited, however, that care is 
frequently rationed and limited to emergency ``life or limb'' 
situations. On Pine Ridge, even these emergency ``priority 1'' cases 
are sometimes rejected by the IHS due to funding constraints. Oglala 
Sioux tribal members routinely forego necessary medical care because 
the IHS refuses to pay through PRC. In the alternative, if these 
patients do seek the care, they often find themselves in financial 
crisis because the IHS will not cover the costs.
    The Oglala Sioux Tribe appreciates the fact that H.R. 5406 seeks to 
extend Medicare-Like Rates to all PRC services. Currently, only 
payments for hospital-based services are capped at the Medicare-Like 
Rate by statute, and Medicare-participating hospitals are required to 
accept those rates as a condition of participation. Extending Medicare-
Like Rates to non-hospital PRC services in the same manner would 
greatly increase the efficiency of the PRC program: in 2013, the GAO 
released a report finding that extending Medicare-Like Rates to non-
hospital PRC services would save the IHS approximately $32 million per 
year, which could be used to pay for needed services that the IHS must 
now deny. However, the Tribe believes that the approach taken in the 
current draft bill could be improved.
    Specifically, the bill would limit PRC payments to providers and 
suppliers by essentially codifying the recently released IHS 
regulations capping PRC rates for non-hospital services. This approach 
would cap the IHS or tribal health program's ability to pay (if the 
tribal health program chooses to opt in), but would not provide any 
enforcement mechanism or consequences to the provider or supplier if 
the provider or supplier refuses to accept the capped payment rates. 
Tribes have argued that, in order for Medicare-Like Rates to be 
effective, they must be a condition of provider participation in the 
Medicaid program, as is the case for the existing Medicare-Like Rate 
caps on payments for hospital services. The IHS regulations do not 
include this enforcement mechanism because the IHS did not have the 
authority to impose those requirements, and as a result the regulations 
have been viewed by tribes as a ``next-best'' alternative to 
legislation. Congress, of course, does have the authority to enforce 
Medicare-Like Rates, and should do so.
    A bill was introduced in the last Congress by Senator Betty 
McCollum (H.R. 4843, 113th Cong.) that would have extended Medicare-
Like Rates to non-hospital PRC services by amending the Social Security 
Act and requiring providers and suppliers to accept the lower rates as 
a condition of their participation in Medicare. That bill had strong 
support from Indian Country, and the Oglala Sioux Tribe strongly 
recommends that H.R. 5406 take the same approach with respect to 
Medicare-Like Rates.
Sec. 302: Allocation of Purchased/Referred Care program funds
    Section 302 would require the Secretary, through negotiated 
rulemaking with tribes, to develop and implement a revised distribution 
formula for PRC funding and would prioritize PRC funding increases in 
service areas where the majority of PRC services currently provided are 
priority level I or II--in other words, in service areas where only the 
most serious health care emergencies are funded. First, what is needed 
and in fact required by the Federal Government's treaty and trust 
responsibilities is full PRC funding for all medically necessary care 
at every level of care. It is incumbent on the United States as our 
trustee to ensure that preventive, primary, and specialty care is 
available to our patients before their conditions become chronic or 
life-threatening, not just after. Not only is that the only humane and 
responsible approach to reduce human suffering, but it is also far more 
efficient and fiscally responsible: rationing and delaying care until a 
health condition becomes an emergency means that condition will be 
significantly more costly and difficult to treat. The tribe cannot 
emphasize strongly enough the importance of fully funding the PRC 
program.

    An associated problem faced by our tribal members is the cost of 
transportation to receive PRC services for primary and specialty care 
that cannot be provided at our hospitals and clinics. Again, due to 
funding constraints, the IHS does not always pay for these costs and 
our patients do not have the financial resources. The tribe frequently 
ends up covering transportation costs associated with medical care, 
which diverts tribal funding that is badly needed for other purposes. 
Dedicated, full funding for transportation for health care referrals is 
necessary to assure access to care. In addition, enhancing the capacity 
of local IHS facilities like the Pine Ridge Hospital to provide the 
full range of primary care services to their full patient population 
and expanding the scope of specialty care available at those local 
facilities--especially for specialty care that is in particularly high 
demand, like psychiatric and respiratory care--would cut down 
significantly on expensive patient travel. This, of course, would 
require funding for increased staffing, improved facilities, and 
necessary medical equipment at the local level. Another strategy for 
reducing the costs and other burdens associated with patient travel is 
the development and support of telemedicine. Developing our 
telemedicine and telehealth capacity has been a priority for the tribe 
and could be an important feature of a reformed, more responsive, and 
higher quality health care delivery system in the IHS. The IHS is 
already exploring telemedicine possibilities, but legislative support--
including authorizations for appropriations, pilot projects or 
programs, and dedicated funding--would help to ensure that these 
efforts bear fruit.

    Improving and fully funding the PRC system, including travel costs 
associated with PRC referrals, is a top priority for the Oglala Sioux 
Tribe and must be a part of comprehensive reform efforts. Though fully 
funding the PRC system would require an up-front investment, the return 
would be substantial in terms of health outcomes and system efficiency.
Improve the PRC Program through Implementation of 25 U.S.C. Sec. 1678a
    The PRC program in the Great Plains area would also be 
significantly improved through implementation of 25 U.S.C. Sec. 1678a, 
enacted as part of the permanent reauthorization of the Indian Health 
Care Improvement Act in 2010, which requires the IHS to designate South 
Dakota and North Dakota as a single contract health service delivery 
area (CHSDA). Subsection (b) of that provision further states:

        The Service shall not curtail any health care services provided 
        to Indians residing on any reservation, or in any county that 
        has a common boundary with any reservation, in the state of 
        North Dakota or South Dakota if the curtailment is due to the 
        provision of contract services in those states pursuant to the 
        designation of the states as a contract health service delivery 
        area by subsection (a).

    However, the IHS is not implementing this provision, and IHS's 
regulations do not include the states of South Dakota and North Dakota 
in its list of CHSDAs. See 42 CFR Sec. 136.22.

    Implementation of 25 U.S.C. Sec. 1678a is not discretionary. 
Congress mandated that North Dakota and South Dakota be designated a 
single CHSDA and, as a result, any action by IHS to deny services to 
any individual based on its pre-existing CHSDAs in those states is 
unlawful. Yet, IHS continues to deny services to individuals throughout 
both states based on the geographic limitations in the CHSDAs it 
established in those states prior to the enactment of 25 U.S.C. 
Sec. 1678a. This has had multiple negative effects throughout both 
states: because the IHS continues to deny PRC authorizations for 
American Indians living outside the pre-existing CHSDAs, those 
individuals are forced to either forgo needed care or seek care even if 
they lack the resources to pay for it. When there is no valid PRC 
authorization, those individuals may be liable for the cost of that 
care. If they cannot afford the care, both they and their non-IHS 
provider suffer. The patient's credit may be affected by bill 
collectors, and the non-IHS provider cannot receive payment for the 
services they have provided. The issue is compounded for emergency 
services because hospitals are required under EMTALA to provide such 
services even when the individual seeking them cannot pay.

    The IHS has taken the position that it cannot implement 25 U.S.C. 
Sec. 1678a without further appropriations. While additional funding is 
certainly needed for PRC programs, 25 U.S.C. Sec. 1678a is not 
dependent on additional funding. Rather, it imposes a mandatory 
statutory duty on the IHS to designate both North Dakota and South 
Dakota as a single CHSDA and ensure that there is no curtailment of 
services to individuals living on or near a reservation in North Dakota 
or South Dakota as result of carrying out Congress's directive that 
those states should encompass a single CHSDA, 25 U.S.C. Sec. 1678a(b). 
The tribe, therefore, suggests that H.R. 5406 include a provision that 
directs the IHS to implement 25 U.S.C. Sec. 1678a. Additionally, as the 
Pine Ridge Reservation includes a portion of Nebraska, we note that the 
CHSDA for Nebraska remains the same.
Sec. 304: Report on financial stability of Service hospitals and 
        facilities
    The tribe supports the proposal in H.R. 5406 to require the 
Comptroller General to submit a report to Congress within 1 year on the 
financial stability of IHS hospitals and facilities that have 
experienced sanction or threat of sanction by the Centers for Medicare 
and Medicaid Services, including any revenues lost as a result and 
recommendations for legislative action.

    The tribe also believes that additional measures to ensure 
transparency in financial management would be helpful. For example, S. 
2953 would require the Secretary to provide a report to Congress and 
tribes each quarter of a fiscal year describing spending and outlays at 
each level of the IHS, and would require the Secretary to consult with 
Indian tribes before spending unobligated funds at the end of the 
fiscal year, except with respect to specific categories of 
expenditures. In addition, the Oglala Sioux Tribe would like to see 
tribal consultation on the allocation of funding for the Pine Ridge 
Service Unit.

    Additionally, the IHS should be required to provide a full 
accounting of the funding received by the Area Office, how it is 
allocated, its employees, programs, and what functions the Area Office 
serves. The tribe believes that a fundamental reorganization of the 
Great Plains area--including quite possibly the elimination of the IHS 
Area Office altogether--may be needed. We suspect that most of the Area 
Office functions could be delegated to the service unit level and that 
the Area Office could operate with only a skeleton crew. Though 
legislation is not necessary to undergo such reorganization, the tribe 
has in the past had difficulty obtaining information it needs from the 
Area Office to fully assess this question. We do note that the IHS has 
recently initiated consultation on this question and appears open to 
discussing the possibility of reorganization. We appreciate that step, 
but a congressionally mandated comprehensive accounting of the Area 
Office could be a great help.

    Finally, to promote fiscal transparency and accountability, H.R. 
5406 should include a requirement that IHS report on the amount of 
third party resources collected by facility and service unit, and how 
those funds are being used to improve patient care in that service 
unit. Section 401(c) of the Indian Health Care Improvement Act, 25 
U.S.C. Sec. 1641(c), requires the IHS to ensure that each service unit 
receive 100 percent of any third party resources it collects. Per 25 
U.S.C. Sec. 1641(c)(1)(B), third party collections are primarily to be 
used ``to achieve or maintain compliance with the applicable conditions 
and requirements'' of Medicaid and Medicare programs. If there are 
amounts collected in excess of what is needed for this purpose, such 
collections shall be used ``subject to consultation with the Indian 
tribes being served by the Service unit . . . for reducing the health 
resource deficiencies (as determined in section 1621(c) of this title) 
of such Indian tribes.'' In addition, Section 207 of the Indian Health 
Care Improvement Act, 25 U.S.C. Sec. 1621f, requires third party 
resources collected at the service unit level to be credited to the 
service unit and used for the provision of health services.

    The tribe has reason to doubt that third party collections at the 
Pine Ridge Service Unit have been left at the Service Unit and used to 
provide health services at the service unit level and to meet Medicare 
and Medicaid conditions of participation. First, as has been well 
documented, the Pine Ridge Hospital is not currently meeting Medicare 
conditions of participation despite the fact that we understand that it 
does collect third party resources from the Medicaid and Medicare 
programs. Second, the IHS recently used $50 million in third party 
collections to pay an administrative settlement of a union grievance in 
arbitration.\3\ The tribe is gravely concerned by the fact that there 
was such a large amount of third party collections readily available to 
the IHS that was not being used for maintaining compliance or for 
reducing health resource deficiencies at the service unit level as 
mandated by Congress in Sections 207 and 401 of the IHCIA. Thus, we ask 
that H.R. 5406 require the IHS to include an accounting of third party 
resource collections and expenditures at the service unit level.
---------------------------------------------------------------------------
    \3\ The settlement had two categories: $60 million for back pay and 
back pay-related costs (such as payroll taxes), and $20 million for 
administrative costs and attorneys' fees. $50 million of the $60 
million amount was paid from third party collections and $10 million 
from expired appropriations. The $20 million was paid from then current 
fiscal year 2015 appropriations.
---------------------------------------------------------------------------
Adequate Funding is a Necessary Component of Meaningful Reform
    One of the most significant impediments to successful reform of the 
IHS and achieving quality health care for Indian people is the severe 
funding shortage faced by the system. The National Tribal Budget 
Formulation Workgroup recently estimated that the full funding need of 
the IHS is approximately $30.8 billion, but the agency's fiscal year 
2016 enacted funding level was only $4.8 billion. Though reforms to IHS 
management practices, hiring, transparency and accountability measures 
are critical, we cannot expect the system to function well with only a 
fraction of the resources it truly needs. Authorizations and 
appropriations are needed to fully fund the PRC program; to cover 
transportation costs when patients must be referred out to far-away 
facilities; to bring our facilities and equipment up to date and in 
line with the level of need; to fund recruitment and retention measures 
including housing, salaries and bonuses so that the IHS is able to 
attract and maintain qualified professionals; and to increase the scope 
of services the IHS is able to provide at a local level. All of these 
are costs, but they are part of the Federal Government's trust and 
treaty responsibilities to Indian people and they are necessary to 
achieve anything more than a quick-fix, Band-Aid response to this dire 
crisis. Moreover, they will reduce suffering and result in significant 
long-run savings by creating healthier tribal communities and reducing 
the high-cost chronic and emergency health conditions that are so 
prevalent among our people today. Our current approach is not 
sustainable and must be remedied. Though many helpful authorities 
already exist in law, they cannot be implemented without sufficient 
funding.

    While the Oglala Sioux Tribe recognizes that H.R. 5406 is not an 
appropriations bill, its drafters must recognize the significance of 
IHS funding needs in order to carry out the reforms the bill seeks to 
implement. We ask for continued leadership and support from this 
subcommittee and individual Members throughout the appropriations 
process. In the meantime, there are non-appropriations measures that 
could be included in H.R. 5406 to take small but meaningful steps to 
ease the IHS funding crisis:

        Advance Appropriations. Although advance appropriations alone 
        would not increase IHS resources, it would promote stability 
        and permit better budgetary planning and help to insulate our 
        health care services from the devastating impacts of continuing 
        resolutions and government shutdowns. It would also help with 
        hiring and retention as the IHS would know what funding is 
        available for those purposes ahead of time, and employees would 
        not be impacted by agency funding interruptions to the same 
        degree. For all of these reasons, tribes have been advocating 
        for advance appropriations for IHS for several years. Our 
        treaty rights are not contingent on Congress' ability to enact 
        a timely budget, nor should the health of our people suffer on 
        that basis.

        Exempt IHS from Sequestration. Likewise, neither our treaty 
        rights nor the inherent value of our tribal members' lives 
        should be diminished on the basis of mandatory, indiscriminate 
        budget cuts or ``sequestration.'' Other key Federal programs, 
        including health care programs like Medicaid and VA health 
        benefits, are exempt from sequestration, and IHS must also be 
        protected.

        Leveraging other Federal funding. Various other measures could 
        also help to ease the funding burden on the IHS system. 
        Directing resources to maximize Affordable Care Act enrollment, 
        for example, would provide a return by boosting third party 
        revenues to the IHS. So would Medicaid expansion under the 
        Affordable Care Act or state waiver or demonstration programs 
        that leverage the newly expanded CMS policy on 100 percent 
        Federal matching for services to American Indians and Alaska 
        Natives. In fact, this subcommittee could investigate whether 
        CMS is doing everything it can to allocate its resources to 
        improve health care for American Indian and Alaska Native 
        beneficiaries and to assist the IHS in doing so. Are there 
        additional Medicare and Medicaid resources that CMS or Congress 
        could direct to the Indian Health System to help it meet CMS 
        standards and Federal treaty responsibilities?

        Ensure that the IHS is Maximizing Third Party Revenues. 
        Finally, the Oglala Sioux Tribe is not convinced that IHS staff 
        are sufficiently trained in the collection of third party 
        revenues, and we are concerned that service unit income and 
        budgets suffer because of that. We would propose a study and 
        report to determine whether the IHS is maximizing the recovery 
        of third party resources at all of its facilities, and if not, 
        why not, and what steps can and should be taken to ensure that 
        reimbursement dollars are not left on the table.

Improve Tribal Consultation for Meaningful Reform

    Executive Order 13175 mandates that each Federal agency shall have 
an accountable process to ensure meaningful and timely input by tribal 
officials in the development of regulatory policies that have tribal 
implications. Every president has reinstated Executive Order 13175 
since President Clinton initially issued it in 2000. This Executive 
Order is regularly cited by tribal governments to keep agencies 
accountable and engaging with tribes as agencies develop policies that 
will affect tribes. However, the consultation process is not always 
effective or followed to the letter. For instance, Section 3(c) of the 
Executive Order states:

        When undertaking to formulate and implement policies that have 
        tribal implications, agencies shall: (1) encourage Indian 
        tribes to develop their own policies to achieve program 
        objectives; (2) where possible, defer to Indian tribes to 
        establish standards; . . .

    This Section calls for deferring to tribes, where possible, to 
establish standards. This provision, however, has been routinely 
overlooked by the IHS, particularly at the Great Plains Area Office. A 
recent example was the tribe's effort to incorporate language into the 
Systems Improvement Agreement (SIA) between IHS and CMS to address 
IHS's deficiencies in operating the Pine Ridge Hospital Emergency 
Department. We, as the beneficiary of the SIA, submitted several edits 
for the SIA, but the IHS did not accept them and they did not appear in 
the final executed SIA.

        Furthermore, Section 5(d) of the Executive Order states:

        On issues relating to tribal self-government, tribal trust 
        resources, or Indian tribal treaty and other rights, each 
        agency should explore and, where appropriate, use consensual 
        mechanisms for developing regulations, including negotiated 
        rulemaking.

    We highlight the use of consensual mechanisms for developing 
regulations. As health care is a treaty right, IHS should be 
implementing the use of consensual mechanisms as we move forward to fix 
the IHS's provision of health care in the Great Plains.
    H.R. 5379, the RESPECT Act, is currently pending in the House. It 
would essentially codify Executive Order 13175, which would ensure that 
its provisions have teeth. Provisions of the RESPECT Act could be 
incorporated within H.R. 5406 to ensure that the IHS carries out 
effective and meaningful consultation. We highlight Section 401 of the 
RESPECT Act which provides a remedy for egregious failures of 
consultation requirements. Per this section a tribe would have the same 
judicial enforcement remedies as provided in the Administrative 
Procedures Act. We believe this would work well for holding IHS 
accountable to its consultation requirements.
                               conclusion
    The Oglala Sioux Tribe thanks Chairman Young, Ranking Member Ruiz, 
members of the subcommittee and, in particular, Representative Noem for 
their leadership on this issue and for the opportunity to submit this 
testimony. We stand ready and willing to offer any assistance we are 
able to provide as you consider H.R. 5406 and move forward to hold the 
IHS accountable for ensuring that our people have the meaningful access 
to quality health care that was promised in our treaties with the U.S. 
Federal Government.

                                 ______
                                 

Prepared Statement of Scott A. Duke, CEO, South Dakota Organization of 
                         Healthcare Association
    Good afternoon Chairman Young and members of the Subcommittee on 
Indian, Insular and Alaska Native Affairs. On behalf of our hospitals, 
health systems, post-acute care providers and our 63,000 individual 
members, the South Dakota Organization of Healthcare Association 
appreciates the opportunity to submit a statement of record supporting 
Congresswoman Kristi Noem's bill, the Helping Ensure Accountability, 
Leadership, and Trust in Tribal Healthcare (HEALTTH) Act of 2016 (H.R. 
5406).
    South Dakota tribal members are suffering. Indian Health Services 
(IHS) has failed--both in its treaty obligation and moral duty--to 
provide the quality care that Native Americans across the Great Plains 
deserve. South Dakota tribal members have the second highest infant 
mortality rate among IHS regions, the highest diabetes death rates, the 
second highest alcohol related death rates, the highest TB death rates, 
the lowest life expectancy rates and the highest age adjusted death 
rates.
    For years, Federal reports have documented shocking cases of 
mismanagement and poorly delivered care. Over time IHS has failed to 
make improvements on their own even though their funding was increased 
almost every year. Tragically the recent IHS crisis in South Dakota at 
several IHS hospitals has resulted in loss of life. For many months the 
Emergency Department at Rosebud has been shut down because of the 
unsafe conditions. IHS facilities in Pine Ridge, Rosebud, and Rapid 
City have been in jeopardy as well. This is unacceptable. IHS must meet 
the same quality, safety, and operational standards as all other 
hospitals.
    The effects of the current dire situation have a profound impact on 
South Dakota and the region. SDAHO member hospitals are actively 
assisting, but have seen a dramatic increase in Emergency Department 
(ED) patient volumes and other services. These situations are 
unpredictable and difficult to manage.
    The proposed legislation introduces comprehensive reform by 
addressing systematic failures in the Great Plains area. To ensure 
contracts are designed to serve those they are intended to help, the 
HEALTTH Act requires a partnership between IHS, with tribal input and 
engagement from independent health care experts. In addition, ensuring 
the Purchased/Referred Care Program formula is based on factors that 
impact access to care and match where health care support is needed. 
Moreover, the bill includes provisions to help drive down prices and 
stretch every Purchased/Referred Care dollar further. The bill seeks to 
make the hiring of medical professionals and administrators easier by 
paying back their student loans. Last, the bill provides critical 
accountability requirements to ensure ongoing monitoring of what is 
happening in IHS facilities.

    SDAHO's support of the HEALTTH Act, would be strengthened by 
addressing additional concerns to ensure the delivery of quality health 
care for our tribal communities. These include:

     IHS facilities should be required to have electronic 
            billing and electronic referral as this will expedite 
            patient care when communicating with non-IHS facilities.

     IHS facilities must be required to reimburse care when 
            referring American Indians to non-IHS facilities.

     South Dakota community hospitals should not have to write 
            off more than $10 million annually because IHS refuses to 
            pay.

     Contract negotiation must have meaningful input from the 
            tribal communities to ensure that selected providers are 
            culturally sensitive to their needs.

     Contract awards must contemplate efficiency and 
            integration of care. A step toward achieving this patient-
            centered objective is implementing contracting terms that 
            allow providers to offer services to individual IHS 
            facilities in a more comprehensive manner.

    IHS and its leaders must be held accountable. The passage of the 
HEALTTH Act will ensure sustainable improvements are achieved. This 
legislation is urgently needed to ensure sustainable improvements are 
achieved. We support the innovative and forward thinking of the HEALTTH 
Act with the additional proposed amendments. We urge your support as 
well.

                                 ______
                                 

 Prepared Statement of the United South and Eastern Tribes Sovereignty 
Protection Fund and Self-Governance Communication and Education Tribal 
                               Consortium
    On behalf of the United South and Eastern Tribes Sovereignty 
Protection Fund (USET SPF) and the Self-Governance Communication and 
Education Tribal Consortium, we write to provide the House Committee on 
Natural Resources Subcommittee on Indian, Insular and Alaska Native 
Affairs with the following testimony for the record of its July 12, 
2016, legislative hearing on H.R. 5406, Helping Ensure Accountability, 
Leadership, and Trust in Tribal Healthcare (HEALTTH) Act. Our 
organizations stand with Tribal Nations across the country in sharing 
our deep concern regarding the deplorable conditions in the Great 
Plains area. We appreciate Rep. Noem and the subcommittee's efforts to 
address the systemic issues which have persisted in the Great Plains 
region and throughout the Indian Health System for decades, and offer 
section-by-section recommendations intended to strengthen the 
provisions of the bill. It is in this spirit that we ask Rep. Noem and 
the subcommittee to strongly consider the national (rather than 
regional) implications of H.R. 5406, and to work with Tribal Nations to 
ensure its impact is positive in all IHS Areas. In particular, we 
encourage Rep. Noem and the subcommittee to re-examine provisions 
related to the Purchased/Referred Care (PRC) program. Moreover, we 
maintain that until Congress fully funds the Indian Health Service 
(IHS), the Indian Health System will never be able to fully overcome 
its challenges and fulfill its trust obligations While our 
organizations support reforms that will improve the quality of service 
delivered by the IHS, we underscore the obligation of Congress to meet 
its trust responsibility by providing full funding to IHS and support 
additional innovative legislative solutions to improve the Indian 
Health System.
           uphold the trust responsibility to tribal nations
    Through the permanent reauthorization of the Indian Health Care 
Improvement Act, ``Congress declare[d] 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.'' As long as IHS remains dramatically underfunded, 
the root causes of the failures in the Great Plains and the Indian 
Health System will not be addressed, and Congress will not live up to 
its stated policy and responsibilities. In fiscal year 2015, the IHS 
medical expenditure per patient was only $3,136 while the Veteran's 
Administration, the only other Federal provider of direct care 
services, spent $8,760 per patient. Disparities in health financing 
lead to disparities in health outcomes. Congress must authorize full 
funding for the IHS in order to make meaningful progress on the chronic 
challenges faced by the Indian Health System.
    Additionally, we recommend the inclusion of language directing the 
IHS to request a budget that is reflective of its full demonstrated 
financial need obligation, as this is the only way to determine the 
amount of resources required to deliver comprehensive and quality care. 
We remain hopeful that Congress will take necessary actions to fulfill 
its Federal trust responsibility and obligation to provide quality 
health care to Tribal Nations, by providing adequate funding to the 
IHS.
   authorize advanced appropriations and exempt the ihs budget from 
                             sequestration
    Stability in program funding is a critical element in the effective 
management and delivery of health services. On top of chronic 
underfunding, IHS and Tribal Nations face the problem of discretionary 
funding that is almost always delayed. In fact, since Fiscal Year (FY) 
1998, there has only been 1 year (FY 2006) in which appropriated funds 
for the IHS were released prior to the beginning of the new fiscal 
year. The FY 2016 omnibus bill was not enacted until 79 days into the 
Fiscal Year, on December 18, 2015. Budgeting, recruitment, retention, 
provision of services, facility maintenance, and construction efforts 
all depend on annual appropriated funds. Many Tribal Nations reside in 
areas with high Health Professional Shortage Areas and delays in 
funding only amplify challenges in providing adequate salaries and 
hiring of qualified professionals. As Congress seeks to improve IHS' 
ability to attract and retain quality employees, as well as promote an 
environment conducive to effective health care administration and 
management, we urge the inclusion of language that would extend advance 
appropriations to the IHS.
    Additionally, IHS and Tribal Nations continue to face the specter 
of sequestration. Through the Budget Control Act of 2011 and subsequent 
failure of the Joint Select Committee on Deficit Reduction, the IHS 
budget was subjected to Federal spending caps and across-the-board 
reductions, despite Congress' Federal trust responsibility to finance 
health care services to Tribal Nations. As a result of the 
discretionary budget cuts, in FY 2013, IHS lost approximately $220 
million from its already underfunded budget. These cuts required the 
IHS and Tribal Nations to reduce the availability of health services to 
tribal citizens who already face severe health disparities and are 
legally entitled to care through IHS. Reductions in funding and the 
overall instability of the IHS budget sustain conditions which lead to 
the crises observed in the Great Plains area and throughout the Indian 
Health System. Restoring these budget cuts and preventing future 
budgets from harmful reductions will be critical to advancing and 
improving the care delivered through IHS. We continue to assert that 
the IHS budget, and all funding for Federal Indian programs, must be 
exempt from sequestration.
                          tribal consultation
    We appreciate Rep. Noem's initiative to take action in response to 
failures in the provision of health care in the Great Plains area. H.R. 
5460 seeks to address many of these issues and will have nationwide 
implications for the Indian Health System. In order to account for the 
diversity of management structures, including self-governance 
compacting and self-determination contracting, across the 12 IHS Areas 
as well as in patient access and experiences among these areas, ongoing 
tribal consultation must be inclusive of all Tribal Nations impacted. 
First, we request that Rep. Noem and this subcommittee consider holding 
an open listening session and soliciting additional comments from 
Tribal Nations across the country. Second, we request that additional 
language be inserted into H.R. 5406 requiring tribal consultation on 
all provisions of the law, as it is implemented, to ensure Tribal 
Nations have a voice in accordance with the IHS Tribal Consultation 
Policy. Ongoing, meaningful tribal consultation is essential to 
mitigating current challenges, preventing future crises, and increasing 
the health status of American Indians and Alaska Natives (AI/AN).
                      section-by-section comments
    In addition to urging the inclusion of the above proposals, we 
offer the following recommendations to strengthen the existing 
provisions of H.R. 5406. If implemented together, we believe these 
policies will provide the necessary framework for IHS and Tribal 
Nations to improve patient health outcomes the quality of care 
delivered through the Indian Health System.
Title I--Expanding Authorities and Improving Access to Care
Section 101. Service hospital long-term contract pilot program
    As Congress considers reform for the Indian Health System, we 
support initiatives which empower Tribal Nations to make their own 
decisions regarding their health care. Through the Indian Self-
Determination and Education Assistance Act (ISDEAA) Tribal Nations have 
made considerable gains in health program administration, patient 
experience, and community health outcomes. We fully support Tribal 
Nations that choose to assume health and other programming under this 
authority. We do, however, want to ensure that Tribal Nations have the 
adequate infrastructure to assume these functions and that the programs 
being transferred are not in disrepair. We believe the interim option 
which would provide Tribal Nations with the authority to pilot self-
governance by contracting with the private sector could be a good first 
step on the path to full self-governance. However, we believe this 
partnership should be one that fosters mentorship and capacity building 
in order to ensure these arrangements do not have the adverse effect of 
diminishing tribal governance.
    To that end, we recommend the inclusion of language to clarify that 
Tribal Nations have the authority to exercise their right to assume 
programs under the ISDEAA at any time, notwithstanding the duration of 
any contracts with private entities. This language will ensure Tribal 
Nations do not unintentionally forfeit their right to assume programs 
under the ISDEAA while remaining under contract with a private entity. 
Further, we request additional language which would clarify provider-
based status when a tribal hospital is contracted with a private group. 
This provider-based status is critical to the collection of third party 
revenue and any disruption could further harm the hospital. Finally, we 
request ongoing consultation on this specific provision to ensure that 
this pilot truly provides greater tools and opportunities to enter into 
self-governance.
Section 102. Expanded hiring authority for the Indian Health Service
    Over the course of dialogue regarding this provision and similar 
language in S. 2953, many have expressed concerns about its 
constitutionality. Some have suggested that the Department of Justice 
may be unable to represent the Indian Health Service in cases where the 
Agency is sued pursuant to action taken under this language. If this is 
the case, we believe this provision has the potential to destabilize 
the Indian Health System, rather than strengthen it. Our organizations 
urge Rep. Noem and the subcommittee to provide Indian Country with more 
information regarding the potential impact of Section 102. We further 
ask that this section, including whether to strike the language from 
the bill, be subject to tribal consultation prior to further 
legislative action.
Section 103. Removal or demotion of employees
    We support expanding the Secretary's authority to remove or demote 
IHS employees based on performance or misconduct. However, in addition 
to the Secretary, Tribal Leadership must also be notified when 
employees within their Service Area become subject to a personnel 
action. In under Sec. 603(c) ``Notice to Secretary,'' we recommend 
inserting ``Tribal Governments located in the affected service area.'' 
Further we recommend inserting similar language included in which S. 
2953 establishes ``Employment Record Transparency'' which ensures that 
prior to employee personnel actions are adequately notated and 
considered in future hiring processes. Increasing transparency and 
access to information for Tribal Nations will be essential to 
rebuilding the confidence and trust in the IHS.
Section 104. Improving timeliness of care
    This provision would establish standards to measure the timeliness 
of care and develop processes for submitting data to the Secretary on 
these measures. It is imperative that these measures and standards are 
developed in consultation with Tribal Nations. Further, for 
approximately 170 IHS and tribally operated sites that have chosen to 
participate in the Improving Patient Care (IPC) initiative, many have 
already taken steps to improve timeliness of care. We suggest aligning 
the standards with existing IPC activities and ensuring that standards 
or reporting are not overly burdensome for tribal health programs. In 
addition, we request that any data regarding timeliness of care be 
provided to Tribal Nations, as well as the Secretary.
Title II--Indian Health Service Recruitment and Workforce
Section 201. Exclusion from gross income for payments made under Indian 
        health service loan repayment program
    We fully support the provisions which would exempt payments from 
the Indian Health Service Loan Repayment Program (LRP) from an 
awardee's taxable income. This will help reduce barriers to recruitment 
and achieve parity with other Federal health workforce programs, such 
as loan repayment under National Health Service Corps. Additionally, 
language should be inserted to ensure that IHS Scholarship Awards 
receive similar treatment under the Internal Revenue Service Code. 
Exemptions like this already exist for the Armed Forces and this will 
assist IHS with creating a pipeline of providers into the Indian Health 
System.
    LRP, and the IHS Scholarship Program, however, are severely 
underfunded, which has weakened efforts to improve recruitment and 
retention in the IHS. In FY 2015, LRP was unable to provide loan 
repayment funding to 613 health professionals who applied, of which 
only 200 accepted employment at an IHS or tribally operated health 
facility. IHS estimates that it would need an additional $30.39 million 
to fund all the health professional applicants from that year. Until 
Congress moves to adequately fund these accounts, the IHS and Tribal 
Nations will continue to have challenges attracting qualified providers 
and there will be gaps in the continuity and quality of care.
    Finally, we request that additional funding be made available to 
assist in the recruitment of AI/AN health professionals from within 
local tribal communities. We believe that the best way to care for our 
citizens is to ensure that health professionals are deeply connected to 
the communities they serve. In order to promote pathways to AI/AN 
entrance into health professions, we request additional funding, beyond 
the President's FY 2017 budget request, be made available for the 
Health Professions Scholarship Program, American Indians into Nursing 
Program, Indians into Medicine (INMED) program and American Indians 
into Psychology Program.
Section 202. Clarifying that certain degrees qualify individuals for 
        eligibility in the Indian Health Service Loan Repayment Program
    We support the provision of the bill which would recognize degrees 
in business administration, health administration, hospital 
administration or public health as eligible for awards under IHS LRP. 
However, we also recommend inserting similar language to recognize 
these degrees as eligible under the IHS Scholarship Program. We believe 
including these degree types into the IHS Scholarship Program will 
increase the number of AI/AN seeking business and health administration 
degrees and increase the pool of qualified health professionals.
Section 204. Relocation reimbursement
    In order to fight ongoing challenges with recruiting qualified 
providers into the Indian Health System, we support the provision 
allowing for reimbursement of reasonable costs associated with 
relocation. In addition to the criteria listed in the provision, we 
suggest broadening the language to include positions that are 
``difficult to fill in the absence of an incentive.'' This language 
will allow IHS more flexibility when determining when to offer 
relocation awards.
    In addition to relocation benefits, we recommend the inclusion of 
language which would authorize IHS to provide other incentives such as 
housing vouchers, performance based bonuses, and increased pay scales. 
Especially in the Great Plains and the other medically underserved 
areas where many of our Tribal Nations exist, access to housing for 
providers is a major barrier to recruitment. Providing IHS with the 
authority to offer a variety of benefits will help improve recruitment 
efforts. We suggest inserting similar language to the provision that 
exists in the S. 2953 bill under ``Sec. 607 Incentives for Recruitment 
and Retention.''
    Although we support the proposed incentives, the IHS is not 
equipped to implement these initiatives without additional 
appropriations. With IHS funding not meeting demonstrated financial 
need, we are concerned any initiatives to provide housing vouchers, 
relocation costs, or increase pay scales must be funded using patient 
care dollars. While the attraction of qualified staff is critically 
important, it must not be done by diverting precious resources from 
health care services. For this reason, we request that H.R. 5604 
include the authorization of additional funding to support these 
incentives without impacting patient care.
Section 205. Authority to waive Indian preference laws
    Although we understand the need to seek ways to recruit qualified 
candidates, we have concerns regarding the waiver of Indian Preference 
laws. We firmly believe the providers best suited to care for our 
communities are ones that come from the communities themselves, and we 
cannot support efforts that would undermine Indian Preference. As we 
note above, our vision for a stronger Indian Health System includes a 
robust pipeline of AI/AN into health professions. In the meantime, we 
believe that the aims of this provision can be achieved by modifying 
hiring practices within the current legal framework. We understand the 
law may be applied in a way that does not provide for timely reviews or 
hiring of qualified non-Indian candidates where no qualified AI/AN 
candidate is available. Rather than waiving the laws completely, we 
think there is room for improvement in hiring practices to ensure that 
positions are being filled in a timely manner with qualified 
candidates. We recommend directing the Secretary to update and 
streamline Indian preference hiring practices to ensure that qualified 
non-Indian applicants will be considered in cases where no qualified 
Indian applicants are available, at the sole discretion of the Tribal 
Nations served.
Title III--Purchased/Referred Care Program Reforms
Section 301. Limitation on charges for certain Purchased/Referred Care 
        Program services
    Although we appreciate the language which would codify existing IHS 
regulation extending Medicare-Like Rates payment methodology to non-
hospital based services, in absence of an enforcement mechanism, we 
believe this could create major access to care issues. Through the 2003 
authorization of the Medicare Prescription Drug, Improvement, and 
Modernization Act, hospital-based Medicare providers and suppliers were 
required to accept Medicare-Like Rates from IHS and tribally operated 
facilities as a condition of their participation in the Medicare 
program. This law has allowed PRC programs to extend their limited 
resources, while preserving access to care for AI/AN patients by 
ensuring providers accept the lower rate of payment. Because IHS does 
not have jurisdiction over Medicare Conditions of Participation, they 
could not include a similar enforcement mechanism. In cases where 
physicians or other providers do not wish to accept lower payments from 
PRC programs, they may refuse to see AI/AN patients and gaps in access 
will continue to persist. We recommend that language be inserted to 
this section which would require the acceptance of the MLR for all 
services authorized by IHS PRC programs as a condition of participation 
in the Medicare program.
Section 302. Allocation of Purchased/Referred Care Program funds
    While we agree that ``life and limb'' PRC priority levels 1 and 2 
provide woefully inadequate levels of care to IHS patients, we assert 
that rather than redistributing funding, Congress should simply fully 
fund the PRC account. Consistent underfunding results in the denial and 
deferral of medically necessary care. In Fiscal Year (FY) 2015, IHS 
reported 132,200 denied or deferred services, which amounted to 
$639,177,512 in unmet health care obligations. As a result, medically 
necessary services are denied by PRC departments and health conditions 
worsen, quite possibly contributing to many of the issues in the Great 
Plains. The PRC Medical Priority Level system itself, which forces 
Tribal Health Programs to ration care based on health condition as a 
result of underfunding, substantiates the need for Congress to fully 
fund the account.
    We are concerned with the HEALTTH Act's current language, which 
would impose funding freezes for IHS programs which authorize care at 
priority level 3 and redistribute funding increases to programs 
treating only more emergent cases. This will not improve access to care 
for AI/AN patients, but rather, will spread financial inadequacies 
across the Indian Health System. Although PRC funding is inadequate, 
some PRC departments are able to extend their resources through 
effective financial planning. This provision could penalize PRC 
programs which have created these types of efficiencies through 
negotiating competitive rates with providers and have been successful 
in funding higher levels of care. Further, the care delivered at 
priorities 3 and below is more likely to be preventive care. A critical 
element in the fight against the types of emergent and chronic health 
problems treated at priorities 1 and 2 is preventive care. Treating 
health problems early avoids more difficult and expensive treatment 
down the road.
    Additionally, we note that the current formula employed by IHS was 
established in consultation with Tribal Nations. The formula was 
crafted in recognition of area differences in cost of services, number 
of patients, access to hospitals, inflation and a number of other 
factors. In fact, the PRC funding formula is regularly reviewed in 
consultation with the PRC workgroup and Tribal Nations, so additional 
work to evaluate the formula is unnecessary at this time. Further, H.R. 
5604 lists a number of factors the Secretary must consider in the 
redevelopment of the formula, which, to our knowledge, were not 
formulated in consultation with all Tribal Nations.
Section 303. Purchased/Referred Care Program backlog
    While we understand that backlogged payments are a major concern in 
the Great Plains area, this is not true across the Indian Health 
System. Many Tribal Nations have instituted or agreed to prompt 
payments. We recommend that the language in this section be amended to 
exempt tribally operated facilities and limit the review to IHS Areas 
and direct service sites.
    Additionally, we contend that the PRC backlog is not simply the 
result of delayed payment due to inefficiencies within the IHS. Many 
PRC providers are unfamiliar with the IHS system and the laws that 
govern the provision of health care to AI/AN. First, there are the 
payer of last resort provisions which require private insurance, and 
other coverage through Medicare and Medicaid, to pay claims prior to 
IHS PRC programs. In cases where a patient does not have an alternate 
resource, the determination process may take weeks. Similarly, in cases 
where a patient fails to attain prior authorization for a service, the 
PRC department will not pay on the claim and financial liability will 
go to the patient. Last, some PRC services may meet medical priority 
but be denied due to lack of funding. In emergent cases, patients will 
need to receive this care regardless of ability to pay. These scenarios 
can happen frequently which result in delays or denials of payment of 
PRC providers. With this in mind, we recommend the inclusion of 
language call for a Government Accountability Office report on the 
causes of the PRC backlog, as well as recommendations regarding PRC 
provider education.
                               conclusion
    Our organizations appreciate congressional efforts to seek 
solutions to the long-standing challenges within the Indian Health 
System. However, we note the initiatives proposed in H.R. 5604 do not 
address the root cause of these issues: the chronic underfunding of the 
IHS. Only when Congress acts to uphold the Federal trust responsibility 
by providing full funding and parity for the Agency will the Indian 
Health System be equipped to provide an adequate level of care to AI/AN 
people. We thank the subcommittee for the opportunity to provide 
comments on this bill and look forward to an ongoing dialogue to 
address the complex challenges of health care delivery in Indian 
Country.

                                 [all]