[Senate Hearing 114-375]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 114-375




                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE


                             SECOND SESSION


                            FEBRUARY 3, 2016


         Printed for the use of the Committee on Indian Affairs

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                      COMMITTEE ON INDIAN AFFAIRS

                    JOHN BARRASSO, Wyoming, Chairman
                   JON TESTER, Montana, Vice Chairman
JOHN McCAIN, Arizona                 MARIA CANTWELL, Washington
LISA MURKOWSKI, Alaska               TOM UDALL, New Mexico
JOHN HOEVEN, North Dakota            AL FRANKEN, Minnesota
JAMES LANKFORD, Oklahoma             BRIAN SCHATZ, Hawaii
STEVE DAINES, Montana                HEIDI HEITKAMP, North Dakota
     T. Michael Andrews, Majority Staff Director and Chief Counsel
       Anthony Walters, Minority Staff Director and Chief Counsel
                           C O N T E N T S

Hearing held on February 3, 2016.................................     1
Statement of Senator Barrasso....................................     1
Statement of Senator Daines......................................    44
Statement of Senator Franken.....................................    50
Statement of Senator Heitkamp....................................     8
Statement of Senator Hoeven......................................     5
Statement of Senator Rounds......................................     7
Statement of Senator Tester......................................     4
Statement of Senator Thune.......................................     9
Statement of Senator Udall.......................................     6


Bear Shield, Hon. William, Council Representative, Rosebud Sioux 
  Tribe..........................................................    75
    Prepared statement...........................................    78
Dorgan, Hon. Byron L., Former U.S. Senator from North Dakota; 
  Founder and Chairman, Center for Native American Youth.........    11
    Prepared statement...........................................    14
Karol, Susan V., M.D., Chief Medical Officer, Indian Health 
  Service, U.S. Department of Health and Human Services..........    35
Killsback, Jace, Executive Health Manager, Northern Cheyenne 
  Tribal Board of Health.........................................    80
    Prepared statement...........................................    82
Kitcheyan, Victoria, Treasurer, Winnebago Tribal Council.........    54
    Prepared statement...........................................    56
Little Hawk-Weston, Sonia, Chairwoman, Health And Human Services 
  Committee, Oglala Sioux Tribal Council.........................    62
    Prepared statement...........................................    64
Mcswain, Robert G., Principal Deputy Director, Indian Health 
  Service, U.S. Department of Health and Human Services..........    28
    Prepared statement...........................................    30
Slavitt, Andy, Acting Administrator, Centers for Medicare and 
  Medicaid Services; accompanied by Thomas Hamilton, Director, 
  Survey and Certification Group, Center for Clinical Standards 
  and Quality....................................................    22
    Prepared statement...........................................    24
Wakefield, Mary, Ph.D., R.N.; Acting Deputy Secretary, U.S. 
  Department of Health and Human Services........................    18
    Prepared statement...........................................    20

                           Listening Session

Listening session held on February 3, 2016 


Archambault, Jacqueline, Cheyenne River Sioux Tribal Member, 
  prepared statement.............................................   154
Brown, Domnic L., Osage Tribal Member, prepared statement........   154
Clown, Yvonne Kay, Cheyenne River Sioux Tribal Member, prepared 
  statement......................................................   136
Colombe, Sunny, MBA, Rosebud Sioux Tribal Member, prepared 
  statement......................................................   131
Dilldine, Jane, Supervisory General Supply Specialist, Pine Ridge 
  IHS Hospital, prepared statement...............................   174
Espinoza, Evelyn, RN, BSN, Rosebud Sioux Tribe Health 
  Administrator, prepared statement..............................   168
Frazier, Hon. Harold C., Chairman, Cheyenne River Sioux Tribe, 
  prepared statement.............................................   134
Goodwin, Tammy Rae, Sisseton Wahpeton Oyate Tribal Member, 
  prepared statement.............................................   166
Houle, Jay, Sisseton-Wahpeton Oyate Tribal Member, prepared 
  statement......................................................   153
Jones, Alexis, Registered Nurse, BSN, prepared statement.........   155
Malerba, Hon. Marilynn, Chief, Mohegan Tribe; Board Member of 
  Self-Governance Communication and Education Tribal Consortium; 
  Chairwoman, IHS Tribal Self-Governance Advisory Committee 
  (TSGAC), prepared statement....................................   187
Miller, Vernon, Chairman, Omaha Tribe of Nebraska, prepared 
  statement......................................................   181
National Indian Health Board (NIHB), prepared statement..........   138
Phillips, Brent R., President/CEO, Regional Health, Inc., 
  prepared statement.............................................   172
Salomon, Donna M. (Waters), Oglala Sioux Tribal Member, prepared 
  statement......................................................   157
United South and Eastern Tribes, Inc., prepared statement........   151
Waters, Stephanie L., Oglala Sioux Tribal Member, prepared 
  statement......................................................   163
Wilcox, Darlene M., Ph.D., LP, Licensed Clinical Psychologist, 
  prepared statement.............................................   169
Additional letters and supplementary information for the record.. 

Response to written questions submitted by Hon. James Lankford to 
  Andy Slavitt...................................................   228
Response to written questions submitted by Hon. John Thune to 
  Robert G. Mcswain..............................................   230



                      WEDNESDAY, FEBRUARY 3, 2016

                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:33 p.m. in room 
216, Hart Senate Office Building, Hon. John Barrasso, 
Chairman of the Committee, presiding.

                   U.S. SENATOR FROM WYOMING

    The Chairman. I call this hearing to order.
    Today, the Committee will hold an oversight hearing 
entitled, Reexamining the Substandard Quality of Indian Health 
Care in the Great Plains.
    In 2010, the Committee held an oversight hearing entitled 
In Critical Condition: The Urgent Need to Reform Indian Health 
Service's Aberdeen Area. At this hearing the Committee listened 
to testimony detailing an investigation led by the former 
Chairman Byron Dorgan and his report on the Indian Health 
Service. He is here with us today.
    The Dorgan Report found atrocious evidence showing the lack 
of quality of care by the Indian Health Service in the Aberdeen 
area, now called the Great Plains area, to Indian tribes.
    Over five years later, the very problems identified in the 
Dorgan Report have not been resolved. In fact, some issues have 
become worse over time, and new ones have developed.
    After hearing loudly from the tribes on the lack of quality 
of health care in the Great Plains Area, I dispatched Committee 
staff to the field to understand what is really is happening in 
the Great Plains Area.
    What we found is simply horrifying and unacceptable. In my 
view, the information provided to this Committee and witnessed 
first hand can be summed up in one word: malpractice. You do 
not have to take my word for it. You will hear today, the 
Indian Health Service has known about these issues all along.
    The Centers for Medicare and Medicaid Services, another 
agency within the Department of Health and Human Services, has 
confirmed not only that these same problems continue to fester, 
but that they pose immediate risk to patient safety.
    The impacts of these deficiencies are not theoretical. 
These persistent failures have led to unnecessary suffering by 
patients, by families, and by whole communities. In fact, they 
have led to multiple patient deaths.
    The Administration is responsible for providing and 
delivering health services to American Indians and Alaska 
Natives across the Country. Their Federal obligation mandates 
that they promote health and safe Indian communities while 
honoring tribal governance. This is not happening.
    The Indian Health Service has failed their patients. This 
Committee knows it, the congressional delegations joining us 
today know it, the tribes know it all too well, and every 
single witness here today knows it. Without question, this is a 
tragedy and a disgrace.
    I stress to the Administration that the status quo will not 
be tolerated. How can we take your word that these issues have 
been resolved, when 5 years ago, you said to this Committee you 
had a plan? How can we trust information coming from Health and 
Human Services and the Indian Health Service or others in the 
    This Committee will not accept any more cover-ups or 
politicking. This is not a game. People's lives are at risk.
    We are now at a place where you must prove to us, each step 
of the way, that you are living up to your word and fulfilling 
your responsibilities.
    Last year, I wrote to Secretary Burwell about the need for 
leadership at the Indian Health Service. To this day, the 
director position remains unfilled. The Administration's 
failure to act on such important matters speaks volumes.
    Testimony submitted by the Administration references many 
plans but we need and the people in the Great Plains need, 
concrete results. Simply changing an area name from 
``Aberdeen'' to ``Great Plains'' will not suffice.
    I urge the Administration to listen to the Indian tribes 
and witnesses here today. Listen to their testimonies. Listen 
to their statements. These are the people you serve, and they 
know what their communities need. I hope you will treat them 
with the respect they deserve, and work with them honestly and 
    As a physician, I know that more can and must be done to 
ensure safe, quality healthcare is delivered at Indian Health 
Service facilities in the Great Plains area. I believe positive 
change is possible. It will be difficult and, at times, 
uncomfortable. This cannot stand in the way of real reform.
    We must put patients first, and that is exactly what we are 
here to do today. We need both short-term and long-term 
solutions, not only to the problems identified by the CMS 
surveys, but also to the many other problems identified by 
patients, tribes, the brave Indian Health Service employees who 
have spoken to the Committee and others.
    I will continue to press the Administration for answers and 
real solutions. I will continue to investigate and convene 
hearings here in Washington or in the field until we are sure 
patients are safe in the facilities that were built to provide 
them care.
    I would also like to say that although this oversight 
hearing will focus on the Great Plains area, the Committee has 
also heard concerns from tribes in other areas served by the 
Indian Health Service.
    We have been told that conditions are most dire in the 
Great Plains, but again, we are not going to take the 
Administration's word for it. We realize that these and other 
issues impacting patients may plague other regions, and will 
demand answers and action in these areas as well.
    When our Committee staff visited the Great Plains area 
recently, they saw firsthand the culture of cronyism and 
corruption that permeates the system. Many Indian Health 
Service personnel have come to the conclusion that they are 
untouchable and that they are accountable to no one. As far as 
I can tell, until now, they have been allowed to act with 
    Instead of being reprimanded for failing to appropriately 
care for patients or for retaliating against providers who 
report deficiencies, these ``untouchable'' employees are being 
recycled throughout the Great Plains area. Some are being 
promoted, even though they are not qualified for the positions 
they hold. Some have been involved in preventable deaths 
identified by CMS.
    These ``untouchable'' employees have continued to see 
patients and collect taxpayer dollars, without fear of being 
held accountable for the many lives they were hired to protect 
and care for. I fear that some members of the IHS leadership 
think they are untouchable as well.
    One particularly egregious incident involves the Chief 
Medical Officer for IHS. In a recent phone call, the Chief 
Medical Officer responded to concerns from congressional staff 
about incidents involving unsafe pre-term deliveries by saying, 
``if you have only had two babies hit the floor in eight years 
that is pretty good.'' This is a sad new low for IHS.
    Another example involves a young toddler lost her life to a 
preventable infection because the IHS facility in her community 
repeatedly failed to provide proper care, and by the time they 
referred her out of the IHS system, it was too late. This is a 
heartbreak that no parent, no family, no community should have 
to bear.
    Yet, tragically, this story is all too familiar. Too many 
lives have been lost because no one was held accountable for 
their actions. The same mistakes are being made again and 
again. This must change immediately.
    To be clear, the total lack of accountability is just one 
of many problems identified during my staff's visit to the 
Great Plains area last month, and relocating troubled staff 
will not be enough to effect real and lasting improvements.
    True reform will require a cultural change at IHS, from the 
top officials responsible at department headquarters, down to 
the employees at each facility.
    The information we have uncovered is overwhelming and 
disturbing, and it will be an important part of addressing the 
problems we discuss here today.
    We must work together to stop the bleeding in the Great 
Plains, and find permanent solutions, so that we are not here 
again in another five years facing the same problems, after an 
untold number of additional preventable deaths.
    Before we hear from our witnesses, I want to thank Senators 
Thune, Rounds and Sasse for joining us today. They have been 
and will continue to be great advocates for the tribes in the 
Great Plains. I also want to thank Senator Tester for his 
attention to this issue.
    I would like to turn first to Senator Tester for an opening 

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

    Senator Tester. Thank you, Mr. Chairman. Thank you for 
holding this hearing.
    Unfortunately, for many of us sitting up here and for the 
tribal nations throughout Indian Country, another congressional 
hearing on the inadequacies of the Indian Health Service is not 
a surprise.
    As disturbing as the news from the Great Plains area is, we 
hear from tribes, as the Chairman said, all over the Country 
with similar stories of inadequate care, a painfully slow 
bureaucratic system of billing and collections and simply poor 
health care delivery for their people.
    We have to work with the tribes to find solutions to these 
problems. Our Country has made a number of commitments to the 
tribes in our Country and that includes providing quality 
health care.
    Those of us on this Committee know all too well the health 
care conditions the American Indians and Alaska Natives across 
this Country continue to face. The statistics are staggering.
    Native Americans are affected by heart disease, cancers and 
diabetes at higher rates than any other ethnic group in this 
Country. In some places, the life expectancy of a Native 
American is significantly shorter than their non-Indian peers.
    In my home State of Montana, an average American Indian man 
or woman will live about 20 years less than their non-Indian 
counterpart. This is an unacceptable reality that both Congress 
and the Administration must work to fix.
    That is why it is my hope that this hearing can shed more 
light not only on the problems that face the IHS but the steps 
that we can take to find solutions to these problems. Despite 
seeing modest increases over the last several years, we all 
know that funding is a major challenge.
    The Administration and Congress have worked together in 
recent years to improve these funding streams but the impact of 
the ongoing threat of sequestration has had negative effects on 
these efforts.
    In addition to funding, we also must ensure that the IHS 
has the tools it needs to be successful. Quality of care should 
be a top priority for the IHS. We need to examine what 
mechanisms are in place to ensure that IHS is providing first 
rate care.
    Part of ensuring that tribal communities consistently 
receive high quality care means making certain that we are 
recruiting and retaining quality health care professionals to 
serve in our IHS facilities.
    Another area of concern is the ability of the department to 
rapidly and effectively respond to health emergency incidents 
to guarantee that care is not being disrupted.
    This current situation is even more frustrating knowing 
that when similar conditions existed in the Veterans 
Administration health care system, Congress did the right thing 
and made changes to the law to ensure that veterans are 
receiving health care we have promised.
    American Indians and Alaska Natives are still waiting. 
Despite the Federal treaty and the trust responsibilities we 
have, these conditions go largely unnoticed by the general 
    I would encourage my colleagues on this Committee and in 
Congress to ask themselves how can we, in good conscience, pass 
legislation to fix the VA but ignore the needs of the Indian 
Health Service?
    I hope we have some solutions proposed today. I look 
forward to working with everyone to make certain that American 
Indians and Alaska Natives are getting the health care they 
    Finally, before we begin, I would like to welcome Jace 
Killsback, a member of the Northern Cheyenne Tribe from 
Montana. Jace serves on a number of health advisory councils at 
home. As well he serves as the Executive Health Manager for his 
    He has been involved in these issues for over a decade and 
will provide us with valuable insights on how to improve health 
care on the ground in Indian Country.
    I would also like to welcome my good friend, Byron Dorgan, 
the former chairman of this Committee. Byron, your presence is 
still felt here even today. I want to thank you for your 
counsel and for testifying as we move forward.
    I would also welcome a couple more folks. To Dorothy 
Dupree, the former head of Billings-Rocky Mountain Region, 
thank you for your good work. Even though it was on a temporary 
basis, you make a difference. I want to thank you for that.
    To Robert McSwain, thank you for being here today. There 
are plenty of reasons that you should not be here today. I am 
not going to elaborate on those but there are serious issues 
going on in your personal life. I want to thank you for being 
here to testify.
    With that, Mr. Chairman, thank you for holding this 
    The Chairman. Thank you, Senator Tester.
    Would anyone else like to make a statement? Senator Hoeven.


    Senator Hoeven. Mr. Chairman, if I could, I would like to 
welcome former Senator Byron Dorgan who served both in the 
House of Representatives and in the Senate from 1980 to 2010. I 
would like to thank him for being here and for his commitment 
on behalf of Native Americans, not only throughout North Dakota 
but across the Country, for many, many years. I welcome back to 
this hearing today.
    Also, I would welcome Deputy Secretary Mary Wakefield for 
her commitment to rural health care both on and off reservation 
and for her presence and testimony here today.
    Thank you so much to both of you.
    The Chairman. Thank you, Senator Hoeven.
    Senator Udall?

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

    Senator Udall. Thank you very much, Chairman Barrasso and 
Vice Chairman Tester, for focusing on this very, very urgent 
issue. I would echo what they said about Senator Dorgan. It is 
great to have you here and to have you involved in Native 
American issues across the Country.
    The conditions recently reported at facilities in the Great 
Plains region are horrific and unacceptable. My State also 
experienced halted emergency medical services at an IHS medical 
center in Crownpoint, New Mexico last year.
    Patients deserve competent and timely care and it is 
intolerable that any IHS emergency facility close for any 
amount of time. The difficult topics we are going to discuss 
today are not new. Unfortunately, staffing issues and the 
facility disrepair are becoming synonymous with the Indian 
Health Service.
    To help address these ongoing staffing difficulties, I have 
introduced a bill with Senator Murkowski that would make the 
IHS Health Professions Awards Program exempt from a Federal 
income tax requirement as the National Health Service Corps 
currently is.
    IHS currently spends approximately 30 percent of its health 
professions account to pay taxes to the Federal Government, 
taking needed funding away from investments and skilled medical 
professionals. We need more resources for the agency to recruit 
and retain competent and committed staff.
    I will continue to push for this change and I hope that the 
Administration has more ideas about how to tackle this issue.
    I also want to take this opportunity to bring to your 
attention a public health crisis in my State. The area in and 
around Gallup, New Mexico has long experienced an alarming 
number of alcohol-related deaths of Native people. Last winter, 
17 people died from alcohol-related incidents, including 
exposure to harsh cold temperatures.
    The NCI Detox Center in Gallup is currently the only detox 
facility serving the population in this remote and rural part 
of the State adjacent to the Navajo Nation and the Pueblo of 
Zuni. An estimated 98 percent of clients served there are 
Native American.
    The center offers a desperately needed social detox program 
geared primarily toward protective custody. Since the facility 
serves such a large Native population, IHS needs to be a part 
of the team working with local officials and other stakeholders 
to solve this public health crisis in northwest New Mexico.
    I am pleased that the IHS officials from Rockville recently 
visited the NCI Detox Center which is expected to run out of 
funding at the end of next month. Senator Heinrich and I have 
been working together on this critical issue and he and his 
staff have been great to work with.
    Later in this hearing, I will have some urgent questions 
about how the Administration can creatively leverage current 
resources to help work on long term solutions to this problem. 
I look forward to discussing the great need to help address the 
crisis in the Great Plains and the larger issues of IHS 
staffing and quality patient services and poor facility 
    As was said earlier, this has been around for a long time. 
When Senator Dorgan was our chairman, we highlighted this. We 
would hope that the Administration would come forward with 
plans to remedy this in an urgent manner.
    Thank you very much again, Mr. Chairman.
    The Chairman. Thank you, Senator Udall.
    Senator Rounds.


    Senator Rounds. Thank you, Chairman Barrasso and Ranking 
Member Tester, and members of the Committee for allowing me as 
a non-member of the Committee to give a very brief statement.
    I do appreciate the work you are doing and I have to also 
give a shout out to your staff members who actually went out to 
the Dakotas. I know they spent over 12 hours in one day alone 
simply taking testimony and learning first hand of the 
challenges we face in the upper Midwest with regard to this 
particular and very serious issue.
    I would also like to mention that we appreciate the 
Honorable Sonia Little Hawk-Weston, Chair of the Health and 
Human Services Committee, Tribal Council of the Oglala Sioux 
Tribe for being here today from Pine Ridge, South Dakota.
    We also appreciate Mr. William Bear Shield, a member of the 
Health Council at the Rosebud Sioux Tribe.
    Afterwards at the listening session, I understand that the 
Chairman of the Cheyenne River Sioux Tribe will be giving 
testimony, our good friend, Mr. Harold Frazier. I think we also 
have the Chairman of the Oglala Sioux Tribe from Pine Ridge, 
Mr. John Yellowbird Steele, who was trying his best to get in 
here. He made it, great.
    We are having a blizzard in that part of the Country, so 
thank you for being here, Mr. Chairman.
    Nearly 122,000 tribal members rely on the Great Plains Area 
Office to deliver safe, reliable and efficient health care. For 
rural tribal members, their IHS facility may be the only 
hospital for more than 100 miles. This is the case for many 
tribal members in my home State of South Dakota.
    For too long, the Federal Government has failed to live up 
to its promise and its trust responsibility to provide adequate 
care for the Native American community. That is the reason that 
I am here today.
    In 2010, this Committee released a report citing chronic 
mismanagement, lack of employee accountability and financial 
integrity at IHS facilities. The report also identified five 
IHS hospitals in the Aberdeen area at risk of losing their 
accreditation or certification from the Center for Medicare and 
Medicaid Services. Fast forward six years and we find that the 
Winnebago facility, the Rosebud and Pine Ridge hospitals in 
South Dakota are all threatened with similar problems. It feels 
as if nothing has changed.
    The health care crisis within the Indian Health Care 
Service needs to be resolved. There is no excuse for hospitals 
to not reach basic benchmarks for providing proper care. 
Reports and hearings can be very good if we also help to 
facilitate a plan of action to remedy the current situation and 
then insist on proper execution of the plan with a follow up to 
assure results.
    Mr. Chairman, thank you for the opportunity to make this 
statement today. Thank you very much for bringing proper 
attention to this very important and critical issue to over 
122,000 member citizens in the upper Midwest.
    The Chairman. Thank you, Senator Rounds.
    Senator Heitkamp.


    Senator Heitkamp. Thank you, Mr. Chairman.
    I want to welcome two great North Dakotans today, one whose 
footsteps I followed in my commitment to do better and to 
change outcomes, Senator Byron Dorgan, and ahead of him, both 
Senator Kent Conrad and certainly Senator Quentin Burdick were 
champions for Indian people, champions for meeting their needs 
and doing what we must do to fulfill our obligations that we 
took a sacred vow when we signed treaties.
    Somehow in every hearing we have, we see the failure of 
meeting those treaty obligations and the failure to do the 
right thing.
    I want to welcome Mary Wakefield who served as Senator 
Burdick's Chief of Staff and has a long history of trying to 
improve the quality of health care in rural areas and certainly 
the quality of health care in Native American communities.
    I want to make what seems to me to be a very simple point 
because we come to these Committee hearings all the time and, 
talk about the parade of horribles. It is not just in health 
care; it is in housing and education. We could just make a long 
    Yet, let me give you some numbers. The average Medicare 
spending per beneficiary is almost $12,000 a year. The average 
spending, national health means everyone, is about $8,000. The 
average spending in the veteran system is $7,000. The average 
spending in Medicaid, per enrollee, is almost $5,600.
    When we look at what we spend in Indian health, it is 
barely $3,000. Is anyone shocked that we are here? Is anyone 
shocked that we have these problems?
    We have to be serious about fixing this problem. If we are 
serious about fixing this problem, we are going to be serious 
about funding the fix. No one should tolerate what we read in 
this report. No one thinks this is okay.
    You have to do better with what you have and you cannot 
accept a culture of failure because we see it over and over 
again whether it is BIA, Indian health or Indian education. We 
have accepted bad results. That has to change.
    Congress shares responsibility. The President shares 
responsibility. If we are serious about fixing this, we are 
serious about funding it.
    I want to lay out some concerns I have. We need to know 
what it will take to fix it and how we are to get the resources 
so that we can.
    The Chairman. Thank you, Senator Heitkamp.
    Senator Thune.

                 STATEMENT OF HON. JOHN THUNE, 

    Senator Thune. Thank you, Mr. Chairman.
    I too want to thank you and Senator Tester for holding this 
hearing and shining a light on what is a major crisis in Indian 
Country in the Great Plains.
    As Senator Rounds did, I want to acknowledge the people who 
are here. I think all nine tribes from South Dakota are 
represented. I particularly look forward to hearing from Sonia 
Little Hawk-Weston from the Oglala Sioux Tribe and Willie Bear 
Shield from Rosebud.
    As Senator Rounds also mentioned, I welcome both President 
John Yellowbird Steele and Chairman Harold Frazier.
    Mr. Chairman, this is deja vu all over again. We have been 
through this drill. With Senator Dorgan's good work back in 
2010, we came out of that with what I thought was a plan, but 
it is disappointing to me that we find ourselves right back 
here where we started.
    In December of this year, when IHS notified me of CMS's 
findings, I immediately followed up with IHS and HHS. In a 
conference call on December 4 between my staff and IHS, members 
from IHS stated that a majority of the concerns at the Rosebud 
facility had been addressed and abated.
    These statements were made merely hours before my staff was 
informed that the Great Plains area office had contacted 
President Kindle of the Rosebud Sioux Tribe and informed him 
that the emergency department at the Rosebud hospital was being 
put on diversion status that following day.
    Mr. Chairman, I would just say how could that happen? We 
have a serious breakdown in communication or somebody is not 
telling the truth. I bring this up as an example of the 
continuing evidence of IHS communication issues.
    Just hours before the Great Plains IHS decision to divert 
patients from Rosebud's emergency department, staff in Great 
Plains and at headquarters were painting a picture to 
congressional staff that did not match events and reality on 
the ground.
    Since this Committee's report in 2010, I continued to 
monitor the actions of the Great Plains IHS. In April 2014, I 
sent a letter to the then Acting Director IHS requesting an 
update on the ongoing work of the IHS to address the 
Committee's findings.
    On June 30, 2014, I received a response to that letter. The 
letter stated ``The Great Plains area has shown marked 
improvements in all categories. Significant improvements in 
health care delivery and program accountability have also been 
    Yet, here we are a year and a half later and one hospital 
in the region has had its provider agreement terminated and two 
more hospital provider agreements have been placed in jeopardy.
    What has to be acknowledged is that CMS findings indicate 
people's lives are in jeopardy. This is unacceptable. We cannot 
tolerate this. CMS's recent findings regarding patient 
experiences at these facilities are beyond comprehension.
    Incredibly the report of dirty and unsanitized medical 
equipment left exposed in an emergency room might be the least 
shocking of these stories. One patient who suffered from a 
severe head injury was incorrectly discharged from the hospital 
only to be called back later the same day once the test results 
arrived. The patient was immediately flown to another facility 
for care and never should have been sent home in the first 
    Another facility which has been mentioned was in such 
disarray that a pregnant mother prematurely gave birth on a 
bathroom floor, a bathroom floor, without a single medical 
professional nearby which shockingly is not the first time it 
has happened at that facility.
    Each one of these incidents is egregious and needlessly 
puts people's lives at risk. CMS's recent findings are not only 
astounding but they are absolutely unacceptable. These are life 
and death circumstances and IHS must make fixing these 
recurring issues a priority.
    Time and again we have had a variety of task forces, 
reports and oversight commissions formed to uncover the 
failings within the Great Plains area IHS, yet to date it is 
evident that IHS has failed to follow through on many of the 
report's findings.
    In addition to poor patient experiences at IHS facilities, 
gaining access to a physician or health care professional is 
made all the more difficult due to sever staffing shortages. 
According to the Robert Wood Johnson Foundation in 2015, there 
were six physicians in all of Oglala, Lakota County where the 
Pine Ridge hospital and Kyle Clinic are located.
    In fact, the doctor to patient ratio in Oglala Lakota 
County is 2,343 patients for every one physician. Keep in mind 
that in addition to Oglala Lakota County, the IHS facilities on 
the Pine Ridge Reservation also serve Jackson County which 
contains another 3,216 people.
    In nearby Todd County, the location of the Rosebud Sioux 
Reservation, in 2015, the Foundation reported there were only 
two primary care physicians or 4,971 patients for every one 
    Currently, to my knowledge, there are now three providers 
in Rosebud. However, there is funding for 11. Filling these 
positions could go a long way to ensuring patients have access 
to care.
    I just wanted to do this for purposes of comparison but if 
you look at similarly populated counties throughout the 
Country, they tend to have way better access to primary care 
physicians. For instance, Plumas County, California, with a 
population of 18,859 or roughly the population of the Pine 
Ridge Reservation according to the South Dakota Department of 
Tribal Relations, has 15 physicians or 1,293 patients for every 
    The 12,503 people who live in Millard County, Utah, similar 
in size to Todd County, South Dakota enjoy a ratio of 1,796 
patients for every doctor, making primary care physicians over 
twice as accessible in Millard County than in Todd County.
    I would say we just have to do better. People are counting 
on us to do better. To date, we have failed to deliver on our 
promise to provide tribal citizens of this Country the quality 
of care they deserve. I am committed to seeing true and lasting 
reform come from this hearing and the discussions that will 
follow. IHS must have accountability and transparency to our 
tribes and to Congress.
    Again, I am grateful, Mr. Chairman, for you and Senator 
Tester allowing those of us not on this Committee to 
participate because this is an issue that obviously is of great 
interest and one about which we care deeply.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Thune.
    With that, I would like to invite Senator Dorgan to the 
table. We are going to hear from a person who is a familiar 
face to the Committee and who is the former Chairman of this 
Committee, who led the 2010 investigation we are revisiting 
    We thank you for your continued service, Senator Dorgan, to 
the Great Plans and to all of Indian Country. We welcome your 
statement and your participation.
    I would also be remiss not to mention that earlier this 
year the Senate passed with unanimous consent the Indian Tribal 
Energy and Self Determination Act of 2015. I recall under your 
chairmanship we were able to get the ball rolling. Thank you 
for that effort and your leadership as well.
    With that, Senator Dorgan, welcome back to the Committee.


    Senator Dorgan. Thank you very much, Mr. Chairman.
    I was surprised and pleased to be invited and very happy to 
come. I know that everyone sitting at this table has a 
passionate desire to fix these problems. You know how difficult 
they are. You pledged to yourselves, the Congress and your 
constituent groups that this must be fixed.
    I am really pleased to be here. When I left the Senate, I 
created something called the Center for Native American Youth 
which is a nonprofit focused just on Native American youth. All 
the spotlights are on that spot. We work on teen suicide 
prevention, educational opportunities, health care and a range 
of things.
    I am going to talk to you about the Indian Health Service. 
I have to grit my teeth a little bit because we hold quarterly 
meetings with Federal agencies that are kind of stovepipes and 
we get them talking to each other.
    There has been no agency that has been better and more 
faithful in sending some terrific people to those quarterly 
meetings than the Indian Health Service. I say that because I 
know today there are some wonderful people working at the IHS, 
both people working with us at CNAY and also people this 
morning who got up and went to work at the Health Service areas 
dedicated professionals, dedicating their lives to these 
    I regret that when we talk about all this, somehow it 
tarnishes the good work of some really good people. I feel sad 
about that but we do not have a choice.
    This morning again I looked at the 2010 investigation we 
did. We had a series of bullet points but let me read the first 
one. ``Over the course of the last ten years, the IHS has 
repeatedly used transfers, reassignments, details, lengthy 
administrative leave to deal with employees who have had 
records of misconduct and poor performance.''
    I do not need to read a lot more than that but just say 
that this system does not work unless there is accountability. 
When there is fraud, misconduct, incompetence, criminal 
activity, you do not need a long investigation for that. You 
fire folks involved and move on with competent people to run 
the system.
    That has not happened. It has not happened not just for the 
five years or the last 10 or 15 years, decade after decade we 
have seen these problems; in Administration after 
Administration, we have seen these problems.
    There is just no way to sugar coat what we are dealing 
with. It has been and still is a tragic failure in delivering 
health care in far too many areas for American Indians. We are 
talking about the Great Plains region but I tell you, I am 
certain this extends beyond it.
    I commend you because taking on this issues is hard but you 
have to start. You have to start with the first step. Building 
on the 2010 report I think can be very helpful.
    The Indian health care issue is underfunded by half. You 
can work on that but the fact is it is underfunded by half 
which promotes full scale rationing of health care. It ought to 
be front page headlines in major city newspapers but it is not.
    In fact, most people do not know of it, see it or hear of 
it. It suffers in quality and is underfunded by half. That is a 
significant problem.
    It is easier to criticize poor quality, but we also need to 
criticize the decision-making of all of us who, with a country, 
signed treaties and made promises to deliver health care and 
have not honored those promises with the adequate funding that 
is necessary. That is a fact as well.
    Senator Heitkamp talked about responsibilities. We are 
responsible for health care for those we incarcerate. We 
incarcerate a lot of people in this Country. We are responsible 
not only for those we incarcerate for health care but also by 
treaty and by promise and by trust, for health care for 
American Indians.
    We spend twice as much per person providing health care for 
those we incarcerate in America's prisons than we do to meet 
the promise of health care for American Indians that we agreed 
to by treaty and trust. That is unbelievable to me. None of us 
experience it because none of us get our health care in these 
    I want to mention a couple of facts about the 2010 
investigation. I mentioned earlier there are some terrific 
people working for the Indian Health Service. There is no 
question about that. I have seen them and you have seen them.
    If you visit these facilities and walk the halls, you see 
some people you care a great deal about and say thank God for 
doing this. Often it is in remote areas and so on but they are 
not the issue.
    The fact is, too many of them are working with outdated 
equipment, I mentioned inadequate funding, but it is also the 
case that there is kind of a split personality in my judgment. 
Having watched the IHS for a long, long time, I see kind of a 
split personality.
    There are some really great people, some people who care, 
people who sign up and commit their lives to the Indian Health 
Service and deliver good health care. Then I see something 
    I see the weaving of friendships and favors, relatives, 
incompetence, corruption and yes, even criminal behavior. It 
has all too often and continues to be, in my judgment, 
overlooked, excused and denied. That cannot continue.
    No organization in American of which I am aware can work 
properly in those circumstances. You have to determine what 
works and who works, what does not work and who does not, and 
then make the necessary changes.
    This is not some ordinary issue because as a number of you 
have mentioned. This is about people who die; this is about 
living and dying. We take for granted every year and every day 
for us and for our families' health care administration that is 
routinely denied to many American Indians.
    Let me give you a couple of examples. It is not about 
philosophy or theory; this is about what they confront. Adele 
Hale Berry is having a heart attack. Because there is no 
contract funding left, it is that time of the year, do not get 
sick after June, she is sent to a hospital in a city.
    When she arrives on a gurney at the hospital, she has taped 
to her thigh an 8 x 10 piece of paper that explains to the 
hospital that if you admit this woman, there will be no funding 
from the IHS, contract funding for that tribe is over. A heart 
attack victim on a gurney with a taped piece of paper to her 
thigh explaining why she is not going to get funded for health 
care for a heart attack is unbelievable.
    I was at the Three Affiliated Tribes once on a tour. We 
walked around the hallway and the doctor who was a terrific guy 
working for the IHS said, here is where we are going to put the 
new x-ray machine. The old one is outdated and does not work 
very well but this is where the new one comes in. It is going 
to be a big deal.
    I said when is it coming? He said, not sure. He said, it 
has been approved and the paperwork has been waiting in 
Aberdeen for 18 months to be signed, 18 months on someone's 
desk. I am sure that makes you feel as I do. What on earth is 
    Finally, something I have described at great length, I want 
to do again because when we finally, after 17 years, passed the 
Indian Health Care Improvement Act, I asked it be named after 
Ta'Shon Rain Little Light. She was the inspiration. I took to 
the Floor a photograph of this beautiful six year old girl 
every single day that I spoke on that bill.
    She was a six-year-old girl with sparkling eyes, dressed in 
traditional dance dress, because she was a little dancer. She 
loved to dance. She died. She became sick and they took her 
three times to the Indian Health Service, two different 
services. Each time she was diagnosed and they sent her home 
saying she was depressed so she should take medicine for 
    In fact, she had terminal cancer. Some months later, she 
died in her mother's arms and said, Mom, I am so sorry I am 
sick. That evening she died. The fact is this is about life and 
death for kids, for adults, and for elders.
    I know this is going to be a hard hearing. I am going to 
conclude because you have a big agenda today. I want to say to 
you as one person, this is not about politics; everyone on this 
dais knows that. This is about the willingness of Republicans 
and Democrats and all people of goodwill to address problems 
and fix them because they need to be fixed.
    I say to you, Mr. Chairman and Vice Chairman, thank you for 
doing this, thank you for putting this on the agenda because it 
matters. You are going to save and improve lives. You will 
never know their names but that is what you will do because you 
have put this on the agenda.
    I want to make one final point. I know you are going to 
hear from a friend of mine today, Mary Wakefield. I have known 
Sylvia Mathews Burwell for decades. I think the world of her. I 
really like her, like the job she does.
    Mary Wakefield, you will excuse my being a homer about this 
but Mary is a North Dakotan who I am so enormously proud of. I 
know that Mary is tough and really smart. When she is told, as 
she has been, you are going to be accountable for this, she is 
going to fix this.
    It is hard to do but I have great confidence in Mary 
Wakefield and I hope as you understand this that she is new on 
the scene but she is one of the best breaths of fresh air I 
have seen to begin putting her fist around this issue and 
tackling it because she cares about Indian health care just as 
all of us do.
    I was given many years ago, as some of you perhaps have 
been, an Indian name called Shante Unwiica, a Sioux name that 
means thinks with his heart. I just think with all my heart, 
Mr. Chairman, when you called me I was happy to say I would be 
happy to come and be a part of what you are trying to do.
    I think with all my heart that what you and members of this 
Committee can do and will do by putting the spotlight on this 
spot will save lives. God bless you for doing it.
    Thank you very much.
    [The prepared statement of Senator Dorgan follows:]

 Prepared Statement of Hon. Byron L. Dorgan, Former U.S. Senator from 
  North Dakota; Founder and Chairman, Center for Native American Youth
    Good afternoon Chairman Barrasso, Vice-Chairman Tester, and members 
of the Committee. My name is Byron Dorgan. I'm pleased to have been 
invited to come back to the Committee today. I served here as a member 
and Chairman for many years, and know how hard you work to deal with 
significant issues confronting the First Americans.
    Following my service in the U.S. Senate, I founded the Center for 
Native American Youth at the Aspen Institute, and currently serve as 
Chairman of the Board of Advisors. Although I retired from Congress, I 
did not want to retire from working on making positive changes in the 
lives of Native Americans, particularly Native American youth. While in 
Congress, I had the opportunity to visit the tribal nations in the 
Dakotas and also many tribal nations throughout this country. I was 
always impressed with the strength, resilience, and cultural knowledge 
of the youth I met along those journeys. I realized that they are the 
leaders of the next generation and we need to make sure that they have 
the resources available to them to become successful.
    You invited me here today to discuss an earlier investigation of 
Indian Health Service (IHS) health care in the Aberdeen Region. I'm 
pleased you are reexamining the delivery of health care services by the 
federal government to American Indians in the Great Plains and 
throughout the country.
    The IHS has the important mission of carrying out our federal 
government's trust responsibility to provide health care services to 
Native Americans. Most people living in tribal communities rely on the 
IHS as the sole source for their health care needs.
    It is not an easy task for the IHS to meet these needs. Failed 
federal policies towards Native Americans over the past two centuries 
have resulted in this segment of the population having the highest 
levels of health disparities within our country. It is a travesty! 
Further, it is a problem that will continue to have negative impacts 
for generations to come. I spent much of my time as Chairman of this 
committee focused on increasing funding for the IHS and trying to force 
some systemic changes in the bureaucracy that plagues that agency. It 
is an agency that seems far too resistant to change.
    In 2010, as Chairman of this Committee, I led an investigation that 
culminated in a report titled ``The Urgent Need to Reform the Indian 
Health Service's Aberdeen Area'' that was issued in late 2010. The 
extensive investigation was prompted by years of serious complaints 
about the healthcare services provided throughout tribal communities in 
my home state and the surrounding states. I have traveled to hundreds 
of tribal nations and communities, met with thousands of individuals, 
and tribal leadership. Although histories, cultures, and languages may 
be diverse, one theme was always consistent--the challenges of 
accessing healthcare and life-saving services. That combined with very 
serious allegations about mismanagement, theft, and full-scale 
healthcare rationing led me to launch this investigation.
    Let me be clear about the purpose of the investigation and report: 
it was not intended to criticize specific employees of the IHS. In 
fact, I have found that the IHS is full of passionate, committed 
employees who seek out their positions to serve and care for their 
families, loved ones, and community members. While there are definitely 
some problem employees within the IHS, merely replacing employees will 
not solve the systemic problems.
    The purpose of the investigation and report was to identify the 
systemic problems within the IHS so that Congress could force changes 
needed to solve the problems and improve the delivery of health care.
    The purpose was to let Congress know about patients like Ardel Hale 
Baker who while having a heart attack could not get lifesaving 
treatment but instead had a deferral letter taped to her leg saying 
that if any hospital treated her, the IHS did not have the money to pay 
for her treatment.
    The purpose of the report was to inform lawmakers about the tens of 
thousands of dollars being spent on expensive temporary healthcare 
providers rather than hiring fulltime doctors, the lost and mismanaged 
equipment, and kids not getting mental health services in communities 
with suicide rates ten times the national average.
    The goal of the investigation was to identify challenges and compel 
major changes within the IHS system in order to save lives. This 
government has a solemn obligation to our First Americans to provide 
adequate healthcare and there is an agency--the Indian Health Service--
specifically charged with that task. Yet, we continue to see the same 
problems plague that agency year after year without real progress being 
made to improve the system. This is unacceptable and I hope the 
Committee will continue to put a spotlight on the IHS until real 
improvements are made.
    Our investigation included: reviewing over 140,000 pages of 
documents; visiting and interviewing three IHS service units; and 
meeting with tribal leaders and IHS employees. Over the course of the 
investigation, more than 200 individuals also reached out to the Senate 
Committee on Indian Affairs to share stories related to the IHS' 
healthcare delivery system.
    In September of 2010, the Committee held a hearing on the findings 
of the investigation. The hearing highlighted deficiencies in IHS 
management, employee accountability, financial integrity and oversight, 
which led to reduced access and quality of health care services 
available in the Great Plains region. Testimony for a second hearing 
was collected and included in the final report, which was released in 
late-December 2010.
    The findings of the final report revealed policies and practices 
within the IHS that negatively impact healthcare provided to tribal 
patients. I will briefly highlight some of the more significant 
findings today, but encourage people to read the full report. Some of 
the major findings from the 2010 report are as follows:

   Over a ten year period, IHS repeatedly used transfers, 
        reassignments, details, or lengthy administrative leave to deal 
        with employees who had a record of misconduct or poor 

   There were higher numbers of Equal Employee Opportunity 
        (EEO) complaints in the Aberdeen (Great Plains) Area compared 
        to the entire IHS, as well as insufficient numbers of EEO 
        counselors and mediators.

   Three service units had a history of missing or stolen 
        narcotics and nearly all facilities failed to provide evidence 
        of performing consistent monthly pharmaceutical audits of 
        narcotics and other controlled substances.

   Three service units experienced substantial and recurring 
        diversions or reduced health care services from 2007 to 2010, 
        which negatively impacts patients and quickly diminishes 
        limited Contract Health Service (CHS) funding.

   Five IHS hospitals were at risk of losing their 
        accreditation or certification from the Centers for Medicare 
        and Medicaid Services (CMS) or other deeming entities. Several 
        Aberdeen Area facilities were cited as having providers with 
        licensure and credentialing problems, Emergency Medical 
        Treatment and Active Labor Act (EMTALA) violations, emergency 
        department deficiencies or other conditions that could place a 
        patient's safety at risk.

   IHS lacked an adequate system to detect instances of IHS 
        health care providers whose licenses have been revoked, 
        suspended or under other disciplinary actions by licensing 

   Particular health facilities continued to have significant 
        backlogs in posting, billing and collecting claims from third 
        party insurers (i.e., Medicare, Medicaid and private insurers). 
        One facility repeatedly transferred its third party payments to 
        other facilities in the Aberdeen (Great Plains) Area.

   There were lengthy periods of senior staff vacancies in the 
        Clinical Director and Chief Executive Officer positions, 
        resulting in inconsistent management and leadership at Aberdeen 
        Area facilities.

   The use of contract providers (locum tenens) was costly 
        ($17.2 million in the last three years). While the overall cost 
        of contract providers had decreased compared to 2009, two 
        facilities had increased their locum tenens expenses in 2010.

    The findings of the report paint a very stark picture of the IHS 
and its ability to provide adequate health care services to Native 
Americans. Some of my colleagues in Congress at the time read these 
findings and suggested that maybe one solution was to completely 
eliminate the IHS. But, that is not a realistic solution. There are 
some wonderful, dedicated individuals who do their best, amid 
substantial challenges, to provide necessary, lifesaving care every 
day. And, there are some IHS facilities that are performing well and 
have the support of the local tribal community. The reality is that 
many tribal communities in remote areas need facilities located on 
their lands to serve their people and others living on their lands. The 
facilities that are doing well provide services in a culturally 
appropriate manner, are well-managed, and regularly engage with the 
local tribal leadership and community about how to improve access to 
    I believe that addressing a few key issues would substantially 
improve the IHS system: (1) Congress needs to improve the level of 
funding to the IHS, (2) the leadership of IHS needs to focus on 
recruiting and properly training individuals who can be good managers 
of the IHS Service Units, (3) problem employees who are underqualified 
or violate laws need to leave the IHS, and (4) IHS needs to focus on 
health professional recruitment.
    The IHS is severely underfunded compared to other federal agencies. 
You may have heard the phrase ``Do not get sick after June,'' because 
if you do, you will not be able to get care. This, to me, is a 
rationing of health care--care that is guaranteed by treaty. If we 
start funding IHS at levels commensurate with need, I believe we will 
solve a lot of the issues revealed in the 2010 report and the ones 
occurring elsewhere in this country.
    Funding challenges aside, it is also clear that the IHS--and tribal 
patients--would benefit from improving accountability and oversight 
within IHS. But, accountability and oversight cannot be improved if you 
do not have adequate managers. One of the biggest concerns that I heard 
from on-the-ground employees was the lack of good managers. After 
investigating the matter, it became clear to me that many problem 
employees get transferred and promoted in order to get them out of 
their existing environment. Over time, this led to some of those 
problem employees being placed in senior positions of the health 
facilities for which they were underqualified. This situation led to 
many of the day-to-day employees feeling demoralized, unhappy with 
their jobs, and many good employees ended up leaving the IHS. The vast 
majority of the problems identified in the report could be resolved if 
there was a concerted effort by the IHS national leadership to recruit 
good, qualified, and experienced managers.
    Once you have good managers in place, the issue of problem 
employees can be properly addressed. When an employee engages in 
misconduct, there need to be systems in place that deal with, and 
correct, that behavior. It is not enough to simply transfer that 
employee to another facility, where they will inevitably engage in the 
same misconduct, and hope the problem goes away on its own. We saw this 
pattern repeat itself again and again. And, it led to the good 
employees within the IHS becoming disgruntled, inefficient, and 
ultimately poor performing.
    I know that there have been genuine efforts by some senior level 
career IHS officials to address these problems, but the problems 
persist. I long worked with Robert McSwain at the IHS, to try and 
address some of these problems, but in some circumstances, the problems 
have gotten worse. I know that the Winnebago Hospital, which is located 
in the Great Plains region of the IHS, recently lost its accreditation 
from the U.S. Centers for Medicare & Medicaid Services (CMS) for its 
in-patient and emergency services managed by the IHS. I do not know all 
of the details surrounding this situation, but am aware that CMS 
conducted an investigation and concluded that there were deficiencies 
that represented an immediate jeopardy to patient health and safety. 
And, unfortunately, the CMS investigation was started only after a 
death of a patient. Too often these problems are ignored until there is 
a tragedy. We know what the problems are, and while finding solutions 
will be difficult, spending the time to solve these problems is worth 
    When I retired from the Senate, I created the Center for Native 
American Youth to raise awareness of the challenges that Native 
American children face and to find solutions to teen suicide, substance 
abuse, high drop-out rates, and many others. We are making significant 
progress on tackling those issues by partnering with tribal leaders, 
tribal organizations, community members, and parents who work hard each 
day--with limited resources--to address the challenges faced by their 
children. We are also working with federal agencies, like IHS, to 
ensure that Native youth are a priority and that agencies are doing all 
that they can to meet their needs.
    Over the last five years we have connected face-to-face with more 
than 5,000 youth to hear directly from them about their priorities; 
held public events to raise awareness of Native youth issues; convened 
a quarterly roundtable series with over 30 federal agencies and ten 
national tribal organizations to increase coordination and 
collaboration among those important entities; and celebrated Native 
youth through our Champions for Change program and the Generation 
Indigenous initiative. Our work is framed around listening to Native 
American children and working with tribal communities to elevate and 
address their priorities.
    During our discussions with youth, we hear time and time again that 
their health is a priority for them, yet they are unable to receive the 
healthcare they need. Whether it is dental care, mental health services 
or routine check-ups, youth are not able to access what they need in 
order to lead full, healthy and successful lives. This has to change. 
Native children are already facing a steep uphill climb when compared 
to their non-Native peers on a variety of issues. Suffering in pain or 
in sickness because they cannot get into a doctor should not be one of 
    As I mentioned, we interact with young Native Americans every day. 
Within our Champions for Change program we have some especially 
talented young people who are addressing health and access to care in 
their home communities. Cierra Fields, a high school student from the 
Cherokee Nation works with her tribe to promote diabetes prevention and 
cancer awareness among her peers. Another Champion, William Lucero, a 
college student from the Lummi Nation, has spent several years 
educating his peers and other community members about the dangers of 
smoking. Lastly, Joaquin Gallegos, a recent college graduate from the 
Jicarilla Apache Nation and Pueblo of Santa Ana, has worked tirelessly 
to expand access to much-needed dental care for tribal nations. We need 
to ensure that amazing young people like these three have the health 
care they deserve so that they can continue to do great work for their 
    I want to again thank the Committee for taking the time to examine 
this important issue, and I would like to offer the Center for Native 
American Youth as an ongoing resource to you. Thank you.

    The Chairman. Thank you, Senator Dorgan. You are always 
welcome here. You are family on the Committee dais. It is 
wonderful to see you. Thank you for that compelling testimony 
once again highlighting the needs of so many people. You do 
think with your heart and we are grateful for you.
    Senator Dorgan. Thank you.
    The Chairman. We will now hear from our second panel of 
witnesses. As Senator Dorgan mentioned, Mary Wakefield will be 
first to testify. I would ask the second panel to please come 
    Mary is a Ph.D., R.N. and Acting Deputy Secretary, U.S. 
Department of Health and Human Services. We will also hear from 
Mr. Andy Slavitt, Acting Administrator, Centers for Medicare 
and Medicaid Services. He will be accompanied by: Mr. Thomas 
Hamilton, Director, Survey and Certification Group, Center for 
Clinical Standards and Quality, Centers for Medicare and 
Medicaid Services. We also have with us the Honorable Robert G. 
McSwain, Principal Deputy Director, Indian Health Service, U.S. 
Department of Health and Human Services. We also have Susan V. 
Karol, M.D., Chief Medical Officer, Indian Health Service, U.S. 
Department of Health and Human Services.
    Thank you all for being here. I will remind the witnesses 
that your full written testimony will be made a part of the 
official hearing record. Please keep your statements to five 
minutes so that we may have time for questions.
    We look forward to your testimony beginning with Dr. 
Wakefield. Please proceed.


    Dr. Wakefield. Chairman Barrasso, Vice Chairman Tester and 
members of the Committee, thank you so much for inviting me 
here today to discuss the quality of Indian health care on the 
Great Plains.
    Let me start by saying that the deficiencies cited in the 
reports by the Centers for Medicare and Medicaid Services are 
unacceptable. They are unacceptable to me and they are 
unacceptable to the leadership of HHS.
    Our department's mission is to improve health, the health 
and well being of all Americans. As these reports have shown, 
we must do better for the Native communities that we serve.
    As was indicated, I am from North Dakota and both of my 
parents spent time working for the tribal community near us. I 
grew up witnessing firsthand the resilience of Indian Country 
and the strength with which they overcame so many challenges.
    As was indicated, I am also a nurse. From the day I started 
working in a small hospital as a nurse's aide, the reason that 
I sought a career in health care was to care for patients and 
to support families.
    I have had the privilege of caring for American Indian 
newborns in a hospital nursery and American Indian elders in 
nursing homes. I have also seen firsthand some of the best that 
IHS has to offer. I know there are many dedicated healthcare 
professionals who are committed to serving their tribal 
communities well. To me any failure in the quality of care that 
patients and their families receive is one failure too many.
    Today I want to discuss with you our actions to address 
challenges in the Great Plains area. We have an intense effort 
underway right now to address the problems cited by CMS at 
these three hospitals. To assist IHS in these efforts, 
additional Commissioned Corps officers are augmenting IHS 
personnel now in the Great Plains region.
    More broadly though, we have instructed the leadership of 
IHS to redouble their efforts to ensure that sustained quality 
care is delivered consistently across IHS facilities. To 
facilitate this, we have augmented leadership at both the local 
level and also at the national level to implement our 
expectations for high quality, consistent and sustained care.
    As part of this effort, IHS has hired two new deputy 
directors, two leaders, Mary Smith, an enrolled member of the 
Cherokee Nation and a longtime advocate for Indian communities 
who has been at IHS for about four months. As deputy director, 
she has a primary focus on management.
    IHS created a new position, Deputy Director of Quality 
Health Care, late last year. Dorothy Dupree is an enrolled 
member of the Fort Peck Assiniboine Sioux Tribes and the former 
Acting Area Director in Billings. She just joined us recently 
in this role.
    From the Phoenix IHS, Dorothy led the implementation of 
groundbreaking quality improvements. These improvements are 
being refined, expanded and considered for wider 
    In her new role, Dorothy is working closely with tribal, 
State and local partners to execute a quality strategy that 
improves safety and the patient's health experience. In 
consultation with tribes, this strategy will be implemented for 
the Northern Plains facilities and broadly across IHS 
    However, IHS is not the only part of HHS that serves these 
populations. That is why we are also establishing a council of 
senior executives across HHS. We will have programs that serve 
American Indians and Alaska Natives.
    This executive council on quality care will use their 
expertise from across the department to ensure that our 
resources are closely aligned and leveraged on behalf of 
American Indian families and communities. Specifically, this 
group will augment IHS's efforts to ensure that sustained 
quality care is delivered across IHS facilities.
    In addition, this group will address the long term, chronic 
challenge of provider recruitment and retention. Among other 
factors, the remote locations of Native communities, the 
housing shortage, and employment opportunities for spouses 
contributes to staffing shortages at many of these facilities.
    This group will use their combined expertise to further 
leverage and develop new approaches to addressing workforce 
shortages. I will give you an example.
    When I served as the Administrator of the Health Resources 
and Services Administration, we cut red tape and made all IHS 
facilities eligible as National Health Service Corps sites. 
Before we made these changes, there were about 100 approved 
tribal sites with 150 National Health Service Corps clinicians 
serving these communities.
    Today, we have more than 670 tribal sites that host more 
than 420 National Health Service Corps clinicians. We want to 
develop more ideas like this from our senior leaders who serve 
these communities.
    Finally, we look forward to working in partnership with you 
to enact the President's budget for fiscal year 2017. We do 
need the financial resources to invest in the high quality care 
that these communities deserve.
    This Administration takes the challenges to delivering high 
quality care to these communities very seriously. You have my 
commitment that we will work tirelessly to make meaningful, 
measurable progress. We will undertake that work with you, 
tribes and our IHS health professionals in close consultation.
    Thank you so much.
    [The prepared statement of Mr. Wakefield follows:]

   Prepared Statement of Mary Wakefield, Ph.D., R.N.; Acting Deputy 
        Secretary, U.S. Department of Health and Human Services
    Chairman Bai-rasso, Vice Chairman Tester, and Members of the 
    Good Afternoon. I am Mary Wakefield, acting Deputy Secretary for 
the Department of Health and Human Services. I am pleased to join you 
today to discuss the Great Plains Area Indian Health Service (IHS) 
Hospitals. I want to begin by assuring you that Secretary Burwell and I 
are committed to working hard to provide high quality care for the 
American Indian and Alaska Native people we serve and are committed to 
making improvements to the quality of the care that we provide.
    By way of background, I am a native of North Dakota. At different 
points in time, both of my parents worked for a neighboring tribal 
community. Through those early ties, and my own subsequent interactions 
with American Indian communities in training nurses and working in 
rural health policy, the remarkable strengths of Indian people and the 
challenges they face are familiar and very much appreciated by me. 
Before becoming acting Deputy Secretary, I was the Administrator of the 
Health Resources and Services Administration (HRSA) for six years. 
During my time there, I made working with tribes and Indian people a 
priority. Consistent with Secretary Burwell's vision, I am working to 
leverage other Agency assets beyond IHS programs to help strengthen the 
health care services we provide to Indian country; in Indian Country. 
The challenges facing hospitals in Indian Country, and those that IHS 
is responsible for helping to address include challenges that are 
common to many hospitals in rural America, such as being less able to 
take advantage of economies of scale because of low volume and 
difficulties in recruiting and retaining qualified healthcare 
    I also recognize that, although facing issues similar to many rural 
hospitals, the IHS has a mission that differs from other hospitals. 
There are circumstances that are unique to AI/AN communities, including 
ensuring that they receive culturally sensitive health care services. 
These and other important characteristics influence both what care is 
provided, as well as how that care is provided Those issues range from 
the behavioral health issues related to historical trauma that the 
Substance Abuse and Mental Health Services Administration (SAMHSA) 
works in tandem with IHS to address, and the economic conditions that 
the Administration for Children and Families (ACF) works with tribes to 
address, to the special needs of Indian elders that the Administration 
for Community Living (ACL) works to help tribes meet. For example, 
SAMHSA's Native Connections grants help tribes reduce suicidal behavior 
and substance use and promote mental health among Native youth. ACF 
funds tribal TANF programs to help Indian families in poverty that 
reach nearly 300 tribes and Alaska Native Villages. And ACL's Older 
Americans Act Title VI program helps fund tribes to provide the 
delivery of home and community-based supportive services for their 
elders, including nutrition services and support for family and 
informal caregivers. These and other HHS programs support tribes so 
that they can provide health and social services for their people in a 
culturally appropriate manner.
    At HHS, we strive to work together with and for Indian Country, to 
leverage programs and resources that support better outcomes for tribal 
communities. We fully recognize the trust relationship with the tribes 
and the need for meaningful consultation. As part of this recognition, 
former Secretary Sebelius established a new tribal leader advisory 
committee that continues to meet with our Secretary and senior 
leadership from around the department on a quarterly basis and provides 
us with a valuable venue for consultation.
    Fundamental to meeting the needs of Indian Country are effective 
program deployment and financial resources. Under President Obama, with 
the support of many of you, funding for IHS has increased by 43 
percent. The President's Budget for FY 2017 will continue to prioritize 
IHS and we look forward to continuing to work with you to enact the 
    The Administration has also renewed its focus on improving the 
lives of Native youth through the Generation Indigenous initiative. At 
HHS, we work with Native youth through a variety of programs. We have 
requested additional resources targeted to provide more and better 
behavioral health for young people and we appreciate your help in 
securing $15 million in the recent omnibus for the Native Connections 
grants I mentioned earlier.
    Now I would like to offer an example of our work across HHS on 
behalf of tribal communities. As a series of tragic suicides began to 
unfold on the Pine Ridge reservation in South Dakota last winter, we 
engaged resources from across HHS, and other cabinet agencies, to 
respond. Within HHS, our Public Health Service Commissioned Corps 
officers deployed to provide immediate additional behavioral health 
services. IHS has also added telebehavioral health services to reach 
the reservation community and we are supporting counselors in schools 
on the reservation on a weekly basis. IHS has also added case manager 
positions to the behavioral health department to help follow-up on 
patients and to be resources for families. And, over the past year, 
other HHS agencies and programs have provided additional resources and 
support to the community.
    For example, ACF's Administration for Native Americans provided 
additional funding to help youth with summer jobs and the development 
of youth councils in the community. HRSA recently awarded the Tribe a 
telehealth grant that they will use to partner with Avera McKennan 
Health System to expand access to health and social services through 
school-based telehealth services. We have partnered with the Department 
of Education to convene the 17 schools across the reservation to 
strengthen their existing collaborations to address the needs of school 
aged youth around critical needs such as nutrition assistance, native 
language support, and immediate crisis response. Additionally, SAMHSA 
has worked closely with the Tribe and extended their current suicide 
prevention grant. The intent is to support suicide prevention efforts, 
assist with the response to the suicide cluster, and help the Tribe 
develop comprehensive suicide prevention activities with the goal of 
minimizing future suicide clusters. A SAMHSA Emergency Response Grant 
is also being awarded to the Tribe to help meet the continued urgent 
need to combat suicides. While today's hearing focuses on reviewing 
care at these Great Plains facilities, we believe it is essential to 
continue to focus on exploring ways that the Administration, Congress 
and Tribal Nations can work together to strengthen behavioral health as 
part of the package of health care services for these tribal 
communities as well.
    And access to behavioral health services is a concern not only for 
Pine Ridge and other tribal communities served by the Great Plains IHS 
facilities, it is also a concern for tribal communities across the 
nation. The FY 2017 President's Budget will continue to prioritize 
behavior health services and we look forward to discussing these 
initiatives once the President's Budget is released in early February.
    We know that more needs to be done to ensure quality health care is 
provided by IHS.
    In terms of the specific issues that the Committee is reviewing 
today, it is our intent to further strengthen not only IHS' work, but 
also the engagement of other parts of the department to assist IHS in 
improving the quality of care at these facilities. Let me share a 
couple of examples.
    First, CMS is providing both technical assistance to a number of 
IHS hospitals and regular reviews to monitor the quality of these 
health care services, as detailed in the statement of Acting 
Administrator Slavitt. For example, in the past, IHS hospitals have 
benefitted from technical assistance provided by Quality Improvement 
Organizations (QI0s) that operate under contract with CMS. Going 
forward, CMS and IHS are working together to explore ways that the 
Quality Improvement Program can continue to more directly provide 
support to the IHS and its hospitals, on a sustained basis, as part of 
the most recent QI0 Scope of Work. Through a strong relationship 
between CMS and IHS, increased technical support to IHS Area and 
hospital leadership and by addressing other underlying systemic issues, 
quality improvements will have a lasting impact, leading to a stronger 
focus on a culture of patient safety. Secondly, as I think we all 
recognize, staffing is a perennial challenge for IHS, given that its 
facilities are often in remote communities with shortages of housing 
and employment opportunities for spouses, challenges that are similar--
and often more acute--than what we see in many other rural remote 
communities across the United States. Recognizing the staffing needs of 
hospitals in Indian Country, while I was at HRSA, we expanded the 
availability of National Health Service Corps-supported providers to 
IHS by making all IHS facilities eligible NHSC sites. Prior to 
eliminating the requirement for Tribal sites to apply to be NHSC sites, 
there were approximately 100 approved sites with about 150 NHSC 
clinicians working at those sites as of July 201 1. Today, there are 
more than 670 approved Tribal sites and more than 420 NFISC clinicians 
providing primary health care across Indian Country. Still, we 
recognize that there is unmet need for clinicians and more to be done. 
Looking forward, the President's FY 2017 Budget will continue to 
prioritize staffing at IHS facilities.
    Recognizing the challenges IHS facilities face in the northern 
plains and elsewhere, and the opportunity to strengthen other efforts, 
at the Secretary's direction, we recently augmented the senior 
leadership team at IHS with two additional deputies that bring 
significant expertise to the Agency. Mary Smith, an enrolled member of 
the Cherokee Nation, joined IHS a few months ago as Deputy Director and 
brings an array of experience in Native American policy, including 
health policy, as well as state-level work in health care policy, 
implementation, and compliance. A long-time advocate for Indian people, 
she is already working to further strengthen efforts that cross agency 
and departmental lines with an eye toward achieving meaningful and 
lasting impact in many policy and operational priorities at IHS.
    We have also recently named Dorothy Dupree as Deputy Director, 
Quality Health Care. As some of you know, Ms. Dupree, an enrolled 
member of the Fort Peck Assiniboine Sioux Tribes, was most recently the 
Area Director for the Phoenix IHS Area and also served as the acting 
Area Director in Billings, where she focused on improving quality of 
care concerns. Ms. Dupree's priority was to ensure strong 
communications with tribal leaders and in using knowledge gained 
through data analytics to improve quality of care. She too brings 
substantial expertise in strengthening financial and clinical 
operations of health care facilities and her responsibilities include 
working with our direct service facilities to provide higher quality of 
care, and achieving that aim by working with external partners 
including tribal, state and other federal agencies. With Ms. Smith, Bob 
McSwain and the other IHS leaders, Ms. Dupree is mapping a Quality 
Strategy that includes northern plains facilities with patient safety 
and the patient experience as central to this strategy. It will include 
a focus on developing stronger data analytic capacity, improving 
training, and ensuring that facility governing boards are effectively 
working to monitor and improve quality of care.
    In summary, we recognize there are significant challenges facing 
hospitals in the Great Plains area that need to be fully addressed. The 
Secretary had directed actions to be taken, some of which I have 
outlined, and we will be taking additional actions in our work toward 
achieving the goal of high quality health care for American Indian and 
Alaska Native populations. We take the challenges we are here to 
discuss today very seriously and you have our commitment to work to 
make meaningful progress.
    Thank you. I welcome your questions.

    The Chairman. Thank you.
    Mr. Slavitt.


    Mr. Slavitt. Chairman Barrasso, Vice Chairman Tester, and 
members of the Committee, thank you for the invitation to 
discuss the quality and safety of health care provided at 
Indian Health Service facilities in the Great Plains.
    At CMS, we work directly with tribal leaders on the 
important issues which affect health care in the American 
Indian community, including expanding access to tribally 
operated behavioral health programs, working with States on 
waivers to expand Medicaid coverage and as it relates to this 
hearing, we evaluate and certify the quality and safety of 
hospitals that serve American Indian populations who are 
Medicare or Medicaid beneficiaries.
    As this Committee well knows and as Senator Dorgan 
mentioned, healthcare quality for American Indians and Alaska 
Natives has been a significant concern in this Country. It was 
highlighted by this Committee's report in 2010 and identified 
serious, ongoing patient safety issues at several Aberdeen area 
    More recently a 2013 Kaiser report found that American 
Indians and Alaska Natives are disproportionately likely to be 
in poor or fair health and suffer from serous conditions like 
diabetes and cardiovascular disease among others.
    I mention these reports to acknowledge that providers in 
the largely remote area of Indian Country face substantial and 
longstanding challenges. Nonetheless, our role at CMS is to 
enforce the same high standards of care and safety for the 
American Indian population as for all others we serve.
    I am joined today by Thomas Hamilton who directs CMS's 
Survey and Certification Group. Thomas and his team are charged 
with the day-to-day work of holding institutions that 
participate in the Medicare Program accountable to provide safe 
medical care no matter who their patients are, and no matter 
where they live, no matter where they seek medical attention.
    To achieve this, CMS requires that all facilities serving 
Medicare and Medicaid beneficiaries, including Indian Health 
facilities, comply with health and safety requirements, that we 
conduct objective on-site assessments to make sure these 
conditions are being met and to call attention to and take 
action in situations where they are not.
    Since 2010, CMS has conducted 18 separate on-site surveys 
at three hospitals: Omaha Winnebago, Pine Ridge Hospital and 
Rosebud Hospital. We identified violations of our safety 
standards in all three.
    Problems have included the hospitals' inability to respond 
appropriately to emergency situations, perform necessary 
screenings and diagnostic tests and ensure staff competencies. 
More details are available in our public survey reports and in 
our written testimony.
    After each survey, we have shared the findings with 
hospital leadership and required plans of action. After several 
years of improvement efforts and evaluations, out of concern 
for patients who were observed at these facilities, last year 
we terminated one of the hospitals, Omaha Winnebago, from the 
Medicare program.
    Recently, we issued two notices of potential Medicare 
termination to two other hospitals, Pine Ridge and Rosebud. 
Management at these facilities is currently in the process of 
responding to the survey findings.
    We appreciate the challenges that operators of these 
facilities face as the survey findings indicate the need to 
address serious, longstanding problems to protect the people 
and their communities.
    Given the systematic nature of some of the issues, 
including the universal challenges often faced by healthcare 
providers in rural and remote areas, CMS has been trying to do 
more than just evaluate the problems but provide resources to 
help the hospitals.
    Over the last five years, we have trained over 500 IHS 
staff in areas of quality and safety and have brought technical 
resources into three hospitals mentioned here today that 
specialize in working through root cause issues and improving 
patient safety.
    We know the challenges are significant and that much work 
remains. As long as patient safety is at risk, we stand ready 
to work side by side with these hospitals and provide whatever 
help we can. We are eager to participate actively in the HHS 
Council on Quality Care mentioned by Acting Deputy Secretary 
Wakefield. We believe this can have significant benefits.
    While the ultimate responsibility for sustained improvement 
lies in the hands of the leaders of these facilities and 
frontline workers, we are committed to doing our part to assist 
the IHS in raising the quality of care for the American Indian 
community served in these hospitals.
    I appreciate the Committee's attention and interest in 
these extremely important subjects. We will be pleased to take 
your questions.
    [The prepared statement of Mr. Slavitt follows:]

 Prepared Statement of Andy Slavitt, Acting Administrator, Centers for 
                     Medicare and Medicaid Services
    Chairman Barrasso, Vice Chairman Tester, and members of the 
Committee, thank you for the invitation to discuss the Centers for 
Medicare and Medicaid Services' (CMS') work to monitor the quality of 
health care provided at Indian Health Service facilities. CMS is 
committed to ensuring the safety of the millions of Americans who rely 
on the U.S. health care system every day. To monitor the safety of care 
provided throughout the country, CMS requires that all facilities 
seeking participation in Medicare and Medicaid comply with basic health 
and safety requirements set forth in the Medicare Conditions of 
Participation (CoPs). The Survey and Certification process is used by 
CMS to assess compliance with these requirements. It is CMS' duty to 
provide objective, onsite assessments of the quality and safety in 
health care facilities, properly identify any deficiencies, and require 
that timely corrections are made to any identified deficiencies. We 
understand that our responsibilities and enforcement requirements may 
bring challenges to health care facilities, and CMS is committed to 
working with facilities and providers in good faith as they strive to 
deliver safe, high quality care.
    CMS has fulfilled this role in our work with Indian Health Service 
(IHS) facilities in the Great Plains area. CMS surveyors have conducted 
numerous recertification and complaint surveys at IHS facilities, 
required that corrective action be taken, and monitored their progress 
in addressing identified deficiencies. Also, in an effort to help IHS 
hospitals better understand the requirements of the CoPs and address 
quality deficiencies, CMS has provided considerable technical 
assistance to a number of IHS hospitals. For example, CMS encouraged 
administrators at IHS hospitals to participate in compliance training, 
and has trained 565 IHS staff to date as a part of that effort. CMS 
also provided onsite technical assistance to staff at the Pine Ridge 
hospital to help staff understand the quality and safety expectations 
embodied in CMS regulations. In addition, Quality Improvement 
Organizations (QIOs), under contract with CMS, provided technical 
assistance at IHS hospitals (specifically Winnebago) with regard to 
methods that the hospitals could use to meet Plan of Correction (PoC) 
requirements. These CMS efforts were intended to support and bolster 
the IHS' own system-wide efforts to provide technical assistance, 
training, and personnel actions that might address quality of care 
CMS Survey and Certification
    CMS maintains oversight for compliance with the Medicare health and 
safety standards for laboratories, acute and continuing care providers 
(including hospitals, nursing homes, home health agencies, end-stage 
renal disease facilities, hospices, and other facilities serving 
Medicare and Medicaid beneficiaries). CMS' Medicare CoPs for hospitals 
set out quality and safety standards on a wide range of topics such as 
emergency treatment, infection control, medication management, 
credentialing and privileging of physicians, and responsibilities of 
the hospital's governing body to ensure safe care.
    Generally, State survey agencies (SAs) \1\ conduct hospital 
recertification surveys every three years on behalf of CMS to assess 
facility compliance with Medicare CoPs and the Emergency Medical 
Treatment and Labor Act (EMTALA) requirements. However, CMS surveyors 
may also conduct these surveys, as is the case with IHS facilities. 
EMTALA requirements impose specific obligations on Medicare-
participating hospitals that offer emergency services to screen, treat, 
or appropriately transfer patients, regardless of their ability to pay. 
Surveyors also investigate complaints alleging hospital noncompliance 
with CoPs. A hospital cannot participate in Medicare unless it meets 
each and every CoP. As part of the CoPs, surveyors conduct Life Safety 
Code surveys to ensure the safety of patients from fire, smoke and 
other environmental hazards. These standards apply to all Medicare 
hospitals to ensure basic health and safety standards. Under section 
1865 of the Social Security Act, CMS has also approved four accrediting 
organizations (AOs) for hospitals whose standards and survey processes 
are determined to be equivalent to those of CMS. CMS deems a hospital's 
accreditation by an approved AO to be sufficient for Medicare 
certification. The AOs conduct recertification surveys at least once 
every three years for hospitals. CMS retains the right to conduct 
complaint investigations of accredited facilities, and remove a 
provider's deemed status if CMS finds serious deficiencies. CMS also 
conducts validation surveys of a sample of accredited hospitals to 
check on the adequacy of the AO surveys.
    \1\ For IHS facilities, Accrediting Organizations (AOs) or Federal 
surveyors conduct recertification and complaint reviews. This is due to 
their status as a federal facility.
    The survey and certification process includes, but is not limited 
to, conducting surveys to determine whether health care entities comply 
with Medicare CoPs or requirements; and conducting enforcement actions 
when these entities are found to be out of compliance with the Medicare 
CoPs. For example, during a hospital survey, the surveyors examine the 
hospital's health records, interview staff and patients and observe the 
processes of care. This includes observing doctors and nurses as they 
provide emergency services to assess the facility's ability to 
adequately provide emergency screenings and services.
    As a result of the survey, the SA or CMS may find the hospital in 
violation of Medicare's CoPs, EMTALA, or find that the hospital has 
deficiencies so serious that they constitute an immediate and serious 
threat to the health and safety of patients, referred to as immediate 
jeopardy (IJ). Hospitals have 23 days to correct IJ violations and 90 
days to correct other CoP and EMTALA violations to avoid termination 
from the Medicare program.
If Deficiencies are Found
    If any deficiencies are found during the survey, the SA certifies 
that the facility is non-compliant and recommends termination to the 
CMS Regional Office (RO). The RO then sends the institution a 
``Statement of Deficiencies'' outlining deficiencies that were 
identified during the survey. CMS follows a specific timeline for every 
hospital where deficiencies are found. \2\ First, the institution is 
given five calendar days to respond to deficiencies at the IJ level or 
10 calendar days in which to respond to less serious CoP or EMTALA 
deficiencies. The response must include a PoC for each cited 
deficiency, which is included on the form containing the statement of 
deficiencies. Once a facility has made a credible allegation of 
compliance, \3\ surveyors conduct a revisit to determine whether 
compliance with the CoP or acceptable progress towards compliance has 
been achieved. Only two revisits are generally permitted in the 
hospital setting; one within 45 calendar days and one between the 46th 
and 90th calendar days. If compliance is achieved, the facility goes 
back to the regular certification schedule.
    \2\ https://www.cms.gov/Medicare/Provider-Enrollment-and-
    \3\ Credible allegations of compliance include, a statement or 
documentation that is realistic in terms of the possibility of the 
corrective action being accomplished, and that indicates resolution of 
the problem.
    If compliance has not been achieved, the SA certifies that the 
facility remains non-compliant. Within 65 calendar days following the 
date of survey, the RO determines whether survey findings continue to 
support a determination of noncompliance. If all requirements are met 
by the hospital, the hospital returns to its normal recertification 
    If the determination of noncompliance continues, the RO sends an 
official termination notice by the 70th calendar day to the facility, 
the public, and the State Medicaid Agency if the facility also 
participates in Medicaid. The termination generally takes effect by the 
90th calendar day if compliance has not been achieved. Termination can 
take effect in fewer than 90 days if all required procedures are 
completed. CMS sometimes extends the prospectively scheduled 
termination date if CMS requires more time to schedule or complete a 
revisit survey that is necessary to confirm that corrective action has 
restored the hospital to compliance with the CoPs, or if there are very 
unusual circumstances such as the need to make alternate arrangements 
for care of patients in remote areas.
    If an adverse action, such as a termination, is likely to be 
initiated against a Medicare participating provider or supplier, the 
CMS RO follows procedures outlined in the State Operations Manual. \4\ 
We note that every facility faced with termination from Medicare 
participation is provided with a full opportunity to take necessary 
remedial action and demonstrate compliance with the CoPs before the 
prospectively-scheduled Medicare termination date. In addition, if the 
institution disagrees with the finding of noncompliance, it may request 
a hearing before an administrative law judge of the Department of 
Health and Human Services, Departmental Appeals Board within 60 
calendar days of the final CMS notice of termination. Finally, any 
provider that CMS has involuntarily terminated from Medicare 
participation has the right to apply for reinstatement at any time. To 
be reinstated, subsequent onsite surveys must confirm not only that the 
provider has restored its services to compliance with the CoPs, but 
that the provider demonstrates reasonable assurance that the 
deficiencies which led to involuntary termination are not likely to 
    \4\ https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
    We appreciate that, in some circumstances, Medicare termination of 
a provider may cause or increase access to care problems for 
beneficiaries. While such considerations do not influence in any way 
the proper identification of quality or safety deficiencies, we can 
consider such factors in the selection of enforcement methods. In an 
effort to balance patient access to care while ensuring high quality 
health care, CMS considers factors such as patient driving times to the 
next nearest facility, specialized services provided at the nearest 
facility, and the identified facility's ability to achieve and maintain 
substantial compliance with CoPs. If patient access to care may be 
greatly affected, CMS may look into additional options to help preserve 
beneficiary access to care and help the hospital meet CoP and EMTALA 
requirements. An example that CMS has used in rare but serious access 
to care situations is a Systems Improvement Agreement (SIA). An SIA is 
an agreement, voluntarily entered into by CMS and a hospital that 
obliges the hospital to engage in a specified regimen of quality 
improvement, and make significant investments in improving the quality 
of care, in exchange for more time to make needed systemic improvements 
before Medicare termination would take effect. All of these 
requirements and timelines are available for public review in the State 
Operations Manual and in CMS regulations. \5\ CMS, SA, and AO conduct 
CoP and EMTALA education and outreach to hospitals through Open Door 
Forums, and additional assistance is also provided to facilities from 
Quality Improvement Organizations (QIOs).
    \5\ https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
Internet-Only-Manuals-IOMs-Items/CMS1201984.html. The SIA content for 
organ transplant programs may be found at 42 CFR 488.61(h).
    Both private and IHS hospitals in the Great Plains area face a 
number of challenges including their location in rural areas and 
difficulty attracting qualified administrators and physicians to work 
in their facility. Due to these and numerous other factors, three IHS 
hospitals, as described below, have had challenges meeting CoP and 
EMTALA requirements in recent years.
Issues Identified at the Winnebago Indian Health Service Hospital
    CMS surveyors have been investigating and monitoring complaints 
made regarding Winnebago Indian Health Service Hospital. CMS conducted 
a complaint survey of the hospital on April 8, 2011 and found the 
hospital to be in violation of various Medicare CoPs. The deficiencies 
included failure to ensure there were systems in place to inform 
patients of their rights, to promptly investigate and respond to 
patient grievances, to ensure patients have information necessary to 
make informed consent regarding their care, and to investigate 
allegations of patient abuse to assure patients are protected. Due to 
the importance of these findings, the hospital was notified that a 
Medicare survey would be conducted to assess compliance with all CoPs, 
not just those that had been the subject of the complaint.
    CMS subsequently conducted a full recertification survey on October 
14, 2011 and found the hospital to be out of compliance with nine CoPs: 
compliance with Governing Body responsibilities, Patients' Rights, 
Quality Assessment and Performance Improvement, Medical Staff, Nursing 
Services, Radiological Services, Infection Control, Organ/Tissue/Eye, 
and Emergency Services. The hospital was notified of CMS' intention to 
terminate the hospital's Medicare agreement on January 16, 2012 if it 
did not correct these violations. A variety of plans of correction and 
improvement efforts ensued, including extensive direct assistance from 
the Nebraska QIO, under contract with CMS, throughout 2013 and 2014.
    In a response to another complaint filed, the hospital was surveyed 
on April 25, 2014, and found to be out of compliance with CoPs 
concerning Nursing Services, specifically related to failure to assure 
the nursing staff were adequately trained and possessed the necessary 
knowledge and skills to ensure patients were provided safe and 
appropriate care. Surveyors determined that this noncompliance placed 
patients in IJ. CMS provided Winnebago with a termination date of May 
18, 2014. Surveyors conducted a revisit survey on May 15, 2014 that 
found Nursing Services remained out of compliance. In response to IHS 
requests for additional time, CMS conducted additional surveys and 
extended the Medicare termination date.
    An additional revisit survey, conducted on July 17, 2014, found the 
hospital remained noncompliant concerning Nursing Services and found 
that Emergency Services were also out of compliance. These concerns 
still constituted an IJ due to the survey's findings that the hospital 
failed to provide services, equipment, personnel and resources within 
timeframes that protect the health and safety of patient receiving 
medical care in the emergency department (ED); and that the hospital 
failed to maintain policies and procedures for emergency medical 
services provided to all patients who receive medical care in the ED.
    An additional survey conducted on August 27, 2014 found the 
hospital to be out of compliance with EMTALA requirements. CMS 
determined that the EMTALA violation constituted an IJ, and also found 
continuing noncompliance with the CoP of Nursing Services and Emergency 
Services. Of the 25 medical records randomly selected from the ED log 
from March 2014 to August 2014, the hospital failed to provide adequate 
medical screening examinations to three patients and failed to provide 
stabilizing treatment within its capabilities to one patient. Winnebago 
submitted a performance plan to stay the termination. As part of our 
responsibilities, CMS scheduled a full Medicare survey before the 
hospital was scheduled to be terminated from Medicare on November 6, 
2014. The termination date was later extended to December 5, 2014 to 
allow surveyors time to complete a survey report.
    On November 6, 2014, CMS surveyors conducted the full Medicare 
survey at the hospital to assess compliance with all the applicable 
Medicare CoPs and to assess that status of the noncompliance findings 
of the previous surveys. During this survey, the IJ findings cited in 
previous surveys were deemed removed and the previous noncompliance 
findings were determined to have been corrected. However, the hospital 
was found to be out of compliance with other Conditions concerning 
their Governing Body, Nursing Services, Food and Dietetic Services and 
Emergency Services. Although the deficiencies cited were serious, they 
did not constitute an IJ to the health and safety of patients. On 
November 21, 2014, CMS notified the hospital of these changes and 
extended the termination date to April 30, 2015 to allow a revisit 
survey. On April 23, 2015, the termination date was extended to June 
15, 2015, to allow the revisit to occur.
    CMS Federal surveyors then conducted revisit and complaint surveys 
on May 14, 2015 and found that the hospital was noncompliant with seven 
CoPs including: Governing Body, Nursing Services, Outpatient Services, 
Emergency Services, Appropriate Medical Screening Examination, 
Stabilizing Treatment, and Appropriate Transfer. The noncompliance was 
found to constitute an IJ. Because of ongoing noncompliance since 2011 
and repeated IJ citations, despite technical assistance from CMS and 
the Nebraska QIO and repeated PoCs prepared by the hospital, it was 
determined no further extensions would be granted and that the hospital 
would be terminated July 23, 2015. On July 8, 2015, CMS issued notice 
of final termination of Medicare participation to the hospital, 
effective July 23, 2015, with concurrent newspaper notice. The hospital 
has appealed the termination. The IHS has continued to work with the 
hospital and Tribal officials, and has engaged a consultant firm to 
assist the hospital and facilitate resolution of the problems. CMS 
stands ready to respond to a request from the hospital for a survey 
that might start a reinstatement process if the hospital is found to be 
in compliance with the CoPs.
Issues Identified at the Rosebud Indian Health Service Hospital
    To investigate an EMTALA violation complaint, Federal surveyors 
conducted a recertification survey at Rosebud Indian Health Service 
Hospital on November 16-19, 2015 and a Life Safety Code Recertification 
Survey on November 17-18, 2015. Based on the survey findings, it was 
found that the hospital was not in compliance with all of the Medicare 
CoPs for hospitals and that deficiencies put patients in IJ, 
particularly related to risk of inappropriate care in the ED. As a 
result, CMS notified the hospital of the intent to terminate on 
December 12, 2015 if the hospital did not prepare a PoC and correct 
these violations. The hospital placed its ED on diversion. IHS later 
notified CMS that it would temporarily close the ED and CMS then 
removed the IJ. Following this closure, the IJ was removed, giving the 
facility until February 17, 2016 to address its remaining ED and CoP 
compliance issues. The hospital has agreed not to reopen the ED without 
seven days prior notice to CMS to allow CMS time to conduct an onsite 
survey of the ED. CMS will also reschedule a revisit survey once the ED 
has reopened.
    On January 5, 2016, CMS also found that Rosebud Hospital was in 
violation of EMTALA requirements, specifically, failure to provide 
appropriate medical screenings and stabilizing treatment to patients 
presenting to the emergency department. On January 6, 2016, CMS sent 
the hospital a notice of intent to terminate Medicare participation due 
to the EMTALA deficiency. The hospital's PoC for the EMTALA violation 
is due to CMS on March 15, 2016 to avoid a termination date of May 19, 
Issues Identified at the PHS Indian Hospital at Pine Ridge
    On October 29, 2015, following a complaint survey of PHS Indian 
Hospital at Pine Ridge, federal surveyors identified that the hospital 
was out of compliance with three CoPs and was in violation of EMTALA. 
CMS identified concerns with the hospital's Quality Assessment and 
Performance Improvement program, which is the hospital's system for 
tracking, analyzing and developing plans to address significant issues. 
As a result, CMS gave the hospital until January 27, 2016 to correct 
these violations to avoid termination. CMS received and approved the 
hospital's PoC.
    On January 14, 2016, federal surveyors completed a revisit of this 
hospital. They found the hospital in compliance with the CoPs, but 
still in violation of EMTALA. CMS issued a termination date of February 
23, 2016 for the EMTALA violation. The hospital will have one more 
opportunity to demonstrate compliance with the EMTALA requirements 
prior to this date. CMS expects the hospital to submit a PoC prior to 
February 23, 2016. If the PoC is accepted, another revisit would occur.
    CMS remains diligent in our duties to monitor every hospital 
participating in Medicare to help ensure patient safety and access to 
care across the country. CMS surveyors have relied on longstanding 
policies when engaging with IHS facilities in the Great Plains area. It 
is our obligation to ensure all health care facilities are safe and can 
meet patient needs. CMS and QIOs have provided numerous hours of 
technical assistance to IHS facilities regarding quality improvements 
and deficiencies. We will continue to work with IHS as these hospitals 
strive to make improvements and to make sure patients are receiving 
quality health care services. We are hopeful that these hospitals will 
soon be able to come in to compliance with all relevant requirements 
and continue to provide much-needed care to patients in the Great 
Plains area. We appreciate the Committee's interest, and I would be 
pleased to address any questions you may have.

    The Chairman. Thank you, Mr. Slavitt.
    Mr. McSwain.

                         HUMAN SERVICES

    Mr. McSwain. Chairman Barrasso, Vice Chairman Tester, and 
members of the Committee, I was reflecting back on previous 
    I first came to the Indian Health Service in 1976. I am a 
proud member of the North Folk Rancheria of Mono Indians of 
California and personally understand the important work of the 
Indian Health Service and its mission.
    I recognize the frustration amongst the tribes and members 
of this Committee. I have worked the past 40 years to improve 
the health of our people. Providing access to quality medical 
care is a top priority for the Indian Health Service.
    When issues do arise, as regrettably has been the case in 
the Great Plains area, IHS is committed to taking immediate 
action which we can discuss later but to preserve patient 
safety above all.
    We are also working to make the improvements more lasting. 
We will talk about that in a moment.
    Despite these efforts, challenges remain. Some of the 
biggest challenges we face in the Great Plains area are 
associated with providing health care in rural, geographically 
isolated communities. You all are aware of the isolation and 
the difficulty with staffing, housing and what have you.
    Three hospitals at issue today, Omaha Winnebago, Pine Ridge 
and Rosebud, have faced additional challenges. From July to 
October, as Mr. Slavitt mentioned, they received non-compliance 
notifications from the Center for Medicare and Medicaid 
    IHS understands and accepts the severity of the CMS 
findings and has taken immediate steps and measures to correct 
them and implement safeguards to prevent recurrence. In 
addition, I know we have gone beyond just the CMS review and 
the area has contracted with a firm to take a wider look at the 
facility, not only in terms of the things CMS looks at but the 
things we need to look at as a comprehensive healthcare system.
    We have done that. We completed the assessment at Omaha 
Winnebago and are doing a similar analysis at Pine Ridge and 
Rosebud. Throughout we are communicating regularly with the 
tribes. In the case of Omaha Winnebago, we communicate weekly 
with them as we progress through the process.
    We believe these actions will address the concerns and 
issues in the immediate term and we also recognize the need for 
the long-term solutions. In that regard, you heard Acting 
Deputy Secretary Wakefield talk about Dorothy Dupree being 
added to our staff. Senator Tester if you are wondering where 
she wound up, she is now working for us. Her title is Deputy 
Director for Healthcare Quality.
    We have converted our hospital consortium established a few 
years ago to a quality consortium. We are working off Ms. 
Dupree's actual work plan. Working with Dorothy will be Mary 
Smith, an enrolled member of the Cherokee Nation as mentioned 
earlier. Mary has extensive background in advocating for Indian 
people and is steeped in health policy.
    In conclusion, the IHS is committed to working to improve 
the quality of healthcare services received by our patients. We 
are also committed to working in a transparent partnership with 
Rosebud, Pine Ridge and Omaha Winnebago hospital leadership and 
their four respective tribes.
    Mr. Chairman, thank you for your longstanding commitment to 
improving Indian health in the Great Plains area and throughout 
the Indian Health Service, and for the opportunity to testify 
    I would be happy to answer any questions you may have.
    [The prepared statement of Mr. McSwain follows:]

  Prepared Statement of Robert G. Mcswain, Principal Deputy Director, 
  Indian Health Service, U.S. Department of Health and Human Services

    The Chairman. Thank you very much, Mr. McSwain.
    Dr. Karol, I know you do not have an official statement and 
are here to answer questions. I do not know if you want to make 
any statement at this time or just wait for specific questions?

                         HUMAN SERVICES

    Dr. Karol. Just to let the Committee know who I am. Thank 
you for the opportunity to present.
    My name is Dr. Susan Karol. I am a Captain in the U.S. 
Public Health Service. I am the Chief Medical Officer for the 
Indian Health Service.
    I am an enrolled member of the Tuscarora Indian Nation 
which is in upstate New York. I graduated from Dartmouth 
College and the Medical College of Wisconsin. For the past 32 
years, I have been a practicing general surgeon.
    My role at IHS Headquarters in Rockville is as the Chief 
Medical Officer. I advise the director and our senior 
leadership of the Indian Health Service. I assist in 
formulating and implementing those national policies adopted by 
the director.
    I have direct responsibility in oversight of the Office of 
Clinical and Preventative Service, the Office of Information 
Technology, the Office of Public Health Support and External 
Affairs for the Indian Health Service.
    I work with each of the 12 IHS Area Chief Medical Officers 
who provide direct oversight of the quality programs and work 
with hospital leadership and providers at our IHS service 
units, military clinics and health stops.
    Mr. McSwain provided our opening testimony. I stand ready 
to answer questions.
    The Chairman. Thank you very much, Dr. Karol. We appreciate 
your being here and joining us today.
    Dr. Wakefield, we are dealing with severe, long term 
problems, a pattern of healthcare facilities that are so 
substantial in terms of the failures that CMS and another 
agency in your department have actually terminated its provider 
agreement with one of the IHS facilities. Other facilities are 
in jeopardy as well.
    You are a registered nurse, a Fellow of the American 
Academy of Nursing, Dean of the School of Rural Health at the 
University of North Dakota, and you were part of the 
Administration when Senator Dorgan had the first hearing on 
this. I just wonder what we can do to fix this problem in the 
Great Plains area, both short term and long term. What 
assurances can you give us that in five years we are not going 
to be in the same situation with the same problems identified 
    Dr. Wakefield. Thank you for that question, Senator. I 
would say a couple of things.
    First of all, in terms of short term strategies, Mr. 
McSwain and the IHS team are working now, immediately with 
assistance from our Commissioned Corps to turn around the 
circumstances in those three hospitals. It is our expectation 
that work is done as effectively and efficiently as possible. 
It is underway now. That is short term.
    Longer term, we have two strategies we are implementing. 
One, we have already started implementing which is to markedly 
strengthen the priority focus on quality in the IHS beginning 
with the leadership of IHS.
    You heard me talk about the expertise brought into that 
part of the agency at the helm of the agency on the executive 
team with specific priority, as I mentioned, placed on quality 
improvement and with expertise and with a plan to do that work 
that has been informed by consultation with tribes and also 
informed by features of that plan having already been 
implemented in the Phoenix area as well as in the Billings 
    Secondly, we are also convening an executive council at the 
HHS at the request of Secretary Burwell to focus our assets 
across HHS from parts of the agency that have resources devoted 
to this particular population to drive and leverage an agenda 
on quality improvement forward.
    Andy mentioned CMS's role briefly in that effort. That is 
the second part of our strategy. First is to strengthen IHS and 
second, to advance this agenda with the assets across HHS.
    The Chairman. We had listening sessions with tribal members 
in the region on the ground, visiting with people specifically. 
We got an earful. Tribal members have told Committee staff 
there is pervasive employee intimidation, retaliation, nepotism 
at every level of the Indian Health Service, that the employees 
are afraid to report their concerns, afraid to be honest and 
forthcoming when surveyors visit, are told not to speak with 
members of Congress, their staff or anyone else who might be 
able to help improve the conditions.
    Doctors and nurses, they tell us, are afraid because they 
are threatened repeatedly and directly and even openly. It was 
astonishing the sort of things they came back and said, this is 
what we heard on the ground. Their families were denied health 
care, reputations were dragged through the mud. They try to do 
something right to protect patients and report criminal 
activity and feel they are ostracized and pushed out.
    I just want to make sure that you are completely aware of 
that and what we are going to do about this culture of 
harassment that seems to exist in the Indian Health Service.
    Dr. Wakefield. Our goal is to deliver high quality, 
consistent care. We have to have providers that are on the 
front lines, administrators on the front lines that share that 
commitment. Most of the providers in the field are absolutely 
committed to delivering high quality care as are the 
    We have bright spots in the Great Plains area. We do. We 
have great providers in the Great Plains area.
    We also need to strengthen our management along the lines 
of what you just indicated. As I mentioned, Mary Smith has 
joined us. That is one of her priorities on the executive team 
of HHS. She brings experience in that area, in management and 
operations and it is a focus for us.
    The Chairman. Mr. Slavitt, first we were told the situation 
at Winnebago was unique. As time went on, we heard from other 
tribes that they were experiencing similar problems impacting 
patient safety and patient care. Still the Administration 
claimed the issues facing Winnebago were an exception to the 
    Then CMS sent notices of intent to Rosebud and the Pine 
Ridge hospitals indicating that their provider status was at 
risk as well. Based on the information we received, I suspect 
the ``immediate jeopardy conditions'' found at these three 
facilities also exists at other hospitals in the Great Plains 
and beyond.
    I am asking how many IHS facilities have been issued this 
immediate jeopardy finding since 2010? Why does the problem 
seem to be so concentrated in the Great Plains area?
    Mr. Slavitt. As you stated, we have issued in one situation 
termination of our participation in Medicare and Medicaid and 
in two situations late last year where there is similar 
potential. The management of the hospitals is in the process of 
giving us a response to those areas.
    I suggest I allow my colleague, Thomas Hamilton, to speak 
more specifically as it relates to the breadth of the work we 
are seeing across the Indian Health Service.
    The Chairman. Mr. Hamilton, welcome to the Committee.
    Mr. Hamilton. Thank you. Thank you for the invitation.
    As Administrator Slavitt indicated, since 2010, we have had 
18 site visits on these three facilities alone. All of our 
survey reports are matters of public record. We appreciate the 
Committee had requested a number of those and carefully 
examined those for the results.
    When we find there are serious deficiencies, then we issue 
a notice to the hospital scheduling a prospectively scheduled 
termination date which communicates a message that there will 
be no discussion about whether or not problems are fixe but 
rather, how quickly and how well. That is the situation playing 
out at these three facilities.
    The Chairman. If I could, Winnebago's first citation after 
the 2010 report Senator Dorgan came out with occurred in April 
2011. But CMS did not terminate the provider agreement until 
four years later in July 2015. Extensions have consequences. At 
Winnebago between 2011 and 2015, there were five extensions 
granted by CMS.
    I wonder if standard termination procedures and timelines 
were followed if it might have been different in terms of 
patient lives possibly being saved. I wonder why it takes so 
long for CMS to act on its own findings and what led the agency 
to finally make the decision to terminate the provider 
agreement at Winnebago?
    Mr. Hamilton. Simply because termination occurred later 
does not mean that there was no activity. In fact, there was a 
great deal of activity. My colleagues in the Quality 
Improvement Group were enlisted. They got four quality 
improvement organizations under contract to provide direct on-
site technical assistance between 2012 and 2014 to Pine Ridge, 
Winnebago and Rosebud facilities.
    We were hoping at that point in time that a regimen of 
intense, technical assistance would do the job. When we went 
back out in April 2014, unfortunately, we found the problems 
had not been remedied to the extent necessary. At that time, we 
issued a termination notice again.
    The director of the Indian Health Service at that time 
personally became involved. Dr. Roubideaux went out to the 
facility, there was a change in the executive officer, a 
variety of other more intensive changes were put in place. For 
six months quality did improve.
    However, when we went back out in 2015, again, we found the 
gains had not been sustained and we reluctantly issued the 
final terminal notice from Medicare.
    The Chairman. Thank you, Mr. Hamilton and Mr. Slavitt.
    Senator Tester?
    Senator Tester. Thank you, Mr. Chairman. Thank you all for 
your testimony.
    I will get right to it. Senator Dorgan brought up the point 
of incompetency and made a solid point. If you have someone 
incompetent, fire them; do not move them. Mary, do you have the 
capacity to fire folks in a timely manner for incompetence?
    Dr. Wakefield. We follow performance, government-wide 
standards associated with performance reviews. I have used 
those standards in my position as the Administrator of Health 
Resources and Services Administration. Yes, staff can be 
    Senator Tester. This is also an argument heard a lot in 
Veterans Affairs healthcare that Senator Moran knows about. Is 
it standard operating procedure to move them around or get rid 
of them if they are incompetent? I am talking about employees 
who do not cut the mustard.
    Dr. Wakefield. Senator, speaking for myself, when I have 
had staff that have not fulfilled their responsibilities, I 
have applied the opportunities that I have to help relieve them 
of their responsibilities, yes.
    Senator Tester. Music to my ears.
    Now I want to talk about recruitment and retention which is 
exactly opposite of what I was saying. If you have someone that 
is good or someone you are trying to recruit, what parameters 
do you have to bring them on?
    We are talking about areas, by the way, that are not like 
areas where I live. We do not have a doctor where I live 
either. We are talking about places that do not have housing, 
police protection is poor and Senator Heitkamp talked about it. 
Police protection is poor, schools are not top notch, you have 
no place to live and the list goes on.
    What can you do to help recruit doctors into areas that are 
one, frontier, and two, do not have places to live?
    Dr. Wakefield. One of our most effective strategies as I 
have looked across our workforce programs deployed by HHS is 
the National Health Service Corps Program. That is a 
scholarship loan repayment program that is extremely effective 
in helping to pay loans for physicians, nurse practitioners, 
psychologists and others. In exchange, they work for a minimum 
of two years in an underserved area.
    We have markedly expanded that program in the last five 
years, as I mentioned earlier. We now have 420 of those 
clinicians working in Indian Country with Indian populations. 
That is a big boost from the just over 100 that we had back in 
2008. We are also focusing on retention, Senator Tester. It is 
recruitment but also retention.
    Senator Tester. Do you have the capacity to incentivize 
these folks with additional wages? For example, Customs Border 
Protection, there are certain areas on the northern border 
where they cannot get people to serve there. They gave them a 
quarter boost right off the top on their salary if they served 
in certain areas. Do you have that capacity?
    Dr. Wakefield. Yes, we do. We actually changed the program 
about five years ago to incentivize and provide more resources 
in terms of loan repayment and scholarship to individuals 
willing to serve in our greatest need areas.
    I could not speak for the scholarship program out of IHS, 
but I can speak to the National Health Service Corps. Yes, we 
have done that.
    Senator Tester. Bob, can you incentivize their salary in 
    Mr. McSwain. We do. In fact, we offer pay packages based 
upon what is available. If it is a scholarship recipient or if 
it is loan repayment, we have a loan repayment program as well.
    Senator Tester. What about salaries?
    Mr. McSwain. We have the authority for physicians and 
dentists under Title 38.
    Senator Tester. How much can you bump their salary?
    Mr. McSwain. I think it is close to $300,000.
    Senator Tester. Can you get back to me with the figures?
    Mr. McSwain. Yes, I will.
    Senator Tester. I will have a lot of questions for the 
record because time is wasting. There is about a 37 percent 
vacancy rate in the Great Plains area for physicians. Is that 
comparable with other IHS regions or is that high?
    Mr. McSwain. I would say it is high for that area.
    Senator Tester. Can you tell me why it is high?
    Mr. McSwain. It is those isolated, remote locations 
primarily and the housing issues.
    Senator Tester. I am going to put some questions into the 
record because we have other folks who want to ask questions. I 
do want to close with one point. It is the point Senator 
Heitkamp brought up talking about what we pay for Medicare 
spending for beneficiaries, veterans and what we pay for IHS.
    Senator Dorgan said it also. He said we are 50 percent. The 
National Congress of American Indians said IHS is about 59 
percent underfunded. I want to tell you if I was a farmer and 
this was my board of directors and you underfunded me by half, 
that means I would only be able to put 30 pounds of seed down 
in the spring and only be able to till my land two and a half 
times and at harvest time, there would not be any money to cut 
the crop. You would ask me how come we failed.
    We can put forth the best words we want in this Committee 
but unless we back it up with money, it is just that. It is 
baloney. Some of the same folks that talk about the problem 
with IHS vote against the budget. They vote against IHS 
    I am telling you guys, we can point the finger at these 
guys but there are three of them pointing right back at us. We 
can talk about the challenges out there with people harassing 
and nepotism. We should not stand for that. The folks who are 
not doing their job, we should fire them.
    In the end, we are never going to be successful if we do 
not deal with what it cost to treat people in medicine. You 
cannot do it with half. We can talk about what it takes to have 
good schools and good housing and good water because you will 
never get people to live there.
    It is a big issue. We can talk about it and say, damned 
that IHS, these guys just are not doing their job and by the 
way, there are cases where you are not doing your job and you 
need to clean it up. We need to clean up our act too.
    The Chairman. Thank you, Senator Tester.
    Senator Hoeven?
    Senator Hoeven. Thank you, Mr. Chairman.
    Again, I would like to thank Secretary Wakefield for being 
here as well as the rest of the witnesses.
    Across the Country on and off reservation, there is a 
shortage of healthcare providers. Senator Tester asked about 
the shortage of doctors. There is a shortage of doctors just 
about everywhere. The reality is we do need more resources on 
the reservation but we also have to figure out how we leverage 
our resources.
    I am going to start with Secretary Wakefield. In drawing on 
your experience at the University of North Dakota, the rural 
health center there which you ran and is a tremendous 
operation, how do you create a culture of accountability and 
empower people, make sure people are accountable but also 
empower them?
    I would like for you to touch on what we are trying to do 
in the VA which is to create that culture of accountability and 
empowerment but also this concept of leveraging resources. We 
not only are striving to make sure that veterans can get good 
care directly through the Veterans Administration but also that 
they have veterans' choice so that where you have issues of 
distance or time delay, they can get services from local 
healthcare providers.
    How do you create that culture of accountability, 
empowerment and leverage your resources for example, like this 
veterans' choice concept? I am going to ask both Administrator 
Slavitt and Mr. McSwain that question as well.
    Dr. Wakefield. In terms of leveraging resources, I think we 
have to be real smart about what we are doing with regard to 
deploying our resources as efficiently as possible. I talked a 
couple of times about the National Health Service Corps 
Program. This puts primary care providers in the field.
    Most of the National Service Corps providers go to rural 
areas. From my vantage point coming out of the Great Plains, 
that is a good thing because we have such significant shortages 
there. As we leverage them to provide primary care, that frees 
up resources to staff out the acute care facilities we are even 
talking about here today. To your point, it really is about 
ensuring that we are not creating redundancies but are 
establishing systems that are working together collaboratively 
among the programs that play out on the front lines.
    In terms of accountability and supporting recruitment, we 
recently have spent more time focusing on retention, 
recruitment and retention and not just trying to retain an 
individual in a location based on what we are doing at the 
Federal level, but we are working with the local community.
    Quentin Burdick Hospital in Belcourt is a good example of 
that. We have a core of clinicians working together. It is that 
core nucleus and looks a lot like Hettinger, North Dakota, 
Senator Hoeven. You will know that experience of creating a 
local culture within the community that is supportive of that 
set of clinicians and clinicians supportive of each other in 
terms of the delivery of high quality care. We have bright 
    Senator Hoeven. Those are great models. If you can help 
your team replicate those, you will go a long way to solving 
these problems. Those are great models.
    Dr. Wakefield. They are great models. The Quentin Burdick 
model at the Quentin Burdick Hospital is a direct service 
hospital. It is the type of hospital we are talking about here 
    Our aim is to achieve consistent, sustained quality care 
across our direct service facilities. We have those models in 
hospitals that already exist. It is a lot about focusing on the 
individual provider, but it is the community as well and 
helping communities establish a culture of support for those 
    Senator Hoeven. I like your giving those concrete examples. 
That is very helpful.
    I would ask Administrator Slavitt the same question, 
particularly leveraging resources. Across the Country, nobody 
is providing adequate health care without leveraging resources 
because of the tremendous demand.
    Mr. Slavitt. Thank you, Senator.
    There are three things in our experience that are important 
here. The first is transparency from the bottom to the top. 
Unless problems can be identified, they cannot be fixed. 
Obviously, that is critical.
    Second is the leadership and engagement and the culture 
that my colleague, Deputy Secretary Wakefield, pointed to. The 
tone has to be set that it is okay to share these problems and 
people have to get engaged in those details.
    Third is accountability and resources. People need to feel 
like they can succeed, we need to know who is held accountable 
and as those things come in place, as my colleague Mr. Hamilton 
said and as Mr. McSwain said, there has been good leadership 
that has moved into these hospitals. When that has happened, we 
have seen progress. That should encourage us that we need to 
keep moving in that direction.
    Senator Hoeven. Director McSwain.
    Mr. McSwain. That is absolutely correct. I want to second 
Dr. Wakefield's notion about Quentin Burdick. There is a model 
that has good leadership. We are finding if we can get good 
leadership, they can recruit people.
    The other part of it too is they do not have as many 
contractor physicians who rotate out. Their vacancy rate is 12 
percent. You heard about the total vacancy rate for the whole 
area is 37 percent. They are at 12 percent. Why is that? It is 
leadership. It is the core staff. That is the model.
    To leverage that, I read your question a little more 
insofar as we are reaching out to other people, the VA, to pay 
for Indian vets, reimbursements. We are reaching out and 
leveraging our resources which are limited to other resources 
that might be available that would treat our population.
    As Dr. Wakefield said, in working with the rest of the 
department, there may be other opportunities that exist in the 
department that will come to bear on our problems.
    Senator Hoeven. The leadership, the leveraging and then 
metrics, if you install metrics and can come back to us with 
metrics to show progress and deficiencies, it is very important 
and really helpful in what we are trying to do here.
    Thank you.
    The Chairman. Thank you, Senator Hoeven.
    Senator Heitkamp?
    Senator Heitkamp. Thank you, Mr. Chairman.
    I have a couple quick questions. Mr. Slavitt, when did CMS 
actually notify not just the hospitals but the leadership of 
Indian Health and potentially the Secretary's office about 
these deficiencies?
    Mr. Slavitt. I am going to ask my colleague to walk through 
the specifics and the timeline but our process is as soon as we 
are aware, we make the local representatives on the ground 
aware. In this particular case, Mr. McSwain and I spoke 
immediately upon the determination. I called him and we had a 
very direct conversation.
    Senator Heitkamp. Are we talking about immediately upon the 
determination of deficiency or immediately upon the 
determination that you were no longer going to certify an IHS 
    Mr. Slavitt. Talking about both. In the case of the 
deficiencies, those were communicated as reports are completed 
at the local level. In the case of my conversation with Mr. 
McSwain, that happened in the case where we were going to 
notify they that were terminating.
    Senator Heitkamp. I might suggest that in the future you 
not leave it up to just notifying the local people at the 
hospital. Obviously, we had an information gap here where 
people who should have been responsible immediately for change 
were not notified. That concerns me.
    Deputy Secretary Wakefield, when did the Secretary's office 
become aware of the problems in these hospitals?
    Dr. Wakefield. Senator Heitkamp, I will have to get back to 
you with an answer to that question. I would be happy to do 
that. I am sorry I could not speak to it specifically. I know 
that is what you are asking for, a specific date.
    Senator Heitkamp. The point I am trying to make is that you 
all work under the same umbrella. We can talk about 
miscommunication and talk about metrics, but you have to all be 
communicating with each other.
    The other point I want to make is the extraordinary 
difficulty of serving a population with chronic disease, with a 
lot of history of trauma, a lot of history of challenges, both 
behavioral and mental health.
    We see it in the substance abuse. We see it in high rates 
of suicide. We see it in chronic disease being reflected from 
these conditions.
    I am a big believer, as a lot of people at SAMHSA, a lot of 
people working on this, that we can do better in terms of 
treating the whole person so we continue to treat chronic 
disease and never really get to the problem.
    I am wondering what IHS is doing and what HHS is doing to 
begin to address things like trauma informed treatment, begin 
to address merging this curative medicine model with behavioral 
and mental health model so that we can treat the whole patient.
    Deputy Secretary Wakefield?
    Dr. Wakefield. Secretary Burwell asked the Administrator 
for Native Americans at the Administration for Children and 
Families to lead our HHS-wide effort on exactly this area. That 
is to develop what would be a comprehensive, integrated 
department-wide approach that stems from an understanding and 
the evidence based around historical trauma. That is 
department-wide. That is underway.
    We are looking forward to consulting closely with any 
member of this Committee who is interested in tracking against 
that work as it pushes forward.
    Senator Heitkamp. I hope as we are looking at recruitment 
and retention, we are looking at recruiting a new kind of 
physician, people who actually have received this type of 
training because I think it is critical if we are going to have 
long term better outcomes that we change the dynamic of how we 
deliver the service.
    Finally, I want to make the point that no one here should 
be happy with this outcome. My frustration always is that there 
is almost a culture of failure. What can we do? There is 
nothing we can do.
    Yes, we have an obligation to fund but you have an 
obligation to come with the plan that changes outcomes. You 
have an obligation to tell us what you need. My frustration 
always is we are going to rearrange and I am not saying that is 
the response we are getting, but rearrange the deck chairs on 
the Titanic because it is going to go down anyway.
    Let us not have this hearing again in five years. Let us 
come back, have constant communication about what we are doing, 
how we are changing outcomes and make sure whatever you do that 
this is done in consultation with the tribes because the people 
who are most concerned about these outcomes are the tribal 
elders, the tribal leaders, the mothers and fathers and people 
who see the core of the lack of delivery of health care every 
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Heitkamp.
    Senator Daines.

                   U.S. SENATOR FROM MONTANA

    Senator Daines. Thank you, Mr. Chairman.
    I first want to give a warm welcome to Jace Killsback, the 
Executive Health Manager of the Northern Cheyenne from Lame 
Deer, Montana. It is great to have you, Jace. Thank you for 
appearing on this next panel.
    I would like to begin by noting that on top of facing the 
bureaucracy of the Indian Health Service, which we have 
discussed at length today, tribes are being hit with massive 
fines under Obamacare which is why we have introduced the 
Tribal Employment and Jobs Protection Act.
    It exempts tribal employers from Obamacare's employer 
mandate. I am hearing about this from virtually all of my 
tribes back home in Montana. I hope through efforts like this 
with this legislation, we as a Committee and as a greater body, 
must continue working to uphold the United States' trust 
responsibility to Indian tribes while honoring this very 
important government to government relationship.
    I recently heard from a constituent of mine, in fact I have 
the email here, who was a member of the Assiniboine Tribe of 
Fort Belknap who contacted me to voice the hardships she has 
faced in seeking treatment through IHS. Listen to this story.
    She drove 35 miles to the closest IHS facility, spent four 
hours there waiting for medication and then drove all the way 
home to find out she had been administered the wrong 
medication. This is all contained in the same email from one of 
my constituents.
    She described the way the IHS had treated her on multiple 
occasions as with extreme negligence. In fact, when she called 
and told them she had the wrong medicine, they told her to 
flush it down the toilet. This is in the context of where we 
have certainly abuse of prescription drugs and sometimes a lack 
of control.
    Problems like this have been happening for decades. The 
fact they are happening today is unacceptable.
    I want to point out something else. As Al Franken said back 
in 2010 when this was first discussed, ``We cannot keep 
throwing good money after bad.'' In fact, in your testimony, 
you stated that under this Administration, funding for IHS has 
increased by 43 percent.
    However, the issues we are addressing today are not the 
result of underfunding. Plain and simple, this is an issue of 
oversight, an issue of accountability, an issue of failing to 
follow through on promises and basic responsibilities to Indian 
    I do not think this is a healthcare system. I think this is 
a healthcare tragedy. I spend a lot of time with the families 
in Indian Country and seeing the outcomes of a system that is 
very, very broken. It is a real tragedy. We are dealing with 
the lives of real people, grandmas and grandpas, children and 
moms and dads suffering and dying prematurely.
    Mr. McSwain. Dr. Wakefield states that the challenges 
facing hospitals in Indian Country and those IHS is responsible 
for helping address include difficulties in recruiting and 
retaining qualified healthcare providers. What specifically 
have you done and what are you doing administratively to 
address the difficulties of retaining as well as recruiting 
qualified healthcare providers, as well as the low volume of 
these providers?
    Mr. McSwain. We are using all the mechanisms available to 
us by existing authorities and requesting additional 
authorities, but a lot of it has to do with pay because we need 
to be competitive and be able to get them onboard. That is a 
big issue as you can well imagine.
    There have to be enough incentives to go to an isolated 
location. Those are the incentives that we are working on. We 
have requested to expand some of our pay authorities. The other 
has to do with working more closely with the tribes on what is 
needed in the community. That is another area we are working 
    I know Dr. Karol has been working heavily on that. If you 
do not mind, I would like to have her respond as well.
    Dr. Karol. I think a big part of our recruitment and 
retention package is also the work we have been doing with our 
scholarship program. I am a good example of that. I am an IHS 
437 scholar. Basically it puts Native students into medical 
school, nursing school, dental school to get them educated and 
brought back either to their home tribes or to others.
    We have a loan repayment program. We are working with the 
United States university health systems, USUHS, in Rockville to 
educate at least two students a year who come back to our 
areas. Previously, they have been assigned to return to the 
Great Plains area so there are a number of students over the 
last few years that did come to the Great Plains area. We can 
give you more information.
    Senator Daines. On the pay gap, how much is enough? What 
are the gaps approximately in percentage that we need to 
address the recruiting and retention issue? How far apart are 
    Dr. Karol. One example is emergency room physicians across 
the Country make about $350,000. Our Title 38 brings them in at 
about $220,000 to $240,000 so there is a gap there.
    Senator Daines. Thank you. I am out of time.
    I know the Committee staff has been provided examples of 
where additional dollars have been put in but unfortunately 
were consumed on the administrative side of this instead of 
going to paying for providers actually on the front lines 
treating people and patients. That is another discussion to 
    Mr. Chairman, I am out of time.
    The Chairman. Thank you very much, Senator Daines.
    Senator Udall?
    Senator Udall. Thank you, Mr. Chairman.
    Director McSwain, I understand the IHS is working to get 
emergency resources for the NCI Detox Center in Gallup. As I 
mentioned in my opening statement, I believe there is a real 
public health crisis going on there. There is a real risk this 
center may close in a matter of weeks.
    The community is alarmed. We alerted you to this. When 
critical public health facilities close, people are going to 
die. That is what is going to happen.
    How can the IHS plan to work collaboratively and creatively 
with tribes and local officials in Gallup to fund a long term 
solution to this funding issue? How can the agency better 
leverage its resources to help address crisis situations like 
the one in Gallup, New Mexico?
    Mr. McSwain. Senator Udall, as you know, we actually have 
identified resources that we are sending out. We are moving it 
through the Navajo Nation. That is the vehicle. Our 
relationship is with the Navajo Nation. We are going to be 
moving on a short gap and then we are having conversations with 
others like our partners at SAMHSA about long term strategies 
to maintain that program. It is a vital program certainly for 
the Gallup community. That is one we desperately need to 
complete. That is what we are doing right now both short term 
and long term.
    Senator Udall. Thank you very much for that work.
    As we have heard today, IHS facilities across the Country 
experience interruptions in service due to staffing issues, 
poor facility conditions, and deficient patient care. I 
mentioned Crownpoint as the recent glaring example in New 
    The emergency room in a rural area closed for over a month. 
Thankfully the situation has improved but I remain very 
concerned about the long term success there and at other New 
Mexico IHS facilities and as we have heard, facilities across 
the Country.
    What is HHS's plan to address these serious, ongoing 
staffing issues at IHS facilities and then the bigger issue we 
are talking about which is this whole issue of 50 percent under 
funding? Senators Tester and Heitkamp mentioned it. The 
National Congress of American Indians talks about 59 percent.
    Normally what has happened in these kinds of situations 
that I have seen in the past is an Administration steps 
forward. You know you cannot do it in a year but you step 
forward with a plan, a five year plan and we are going to wipe 
out this under funding.
    I hope with this hearing and the attention given to this 
that President Obama and your agency will step forward and give 
us a plan so we can get people to see here is the plan and who 
will vote for and support it because that is what is really 
needed here. Please go ahead.
    Dr. Wakefield. We agree that there absolutely is a need to 
fill the gap, not just to recruit into underserved areas in 
Indian Country but also to retain those clinicians. There will 
not be just one strategy to accomplish that, it is going to be 
a set of strategies.
    We have already been talking inside the agency. You talked 
specifically about emergency departments. One of the strategies 
we have focused on, and Mary Smith, the individual I mentioned 
who has been brought into the leadership of IHS, is focusing 
on, is a much more comprehensive approach to thinking about 
deploying telehealth technology.
    I am from a rural area. I know the difference that can 
make. We have in Montana and also out of Arizona associated 
with our direct service facilities, direct service hospitals, 
the application of telehealth technology.
    In Pine Ridge, for example, we have telebehavioral health. 
We have tele-ED out of Montana. That is one strategy but again, 
it will take a number of strategies. That is one strategy that 
I do not think we are leveraging as comprehensively as we 
    It is important to back up those frontline providers and 
emergency departments that may see infrequently a particular 
case come in with special healthcare challenges. It is also an 
appropriate technology to use in connecting to specialty 
services, sort of a backup of primary care providers on the 
front end and also to deliver specialty services into 
particular areas.
    I mention that because you mentioned emergency departments 
specifically. We have some resources going into telehealth 
technology applications. We will continue to look at that and 
push the boundaries of that in our planning going forward.
    Telehealth does not solve it all. That is simply one 
strategy. Another strategy is also to make sure that we are 
investing in primary care providers to free up providers to 
provide care in acute care settings.
    I talked already about National Health Service Corps 
clinicians but should have also mentioned we have markedly 
expanded over the last five years our community health centers. 
As a result, today, our community health centers probably since 
about 2009 are seeing 30 percent more American Indian, Alaska 
Natives than they did four or five years ago.
    That is good news because that allows us to free up 
resources and personnel to be able to provide other non-primary 
care services, a set of strategies from expanding technology 
but also expanding the provider pool in a more comprehensive 
way rather than looking at this specialist by specialist, and 
rather leveraging those assets together.
    Senator Udall. Thank you very much for that answer and for 
looking at this in terms of strategies. I am a big supporter of 
telehealth and many of the other strategies you mentioned. If 
you put them forward, you will get a lot of support from this 
Committee and in the Congress.
    Thank you very much, Mr. Chairman.
    The Chairman. Thank you, Senator Udall.
    Senator Thune?
    Senator Thune. Thank you, Mr. Chairman, again for the 
opportunity to ask some questions and participate in the 
    I too want to echo what was said. One of the things I hope 
comes out of this is better use of telehealth and telemedicine. 
We have three regional health systems in South Dakota, all of 
whom have done some pioneering work in the area of telehealth 
    That is a way, I believe, that we can do a better job of 
delivering healthcare services not just in our tribal 
communities but in rural areas of the Country. I would 
encourage you to carry on with that.
    Secretary Wakefield, in your oral testimony you noted the 
hiring of additional administrative staff, two new deputy 
directors and created executive level working groups, is that 
    Dr. Wakefield. Yes.
    Senator Thune. Did IHS consider using that funding at the 
local level to invest in additional providers, those that 
directly serve patients or to address the emerging situation in 
Rosebud and Pine Ridge?
    Dr. Wakefield. I would ask Mr. McSwain to speak to 
additional clinicians and administrators that have been or are 
being seeded into those three facilities.
    I would say the resources that we have committed at the 
local level from HHS, not from IHS, into that region are 
additional Public Health Service Corps clinicians, physicians, 
nurse, quality improvement experts into the Great Plains area 
to focus very sharply on the current challenges we have right 
now. They are there on the ground, have been on the ground and 
will continue to stay there as we work to stabilize and 
strengthen those three facilities and more broadly the area.
    With regard to the two positions I mentioned, I think these 
two positions are absolutely critical. We have to have a much 
sharper focus on quality improvement if we are going to sustain 
and strengthen the quality of care that IHS is responsible for 
delivering. That starts at the top.
    We have a tremendous expert we have brought to the table 
and were fortunate to get her. She has a plan that can be 
operationalized. It is concrete. I am not talking about it in 
the abstract. There are very specific strategies. I have looked 
at that plan. I have had people from CMS and the Federal Office 
of Rural Health Policy look at that plan.
    Her expertise at this level and that priority for that 
agency is one of our major strategies to begin to do the work, 
not just in the Great Plains area, but across Indian Health. 
This is a reset. This is a reengineering of how we are doing 
our work and our focus on quality.
    I think those two positions at the executive level set the 
tone for what we need to be focusing on, making this a top 
priority. It is for us.
    Senator Thune. I guess I would say in addressing the 
situation, I am glad you are putting that kind of spotlight on 
it and focus, but I think it is important to remember that the 
solution to every problem is not growing the administrative 
size of the agency. We want to get people on the ground 
delivering healthcare services, doctors and nurses inasmuch as 
you need somebody that is going to do this.
    I hope that this time it gets done because after the 2010 
report, there was a paper put out that had a strategy that was 
going to be implemented in the Aberdeen area. The Aberdeen area 
responded to that report with their own report about all the 
things they were going to do. In 2013, we had another report 
about all the things that were going to be done and none of the 
stuff gets implemented.
    I guess my point is that when you look at these issues, 
clearly there are problems up the food chain and there is not 
the efficient oversight, follow through and implementation and 
all that. I am glad you are rightly focused on that.
    I think it is really critical that we get the help to 
people on the ground where we have the needs not being met and 
the conditions that have been so well documented.
    Mr. McSwain, I want to follow up with that because there 
was a lot of work done in 2010. The Committee report created 
this program integrity coordinating council that was to make 
recommendations for changes within IHS. As I said, they 
reported and the Aberdeen area responded with specific plans to 
better the region.
    Who was responsible at that time for compliance with the 
July 2011 plan?
    Mr. McSwain. You are testing my memory but let me answer 
the other question you had about staffing at the local level. 
Bear in mind we are talking about a 37 percent vacancy rate. 
How are we actually filing those positions? We are dealing with 
contractors. We would like to get away from the contractors 
because the contractors are costing us at least triple. That is 
another point.
    Getting back to your question about the program integrity 
coordinating council oversight and the actual work group that 
went into that, during that time, actually I may have been that 
in my previous job. I may have been the Deputy Director for 
Management Operations and therefore was actually overseeing the 
activities going on out there until I was changed out.
    That particular report focused on helping the agency move 
ahead with addressing the report itself, the report findings, 
some 19 findings. We walked through all of those items. We 
actually made very good progress on some of those items. Some 
of them are still very challenging.
    Senator Thune. To your knowledge, are the reports submitted 
on the 30th of each month, something called for by each 
hospital outlining the level of compliance with the CMS 
conditions of participation, a requirement of the July 2011 
plan, are those reports submitted, to your knowledge?
    Mr. McSwain. Yes.
    Senator Thune. On the 30th of each month?
    Mr. McSwain. Yes.
    Senator Thune. How is it possible that three hospitals in 
the Great Plains area have failed to satisfy the conditions of 
participation? Were IHS officials in the Great Plains area just 
rubber stamping these documents? How did this happen?
    Mr. McSwain. They were not rubber stamping so much, 
Senator. They were taking and processing them through. What 
happened on the surveys is, and I will defer to Mr. Slavitt and 
Mr. Hamilton, but there were times where we actually achieved 
satisfaction on the surveys.
    Then, as I think Mr. Hamilton mentioned, we failed again. 
We fell back, so that was a year later. We achieve and then we 
fail. That has been the cycle. I think Dr. Wakefield is saying 
we want to sustain while we are up there and continue to move 
    Senator Thune. My time has expired, Mr. Chairman. There are 
some questions I would like to submit for the record.
    I would say in closing that in response to Secretary 
Wakefield's comments about creating a structure or model, that 
this time it has to work. Mr. McSwain, even in response to the 
2010 report, we are not sure exactly who was responsible.
    I am saying there has to be accountability. There has to be 
a chain of command, the buck has to stop somewhere to prevent 
these sorts of things from happening and to ensure that the 
conditions we have been finding and that CMS is responding to 
just do not happen again. That will take a lot of work on the 
part of a lot of people.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Thune.
    Senator Franken.

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

    Senator Franken. Thank you, Mr. Chairman, for holding this 
    I want to thank Senators Thune, Heitkamp and Rounds for 
requesting this hearing and Senator Tester as well.
    I want to clarify something. What I said in 2010, I do not 
know if I necessarily said you cannot throw good money after 
bad. That might be a paraphrase of something I was saying. We 
did a word search for that and we do not quite have that.
    What I was saying was that we kind of a catch 22. We have 
members who do not want to increase funding because the 
bureaucracy is dysfunctional but you have a situation where the 
system is dysfunctional because it does not get enough funding.
    I think that is the nub here. I do not want to be taken out 
of context.
    Senator Heitkamp brought this to the Committee, to the 
hearing today. She has gone over it, Senator Tester has 
referred to it. Average spending per capita in the United 
States on healthcare is $8,097 as of 2014. The average for IHS 
per user is $3,600, less than half.
    Add to that everything we have talked about in this 
Committee in terms of housing, in terms of education. When you 
are attracting a healthcare provider to a hospital or clinic, 
if they are married, you are also recruiting their wife or 
their husband and their kids. It matters to that spouse what 
the schools are like.
    How much do we spend on the schools? How much is spent on 
law enforcement considering that we have the levels of violence 
that we have? When I am quoted as saying, you cannot throw good 
money after bad, that is not what I was saying.
    We had a hearing on suicide a few months ago. We have an 
epidemic of suicide in Indian Country. Senator Heitkamp talks 
about this all the time, talks about trauma, cultural trauma, 
but there is individual trauma. If you are living with another 
family, the chances are exponentially higher that you are going 
to see violence or domestic abuse or drug addiction.
    Though we spend less than half per American Indian on 
health care, we have heard in the testimony that the health 
condition of the average Indian Native American is not as good 
as the average non-Indian American.
    We have to get real about this. I tried to get an $11 
million loan guarantee for energy projects in the last omnibus 
bill. After we had that hearing on suicide, I asked for that 
member's support and that member said, is there a paid for.
    When we did the doc fix, $120 billion was not paid for but 
I could not get a member here on Indian Affairs after a suicide 
hearing where we know that unemployment on Pine Ridge must be 
75 percent, I could not get $11 million for economic 
development so people could have jobs. Please staff, ``in 
    Let me ask about telehealth. I know I am over my time. Is 
there a problem with broadband in Indian Country because we are 
talking about telehealth? I think telehealth is great. I am co-
chair of the Rural Health Caucus. I know the importance of 
broadband for telehealth.
    Dr. Wakefield. I cannot speak specifically to broadband in 
Indian Country but I assume that it is going to be very similar 
to what I am going to say in terms of rural areas at large, so 
we do not have access to broadband across rural America but 
probably the bigger challenge in some respects or an additional 
challenge, I should say, is the cost associated with broadband.
    You are right, that can be a rate limiting factor to 
implementing telemedicine, yes.
    Senator Franken. Mr. McSwain?
    Mr. McSwain. Agreed. I agree with Dr. Wakefield. It is the 
cost of the broadband. We have had examples of challenges in 
Alaska, for example, where they have to rely on broadband. I 
heard of a case where the person was going to send an x-ray 
result and had to send it tonight so they can get it tomorrow. 
That is how long it took to get there.
    There are challenges about telehealth but I think more 
importantly, it is the staff support for telehealth on both 
    Senator Franken. I think everyone on this Committee agrees 
with that.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Franken.
    Director McSwain, you have been around from previous 
Administrations and spent decades doing this. You know the 
agency well.
    I have a number of tribal resolutions and letters addressed 
to you and others seeking the removal of some specific IHS 
employees. I know Senator Heitkamp you asked a specific 
question during this.
    The joint resolution was adopted by the Omaha and Winnebago 
Tribes on August 12, 2015. It specifically identifies a number 
of underperforming IHS managers. As far as we can tell, these 
people have been shifted around the Great Plains area, in many 
cases given pay raises and promotions, not fired even though 
most of these people seemed to be directly responsible for the 
violations that were cited in the CMS surveys we are talking 
about today.
    I would like you to explain to the Committee why these 
people are still employed by the IHS?
    Mr. McSwain. I would be happy to speak with you not in this 
public setting only because of personnel issues and privacy 
issues with the employees and perhaps provide a full response 
to that question.
    It is a good one and I appreciate the question, Mr. 
Chairman, but we would need another forum to provide the 
    The Chairman. I appreciate that and the confidentiality of 
workers and those issues but it does highlight the concerns 
that all of us on the Committee have about the ability to deal 
with problems when they exist. If they cannot be dealt with, 
how do we solve the problem?
    We have heard from some of our colleagues money is an 
issue. We also hear about lavish expenses, that so much of the 
money ends up at headquarters rather than being spent to 
actually take care of people.
    You would be astonished how many heads in the audience are 
shaking yes as I say that, Director McSwain and the smiles that 
coming to the faces because they know that is the case. There 
are huge concerns about that.
    Dr. Karol, I wanted to visit with you about one other 
thing. There was a December 4, 2015 conference call with 
congressional staff and HHS officials. My report is you almost 
brushed off concerns raised by the congressional staff about an 
incident described in one of those CMS surveys saying ``If you 
only had two babies hit the bathroom floor in eight years, that 
is pretty good.''
    I want to be absolutely clear. You and I both took the same 
Hippocratic oath, we are both physicians. You have a 
professional duty, a trust responsibility, a moral 
responsibility to our patients seeking care. I just wonder if 
you would like to say anything about that and perhaps 
straighten out the record, clarify or say things to the folks 
here including the young mothers who you referenced on the call 
and the tribes actually impacted by this?
    Dr. Karol. Thank you, Chairman Barrasso.
    Yes, I would like to say something. I am the Chief Medical 
Officer for the Indian Health Service. I am a Native and I am 
100 percent committed to the Indian Health Service.
    Those comments are totally unacceptable, were really made 
after a long day. You know we all work very hard. I really am 
sorry that I made any reference to any negativity to patient 
care. My 100 percent priority is improving patient care, 
providing quality is my highest priority.
    Thank you.
    The Chairman. Thank you.
    Senator Thune, I know you had a question?
    Senator Thune. I have just one question, Mr. Chairman, for 
Mr. McSwain because this came up earlier and was in sort of a 
passing sense.
    I want to ask the question, to your knowledge is IHS still 
discouraging IHS employees from communicating with Congress and 
tribal governments?
    Mr. McSwain. No. We actually have a process whereby if they 
are going to make a statement to folks that we know what they 
are going to be saying, that it is accurate and correct. Aside 
from that, there is no prohibition at all.
    Senator Thune. I would just say I hope you will revisit 
this with your department because I will tell you personally 
from my staff's experience, we continuously have issues gaining 
information from IHS employees who observe some of these 
incidents but are fearful to step forward.
    It was an issue identified in the 2010 Committee report. I 
would like to remind you and your entire staff that it is 
against Federal law to interfere with an employee's right to 
speak with Congress. I think if some of these employees had 
been able to come earlier, we might be having a different 
hearing today.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Thune.
    Senator Heitkamp.
    Senator Heitkamp. Mr. Chairman, I have just one point.
    I almost got jealous listening to Senator Udall. Do you 
know why? We do not have any place for detox in North Dakota. 
It is a desperately needed service. In a recent visit with a 
tribal chairman, he told a story about tribal police being 
called. A woman high on methamphetamine was coming down and 
they had no place to take her. As they left, she walked to the 
church, sat on the steps of the church and froze to death.
    It is not just about the quality of care. It is access to 
care. If we do not build access to detox, substance abuse, 
rehabilitation, we will always fail. Those conditions add to 
and exacerbate chronic disease.
    We have record amounts of smoking. The highest rates of 
smoking in this Country occur among Indian people. We know what 
that means in terms of diabetes and chronic heart conditions.
    We not only need to look at how we do better with the 
services we provide but we need to think about new services. I 
asked Senator Barrasso if he had detox. I do not know if South 
Dakota has any detox but let me tell you, this is a desperately 
needed service in the Great Plains region.
    The Chairman. I want to thank all of the members of the 
panel for being here. I would remind the Administration our 
work is not complete. I look forward to continuing dialog 
including Committee briefings, listening sessions and more 
    We do expect prompt, thorough and accurate responses. Some 
members may have some written questions as well. I hope that 
you would get back to us on those.
    This concludes our second panel. Thank you for being here.
    We will now hear from our third panel of witnesses who have 
traveled a long way to be here today. We welcome each of you to 
the panel. I will remind the witnesses your full testimony will 
be made a part of the official hearing record.
    Before we move forward with the testimony, I want to thank 
Sunny Colombe for her efforts to be here today. Unfortunately, 
due to weather, she was not able to be here to testify. We are 
very fortunate to have the Honorable William Bear Shield here 
today to provide testimony to the Committee. He is the Rosebud 
Sioux Tribe Council representative and sits on the tribe's 
health boards. We thank you for being here.
    I also ask all of the members to please try to keep their 
statements to five minutes so that we have time for questions. 
I look forward to hearing testimony from each and every one of 
    As the panel takes their seats, I would like to turn to 
Senator Thune to introduce a special guest from South Dakota.
    Senator Thune. Thank you, Mr. Chairman.
    I would like to introduce Sonia Weston who was mentioned 
earlier from the Oglala Sioux Tribe. Sonia is an enrolled 
member of the Oglala Sioux Tribe as well as a four time elected 
member of the Oglala Tribal Council.
    She graduated from Oglala Lakota College in 1996 with a 
Bachelor of Arts in Business Administration. She served two 
terms on the Pine Ridge High School Board and currently serves 
on the Tribal Public Safety Review Board, Personnel Board and 
as the Chairwoman of the Health and Human Services Committee.
    Sonia has been a longtime advocate for improving health 
care for Lakota people. I have enjoyed working with Sonia and 
her insight and expertise is greatly appreciated. I want to 
thank her for being here today and look forward to gaining her 
    I will also mention Mr. Willie Bear Shield who is an 
enrolled member of the Rosebud Sioux Tribe. He received an 
honorable discharge from the United States Army in 1991 where 
he was a combat veteran in Desert Storm.
    He returned home and shortly after was elected to the 
tribal council on which he currently serves. Willie is also the 
chairman of the Tribal Health Board and is a member of the 
Great Plains Tribal Chairmen's Association and the Unified 
Tribal Health Board.
    I have the deepest admiration for Willie's dedication to 
his country and the people he represents. As you will see and 
hear, Willie is passionate about what he believes in and fights 
    Thank you, Mr. Bear Shield for being here today. Thank you 
for your service to this great Country.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Thune.
    With that, we will start in order with the Honorable 
Victoria Kitcheyan, Treasurer, Tribal Council, Winnebago Tribe 
of Nebraska.


    Ms. Kitcheyan. Good afternoon, Mr. Chairman and members of 
the Committee. My name is Victoria Kitcheyan, an enrolled 
member of the Winnebago Tribe, currently serving as Treasurer 
of the Tribal Council. I thank you all for holding this very 
important meeting.
    I want to thank all those who have taken a personal 
interest in our crisis and have done things to elevate our 
    I am here today with a heavy heart. I carry the burden of 
the countless tribal members who have been harmed at the IHS, 
including the five defined in the CMS survey who died 
    I carry the burden of the mourners and the concerns of the 
tribal members who are afraid to go to the Winnebago Hospital 
as we speak. It has been said in my community that the 
Winnebago Hospital is the only place you can legally kill an 
Indian. It is 2016 and our people are still suffering at the 
hands of the Federal Government. Kill the Indian, save the IHS 
sounds appropriate.
    It is terrible what is going on at Winnebago. For decades 
and generations, IHS has had a notorious reputation in Indian 
county but it is all we have to count on. We do not go there 
because they have superior health care; we go there because it 
is our treaty right and we go there because many of us lack the 
resources to go elsewhere. We are literally at the mercy of 
    Since 2007, there have been documented deficiencies at the 
Winnebago Hospital. My community believes that it is the 
dumping ground for poor administrators and unskilled providers.
    The back to back CMS findings have given our concerns some 
credibility. It took the loss of our CMS certification to 
finally bring light to the real issues going on. We thank you 
CMS for highlighting that and bringing us to this point.
    The Winnebago Hospital has a variety of issues from 
mismanagement to collusion, waste, fraud and abuse but most 
importantly, we are at the hands of a dated bureaucratic system 
that is not offering quality health care to many of the 
deserving Native patients it serves.
    We have a nurse who cannot properly administer a dopamine 
drip. We have an ER where nobody can find a defibrillator as a 
patient lies dying. We have a nurse who does not know how to 
call a Code Blue. All these things happened and are noted in 
the CMS report. It sounds ridiculous but it is true and our 
people have experienced this.
    Mr. Chairman and members of the Committee, I know you all 
have families and close friends you love and we have all lost 
someone at some point. It is painful and even more 
heartbreaking to learn that your family member died at the 
hands of a Federal employee at a Federal facility.
    The hospital is supposed to be a place of healing, yet our 
people go there and are leaving in worse condition or not at 
all. God rest those souls.
    Our relatives do not have to die in vain. If you take a 
look at page four, there are some details in my testimony. Our 
relatives also do not have to be minimized to a patient number. 
Our relatives have names, Debbie, Shayna, Paulie, to name a 
few. I could go on and on but the point here is that these 
people had a role in our community and a place in our hearts.
    My Auntie Debbie was cited in the 2011 CMS report. She was 
overly medicated and left unsupervised. Even though the nursing 
staff was aware of this, they neglected her, she fell and it 
was undocumented. When we requested the chart, we met 
resistance. My other aunt was retaliated against when she was a 
nurse at the hospital because of our inquiries.
    Bad decisions continue to happen. Just yesterday, our 
hospital was closed down due to the blizzard and patients were 
being diverted to Sioux City, 20 miles away. It took an hour 
and a half to drive there. Our EMTs, our crews and patients 
were put at risk while a doctor and nurses sat collecting a 
paycheck in the ER. This is unacceptable.
    A corrective action plan is in place but it is useless to 
us when, excuse me, but stupid decisions are being made on a 
daily basis that affect our tribal members and the many other 
tribal members that facility serves.
    The Winnebago Tribe is fed up. We have had enough. We have 
lost all confidence in the IHS. We have begun a draft planning 
phase to assume control of that facility through the PL 93-638 
compact but it cannot happen soon enough.
    As I stated, just yesterday, these things were happening. 
Someone could have died. Someone could have wrecked or died of 
exposure. It was that bad, yet these decisions are being made 
on behalf of Native people.
    Mr. Chairman, the Winnebago Tribe truly appreciates all you 
have done. We have some solutions we would like to offer in the 
listening session. We stand willing and anxious to work with 
you, members of the Committee and our fellow tribes in the 
Great Plains region.
    We cannot stand by and let this happen to any other tribe. 
IHS is killing our tribal members, patient by patient. This 
tragedy cannot continue.
    We thank you.
    [The prepared statement of Ms. Kitcheyan follows:]

 Prepared Statement of Victoria Kitcheyan, Treasurer, Winnebago Tribal 
    Good afternoon Mr. Chairman and Members of the Committee:
    My name is Victoria Kitcheyan. I am a member of the Winnebago Tribe 
of Nebraska and I am currently serving as Treasurer of the Winnebago 
Tribal Council. Thank you for holding this very important hearing. Your 
Committee's interest and your personal involvement in this matter is 
encouraging as we work collaboratively to improve the health care 
provided to our people. I would also like to thank the Members of our 
Nebraska and Iowa Congressional delegations, who have given us a great 
deal of support in these past few months, as well as the Members of the 
South Dakota and North Dakota Congressional delegations and the House 
and Senate Appropriations Committees. Without all of this support, none 
of the preliminary improvements that we have seen in these past few 
months would have happened. We also appreciate the work of the other 
Tribes in Nebraska and the Tribal leaders and staff of the Great Plains 
Tribal Chairmen's Association, the Great Plains Tribal Health Board and 
the National Indian Health Board, all of whom have gone out of their 
way to assist.
    The Winnebago Tribe is located in rural northeast Nebraska. We are 
served by a small 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 sizable 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.
    The Winnebago Tribe has already provided the Committee staff with a 
number of documents, including numerous independent reports from the 
Centers for Medicare and Medicaid Services (CMS) and a report from the 
independent contractor hired by IHS last fall to evaluate the facility. 
These materials document in great detail the appalling conditions which 
exist at the IHS hospital in Winnebago. I would ask that these 
materials all be incorporated into the record of this hearing.
    It would be impossible to cover everything contained in those 
hundreds of pages, so I will summarize a few of the very disturbing 
problems that these outside investigators uncovered. Many of these are 
problems that the Winnebago Tribe has been pointing out for years, but 
which have remained unaddressed. Many of these issues were also 
documented in this Committee's 2010 Report ``In Critical Condition: The 
Urgent Need to Reform the Indian Health Service's Aberdeen Area'', 
which is now known as the Great Plains Area. Since 2010, the situation 
has moved from bad to worse and we are anxious to work with you and the 
other Members of Congress to find real concrete solutions. This is 
imperative because people's lives are literally at stake.
    Because my testimony will be highly critical of the IHS, I would 
like to note that there are a number of fine and talented people who 
work for that Agency. Many of these individuals are as appalled as we 
are about what has happened at the Winnebago Hospital and are working 
hard to find solutions. Some are even risking their careers to 
accomplish this goal and have had to seek whistleblower protection for 
choosing to report incidents at an IHS facility. We thank each and 
every one of those fine IHS employees who perform a difficult job 
correctly under difficult conditions. We therefore call upon this 
Committee to protect every federal employee who stands up and does what 
is right.
    Before I provide you with the history of the CMS findings at the 
Winnebago Hospital, I would like to ask you to think about one thing. 
When a person suffers a medical emergency, we all do the same thing: We 
try to get to the place that displays the big bright sign ``Hospital.'' 
We learn as children that a hospital is a place where we will be 
assisted by highly trained professionals who have the skills and the 
desire to make us better. We are taught that we can trust a doctor and 
a nurse. When they tell us to take the blue pill twice a day for ten 
days and we will be fine, we believe them. Unfortunately, too many of 
our tribal people have not found these things to be true at this IHS 
    Since at least 2007, this IHS facility has been operating with 
demonstrated deficiencies which should not exist at any hospital in the 
United States. I am not talking about unpainted walls or equipment that 
is outdated. I am talking about a facility which employs emergency room 
nurses who do not know how to administer such basic drugs as dopamine; 
employees who did not know how to call a Code Blue; an emergency room 
where defibrillators could not be found or utilized when a human life 
was at stake; and a facility which has a track record of sending 
patients home with aspirin and other over-the-counter drugs, only to 
have them airlifted out from our Reservation in a life threatening 
state. I am also talking about a Hospital which had at least five 
documented ``unnecessary deaths,'' including the death of a child under 
the age of three. These are not just our findings, they are the 
findings of the Federal Government's own agency, CMS.
    In fact, the CMS uncovered deficiencies which were so numerous and 
so life threatening that this last July 2015, the IHS operated 
Winnebago Hospital became what is, to the best of our knowledge, the 
only federally operated hospital ever to lose its Medicare/Medicaid 
Certification. Because this Committee's 2010 Report was fairly 
comprehensive, please allow me to pick up where that report left off.
    In 2011 CMS conducted a re-certification survey of our 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. According to what our family learned, Debra was overmedicated and 
left unsupervised, even though the nursing staff at the Hospital knew 
that she was dizzy and hallucinating from the drugs and should be 
watched closely. After her death, a nurse at the hospital told my 
family that Debra had fallen during the night. She said that 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 inpatient 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 doing the questioning 
was Debra's sister, Shelly, who was a nurse at the hospital during that 
period. Unfortunately, Aunt Shelly was not on duty when this occurred, 
but she did know enough from her professional training to question why 
the body temperature and reported time of death did not appear to match 
up. The body was still warm when the family arrived after receiving the 
    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 is was and dismissed the 
inquiry almost immediately, but this is a prime example of why we have 
been unable to get the proof that this Committee has been asking for, 
before the CMS Reports were released. Fear of retaliation within the 
IHS system is real and as your Committee's 2010 Report document, such 
retaliation has been present at the Winnebago Hospital since well 
before 2010. One former IHS employee of our Hospital even told your own 
Committee Staff that those employees who threaten to speak out are 
regularly reminded to ``remember who you work for.'' Another employee 
told your staff that Hospital employees, at least for a period of time, 
were told not to report incidents of improper care on the Webcident 
system. This, as you may know, this is the federally established system 
for reporting improper care in all federally funded facilities.
    When the CMS was finally able to obtain the records that we were 
denied, there was no record whatsoever of the fall that my Aunt Debra 
suffered. A fall which a nurse told us about in some detail. It is 
common knowledge in our area that the then Director of Nursing and the 
two other nurses involved in Debra's care are close friends. It is 
regularly asserted by other IHS hospital staff that they have been 
known to cover up events which might get one of them in trouble.
    My Aunt Debra Free left behind a nine 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 was 
sent home from the emergency room. The staff failed to diagnose that he 
had suffered a stroke.
    When some of the findings of the CMS 2011 Report became public, in 
early 2012, former IHS Director Roubideaux publically promised 
improvements. While some minor issues were addressed, many other things 
got worse.
    In just the past 2 years, four additional 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 investigated this incident and 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 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 conducted a month later 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. This is 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 
        a 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 at the hospital. 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 this year, 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 of this hospital was 
        transferred from the Kansas City regional office to Region VI 
        in Dallas, TX.

   November 2014. Just four months later, CMS returned again 
        for another survey. This report again identified more than 25 

   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 his 
        lab reports showed critical lab values telling him to return in 
        2 days. The patient died at home from renal failure. 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 

   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.''

    Mr. Chairman and Members of the Committee, I know that each of you 
have families and close friends, and I assume that most of you have 
also suffered a loss or know someone who has. It is a profoundly 
painful experience. Now, imagine going through that pain only to learn 
a year or more later, through some government report, that the death 
might have, or even should have, been avoided. Keep in mind that the 
deaths and findings cited here 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. Our people are devastated, angry and demanding change. 
Given what has happened, and been allowed to continue to happen, I 
respectfully submit that we have every right to those feelings.
    As the CMS reports piled up, we have started to see less Hospital 
admissions and less care being provided in the Emergency Room. We 
believe this is due, at least in part, to hospital staff fearing on-
going CMS oversight of their lack of training and skills. We have 
actually been told this by some of our members who work at the 
facility. This is possibly contributed to the most recent documented 
death in January 2015 (noted above).
    The totality of these circumstances finally led CMS to notify the 
Indian Health Service in April of 2015 that it was pulling its CMS 
Certification of the Winnebago Hospital, unless substantial changes 
were made. Changes were not made and CMS terminated that certification 
on July 23, 2015.
    I wish to note for the record that 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 two weeks before CMS 
actually pulled the Certification, the IHS Regional Director was still 
telling the Tribal Council that the threatened CMS decertification 
would not happen because IHS was talking to its lawyers and planning an 
    When the termination happened, the Winnebago Tribe and its 
attorneys asked to see a copy of the latest CMS report. We 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. Perhaps this Committee can get the answers that we 
    Immediately after the hospital lost its' CMS Certification, the 
Winnebago Tribal Council got on a plane and came here to this Committee 
and to its Congressional delegation for help. You responded. Thank you!
    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 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. I can assure you 
that this would not happen at the Georgetown Medical Center or Med Star 
Hospital in Washington, D.C. 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!
    Again, many people have asked us why the families of these 
individuals did not sue. The answer is simple: Most Indian people do 
not place a dollar value on human life. Others, who might be willing to 
sue, either did not know that they could, did not know how, or could 
not afford it. Medical malpractice cases are complicated and expensive. 
You need expert witnesses who are willing and able to testify, and we 
have trouble getting federal employees to answer questions about CMS 
findings. A litigant also needs access to medical records which are not 
easy to get from the federal government, and they need a lawyer who has 
the financial means to front the costs for a family with few financial 
resources. These types of lawyers are not plentiful in our area. So 
yes, our people have rights under the Federal Tort Claims Act, but 
taking on an federal agency which has all of its own experts on salary 
is not as easy as its appears.
    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 the 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 
serious undertrained. The negative media coverage of our hospital over 
the past six years has made recruiting all the more difficult. Would 
you want to see your daughter, fresh out of medical school, step into a 
mess like this in a hospital managed by a dentist or pharmacist?
    After the Tribe met with Secretary Burwell's legal counsel in 
August of 2015, the IHS finally 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 also employed that consultant to develop a corrective 
action plan for the Winnebago facility. This is clearly a step in the 
right direction. At the same time, I, and the other Members of our 
Tribal Council, will not be satisfied, until one of our members comes 
up to me and says ``I was just at the emergency room with my mom--what 
a difference.'' I am not going to trust that simply checking an item of 
a list is getting us the real change that we need to see or that those 
changes will be sustained.
    To this day, when we pressure the IHS on the big issues, we get the 
same excuses:

   ``Employees are protected by the Federal Employee 
        Regulations''. In fact, it seems all but impossible to fire a 
        federal employee. In conversations with your own Committee 
        staff, Winnebago hospital employees reported that some of their 
        colleagues believe that their job can never be put in jeopardy 
        because they are protected by the Civil Service System. When 
        did there become two standards of care- one for the private 
        sector on one for federally operated hospitals?

   ``We wished that we could hire people more quickly but the 
        OPM system has to be followed.'' How many professional people 
        can wait months for an OMP approval? We have lost a number of 
        good candidates who refuse to wait six months or more to be 
        hired. You simply cannot recruit under these circumstances.

   ``IHS lacks the resources to recruit the best people.'' 
        There is truth to this and we encourage the committee to look 
        into this problem. At the same time, while we hear about 
        recruiting problems, we have seen no real effort to recruit 
        from our local Nebraska, Iowa and South Dakota Medical 
        Colleges. In any event, we will never agree that inadequate 
        resources justifies the continued employment of an undertrained 
        or incompetent individual. It seems like the IHS positon has, 
        over time, evolved into ``even a poor doctor is better than 
        none at all.''

    The IHS hospital management has also been an on-going problem. Even 
though CMS has documented countless problems in the emergency care 
division, we have had a pharmacist and a dentist as acting CEO's, and I 
have to ask you what training a dentist, even one of the top dentists 
in the country, has in dealing with issues like renal failure, cardiac 
arrest and overdoses.
    So what should be done?
    First, we ask the Committee to examine the role that Federal 
Employment Policies and Regulations are playing in allowing incompetent 
and undertrained employees to continue to work in the Indian Health 
Service. Employees need to be held accountable for their actions. No 
longer can IHS continue to protect, cover up, shuffle, transfer, or 
perpetuate incompetency.
    Second, we recommend that the IHS be mandated to institute a formal 
process for investigating any report of a questionable death or other 
unusual medical incident in any of its facilities. If problems are 
identified, immediate action must be taken to correct the problem, 
including disciplinary action against any employee who has failed to do 
their job.
    Third, we recommend that the IHS mandate, as a condition of on-
going employment, that its employees report any improper care or 
mismanagement that they observe, and that those reports be sent 
directly to Central Office. The standard of care must be raised and 
every IHS employee should feel responsible for helping to fix this 
    Fourth, we recommend that IHS be authorized and directed to 
immediately terminate any employee who retaliates or threatens to 
retaliate against a person who files such a report. The culture must 
change. Employees should be encouraged to make improvements and find 
better ways of doing things, not intimidated into maintaining the 
status quo.
    Fifth, we feel strongly that each of the tribes who are served by a 
direct care facility should be given full and immediate access to any 
CMS, Accreditation or other third party reports or studies performed on 
that facility. We further recommend that all negative reports should be 
shared with this Committee and its counterpart in the House. IHS needs 
to stop hiding the ball.
    Sixth, we recommend that the IHS be directed to insure that no 
tribe suffers the loss of services or resources because of IHS 
mismanagement. The third party billing from Medicare and Medicaid 
represented a sizable percentage of the Winnebago IHS Hospital's 
operating budget.
    Seventh, we insist that IHS mismanagement should not be used as an 
excuse for eliminating or cutting back on services. Already, IHS is 
discussing how the underutilization of our facility makes it difficult 
to seek the funding necessary to fix its problems. It like a death 
spiral--IHS creates an environment that people do not want to go to. 
They refuse to admit patients because they fear further scrutiny. Then 
they conclude that the hospital is too underutilized, so maybe they 
should shut down some services. This is a totally unacceptable. It is a 
flagrant violation of the Federal Government's treaty and trust 
obligations, and someone should be fired for even raising this as a 
    Eighth, tribes should be given a real role to play on the governing 
bodies of IHS operated facilities, not just a token attendance right. 
Let me give you an example. The IHS will tell you that since the 
``corrective action plan'' has been implemented, our tribal Chairwoman 
has been invited to participate in the final interview process for key 
positions at the hospital. This is true. What they do not tell you is 
that she only received the resume just before the meeting and she was 
never told how many others applied for the job, who they were, what the 
differences were in their credentials, or even how many candidates 
there were.
    The bottom line, Mr. Chairman, is that things need to change and 
they need to change now. We have just heard that both the Pine Ridge 
and Rosebud Hospitals are now threatened with a loss of CMS 
certification and we also know that many of the things that CMS has 
documented at Winnebago are happening at other hospitals throughout the 
Great Plains and Billings Regions. These are our families, many of our 
people are veterans, and they all deserve better.
    Two of your own Committee Staff Members were at Winnebago earlier 
this month. Would any of you want to see one of them to end up in an 
emergency room with IHS Winnebago's reputation, if they were involved 
in an automobile accident?
    The Winnebago Tribe has already begun developing a draft plan to 
assume control of this hospital under a P.L. 93-638 compact. For years 
we have trusted the IHS to do its job. Over and over again, the IHS has 
failed. At this point, the Tribe feels that it has no alternative. 
Contracting is a great thing, and our tribe already operates a number 
of programs under P.L. 93-638. At the same time, contracting or 
compacting should be a tribal choice, not something forced upon us by 
circumstances like this. We know that if we move forward with this 
effort, we are taking on a highly troubled enterprise. That is very 
concerning to us, and to our members.
    Mr. Chairman, the Winnebago Tribe truly appreciates your efforts to 
date and stands ready, willing and anxious to work with you, the 
Members of this Committee and our fellow tribes to insure that our 
members receive the health care that they deserve and that no other 
tribe suffers these same tragedies.

    The Chairman. Thank you so much for your compelling and 
heartfelt testimony. We are very grateful that you have come to 
share that with us.
    I will let you know that the prior panel has all stayed. 
They are here in the audience in the room and are hearing every 
word that all of you are saying, just so you know that your 
words are being heard by them as well as by the Committee 
    I would like to turn to the Honorable Sonia Little Hawk-
Weston. Thank you for being with us.


    Ms. Little Hawk-Weston. Thank you. Good afternoon, Mr. 
Chairman and members of the Committee. Thank you for holding 
this important hearing. Thank you, Senator Thune for your help 
in requesting this hearing.
    My name is Sonia Little Hawk-Weston. I am the Chairwoman of 
the Oglala Sioux Tribal Council's Health and Human Services 
    First, I would like to thank Senator Dorgan for the 2010 
report. The lack of adequate health care is one of the greatest 
challenges facing our reservation and community. Clearly not 
enough progress has been made since the 2010 hearing and 
Senator Dorgan's report.
    Just last November, CMS cited the Pine Ridge Hospital for 
several EMTALA and certification violations. This put the 
hospital at risk of losing its right to participate in the 
Medicare program. This would pose serious financial problems 
for the Pine Ridge service unit which is underfunded as it is.
    It is more than the funding issue we are worried about. The 
CMS finding shows that the hospital failed to meet basic 
Federal standards for quality of care. CMS accepted IHS's 
corrective plans but the tribe is wary that this will result in 
a temporary fix. We want to work with this Committee and the 
IHS towards true lasting reform.
    The tribal council hears ongoing complaints from our 
members about the quality of health care on our reservation. In 
one case, a tribal member with severe back pain was told 
several times that a complete hysterectomy was needed. 
Thankfully, prior to the surgery this member was seen at a non-
IHS hospital off the reservation where the member was diagnosed 
with a herniated disk in the spine and advised that no 
hysterectomy was needed.
    Another tribal member went to the hospital complaining of 
chest pains and was diagnosed and treated for acid reflux. 
Hours later at home, this member suffered a massive heart 
attack and passed away.
    Access to care is also a serious problem for our members. 
Often the IHS cannot provide the kind of services that tribal 
patients need. Due to limited funding for purchase of referred 
care, IHS often refuses to pay when patient are referred to 
non-IHS providers unless the issue is life threatening.
    For example, IHS referred a tribal member to a specialist 
for an assessment. The specialist said surgery was needed but 
IHS refused to cover the cost of the surgery. What good is an 
assessment if the patient cannot pursue the recommended 
    Those who do go to appointments often cannot pay when IHS 
denies the service. Members have shared with the council stacks 
of IHS denial letters and bills for medical services they have 
received. Many tribal members cannot bring on lawyers to deal 
with the situation. Instead, they are plagued by debt 
collection actions and credit score downgrades.
    One member told us he is being pursued by a collection 
agency for $72,000 for medical services. Our members cannot pay 
that. Many of our members who are referred to Rapid City or 
elsewhere for treatment do not have the means to cover the 
transportation cost.
    For on-reservation access to care, our hospital lacks the 
staff, space and equipment to meet demand. The service unit 
estimates it operates at 50 percent of need. Patients endure 
long wait times to be seen by medical staff. Seriously ill 
patients cannot withstand these wait times. Nobody should have 
    Further, we truly appreciate the efforts to address suicide 
prevention but more is needed. Recently, a clinical 
psychologist brought in to help a suicide prevention worked for 
one day before quitting. Providers usually only stay as long as 
their contract term.
    We need permanent physicians who will stay and become a 
part of the community and get to know their patients. The area 
needs to recruit, hire and retain skilled medical staff. That 
is not happening for several reasons.
    One major factor is the critical shortage of housing for 
medical staff. Limited funding for facilities and equipment is 
another challenge. Work environment is also a key factor in 
recruitment and retention. Medical personnel want to work in a 
well managed facility where high quality patient care is a 
    We have heard that the practices of recycling problem 
employees through reassignment or administrative leave cited in 
the Dorgan report continues in our area. We would like this 
issue looked into.
    We want greater transparency in the allocation of funding 
for the Pine Ridge service unit. We cannot make sure the area 
is maintaining its funds to ensure that the greatest amount of 
funds possible are used for direct patient services.
    We hope this hearing will spur further reform but we are 
wary of a temporary fix. We need to make sure that the Great 
Plains area is managed in a way that patient care comes first, 
noncompliance issues are nonexistent and our service unit is an 
attractive place to work. All we want is quality health care 
for our people without the struggles we currently endure to 
receive any health care at all.
    This should not be unachievable in the United States of 
America, especially when the United States of America bears 
treaty and trust responsibilities to our people.
    Mr. Chairman and Committee members, thank you for the 
opportunity to testify. I am happy to answer questions.
    [The prepared statement of Ms. Weston follows:]

Prepared Statement of Sonia Little Hawk-Weston, Chairwoman, Health and 
         Human Services Committee, Oglala Sioux Tribal Council

    The Chairman. Thank you very much, Ms. Weston.
    If I could ask the Honorable William Bear Shield to 

                      ROSEBUD SIOUX TRIBE

    Mr. Bear Shield. Honorable Chairman Barrasso, Vice Chairman 
Tester, members of the Committee, and Senator Thune, good 
    I am William Bear Shield, an enrolled member of the Rosebud 
Sioux Tribe of South Dakota. My family has served as public 
servants for generations. My father, William Bear Shield, Sr., 
was Chief of Police for the City of Gregory, South Dakota and 
killed in the line of duty on July 26, 1976.
    We have served during World Wars I and II as well as in the 
Korean and Viet Nam Wars and in current wars. I served in the 
United States Army and was a combat veteran during Desert 
Storm. I lost my hearing from artillery fire during combat. 
Since Desert Storm, I have suffered nerve problems, skin 
irritations, back problems and had cancer surgery.
    After receiving an honorable discharge in 1991 from the 
United States Army, I returned home and was elected to Tribal 
Council in the fall of 1991 for the first seven terms and 
served on the Rosebud Tribal Health Board for several terms.
    In 2011, I was again elected to Council and I was placed on 
the Health Board and elected Chairman. I also have been 
designated by the Tribe to sit on the Great Plains Tribal 
Chairman's Association and Health Board which covers the States 
of Nebraska, North Dakota and South Dakota.
    Because of health concerns for tribal members being 
mistreated at the Sioux San Hospital in Rapid City, the tribes 
created the Unified Tribal Health Board of which I am currently 
the Chair. This board allows for support and advocacy of our 
membership in the Rapid City area.
    I recently have been nominated to sit on the Health and 
Human Services Secretary's Tribal Advisory Committee.
    I want to start by thanking you and the Committee for 
sending out your staff to our area last month to gain insight 
into our concerns. I am here on behalf of President William 
Kindle and the Sicangu Lakota Oyate.
    Our utmost concerns are quality and safety of health care 
for our people. These concerns have been ongoing for 
generations and unfortunately for our tribe, continue to get 
worse. The lack of funding plays a crucial role in our 
challenges. However, we have witnessed firsthand the level of 
mismanagement and unethical practices both at the area level as 
well as at the local level that is completely unacceptable and 
disrespectful to our ancestors and our treaty with the Federal 
    The dysfunction of the Great Plains area has only grown in 
intensity since 2010. Our people continue to pay the price for 
these atrocities with our lives and health. I would like to 
take the opportunity to share with you some of these concerns.
    Our tribe has organized numerous meetings with IHS 
leadership nationally, regionally and locally, HHS leadership 
and congressional leadership over the past 15 months. We have 
been voicing our concerns and demanding to be involved. We have 
said that the current situation was going to occur and wanted 
to prevent it but we went unheard.
    HHS acknowledges the trust responsibility and the need for 
meaningful consultation with the tribes in their testimony 
today but their actions contradict this. Just this week, the 
decision was made to remove our current director from the Great 
Plains area and a replacement was appointed. However, there was 
no tribal consultation regarding this. This is only one example 
but the point is their actions do not align with their words.
    We want an explanation as to why the past area director was 
abruptly detailed somewhere else and is not here today to 
answer our concerns.
    On November 16th, CMS came to our IHS facility for a full 
hospital recertification survey and to investigate alleged 
EMTALA complaints. Two days into the survey, they found 
significant quality and safety issues in the emergency 
department that posed an immediate and serious threat to any 
individual seeking care and placed the service in an immediate 
jeopardy status. This extremely significant finding was not 
timely addressed by IHS.
    At 4:00 p.m. on Friday, December 5th, our tribal health 
administrator and president were informed that HHS continued to 
identify significant issues in the ER and they were going to be 
relieving multiple staff of their duties. Therefore, effective 
the following day, Saturday, December 6, 2015, the IHS was 
suspending their designation as a dedicated emergency service.
    The tribe was outraged. The lack of planning and 
communication on the part of IHS caused severe and significant 
hardships to our communities and surrounding healthcare 
facilities. In fact the surrounding hospitals, who then became 
responsible for providing this service to our people, were not 
contacted by IHS at all.
    Furthermore, we were informed this diversion would last 
about six weeks. We are still on diversion and have been 
informed it could be another 30 to 60 days.
    Another interesting fact is that no employees were relieved 
of duty. The same staff providing care in the ER is now the 
same staff providing care in the urgent clinic. To put this in 
perspective from a patient view, three weeks ago our ambulance 
was dispatched for a patient having chest pains. They responded 
within 10 minutes of the call. Immediate CPR was started and 
the patient was transferred to the nearest ER in Valentine, 
Nebraska, over 50 miles away. Our hospital was seven miles 
    The staff at Valentine worked on our relative but 
unfortunately he did not make it. This diversion poses real 
life or death risk to our people. We cannot predict when an 
emergency will happen but we are confident that the longer the 
service is available, the higher the risk to our people. This 
is unacceptable.
    Over the past year, we have had at least five executive 
level positions filled with acting problematic employees who 
have been asked to leave other reservations in our region. 
These employees played a huge role in getting us in the 
situation we are in today.
    We have been informed of recent hiring practices of at 
least five nurses of whom at least one did not have an active 
license and three were hired with temporary licenses. 
Furthermore, the relocation expenses and hiring practices with 
regard to these nurses was extraordinary.
    We have been informed that the interview of one of the 
nurses was conducted in another language. How is this 
justifiable when we have elders that only speak Lakota who now 
are being expected to understand and convey their health issue 
to these providers.
    It is a direct reflection of the severe lack of leadership 
and oversight of our facility and of the Great Plains area. The 
disheartening and traumatic realities described above are the 
creation of choices to create treaties long ago, choices to 
dishonor those treaties, budget choices, allocation choices, 
the choice of professional leadership to act unethically and 
against the exact mission with which they are tasked and the 
health and behavioral choices of individual people.
    If there is to be meaningful and sustainable change, all of 
these issues must be explored and addressed. Such public and 
political education will only occur when the current dangerous 
status quo is exposed and a mobilization by politicians, native 
communities and the healthcare community unite for change.
    Until then, the premature deaths of our people and this 
dysfunction we speak of will continue to flourish. We expect 
change. We are here willing to be an active player to achieve 
this change we dream of. We will not accept anything less than 
you or the President of these United States or anyone else 
expects of your healthcare and needs of your loved ones.
    In the next couple of week through written testimony, we 
will offer solutions to our healthcare woes. We need your help. 
Address tribal resolutions. Besides addressing the budgetary 
shortfalls, cut the wasteful spending of the area office. Get 
rid of the area office. It does us no good. Historically, they 
work against us.
    Help us get funding straight to our service units from HHS 
where the money will go towards the health care of our people.
    I would also like to thank Senators Thune, Rounds, Franken 
and Heitkamp for their letter to the Committee and asking for 
this hearing.
    It may be too late for many of our members, but it is not 
too late to make a change for better health care for the Native 
children that come from the poorest counties in our Nation.
    Thank you.
    [The prepared statement of Mr. Bear Shield follows:]

Prepared Statement of Hon. William Bear Shield, Council Representative, 
                          Rosebud Sioux Tribe
    Good afternoon, Chairman Barrasso, Vice Chairman Tester, and 
Members of the Committee:
    I am William Bear Shield and an enrolled member of the Rosebud 
Sioux Tribe of South Dakota.
    My family has served as public servants for generations, my father 
William Bear Shield was the Chief of Police for the City of Gregory, 
South Dakota and was killed in the line of duty on July 26th 1976. We 
have served during World War I and II as while as the Korean and Viet 
Nam War. I served in the United States Army and was in combat during 
Desert Storm. I lost my hearing from artillery fire during combat. 
Since Desert Storm I have suffered nerve problems, skin irritations, 
back problems and had cancer surgery.
    After receiving an honorable discharge in 1991 from the United 
States Army, I returned home and was elected to Tribal Council in the 
fall of 1991 for the first seven terms and served on the Rosebud Tribal 
Health Board for several terms. In 2011 I was again elected to Council 
and I was placed on the Health Board and elected Chairman. I also have 
been designated by the Tribe to sit on the Great Plains Tribal 
Chairman's Association and Health Board which covers the States of 
Nebraska, North Dakota and South Dakota. Because of health concerns for 
Tribal members being mistreated at the Sioux San Hospital in Rapid City 
the Tribes created the Unified Tribal Health Board which I am the Chair 
of. This board allows for support and advocacy of our membership in the 
Rapid City area. I recently have been nominated to sit on the Health 
and Human Services Secretary's Tribal Advisory Committee.
    I want to first start out by thanking you and the committee for 
sending your staff out to our area last month to gain insight to our 
    I am here on behalf of President William Kindle and the Sicangu 
Lakota Oyate. Our utmost concern is the quality and safety of 
healthcare for our people. These concerns have been ongoing for 
generations and unfortunately for our Tribe continue to get worse.
    The lack of funding plays a crucial role in our challenges however, 
we have witnessed firsthand a level of mismanagement and unethical 
practices both at the Area level as well as the local level that is 
completely unacceptable and disrespectful to our ancestors and to our 
treaty with the federal government. The dysfunction of the Great Plains 
area has only grown in intensity since 2010, our people continued to 
pay the price of these atrocities with their lives and health.
    I would like to take this opportunity to share with you some of our 
Mutliple Attempts for Meaningful Consultation to Prevent the Current 
    Our tribe has organized numerous meetings with IHS leadership 
nationally, regionally, and locally, HHS leadership, and congressional 
leadership over the past 15 months. We have been voicing our concerns 
and demanding to be involved. We have been saying that the current 
situation was going to occur and wanted to prevent it. We went unheard.
    The HHS acknowledges the trust responsibility and need for 
meaningful consultation with tribes in their testimony today but their 
actions contradict this. Just this week the decision was made to remove 
Ron Cornelius as the Great Plains Area Director and a replacement was 
appointed however, there was NO tribal consultation regarding this. 
This is only one example but the point is their actions are not aligned 
with their words. We want an explanation of Ron Cornelius' abrupt 
detail and not being here today to answer to our concerns.
Closure of ER Services
    On Nov 16th, CMS came to our IHS facility for a full hospital 
recertification survey and to investigate alleged EMTALA complaints. 2 
days into the survey, they found significant quality and safety issues 
in the Emergency Department that posed an immediate and serious threat 
to any individual seeking care and placed the service in an Immediate 
Jeopardy status. This extremely significant finding was not addressed 
by IHS timely. At 4pm on Friday Dec 5th, our tribal health 
administrator and President were informed that IHS continued to 
identify significant issues in the ER and they were going to be 
relieving multiple staff of their duties and therefore effective the 
following day, Saturday Dec. 6th the IHS was suspending their 
designation as a dedicated Emergency Services. The tribe was outraged. 
The lack of planning and communication of the part of IHS caused severe 
and significant hardships on our communities and surrounding healthcare 
facilities. In fact the surrounding hospitals who then became 
responsible for providing this service to our people, were not 
contacted by IHS at all. Furthermore, we were in formed this diversion 
would last about 6 weeks, we are still on diversion and have been 
informed it could be another 30-60 days. Another interesting fact is 
that no employees was relieved of duty. The same staff providing care 
in the ER is now the same staff providing care in the Urgent Clinic. To 
put this in perspective from a patient view, 3 weeks ago our ambulance 
was dispatched for a patient having chest pain. They responded within 
10 mins of the call. Immediate CPR was started and the patients was 
transferred to the nearest ER in Valentine NE over 50 miles away. Our 
hospital was 7 miles away. The staff at Valentine worked on our 
relative but unfortunately he did not make it. This diversion poses 
real, life or death risk to our people. We cannot predict when an 
emergency will happen but we are confident that the longer this service 
is unavailable, the higher the risk to our people. This is 
Recycling of Problem Employees
    Over the past year, we have had at least 5 executive level positons 
filled with Acting problematic employees that have been asked to leave 
other reservations in our region. These employees played a huge role to 
get us in this situation.
Recruitment Practices
    We have been informed of recent hiring practices of at least 5 
nurses of whom at least 1 did not have an active license and 3 were 
hired with temporary licenses. Furthermore, the relocation expenses and 
hiring practices with regard to these nurses was extraordinary. We have 
been informed that the interview of one of the nurses was conducted in 
another language. How is this justifiable? When we have elders that 
only speak Lakota and now are being expected to understand and convey 
their health issue to these providers. It isn't, but it is a direct 
reflection of the severe lack of leadership and oversight of our 
facility and of the Great Plains Area.
    The disheartening and traumatic realities described above are the 
creation of choices. Choices to create treaties long ago. Choices to 
dishonor those treaties. Budget choices, allocation choices, the choice 
of professional leadership to act unethically and against the exact 
mission they are tasked with and the health and behavioral choices of 
individual people. If there is to be meaningful and sustainable change 
here, all of these issues must be explored and addressed. Such public 
and political education will only occur when the current dangerous 
status quo is exposed and a mobilization by politicians, native 
communities and the healthcare community unite for change. Until then, 
the premature deaths of our people and this dysfunction we speak of 
will continue to flourish. We expect change. We are here willing to be 
an active player to achieve this change we dream of. We will not accept 
anything less than you or the president of these United States expects 
for your healthcare and that of your loved ones. It may be too late for 
many of our members, but it is not too late to make a change for better 
healthcare for the native children that comes from the poorest counties 
in our nation.
    This concludes my testimony and I am happy to answer any questions 
you may have.

    The Chairman. Thank you for your testimony and thank you 
also for your service.
    Our next witness to testify is Mr. Jace Killsback, 
Executive Health Manager, Northern Cheyenne Tribal Board of 
Health from Lame Deer, Montana. Thank you so much for joining 
us today.


    Mr. Killsback. Thank you, Chairman Barrasso and 
distinguished members of the Committee who are still here with 
their staffers.
    I am submitting written testimony so a lot of the issues 
that were brought up we share that sentiment with the tribes. I 
do thank Senator Thune, the non-Committee member, for sticking 
it out with us.
    On behalf of the Northern Cheyenne Tribe and the tribes of 
Montana and Wyoming, your State, I provide this testimony.
    It was my ancestors, my great grandparents, who paid for 
goods and services in exchange for lands, freedom and peace 
with their blood. We expect nothing less in return with our 
treaty rights and our trust responsibilities. That is not being 
fulfilled by the Federal Government.
    It took a lot to come here to the place of power, for my 
office to come here, getting resources to travel here. I would 
like the staffers to take these messages to their bosses. It 
would have been more appropriate for the tribal leaders here to 
speak first; they have traveled a long way.
    I am reiterating the fact that IHS is a broken system, a 
broken system with no funds. Constantly having to deal with 
decisions and budget cuts and never being able to recover from 
sequestration, tribes constantly ask and have in the last few 
years for advance appropriations and to have our funds 
protected from discretionary title. We have an entitlement to 
these funds.
    We learned through the Affordable Care Act that IHS is not 
health insurance. Indian tribes were left in the dark when it 
rolled out because none of our community members were able to 
be properly empowered or educated on the importance of having 
health insurance.
    This opportunity is being missed by the IHS as a means to 
improve or enhance their third party collections. The culture 
we talked about today, the culture of misdiagnosis, poor 
customer service, lack of resources, not having proper 
equipment, losing accreditation, will continue.
    I ask the leadership, the Senators and their staffers, do 
you know the difference between direct service tribes and self 
governance tribes? Do you now the dichotomy that exists with 
the budget formulation process tribes currently go through 
right now?
    Do you know that we, the Northern Cheyenne, view this as a 
tactic of divide and conquer amongst tribes who fight over 
scraps for IHS funding? Funding is an issue. We know it is the 
major issue. We wonder why and how these areas, the Great 
Plains, the Billings area, the Rocky Mountain area, 
consistently have to deal with IHS's substandard quality of 
care and the lack of resources. The tribes are labeled the do 
nothing tribes or the handout tribes.
    One of our elders likened it to the old notion of hang 
around the fort. Which tribes hang around D.C.? In the past, 
which Indians hung around the fort to receive rations first? 
Tribes who do not have the resources or the wherewithal, the 
consultants or the lawyers to travel to this place of power, 
Washington, D.C., to get help or get your ears, are the ones 
left out.
    Capacity is an issue. Capacity is an issue for tribes in 
our region because our tribal governments lack those resources. 
When we try to move forward towards Title V under the 638 law, 
we are met with red tape and resistance because career and 
legacy IHS employees do not want to lose their jobs.
    It should be the opposite. They should be working 
themselves out of a job and letting us become more self reliant 
and self determinant as tribal nations.
    The healthcare system and the Federal Government, I want to 
again reiterate that the bureaucracy is causing these issues we 
are talking about, that our tribal counterparts are mentioning.
    A perfect example was contract support costs. Self 
governance tribes agreed probably at the detriment of direct 
service tribes to take funds from the headquarters and tribal 
shares to pay for fully funding contract support cost claims. 
That is a perfect example of this divide and conquer tactic.
    Other issues I wanted to bring up are in regard to the 
issue of life or limb. The PRC changed its name to Patient 
Preferred Care but it is still CHS. Often doctors in our local 
IHS service units have to game the system to get a CT scan. It 
may be considered a Level 2 service but they will find a way to 
game the system and make it a Level 1 so their patient who they 
care about can get that CT scan.
    Yesterday I heard my board member lost his wife to cancer. 
If she had gotten a colonoscopy sooner, maybe they would have 
been able to treat the cancer. The issue was the doctor said 
there was no blood in her stool so they could not refer her 
    That touches home because that is a tribal leader who lost 
his wife because of this direct care. As direct service tribes, 
we constantly have to battle funding issues related to the PRC 
system and the level of care we ask for. This is a trust 
responsibility and a treaty right.
    Solutions I want to recommend in closing are you heard 
about recruitment and retention. IHS does need to be able to 
compete with the private sector. There need to be more 
opportunities than just the loan repayment program.
    In Montana, recently the legislature passed the Help Act 
which provided us with Medicaid expansion. In consultation with 
the tribes, the State of Montana and the Governor created an 
Office of American Indian Health to deal with the health 
disparity that Senator Tester mentioned earlier, that a whole 
generation of Indian people in Montana is dying before our 
white counterparts.
    We think there should be some facilitation to improve and 
increase tribal-State relations and also build capacity and in 
the transition for direct service tribes to self governance. We 
hope the Committee hears these and we thank the distinguished 
members of this Committee for allowing me to express the views 
of the Northern Cheyenne Tribe and the region of the Billings 
    Thank you.
    [The prepared statement of Mr. Killsback follows:]

    Prepared Statement of Jace Killsback, Executive Health Manager, 
                Northern Cheyenne Tribal Board of Health
    Chairman Barrasso, Vice Chairman Tester, and Members of the 
Committee, thank you for holding this important hearing on the 
substandard quality of health care experienced by Indians in the Great 
Plains and more specifically in my region, the Rocky Mountain Area 
which includes both the Chair and Vice Chair's home states Montana and 
    On behalf of the Northern Cheyenne Tribe and the Tribes of Montana 
and Wyoming, I submit this testimony.
    My ancestors, my great grandparents paid for goods and services in 
exchange for lands, our freedom and peace--with their blood. Their 
sacrifice was made for me, my grandchildren and their grandchildren 
into perpetuity. Because of our Treaties with the federal government 
and your promises to my people there is a trust responsibility for your 
government to provide health care to my People: Your trust 
responsibility is not being fulfilled! I come to you revealing a tragic 
and sad truth: health care is rationed and inadequate for the Northern 
Cheyenne and surrounding Direct Service Tribes. We are required to 
utilize this inadequate, hostile system in our isolated and frontier 
parts of the United States--the places we call home.
IHS: A Broke and Broken System
    The Senate Committee on Indian Affairs should be experts now on the 
funding issues that plague the Indian Health Services (IHS). For years 
the data show that the IHS has continually operated on a close to 40 
percent budget. IHS has never been fully funded based on need. In 
addition, the IHS Budget has never recovered from budget cuts, 
recessions and sequestration. We all should know by now that increased 
funding and advanced appropriations will make a huge and positive 
impact in the IHS healthcare system. Even more important, Congress 
needs to protect the IHS budget from discretionary funding and budget 
cuts. Of course these realities help create and sustain a health care 
system that the Northern Cheyenne and other DSTs are forced to utilize 
because it's the only game in town. No matter that it is substandard, 
lacks any real resources, and is not customer-friendly or culturally 
appropriate toward its patients. We need to be progressively aggressive 
in preventing and treating diseases in our communities, to remain 
eligible and mission driven to meet accreditation standards and to 
effectively compete with the private sectors. IHS is not a public 
health system.
    IHS is not health insurance. We learned this the hard way with the 
implementation of the Affordable Care Act in Indian Country. This 
distinction about insurance was not made clear in our communities and 
the federal government missed an important opportunity to educate and 
empower tribes and Indians. Now that tribes have to subsidize the 
underfunded IHS system with other agency grants, third-party revenue 
and even Tribal dollars, when possible. Tribes have to be more and more 
creative in providing support for the direct health care of our tribal 
citizens. I say direct care because the Tribes in our regions are still 
a majority direct service tribes.
Direct Service Tribes
    How many distinguished members of the committee know the dichotomy 
of the IHS Tribes? It is Public Law 93-638, the Indian Self-
determination and Education Assistance Act of 1975, empowered and 
created authorities for to tribes to be truly sovereign nations in 
managing and governing federal resources for their people. In 
healthcare, PL-638 has shown that the levels of tribal government 
capacity in regard to self-governance varies within the 12 IHS regions. 
Most commonly, the Tribes in Montana, Wyoming, South Dakota and North 
Dakota remain Direct Service Tribes. And in the more recent decade, 
this label has had a negative connotation that is associated with the 
``do-nothing tribes, hand-out tribes, or the tribes who don't have 
stable governments, lack tribal resources to hire consultants and 
lawyers, who lack funds to lobby and travel to the place of power--
Washington DC.'' The playing field for tribes is far from level.
    Direct Services Tribes receive health care directly from the 
federal government and these areas that still have direct service 
tribes tend to be viewed by other Tribes and by IHS as unsophisticated 
and uneducated governments who lack the understanding to taken 
advantage of Title 5 of the Indian Self-determination Act. The scrutiny 
is that if we, the Direct Service Tribes of the Great Plains and Rocky 
Mountain Area complain so much about IHS, than why don't we just take 
over the clinics, hospitals and programs and run them ourselves? First 
of all, why should we have to? But, it's just not that easy to do.
    Tribes like the Northern Cheyenne still have our language and our 
ceremonies, we still have customs and traditions that are original to 
this land and seem foreign to the federal government. The Northern 
Cheyenne were one of the last tribes to lay down our arms against the 
US Army. We resisted the longest and now we suffer the most.
    Now when Tribe's in our areas want to contract or compact, we are 
met with resistance and red tape. Federal employees who work for the 
IHS would be working themselves out of a job if they help to ensure 
that the Tribes and Tribal Health Programs can properly manage their 
own health care functions, the purpose of PL-93-638. In the DST-
dominant areas of IHS, our federal Indians are career driven and legacy 
minded professionals who are quick to hinder our efforts instead of 
helping our cause to be self-determined in our healthcare. Examples 
include the contracting of clinics, business office functions and the 
Patient Referred Care for tribal premium sponsorships programs under 
the ACA.
    The healthcare system under the Federal Government is set-up as a 
divide and conquer tactic that can be compared to the ``hang-around the 
fort Indians'' concept where those who are in Washington, DC (the fort) 
get the help (the food and health rations) first.
    Direct Service Tribes are pitted against the Self-governance Tribes 
annually when it comes to IHS and HHS Budget Formulation process. 
Priorities of one group versus another group are discussed and debated 
on where the already underfunded budget allocation (or increases) for 
IHS will go. The federal government has us fighting over scrapes again 
and history is only repeating itself.
    The problem with this and the difference between Direct Service 
Tribes and Self-Governance Tribes is capacity. As a direct service 
tribe, I know we are still making gains to build our capacity to be 
able to take over our clinic and run it the way we would like in a 
culturally significant manner, free of federal bureaucracy. But because 
we, ourselves, have been given a tribal government system through the 
Indian Reorganization Act that assures a revolving door of tribal 
instability, we continually have to start over every two years to make 
any real progress towards true self-governance. Yes, this portion of 
the situation is ours and we are moving towards tribal government 
reform and we will revise our tribal constitutions: we will get there.
    Take for example the hot issues of Contract Support Cost (CSC). The 
fact is the IHS had to eat the cost of fully funding CSC last year and 
did so mostly at the expense of Direct Service Tribes. Then on May 22, 
2015 we learned that the IHS paid out $68 million to settle overtime 
disputes with 20,000 IHS employees. $48 million came from the third 
party billing revenues Tribes fight to bring in to fund our system. Why 
was that funding sitting at Area IHS offices, available for re-
purposing when our People are desperate for doctors and other health 
care providers? Again, 11 IHS doctors were sent to Africa to address 
the Ebola Virus outbreak--when our own People are dying in a health 
system with nearly 40 percent vacancy rates for physicians in the Great 
Plains Area, alone. Here we have an already underfunded healthcare 
system being gouged to take from its coffers money funds and capacities 
that are supposed to be used to provide direct health care for tribes 
like the Northern Cheyenne. And now these funds are being used to pay 
for indirect cost for tribes who are empowered and experts of PL-638 
and who provide their own tribal health care; back pay from a mis-
managed personnel system and for Peoples overseas with whom the federal 
government does not have a trust responsibility!
    In the case of the CSC case, the federal government with approval 
of Tribes (mostly self-governance tribes) agreed to support the taking 
money from the direct service tribes to pay for the majority of self-
governance tribes contract support cost. Sure, the Northern Cheyenne 
will be settling our CSC claims but it is sad to think that the money 
is coming from our IT support shares from headquarters or the IHS 
nurses and doctors salaries in Lame Deer, Montana.
    So why doesn't the committee question the system they authorize and 
fund? This system is still a paternalistic model of colonization. There 
are tribes at all different levels of success and self-governance. Take 
a look at the Tribes in the Great Plains and Rocky Mountain areas and 
see where our capacity is and see how our relationship with the federal 
government is. It has become normal and ``ok'' to: be misdiagnosed by 
locums who are contacted on the weekends to work in our ERs; to wait 
until you're going to lose a leg or your life in order to be referred 
out to receive the right healthcare you need; for a baby to be born in 
a car on the way to the Northern Cheyenne hospital because IHS no 
longer delivers babies at Crow hospital. If you go out of IHS to make a 
life decision for your family or yourself that does not meet the IHS 
standard of ``life or limb,'' you will have to pay for it yourself. 
Many of my people have been sent to debt collectors or had their fixed 
incomes compromised because they could not pay for medical care that 
IHS denied. This protocol has administrators making business decisions 
over medical providers' medical directions. Now you have doctors at the 
local level learning ways to game the system in order to ensure that a 
tribal member receives a CT scan that will eventually save their life 
versus waiting until one's health erodes into a far more costly and 
life-threatening condition.
    Since we cannot get referred out to for ``Level 2 or Level 3'' 
services under the PRC system, tribal members remain in pain or their 
diseases go undetected and untreated. Most become addicted to pain 
bills or lose faith altogether and resort to self-medication with 
alcohol or substance abuse. This vicious cycle, along with the 
circumstance I mentioned with the funding and capacity issues for 
Tribes, makes one believe that the Indian Wars are not over and that 
the treaties continue to be broken and that there is not ``trust'' 
worthy of our U.S. Government's responsibility.
    In closing I want to point out some positives and solutions that 
seem to be working in Montana.
1. Montana, Medicaid Expansion and Tribal-State Relations
    The Northern Cheyenne has a political and government-to-government 
relationship with the federal government and yet we are still being 
classified and grouped into race or ethnicity driven discussions. For 
example, in Montana, the state issued a report in 2013 identifying the 
mortality rate of American Indians to be 20 years less than that of our 
white, non-Indian neighbors. We die a whole generation before our white 
counterparts. This figure went unmentioned and was not addressed. With 
an alarming health disparity that is based on a denominator of race/
ethnicity, the report and the figure neglected to acknowledge the 
political status First Montanans have in respect to State-Tribal 
relations. Montana responded and Governor Steve Bullock met with Tribes 
to create, by Executive Order, the Office of American Indian Health to 
address the health disparities Indian people face in the State.
    As of January 1st, 2016 some 20,000 American Indians in Montana 
became eligible for Medicaid Expansion under the HELP Act. With 
Medicaid Expansion. Tribes and more importantly, IHS facilities are 
able to increase their billing opportunities for the services they 
provide to increase revenue that hopefully increases the PRC referrals 
and direct services. We thank the state for picking up the slack of the 
federal government.
2. Recruitment and Retention
    Recruitment and retention of qualified medical providers is a game 
changer. For example, the emergency rooms are difficult to staff with 
permanent ED physicians. Coverage is provided by contract doctors. 
Primary care doctors then have to cover the ED, which destabilizes the 
primary care setting and that is our core function. I believe that if 
IHS fully staffed all the service units with providers many of their 
issues would disappear. IHS could then focus on optimizing the delivery 
model and improve access points for the patients. Again, speaking as a 
Direct Service Tribe, recruitment is more than just pay and with 
competing against the private sector, IHS should consider their own 
health care infrastructure (newer equipment, robust EHR, support staff, 
adequate space etc.), schools, housing, shopping, cell coverage and 
spouse satisfaction to name a few.
    Fill all vacancies and streamline the selection and hiring process 
for positions. Work with Tribes on fillings positions and remove the 
PSA requirements for top-level positions. Too often the IHS is burdened 
with career-oriented and legacy minded individuals who lack any true 
commitment to the service of tribes and American Indians. Cultural 
competency should be a standard in recruitment also.
3. Transition Toward Self-governance
    Provide better technical assistance and funds for Direct Service 
Tribes to begin to transition into Self-governance. Begin a pilot 
project for Tribes in the Great Plains and Rocky Mountain areas to help 
build capacity and strategize a plan to increase contracting and 
eventually compacting services and function of the IHS.
4. Allow Tribes to be Voting Members on IHS Governing Boards
    Tribal participation on IHS's Clinic/Hospital Governing Boards is 
limited to ex-officio status. Allow Tribal representatives to have full 
membership and insurance coverage to make decisions on these boards in 
a true government-to-government manner. This would also train and 
prepare Tribes to transition into self-governance.
    Thank you for the opportunity to offer this testimony for the 
committee on this important topic that I am so passionate about. I 
express the Northern Cheyenne Tribe's support for the work that this 
Committee has previously done to support the Indian Country and look 
forward to working with you to find solutions for to achieve excellent 
health care delivery and status of our indigenous people.

    The Chairman. Thank you very much, Mr. Killsback.
    At this time, we will go to questions. Senator Thune.
    Senator Thune. I would direct this to the panel. You 
obviously heard Mr. McSwain state that the IHS is committed to 
a transparent working relationship with Rosebud, Oglala and 
Omaha Winnebago tribal leadership.
    To date, how transparent do you feel the IHS has been and 
what recommendations would you make to improve IHS's 
transparency with the tribal leadership?
    Ms. Kitcheyan. I would like to address that. I would say we 
have made great strides from last July when we first learned of 
our CMS termination through the media. The former area director 
was in our tribal chambers reassuring us that everything was 
fine. We have come a long way since that time.
    We have weekly calls, a monthly face-to-face but we have 
begun to feel as if it is just lip service. We are not seeing 
improvements that we would like to see quick enough, as I 
mentioned in the blizzard situation.
    There is not complete transparency. We ask for things. Some 
of the questions seem repetitive. We ask for them over and over 
again. In some sense, we are being entertained but are not 
getting the solutions our community needs and that we need to 
provide to assure them that the health care is back on track.
    Senator Thune. Do you feel that IHS is responsive to the 
concerns of the tribal council and the Tribal Chairman's Health 
Board when they bring forward issues?
    Ms. Kitcheyan. I think collectively between the Tribal 
Health Board and IHB, the National Indian Health Board, the 
tribal councils, it is taking all of us to work together to get 
to this point. Each individual agency, I do not think, has 
received answers they deserve or have asked for.
    Mr. Killsback. Senator, in the Billings area under Dorothy 
Dupree as Acting Director, she allowed the tribes to be ex 
officio on the governing boards for the facilities. In my 
written testimony, I have asked that they allow tribal 
representation to be voting members of these governing boards 
over these facilities so that they know the ins and outs of the 
accreditation standards that are needed, the reporting 
standards that are needed in managing a medical facility.
    That was a solution and right now we are asking for full 
voting authority to be members of these governing boards.
    Senator Thune. Ms. Weston?
    Ms. Little Hawk-Weston. I believe that IHS need to needs to 
be more I guess based on consultation. I believe they need to 
do more of the consultation piece to the tribe, especially the 
tribal leaders.
    One of the Senators talked earlier about a communication 
breakdown between the staff in D.C. and the Aberdeen area down 
to the local service units. I believe that sometimes 
communication is not happening between the staff here in the 
D.C. area and down to our service unit directly at times.
    I think there is a communication breakdown but I really 
believe that the tribal leadership needs to be involved in a 
lot of these meetings. I know what Mr. Killsback mentioned is 
the governing body meetings. I know representation from the 
tribe all the time is the chairman of the tribe or the chair of 
the Health and Human Services committee.
    I believe sometimes we are notified and there are times we 
are not notified. I really believe the consultation piece needs 
to be reinforced to make sure that IHS is consulting with 
tribal leadership, especially when it comes to budgetary or any 
other important decisions based on our IHS service units. That 
needs to continue all the time.
    Thank you.
    Mr. Bear Shield. Senator Thune, I think even since the CMS 
review and we had a plan of correction in Rosebud that was 
accepted by CMS, there still continues to be practices that 
continue that just do not give us any hope that things are 
being taken seriously.
    I feel there needs to be more direction as far as up the 
chain where they need to be more actively involved and help us 
work towards getting our ER services reopened. The other day it 
was supposed to be reviewed to see if we could open the first 
part of February. From what we are hearing, by no means are we 
ready for that.
    In answer to your question, I feel that there is a lot of 
work yet to be done. In my testimony when I mentioned our 
resolutions between the Committee and Congress, besides 
budgetary woes that we fall on, listen to the tribes.
    Your staffers are great. Ms. Hoelyn is a great asset in 
listening to us and addressing and letting me know how things 
are. You will be seeing some of the resolutions coming from us. 
We are addressing some of what we want to see for the future.
    Some are short term but there will be long term solutions. 
We need your help. You will see that in the next ten days or 
    Senator Thune. My time has expired.
    The Chairman. Go right ahead.
    Senator Thune. Ms. Weston, you mentioned in your testimony 
air ambulance flights that place a significant burden on the 
service area's budget. I have recently been told that IHS does 
not have a flat contract with providers in the area.
    Since this is clearly placing a burden on the operating 
budget, do you know if IHS has been exploring ways to 
standardize these flights to ensure continuity when it comes to 
    Ms. Little Hawk-Weston. I think the area of the air 
ambulance was a concern a while back with the HHS committee as 
well as leadership. We only had one air ambulance picking up 
our patients and taking them either to Rapid City, Sioux Falls 
or Scotts Bluff, Nebraska.
    We had inquired about what was going on, we only had one 
air ambulance. Come to find out there were other vendors that 
also transport patients but according to the Acting CEO they 
call on one air ambulance because they have a contract with 
that air ambulance according to the way the structure is with 
the Aberdeen area on how they RFP out vendors to pick up 
patients within the Indian Health Service.
    They utilize only one air ambulance right now. The cost of 
it we were told was enormous. We did get copies from the Acting 
CEO on the amount of money we were spending. I will tell you 
that it is quite high. I think she did mention it does take a 
lot from the base budget of the Indian Health Service at our 
service unit.
    Senator Thune. Thank you, Ms. Weston.
    Mr. Chairman, thank you so much. Thank you so much for 
being here today. It has been very, very helpful.
    The Chairman. Ms. Weston, if I could follow up a bit on 
what Senator Thune was talking about. When these folks are 
transported for care, families are a long way away. Can you 
talk about some of the challenges of just getting people back 
home after they have received their care?
    Ms. Little Hawk-Weston. That is one of the concerns of our 
tribal membership back home on the Pine Ridge Reservation. One 
of the things that we as tribal leadership has found is that we 
are spending quite a bit of money out of our general fund 
budget within the Oglala Sioux Tribe to transport our families 
to and from the hospital.
    At times, we have to pay for the cost of their 
transportation, their hotel room, food and whatever else that 
comes with the time the family has to stay there at the 
    On the tribal side, we are spending quite a bit of money. I 
think I did address that in my testimony, how much we are 
spending within the Pine Ridge Indian Reservation, the general 
fund of our tribe.
    It is always a concern because we have to send the family 
when a loved one is in a hospital, whether it be in Rapid City, 
Sioux Falls, Minneapolis or in one of the Nebraska hospitals. 
It is a big concern of ours and a big concern of our families 
back home.
    The Chairman. Ms. Kitcheyan, you talked about CMS's 
confirmed surveys that a number of tribal members have died 
unnecessarily due to deficiencies. Can you discuss what impact 
that had on the community?
    Ms. Kitcheyan. It has had a horrible impact on the trust. 
Our people do not want to go to the facility. IHS then tells us 
that our average daily patient load is down, a means of 
determining the needs of the hospital. The need is there but 
our people do not want to go. They look at it as a death trap.
    People are suffering at home. They are refusing to seek the 
care they need. As I mentioned in my testimony, this is our 
only option. Most of our tribal members do not have insurance 
or do not even have a vehicle or resources to go somewhere else 
to maybe an urgent care facility or something like that.
    It really has impacted the morale of our community and the 
morale of the employees at the hospital. They are afraid. We 
have been told that the nurses were told not to admit because 
they do not want to be scrutinized and further cited in CMS 
    In addition, we have many people who have procedures done 
in Sioux City or other places and they want to come home to 
recover. They cannot come home because they will not admit 
them, yet we have vacant beds and patient nurses and staff who 
refuse to go downstairs and help the clinic.
    Who can make these nurses work? These are Federal 
employees, collecting a paycheck, refusing service. It has had 
a terrible impact on the trust of the community. They come to 
the tribal council. We feel helpless. We cannot make those 
nurses work. We cannot make them admit our people.
    Beyond that, sometimes they lack the equipment to even 
service these patients who want to come home. My Auntie Debbie 
who I mentioned in this report was one of those people who came 
home after having an amputation. She died just recovering, 
over-medicated, did not take the pain patch off and continued 
to give her medication. She was a dialysis patient. They 
overdosed her.
    There is fear within the community to even go there. It is 
    The Chairman. Would any of the other three of you like to 
comment on that or give some final thoughts or comments you 
might have or something else that has come to your mind?
    Mr. Killsback. I just want to reiterate the capacity topic 
I brought up about tribes in our area that want to go to self 
governance, that there should be some additional resources or a 
pilot project where we can take on the function of our service 
units, manage our clinics in a more culturally significant way 
that benefits or people because we know our people. Let us do 
the recruitment and retention piece.
    Again, with capacity building and self governance tribes 
are able to be more a lot more flexible, have a lot more 
billing opportunities that brings in revenue to supplement the 
underfunding that IHS already receives and would allow us to 
build better capacity in regard to consultants and having 
lawyers and experts help us with our governance piece.
    The Chairman. Anyone else?
    Mr. Bear Shield. Once again, I would like to thank you for 
having us today and allowing us to voice our concerns. I think 
the main thing is we are also here to offer possible solutions. 
We just need the help of Congress and committees like you.
    Thank you.
    The Chairman. Ms. Weston, any final thoughts?
    Ms. Little Hawk-Weston. I also want to say thank you for 
holding this important hearing today and bringing us all the 
way from our reservation.
    I want to say everything we spoke about in our opening 
statement is very true to our heart. Also, we need to make 
improvements within the IHS facilities but we cannot do that 
unless we have full funding.
    Today, I think our service unit only receives 50 percent of 
base funding. We would like to see one day 100 percent funding 
so that we can address the adequate space, equipment for our 
facilities and staffing. We also want to see maybe an increase 
in our purchased referred care, including our transportation 
    All of this comes back to how we would like to work with 
IHS to sit down and look at ways of how we can improve the 
quality of health care for our people back home. That is what I 
want to say today, Senator.
    With that, I would like to say thank you for bringing us 
here and giving us time to talk about the many concerns we have 
about our tribal members back home.
    The Chairman. Thank all of you so much for your testimony. 
The hearing record will remain open for two weeks. I want to 
thank you all for being here.
    I think you all know that when this oversight hearing 
concludes in a few moments, we are going to have a very short 
recess and then follow this with that a listening session 
called Putting Patients First, Addressing Indian Country's 
Critical Concerns Regarding the Indian Health Service.
    The statements made during that listening session are also 
going to be included in the record of this hearing for today. 
Everyone's voice will be heard.
    I know numerous tribal leaders and tribal organizations 
have traveled to Washington to provide their statements at the 
listening session. It is my hope that hearing directly from 
these leaders will help guide Health and Human Services and all 
of its agencies to develop, as you said, answers and lasting 
solutions for better patient care.
    Thank you all very much. The hearing is adjourned.
    [Whereupon, at 5:24 p.m., the hearing was adjourned. The 
Committee proceded with a listening session.]


    The Committee and participants met, pursuant to notice, at 
5:40 p.m. in room 216, Hart Senate Office Building.

                         CHIEF COUNSEL

    Mr. Andrews. I feel like a captain of an airplane here. Can 
we all take our seats before takeoff, please?
    Let me first start and obviously thank everyone for staying 
through a very important and long hearing. I think overall it 
was a good dialogue. I think any time you get the diverse 
witnesses that we had, the Administration, of course, being a 
central part of that, and then our tribal representatives, I 
think it's a good recipe for solutions.
    Really that's kind of the premise for this listening 
session. I think Tony Walters and I, who are staff directors on 
the majority side and on the minority side, when we put this 
concept together of this hearing, we knew about the outcry and 
the demand of listening to everybody, giving everybody an 
opportunity to come before the Committee and telling us your 
story, telling us areas that you think that we to improve upon 
as Committee staff who draft the legislation.
    So that is our goal here. We want to get to everybody. I 
think Mr. Killsback said it best, about the tribal leaders have 
an opportunity to speak first. And so I think in terms of that, 
I think that's probably the correct procedure, how I think we 
ought to run this listening session. And really not to outweigh 
one or the other, I think the safest thing to do, without 
getting in the crosshairs of picking one tribe or the other is 
really to go by alphabetical order, to hear from the tribes, 
first, then tribal organizations, and then anybody else. I 
think that will be kind of in a systematic way. This way we 
capture everything. And as Chairman Barrasso said, we have a 
court reporter here. Whatever you say will be part of the 
record. And it will help drive the discussion with Committee 
    And in terms of you statement, try as best you can, and I 
know it's a sensitive topic, if you can, to adhere to a three 
or five minute rule. Again, it's a sliding scale. We want to 
capture what you have to say.
    And I think in terms of the tribes, obviously the chairmen 
and the presidents and the elected officials, I will defer to 
you on who best to represent your tribe coming before us.
    With that, Tony, do you have anything you want to add 
before we kick this off?


    Mr. Walters. Sure, thank you. I'll be pretty brief.
    I just want to tell everyone I appreciate their being here 
and spending this whole evening with us, essentially, afternoon 
and evening. It's one of the longest hearings we've had on this 
important topic. I think you can see how the Senators were 
engaged. Obviously, Senators have to come and go. But clearly, 
some of them stuck it out. Obviously they know the importance 
of these issues brought in. Senator Dorgan, who was chair of 
this Committee five or six years ago, obviously he still 
understands these issues. And we wanted to even get input from 
him from having that perspective.
    Thanks to all the tribes who have come in today to provide 
more statements at the listening session. If you have anything 
in writing, of course, feel free to always send that in to the 
Committee. Staff is always here to look at anything that comes 
in. I know Mike's staff and mine as well have regular, constant 
dialogue with IHS folks here in D.C., in the regions where the 
tribes are having issues. So we're here to be as helpful as we 
can, we want to understand as many of the issues that you all 
have as you can bring forward to us, so we get a better grasp 
on it and know how we can help the best.
    So I'm not sure if we have any overall time constraints, 
but we're going to be here for as long as we need, I guess.
    Mr. Andrews. We will be here until we hear from you all. In 
terms of the listening session, the microphones are up front 
here on the side. So looking at alphabetical order, Cheyenne 
River Sioux Tribe, Chairman Frazier, if you want to address us 
    Chairman, thanks.

                          SIOUX TRIBE

    Mr. Frazier. I'm Harold Frazier. I'm Chairman of the 
Cheyenne River Sioux Tribe in South Dakota.
    As I was back here and I was listening, I felt like 
grabbing my papers and throwing them away. Because everybody 
knows the problems. Everybody knows the solutions. I can't 
understand why we're not fixing them, or addressing them. We 
know about recruitment and retention. We know the barriers. We 
know the weaknesses. We all know that. But nobody's doing 
anything about it.
    I got elected in 1988 on tribal council, four years, and I 
served another four years as tribal chairman. Health care was a 
priority back then and it still is. One of the things is that 
presently, when there's something wrong with the Indian Health 
Service, we get rid of the service unit director. Since 1998, 
on the Cheyenne River Service Unit, I think we've gotten rid of 
about 10, 12 of them. And I'll guarantee the problems are still 
    Even today, with our area director getting rid of 
Cornelius, I guarantee you tomorrow the problem is still going 
to be there. It is a system with regulations.
    One of the questions was answered, and you were talking 
about corruption. A colleague of mine in tribal council says, 
why do you think that's happening, the corruption? I said, 
because they think they're untouchable. When you're a Federal 
employee, you don't get terminated. You get transferred on or 
moved on. And that's reality. They're protected by somebody.
    To me, when I got in office, just one year ago, I dealt 
with the Indian Health Service. But to me, the solution is, the 
only way I see for Cheyenne River is to compact and let some 
professional company manage it for us like Avera, Sanford 
Health. Those are the two big health companies back home in 
South Dakota. I think that's the only way. You can play these 
games, spend a lot of money on travel, hire experts.
    About 10, 12 years ago we did a health care seminar like 
this, had a court reporter, did testimony, with up to five of 
our biggest communities. One of the things we found that was 
common throughout the testimony was our people were upset by 
having to see a new health physician or health professional 
every time they went into the IHS. They were tired of telling 
their health history. And at that time, pharmacy was a big 
problem on Cheyenne River.
    So we looked into it and we found that our service unit, 
because of the regulations, they could only pay $45,000 a year. 
And when we looked into the private sector, they were paying 
$100,000 to $150,000 a year. But I still have to provide that 
    So then they get into a contract with a firm or some 
company. And that company locates them. That's why our people 
have seen that.
    So I know regulation is a big issue, big problem. I feel 
that. To me, government is over-regulated itself. And I want to 
quote Senator Rounds, from about six, seven years ago when he 
was Governor of South Dakota, VA was having problems, he said, 
governments cannot run the hospital. I agree with that. Tribes 
can't, Federal Government can't, you guys can't. It's a proven 
    Now I'll get to my speech. That was my opening. You guys 
know all the statistics, you guys know all the concerns. One 
thing I want to talk about I think is a big issue is suicides. 
Right now, I think our delegation is looking at building a 
treatment center or putting a behavioral health center in Pine 
Ridge. I think, I mean, we would support something like that. 
Because I want to tell you something, IHS, they refer a lot of 
our kids to Rapid City Regional West and Rapid City. I get 
reports back from our tribal staff that the people over there 
that work at Rapid City Regional West are telling our kids, you 
tell us you're not going to kill yourself and we'll let you go. 
And the kids, many times, are not ready to be sent home.
    So I did talk to our service unit director, I said, hey, 
you need to, I hear this is happening, I hear it's happening 
from reliable sources, you need to sever that contract with 
Rapid City. I also told him, what you should be doing is 
interviewing patients. How are you treated out there, good, 
bad? So then, whenever you do go into contract with whomever, 
it would be justified, whether we go on with them or we sever 
ties with them.
    Right now, there's no prevention. And that does lead on 
into higher costs and also a loss of life, as was addressed 
earlier. Specialty clinics, we don't have them, and we used to 
have them. It's a hardship for our people to travel to Rapid 
City. Rapid City from Eagle Butte is 166 miles one way, Sioux 
Falls probably 300 and some miles. Bismarck, 120 miles.
    And we probably live in the top 10 of the poorest counties 
in the United States and probably in South Dakota, on the 
reservation. So you can imagine the struggles for many of our 
people just to go to these places for a clinic. So that's 
    I have also seen too, and studied IHS, like I made a 
comment earlier about them being over-regulate. Our history is 
that 1908 Homestead money, we built our hospital. We built it 
down on our agency along the Missouri River. Then in 1960, the 
Government built their dam and flooded us out. So the Corps of 
Engineers replaced our hospital in 1960 in Eagle Butte. They 
built a 26-bed inpatient facility. Just recently, about four or 
five years ago, we got a new hospital from IHS.
    But one of the things a lot of our elders can tell you, the 
patient rooms used to be filled up. But before they closed the 
old facility, many of the patient rooms were turned into 
offices. So I think when they closed up, there was probably two 
or four patient rooms. Because IHS is so worried about being in 
compliance, they are forgetting patient care.
    You look in our area, third-party billing, they can do it. 
It's a proven fact. It's why they closed Rosebud. I'm sure 
that's the problems in Winnebago.
    But I think if Congress really wants to do something, they 
need to look at the recruitment, the bonuses that should be and 
can be given out. Money talks. We all know that. And I talked 
to our service unit director and he said he wished he could 
offer another $100,000 a year to recruit doctors. But the 
regulations prevent him from doing that.
    President Steele is here, he was going to mention something 
to me out there. IHS in their statement and their testimony 
said they consult with the tribes on everything. Last week, 
Friday, I found out Ron Cornelius was transferred out, and it 
was from one of our tribal staff. I had no idea. And it just 
happened to be, I was meeting with our service unit director. 
And he didn't know, either.
    So why weren't we consulted about him? Was it because this 
hearing was going to happen and IHS did not want him to 
testify? That's a question that Congress should ask IHS. Why 
was he transferred? Was an evaluation done on his performance? 
Not that I'm sticking up for him, but I think it's important to 
know why he was transferred out. It should be for Congress as 
    And I liked Senator Tester's comments, that's the bottom 
line. Find it.
    Thank you.
    Mr. Andrews. Thank you, Chairman. How about the 
representative for the Crow Creek Sioux Tribe? A couple of 
councilmen, I believe. President Steele? We can always go back.

                          SIOUX TRIBE

    Mr. Steele. I think everything has been said. The Senators 
know everything. I would just like to emphasize that that 
individual person, the patient, a lot of them get no care at 
all. They go to the hospital, and the doctor tells them, we 
don't have any services for you here. I'm sending you to Rapid 
City. So they go home, not knowing what's wrong with them.
    And two weeks later they get a letter, you're declined an 
appointment in Rapid City, lack of funds. So there is no health 
care at all. And we jump up and down and say, we have a treaty 
that promises health care. In 1980, the United States Supreme 
Court, its words were the most rank and ripe case in the 
history of the United States to illegal taking of the Black 
Hills. Why won't the government sit down with us over that? We 
wouldn't be here today asking you for health care for our 
people, basic health care.
    Gentlemen, they are helpless. They can't do anything about 
it. We all here feel a responsibility to see that they get any 
kind of health care. Sometimes when they do, they finally get a 
second opinion from Gordon, Nebraska, or Rapid City, the doctor 
there tells them that they were misdiagnosed. You were given 
the wrong medication, that medication is dangerous.
    People have no faith in the Federal Government. They're 
just caught up in the system, and who cares?
    Everything the Senator said today applies. I applaud 
Senator Thune and his staff for getting that letter signed by 
four Senators for this hearing. We hope something comes of it. 
And I think it already has. I talked to one of the IHS staff 
here after the hearing, and I'm getting some action on some 
specific points. So I don't need to tell them to you.
    I just thank you for having this hearing.
    Mr. Andrews. Thank you, President Steele. We really 
appreciate those words.
    Chairman Vernon Miller, Omaha Tribe of Nebraska.


    Mr. Miller. Good evening. My name is Vernon Miller and I'm 
Chairman of the Omaha Tribe. I want to first of all thank Mr. 
Andrews and Mr. Waters for providing this opportunity during 
this listening session to hear the tribal leaders who weren't 
allowed to provide testimony today to the Committee. It is very 
important, this hearing that was held today, to specifically 
address the mismanagement of the health care within our region.
    I speak on behalf of the Omaha Tribe, who is a part of the 
Omaha Winnebago Hospital. Oftentimes it is miscommunicated and 
not understood that that hospital just isn't for the Winnebago 
Tribe, it is for the Omaha and Winnebago Tribe. That is 
historically how the hospital was formulated and how it came 
about, was because of Winnebago Omaha people. Sometimes that is 
not often communicated. And both tribes are very separate 
tribes as well. That is sometimes misinterpreted as well, that 
because it's Omaha Winnebago Hospital, it's one tribe, but 
we're very two distinct, separate sovereign nations and we both 
have our own issues and concerns.
    So I want to take this time to express some of my people's 
concerns with the Omaha Tribe. And I already submitted my 
written testimony, so I'm going to deviate a little from that 
so I can address specifically some other concerns that came to 
my attention as the hearing was transpiring.
    The first one is in regard to the inadequate consultation 
from the tribes in regard to the removal of Ron Cornelius. 
We're happy that finally happened. The Winnebago Tribe and 
Omaha Tribe identified that as one of the most important 
actions that needed to be taken clear back several months ago. 
So when we talk about the communication level, it is very 
indicative if you look at the date on that joint resolution 
that was displayed. It shows the date on there and how long it 
took the IHS headquarters to even address that concern.
    It is unfortunate now that we have two other hospitals or 
facilities within the region now who are in the position that 
the Omaha and Winnebago Tribes are in. When our hospital was 
put into immediate jeopardy, that was known for two years. You 
can kind of see how that finally, the CMS finally said, okay, 
we're going to pull the accreditation. And now the hospital can 
no longer bill for Medicare and Medicaid now.
    And they are maneuvering it somehow, they are able to bill 
for certain things now, they are telling us, and they cannot 
bill for this yet. So like I said, communication is kind of 
spare, I'm going to be honest with you. There isn't adequate 
consultation when any decisions are made. Like I mentioned 
earlier, the removal of the area director, we're happy to have 
it happen, but it would have been nice to have some feedback 
from us on who was going to be put in that position. Because a 
lot of us, through our tribal programs as well as our 
employees, have history with some of the members that are being 
put in those positions.
    I want to further go on and talk about how when people are 
removed they are placed somewhere else and are transferred to 
other places. The Omaha Winnebago Hospital is one of those 
places that a lot of the employees that are sent from other 
tribal facilities went to. Our hospital was, okay, let's send 
them to Omaha Winnebago Hospital, we'll get them out of 
Sisseton Wahpeton's facility and move them down there. We'll 
get them out of somewhere and send them on over to Winnebago. 
Let them transfer out there so we can show the tribe, yes, they 
were removed. But they were given to some other tribe and made 
somebody else's problem.
    As a result of that, you see what happened with our 
hospital, losing our accreditation, several patients have died, 
several patients are afraid to go there now. I can honestly 
tell you as one of the tribes with a dialysis center as well as 
a nursing home, we divert all of our patients to go to that 
hospital now, because that health care is not safe. So we take 
them to other facilities, we utilize our own third party 
revenue. We never use Medicaid or Medicare. We take them to 
other facilities to get adequate health care.
    So it's truly indicative of how there is no trust in our 
community for that hospital. And that still hasn't improved. 
Mentioned yesterday, the hospital emergency room was shut down. 
There was no tribal consultation in that decision at all, to 
how can tribes help find a solution to that. That's truly 
another reason why there's some miscommunication here.
    I also wanted to bring up another issue in regard to one of 
the questions that was asked to the IHS staff was about 
employees that are working in the facilities, they've been 
told, do not talk to members of Congress, do not talk to their 
staff and do not talk to tribal council members. That is true. 
I can tell you that we have had several of those employees come 
to us and say, I've been told if I say anything I'm going to 
lose my job. We obviously respect their confidentiality. We're 
not going to go that.
    But I can give you specific names. I'm not going to give 
them here now because there are personnel issues that are going 
on, of which employees do tell our tribal members that and tell 
employees of those hospitals, if you want those. So that is 
another whole section and even hearing on that.
    I also want to talk about the consultation process a little 
bit further. We have a DDU within our area, the Omaha Tribe and 
Winnebago Tribe. I can tell you another example of how there 
was no adequate consultation, because when I first got elected 
chairman, not even three days later, I was informed through one 
of CMS's reviews that they were going to pull, after a survey 
was done, the DDU was found not in compliance because our 
polices were not consistent with the actual hospital. Well, 
they are two separate entities. Because there's a hallway that 
connects those two buildings, they considered it one building. 
As a result of that, I got a phone call on a Saturday morning, 
said, Chairman Miller, I just want to let you know, it was one 
of the acting CEOs saying, we're going to have to close down 
the DDU. We were just starting a cycle of treatment and our 
patients that were there, we're going to have to send all the 
patients home that are there for treatment because you don't 
have enough adequate nurses and doctors on staff according to 
what CMS is requiring. So we need you to say that's okay, that 
area takes over this now. And obviously I don't want to see 
anybody who's going through treatment process to be sent home 
and to now be able to utilize services that are supposed to be 
guaranteed to them.
    So I and the other chairman of the other tribe, obviously 
we don't want to see those patients go home, said okay, do what 
you have to do to make sure that facility can stay open. Like I 
said, that adequate consultation wasn't there and as a result, 
that DDU's now sitting in area's hands, not tribal control 
which it was before.
    So that's a concern of adequate consultation that's not 
happening. That's a good example of how we need to really think 
about how that consultation process is occurring.
    Another issue I want to talk about is echoing the issue of 
the governing board. Apparently the tribes, the chairmen are 
sitting as ex officious on the board. The rest of the board is 
all area staff, who aren't even at the hospital, who aren't 
there in the field at the actual hospital level, hearing these 
concerns and hearing directly what's happening, the level of 
inadequate health care that's being delivered to them. So we 
really need to reconsider how we're even providing the 
governing process for those hospitals. I know Chairman Frazier 
mentioned earlier, maybe I should be privatized. That's 
something I would like to consider talking a little bit further 
about before we take those steps. But the governing process is 
definitely an issue. That corrective action plan which we've 
had from the Omaha Winnebago Hospital, they've identified as an 
issue is the governing process.
    So I've brought that up numerous times already, but I want 
to make sure you are aware of that, that issue, and that we 
brought that up.
    I also just want to talk about patient advocacy. That's a 
huge portion of why the hospitals are the way they are. At our 
hospital, we did have a patient advocate, but unfortunately, 
because of the structure of the hospital, my tribal members' 
needs weren't being adequately addressed when they were 
receiving this inadequate health care, when our go in and work, 
didn't feel safe there, they had no one to turn to. I want to 
thank the area office for identifying that after we brought 
that to their attention.
    So what they've done, just so you're aware, is they 
allocated specific funding for the Omaha Tribe to have an 
advocate there. Because they recognized that they weren't 
receiving advocacy and they weren't being made aware of those 
mistreatments and misdiagnoses as well as inadequate health 
care. So that's indicative of how if you communicate with the 
tribes, it's something that we can do.
    We also just want to make sure that we're maintaining a 
level of communication that's necessary. We do have weekly 
phone calls, but they're really short. And I think they're 
almost just there as an obligatory action, it has to happen. We 
are really concerned, because since we lost accreditation in 
July, it's almost about into the third quarter now, when we're 
going to start into the funding, or half of the second third 
quarter of the funding mechanisms, for no longer being able to 
rely on that Medicaid or Medicare as a revenue source to 
operate that hospital. So we're really concerned what services 
are going to be cut. Is our emergency room going to get shut 
down? Are they going to have to lay off employees? We're 
already standing at 60 to 70 percent rate of not having enough 
employees to even staff. We've had a turnover almost every 30 
days of a new CEO.
    So when we talk about trying to have management there, 
leadership there to help get the hospital there to a level of 
performance, when you have a new CEO coming in, all that work 
that was done in that 30 days gets kind of thrown to the back 
again and restarted over. So it's a cycle that's completely 
starting over and over again.
    So I wanted to make sure you are aware of that, as we just 
had another acting CEO who was just now cycled out again and 
now we have another one. I'm not even sure who it is, Seneca 
Smith? Maybe somebody else. But just one of those things, 
that's kind of what we're dealing with. We can't hire a CEO 
there for some reason. We're not able to, I guess, get a 
correct panel that can get adequate support to move along the 
    I just want to relay those issues to you. I know we've had 
other side conversations. I want you also to remember that it 
is the Omaha Winnebago Hospital. We recognize that the 
Committee wanted to come to the region. We were left out of 
those conversations, and so we made a special time two weeks 
ago when our tribe was in town for the Supreme Court case, to 
let you know, hey, it's also the Omaha Tribe, here's our 
concerns as to what's going on. I just want to remind everyone 
that we are here too, we are here to make sure that our tribal 
members' needs are being met as well.
    Thanks to the Committee, and thanks, everyone else, for 
    Mr. Andrews. Thank you, Chairman.
    Is there a representative from Three Affiliated? How about 
a representative from the Rosebud Sioux Tribe that would like 
to address us?

                          SIOUX TRIBE

    Ms. Espinoza. Good afternoon. My name is Evelyn Espinoza. 
I'm an enrolled member of the Rosebud Sioux Tribe. I'm also a 
registered nurse. I'm currently the health administrator for 
our tribe.
    Who am I speaking to? Who's represented here? I see a lot 
of tribal representation. But who else is represented here. I 
may have missed the introduction. I apologize for that.
    Mr. Andrews. We opened this up to really any tribal 
organization that would like to talk about--oh, are you talking 
about staff?
    Ms. Espinoza. No, is this Congressional folks, is this HHS?
    Mr. Andrews. These are all Congressional staff.
    Ms. Espinoza. Okay. Well, the reason why I asked is it's 
very disappointing that we're here talking about such an 
important issue that is devastating lives and spirits of our 
tribal members and everybody gets up and leaves. We have made 
the trip to come out here and talk to people and have our 
voices be heard and our stories be heard. And everybody left. 
And I'm very disappointed by that.
    Mr. Andrews. I did want to say, I do see--thank you--that 
other Congressional folks and HHS, IHS, is here as well.
    Ms. Espinoza. Thank you. I do see Mr. Grinnell, and I was 
really intending, he said he wasn't going to be here, so I'm 
really happy that you did decide to stay.
    This is very, very frustrating. I'm sure you can tell by my 
tone. But we're talking about entire communities being 
destroyed. We are talking about families being affected for 
generations. And we see here, it's almost like we have to prove 
these awful things are happening, when they're documented 
things happening. It's so frustrating to be on this side and to 
be a person that has a responsibility to advocate and protect 
our tribal people. You feel helpless. It's like hopeless. You 
get stuck in this, the sense of gloom, like it's never going to 
    How many people have to die? There are babies that have 
lost their lives because of this.
    We talk about suicide rates, we talk about alcohol and 
substance abuse, we talk about all this. But this situation 
that we're in is completely unhealthy. We're talking about the 
health care of our people. The way things are practiced, the 
way medicine is being delivered, the way communication is 
between these agencies and our tribes is unhealthy. It's 
creating the same exact challenges that we're here trying to 
fight against.
    Until we can come together and respect one another and 
acknowledge that things have to change, it's going to continue 
to go on. People are going to continue to lose their lives. Our 
parents are going to continue to lose their children and our 
children are going to continue to lose their parents. This 
directly affects us. The majority of the people in this room, 
you have no idea the level to which this affects us. Our whole 
being as tribal people, we're very spiritual people. Our spirit 
is very sacred to us. And this current situation and the way 
health care is provided to our people completely goes against 
our beliefs.
    We at one time had a very solid foundation, a very solid 
understanding of who we were and what we believed in. And that 
was taken from us. A hundred and fifty years of history created 
the situation that we're in. We have tribes fighting against 
tribes over scraps. We have other relatives being left out, 
their voices not being heard. We have tribes that are in better 
condition, IHS's that are in better condition than the Great 
Plains area and the Billings area, that don't have the 
problems. But they're the ones that continue to get the 
improvements, while us that struggle and have these challenges, 
we continue to go down.
    We've had multiple meetings, multiple opportunities to 
share concerns, asked to be involved, we want to be involved, 
we want to be an active player in this game. We want you to 
take our suggestions and take action on them. We sit in 
situations like this and we end up with this afterwards, okay, 
maybe finally something will happen. And nothing happens. No 
follow-through. We have a beautiful report Senator Dorgan 
initiated six years ago. And it's only gotten worse.
    No follow-through. No expectation. It's like we're not 
being treated as human beings. We have blood vessels, 
structures, anatomy the same as anybody else. We're no less 
than anybody else.
    I'll give you a little timeline here of the last six 
months. Our relatives in Winnebago and Omaha were put in a 
horrible situation last July. My heart is heavy for them and 
for what they're going through, and for all of our tribes. In 
August, the second week in August we had a council meeting. The 
acting CEO came to our council and I said, what are we doing to 
prepare for CMS? What do we have in place? How can we help? 
What resources do you need? How can we work together to make 
sure we're ready, that this doesn't happen to us?
    That CEO told us, they're completely ready. They didn't 
need any help. They had everything under control.
    November 4th, an organization known as DNV that's hired 
under contract by Indian Health Service came in, surveyed the 
facility, said it was the best survey that our facility had in 
eight years. Best survey, very minimal concerns found. A week 
later, on November 8th, OIG visited. The CEO sends an email out 
and says, congratulations, staff, passed with flying colors, we 
impressed the OIG, we impressed DNV. CMS, bring it on.
    On November 16th, CMS arrives. On November 18th, they put 
our emergency services in immediate jeopardy because they found 
situations that existed that posed immediate and serious threat 
to the health and wellness of any individual seeking emergency 
services there. On December 6th, our ER went on diversion.
    All that happened within one month. We were told 
continually a year prior to that, everything's okay, don't 
worry about it, we have it under control. I had regular 
meetings, multiple meetings every month, IHS, this is the 
complaints I'm getting. These are the stories I'm hearing. 
Here's a copy of the complaints.
    Seventy-nine documented complaints that I have not received 
a response from Indian Health Service on. Seventy-nine.
    They told us their main problem is contractors, the quality 
of contractors. Last week on our call, our weekly call that 
they update us with, well, what are you doing about that, IHS? 
You have an area-wide contract with these companies. What are 
you doing to hold them accountable? How many meetings have you 
had with them? What expectations have you provided to them? How 
many contracts have you canceled, if this is such a problem?
    Ms. Espinoza, you make a good point. I'll take that into 
consideration, that's something that we can start working on. 
But no, we haven't done any of that yet.
    I sat in the close-out at the hospital when CMS left, 
listened to what they had to say. The survey, Interior's, mind 
you, at the end of the survey is saying, the quality of care 
here has to improve, and I highly recommend you include the 
staff providing this care in the plan for correction that 
you're going to submit to us. Last week on that conference 
call, same conference call, same group of people, the staff is 
telling me they haven't even see the report. They don't know 
what their corrective actions are.
    So I asked this governing body of our hospital, how have 
you involved the staff that's doing the work? Because I sat 
there and witnessed in these meetings, it's not them involved 
in this. It's this team for area office that has been deployed 
here made up of people removed from other reservations, 
developing a plan of correction for the Rosebud Hospital that 
the staff doesn't know about. So, one, if the staff doesn't 
know that there's an issue and there's something that they need 
to improve on, why would they improve it?
    So this recommendation by CMS at that close-out, that that 
area office was on the call with, they ignored it. So we 
continue to have the same things happening. The practices 
haven't changed. The policies haven't changed. Nothing has 
changed. The only thing that continues to change is our people 
continue to suffer and our services continue to decrease.
    I can stand up here and I can go on and on. I could share 
my horrible experience with the Indian Health Service that I 
had. I was a registered nurse for them for 10 years. I work for 
them, hard. And it was such an unhealthy environment, and it 
affected me in such a negative way, I had to leave that. My 
profession that I had worked for, I put that down and walked 
away for my own health.
    This has to change. Has to change. It's unacceptable and 
people are going to continue to die, we're going to continue to 
have this. For what? All this drama? It's not changing 
anything. It's horrible. It affects every one of us on a level 
you can't even imagine.
    And I'm asking everybody here to take these things back to 
who you can to help us change this. Mr. Ganard, I'm asking you 
to hold your staff accountable. If your job is quality, then I 
want to see quality. And if you can't do the job, then step 
down so somebody else can.
    Thank you.
    Mr. Andrews. Thank you, Ms. Espinoza, for that heartfelt, 
we can all say how heartfelt were your comments.
    Is Chairman Flute here? Is there a representative for the 
Sisseton Wahpeton?

                      WAHPETON OYATE TRIBE

    Ms. Dakota. Yes. Chairman Flute was not able to come. I'm 
Sarah Dakota, I'm the Health Coordinator from Sisseton Wahpeton 
Oyate. So I'm here on behalf of the tribe.
    I agree that everything that has been said today, a lot of 
important things have been said today. The thing that is, a 
week ago I really had not heard about any of this. I want to 
thank Evie Espinoza for sharing with us at Sisseton Wahpeton 
the report from Rosebud. We were not aware that some of these 
problems that are occurring.
     So east of the river, we don't have hospitals. We have 
health centers. And the same types of issues with the emergency 
room and hospital is not occurring. But I guess what we were 
aware of was that our doctor, one of our permanent doctors, was 
assigned to go over and help at Rosebud. And I'm sure we want 
to help. But it leaves us short-staffed, because our positions 
aren't all filled either. And we have vacancies. We're using 
the contract doctors, and many of the same issues that have 
been talked about today are our issues, too.
    The other mystery that was solved is that our practice, 
when we don't, because we don't have a hospital, and is that if 
someone needs an elective surgery, like a tubal ligation or 
something of that nature, they need to be referred to an IHS 
facility. So we had a patient who has been waiting for a tubal 
ligation since November, kept faxing her stuff out. And she had 
the impression, the staff at our IHS must not have been aware 
that this was happening in the referral facility either at 
Rosebud. So they kept faxing the paperwork out. This person's 
been waiting for their elective surgery and wondering, well, 
they keep losing my paperwork.
    I wanted to mention about vacancies. We have had vacancies 
in our behavioral health department for three years. This past 
year, we're having a lot of suicidal behavior in children. We 
had some completions. And it isn't that we don't have the 
funding to hire the positions, we just can't get the positions 
filled. So the question is why? Why can't we get the positions 
    We have the same concerns as Sisseton Wahpeton about 
quality. I think you've noticed that Mr. Tom Wilson from KXSW, 
our radio station, is here. He also has something to say about 
quality that I think would be, if he would be willing to speak 
at this time.


    Mr. Wilson. Good evening. The quality, it's like we get put 
on the back burner. To come out here, I had to wait an extra 
day and change my flight to see the doctor to get my meds 
filled. And to see the doctor only took me five minutes, to get 
my meds filled. But it cost me like $75 to change my flight to 
come out here, which I said, be there Friday, we had a set, 
scheduled appointment to get everything filled. And it only 
took me five minutes to see the doctor, because I had to cancel 
everything just because of that one thing.
    Some of the listeners are FaceBooking me and asking if they 
can ask a question. So I don't know if I could or not. One of 
them is why the SWO and the Great Plains Region can't retain 
doctors permanently.
    Mr. Andrews. You ask a good question. We will certainly 
take that back. Of course, we have our friends from HHS here 
that we'll be obviously directly communicating with. I don't 
want to put them on the spot, but this is the type of 
information, that back and forth, that Tony and I need so we 
can continue to develop and advocate for all your health and on 
all your behalf. So that is the best I can give you right now.
    But I expect other great questions to come forward as a 
result of this listening session. And of course, the many 
questions that were generated by both, all three panels today.
    Mr. Walters. I'll just add a real quick thank you. The 
question of attention, that's across the board. I don't think 
it is just in the Great Plains Region, as you mentioned. But I 
think we've heard from different folks all day today that it's 
across the board with IHS, that issue. They're trying as much 
as they can to work on those issues.
    So we'll keep working with them and tribal folks and tribal 
leaders who come in and express these issues with us.
    Mr. Wilson. The doctors, the nurses, the staff, they need 
all that. So kudos to all the nurses that are out there that 
give you that extra care. When we make an appointment, the 
daily appointment, 8:00 o'clock you start calling. By 8:03 it's 
all filled up. And that's the frustrating part. I don't know 
how it can fill up that quick, in three minutes. It takes me 
three minutes just to say ``ah'' before I go on and get my 
    So thank you.
    Ms. Dakota. Sisseton Wahpeton is interested in being a part 
of the finding solutions. We're interested in that. And we look 
forward to more dialogue. Because we don't want what has 
happened at Rosebud, Pine Ridge and Omaha Winnebago to happen 
to us. Thank you.
    Mr. Andrews. Thank you. Is there a representative from the 
Winnebago Tribe of Nebraska?


    Mr. Bass. Good evening. My name is Vince Bass. I'm Vice 
Chairman of the Winnebago Tribe in Nebraska, northeast 
    I heard a lot of real good testimony today. I am not going 
to go over it and be redundant. I know you're looking for 
solutions also. First, allow me to say that I think it's 
important to note that Winnebago Tribe is a treaty tribe. Our 
forefathers had the wisdom to put into our treaty that the 
Federal Government take care of our health care of our people 
forever. So that's in there. That's noted, that's in there. 
That's a big part of the reason why IHS decided to locate the 
Winnebago IHS hospital on our Winnebago trust land.
    So I wanted to get that out, I wanted to make that clear. 
Also, I wanted to say our people were moved from Ohio, 
Michigan, Minnesota, Wisconsin, Iowa, western South Dakota and 
back down to Nebraska, where we currently reside. We lost 
thousands of tribal members during those, as they moved us, due 
to disease, due to starvation, punishment and just the, they 
didn't have planes or anything back then, so naturally they had 
to walk. Most of our women and children and elders had to walk.
    So what I'm saying is we paid for this hospital already in 
blood. So we feel that we don't need to continue paying for 
this hospital in blood. We lost five Winnebago tribal members, 
and one was too many. So we're very, very angry.
    And yet we want to be able to work with everyone involved 
to try to resolve some of these issues that we currently face. 
It's really a huge issue. I mean, look at all the different 
people, look at all the different tribes. We're very thankful 
that the Senate Committee on Indian Affairs held this oversight 
hearing, so we can bring this to light and bring up a lot of 
evidence and have people testify, and bring the truth out. We 
heard from IHS. And we also heard the truth from the tribal 
members. So I kind of wanted to say it like that way.
    I don't want to go on and on, either. But I do have a list 
of some recommendations from our tribe that I would like to 
share with you. It's also in our testimony, but there may be 
people here who don't have that testimony. So if you don't 
mind, I would like to go, starting with number one.
    First of all, we would ask the Senate Committee on Indian 
Affairs to examine the role that the Federal employment 
policies and regulations are playing in allowing incompetent 
and under-trained employees to continue to work in the Indian 
Health Service. Employees need to be held accountable for their 
actions. No longer can IHS continue to protect, cover up, 
shuffle, transfer or perpetuate incompetency.
    Second, we recommend that IHS be mandated to institute a 
formal process for investigating any repot of a questionable 
death or other unusual medical incident in any of its 
facilities. When problems are identified, immediate action must 
be taken to correct the problem, including disciplinary action 
against any employee who has failed to do their job.
    Third, we recommend that the IHS mandate as a condition of 
ongoing employment that its employees repot any improper care 
of mismanagement that they observe, and that those repots be 
sent directly to central office. The standard of care must be 
raised and every IHS employee should feel responsible for 
helping to fix this problem.
    Fourth, we recommend that IHS be authorized and directed to 
immediately terminate any employee who retaliates or threatens 
to retaliate against a person who files such a report. The 
culture must change. Employees should be encouraged to make 
improvements and find better ways of doing things and not 
intimidated into maintaining the status quo.
    Fifth, we feel strongly that each of the tribes who are 
served by a direct care facility should be given full and 
immediate access to any CMS accreditation or other third party 
reports or studies performed on that facility. We further 
recommend that all negative reports should be shared with this 
Committee and its counterpart in the House. IHS needs to stop 
hiding the ball.
    Sixth, we recommend that IHS be directed to ensure that no 
tribe suffers the loss of services or funding because of IHS 
mismanagement. The third party billing for Medicare and 
Medicaid represented a sizeable percentage of the Winnebago IHS 
hospital's operating budget.
    Seventh, we insist that IHS mismanagement should not be 
used as an excuse for eliminating or cutting back on services 
or funding. Already, IHS is discussing how the under-
utilization of our facility makes it difficult to seek the 
funding necessary to fix its problems. It's like a death 
spiral. IHS creates an environment that people do not want to 
go to. They refuse to admit patients because they fear further 
scrutiny. Then they conclude that the hospital is too under-
utilized, so maybe they should shut down some of the services 
and funding. This is totally unacceptable. It is a flagrant 
violation of the Federal Government's treaty and trust 
obligations and someone should be fired for even raising this 
as a possibility.
    Eighth, tribes should be given a real role to play on the 
governing bodies of IHS-operated facilities, not just a token 
attendance right. I'll give you an example. The IHS will tell 
you that since their corrective action plan has been 
implemented, our tribal chairwoman has been invited to 
participate in the final interview process for key positions at 
the hospital. This is true. What they fail to tell you is that 
she only received the resume just before the meeting and she 
was never told how many others applied for the job, who they 
were, what the differences were in their credentials or even 
how many candidates were there. That's in my testimony. I came 
up with a couple more.
    As Chairman Frazier alluded to earlier, he feels that 
compacting may be the only way out of this. That's why the 
Winnebago Tribe is doing this, because we feel this is the only 
way out. Our hospital has been managed by IHS for all these 
years, even after the Dorgan Report. The same things that 
you're hearing today, it's still happening. In fact, it's even 
worse than when the Dorgan Report came out in 2010.
    Tribes shouldn't feel that they need to exercise self-
governance to fix IHS issues. We have no confidence in IHS. We 
will take over using the compacting, self-governance process to 
manage our hospital. We are in the process now, in the planning 
    There is a major lack of communication. For example, we 
lost accreditation on July 23rd of 2015. No one told us, 
neither CMS, IHS. I heard it on the evening news. So that's 
just an example. And you heard other examples of lack of 
communication that occurs over and over and over again.
    As you are doing today, I would allow tribes to have input 
on what's going on. Because as you know, the solutions to the 
problems in Indian Country are best provided by Indian people. 
So we haven't had a whole lot of communication with the other 
tribes in the Great Plains area, but we intend to. And I hope 
that all the tribes don't feel that they need to feel obligated 
to compact, even though we're going to have that discussion and 
we're going to work at it together if that's what we decide to 
    So I wanted you to know that the tribes in the Great Plains 
are pretty much all united on this. I do not know one tribe 
that is not united on the issues that are facing us right now. 
In fact, throughout Indian Country, I think I can say that's 
almost true as well. I think you'll see other things coming up 
in other parts of the Country that's happening in the Great 
Plains region today.
    So I just want to say thank you again for taking the time 
to listen to tribes. We're in a situation where we need to all 
work together. And I think we can do that. I think awareness 
has been raised. Because a lot of people didn't know what was 
going on. That lady from Sisseton Wahpeton did not know what 
was going on.
    So now that everybody knows what's going on, I think we 
could all get together, and we really look forward to future 
meetings where we can collaborate and work jointly to resolve 
these issues. I thank you very much.
    Mr. Andrews. Thank you, Chairman Bass. Very heartfelt as 
    Have I missed any other tribes that would like to have 
their representative speak? Sir?


    Mr. Headdress. I want to thank the Committee here who is 
absent at the time. I think they have our back. I think the 
Winnebago Tribe and the Rosebud Tribe should have been the 
first ones at the table to be heard while they were here, 
because that impact would have been, it would have been sent 
home a lot better. I'm not saying that the staffers don't work 
hard, we appreciate all the work that you guys do, also.
    My name is Charles Headdress, and I am the Vice Chairman of 
the Fort Beck Assiniboine Sioux Tribes in Montana. We have the 
very same issues. We've had two hospitals that kind of teetered 
from time to time, Blackfoot Hospital and the Crow Hospital.
    I'm also the regional representative to the National Indian 
Health Board board of directors. We did have, two weeks ago we 
had the Winnebago Omaha Tribe in to talk with us, and Rosebud 
also, by teleconference.
    As you know, last year we had those non-profit 
organizations serving all 565 federally-recognized tribes when 
it comes to health. The United States assumed the Federal trust 
responsibility for health by exchanging compensation and 
benefits for peace in Indian land. We all know that. In other 
words, we prepaid for these programs.
    As recently as 2010, when Congress renewed the Indian 
Health Care Improvement Act, they have found 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. I think Senator Tester said it best when he says, fund 
    I'm not going to go over a lot of this stuff because it's 
redundant, everybody has had their say on a lot of it, so I 
won't repeat it. So I'm going to skip over some of this stuff. 
The problems that were in the Dorgan Report exposed much of 
this chronic mismanagement. A subsequent 2011 report by a 
separate HHS task force 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.''
    The Administration was quick to deploy National Health 
Service corps members to West Africa to treat the Ebola 
outbreak in 2014. But when the health crisis occurred in Indian 
Country, the tribes were told that there was just a national 
shortage of physicians, there's nothing that could be done to 
get more medical staff to the reservations.
    While the issues in the Great Plains are certainly 
concerning to all of us, we have no reason to believe that they 
are isolated to this area, and they aren't, believe me. The 
National Indian Health Board has received reports from other 
IHS service areas of patient misdiagnoses and subsequent death, 
lack of competent providers and IHS' continued failure to 
provide safe and reliable health care for our people.
    One of our members recently went to the doctor and laid out 
the problems that they were having. The doctor asked them, 
after all that was said and done, well, what is it that you 
want? So in other words, he could have said, well, give me some 
Percoset. Give me some pills. Let me take care of it.
    That's the kind of reaction that we get from some 
providers. Not all providers. This provider happened to be a 
contract doctor with no skin in the game, really. They get paid 
a high salary just to give you a Band-Aid.
    Alcohol and substance abuse are very prevalent, and this 
leads to many, many health care problems. We have the Bakken 
oil plate right next to us, and with that, they had 100,000 
people come in from all over the United States and foreign 
countries to work. And with them they brought all the problems, 
from crime to drugs. We have a funnel of methamphetamine coming 
up through there right now that has affected our tribes 
greatly. Once beautiful people are walking around like zombies 
now because of this. And it's happening all over Indian 
Country, not just where we're at.
    A problem with lack of dentists is another huge issue. As 
we all know, dental care plays a big role in your health care. 
It can cause major health care problems if your teeth aren't 
taken care of. We are so understaffed that we quit making 
appointments up at our reservation and have five slots a day 
for the doctor to see patients. We almost have fights outside 
the clinic because people are fighting to get in to see that, 
to get in one of those slots. That's ridiculous. It wouldn't 
happen anywhere else. At least open the door, let them stay 
    And again, I'm going to skip through all this, because it's 
been said already. We have testimony from the Phoenix area, a 
report to that the National Indian Health Board that her mother 
was treated for a urinary tract infection by the White River 
IHS Hospital. When her condition did not improve, the patient's 
family was reportedly told by IHS medical staff, ``What do you 
want me to do with her? She's an old woman.''
    After several more days, the patient was transferred to 
another facility in Gilbert, Arizona and found to have 
pneumonia, there was kidney stones in her gall bladder, two 
blood clots in her left arm and a serious blood infection from 
the previous urinary tract infection. The patient passed away 
just a few days later.
    Now, we could go on and on. What will it take for the U.S. 
Government to fulfill its promise of providing care to Indian 
Country that is safe and reliable? In my home State of Montana, 
the State Government has created a Director of American Indian 
Health position. We applaud them for that. We work very well 
with our Governor and Senator Tester and Senator Daines. I wish 
they were here to hear this.
    But is emblematic of the Federal Government falling down on 
the job. While it is a good move for our State, why is the 
State doing it? Our treaties promise health care delivery from 
the Federal Government, but clearly it hasn't been working. We 
understand the Federal budgets are tight, but the treaties that 
we signed are not discretionary and should not be held to 
unrelated political battles in Washington.
    Nation Indian Health Board tribes have asked for budgets 
each year that would bring IHS up to the same status as other 
American health facilities. Right now, this is $30 billion. To 
begin to phase in this amount over 12 years, we are requesting 
$6.2 billion for IHS in fiscal year 2017. But funding is 
another thing. All of the facilities are lacking medical 
doctors, nurses, everybody. We just are totally lacking. And we 
realize that recruitment, housing and all those things that 
have been spoken about impact all of that.
    But again, I go back to what Senator Tester said: fund it. 
The Federal Government needs to fund it adequately.
    Now, I don't know where they all went, I know they have 
very busy jobs. But they could be talking about getting rid of 
Obamacare again, for example, or maybe how many bombs we will 
need for this next war we will be in. Well, we are in a war, 
and we have been in a war for years. In our community, for 
example, if you have a heart attack, it will cost $25,000 to 
$30,000 to get you to the closest critical care hospital, which 
is 300 miles away. Here in Washington, if somebody had a heart 
attack, not near that amount. All that eats into the budget 
that the local IHS is meting out to us for health care. And we 
have many heart attacks up there.
    This is why preventive medicine investments are so 
critical. We cannot be wasting our resources on treating 
symptoms, we need to invest in whole health systems. We 
consistently hear again that IHS mismanages and IHS is 
substandard. Accountability measures are enforced sporadically 
at best and often managers have little training. When issues do 
arise, it is unlikely that an employee would be let go. They 
just get moved somewhere else. And that's been said.
    Unlike in the private sector, where the number of patients 
impacts the overall physician pay, IHS medical staff have a set 
salary and there is really on incentive to go above and beyond 
to meet the needs of the patient. In many ways, IHS is still 
operating a health system designed for the 1950s. Several of 
the reforms enacted by the Indian Health Care Improvement Act 
of 2010 like demonstrations that tests no knowledge of health 
care delivery have not been implemented. This represents 
another broken promise to Indian Country.
    In Alaska, the tribes have a primary health system that 
works closely with the VA and focuses on a hub and spoke system 
to get better access for care to rural villages. Why can't the 
IHS be a leader in innovative health care strategies as the 
tribes have been?
    Two weeks ago the National Indian Health Board passed a 
motion that would call for our representation to investigate a 
situation at IHS facilities across Indian Country and embark on 
a path toward finding real, sustainable change at IHS. As part 
of this work, the National Indian Health Board conducted 
listening sessions with tribal leaders, patients and medical 
professionals to determine new policy steps that IHS should 
take. This effort will be targeted at finding ways to achieve 
sustainable, long term change across the Nation's health 
    In closing, I want to share a story about my health care. I 
hope no one takes it too seriously. It is a funny story, but 
it's not funny. But I went to, four years ago I had an issue 
with my heart. I went in to see IHS two or three times before I 
was finally referred. I said, I'm short of breath, I need to be 
sent somewhere they can look at it. After two times, I was 
turned down, they finally sent me out to a cardiologist 300 
miles away. So when they went in and did the tests on my, they 
found out I had 94 percent blockage in two arteries. So they 
immediately took me into the ER and put in two stents.
    I came home 100 percent better, could breathe a lot better. 
And I was scheduled to go down for my follow-up in one month. 
So as the health care process goes with IHS, you have to take 
that follow-up paper to your provider, your provider at IHS, 
and he takes it to the Committee, the PRC committee, and they 
either deny it or approve it. Well, I was denied my follow-up.
    So what I want to say is, what they were telling me is, 
forget about your engine, we'll just fix your exhaust. Because 
they gave me a colostomy appointment just one week after that 
denial. So they said the hell with your engine, let's just fix 
your exhaust.
    Mr. Headdress. And I told that to Tester at one of our 
hearings in Montana. It's funny in a way, but it's not. And it 
happens all the time in Indian Country, not just to me or 
anybody else in our area. We have dealt with this for a long 
    And I do want to give a shout-out to Indian Health Service. 
I've worked with some of these people, I was an employee of 
Indian Health Service for 30 years. I retired in 2004. And I 
worked with some of the people in this very room, Dorothy, Mr. 
McSwain, is he still here? And some of them are very dedicated 
    But again, they do not have the money to do the things that 
they know they need to do. And we beat up on them all the time. 
Some of it deservedly, but a lot of them are very hard workers, 
especially the nurses, the people that are out in the trenches 
doing the work. We need to get rid of some of the 
administrators and make more doctors. That's the bottom line.
    So thank you for your time.
    Mr. Andrews. Thank you, Mr. Headdress.
    Any other tribal organizations that want to address us? 


    Ms. Saunsoci. Good evening. My name is Adriana Saunsoci, 
and I'm the Vice Chair for the Omaha Tribal Council. I'm here 
on behalf of the Omaha tribal members and all the rest of our 
nations, our tribes, not just my own. I'm here for the mothers, 
the fathers, the brothers, the sisters and all the family for 
patients of facilities of Indian Health Services and the 
    I want to say thank you to all those tribal leaders and 
individuals that were up to share their stories to you. Again, 
it was said that a lot of us have a lot of very similar issues. 
And they are very, very similar.
    I want to say thank you to the Winnebago Tribal Treasurer, 
Tori Kitcheyan, for being up there and speaking on behalf of 
the hospital. I think she just kind of forget to mention Omaha 
Winnebago Hospital over a handful of times. But regardless, I'm 
here on behalf of all of us.
    I'm speaking, not reading anything. What I want to share 
with you is, some of you may know, on August 3, 2013, I myself 
had a child. I don't know how many of you are parents in here. 
But I had a child. She was just a month away from being three 
years old. There was a horrible, tragic accident. We got my 
child to the ambulance. From the ambulance we went to what's 
our life link on the Winnebago Reservation, it is the Omaha 
Winnebago Hospital. We went to our life link to try to save my 
    We were unsuccessful. So I stand here before you as a 
grieving mother today and the vice chair, again, not just for 
my people, but for all tribes, to say that this cannot continue 
to happen. I pray for better things for our people.
    I blamed myself for a long time and held guilt for my 
child's death because of the way that it happened, so 
tragically. And a year later, just a little over a year later, 
we get a new acting CEO at our facility. So when she came to 
report to us in Macy, Nebraska, the Omaha tribal reservation, 
about the issues at the hospital, she told us some very 
disturbing things. And with the things that she shared with me, 
one of the questions I asked her, I try not to mix my personal 
and my own life with my work, but at that very moment I 
couldn't help it.
    I asked this individual, and her name was Dixie Dykowski, 
which by the way I think she did a very good job while she was 
there, but when I asked her, so you're standing here and you're 
telling me, you're telling me that if you had a trained staff 
in that hospital, people that knew what they were doing, the 
crash carts were working or they knew how to use them, you're 
telling me that my child could have been here? And she said 
yes. I'm so sorry, but, yes. So these are the things that are 
happening, not within just my own community, but within all 
tribal nations.
    A year later, I had to take my son back, and of course I 
suffer from post-traumatic stress disorder. I have to take my 
son back repeatedly because he had fevers, he had chills, he 
was convulsing. But they would get his fever down and they 
would send him home. It happened twice.
    I couldn't take it, I couldn't go back there anymore, so I 
took him to the city of Onawa, Iowa. And they kept my son a 
little over a week and gave him antibiotic treatments and said 
I was lucky that I got him there.
    Now, can you imagine, after the loss of one child, if I 
were to lose two? Now, again, I don't know how many of you have 
children, but that's the worst fear of a mother, is to lose 
another child. Let alone lose one.
    So I come here today again to share my story, not just to 
get her story out, but to share that this happens all over 
Indian Country. So be our voice, I'm asking each and every one 
of you to be our voice and help us to improve the quality of 
life. It is not about the almighty dollar. It is about the life 
of our people.
    Thank you.
    Mr. Andrews. Thank you for sharing that story with us, very 
powerful. I think your words resonate with all of us here that 
are listening to you, that I think that's our goal, to make 
sure that tragic events like that don't happen anymore, to 
anyone, anywhere. So thank you.
    Is there anybody else? We've come to a point here where 
we've heard from tribal leaders and tribal organizations. So 
feel free, this is your time. If you want to address us. Sir, 
please. If you'd just introduce yourself.

                       OGLALA SIOUX TRIBE

    Mr. Red Willow. Thank you. My name is James Red Willow. I'm 
with the Executive Committee of the Oglala Sioux Tribe. Our 
President Steele had given earlier testimony as well as our 
tribal council representative on the HHS committee, Sonia 
Little Hawk Weston.
    But there aren't too many things I can say that haven't 
already been said except treaty obligations, of course. McSwain 
was near our reservation but within our treaty territory of the 
Black Hills in a town called Spearfish, where he heard many of 
the stories that were told today concerning lack of health 
care. It wasn't too long ago in our past history that the only 
health risks that many of us tribal nations faced were the 
bullets and sabers of our enemies. But because of our 
ancestors' refusal to surrender, we entered into treaties. And 
our treaty, the 1868 Fort Laramie Treaty, Article 13, 
guarantees us health care, recognizable in international 
    Now, at this point in our lives, the things we have to 
worry about concerning our health are the stresses that we have 
to go through to guarantee that we will have proper health 
care. And that stress upon our individual members, especially 
our women that have the care in their hearts for the people, 
the children. There's an old saying amongst our ancestors that 
if the women of our nation's hearts are on the ground then we 
are no longer a nation, we will not survive.
    So the stress that is put upon our people compounds those 
health issues that our people face, diabetes, heart disease, a 
myriad of smaller ailments that aren't treated properly or have 
the necessary physicians there to see you through your 
illnesses, physicians that leave because their obligations in 
the military are ending or they're no longer wishing to be 
there. So patients have to rely on a new physician for health 
care, and they might not have the same treatment by the 
previous physician, given different medications, et cetera. 
This stress also relates down to our children.
    I gave testimony here when Senator Abourezk was the 
chairman of this particular committee. I don't know if there's 
too many people in this room that remember Senator Abourezk, 
but I was on a council, tribal council in a treaty organization 
back in 1976 when I gave testimony regarding health care, law 
and order, et cetera. And here I am today, 40 years later, 
still giving testimony. But I'll continue to do so. I have 
exceeded the expectations of the statistics of the government 
in living past my 50 years as expected by the U.S. Government. 
The women of our nation are only a few years beyond the mid-50s 
that are expected to live.
    So I'm going to defer further testimony to give others, and 
submit written testimony. There is a lot of complaints that my 
office receives from the people of the reservation. I live 100 
plus miles from Pine Ridge in the northeast corner of the Pine 
Ridge Reservation with the Eagle Nest District. Daily I travel 
to Pine Ridge. I pick up hitchhikers that are hitchhiking to 
the facility in Pine Ridge and have to wait for hours and 
hours, some tell up to 10 hours in the emergency room, waiting.
    But there's a shining example on our reservation of 
dedicated people within IHS as was mentioned by the gentleman 
previously. Some of those individuals work tirelessly in what 
is known as boots on the ground in some circles. Pine Ridge 
Indian Health Service has two satellite clinics in the Medicine 
Root District and the Eagle Nest District. We in those two 
outlying satellite health centers would like to be a standalone 
in case the hospital in Pine Ridge was ever to be shut down. 
That would not affect our two health centers, we would still be 
operational and not be shut down.
    But the health issues that confront our people, no doubt we 
will, in the future, our systems will develop to the point 
where we will be a healthy people again. Our diet in the past 
consisted of natural foods. And we didn't have the myriad of 
diseases that affect us now. It's with the diet also that our 
people are suffering.
    But with that, I would just like to say that with these 
testimonies that we all give, we are expecting some type of 
action that would give us better health care. And that is 
through the Indian Health Service. So may the Great Spirit help 
us all if IHS does not live up to the expectations that we 
    Thank you.
    Mr. Andrews. Thank you for that.


    Ms. Salomon. Thank you. My name is Donna Salomon, and I'm a 
member of the Oglala Sioux Tribe. I traveled here from Pine 
Ridge Indian Reservation in South Dakota.
    I had a number of issues to address, but I know from 
listening all day that all of it has been said as to what our 
tribes need. So I want to share a personal experience. I'm the 
eldest daughter of ten siblings. Three years ago, in July of 
2013, my father was injured in a car accident on the Pine Ridge 
Reservation. He was taken to the Pine Ridge Hospital and 
transferred on to Rapid City Regional Hospital. That happened 
on May 11th of 2013.
    On May 30th, he was transferred to the advanced care 
hospital in Billings, Montana, where he stayed until July 26th, 
2013. For almost three months he was hospitalized, they had him 
on a trach and a ventilator. He had a fractured neck and had a 
punctured lung.
    Repeatedly, he wanted to go home. I come from a family that 
believes in traditional healing. We have medicine people. We 
made repeated requests to Indian Health Service and they denied 
us every time to take him home. I felt confident had he gone 
home, our ceremonies, we have Yuwipi ceremonies that could have 
helped him to recover. But instead, our CEO of that hospital 
continued to deny our request. All we wanted was to take him 
home. And he would not provide a receiving physician to accept 
him home. He said Pine Ridge did not have respiratory care 
services, did not have certified nursing staff nor equipment.
    And finally, we just said, we don't want him to go to the 
hospital, we want him to go home so we could have the 
ceremonies that he wanted to help him with his healing.
    On the last day, when we finally contacted tribal 
leadership to help us, I had guardianship of him. I wrote to 
Senator Tim Johnson, I contacted Tex Hall, from the Chairmen of 
the Great Plains tribal chairmen, I reached out all over. I had 
him courtesy copied to Department of Health and Human Services, 
Indian Health Service, everywhere I could think of. I have my 
letters that I am going to attach to my written testimony.
    While he was in Billings, he contracted MRSA. And I know 
that it was there, because right across the hall from him there 
was another with MRSA. And that weakened his system so bad, the 
medicine, the ten days of those strong medicines took him down. 
My father was 84 years old, he hardly ever went to health 
centers. If he got sick, he went to the ceremonies. His first 
language was Lakota and he only went to sixth grade. So he 
couldn't talk to the doctors, he couldn't understand some of 
the services that they were giving him.
    He already had a weak kidney. He already had problems with 
his lungs. But they insisted that they continued to keep him on 
oxygen, continued keeping him on medicines to bring his kidney 
tests up. And when they did that, it knocked his liver tests 
down. So they were constantly going back and forth trying to 
get him stabilized.
    And he kept motioning to us, take me home. And we would 
reach out to Allen Davis and he would deny us.
    Finally, on the last day, on July 26th, he finally agreed. 
And so we got happy and we were going to go. And then he 
changed his mind and he said he couldn't do it. So we called 
our leadership, we called President Brewer, we called all the 
tribal council to help us. So they called up there, and so he 
changed his mind, said, okay, we're going to bring you home, or 
you bring him home.
    The attending doctor at Billings, Dr. Fenn, he must have 
felt sorry for us because of the struggles trying to get him 
home, that he finally said, when he heard Allen Davis say, I 
will send for air ambulance to bring him home, but you need to 
provide for the nurses to accompany him back, and he's not 
going to come back to the hospital. He's going to go straight 
to his home. And I'm going to receive him and that's about it.
    So we had to have the tribe meet us at the airport with the 
tribal ambulance. They met us there. He had Dr. Mitchell meet 
us at the airport and Jay Sambutans, who was a social service 
worker. They met us there in Rushville, Nebraska, which is only 
a 25 minute drive from Pine Ridge. And this is my dad. He was 
still conscious. When we left from Billings, he was happy. He 
indicated to me as happy. I reached around, I rode with him on 
the air ambulance, reached around, hugged him and said, Dad, 
we're going home. Are you happy? And he nodded his head.
    And when we pulled into Rushville, he was still up. All my 
family was there and they greeted him. And Dr. Mitchell got in 
the ambulance with him and we went home. I don't know what he 
did to him on that 25 minute ride, but when he got home, he was 
unconscious. He stayed that way until 3:00 o'clock, 3:27 the 
next morning, he passed away.
    The worst thing was, before we left, when he told us he 
would not give my dad any medicine, Dr. Fenn gave me a 
prescription because he was worried that my father needed 
comfort care, some type of medicine to keep him from being too 
agitated when that time came. So he gave me a prescription and 
I filled it.
    He told Dr. Mitchell about it, so when we got there, Dr. 
Mitchell asked me if I had it, and I said yes. He didn't 
administer it. He told me he would let me know when I had to 
give him the medicine.
    About 12:30 that night, he was still there and he told me, 
I think you'd better give him some medicine. And I looked at my 
dad and he was still laying there unconscious. So I looked at 
the little bottle and I just gave my dad about one little drop 
that was not even a third of what was prescribed, because I 
didn't think he needed it.
    About 2 o'clock in the morning, I was surprised because Dr. 
Mitchell came up to me and he told me he was leaving now. And 
when I looked at him, he had tears in his eyes, because 
throughout that time we were singing, and my brother was trying 
to do the ceremony, but he said my dad's spirit had, something 
had happened, his spirit was weak. And Dr. Mitchell approached 
me in tears and red-eyes, and told me, had I known how 
important it was for your father to get here so you, your 
family could go through this, I would have told Mr. Davis to 
bring him home weeks ago.
    I could have slapped him but my father taught us not to 
disrespect people. My father passed away. The next morning the 
funeral home came after him. About a half hour later, or an 
hour later, we got a call from the funeral home and they said, 
you need to come up and do our arrangements now. We could not 
take your father's body to the hospital, to the morgue because 
their refrigeration units broke down. We can't keep him too 
    I'm here today to tell the Committee, we need respiratory 
care services on our reservation. When my father wanted to come 
home, we were told, there are no respiratory care services 
close to home. We contacted Rapid City, there was nothing 
there. We contacted the VA, because he's a veteran. Fort Meade 
doesn't have it, Black Hills, veterans hospital doesn't have 
it. No other tribes in the Great Plains area has respiratory 
care services.
    We're in Pine Ridge. We're 300, 400 miles away from the 
closest respiratory care. And that's only if they're available. 
What's appalling is that IHS told us that during this time 
there were five other cases similar to my dad. They were in 
Denver and Omaha and Billings and Minneapolis. For our family 
to stay in Billings for almost two months, it cost us almost 
$2,000 just to stay there. That was not counting the 
transportation or the food. Luckily, I have a job and I have a 
business, so I was able to keep the rest of my family so we 
could remain there. My father not being able to understand very 
much English, one of us always had to be there so we could 
    That's what happens to our tribal elders. They don't need 
to do that. IHS does not have enough money, they told us, to 
provide that type of service. I have a lot of people that came 
to me after they heard my story. It was in Lakota Country Times 
his story was printed. And they told me that their husbands, 
mothers, grandmothers all died outside. Chief Oliver Red Cloud 
was one. He was on respiratory care services and they sent him 
to Denver. He could never go home. He died in Denver. He was 
the Chairman of the Black Hills Sioux Nation Treaty Council. 
His life, whole life, he fought for treaty, treaty rights, 
treaty obligations. His forefathers fought for treaty. And it's 
a darned shame that there's a grandson of Chief Red Cloud who 
could not go home because of lack of the type of specialized 
care that he needed. They wouldn't even take him home, to go 
home to his home where he wanted to go.
    These elder men and women who tried to protect us, who 
tried to teach us, preserve our ceremonies, I just cannot help 
this. They failed our people. The episode of care for my dad 
started in Pine Ridge. They had that responsibility all the way 
to when he was brought back. There were no advocates that went 
there. There was no follow-up. They did not check to see how he 
was doing.
    I didn't even realize that Medicare only paid for 45 days 
for that type of care. At the end of that 45 days, they were 
trying to make us turn his machines off, not because he had 
internal organs shutting down or nothing, just that there was a 
45-day limit.
    How many of our people who do not understand Medicare 
limits are told to go make a decision to shut a machine off? 
How many? We almost did, at that 45-dya limit, we almost shut 
that machine off, because they told us we had to. We didn't 
understand, we thought it was because it was of his health. But 
we found out it wasn't. IHS informed us that our dad had 
Medicaid as well, so once advanced care hospital found out my 
dad was Medicaid eligible, they went in there and they started 
respiratory, physical therapy, everything.
    But by then, it was too late. It was too late. And I'm a 
living testament to what happened to my dad. And this is just 
one tribal member. And I know, Great Plains Tribes, you all 
have the same problem. Your people are sent out there and some 
of them, the majority of them never return. They come home in a 
    My father wanted to come home and be connected to his 
homeland. And we made sure that he was brought back. Had he not 
been brought back, we had a van ready and we were going to, if 
we had to get an air tank and a vacuum, we were going to make 
sure, if he died on the way, just so he knew he was going home. 
That's all we were worried about. But these are stories, you 
heard the lady earlier tell you about losing her baby. This is 
our dad. He has over 130 grandchildren who walked in a walk to 
the Pine Ridge Tribal Headquarters asking to bring their 
grandpa home. And we had to fight and fight and fight.
    I thank you for listening. I thank Emily and Jackie for 
going to Pine Ridge. I thank Darren Benjamin for going to Pine 
Ridge to see how we actually live and what we actually go 
    I thank you, and the Senators who sent their staffers, to 
Senator Thune for sending Jeannie down there all the time. I'd 
really like to thank all of you for listening. Thank you.

                    CHAIRMEN'S HEALTH BOARD

    Ms. Church. My name is Jerilyn Church and I'm the CEO for 
the Great Plains Tribal Chairmen's Health Board.
    I purposely waited to speak because I wanted to give our 
tribes an opportunity for their voices to be heard, because for 
far too long, they haven't been heard. The stories that you've 
heard today are probably just the tip of the iceberg. We hear 
stories like that over and over again.
    So I won't take too long, but I just wanted to share with 
you from the perspective of our organization. Our organization, 
the governing body consists of the 18 tribal chairmen of the 
Great Plains region. Our role really is to help be a collective 
voice, to be present when there are many tribes that are not 
here today, because they didn't have the resources to get here 
or to be here, and to be of support for our tribes in their 
    I think our organization has also a really unique 
perspective in that we work very, very closely with the Indian 
Health Service regionally as well as nationally. And our 
organization consists of predominantly tribal members of the 
tribes that we represent and that we work for. We advocate for 
the priorities that the chairmen set as board of directors.
    I have to say that I've read the reports from Winnebago and 
Rosebud and Pine Ridge. My emotions vacillated between 
incredible sadness and just incredible anger. Our region asked 
for a hearing, but at the same time, my thoughts were, we had 
this hearing six years ago. And there isn't anything that you 
heard today or anything more than you could hear that wouldn't 
have already told you and you wouldn't have already known from 
six years ago.
    So I also come with a little bit of skepticism. I'm also a 
little tired so I probably don't have a very good filter right 
now, either. But when I look at our region and I look at Indian 
health in our region, Indian Health Service, they are also our 
community. What I don't want to see happen as a result of this 
is that the challenges and the discrepancies are used in such a 
way that hurt us further. So I'm aware that there are some 
political leaders that would just as soon give out cards and do 
away with Indian Health Service, and contract it out maybe even 
    But there are no other providers out there that are going 
to love our people as much as our own people do. And there are 
a lot of good people within the Indian Health Service that 
dedicate their lives.
    So what I hope will happen, and my suggestion, I want to be 
solution-oriented, I kept telling myself, okay, solution-
oriented. So the solutions that I see as viable solutions, 
first and foremost, is fund Indian Health Service at the level 
of need. We facilitate budget consultation, and this will be 
the fourth year of doing that. We don't provide a needs-based 
budget. We provide a zero-based budget. So they come and ask 
us, if you had this percent, what would you do, if you had this 
percent, what would you do. And if you had a decrease, what 
would you do. Well, we just ignore the decrease.
    But that's not budget consultation. That's dictation. And 
that keeps us at a level that we will continue to hear and 
experience the kinds of things that our region has experienced 
if we don't have that budget.
    And I'm not talking about throwing money at a broken 
system. I'm talking about funding systematic change from the 
top down. Congress is just as culpable as the person that was 
in the service unit that didn't respond in a way that was 
appropriate. That responsibility starts from there all the way 
down. So fund the region so that we can have systematic change 
and that we can expect and have care at a level that our region 
    I spoke with, I'm on the Coalition for Medicaid Expansion 
in the State of South Dakota. One of the conversations that I 
had recently was about the VA and how the providers in our 
region were complaining that they couldn't compete with the VA, 
they couldn't compete with their salaries and they couldn't 
compete with the benefits packages that they offered. And we're 
struggling to just pay even at a level that is appropriate and 
    So I want us to have a system where providers wish they 
could provide as good a care as Indian Health Service, as IHS. 
I want a health system in our region that we can be proud of. 
Because our family members, many of our family members are 
working in that health system feeling very demoralized, feeling 
very helpless, and feeling as though they're doing the best 
they can with what they have and it's not good enough. They get 
beat up over and over and over again.
    I want people to be held accountable that need to be held 
accountable. I came into an organization four years ago that 
wasn't functional. It took me six months to determine who 
needed to stay and who needed to go. And it took me three years 
to get that organization to a level where it's functioning with 
ethics and financially viable. That can happen with Indian 
Health Service.
    But the investment, Congress needs to be willing to put 
that investment into it. And it is not asking too much. We make 
up 2 percent of the entire population of this Country. We are 
the genocide survivors. So it's not a big ask for this Country 
to fund schools, health, our judicial systems at a level that 
allows us to live functional, healthy lives.
    These reservations were created by this government. Those 
treaties were made with this government in exchange for the 
well-being of our people, and it's not happening. I'm singing 
to the choir for the most part, here.
    But I hope I'm proven wrong. Because throughout this 
process, from the time when Ms. Newman came out to South Dakota 
into our region, on one hand I was happy that they were there; 
on the other hand, I have no reason to believe that you're 
going to do anything different than what you've done before. So 
I hope you prove me wrong.
    Thank you.

                      ROSEBUD SIOUX TRIBE

    Ms. Wooden Knife. Hello, thank you. My name is Kathleen 
Wooden Knife. I'm a Rosebud Sioux Tribal Council 
representative. And I'm also the vice chair of our health 
    I have listened to everything today and it's been quite 
emotional. I'm going to do my best not to get emotional, 
because I have a lot of compassion, every direction. And 
listening to my colleagues and listening to my other relatives 
speak today, I sat here in tears many times. I will try not to 
do that; if I do, please bear with me.
    I want to give a little bit of a balance here for myself. I 
left, I was two days short of my 15 years in the Federal 
Government when I was elected to my position as a tribal 
council leader. My goal was, one of the things I wanted to do 
was to see what I could bring from the government to the tribe 
and the tribe to the government. Because I lived it. We've 
heard a lot of testimony on the bad experiences we've had. I've 
had them. I've had family members that have died. We all have. 
My colleague has experienced quite a bit of sadness. And so it 
become very emotional when you have family members that die and 
you can't do anything about it.
    I know from being an employee at Indian Health Service, I 
had five years with the Bureau of Indian Affairs and ten years 
with the Indian Health Service. While employed there, I know 
that it is factual, it isn't disgruntled employees that are 
saying we're threatened, or, I have to be afraid for my job. 
When I first started working for the Federal Government, I 
walked into a department that had so much hostility. I did a 
ten-year history on the supervisor of that department.
    And as you hear people say that people are protected, okay, 
she had people as high up as HHS. And the experiences that we 
go through, in the department I was in, employees were becoming 
ill. One of the people I worked with was a relative, she almost 
lost her baby, she had complications. I was sent to a heart 
hospital thinking that I had heart problems. It was the stress 
level of the environment we worked in.
    That isn't something that is made up by employees. That is 
factual. We have employees in our system now that want to talk, 
but they can't. We have things going on as far up the echelon 
as you can reach, that are experiencing this fear of 
    There are a couple of situations, I'm going to just do a 
small comparison. You have a violation of sexual harassment at 
a high level. That person still works. He gets moved around and 
is still employed. You have the same complaint at a lower 
level. That person, the lower level echelon people, the blue 
collar workers, the people that have their feet on the ground, 
that do the laborers' work. That person can just immediately, 
with a little bit of paperwork, be removed.
    I know for a fact, I worked in administration. And so, we 
talk about our health, our losses of our people. We chose 
[indiscernible] health for our people. And all my relatives 
here have touched on that.
    But I'm going to touch on the other part of it. Because 
being the voice of the people, we have to speak for both sides, 
and we have to speak for the ones that are getting that bad 
health care, and we have to speak for the ones that are within 
our system. As somebody has said, we have good employees, we 
have bad employees. We have good administrators, we have bad 
    One of the things that I experienced is, and I don't know 
if it's just overlooked or why we can't come to a resolution 
with it, is that when you're at a health service unit and we're 
having issues, in administration, I was administrative 
assistant for our clinical director. I had at least 10 clinical 
directors in the time frame that I was there.
    One of them, his main priority was warm bodies. He didn't 
care about the quality of health care we were bringing in with 
our physicians. Every time a contract position would come in, 
let me make you a deal here. I want to make you a deal here, 
because I've got to fill my quota of warm bodies. Because when 
I signed on here, that was my goal.
    This same physician, before he left our Rosebud Indian 
Health service, had a fist fight with one of our doctors on our 
inpatient ward. The same doctor who we knew had a history. And 
I'm going to bounce around a little bit, because I've worked in 
property and supply and I've worked in administration. I've 
seen stuff at both levels. In the department I worked in, I 
wore a lot of different hats. I worked with HR, I worked with 
backgrounds, I worked with the medical staff, I worked with 
contract, I worked in a lot of different areas, because our 
service unit doesn't have that funding to have that number of 
employees there sometimes.
    So those of us that sat in that main office, we were the 
main people that caught everything. I've heard stories from our 
people in housekeeping, our security, our nurses, our doctors, 
our administrators. They come into administration and they need 
somewhere to vent. And because we're the ones that are up front 
and center, we're the ones that they vented to.
    So there's a lot of things that I knew. I sat in medical 
staff meetings and I listened to the review of credentials. I 
finally refused to sit in there any more, hearing the dings 
that were on the physicians that were coming to our hospital to 
take care of our people. I told my boss, I'm not doing this 
anymore, I don't want to sit in these meetings anymore, because 
I don't know how you people sleep at night, knowing that we're 
bringing physicians in that have issues or have these dings on 
their credentials. I would sit there and I'd go home and night 
and I'd think, how, you know, I don't want my relatives having 
this doctor take care of them when wherever he was he lost his 
license for this reason. But yet we're forced to accept 
whatever we're given. That's unacceptable. I mean, it was so 
sad I refused to do it anymore.
    Like I said, I come from being a patient, I come from being 
an employee. I left there because I wanted change. I wanted to 
see both sides of it.
    When you bring in these quick fixes, when I left the 
government and I became a tribal council leader, within months 
we had our meeting with the area director. He refused to come 
to our reservation and meet with us. He wanted us to go to 
Pierre, 100 miles away from where our reservation is, to meet 
with him. And when I got there, I was pretty fired up, because 
when I walked in, I walked into a conversation that pretty much 
got me riled up. And my colleagues know that, sometimes I get 
excited and I talk really fast. And when I start going, things 
shoot out one after another.
    It was my opportunity to say, I am no longer a Federal 
employee and I finally get to say what I need to say because I 
don't have to worry about losing my job. I don't have to work 
about getting written up for this. And so I said what I needed 
to say because I was very upset. And I said to this person, 
more than one time, a lot of people have mentioned today 
they're happy that this person is no longer with us, but I 
said, you know, you don't know what it's like. You, and I don't 
mean to insult anyone, but I said to him, you are an urban 
Indian. You have no idea what we go through. I said, you need 
to come to our hospital and see our doctors and get our care 
for a month.
    The last time that he was at our council meeting I told 
him, no, not a month, I want you to come for a year. I want you 
to bring yourself and our family and see what it feels like 
here. Because you have no idea what we suffer from, what we go 
through. And he stood and he told us, and you know, I've heard 
other tribal members say this, lip service, it's really amazing 
to hear how many of us know lip service very well. Because many 
times that's what I say we get. As a tribe, we get lip service. 
We're going to do this, we're going to do that.
    I finally said, in here, in my [word in native tongue], I 
don't believe you no more. Everything that you've told us, 
everything that you've committed to that we're going to fix 
this with, the transparency isn't there. Because everything 
that we're told, you can take it with a grain of salt. Some of 
this will get done in due time. But you know, if you're up here 
and we're down here at the service unit level, at the IHS level 
and you're getting this care, if you suddenly see it's up here 
and you've never been there to have that care, if you've never 
been there to experience the deficiencies that we have, that 
lack of quality of care, that lack of continuity.
    I lived off the reservation a part of my life, so I know 
what it's like to be on and off the reservation. It was nice 
living in the city, seeing the same doctor, knowing that I was 
having that good care. But like somebody else here mentioned, 
you go into our hospital, we see a different doctor, we give 
our whole history. You can never go back and see that same 
    You know how frustrating it is to have to repeat your 
entire health history? Okay, now, what were you, oh, I see in 
your record, this is in here. And you get so frustrated you 
just say, well, this is what they told me the last time and 
this is what I have and I went on WebMD and these are the 
diagnoses that I found with myself, so if you could just give 
me the medication or refer me or do something else then I won't 
have to repeat my whole history again. Because these are my 
symptoms. You know, it becomes very frustrating.
    The part on the administrative part that I wanted to 
mention, I know I bounce around a lot because I get really 
excited. And sitting here, everything turns, my wheels turn and 
I kind of get carried away. But every time we have this Band-
Aid, this quick fix, and that's what I call it, you know, 
assessment after assessment, why are you going to keep 
assessing us? Why? Because you do these assessments that 
somebody else already did. Why aren't the people in our own 
facility capable of assessing their own issues? A lot of it 
comes from up here. Senator Dorgan's report is almost ebbed in 
the back of my brain because I've read it and I've read it and 
I've read it. And I get so frustrated because I say, this is 
everything that we've been going through. I printed it off and 
I gave it to all my colleagues at council. There's 20 of us. I 
gave everyone a copy, I said, read this. Read this before IHS 
comes here so you guys will understand we're right where we 
were before.
    But bringing people into our facility to temporarily fix 
us, you're bringing people in that are going to come in, 
they're going to have knowledge of where they were, what worked 
in their system. As I talked to some of the other tribal reps, 
I said, you could take this person, this person and this person 
and send them to our facility. And each time you do, coming 
from administration, we sit back, we know, okay, we have a new 
acting CEO coming in, we have a new deputy coming in. Which 
people are going to be there first so they get their way? So 
they can still get things how they want them? That does happen.
    The next thing is, now, I wonder what kind of a plan this 
one has for us? Because we just got adjusted to the last CEO, 
and this is how their management functioned. This is what 
worked at their facility. This is what worked at their tribe. 
Now they're going to come to our facility and this is how we're 
going to run. So everyone has to adapt to this person.
    Then something happens and they get sent out. And then the 
next one comes and it starts all over again.
    What this actually does is causes a great hardship on the 
facility employees. Yes, we have good employees. And we have 
bad. And we have these people that come in, yes, some of the 
ideas are good. But maybe they're not fit for our facility, 
because we're alike but we're different.
    But every time this happens we all have to readjust. But 
what happens is it affects us in many ways. It affects the 
people in administration that are not administrators. It 
affects our entire support staff. Because everybody has to 
    But after we do this for so many times, the morale drops. 
And everybody only wants to do what they have to do. But what 
hurts us the most is when this keeps happening, this effect, 
this merry-go-round that we're on, is our people suffer. 
Because if our employees aren't happy and they're not 
functioning fully, because of the administrative changes, and 
giving up that, well, Aberdeen has got their favorites, 
Aberdeen has their family, now they're going to send somebody 
else, now they're going to start over. When people just kind of 
getting into it and they give, they kind of almost want to give 
    But it hurts our patients, that's what hurts. It hurts our 
people. Because as you climb that ladder, to the nurses, the 
MSAs, to the people in the offices, how they feel affects how I 
get my health care treatment. So it goes on and on.
    So from coming from the inside, I know this stuff is true. 
I have experienced it. I've witnessed it. I have seen Douglas 
factors done, just like that, to get rid of an employee. But 
administratively, what I say and I say we all share that same 
thought is that, recycle, recycle and promote. Recycle. We did 
resolutions. We didn't want this person here because they were 
resolutioned off another reservation. Here they come. Re-do how 
our system is.
    I walked out and I came back in and I thought about 
something. We try to figure out what's broken, we know what's 
broken. We tried something different, we said, okay, well, we 
keep getting people from within the system. And they're just 
already conditioned to do things this way. You're already like 
robotic in how you do it. I used to get so frustrated at Mr. 
Cornelius, because he seemed to be, and I said it to him and I 
won't deny it, I said, you're very well versed, you sit there 
very, with that Chessie-cat grin and you bob your head and you 
smile. And the thought behind that smile you don't know. But 
because everyone comes in this way, after a while you start to 
wonder, is it the Federal Government? Is it the people that 
we're bringing in? Still we tried it. We went with a CEO and a 
clinical director that weren't Federal Government, that weren't 
in IHS. And it was just this catastrophe, such a big 
catastrophe as what we already experienced.
    Right before all this stuff happened with Rosebud, they 
both left and went to the VA. Poor VA. Because as my friend and 
colleague here said, they told us we were good. I sat in on 
that one review with her. We sat across the room from each 
other and my mouth was like, because I was saying, they said 
we're the best. They said we have this good review, our ER was 
    When our last CMS review had come to Rosebud, we had so 
many dings, we had so much wrong. And then for five years 
later, or however many years later it was, for them to come to 
our ER and say how fantastic our ER was, I couldn't believe it. 
I was in disbelief. I was angry and went out of there cussing 
and I don't really cuss that much unless I'm really angry.
    But I could go on and on but I'm not going to, because 
everyone here has shared the exact same things. What goes on at 
your hospitals goes on at our hospitals and we suffer. With our 
diversion, people are being sent out.
    I sit on way too many committees at our tribe. And I sit on 
budget and finance committee. We have to find money. Last year, 
by February or March, our money was gone. Because when people 
get sent out, they come to us, we have to make up that 
difference, for families to travel, for their motel, for their 
gas, for their food. But also for the people they leave behind, 
because in our culture, there's always that main person that 
goes and you also have that main person that takes care of the 
family at home. And it's usually that person that's going with 
the relative. So then he or she has to make sure that she's 
taken or he's taken care of, whoever's left at home.
    I didn't get to write down what I wanted to say, but I 
really have talked and talked. But one of the other things that 
I want to talk about before I sit down is the safety and health 
of our employees is also of a great concern. It's not just the 
people that come to our hospital for care, it's our people that 
work in our hospitals.
    In our hospital, our former CEO, I went up to address an 
issue and he called me very unethical, because I didn't, you 
know, we come here with our history of everyone nets out on our 
reservation, all the things that are going on. I went, and I'm 
going to touch on my personal at the moment. I went there, 
first as a tribal council rep, then as the vice chair of our 
health board. I went on behalf of three tribal members. One of 
them happened to be my husband. And I went there because I 
couldn't get hold of one of my other colleagues to address it 
and it was something that needed to immediately be addressed.
    We don't follow safety, health and safety standards like 
what we should. My colleagues standing behind, he and I and 
Evelyn Espinoza, we all come from IHS. Fresh from there to 
where we're at. Evie left about a year before us. But my 
colleague back here was a safety officer, so he knows a lot 
about what I'm going to mention. But the houses there are so 
old on the lower compound, you have a lower compound and you 
have a new compound. The ones at the lower compound are very 
unsafe, they're very unhealthy. They have asbestos in them.
    There was a fire and there was an old building with both 
asbestos and black mold. These three employees had to go down 
there without any safety gear. I asked the CEO to do a 
webcident. I asked him to do an air quality check. Neither one 
was ever done. My person that was very special to me has been 
subjected to one house where, when they got done, they brought 
them the safety gear and said, oh, this house tested positive 
for methane, you need to put this on, they were already done 
with the house. He tore out the entire living room and a 
kitchen area, the tile had asbestos in it, the glue.
    Okay and then comes the thing with the black mold. I went 
in there, I'm asthmatic. I barely got into the building, I 
couldn't breathe, I had such a severe asthma attack. Well, he 
no longer works there, because I'd rather have him in my life 
than have that second income.
    But my point in this is that you take these concerns to 
them and they don't listen to you. There's other things there 
that go on, and we're not heard. I could go on and on, I could 
write a whole book on all of the bad issues that our people 
have suffered from, because I hear them and I've experienced 
them and what goes on with the employees. Our employees also 
need to be heard.
    When people come out to talk to us, it's just like someone 
else mentioned, I was an employee there, I know, you can't. 
You're afraid to go to the tribe because you don't want to get 
fired. We had a contract person that came to the tribe and the 
next day, he was fired. So we know, those that work there at 
the IHS tribal level within our reservations and at the area 
office level. I don't know about the HHS level, but as far as 
our area office level, there are employees that know things, 
there are employees that are going through hostile work 
environments, there are people that are mistreated. There are 
cliques, there are favorites. There are unfair hiring 
    I have been getting information along the way, and I know 
for a fact that this happens. So when you go out and talk to 
people, Emily knows, she walked with us through our IHS, it's 
very difficult to do because there's that barrier, there's that 
protective arena that you can't get beyond. You're going to be 
told, oh, no, we have transparency, we work with you, we do 
this and that. It isn't there.
    So when the times comes and you do another hearing or you 
take testimony, I ask that you go and afford the employees at 
the service unit level and at the area level the opportunity to 
talk to you and protect them so they don't have to worry about 
being fired. Because you know, they're going to tell you things 
that, sometimes when you're in an administrative position 
you're going to believe the person that's at the next level 
below you because you have that confidence in them. But it 
doesn't always work that way. Sometimes you're believing things 
that you are being misled, information being misconstrued.
    I have more to say but I'm going to quit because I could 
probably stand here all night. Ten years of history in the IHS 
is a long time. And working in property, going to 
administration, being the clinical director's assistant, there 
are some nightmare stories that I could tell you about things 
that went on at our hospital.
    I have information that I protect because I was background 
coordinator. There's things that I know that are done not 
according to policy. So I wanted to share that, because I know 
that it's mentioned and a lot of people are giving their 
testimony on their actual heartbreaking family losses. But I 
wanted to give the other side of it, being an employee there, 
being a Federal employee for Indian Health Service. I know.
    And so I'm speaking on behalf of my former friends and 
colleagues at IHS and family and members on our reservation and 
others. Thank you.
    Mr. Andrews. Thank you.


    Mr. Clifford. My name is C.J. Clifford and I'm from the 
Oglala Sioux Tribe. I'm a representative out of the Wounded 
Knee District.
    I will try to be brief and directly to the point. First I 
would just like to share with you, I would like to see some 
immediate action taken. Most recently here, as of Sunday, we 
lost a 23 year old young man that paid a visit to the hospital, 
was given some meds, went home. A few hours later, he told his 
mother he was having a hard time breathing. They loaded him up 
in a vehicle and he passed away in the vehicle before it could 
leave the yard. That just happened Sunday. They're making 
funeral arrangements and I understand, speaking with his 
mother, they are doing an autopsy. But that's something that's 
very alarming, that came out of the Pine Ridge Agency.
    Also another medical one is a young 40 year old male went 
to the dentist for toothache, was given five shots on the side 
of his mouth and now he's got a permanent droop on the whole 
left side of his face. Indian Health Service out of Pine Ridge, 
their dental unit.
    Also I want to talk briefly about the consultation process 
that Indian Health Service and other agencies use, Federal 
agencies use to address issues. It's not a true consultation, 
nor do they follow their consultation policy. It's more of a 
dictation, that this is what we're going to do, and we just 
come to have you sign in and we say it's a consultation. 
There's no notice going out. I believe that there should be a 
uniform consultation policy for all extensions of the 
government that deal with Indian affairs. They should all 
follow one base, because they're all different.
    I want to talk about the employees' rights and their job. A 
person's life in the Indian Health Service, it's more important 
for them to take care of one another, rather than the people 
that they're there to serve.
    I want to talk about the drug testing part of our lives 
with Indian Health Service. You people don't have to drug test. 
And I have a problem with that, because we have people out 
there that are in actual need of pain medications, and they 
enforce what they call a pain management contract. They enforce 
that on each and every Native person that goes to the hospital, 
to sign a pain management contract prior to getting medication. 
And then from that point on, they are drug tested each time 
they go in to get a refill.
    Now, tell me how that's supposed to work with the fact that 
we have rampant drug use amongst our employees at these areas? 
And they're not mandated to drug test. But yet you can enforce 
it on a person that's in actual need of a narcotic to help them 
live through their life through the day and they're forced to 
do a drug test constantly. There's many problems with Indian 
Health Service today. And it needs to change. There's new and 
better ideas out there people have that I think they should be 
listening to.
    I want to thank you guys, because I do know you are the 
ears and eyes and hands of the Congressional people. Thank you. 
And I guess not to keep you guys very long, I too would like to 
have you guys relay a message to your bosses that we thank you 
for listening to us from the Oglala Sioux Tribe.
    Mr. Walters. Thank you.

                      ROSEBUD SIOUX TRIBE

    Mr. Dillon. My name is Brian Dillon. I'm a representative 
of the Rosebud Sioux Tribe out of the Parmalee community. I 
also am a member of our health board.
    I'm going to be as quick as I can here. I want to start off 
by saying, we are all valued on our contribution to others in 
our life. Our family and relatives and our tribe rely on our 
contributions, our productivity as an individual. For us to be 
at or near our potential as productive tribal members and 
citizens of the United States, we must be healthy in our body, 
mind and spirit.
    Currently, our productive and contributions in life are 
severely impacted by inadequate health care. It reduces our 
educational, economical and parental viability.
    Just to give you a couple quick examples that are personal 
to me, my daughter, second oldest daughter, just gave birth to 
my first grandson, four and a half days ago. And the reason why 
it's kind of a big deal is currently at our hospital, we don't 
have, well, we might today, have an OB doctor. I'm not too 
sure. It's kind of a two weeks on, two weeks off type rotation. 
Prior to that, they didn't have an OB doc, so we had to change 
her health care provider from IHS to a local facility, which 
happened to be 53 miles from my house.
    Luckily, it didn't provide us with any major complications. 
She was able to deliver a healthy baby and it wasn't a big 
deal. But if it had been, that may have impacted not just her, 
but my grandson's productivity in life. It could have ended or 
it could have been impacted to where the child or the mother 
could be less productive as a parent, eventually, economically 
for their family and for their tribe, their community, been a 
viable aspiration for the local education system or what have 
you, all of those things.
    I have another daughter, my youngest daughter, who's 13 
now. When she was a first grader, she was diagnosed with 
discoid meniscus, which required surgery to correct, or hers 
did. The IHS, Indian Health Service, decided that they were 
going to pay for, she had to have it done on both knees. They 
decided they were going to pay for her to have it done on one 
knee first, go through a little bit of the healing process, 
rehab and then do the other side.
    Well, we went through the process on the first knee, and 
when it came time for the second one, her referral is not 
approved. So she's only had surgery that she should have had on 
both knees on one knee. And the reason why I'm bring up the 
productivity is, it's causing her, she's a very adamant 
athlete. She runs cross country with a great, severe amount of 
pain. She plays basketball, jumping, with a great, severe 
amount of pain. She likes to lift weights, volleyball, you name 
    And it has impacted her negatively. She struggles through 
it, but again, as a father, it makes me wonder, if it's 
impacting her to where she's not going to realize her full 
potential as a child growing and doing those things, and how 
that might affect her as an adult. Because she's starting to 
exhibit things that are in her decision-making process that are 
negative right now because of that limitation. And I'm done 
with that.
    On that note, I ask the following questions of the Indian 
Health Service. Question one would be, can the Indian Health 
Service determine the loss of productivity of tribal member 
patients that die due to inadequate care? Differentiating from 
if they just die of natural causes or what have you.
    Now, the second question would be, with that in mind, can 
it be determined, the loss of productivity for those with a 
debilitating illness as it progresses from a category four to a 
category one? One being loss of life, potential loss of life or 
limb, and that's when our purchased referred care dollars kick 
in. That's what I'm getting at with the example of my daughter. 
She's at probably a four or a three. The reason why she had the 
surgery on the first knee was because at that time I had 
insurance through my employment provider, which was the Indian 
Health Service, at the time. When it came time for the second 
surgery to be done, I had dropped my insurance and I was no 
longer an employee there.
    So the referral process probably went so far as, no longer 
somebody else to pay for a majority of it, or IHS pays the co-
pay, the instituted the payer of last resort. And I can't 
afford the surgery on my own. And being a tribal member and now 
employed by the tribe, indirectly I guess, I have a choice 
whether I want to have health care or not through the 
Affordable Health Care Act or if I want to ask for the waiver 
and all that kind of stuff. Those are just two questions that 
I'd like to have answered.
    I know within Indian Health Service also they have, in 
their Office of Environmental Health, they have the sanitarian 
to do similar type studies on loss of productivity due to motor 
vehicle accidents or things of that nature. So I know it 
probably can be done.
    Thank you.
    Mr. Walters. Thank you.


    Mr. Smith. First of all, I want to greet each and every one 
of you. Good evening and thank you for your time. I'll keep 
this short, just like everybody else said.
    The second thing is, I'm from the Winnebago Tribe of 
Nebraska. I'm a tribal council member. Currently, right now, I 
serve on there and I also am the fire chief for the volunteer 
fire department back home.
    A lot of the stories and a lot of the things that were 
shared here this evening really pull at your heart. And if they 
don't, that's when you really got to stop and think, what did I 
sign up for this job for.
    The other thing is, I was on a call, several calls, but 
I'll share just two with you real quick, and I'm going to speed 
up my talking a little bit. I do better that way. I know 
everybody's probably hungry, because I am. One of the things 
is, we got a call on this veteran who was at home. So we ran 
the ambulance out there with the EMTs. We got out there and 
they were doing CPR. We walked in there, we carried our stuff 
in there and we started doing what we had to do. His family was 
standing around. And we knew that if we can get this gentleman 
to the hospital, he has a good chance, more of a chance than 
what we could provide right now.
    So we kept CPR in progress, we loaded him in the ambulance, 
we even stopped a train midway and made them back up so we 
could get the ambulance through. We drove him into the hospital 
there in Winnebago. And some of you are familiar with crash 
carts, what crash carts are. So I got to see it from my own 
eyes and to this day it still carries a certain place in my 
heart for this family and for this gentleman.
    One of the things was, we unloaded him out of the ambulance 
there and we turned around and we were taking him into the ER. 
And the doctor came in, we called ahead, they knew we were 
coming, we told them we were three minutes out, we're going to 
be at your front door pretty quick. So we turn around and we 
brought him in there. And the nurses in the ER didn't know how 
to even operate the crash cart.
    So that's one of the things that's crazy about this whole 
situation. And one of the other things is that, when you go 
into health care, ultimately you are there to help people. You 
are there to help all the people that may have an issue with 
their physical being.
    So the wires on this crash cart were all tangled up. Now, I 
don't know what kind of degree you got to have to untangle some 
wires to some life-saving equipment. That's one of the things 
that really was frustrating.
    The other part of that was this crash cart wasn't even 
charged, wasn't even plugged into the wall. So I'm still trying 
to find a way to find out how you get these guys with a degree 
to plug in these carts.
    So the other thing is, I went through that, I got to see 
that and we did CPR on this gentleman for 45 minutes. On top of 
that, we had another shift come in and they started in. We 
worked on him for an hour and a half before they called it on 
him. We had a faint pulse come up, and so they turned around 
and they tried to bring him back. Because that crash cart 
wasn't taken care of properly, we had to pull the stuff off the 
ambulance. And the stuff off the ambulance only lets you go to 
a certain limit. So the stuff at the crash cart would have 
helped if it was there. Little simple things like that.
    Another time was another gentleman, he lived in town. So 
the transport was a little bit quicker, a little bit faster. We 
got him in there and we were doing CPR on this guy. And he 
already had a leg that was cut off from diabetes. We brought 
him in there and we were doing CPR on him. And it's the same 
issue. These are two weeks, about two weeks apart. Same issue. 
The crash cart was tangled up, wasn't charged.
    So then this time, there was two crash carts there. All 
right, we might get somewhere now, they're pulling out a second 
crash cart. But the thing was, neither one of them was charged. 
But the second one was untangled, all the wires were untangled. 
So they did try to make an attempt somehow there.
    But there's a lot of different things like that that go on 
in this hospital there in Winnebago, Nebraska. Yesterday, we 
got word that there was a vehicle accident in Macy, Nebraska, 
these representatives of the tribal council that was here 
earlier. There was a police officer, his vehicle flipped. So at 
the time, they pronounced him at the scene from what I know. 
But they didn't let the hospital know that they were going to 
bring these people in that were involved in this wreck. So what 
they did was they turned around and they started diverting 
everybody up to Sioux City, 20 miles away.
    And these are some of the stuff that goes on. Some of the 
stuff isn't going to take the swipe of a pen. Some of the stuff 
is just going to take common sense. But these are the people 
that we pay high bucks for to come in there and be able to push 
that crash cart from point A to point B. Plug it in and start 
it, everything. It's common sense, some of these problems.
    So if there's anybody that's out there that get hold of a 
common sense, let me know, because I'll try to get some for 
everybody. That will take us a lot farther.
    But I just wanted to say that much, and to the tribal 
members and the different representatives that are here, I want 
to say thank you for sharing all the stories, all the thoughts 
and feelings with us. Because these are the kinds of things, if 
we work together, and be good to one another and help one 
another, we can make this happen in a good way for all of us.
    Then when we are able to do that and we reach a certain 
point, there's going to be something that we're going to take 
home with us. It's not going to be a paycheck. It's not going 
to be money. It's going to be a good feeling in your heart, 
knowing that you helped people, clear over on different sides 
of the Country.
    And if you have a hard time at work one day, some day, 
somehow, stop and close your eyes and imagine one of your 
closest loved ones laying there in a hospital bed with all 
kinds of things going wrong and not being able to get taken 
care of.
    So I just wanted to leave you guys with that thought. I 
really appreciate all your time. Everybody that does something 
here, I want to say thank you to you, from the bottom of my 
heart and from where I come from. There's a lot of people back 
home that are really grateful that you guys made time for us to 
come over here and to hear what we had to say.
    So thank you, God bless you.
    Mr. Andrews. All right. I think we've hit that hour of 
night, it's been a long night. Let me first and foremost say 
thank you to you all. Part of a listening session is exactly 
this; we're in listening mode so we can then act on your 
behalf. I know the hour is late for staff, and obviously I want 
to thank them for staying with us and listening collectively on 
this side of the aisle, on this side. We will take what you 
have to say and we will work for the betterment of your 
communities, especially the health care, which we've heard all 
day today.
    For those who didn't get an opportunity to speak, obviously 
you can submit your statement. The record will be open for a 
couple more weeks. But even then, we will continue to have the 
dialogue so we can improve the process.
    I want to thank everybody for their time. Obviously the 
heartfelt stories will stay with us. I really appreciated that.
    Tony, any last words?
    Mr. Walters. I just want to thank everyone for coming out 
and sharing their stories and concerns and suggestions and 
ideas for how to improve IHS in every aspect of health in the 
communities. I know a lot of you traveled from pretty far away, 
so it's good that you were able to come in and share these 
stories with us, good for us to hear. I know they are difficult 
stories to hear and difficult stories to tell. But they do need 
to be told, they need to be heard. They do drive action, they 
drive agencies to do better, they drive staff here to advocate 
harder for these issues. So we certainly appreciate everyone's 
time and commitment to improving these issues in your 
communities. Hopefully they will drive some solutions here from 
D.C. that can help communities out in Indian Country. Thank 
    Mr. Andrews. Thank you, folks. That concludes the listening 
session, but it doesn't conclude the work that we're going to 
do. Thanks again. Safe travels back.
    [Whereupon, at 8:25 p.m., the listening session was 

                            A P P E N D I X

 Prepared Statement of Sunny Colombe, MBA, Rosebud Sioux Tribal Member
    Good Afternoon Chairman Barrasso, Vice Chairman Tester, and Members 
of the Committee. My name is Sunny Colombe. I am an enrolled member of 
the Rosebud Sioux Tribe in South Dakota. Although I was not born or 
raised on the reservation, I remain close to the community through my 
family and friends. My family is dedicated to the welfare of our 
people, and my mother has been with IHS for over 40 years.
    Growing up hearing about the health disparities our people face, I 
believed I needed to take what I had learned and put it to use in the 
healthcare field. After receiving my master's degree in business 
administration from National American University, I applied for a 
position with the Rosebud IHS Hospital. In 2006, I moved to Rosebud, SD 
after accepting a position as a supervisor for Contract Health Services 
at the Rosebud IHS Hospital. After five years of service, I resigned in 
    I left IHS because I wanted to improve the overall health of my 
community. As the contract health supervisor, the people coming into my 
office were often afflicted with terminal illnesses. The only patients 
approved for contract health funds during my employment were priority 
one. Priority one care includes or emergent or acutely urgent services 
that are necessary to prevent the immediate death or serious impairment 
of the health of the individual.
    I now work for Great Plains Tribal Chairmen's Health Board, a non-
profit organization which promotes preventative healthcare for the 
tribes in South Dakota, North Dakota, Nebraska, and Iowa.
    My views today reflect my personal experiences with the Indian 
Health Service (IHS), and not that of my organization, nor the tribal 
nations in our service area.
    During my time at IHS, I witnessed multiple obstacles that directly 
impacted patient care including antiquated technology systems, 
cumbersome policies and numerous employment vacancies and employee 
retention issues. This is not to say that IHS lacks passionate 
employees who advocate for their patients and the best possible 
healthcare, because I also witnessed those employees in action. ``Do 
more with less,'' was repeated frequently, but at the end of the day, 
only so much can be done with less before the population it serves 
suffers the consequences.
    While living in Rosebud, I was fortunate enough to give birth to 
one of my daughters (Addison) in the Rosebud IHS Hospital. I am 
thankful that I was able to receive obstetric care from the same 
medical provider during my whole pregnancy and delivery. I was also 
lucky enough that at that time there were ultrasound services available 
to complete and complement my prenatal services. The care I received 
was wonderful. The nurses and doctors were compassionate and capable.
    The problem is that my positive experience with Addison is unique. 
In most IHS facilities, especially those in extremely rural areas, 
expecting mothers do not have access to continuous, competent and 
compassionate care. Other patients seeking care at Rosebud IHS 
Hospital, the facility where I delivered, also do not have access to 
basic prenatal services.
    I was recently visiting a fellow member of the Rosebud Sioux Tribe 
who expressed his frustration with the lack of obstetric care available 
to his daughter. She is a first-time mother and there was not a 
provider on staff for her general prenatal care. She was told that an 
obstetrician-gynecologist had been contracted and would be available 
``soon'', but gave her no more indication of how long they would be 
available to provide care. This young lady has become so frustrated 
with the situation that she no longer wants to seek care. Her 
experience at IHS has resulted in being skeptical of need for prenatal 
    In my experience as a former employee, contracted physicians come 
and go frequently, or alternate week to week or month to month, at 
best. Contracting providers is a great alternative when a vacant 
position cannot be filled; however, when this tool is over-utilized it 
undermines quality and continuity of care. There is often no 
relationship developed between the provider and the patient. When 
capable and accountable providers are not consistently available, 
patients suffer the consequences.
    Within the first few years of my daughter Addison's life, we 
utilized the Rosebud IHS Hospital emergency room and clinic frequently. 
Since she was born, she has had digestive and respiratory issues and 
extreme eczema. Every day she experienced severe vomiting; so much so 
that she slept in her infant swing to prevent choking in her sleep. She 
had open eczema sores that bled on her arms and chest. Despite our many 
visits to the Rosebud IHS Hospital, we received little more than 
recommendations to take Benadryl and to provide albuterol treatments.
    When no solutions were forthcoming from providers in Rosebud, I 
traveled 180 miles to the Rapid City IHS Hospital, the closest IHS 
facility with a pediatrician at that time. The pediatrician there had 
been a long-time IHS provider, and always ensured that my daughter 
received the best care IHS had to offer. The doctor mentioned numerous 
times that my daughter's symptoms could be allergy-related. However, an 
allergy test from a specialist does not, nor would ever, meet the 
criteria for an approved PRC referral, as most facilities in South 
Dakota are only able to refer priority one cases, where life or limb 
are in jeopardy. At the time, I could not afford insurance, nor was I 
eligible for Medicaid. So my daughter continued to suffer for two years 
while waiting for basic diagnostic testing.
    In 2010 my daughter's symptoms ultimately became so severe that she 
was transferred by air ambulance from Rosebud to Sioux Falls, SD for 
care. The expense of her continued emergency care far exceeded the cost 
of an allergy test. The cost of emergency air transportation is about 
$20,000 and a consultation and allergy test is about $500. After my 
daughter turned two, about six months after her emergency transfer, she 
was finally able to have an allergy test in Rapid City, SD with a 
specialist. It was confirmed that she was extremely allergic to foods 
containing peanuts, milk protein, and eggs--all things she frequently 
ate. Once the results were shared with the pediatrician at the Rapid 
City IHS Hospital, she was able to provide education, diet and 
medication to address my daughter's needs. The results were almost 
instantaneous. My daughter was able to eat, her asthma was controlled 
and her eczema cleared up.
    Addison is a healthy, active seven year old now. She knows her 
limits, and is capable of monitoring her own diet and asthma based on 
the support and continued education we received.
    Recently, I was saddened to hear that the pediatrician who helped 
us at Rapid City IHS quit. She told me she just couldn't do it anymore. 
Unfortunately, she's not alone. I repeatedly hear of the recruitment 
and retention issues within IHS. This was a wonderful dedicated 
physician who was with the facility for a long time. I wonder if an 
exit interview was completed to identify what it was she couldn't do 
any longer. What made her service there difficult? Could a solution 
have been found to retain her services?
    I also have a three year old daughter, Jordan. She was born at 
Rapid City Regional Hospital in 2012, as the Rapid City IHS Hospital 
does not do deliveries at their facility. Having been an employee, 
specifically a contract health supervisor, I knew the conditions under 
which her birth would be covered by Purchased/Referred Care (PRC). 
There are various denial reasons for PRC, include residing outside of a 
Contract Health Service Delivery Area, not qualifying as a medical 
priority, having alternate financial resources available, not providing 
notification within 72 hours of receiving care, and IHS available to 
provide care. To ensure I met the notification requirement, I called 
the Rapid City IHS Hospital within 24 hours of admission.
    Typically a patient is contacted by mail or phone about the status 
of their referral. As I was never contacted, about a month after 
Jordan's birth, I called to check on my claim. I was waiting for 
verification that they had all they needed to process the claim for 
payment, or at the very least, a denial of payment.
    They could have denied the call-in for alternate resources 
available as many pregnant woman and children are required to provide 
proof that they are not Medicaid eligible. No other denial reasons 
should have affected the coverage of that medical event. I was required 
to apply for Medicaid and provide documentation of my ineligibility 
while receiving care in Rosebud with my eldest daughter. It was just 
another hoop to jump through, even though I knew I exceeded the income 
level before applying.
    I called and spoke to a Purchase and Referred Care staff member at 
Sioux San IHS, who told me there was no referral in the system 
regarding my PRC claim for Jordan's birth. He offered to begin the 
referral process and stated he would be happy to take the information. 
Shortly after this conversation, I received a denial letter in the mail 
for failing to notify within 72 hours.
    In my experience, it is impossible to appeal an unmet notification 
requirement. So even with my knowledge of the PRC regulations and 
taking specific steps to follow the process, I was responsible for 
payment of the care I received.
    At the time, I was fortunate to have private insurance and 
resources to cover the expense. The average IHS consumer without 
private insurance or Medicaid would most likely find him or herself 
responsible for the total cost of care and be sent to collections.
    After resigning from IHS, I accepted my current position as the 
Chief Administrative Officer at Great Plains Tribal Chairmen's Health 
Board. Our organization provides technical assistance and health 
education to our member tribes in South Dakota, North Dakota, Nebraska, 
and Iowa. We have a variety of programs which provide preventative 
health education, including increased access to healthy, traditional 
foods, cancer prevention, tobacco cessation, maternal and child health, 
behavioral health, and epidemiologic support. Our focus on preventative 
health techniques gives me hope that the health of our people will and 
can improve.
    With insurance through my employer, I am no longer limited in my 
personal healthcare choices. I choose to utilize the Rapid City IHS and 
I am glad that they are able to receive reimbursement for my care 
through third party collections. I know many of the permanent providers 
in the clinic and have absolute faith in them regarding the healthcare 
needs of myself and my children. However, based on the services 
available, I pick and choose which care I receive there.
    Services at Rapid City, Rosebud, and many other IHS hospitals are 
limited, and there are some services that my family and I do not 
utilize. For example, my family and I do not utilize the IHS dental 
services because only very limited emergency services are available on 
an unpredictable basis, and when treatment is available, it often is 
not what a patient needs.
    The Rapid City IHS does not have enough providers available to make 
an appointment for routine dental care. Based on which providers are 
available and the treatments they offer, a given patient may or may not 
receive care. The typical patient is expected to sign in at 7:30 a.m. 
on a first-come, first-serve, basis.
    I have tried multiple times to receive preventive and routine 
dental services at IHS, and have been repeatedly told that they were 
not taking appointments. They take emergency walk-ins on a daily basis, 
but whether it is because of the lack of resources or provider 
knowledge, the universal IHS treatment for an injured tooth is to 
extract it.
    Also, a year ago, I went to the Rapid City IHS Dental Clinic and 
was told that one of my teeth needed a root canal. While the clinic 
could not provide this service as they only provided emergency care, 
they did offer to pull it out. I chose to save the tooth and go 
elsewhere. Unfortunately, not all patients have these resources or 
options. Many are stuck with whatever services IHS chooses to provide.
    My experiences as an IHS employee and my current position with the 
health board have provided me a distinct opportunity to see the big 
picture of Indian health care. While I understand that there are 
inefficiencies within the IHS system, I firmly believe that multiple 
opportunities for improvement exist in the Great Plains area, but the 
issues I have highlighted today, in conjunction with inadequate 
funding, makes improvements impossible and continues to punish the 
people we are all here to serve. IHS is funded at about 50 percent of 
the current need. Increasing one line item here or there when the 
entire system is under resourced won't solve the issues we face.
    To say the least, it is disheartening to hear the personal stories 
of the communities the tribal leaders represent and the dire need for 
increased preventative care. The medical conditions may change, the 
communities may differ, the gender and age may vary, but their stories 
of inadequate healthcare remain the same year after year. While the 
need for preventative healthcare is universal, budgetary allotments 
coupled with poor management and inadequate oversight are never enough 
to support implementing adequate prevention services, even though they 
can often be more cost effective.
    If my daughter Addison had been able to receive a simple allergy 
test at IHS, or been referred out for care earlier, tens of thousands 
of dollars, and more importantly her immediate well-being, would have 
been saved.
    Again, thank you Chairman Barrasso, Vice Chairman Tester, and 
Members of the Committee for inviting me to testify before you today. 
It is my ultimate hope that the Indian Health Service, Tribes, and 
Congress can work together to find lasting solutions today to ensure 
and promote the health of American Indians well into the future.
Prepared Statement of Hon. Harold C. Frazier, Chairman, Cheyenne River 
                              Sioux Tribe
    The Cheyenne River Sioux Tribe is pleased to present these comments 
on the quality of Indian Health Care in the Great Plains. Throughout 
the past century the United States has repeatedly acknowledged its 
obligation to provide health care for enrolled members of federally 
recognized Tribes. This obligation was established through Treaties 
grounded in the U.S. Constitution, through Supreme Court cases which 
defined and clarified the federal trust responsibility to Indian 
nations and people, and through federal statutes, most recently the 
Affordable Care Act, which strengthened and made permanent the Indian 
Health Care Improvement Act. And yet, despite the law, despite well-
intentioned providers and administrators in our health systems, and 
despite the repeated efforts of this Committee, our Tribal members 
continue to suffer from levels of disease and mortality not only 
disproportionate to other United States citizens, but also to Tribal 
members in other regions of the United States. Thank you for once again 
reviewing the inadequate standards of care provided by the Indian 
Health Service in the Great Plains; it is my greatest hope that this 
hearing may lead to actual, positive change in the Great Plains Region.
    In that spirit, I submit the following specific comments on ways in 
which the Committee can improve health outcomes for Tribal members both 
at Cheyenne River and throughout the Great Plains.
1. Adequate Funding
    Despite historic increases in the Indian Health Service's (IHS) 
budget since 2009, IHS continues to be underfunded at approximately 59 
percent of need. The Tribal Budget Formulation Workgroup for IHS 
estimates fully funding IHS's budget on a true needs basis would result 
in an annual appropriation of $28.6 billion. Were IHS funded at this 
level, Tribes would be able to partner with IHS to achieve health care 
on a par with the rest of the United States. The Cheyenne River Sioux 
Tribe urges the Committee to accept the recommendation of the National 
Congress of American Indians by enacting advance appropriations for the 
Indian Health Service and by increasing IHS's appropriation by 2 
billion a year for 12 years, which would result in fully funding IHS on 
a true needs basis by 2028.
2. Immediate Needs: Mental Health and Substance Abuse
    Two of the most immediate needs at Cheyenne River are mental health 
and substance abuse. In particular, youth suicide and methamphetamine 
use are at record levels on our Reservation. It is established that 
conventional, western treatment methods have little success treating 
methamphetamine addiction, because of the particular effects of 
methamphetamine on the user's brain and body. Successful treatment of 
methamphetamine addiction in Native Americans has been achieved in 
treatment centers which provide long-term, specialized treatment 
designed around Lakota principles and values. But there is only one 
such 16-bed treatment center in the Great Plains region, located on the 
Rosebud Reservation. To successfully combat the epidemic of 
methamphetamine addition we need a robust network of culturally-
appropriate treatment options.
    Likewise, our mental health program, which the Tribe operates 
through a self-determination contract with IHS, is severely 
underfunded. We do not have the resources needed to respond to the high 
numbers of children with thoughts of suicide, and who attempt suicide 
or who copycat other suicides at Cheyenne River. In 2015, our number of 
completed suicides was triple that of 2014. We rely on outside 
facilities to provide higher levels of care for our youth who need 
treatment for thoughts of suicide and self-harm. With adequate mental 
health resources, proportionate to those provided to non-Indians, we 
could develop an in-patient mental health treatment center at Cheyenne 
River, which could potentially lower our rate of youth suicide.
    The Cheyenne River Sioux Tribe urges the Committee to appropriate 
emergency supplemental funding for mental health and substance abuse in 
the Great Plains. In particular, we support continued funding of the 
treatment center at the Rosebud Reservation and funding of a new 
regional treatment center at the IHS Sioux San Hospital in Rapid City.
3. Long-term Elder Care
    In the Affordable Care Act, Congress authorized expenditures of IHS 
funds for Long Term Services & Supports (LTSS). However, Congress has 
not to date appropriated funds to IHS for LTSS. Developing an 
effective, culturally-appropriate LTSS system is a priority of the 
Cheyenne River Sioux Tribe. We demonstrated this priority by 
constructing the Medicine Wheel Village, intended to be a 45-bed 
nursing home and assisted living center in the heart of our 
Reservation. But without actual funding to LTSS through IHS, we have 
only been able to open the assisted living portion of the center, and 
currently serve only 27 residents. Elders who need higher levels of 
care must still relocate to off-Reservation nursing facilities. The 
Cheyenne River Sioux Tribe urges the Committee to fund at a meaningful 
level the long term care services that were authorized in the 
Affordable Care Act.
4. IHS Staffing Issues
    At Cheyenne River we have a new hospital facility and modern 
staffing quarters. Despite these advantages, our service unit has a 27 
percent vacancy rate, with 70 of the 262 positions vacant. While the 
majority of vacancies are clinical positions, IHS cannot recruit and 
retain not only providers, but also administrators and key staff. Key 
positions have remained unfilled for over a year. This situation can 
also be traced to funding. Because of limited funding, IHS providers 
are paid according to limited pay tables. Providers entering the IHS 
system, therefore, can expect to be paid well below their private 
hospital counterparts, and therefore do not choose to work for Indian 
Health. Because of this problem, the Eagle Butte service unit depends 
heavily on temporary contract providers, which cost three times more 
than a permanent employee. This not only depletes our local budget 
without improving services, it decreases patient trust in the hospital. 
Our patients know they will most likely be seen by a stranger whom they 
will never see again, which discourages patients from using the IHS 
system at all. Patients only seek care as a last resort, exacerbating 
the health problems we seek to improve.
    The Great Plains Area Office responded to this problem by hiring 
two recruiters based in the Area Office in Aberdeen, South Dakota. The 
recruiters were tasked with recruitment and retention responsibilities 
for service units throughout the Great Plains Area. However, neither 
recruiter has been to our hospital, nor have they been successful in 
filling any of our open IHS positions. Instead, as other Great Plains 
Tribes have testified, IHS recycles bad employees from service unit to 
service unit. It is alarming that many of the doctors and 
administrators that performed poorly at Cheyenne River were promoted to 
Area office jobs or shifted to another Tribe. This is a great 
disservice to Tribal members.
    The Cheyenne River Sioux Tribe asks the Committee to adopt and 
recommend to Congress the IHS budget increases under paragraph 1, to 
instruct IHS to waive its pay tables in areas such as the Great Plains 
where there are persistent problems with recruitment and retention, and 
to disallow IHS from recycling underperforming employees from Tribe to 
5. Patient Relations
    In 2012, the Cheyenne River Sioux Tribal Council passed a 
resolution detailing problems in customer service and patient relations 
at the IHS hospital in Eagle Butte. The problems included a rigid and 
unreasonable appointment system, poor communication with patients 
regarding prescriptions and refills, and an institutional culture 
within IHS that did not engage patients in their treatment, did not 
respect their time, did not build trust with patients, and generally 
was neither compassionate nor respected the dignity of Cheyenne River 
patients. The Tribal Council demanded that the Service Unit Director 
create a written plan of action to improve patient experience in the 
Eagle Butte Hospital, to include a visible and accessible method of 
collecting patient feedback and a long-term patient experience strategy 

   A cultural assessment by a competent consultant group in the 
        area of customer service improvement for healthcare 

   Adoption of a patient bill of rights;

   Development of standards of service excellence;

   Employee training on these standards; and

   Ongoing protocols for continuing self-assessment and 

    The Tribal Council asked for a written response to these demands, 
but IHS gave no response, and none of these changes were made. The 
Cheyenne River Sioux Tribe renews its 2012 resolution through this 
statement, and asks this Committee to refer the issue of patient 
experience to IHS for their immediate response.
6. IHS Priority System
    The Cheyenne River Sioux Tribe must again state our displeasure 
with the IHS priority system. You have heard many reasons, from many 
Tribes, over many years, over the problems the five level priority 
system causes with our patients. IHS's justification for the priority 
system is simple: Congress does not give us adequate funding to meet 
all of the health needs of our population. Because we cannot pay for 
all needed health services, we must prioritize which health services we 
will pay for and which health services we will not. It is 
unconscionable to not provide health care to patients needing emergency 
or acute care, we will pay for those services as a first priority. If 
care can be delayed, we will delay it until patients need emergency 
care. While this may make sense to accountants, it is completely 
backwards to medical caregivers. If care was not delayed, then 
emergency care would not be needed, and the cost of care overall would 
decrease. Tribes have challenged the priority system in federal court, 
but the courts have upheld IHS's agency-level discretion to choose to 
fund some individuals' care while denying others', given that Congress 
has never funded IHS at its true level of need. But the priority system 
has a deeper effect on our patients than being denied for a particular 
procedure. It erodes trust in the system, and creates fear of rejection 
in our patients, which pushes them to avoid care, often until 
preventative care is too late.
    The Cheyenne River Sioux Tribe asks this Committee to support the 
funding request in paragraph 1, and in the short-term, to order the 
Indian Health Service to enter negotiated rule-making with Tribes to 
revise and reform the priority system.
7. CMS State Plan Amendments
    Because of chronic underfunding, IHS and Tribal health programs 
have turned to other funding sources to supplement our budgets. Third-
party billing, particularly to Medicaid, has been one of the largest 
sources of outside money. However, Tribes are limited in our 
application of Medicaid dollars in our program under the Social 
Security Act only states can design, implement and administer Medicaid 
programs. Tribal government are treated as local governments with 
respect to CMS, and must go through state Medicaid certification to 
access Medicaid dollars. The problem with this model, other than that 
it does not reflect the government-to-government model of federal-
tribal relations, is that it limits the Tribe's control in including 
culturally relevant health services, such as peer counseling, in the 
Medicaid state plan amendments.
    CMS does require states to consults with tribes regarding state 
plan amendments. In 2013, CMS created a best practices booklet to guide 
states in establishing meaningful consultation with tribes. However, 
the consultation process is essentially passive. States attempt to 
educate Tribes on how to maximize reimbursement of services provided by 
IHS and Tribal health programs, and to educate Tribes on proposed 
changes to the state plan and their impact on Tribes. However, under 
this model Tribes do not propose changes to state Medicaid plans. 
Cheyenne River would like this model to change from a teacher-student 
model to a health partnership model. If Tribal health programs are to 
increasingly depend on CMS dollars, then our governments need expanded 
control over the scope of the programs which are reimbursed. If 
Congress does not wish to amend the Social Security Act to allow Tribes 
to directly enter into agreements and plans to administer CMS programs, 
then we need a greater voice in the state agreements and plans.
    Therefore, the Cheyenne River Sioux Tribe asks the Committee to 
require CMS to change its consultation policy requirements for states 
to a requirement for negotiation or joint-decisionmaking between Tribes 
and States with regard to Medicaid state plan amendments.
    The Cheyenne River Sioux Tribe is honored to have this opportunity 
to share our experience and knowledge on this issue. Thank you for 
considering our comments on Indian health care in the Great Plains.
  Prepared Statement of Yvonne Kay Clown, Cheyenne River Sioux Tribal 
    Thank you for having this hearing and testimonies.
    We need drastic changes in the following issues:
    Prevention healthcare, we need to be seen by specialists sooner 
than reach the priority one status. Prevention could have prevented my 
mom from dying of congestive heart failure; she was seen by IHS 3 times 
in same week and diagnosed as flu symptoms, while her autopsy reported 
CHF. SHE SUFFERED as huge needles were inserted into her lungs n heart 
areas to pull out the fluid by Dr. Virginia Updegraff, with 3 white 
nurses holding her in position as she moaned in pain. When mom saw me, 
she cried out my name and reached for me. The nurses were Jean 
Schupick, Pat Lane, and Lorraine Kintz. They ordered me out of her 
room. Then, they transferred her towards Mobridge, SD, in her ICU 
condition after our family was told she may not make it to morning. 
MaryC and I rode with her in the ambulance. Mom died 5 miles out of 
Eagle Butte, SD. She could have been sent out sooner than ICU status.
    Eligibility for Contract health services aka Preferred Care: 
American Indian blood is defined as \1/4\ Indian blood to be eligible 
for services. Eagle Butte Indian health service has always paid for all 
enrolled tribal members. If this is allowed, funding has to be 
increased for all 21,000+ tribal members, scattered throughout the 
united states.
    We need steady, long term, real certified Drs., not family nurse 
practitioners or physician assistants. I've been misdiagnosed several 
times. Number 1, my right eye needed an ophthalmologist asap. We have 
only an optometrist, who takes leave as he pleases. Its hard to get in 
to see him, even if the medical officer in charge referred me to him. 
His secretary said although he was present it was after 4 p.m., and he 
would see me next day. I suffered with severe eye pain with a hx of 
iritis. I returned to ER another day with similar symptoms, I was told 
I had only makeup in my eye. I was given meds that were of no help. 3 
days later, I was admitted to the Rapid City Regional hospital for 
irretractable eye migraines, and spent 4 days for eye care. We need an 
ophthalmologist on site. Dr. Clarkson, optometry on board is very rude, 
unprofessional, scare, and appts are made at his direction. He needs to 
be replaced.
    Number 2, I slipped off my sons porch in July 2015 after a small 
rain shower, and fell onto the sidewalk face first. I broke my nose, 
skinned my face, injured both my knees badly. The left one was swelling 
awfully. My right shoulder arm was very painful. The ER doctor said the 
arm was not or bruised, and was not worried about it. After treated and 
sent home, the next week the shoulder was very painful. I went returned 
to Er. I saw. Dr. Mclane, med officer in charge. He ordered an xray, 
said there was no tears or fractures. When I was referred to Black 
hills orthopedics and ENT, the specialist saw that I favored my arm 
upon physical exam of my knees and arm. He ordered an MRI. That week, 
his staff said the rotor cuff was turn, fell out of the shoulder. I was 
setup for surgery in January 2016. Dr. Mclane could have ordered an arm 
scan as I was told there is a scan machine in the hospital. He is a 
Locum. We can save $$$$$$$$$$ of dollars by recruiting regular 
physicians, who are willing to live and work in Eagle Butte. We need to 
get rid of locums.
    CEO, Charles Festes Fischer, has no MEDICAL BACKGROUND, only a cop 
background. He is incapable of running our EBIHS. He does not know 
medical terminology, or can't recommend patients for preferred care 
referrals, and has to rely on other staff to do that. He denies me, and 
others, 3rd party billing dollars. I have Medicare and Medicaid. He 
sends me denial letters first on this issue, so when I see a 
specialist, his staff tell me IHS has already told them, they will not 
pay 3rd party billing. Or, I get a letter from the CEO, before I go to 
my first visit stating that too. This is wrong. I believe this CEO had 
no clue what our Treaty with the U.S. government states on quality 
healthcare for all full-blood Indians. The CEO and IHS has failed me, 
and all other enrolled tribal members, by sub substandard health care. 
The wait in between injuries and getting referred to a specialist is 
way too long. Specialists from Rapid City and Pierre SD have told me, 
the IHS physicians send us out too late, and under medicate severe 
cases of pain in many instances, where I and my relatives have been 
referred out. Or, they've misdiagnosed us. We need regular, stable 
doctors who live in town, on site, not family nurse practitioners or 
physician assistants. The current CEO, Charles Festes Fischer, has to 
be fired, as he is incompetent and unqualified to run our IHS: And 
count his unqualified relatives and friends who he has hired currently.
    Nepotism, tribal council representatives have played politics and 
the health committee members, related to the CEO, have allowed AAO to 
hire Charles Fischer over the objection, and Motion by Resolution from 
the tribe, to reject his application and readvertise that position has 
been ignored by the health committee and AAO.
    The CEO has allowed our laboratory department to hire and train 
anyone without a certification instead phlebotomists. One employee told 
me all she had was a degree from black hills state university; she is 
working on job learning how to draw blood. She poked me 5 times and 
drew about 1cm because she couldn't get anymore. She said she maybe 
able to work with it? She left bruises that took a week to heal. This 
is risking my life, I'm glad she didnt create an air bubble with my 
    Incident in ER, an EMT was sent to draw my blood. She said I was 
her 7th person she was learning to draw blood, OJT, this is 
unacceptable. She couldn't draw me and hurt me. Finally, she went to 
get help. Robin lebeau, RN, came in and quickly drew my blood. I was 
scared and glad Robin helped.
    PRIVACY HIPPA: When new staff mainly doctors arrive they are told 
this family is addicted to pills, etoh, etc.--this causes and presets 
these new doctors to become biased against patients. My niece called me 
up to hospital because they wouldn't give her any pain relief. I 
witnessed the staff forcing her to sign a pain contract to get a 
toradol shot just to get her out of the hospital. When Dr brant, med 
officer in charge, came into room, he said to me I know you're not 
addicted to meds. This was after I asked to see him. I said a 
physicians assistant told my niece that ``all Clowns'' (our traditional 
ladt name) were drug addicts. He never disciplined Commander Fish, PA, 
who made the statement. This is an example of staff/nursed telling new 
staff breaking the HIPPA laws as written, violating patients to be 
treated without prejudice.
    TORT CLAIMS: IHS needs to offer their employees due process. My 
daughter in law was not offered due process when she filed a complaint 
against her supervisor for sexual harassment. Her supervisor's boss was 
present when he disciplined her after she filed her complaint. That is 
not due process. I filed a complaint against CEO, their timely 
responses from the local IHS TO AAO WERE disregarded, and Edwin chasing 
hawk, AAO, said they were backlogged in dealing with complaints but he 
would pull mine, and respond. This is sooo wrong.
    PAIN CONTRACTS: I was referred to the ACLU website. I read on that 
page the current pain contracts forced by staff to have patients sign 
them before they give them pain relief were illegal. I told our local 
tribal health committee. They assigned peg bad warrior, attorney, to 
check into the legality, as our relatives and member ate forced to sign 
them. I'm still waiting for their response
    Physical therapy: This department do not answer their phone calls 
or return calls. They work with one patient at as time. No in else can 
be in that room full of equipment and can comfortably hold 6-10 
patients pet hr. There are lots of equipment and space. They're not 
earning their salary, kind of like bankers wages and hours. I had rotor 
cuff surgery on January 20, 2016, my first appt. Is Feb. 19, 2016, the 
specialist is spercless at how IHS has deals with patient. Therapy is 
important to regain full use of my arm. My sister had similar surgery, 
due to no local therapy spots. Asap, she lost 30 percent use of her 
arm. Please get us more pt time, change it for the better.
    Employees, we need more Indians who can speak our language. Were 
out the unqualified and those who are not \1/4\ Indian blood but claim 
Indian preference. We need to use our tribal preference with the 
mandatory lakota language required.
    FETUS REMAINS: Ensure that all aborted fetuses are given a chart, 
and wait until moms are not drugged up before signing their fetuses 
sway to be burned up at Bismark.ND. It happened to my niece who still 
has nightmares and is seeing a psychiatrist for them and on meds.
    We need you to put a moratorium on all IHS hirings here so no more 
nepotisms' will continue.
    Why was Cheyenne River never investigated when Charlene In the 
woods aka Red.Thunder was the Area doctors for AAO, in 2010, along with 
all other 17 tribe back in 2010? We had these problems then, they're 
worse now. Thank you,
    Thank you for your time. Please review my testimony and help us get 
quality healthcare. Please get rid of Charles Festes Fischer, 
unqualified and incompetent. Give us more funding to recruit better 
doctors and a CEO who is qualified. Please get rid of unqualified 
Tribal health CEO, whose degree is in bugs, animals, prairie dogs as in 
biology; she has no experience in the medical field to run our tribal 
health department.she is filling position with unqualified tribal 
council's children or relatives. Her name is Julia Thorstenson.
     Prepared Statement of the National Indian Health Board (NIHB)
    Chairman Barrasso, Vice Chairman Tester and Members of the 
Committee, thank you for holding this important hearing on ``Re-
examining the Substandard Quality of Indian Health Care in the Great 
Plains.'' On behalf of the National Indian Health Board (NIHB) \1\ and 
the 567 federally recognized Tribes we serve, I submit this testimony 
for the record.
    \1\ 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 all Tribal Governments. Whether 
Tribes operate their own health care delivery systems through 
contracting and compacting or receive health care directly from the 
Indian Health Services (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. The 
NIHB is governed by a Board of Directors consisting of representatives 
elected by the Tribes in each of the twelve IHS Areas. Each Area Health 
Board elects a representative and an alternate to sit on the NIHB Board 
of Directors.
    The federal promise to provide for the health and welfare of Indian 
people was made long ago. 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 Tribes that was created through treaties, 
executive orders, statutes, and Supreme Court case law. The United 
States assumed this responsibility through a series of treaties with 
Tribes, exchanging compensation and benefits for Tribal land and peace. 
The Snyder Act of 1921 (25 U.S.C.  13) legislatively affirmed this 
trust responsibility. To facilitate upholding its responsibility, the 
federal government created the Indian Health Service (IHS) and tasked 
the agency with providing health services to American Indians and 
Alaska Natives (AI/ANs). Since its creation in 1955, IHS has worked to 
fulfill the federal promise to provide health care to Native people, 
but has been routinely plagued by underfunding and mismanagement.
    In passing the Affordable Care Act (ACA) (P.L. 111-148), Congress 
also reauthorized and made permanent the Indian Health Care Improvement 
Act (IHCIA). As part of the IHCIA, Congress reaffirmed the duty of the 
federal government to AI/ANs, declaring that ``it is the policy of this 
Nation, in fulfillment of its special trust responsibilities and legal 
obligations to Indians--to ensure the highest possible health status 
for Indians and urban Indians and to provide all resources necessary to 
effect that policy.'' \2\
    \2\ 25 U.S.C.  1602.
    But the promise made by the federal government and renewed by 
Congress over five years ago has not been kept. The issues identified 
by recent reports from the Centers for Medicare and Medicaid Services 
(CMS) indicate as much. In the last year, several hospitals serving 
Tribes in the Great Plains region of IHS have lost, (or received 
threats of revocation) their ability to bill CMS. This not only 
severely hampers the critical 3rd Party Revenue on which these 
facilities depend, but it also raises serious questions about the 
quality of health care in the Great Plains Region. These recent 
developments in the Great Plains region have exposed a systemic lack of 
quality care being provided in at least two hospitals being run by the 
Indian Health Service. At the Winnebago Indian Hospital, Pine Ridge 
Indian Hospital and the Rosebud Indian Hospital the deficiencies in 
question are deplorable, and simply unacceptable. The incidents exposed 
by these investigations are evidence of a complete failure by the IHS 
to provide safe and reliable health care for American Indians and 
Alaska Natives (AI/ANs) and in turn, an abrogation of the government's 
trust responsibility toward the Tribes.

        ``For decades and generations, IHS has had a notorious 
        reputation in Indian Country, but it is all we have. It is all 
        we have to count on. We don't go there because they have 
        superior health care. We go there because it is our treaty 
        right. And we go there because many of us lack the resources to 
        go elsewhere. We're literally are at the mercy of IHS.''

        -Victoria Kitcheyan, Treasurer, Winnebago Tribe, February 3, 

    But the issues identified by these reports are not limited to the 
Great Plains Region. NIHB hears similar stories from almost all regions 
where there are IHS-operated facilities. NIHB has received reports from 
other IHS Service Areas of patient misdiagnosis and subsequent death, 
lack of competent providers, and continued failure to provide safe and 
reliable healthcare for our people. This must change.
    As you are well aware, in 2010, this committee commissioned a 
report titled: ``In Critical Condition: The Urgent Need to Reform the 
Indian Health Service's Aberdeen Area.'' This report discussed the 
substandard health care services and widespread mismanagement in the 
region. Five years later here we are again. The hearing on February 3, 
2016 felt like deja vu, from the hearing held in 2010. The issues in 
the so-called ``Dorgan Report'' included:

   IHS using transfers and reassignments to deal the employees 
        with a record of misconduct or poor performance;

   Substantial diversions and reduced health care services;

   Mismanagement of the purchased/referred care dollars; 
        hospitals at risk of losing their CMS accreditation;

   IHS providers treating patients with expired state licenses 
        or other certifications; and the use of contract health 
        providers (locum tenens).

    It is clear from the February 3rd hearing and testimony that these 
exact same issues are still very present in the IHS system six years 
later. The time for reports and additional research has passed. It is 
time to change the system; we must do better to provide health services 
to the First Peoples of this nation.
    In the next several weeks, NIHB will be convening a special task 
force to come up with solutions and policy recommendations with the 
goal of reforming the systemic challenges of the IHS. This includes 
policy recommendations for long-term, sustainable reform of IHS. 
However, we also are eager to work with the Committee, building on the 
findings in this hearing, to enact interim solutions for IHS to ensure 
that the care our people receive is the care that they are entitled to 
and deserve. This hearing should mark a watershed moment for Tribal 
health; a time when Congress decided to say ``enough'' to the 
inadequate health care in Indian Country. That is when real change 
Health Statistics for American Indians and Alaska Natives
    The findings in the CMS reports described in this hearing should 
not come as a surprise when considering the state of health for AI/ANs. 
Devastating impacts from historical trauma, poverty, and a lack of 
adequate treatment resources continue to plague Tribal communities. 
American Indians and Alaska Natives continue to suffer from a variety 
of health disparities when compared with the rest of the U.S. 
Population. While some statistics have improved for American Indians 
and Alaska Natives over the years, they are still alarming and not 
improving fast enough or on a regular basis. In 2003, it was reported 
that AI/ANs have a lower life expectancy of almost 6 years less than 
any other racial/ethnic group. While the group still has a lower life 
expectancy than any other group, it is now 4.8 years less. In some 
areas, it is even lower. For instance, ``white men in Montana lived 19 
years longer than American Indian men, and white women lived 20 years 
longer than American Indian women.'' \3\ In South Dakota, in 2014, 
``for white residents the median age was 81, compared to 58 for 
American Indians.'' \4\ Twenty-five percent of AI/AN deaths were for 
those with ages under 45. This compared with fifteen percent of black 
decedents and seven percent of white decedents in 2008 who were under 
45 years of age. \5\
    \3\ ``The State of the State's Health: A Report on the Health of 
Montanans.'' Montana Department of Public Health and Human Services. 
2013. p. 11.
    \4\ ``2014 South Dakota Vital Statistics Report: A State and County 
Comparison of Leading Health Indicators.'' South Dakota Department of 
Health. 2014. P. 62.
    \5\ Trends in Indian Health 2014 Edition.'' U.S. Department of 
Health and Human Services, Indian Health Service, Office of Public 
Health Support, Division of Program Statistics. 2014. p 63.
    Across almost all diseases, AI/ANs are at greater risk than other 
Americans. For example, AI/ANs are 520 percent more likely to suffer 
from alcohol-related deaths; 450 percent more likely to die from 
tuberculosis; 368 percent more likely to die from chronic liver disease 
and cirrhosis; 207 percent greater to die in motor vehicle crashes; and 
177 percent more likely to die from complications due to diabetes. \6\ 
Infant mortality rates for AI/ANs is 8.3 per 1,000 live births, a 
decrease of 67 percent since 1974. However, AI/ANs still have a higher 
rate compared to the U.S. all rate of 6.6.
    \6\ Ibid, p 5.
    Most statistics have shown no improvement over the last decade to 
the detriment of American Indian and Alaska Native people. In 2003, AI/
ANs were 204 percent more likely to suffer accidental death than other 
groups, and it has now risen to 240 percent. Our youth continue to be 
2.5 times more likely to die from suicide than other Americans. \7\ 
Suicide rates are nearly 50 percent higher compared to non-Hispanic 
whites, and are more frequent among males and people under the age of 
25. These staggering suicide statistics remain disturbingly unchanged 
from the 2003 report.
    \7\ Ibid, p 5.
    According to CDC data, 45.4 percent of Native women experience 
intimate partner violence, the highest rate of any ethnic group in the 
United States. AI/AN children have an average of six decayed teeth, 
when other US children have only one. \8\ There must be a comprehensive 
change to prevent another decade from going by and countless American 
Indians and Alaska Natives becoming victims to a broken, under 
resourced health system.
    \8\ Indian Health Service FY 2016 Budget Request to Congress, p. 
Mismanagement/Accountability at the IHS
    Of grave and immediate concern is the quality of care being 
provided to Tribes in the Great Plains and other IHS-operated 
facilities. The rampant disregard for human life that has occurred at 
these hospitals amounts to, as Chairman Barrasso stated at the hearing, 
``malpractice'' and is nothing short of criminal. Victoria Kitchyean, 
the Treasurer for the Winnebago Tribe, poignantly noted at the hearing: 
``It's been said in my community that the Winnebago Hospital is the 
only place you can legally kill an Indian. It is 2016 and our people 
are still suffering at the hands of the federal government. Kill the 
Indian, save the IHS sounds appropriate.''
    America is too great a nation to live with this status quo any 
longer. NIHB has heard reports of patients giving birth on hospital's 
bathroom floor; patients with a highly contagious disease not being 
isolated; patient death as a direct result of medical staff not knowing 
how to respond to medical crisis; and frequent misdiagnoses (or lack of 
any diagnosis at all) of critical illnesses. NIHB spoke with one person 
living on the Rosebud Sioux Reservation who told of a patient who 
presented with typical stroke symptoms and was told to go home with 
just an aspirin. It was 12 hours before the patient was actually 
treated in Sioux Falls (4 hours away) because the Rosebud Indian 
Hospital's Emergency Room (ER) was place on ``diversion status'' in 
December 4, 2015 due to the unsafe nature of the hospital.
    Since the ``diversion'' of the ER, the situation has gotten even 
worse. Patients with emergency needs are being sent to other area 
hospitals 40 to 50 minutes away. These hospitals cannot handle the 
patient load and the individuals are often turned away. Others are 
forced to drive to Rapid City (3 hours) or Sioux Falls (4 hours) for 
care. And if they are fortunate enough to receive care, they do not 
have the means of returning home because they were brought by 
ambulance. Individuals at risk of suicide also have nowhere to go. Off-
reservation service providers do not have the cultural training 
necessary to treat patients from Rosebud.
    One individual from the Phoenix Area reported to NIHB that her 
mother was treated for a urinary tract infection by the Whiteriver IHS 
Hospital. When her condition did not improve, the patient's family was 
reportedly told by IHS medical staff: ``What do you want me to do with 
her, she is an old woman?'' After several more days, the patient was 
transferred to another facility in Gilbert, Arizona, and found to have 
pneumonia, numerous kidney stones in her gallbladder, two blood clots 
in her left arm, and a serious blood infection from the previous 
urinary tract infection. The patient passed away just a few days later.
    Over the summer, NIHB heard from two young people on the Navajo 
Nation, that their grandmother went to the local IHS who sent her home 
several times telling her she had migraines. Yet, when she went to 
another hospital off the reservation, she was diagnosed with brain 
cancer. But again, it was too late to save her life. We see this theme 
again and again. One patient from the Cheyenne River Sioux Tribe told 
NIHB that, ``Medical providers do not listen to their patients and do 
not include patients' information at times when making a diagnosis.''
    The response to these claims by the IHS and HHS leadership has also 
been frustrating for Indian Country. Tribal leaders have consistently 
complained about a lack communication between CMS, IHS and the Tribes. 
Little has been done to correct the problems. This is likely no 
surprise given the outward attitude of IHS leadership. As Chairman 
Barrasso called out at the hearing, one senior IHS official recently 
remarked: ``If you've only had two babies hit the floor in eight years, 
that's pretty good.''
    Accountability measures are enforced sporadically at best, and 
often managers have little training or are filling several positions at 
once. When issues do arise, it is unlikely that an employee would be 
let go. They just get transferred somewhere else. Unlike in the private 
sector, where the number of patient visits impact the overall physician 
pay, IHS medical staff just make a salary and there is no incentive to 
go above and beyond to meet the needs of patients. In the 2010 Dorgan 
report, it was discussed that IHS routinely transfers or reallocates 
employees at all levels with a history of misconduct and we still hear 
about this today. It is unclear what actions IHS has taken to terminate 
problem employees from the three service units who have been threatened 
with the loss or have already lost CMS accreditation.
    How many more people have to die before AI/ANs can access quality 
health care? What will it take for the U.S. government to fulfill its 
promise of providing safe and reliable health care to Indian Country?
Lack of Communication between Tribal Leadership and the IHS
    Inconsistent communication between IHS officials and local 
leadership continues to be major a challenge for the Tribes when it 
comes to management of hospitals on their land. For the Tribes who have 
been involved in the CMS certification issues, Tribal leadership has 
requested that they be informed on a weekly basis about progress from 
IHS. But, according to local Tribal staff, the Tribal government has 
not received adequate updates from IHS. It is our understanding that 
CMS also has regular discussions with the IHS on the issue, but has not 
involved the Tribal government in any of these conversations.
    However, all the Tribal leaders present in the hearing discussed a 
lack of consultation by IHS on issues at certain service units. One 
Tribal leader present at the listening session noted that his Tribe 
found out about the loss of CMS accreditation at their hospital on the 
local news. Mr. William Bear Shield with the Rosebud Sioux Tribal 
Council noted, ``There's still continuing to be practices. . .that 
doesn't give us any hope that things are being taken seriously [by 
IHS]. There needs to be more direction. . .they need to be more 
actively involved in helping us get our ER services back open.''
    One suggestion offered by several of the Tribal leaders present at 
the hearing was that Tribal leadership should have voting positions on 
hospital governing boards. It was reported during the hearing, that 
Tribal leaders only serve as ex officio members and the voting members 
typically consist of IHS area staff. Tribal leaders also reported that 
they found out about deficiencies or key decisions affecting hospitals 
on their reservations after decisions had already been made.
    These claims should not be taken lightly. Even though IHS operates 
a facility, it is by no means an excuse to exclude Tribal leadership 
from hospital decisions. The elected Tribal leadership has a duty to 
ensure the health and well-being of their people, and without 
substantive engagement from IHS and other federal agencies, it is 
impossible for these leaders to do that. Someone must be there looking 
out for the people in each of these communities, and it is imperative 
that Tribal leadership be given an active and formal role in the 
hospital governance.
Budget Disparities for American Indian Alaska Native Health
    The quality of health care provided is underscored by the low 
quality budget that IHS receives each year. NIHB understands that 
federal discretionary budgets are tight, but there are many things that 
just cannot be achieved with the amount of funds available. The 
treaties that Tribes signed are not discretionary and should not be 
held hostage to unrelated political battles in Washington. It is 
shameful and dishonorable that the United States refuses to live up to 
its treaty and trust responsibilities. Congress must make funding of 
the Tribal health system a priority. NIHB and Tribes have consistently 
asked for budgets each year that would bring IHS up to the same status 
as other American health facilities. Right now, this is $30 billion. To 
begin a phase in of this amount over 12 years, we are requesting $6.2 
billion for IHS in FY 2017.

    It is true that IHS budgets have increased over the last several 
years. However, most of these increases have gone to provide for full 
funding of Contract Support Costs after the decision by U.S. Supreme 
Court in Salazar v. Ramah Navajo Chapter (2012), requiring that these 
costs be paid in full (CSC is currently $717 million, an increase of 62 
percent since FY 2004). Other important increases have been made to 
Purchased/Referred Care Services (currently $914 million, an increase 
of 48 percent since FY 2004). But it is important to note that 
inflation and population growth have played a big part in the 
diminished purchasing power of the IHS. For example, putting FY 2004 
funding in 2015 dollars, the overall increase to the IHS budget would 
only be about 4 percent, yet the IHS patient population has grown by 
about 27 percent.
    Per capita spending for AI/ANs also continues to lag far behind 
other Americans. In 2014, the IHS per capita expenditures for patient 
health services were just $3,107, compared to $8,097 per person for 
health care spending nationally. Compared to IHS calculations of 
expected cost of Federal Employee Health Benefits, average IHS per user 
spending in 2014 was only 59 percent of calculated full costs. It is 
also important to note that the IHS spending per capita on actual 
healthcare services was only about $1,940 in FY 2014. The actual 
percentage varies widely between IHS areas, with some funded at much 
less than 59 percent of need.

    New health care insurance opportunities beginning in 2014 and 
expanded Medicaid in some states may expand health care resources 
available to American Indians and Alaska Natives. However, these new 
resource opportunities come with a cost for billing, collections and 
compliance, and are no substitute for the fulfillment of the federal 
trust responsibility. With the funding gap already reaching upwards of 
$25 billion, even if 100 percent of these were recouped and put into 
services, the huge budget gap and associated health disparities will 
Indian Health Care Improvement Act
    In 2010, the Indian Health Care Improvement Act (IHICA) was 
permanently enacted as part of the Affordable Care Act. This landmark 
legislation was hailed as a great victory for Tribes, as renewal 
efforts were over 10 years in the making. Specifically, the renewed 

   Updates and modernizes health delivery services, such as 
        cancer screenings, home and community based services and long-
        term care for the elderly and disabled.

   Establishes a continuum of care through integrated 
        behavioral health programs (both prevention and treatment) to 
        address alcohol/substance abuse problems and the social service 
        and mental health needs of Indian people.

    This historic law has meant many great new opportunities for the 
Indian health system, but not all provisions have been equally 
implemented or at all. With the passage of the ACA, the American health 
care delivery system has been revolutionized while the Indian health 
care system continues to wait for the full implementation of the IHCIA. 
For example, mainstream American health care increased focus on 
prevention as a priority and coordinated mental health, substance 
abuse, domestic violence, and child abuse services into comprehensive 
behavioral health programs. This is now a standard practice as a result 
of the ACA but not for Indian Country. Tribes fought for over a decade 
to renew IHCIA and it is critical for Congress and the Administration 
to ensure that the full intentions of the law are realized.
    To provide context for how much of the law has not been 
implemented, the following provides several categories of programs that 
have not been implemented and funded:

    1) Health and Manpower--67 percent of provisions not yet fully 

     Includes: establishment of national Community Health Aide 
        Program; demonstration programs for chronic health professions 

    2) Health Services--47 percent of provisions not yet fully 

     Includes: authorization of dialysis programs; 
        authorization of hospice care, long term care, and home/
        community based care; new grants for prevention, control and 
        elimination of communicable and infectious diseases; and 
        establishment of an office of men's health.

    3) Health Facilities--43 percent of provisions not yet fully 

     Includes: demonstration program with at least 3 mobile 
        health station projects; demonstration projects to test new 
        models/means of health care delivery.

    4) Access to Health Services--11 percent of provisions not yet 
fully implemented

     Includes: Grants to provide assistance for Tribes to 
        encourage enrollment in the Social Security Act or other health 
        benefit programs.

    5) Urban Indians--67 percent of provisions not yet fully 

     Includes: funds for construction or expansion of urban 
        facilities; authorization of programs for urban Indian 
        organizations regarding communicable disease and behavioral 

    6) Behavioral Health--57 percent of provisions not yet fully 

     Authorization of programs to create a comprehensive 
        continuum of care; establishment of mental health technician 
        program; grants to for innovative community-based behavioral 
        health programs; demonstration projects to develop tele-mental 
        health approaches to youth suicide; grants to research Indian 
        behavioral health issues, including causes of youth suicides.

    7) Miscellaneous--9 percent of provisions not yet fully implemented

     Includes: Provision that North and South Dakota shall be 
        designed as a contract health service delivery area.

    Clearly, more must be done to ensure that the promises made by this 
law are actually implemented. Otherwise, Indian Country will continue 
to operate with a health system designed for the 20th Century, not a 
modern health delivery system. The passage of this seminal law, and 
then subsequent failure to appropriate funds to carry it out represents 
just another broken promise to Indian Country.
Recruitment and Retention at IHS
    At Rosebud, the IHS Area Director claimed that the hospital had a 
need for 22 doctors but only had funding for 11. YET, there were only 2 
full time physicians at the hospital. NIHB's Board Member for the 
Billings Area, Charles Headdress, Vice Chairman for the Assiniboine and 
Sioux Tribes of the Fort Peck Reservation, reported he had to wait 
three years to get a dental appointment. NIHB has heard countless 
reports of patients showing up at the beginning of the day for just a 
handful of emergency appointments--even if this means waiting outside 
in the cold. To make matters worse, the use of contract physicians 
makes it impossible for patients to form a trusting relationship with 
their medical providers, further exacerbating distrust in the system.
    While we understand that it can be challenging to recruit medical 
professionals to remote areas, it is critical that IHS and HHS employ 
all tools at their disposal to do so. For example, increasing the 
ability of IHS to use Title 38 salary authority would help. We also 
must expand the ability of IHS to offer student loan repayment with 
already appropriated funds by passing S. 536--The Indian Health Service 
Health Professions Tax Fairness Act. In addition, Congress must make 
investments in reservation housing so that people working in IHS 
facilities have a place to live. It is also critical to provide support 
for schools so that the families of medical providers will have access 
to adequate educational opportunities.
    But most importantly, we must make IHS a desirable place to work. 
Time and again, NIHB hears from physicians who leave IHS and cite the 
obstacles to working at these poorly-operated facilities on a daily 
basis. One of the most common reasons physicians leave is because they 
can't practice medicine with the resources available. Too many of them 
have had their hands tied by budget constraints and other bureaucratic 
Conclusion and Policy Recommendations
        ``Congress needs to be willing to put that investment into 
        [IHS]. It is not asking too much. We make up 2 percent of the 
        entire population of this country. We are the genocide 
        survivors. It is not a big ask for this country to fund 
        schools, health, our judicial systems at a level that allows us 
        to live functional healthy lives.''

        -Jerilyn Church, Executive Director, Great Plains Tribal 
        Chairmen's Health Board, February 3, 2016

    Thank you for holding this important hearing on the substandard 
quality of healthcare provided by the IHS. It is clear that the federal 
government is not living up to its trust responsibility. From 
underfunding to employee accountability, to recruitment and retention, 
NIHB calls on this Committee to enact solutions that will change the 
course for Indian health services.
    Sadly, we knew about many of these issues six years ago when the 
Dorgan Report was released, but are still dealing with the same issues. 
We call upon this committee to be the leaders in making this change.
    As noted above, NIHB will be working in the coming months to 
coordinate a task force that will develop recommendations on how to 
improve the IHS. However, NIHB makes the following interim policy 
recommendations that will help improve the quality of care at the 
Indian Health Service:

   Fully fund the IHS at $30 billion. In FY 2016 Tribes are 
        recommending $6.2 billion for IHS in order to start a 12-year 
        phase in of this $30 billion

   Enact Advance Appropriations for the Indian Health Service 
        which will enable IHS to operate budgets that are more 
        predictable and sustainable

   Enact legislation that would require all Medicare-
        participating providers to also accept Medicare Like Rates for 
        referrals from the IHS

   Require Tribal leadership on IHS-operated hospital governing 
        boards, and provide training for those Tribal leaders. It is 
        critical that Tribally elected officials are a part of key 
        hospital decisions

   Support the use of Dental Health Aide Therapists in Tribal 
        communities by repealing Section 119 of IHCIA which will bring 
        oral health access to Tribal communities.

   Enact the Indian Health Service Health Professions Tax 
        Fairness Act (S. 536) which would allow IHS to fund more 
        student loan repayment within existing funds

    Please see the attached NIHB 2016 Legislative and Policy Agenda 
which also contains additional policy recommendations to improve Indian 
health. We look forward to working with you on these and other 
proposals as we work towards our joint goal of improving the health of 
American Indians and Alaska Natives.

          2016 Legislative and Policy Agenda--January 21, 2016
    Founded by the Tribes in 1972, the National Indian Health Board 
(NIHB) is dedicated to advocating for the improvement in the delivery 
of health care and public health services and programs to American 
Indians and Alaska Natives. To advance the organization's mission, the 
NIHB Board of Directors sets forth the following priorities that the 
NIHB will pursue through its legislative and policy work in 2016.
Phase in Full Funding for Indian Health Services and Programs for 
        American Indians and Alaska Natives in the Indian Health 
        Service (IHS) and Beyond
    Each year the National Tribal Budget Formulation Workgroup to the 
IHS works diligently to synthesize the priorities identified by Tribes 
in each of the health care delivery Service Areas of the IHS into a 
cohesive message outlining Tribal funding priorities nationally. These 
priorities are the foundation and roadmap for the work that NIHB does 
on behalf of Tribes in pursuit of much needed funding for health care 
services and programs for American Indians and Alaska Natives (AI/ANs). 
In addition to advocating for these national Tribal priorities, NIHB 
will call on Congress and the Administration to:

        ****NOTE: Specific Recommendations to be updated with the 
        Tribal Budget Formulation Workgroup's recommendation after the 
        national meeting on Feb 11-12.*****

   Phase in Full Funding of IHS--Total Tribal Needs Budget of 
        $29.7 Billion Over 12 Years

   Present a 22 percent increase in the overall IHS budget from 
        the FY 2016 President's Budget request planning base for a 
        total of $6.2 billion

   Advocate that Tribes and Tribal programs be permanently 
        exempted from sequestration

   Provide an additional $300 million to implement the 
        provisions authorized in the Indian Health Care Improvement Act 

Enact Mandatory Appropriations for the Indian Health Service
    In addition to fully funding the Indian Health Service, NIHB and 
Tribes are committed to seeing IHS treated as `mandatory' spending. The 
federal trust responsibility toward the Tribes is not an optional line 
item, and it should not be treated this way during the annual budgeting 
process. To reaffirm its commitment to the Tribes, IHS funding should 
be treated as mandatory spending so that fulfillment of the U.S. 
government's treaty responsibilities is not a victim of unrelated 
political battles.
Seek Long-Term Renewal for the Special Diabetes Program for Indians at 
        $200 Million
    NIHB is asking Congress to pass legislation by this year to renew 
funding for this vital program for at least 5 years at $200 million per 
year. The Special Diabetes Program for Indians (SDPI) has not received 
an increase in funding since 2002; the program has effectively lost 23 
percent in programmatic value over the last 12 years due to the lack of 
funding increases corresponding to inflation. Few programs are as 
successful as SDPI at addressing chronic illness and risk factors 
related to diabetes, obesity, and physical activity. SDPI has proven 
itself effective, especially in declining incidence of diabetes-related 
kidney disease. The incidence of end-stage renal disease (ESRD) due to 
diabetes in American Indians and Alaska Natives has fallen by 29%--a 
greater decline than for any other racial or ethnic group. Treatment of 
ESRD costs almost $90,000 per patient, per year, so this reduction in 
new cases of ESRD translates into significant cost savings for 
Medicare, the Indian Health Service, and third party payers.
Secure Advanced Appropriations for the Indian Health Service
    NIHB is asking Congress to enact advanced appropriations for IHS. 
If IHS had received advance appropriations, it would not have been 
subject to the government shutdown or automatic sequestration cuts as 
its FY 2014 funding would already have been in place. Adopting advance 
appropriations for IHS results in the ability for health administrators 
to continue treating patients without wondering if--or when--they have 
the necessary funding. Additionally, IHS administrators would not waste 
valuable resources, time and energy re-allocating their budget each 
time Congress passed a continuing resolution. Indian health providers 
would know in advance how many physicians and nurses they could hire 
without wondering if funding would be available when the results of 
Congressional decisions funnel down to the local level.
Seek a Legislative Fix of the Definition of Indian in Affordable Care 
    NIHB is asking for a legislative fix of the ``Definition of 
Indian'' in the Patient Protection and Affordable Care Act (ACA). The 
``Definition of Indian'' in the ACA are not consistent with the 
definitions already in place and actively used by the Indian Health 
Service (IHS), Medicaid and the Children's Health Insurance Plan (CHIP) 
for services provided to AI/ANs. The ACA definitions, which currently 
require that a person is a member of a federally recognized Tribe or an 
Alaska Native Claims Settlement Act (ANCSA) corporation, are narrower 
than those used by IHS, Medicaid and CHIP, thereby leaving out a 
sizeable population of AI/ANs that the ACA was intended to benefit and 
protect. Congress should:

   Enact legislation that would clarify the definitions in the 
        ACA to align with other definitions used by federal providers

Promote Better Public Health Outcomes for AI/ANs through Centers for 
        Disease Control and Prevention
    The Centers for Disease Control and Prevention (CDC) is the 
nation's public health agency responsible for the public health of all 
populations, however, their actions on American Indian and Alaska 
Native health have not demonstrated a firm commitment to fulfilling the 
trust responsibility that the federal government has to maintain the 
health and well-being of Tribal citizens. The CDC's past efforts, 
although lauded and appreciated, have been indicative of a both a 
`helicopter' and `band-aid' mentality--serving often to micromanage 
Tribal health programs and only seeking to solve symptomatic issues, 
rather than improving whole health systems. Efforts, more specifically 
funding streams, have been temporary and have only served to draw 
fleeting attention to bigger and broader issues. The funding creates 
fruitful and effective programs within the Tribal communities (i.e. 
traditional foods, motor vehicle safety, HIV capacity building), 
however these programs are woefully dismantled upon the termination of 
the funding. This only reinforces a lack of long-term and sustainable 
commitment to American Indian and Alaska Native communities. The 
funding is not sufficient enough to create systemic change, embed a 
community consciousness aligned with public health goals, re-align 
programming and governance to longer-term public health strategies, and 
address tribal priorities. There needs to be a significant increase to 
the CDC's bottom line budget, and then that increase used to:

   Create an American Indian and Alaska Native public health 
        block grant administered through the Tribal Support Unit within 
        the Office of State, Tribal, Local and Territorial Support.

   Create flagship funding for Tribal health departments for 
        key public health issues in Indian Country. State health 
        departments receive multi-year funding from the CDC for such 
        issues as HIV, hepatitis C, diabetes, cancer, and sexually 
        transmitted diseases. These funds are used to establish the 
        state's own programming and presence around these issues. 
        Tribes should be permitted the same opportunities through their 
        own flagship awards.

   Each institute, office or center operating significant 
        programmatic outreach at the community level should create 
        standing funding streams dedicated only to federally recognized 
        American Indian or Alaska Native Tribes.

   The CDC should work directly with the CDC Tribal Advisory 
        Committee meeting to establish subcommittee that will actively 
        seek out Tribal input during the internal budget negotiations 
        and formulation. It is important that Tribal input is reflected 
        in the budget that CDC prepares for the White House's initial 
        proposal and all subsequent revisions.

Achieve Medicare-like Rates for the IHS
    NIHB is requesting Congress to extend the Medicare-like rate cap on 
Purchased and Referred Care (PRC) (formerly Contract Health Services) 
referrals to all Medicare participating providers and suppliers. The 
IHS-operated PRC program alone would have saved an estimated $31.7 
million annually if Medicare-like Rates applied to non-hospital 
services. These savings would result in IHS being able to provide 
approximately 253,000 additional physician services annually. On 
December 5, 2014, IHS released a proposed rule that would amend the IHS 
PRC regulations to apply Medicare payment methodologies to all 
physician and other health care professional services and non-hospital 
based services that are either authorized under such regulations or 
purchased by urban Indian organizations. The National Indian Health 
Board, along with multiple Tribes and other Tribal organizations 
submitted comments supporting the Proposed Rule as long as any 
regulation is flexible enough to allow Tribes to opt out of the 
regulations requirements if they so choose. While NIHB is generally 
supportive of the proposed rule, it recognizes that the proposed rule 
has no enforcement capability. As a result, NIHB is still calling on 
Congress to pass legislation to extend the Medicare-like rate cap on 
Seek an Exemption for American Indians and Alaska Natives from the 
        Employer Mandate Requirement
    The Employer Shared Responsibility Rule, otherwise known as the 
Employer Mandate, states that all employers with 50 or more employees 
must offer health insurance to their employees or pay a penalty. Tribal 
governments are currently counted as large employers for application of 
this rule even though they are not specifically listed in the language 
of the statue. Yet, AI/ANs are exempt from the Individual Mandate to 
purchase health insurance. Requiring Tribal employers to provide AI/ANs 
with such coverage anyway, and penalizing them if they do not, 
functionally invalidates the AI/AN exemption from the individual 
mandate by shifting the penalty from the individual to the Tribe 
itself. NIHB has reached out to members of Congress to educate them on 
this important issue and it has garnered some interest and support. 
However, given the political climate, NIHB believes that a regulatory 
fix would be more likely to succeed than a congressional one. However, 
NIHB continues to advance both strategies in 2015.

   The Administration should exempt AI/AN employees from the 
        Employer Mandate through a regulatory fix

   If the Administration can't exempt AI/AN employees from the 
        Employer Mandate altogether, Tribal consultation needs to occur 
        on how to mitigate the impact that the Employer Mandate has on 

   Congress should explicitly exempt AI/AN employees from the 
        Employer Mandate to purchase health insurance under the ACA

Improve Recruitment and Retention of Medical and Health Professionals 
        at the Indian Health Service
    Like most rural health providers, IHS has difficulty recruiting and 
retaining medical staff at many of its sites. As a result, patients 
experience very long wait times, and serious illness is often left 
untreated. Congress and the Administration must do more to ensure that 
providers are seeking out the IHS as a desirable place to work. 
Recommendations include:

   Securing tax exempt status for IHS student loans

   Engaging in formal Tribal consultation on how to better 
        recruit and retain medical staff

   Shortening hiring times for medical professionals

   Increasing funding to build staff housing on reservations

   Create specialized residency programs within IHS to attract 
        a service provider corps with more diversified professional 

   Increase professional development opportunities for existing 

Enact Special Suicide Prevention Program for AI/ANs
    AI/AN communities grapple with complex behavioral health issues at 
higher rates than any other population. Destructive federal Indian 
policies and unresponsive or harmful human service systems have left 
AI/AN communities with unresolved historical and generational trauma. 
According to the Substance Abuse and Mental Health Services 
Administration, suicide is the 2nd leading cause of death--2.5 times 
the national rate--for AI/AN youth in the 15 to 24 age group. Tribes 
have noted that federal support seems to increase whenever there is an 
acute crisis, but then dwindles over time, preventing long-term, 
sustainable improvement in mental and behavioral health systems. The 
Attorney General's Advisory Committee on AI/AN Children Exposed to 
Violence, describes the foundation that must be put in place to treat 
and heal AI/AN children who have experienced trauma: ``We must 
transform the broken systems that re-traumatize children into systems 
where [AI/AN] tribes are empowered with authority and resources to 
prevent exposure to violence and to respond to and promote healing of 
their children who have been exposed.'' * NIHB recommends that:
    * U.S. Department of Justice. (2014) ``Attorney General's Advisory 
Committee on American Indian and Alaska Native Children Exposed to 
Violence: Ending Violence so Children can Thrive,'' p. 7.

   Congress should enact a program to target suicide prevention 
        program for Indian Country that would be modeled off of the 
        Special Diabetes Program for Indians

   Create an American Indian and Alaska Native mental health 
        block grant to be Administered by the Substance Abuse and 
        Mental Health Services Administration

   Congress and the Administration should require that states 
        engage in meaningful Tribal Consultation with Tribes within 
        their borders in order to receive any funds under the Mental 
        Health Services Block Grant

   Increase appropriations across the federal government for 
        Tribal behavioral health programs and empower Tribes to operate 
        those programs through Tribal Self-Governance contracts

   Congress pass statutory language supporting traditional and 
        cultural healing practices in any national mental health reform 

Repeal Language in the Indian Health Care Improvement Act Limiting the 
        Use of Dental Therapists in Tribal Communities
    Tribal communities suffer from some of the worst oral health 
disparities in the United States. AI/AN children have an average of 6 
decayed teeth, while the same age group in the U.S. population overall 
has only one. For over a decade, Tribes in Alaska have successfully 
employed Dental Health Aide Therapists (DHATs), who have expanded oral 
health services to over 40,000 Alaska Natives. These safe and effective 
mid-level oral health providers deliver basic and routine services 
(i.e. cleanings, fillings, simple extractions, oral health education, 
sealants, etc.) to communities who do not have access to a regular 
dentist. However, when Congress passed the Indian Health Care 
Improvement Act in 2010, language was included that would limit the use 
of DHATs outside of Alaska within the Community Health Aide Program 
unless a state legislature approves. NIHB believes that this is a 
direct violation of the principle of Tribal sovereignty, and that 
Tribal governments, not state legislatures, should dictate who is able 
to deliver care in their community. Therefore, we recommend that:

   Congress should repeal Section 119 of the Indian Health Care 
        Improvement Act which bans the expansion of Dental Health Aide 
        Therapists (DHATs) to Tribes in the lower 48 within the 
        Community Health Aide Program at the Indian Health Service 
        unless approved by a state legislature

   Congress should pass legislation that would express support 
        for the use of DHATs in Tribal communities outside of Alaska

Expand Tribal Self Governance at the Department of Health and Human 
    For over a decade, Tribes have been advocating for expanding self-
governance authority to programs in the Department of Health and Human 
Services (DHHS). Self-governance represents efficiency, accountability 
and best practices in managing and operating Tribal programs and 
administering Federal funds at the local level. In the 108th Congress, 
Senator Ben Nighthorse Campbell introduced S. 1696--Department of 
Health and Human Services Tribal Self-Governance Amendments Act--that 
would have allowed demonstration projects to expand self-governance to 
other DHHS agencies. This proposal was deemed feasible by a Tribal/
federal DHHS workgroup in 2011. Therefore, in 2016, NIHB recommends 
that Congress:

   Expand statutory authority for Tribes to enter into self-
        governance compacts with HHS agencies outside of the IHS.
Improve Enrollment through the Federal and State-based Insurance 
    NIHB is committed to working with CMS to set goals for enrollment 
and measure progress towards those goals. It has been estimated that 
about 460,000 AI/AN are eligible for tax credits or premium assistance 
yet only about 24,000 AI/AN have enrolled. There are a number of ways 
to increase enrollment of AI/ANs.

   Funding for enrollment assistance for the I/T/U. Navigator 
        grants have been limited to only a few regions in the country; 
        and the rules associated with Navigator grants make them 
        unattractive to some Tribes and Tribal organizations, which are 
        in the best position to do outreach, education, and enrollment 
        assistance. NIHB needs to work with CMS to consider 
        alternatives for funding for enrollment assistance that is 
        specifically designated to reach the I/T/U.

   Change the rule for AI/AN in family plans. A regulatory 
        decision was made in the first year that everyone on a family 
        plan would get the least generous cost sharing reduction that 
        anyone qualified to receive. NIHB will recommend that a family 
        plan includes one person who is eligible for Indian-specific 
        cost sharing reductions, then others who are in the tax-filing 
        unit who are eligible for the Indian Health Service will get 
        the same cost-sharing reduction as the person with Indian 

   Access to analytics to manage enrollment for AI/AN. To 
        manage the problem of increasing enrollment requires a system 
        of reporting and analyzing enrollment data in a regular and 
        consistent way that allows us to better understand the 
        impediments and the approaches that are successful. NIHB and 
        TTAG have made recommendations about the most useful types of 
        information and how they can be retrieved from existing data 
        files and we intend to follow up with CMS until we receive 
        access to the data that we need.

AI/AN-Specific Call Centers
    NIHB has reported to CMS numerous times that AI/ANs continue to 
experience poor assistance when contacting the marketplace call center 
for help. Issues range from technicians having no knowledge of the 
Indian-specific protections like exemptions and tax credits, to 
technicians being rude and having no patience to walk elderly consumers 
through the troubleshooting process.
    Because AI/AN consumers continue to receive such poor customer 
service we have suggested before and continue to suggest that the 
Center for Consumer Information and Insurance Oversight (CCIIO), in 
CMS, establish an AI/AN-specific call center to respond to questions 
and provide technical assistance to AI/ANs, as well as enrollment 
assisters such as navigators and certified application counselors. We 
also believe that an AI/AN-specific help desk would be better equipped 
and more sensitive to the needs of AI/AN consumers.
Support Increased Oversight of QHPs
    CMS put into regulations the provisions in the 2015 Issuer Letter 
requiring Qualified Health Plan (QHP) Issuers to offer contracts to all 
Indian health care providers that operate in the QHP's service area and 
to do so by including the QHP Indian addendum with ``good faith'' 
payment provisions. However, not all QHP Issuers are complying with the 
requirement. Depending upon the region of the country, some QHP issuers 
are offering contracts, but in other regions, QHP issuers do not appear 
to be offering contracts to Indian health care providers. NIHB is 
advocating and working with CCIIO to provide better oversight in 
federally facilitated marketplaces (FFM) states and that the contract 
requirement be extended to state-based Marketplaces to ensure Indian 
Health Care Providers are included in plan networks in those states.
    For a variety of reasons, an I/T/U may be unable to join the 
network of plan providers or chose not to do so. In any case, if the I/
T/U is an out-of-network provider, AI/AN will continue to seek the I/T/
U for many of their health services. CMS should ensure that:

   Marketplace plans make accurate and timely payments to the 
        I/T/U for services to people enrolled in the Marketplace plans, 
        and that the cost sharing reductions for AI/AN are handled 
        properly at the time of service.
Meaningful Use of Electronic Health Records
    Meaningful Use (MU) of electronic health records (EHR) requires 
both changes in technology and changes in business practices. For a 
variety of reasons, this has been difficult to accomplish in many 
places within the I/T/U. Now Indian health providers are threatened 
with reduced revenues for lack of progress on MU. In addition, many I/
T/U facilities are small and located in extremely rural areas where it 
is difficult or impossible to attract and retain the kind of personnel 
who can understand, implement and manage the new requirements for 
reporting that result in Medicare payments being reduced. NIHB will 
advocate for exemption to these requirements.
Support Medicaid Expansion and 100 percent FMAP Policy
    Medicaid Expansion is a shared partnership between states and the 
federal government. Under Medicaid, AI/ANs are eligible for a 100 
percent federal match (also known as 100 percent FMAP), meaning that 
the money spent by a state Medicaid program is fully reimbursed by the 
federal government. Medicaid reimbursement is a significant source of 
third party revenue that is essential to supplementing the limited 
resources of the Indian health system. In states that have expanded 
Medicaid, like Washington, as much as $2 billion has been added to the 
Indian Health System. A recent White House report estimates that 5,200 
deaths could be avoided annually if those 16 remaining states that have 
stated that they are not expanding Medicaid continue to do so. NIHB 
must continue to advocate and provide technical assistance for those 
states that wish to expand Medicaid.
    In addition, CMS recently proposed updating its policy concerning 
the circumstances under which a 100 percent federal match can be 
applied. CMS proposes expanding the match to include services furnished 
outside an IHS or Tribal health facility. This would have substantial 
benefits to Indian Country and the revenue generated from expanding the 
federal match could be used to expand Medicaid in the state, as South 
Dakota has proposed. NIHB will continue to advocate for this expansion 
and provide all necessary technical support.
Public Health Infrastructure Workforce Development
    AI/AN communities have some of the largest public health 
disparities in this country, with disproportionately higher rates of 
depression, suicide, HIV, motor vehicle accidents, other accidental 
deaths, sexually transmitted diseases, viral hepatitis, substance use, 
tobacco use, and cancer when compared to other reported races and 
ethnicities. Indian Country does not have the established public health 
infrastructure that exists within state governments or even local or 
country systems. This lack of infrastructure and accompanying workforce 
will only continue to perpetuate the disparities, and quite possibly 
compound them. The recent movement to accredit the public health 
operations of health departments has proven quite successful but uptake 
has been slower in Tribal communities, primarily because the lack of 
public health infrastructure makes public health accreditation seem 
unachievable. An effective public health system, especially the 
practices of disease surveillance and prevention, can save hundreds of 
thousands of dollars in health care costs to Indian Health Service, 
Veteran's Administration, Medicaid, and third party payers. In order to 
bolster the public health infrastructure and workforce of Tribes, NIHB 

   IHS create targeted capacity building to Indian Health 
        Service medical providers on the integration of public health 
        and behavioral health services into clinical settings.

   Congress re-instate the CDC's National Public Health 
        Improvement Initiative (NPHII) which was discontinued in 2015, 
        as this funding was solely for the purpose of strengthening 
        gaps in public health services or systems, as identified by the 
        funding recipient. However, the re-instatement of this program 
        should include a Tribal set-aside, as data clearly indicates 
        that not only are health disparities greater, but the 
        infrastructure is weaker within Tribal communities than their 
        non-Tribal counterparts.

   Indian Health Service create a health education 
        certification program for Tribal and IHS employees.

   That Congress require the Indian Health Service and the CDC 
        to report to Congress every two years how it supports the 
        creation and effective implementation of the ten essential 
        services of public health within AI/AN communities.
    Prepared Statement of the United South and Eastern Tribes, Inc.
    The United South and Eastern Tribes Sovereignty Protection Fund 
(USET SPF) is pleased to provide the Senate Committee on Indian Affairs 
with the following testimony in pursuit of solutions to the systemic 
challenges facing the Indian Health Service (IHS) and Tribally-Operated 
facilities. Following the unacceptable and devastating failures of the 
Indian Health System in the Great Plains, that is in part responsible 
for the unfortunate loss of lives, it was vital that the Committee 
investigate the state of Indian health care regionally and beyond. USET 
SPF thanks the Committee for hosting the hearing on the quality of 
health care within the IHS Great Plains Area and the subsequent 
listening session on ``Putting Patients First: Addressing Indian 
Country's Critical Concerns Regarding Indian Health Service.''
    USET SPF is a non-profit, inter-tribal organization representing 26 
federally recognized Tribal Nations from Texas across to Florida and up 
to Maine. \1\ Both individually, as well as collectively through USET 
SPF, our member Tribal Nations work to improve health care services for 
American Indians. Our member Tribal Nations operate in the Nashville 
Area of the IHS, which contains 36 IHS and Tribal health care 
facilities. Our citizens receive health care services both directly at 
IHS facilities, as well as in Tribally-Operated facilities operated 
under contracts with IHS pursuant to the Indian Self-Determination and 
Education Assistance Act (ISDEAA), P.L. 93-638.
    \1\ USET member Tribes include: Alabama-Coushatta Tribe of Texas 
(TX), Aroostook Band of Micmac Indians (ME), Catawba Indian Nation 
(SC), Cayuga Nation (NY), Chitimacha Tribe of Louisiana (LA), Coushatta 
Tribe of Louisiana (LA), Eastern Band of Cherokee Indians (NC), Houlton 
Band of Maliseet Indians (ME), Jena Band of Choctaw Indians (LA), 
Mashantucket Pequot Indian Tribe (CT), Mashpee Wampanoag Tribe (MA), 
Miccosukee Tribe of Indians of Florida (FL), Mississippi Band of 
Choctaw Indians (MS), Mohegan Tribe of Indians of Connecticut (CT), 
Narragansett Indian Tribe (RI), Oneida Indian Nation (NY), 
Passamaquoddy Tribe at Indian Township (ME), Passamaquoddy Tribe at 
Pleasant Point (ME), Penobscot Indian Nation (ME), Poarch Band of Creek 
Indians (AL), Saint Regis Mohawk Tribe (NY), Seminole Tribe of Florida 
(FL), Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY), 
Tunica-Biloxi Tribe of Louisiana (LA), and the Wampanoag Tribe of Gay 
Head (Aquinnah) (MA).
    We echo the comments of many Members of the Committee, as well as 
witnesses, highlighting the financial obstacles facing the Indian 
Health Service and Tribal Nations, as they seek to provide quality 
health care to American Indians and Alaska Natives (AI/AN). While the 
issues surrounding the deplorable conditions in the Great Plains are 
multi-faceted, much of the problem can be attributed to the persistent 
underfunding of IHS. With this in mind, USET SPF is hopeful that 
Congress will take necessary actions to fulfill its Federal Trust 
responsibility and obligation to provide quality health care to Tribal 
Nations, including providing adequate funding to the IHS. In addition, 
we urge this Congress to introduce and approve no-cost legislation that 
will stabilize and extend the limited resources of the IHS.
Uphold the Federal Trust Responsibility and Obligations to Tribal 
    As this Committee is well aware, many of the systemic inequities in 
the Indian Health System and strikingly high health disparities \2\ in 
Indian Country result from the chronic underfunding of the IHS budget. 
The IHS is the primary agency tasked with ensuring the federal 
government fulfills its promise to provide health care to AI/AN. 
However, the IHS is consistently underfunded, meeting just around 59 
percent of the demonstrated financial need to deliver care to AI/AN 
patients. As a result, IHS health expenditure per capita for patients 
is just $3,099, which is approximately 61.7 percent less than health 
spending for the total U.S population at $8,097 per capita. \3\ 
Although Congress has appropriated additional funding for IHS in recent 
years, the costs of health care continue to increase. Current levels of 
funding are barely able to meet non-medical inflation rates and is 
completely unable to meet the medical inflation rate. As a result, 
major barriers to accessing care exist due to the lack of resources in 
the Indian health system. These barriers lead to poor health outcomes 
and severe health disparities.
    \2\ Tribal Nations face disproportionately high rates of mortality 
from diabetes, major heart disease, chronic liver disease and injuries, 
when compared with all other races in the United States (U.S.).
    \3\ Indian Health Service ``Year 2015 Profile'' December, 2015.
    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. \4\'' As long as the IHS is so dramatically 
underfunded, Congress is not living up to its own stated policy and 
responsibilities. USET SPF urges this Committee to consider carefully 
the level of funding for IHS it will support as it makes requests of 
appropriators for Fiscal Year (FY) 2017 and beyond. Fulfillment of the 
Federal Trust responsibility, both from a fiduciary and moral 
perspective, means fully funding the Indian Health Service.
    \4\ 25 U.S. Code  1602
Extend PRC Resources by Passing Legislation to Extend Medicare-Like-
        Rates Payment Methodologies to Non-Hospital Services
    One of the most severely underfunded line items within the IHS 
budget is the Purchased/Referred Care (PRC) account (formerly known as 
Contract Health Services). PRC resources allow Indian Health programs 
to purchase care that is furnished by outside, non-Indian health care 
providers (non-IHCPs) in the private sector. PRC funding is essential 
for AI/AN patients to access primary care, specialty care, and other 
services not readily available at their Indian Health Facility. At 
current funding levels, many IHS and Tribally operated programs are 
only able to cover Priority I \5\ services to preserve life and limb 
and are often unable to fully meet patients' needs at even this 
restrictive PRC service category. In FY 2015, IHS estimates that it 
denied 132,000 necessary services to AI/AN patients due to lack of 
    \5\ For a breakdown of IHS Medical Priority Levels see: http://
    Compounding and contributing to this challenge are the rates PRC 
programs pay to non-IHCPs. Non-IHCPs routinely charge, and expect to be 
paid, full-billed charges to PRC programs. According to an April 2013 
Government Accountability Office (GAO) report, federal PRC programs 
paid non-contracted physicians two and a half times more than what it 
estimates Medicare would have paid for the same services. The PRC 
program may be the only program in the federal government that pays 
rates above the Medicare rate. Neither the VA nor the DOD pay full 
billed charges for health services furnished by outside providers. Nor 
do insurance companies, including those with whom the federal 
government has negotiated favorable rates through the Federal Employee 
Health Benefits program. IHS and Tribally-Operated Health Programs' 
regular payment of full billed charges is both a major barrier to 
accessing necessary care for AI/AN patients, and an inefficient use of 
taxpayer dollars.
    The 2013 GAO report concluded that paying a Medicare-like Rate 
(MLR) for services purchased by PRC programs would allow the IHS to 
provide approximately 253,000 additional physician services annually. 
Payment under this rate would have resulted in hundreds of millions of 
dollars in new federal health care resources being made available to 
AI/ANs in 2010 alone. Furthermore, the implementation of this payment 
mechanism would be achieved at no cost to the federal government.
    Over the past year, IHS has been working to implement a regulation 
that would provide Tribal Nations with the option to apply MLR to their 
PRC programs. The rule, however, does not include an enforcement 
mechanism, namely, conditioning participation in the Medicare program 
on the acceptance of MLR. A lack of enforcement could lead non-IHCP to 
refuse to AI/AN patients due to the decrease in payments. Particularly 
for USET Tribal Nations that reside in areas with few specialty care 
providers, this rule could create additional barriers to accessing 
health services. This is why legislation is necessary. The 
Administration, in its FY 2017 Budget Request, recognized the need for 
legislation over regulation, stating in its Congressional 
Justification, ``unlike the legislative proposal, the regulation cannot 
require that providers participating in Medicare accept the capitated 
PRC rate from IHS.''
    USET SPF urges this Committee to support and work toward the 
passage of legislation extending MLR to non-hospital services that 
includes an enforcement mechanism to ensure AI/AN patients' continued 
access to care. Doing so would be a more efficient use of taxpayer 
dollars, dramatically improve AI/AN patient access needed care, and be 
an important step toward improving the health inequities between AI/AN 
and the U.S. population.
Provide Advance Appropriations for the Indian Health Service
    In addition to the more efficient spending of IHS dollars, Congress 
should work to ensure funding is received on time by approving 
legislation that would authorize advance appropriations for IHS. 
Advance appropriations is funding that becomes available one year or 
more after the appropriations act in which it is contained, allowing 
for increased certainty and continuity in the provision of services.
    On top of chronic underfunding and drains on precious dollars, IHS 
and Tribes face the problem of discretionary funding that is almost 
always delayed. In fact, since FY 1998, there has only been one 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.
    Late funding has severely hindered IHS and Tribal health care 
providers' ability to administer the care to which AI/AN are legally 
entitled. Budgeting, recruitment, retention, the provision of services, 
facility maintenance, and construction efforts all depend on annual 
appropriated funds. Many of our USET SPF member Tribal Nations reside 
in areas with high Health Professional Shortage Areas and delays in 
funding only amplify the challenges with salary and hiring of qualified 
professionals which are systemic across the IHS System. IHS and Tribal 
facilities must continue to operate while Congress engages in 
philosophical debates about federal spending. However, they are forced 
to do so at a severely reduced capacity. In a world where it is not 
unusual to exhaust funding before the end of the Fiscal Year, surgeries 
are delayed, services are reduced, and employment is in jeopardy.
    Congress has recognized the difficulties inherent in the provision 
of direct health care that relies on the appropriations process and 
traditional funding cycle. When it became clear that our nation's 
veterans were not able to receive the quality health care earned in the 
protection of this country due to funding delays, advance 
appropriations were enacted for the Veterans Administration (VA) 
medical care accounts. Advance appropriations serve to mitigate the 
effect of delayed and, at times, inadequate funding for the VA. As the 
only other federal provider of direct health care and a consistently 
underfunded agency, IHS should be afforded this same consideration and 
certainty. USET SPF urges this Committee to support legislation that 
would extend advance appropriations to the IHS.
    As the February 3rd hearing revealed, the chronic underfunding of 
the IHS has life or death consequences for many of the AI/AN patients 
from our USET SPF member Tribal Nations. Any loss of life resulting 
from failure to fulfill trust responsibilities and obligations is 
unacceptable. The rationing of care through the PRC program, and major 
obstacles with the recruitment and retention of providers are examples 
of the direct result of Congress' failure to meet its Trust 
responsibilities and obligations to adequately fund the IHS. In 
recognition of the political climate that enables the underfunding for 
Indian Health Care, we offer the preceding solutions to extend and 
stabilize IHS resources. We hope that Members of the Senate Committee 
on Indian Affairs will join us, and others in Indian Country, in 
advocating for the introduction and passage of these two common-sense 
proposals, in addition to increased funding for IHS.
    We thank the Committee for holding both the hearing and the 
listening session to examine the quality of care delivered through IHS. 
USET SPF is a willing partner in your efforts to address systemic 
problems at IHS and improve the health outcomes of AI/AN patients.
 Prepared Statement of Jay Houle, Sisseton-Wahpeton Oyate Tribal Member
    Dear Senate Committee,
    I normally do not speak out about much, but this issue is getting 
out of hand. Healthcare in the Native American world is sliding 
downhill out of control. Referrals to private providers that were paid 
for 5 years ago are now being denied. I know not all referrals will be 
paid for, but many are serious heath issues than are at minimum 
uncomfortable, not to say extremely painful and/or life threatening. At 
the personal level, my wife has a hernia and a bone spur on her spine, 
both of which have had the referral denied, so she must try to handle 
the pain with medication and lifestyle adjustment because physical 
therapy is not recommended.
    This nation can spend HOW MUCH money on other countries and their 
citizens but cannot spend that much for the first people of this 
continent. I do not claim to understand the complexities of Washing, 
D.C. and the leaders of our nation. I do know that not many Native 
Americans are willing to raise a voice and comment. I pray that you 
will find a solution to this issue soon. Thank you.
       Prepared Statement of Domnic L Brown, Osage Tribal Member
    I was employed at the Rosebud Indian Health Service and what I had 
seen is the patients would have appointments for specialist, but they 
would end up with the medical bill. The Rosebud Tribe Members, don't 
have insurance, because they don't have jobs, they should not be 
punished by not being sent to Specialist or having to be responsible 
for the Medical bill, that they can't pay. The Indian Health Service 
should pay all these bills and whether they have medical insurance or 
    I have sat in on the meetings when they go through the referrals 
and it was yes or no who would get sent out and that isn't fair, what 
happens the person that doesn't get sent out for medical attention and 
they die, oh well? It is sad.
    They open clinic up on Sundays. because of the patient load we were 
seeing during the week, so they have Sunday Clinic and then only see 10 
patients, the could see more than 10 patients with 2 physicians. Then 
the patient is prescribed medicine, but they can't pick it up because 
the pharmacy will not open up on weekends. Then why have clinic if 
patients can't receive there medicine?
    I had slipped on the ice March 31, 2014 and I had bruised my ribs 
really bad and my ankle was hurt as well. I worked for the Hospital and 
my ankle was always swelling up so bad that I couldn't walk and was 
missing work, due to I could barely make it to my bathroom at my home, 
I was continuously seeing the doctor and they told me that it was just 
fractured, never offered me to be sent to a specialist, so I took 
myself to Rapid City Black Hills Orthopedic and had an MRI, within a 
week, I was in surgery, my inner ligaments were torn apart and had to 
have my whole ankle reconstructed on August 8, 2014, this is how long I 
had to deal with the pain and suffering and was out of work for 90 
days, and was denied advance leave, was told that I should have saved 
my leave for something like this, will I used my leave to stay home and 
see the doctors, because of my ankle. I was punished and was off work 
without pay. This is how they treat there employees and that is why 
they have a large turnover. The management do not care about the 
employees or patients, they just make sure that they look good and not 
get any blame for things that are wrong doing.
    I hope this gives you some light on what goes on at Rosebud Indian 
Health Service, and hope to hear from you on your opinions on what I 
have discussed todayI don't expect much to happen, I just needed to 
speak my mind today. I am a Desert Storm Veteran, and from the Osage 
Tribe. I enjoyed helping the Rosebud Tribe Members while I was there 
and want to go back and work for the Indian Health Service, at least I 
showed some compassion, other workers don't, they don't care.
    Thank you.
  Prepared Statement of Jacqueline Archambault, Cheyenne River Sioux 
                             Tribal Member
    Hello, My name is Jacqueline Archambault, I live on the Cheyenne 
River Sioux Tribe, Eagle Butte, SD. I am submitting a statement in 
behalf of my daughter and grandson. I hope you are able to view the 
attachments. *
    * The information referred to has been retained in the Committee 
    She is unable to submit her statement on her own as her work place 
won't allow her to use the computer for personal use. So, I as her 
parent and grandmother to her son, I am submitting from my email.
    I hope you can help us, as my grandson got the poorest health 
service from the IHS in Eagle Butte, SD.
    He had to go without a cast on his right leg for 10 days, because 
the IHS said, his right leg showed no facture, but he still would not 
walk on it. My daughter kept taking him back to IHS and they kept 
saying it was not broke. So, I kept telling her to take him back. On 
Friday, March 4th, 2016 they finally saw the facture, but the soonest 
they can refer him out was in five days, which was March 9th. He went 
to Black Hills Orthopedic and Spine Center, Rapid City, SD Then they 
place a cast to his right leg and he had a compound facture.
    I am so disguised with IHS that they could not help my grandson, 
who had to suffer for 10 days w/out a services and be in pain.
    I told my daughter to file a law suit on IHS but that is probably 
not an opinion.
    But I think the IHS needs to get qualified x-ray technicians and 
physicians to make the right diagnosis on the patients. This way to 
much for us people to suffer.
    My daughter, LaToya F. LaPointe always has the x-rays on disk.
    I hope you help her and her son. He didn't have to suffer this 
       Prepared Statement of Alexis Jones, Registered Nurse, BSN
    To Whom It May Concern;
    I started at the Fort Thompson Indian Health in September of 2014. 
Upon continuation of working here, there have been many issues that 
have progressed or have happened during my employment.
    One incident that occurred was with the schedule change due to an 
employee leaving and closing at 4:30 p.m. on Wednesdays. After 
reviewing the schedule I noticed there was an employee (Abby Bacon) who 
did not have any late shifts. I was switched to take her late shifts 
and was shifted to another charge nurse day. After noticing the changes 
I went to the Acting DON, Robert Douville and asked him why this was. 
He said Abby was going to the school to do immunizations and that she 
runs reports for the CEO. I asked him why nobody else was trained or 
asked to do those reports. He said he that it was set up before he got 
there and he was going to ask the CEO.
    He asked me if I would be willing to do the reports and I said I 
would be away from Mcfee and that would take me away from patient care. 
I really enjoy seeing my patient's and doing my job that is why I am 
here. Running any kind of reports takes away from patient care. We are 
the busiest area in the facility. Providing immunizations is a busy job 
as well and should be prioritized over running reports.
    Running reports or doing any other task will be helpful in 
providing growth for the individual and for the facility to provide 
better care. Growth to expand one's knowledge in the facility should be 
offered to everyone. During my employment here I asked my supervisor 
(Abby Bacon) at the time and CEO (Bernie Long) if I could attend a 
Health Care conference. After discussing with CEO, he said that they 
would be able to pay for the registration fee and I would have to pay 
for the rest. I would have been responsible for my hotel and travel. 
Due to lack of funding I was unable to go.
    A few months ago a co-worker of mine who is now gone, attended a 
wound care workshop in Texas. All of hers was paid for and she also 
earned comp time. I thought this was really unfair and why was hers 
prioritized more than mine. Especially being a Native American, as a 
facility on reservation you would want your employees to grow and to be 
more educated.
    My reasoning behind going was I provide complex care to a wide 
variety of patients. I felt as though my reasoning was just as 
important if not more important. I felt as though there was no 
justification behind their decision. Decisions that are being made 
affect everyone including our patient's.
    Another issue that affects this facility is the amount of 
Commissioned Corp officers. The management of this facility has been 
mostly Commissioned Corp officers. Earlier in the year if you were to 
review the chain of command for the nursing staff it was all completely 
Commissioned Corp officers. During the last year that I have been here, 
we have had 4-5 acting DON's. We did have one permanent supervisor when 
I first started who was Native American and she left only after a few 
months. A co-worker and I are both Native American and she has over 5 
years of experience and I have been a nurse for 3 years and have not 
been offered an opportunity to be acting DON. Every acting DON has been 
a Commissioned Corp officer. I don't think I deserved the opportunity 
due to lack of experience, but my co-worker did and she has Indian 
preference. Indian preference is a law that the facility must abide by. 
This facility or any other facility should promote the natives and 
encourage them to stay and provided opportunities for advancement or 
    Also with the amount of commissioned corp officers one would think 
that extended hours would be provided and that they would be able to 
provide that. They are on call 24/7. Some of the officers do the same 
amount of work we do and get paid 2-3x as much as we do.
    The same co-worker also applied for another position in the 
facility. This position is a nurse who helps out in behavioral health. 
The nurse who worked there was actually detailed from public health and 
was of Caucasian descent. She has been there for an extended amount of 
time. An unusual event occurred where they actually advertised for the 
position. My co-worker applied for it amongst others, come to find out 
she didn't get the position. She again is Indian preference and the 
lady of Caucasian descent was offered the position. This goes to show 
that favoritism and pre-selection occurred during this event.
    My co-worker and I were fed up one day with the amount of nepotism 
that occurs in this facility and how being a Native American in this 
clinic works against us. We addressed the tribal council during our 
lunch period. We were a few minutes late coming back from lunch. After 
administration found out where we were at they started an investigation 
against my co-worker, and not I. I felt this was an act of retaliation 
against her. I even went to the compliance officer and asked him why 
she was being investigated. He said he thought I was being addressed as 
well. After that I left it alone.
    During a personal conversation with Bernie, I had mentioned I 
thought about leaving and he told me I should. I said there was no 
opportunity and that as a young nurse I wouldn't gain that here. I 
guess at that moment I realized I would forever be at a dead end road 
here in Fort Thompson.
    Bernie, along with other administration staff have a great deal of 
unprofessionalism. I must say with the gentleman from Spirit Lake was 
sent from Aberdeen to collect statements from the employees regarding 
Bernie Long, there was an overhead page for the providers to report to 
the conference room. That is where the provider's were asked to write 
statements on Bernie's behalf. This is the most crooked move I have 
ever heard of. No CEO should even have to beg for any kind of 
statement. That is something you earn along the way.
    Lastly, I would like to mention the uncomfortable environment and 
the amount of stress the nepotism has created. A few months ago our 
supervisor had a hired a friend of the one of the nurses at as a new 
clinical nurse. Only after a few weeks of being there she put in her 
notice and quit due to a hostile environment and was effective 
immediately. The working conditions are unfavorable due to most because 
there is so much favoritism and gossip. We should not have new nurses 
coming on board and quitting due to a hostile environment. Any signs of 
hostility should be addressed immediately by our supervisor.
    The everyday decisions of this facility have made me explore other 
options outside the reservation. I feel there are no opportunities for 
me to grow here. As a graduate from the Retention for Native American 
Nurses at UND, I always wanted to come home and help the people. This 
is not what I pictured coming home. It has been so hard coming to work 
every day. As a young nurse in IHS, this has been the most 
unprofessional and complex facility I have ever worked at. This affects 
the people we care for and ourselves as providers.
    Thank you.
 [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]                                
Prepared Statement of Tammy Rae Goodwin, Sisseton Wahpeton Oyate Tribal 
    I am an enrolled member of the Sisseton Wahpeton Oyate and I 
receive services at the local IHS clinic. Woodrow Wilson Memorial 
Healthcare Center located in Sisseton, South Dakota. I believe this 
facility is another example of the governments genocide of native 
peoples. Abundance of misdiagnosis, accusations of being a drug seeker, 
no confidentiality, drug use of employees, etc. I do not have medical 
insurance so I'm stuck with what care I receive at IHS.
    I am not a person whom I consider doctor runners, I only go when 
absolutely necessary for my basic medication. I have arthritis, 
diabetes, COPD, avascular necrosis in my hands, PTSD, anxiety, along 
with other mental health issues and have recently applied for SSI 
    On December 17, 2014 I went to Acting Director Gail Williams to 
voice a complaint of employees not following confidentiality guidelines 
and she listened to my concerns involving specific individuals and said 
someone from the HIPPA office would be contacting me. No one ever did 
and she was removed from office or resigned due to other issues going 
on in administration.
    The receptionist involved with intake and making appointments would 
report to the Director of a domestic violence shelter I worked at, of 
which this IHS employee was the on the Board of Directors for the 
shelter, would report to the director under her, employees of the 
shelter when they would go to see the doctor and what it was for. 
Example, an employee went to IHS for a physical necessary for treatment 
she was going to attend for codependency issues. One day the Director 
of the shelter asked me if I knew this employee was going to go to 
treatment. She said, ``I didn't know she was drinking again.'' I knew 
she was going to treatment but how did the Director know about this 
when I know this employee did not speak to her about it. It wasn't hard 
to figure out where the information derived from. This employee still 
works at IHS.
    In April of 2015 I went to see the doctor for other issues and 
while he was typing on the computer, I showed him my left hand with a 
swollen, red knuckle and mentioned how much it hurts. He looked up from 
his typing and said ``yeah, you irritated something.'' and then resumed 
typing and didn't try to look at it again. In frustration, I left. In 
June of 2015, I returned to clinic to see about getting some relief 
from the pain in my left hand and was told by a nurse, ``You can't just 
come in here and ask for a pain pill.'' Again nothing was done. There 
was no exray or examination made of the left hand and now I'm accused 
of drug seeking because of addictions in my past. I have been sober now 
for five years.
    In September of 2015, again I returned because the PA that I was 
seeing in the past, returned to the facility. She immediately sent me 
to exray and had images taken of my hand. This is when I received the 
diagnosis of Avascular Necrosis, which I'd like to add is normally 
found in the hips and knees, hence the total joint replacement. I have 
it in my left hand with one knuckle totally collapsed and now it's also 
affecting my right hand with other knuckles dying off. Within two days, 
my referral was approved and I was sent to an orthopedic surgeon. When 
I asked about my knuckle, he stated there wasn't anything he could do 
about that but he was going to do the carpal tunnel surgery. He stated 
I needed to see a doctor that specializes in hand surgery because I 
needed a total knuckle replacement surgery and he didn't do that. On 
December 9, 2015 I had the carpel tunnel surgery and I guess it was a 
success, but it didn't change the pain in my hands one iota. By then 
the PA I was seeing, transferred to another facility and another new 
doctor took her place. I asked for pain meds to be refilled and was 
told no, the surgery was a success and there was no more pain in my 
hand. Without looking at my hand, or the doctor looking at my file, she 
was able to make this decision. Again, accused of drug seeking. During 
December, we got a doctor from the east coast who likes to come help 
out the natives during his vacation. When I visited with him, he was 
actually kind of excited and he logged onto the New England Journal of 
Medicine and even there, there is no mention of this affecting the 
hands. Well now it's in both my hands. The major cause of this is 
alcohol usage and steroid use. I was an alcoholic for many years and 
due to asthma, and now COPD, I have been inhaling steroids for approx. 
30 years. Who knew? Now this doctor has returned to his normal practice 
and I'm stuck with the ignorance left at IHS with a diagnosis that many 
are not familiar with and have absolutely no experience with. In 
layman's terms--I'm fucked. Please excuse me for saying that but there 
are no other words to express my sadness and fear of the unknown of 
what's going to happen now. Where can I turn to get relief from the 
pain now, without getting accused of drug seeking. I'm sure just 
looking at me, I look fine.
    This is only ONE example of what I've gone through, and continue to 
go through. I have been going to IHS since around 1965.
    The being accused of drug seeking is really what irritates me the 
most. I only wanted a pain pill to take when the pain is incredibly 
bad, I am very active and live on a farm so there is always things to 
do. Even though I'm in pain daily, there are critters here that depend 
on me and land to work. I seek relief from the pain occasionally. Just 
a break. If I was drug seeking, I would go out to our housing project 
and pick up what I think I need, not go to IHS. THEY are the one's that 
lead people back to their addictions. Since I no longer choose to go 
that route, YOU tell me what I can do.
    This leads me to my last statement. The first question the nurse 
asks is: On a scale of 1 to 10, what is your level of pain today? Now I 
just say a random number in their scale because my level of pain is off 
their chart, and nothing will be done anyway. It's an insult for them 
to ask me that question. One thing that sort of tickled me was when I 
told the PA I didn't consider myself an doctor runner, she looked at me 
with big eyes and said `` I would never accuse you of that, with your 
diagnosis other people would be in here everyday screaming for a pain 
pill.'' That's kind of when it was determined my high pain level is 
different than other people.
    I appreciate having an outlet to voice the things I have stated 
because no one else listens. I only pray the disability is approved 
soon and medicaid kicks in so I will be able to see real doctors in a 
real hospital/clinic. IHS genocide is working.
    I have been unemployed for a year now, I'm 57 years old and 
homeless as described by peoples opinion. I live in an abandoned camper 
on a Caucasian friends farm in a machine shed. I am grateful to have a 
roof over my head and able to keep my animals. I have no problem living 
this lifestyle because I know how to live without electricity and 
running water quite comfortably. I am resourceful, I am a woman and I 
am Dakota.
  Prepared Statement of Evelyn Espinoza, RN, BSN, Rosebud Sioux Tribe 
                          Health Administrator
    Dear Honorable members of the Committee,
    My name is Evelyn Espinoza. I am an enrolled member of the Rosebud 
Sioux Tribe and a registered nurse. Currently I serve as the Health 
Administrator for my Tribe. I am also a consumer of our Indian Health 
Services as is my family. I would like to take this opportunity to 
share with you my experience with the Indian Health Services in my 
current role.
    I began working for the Tribe on Sept. 30, 2014 as the Tribal 
Health Administrator. I entered this position after taking a year off 
from work and with just under 10 years of experience working for the 
Indian Health Services. The second week into this role, I went to 
Washington, DC where I had the opportunity to meet facetoface with the 
then Director of IHS, Dr. Roubideaux. I provided her and her staff in 
detail our concerns. I shared with her real life examples of 
substandard care being delivered at our facility. I spoke very directly 
that practices needed to change or lives were going to be lost, our 
certification with CMS would be lost, and we would lose services. I 
provided the agency with our expectations and what we wanted to see in 
the future. At the top of our list, next to safe, quality care, we 
asked to be involved. I asked to help, to be included in the 
decisionmaking for our facility and to have our input respected and 
acted on. I stressed the importance and critical need for the IHS and 
the tribe to work together, to create a healthy and trusting working 
relationship where we are both moving in the same direction 
accomplishing our common goals. She agreed with me, committed to 
actionable steps, but unfortunately, the follow thru did not occur.
    During the same visit we had the opportunity to meet in person with 
our SD Senators Thune and Rounds and Representative Noem. We met as a 
group and our tribal delegation met individually with each. We informed 
these officials of our same concerns. We shared real life examples. We 
asked for their support and we asked for the same from them as we did 
IHS. We asked to be involved, for our feedback to be considered and 
acted on. We voiced frustration with the ``tribal consultation'' 
practices and felt like it was not meaningful, rather felt like a 
dictatorship. We voiced frustrations about the lack of response and 
communication from IHS. Actually we all had this in common. IHS did not 
only disregard the tribe but also their leadership. To this day, I do 
not understand this.
    This visit I write about was the first of many held over the past 
year and a half. Our tribe has met regularly with local, regional and 
national IHS leadership. We have met with HHS leadership and CMS. The 
OIG came recently for a visit. Despite all these meetings and telling 
our story over and over, reliving the traumatic events repeatedly, 
demanding to be involved, to help, nothing changed and we continue to 
not have a voice. Infact, for our facility, we have steadily been 
declining and the decisions continue to be made for us not in 
collaboration with us.
    It is a very stressful situation for me, for my tribe, for my 
relatives. I have the responsibility to advocate for and protect our 
tribal people. It is asif I am being held down against my will and 
forced to endure abuse after abuse and no matter what I do, how hard I 
fight back, what approach I take, I cannot get out of this choke hold. 
We are forced to watch our relatives around us suffer, die prematurely, 
or take their own lives to escape this hopeless environment. What is 
going on in our community, with our healthcare delivery system is 
inhumane, its criminal and cannot be allowed to go on any further. How 
many people have to lose their lives to change how medicine is being 
delivered by the IHS?
    While there is an obvious need for additional funding, there is 
absolutely no reason other than poor leadership and mismanagement to 
account for our current situation we are living through today. A brief 
timeline of the last 6 months includes multiple false reassurances 
provided by IHS leadership. We have been told over and over ``things 
are under control.'' In fact, 2 weeks after the Winnebago Hospital lost 
their Medicare Provider agreement on July 23, 2015, I asked the Acting 
CEO of our hospital what they were doing to prepare for our CMS survey 
and how I could help. He told us they were prepared, they didn't need 
any help, things were on track. On Nov. 4, 2015 an accrediting body 
know as DNV hired under contract with IHS, came and surveyed our 
facility and noted we had the best survey we had in the past 8 years. 
They found very minimal concerns. A week later on Nov. 8, 2015 the OIG 
visited and the CEO of our hospital sent an email out saying 
``congratulations staff, we impressed the OIG, we impressed DNV, CMS 
bring it on!'' On Nov. 16, 2015 CMS arrives. On Nov. 18, 2015, CMS 
placed our emergency services in immediate jeopardy, stating they found 
situations in our ER that posed an immediate and serious threat to any 
individual seeking care there. On Dec. 6, 2015 our Emergency Services 
were diverted and continue to be.
    This diversion is not only affecting tribal members, it is 
negatively affecting ALL our community members regardless of race who 
are in need of emergency care. Furthermore, it is negatively affecting 
our surrounding communities and those small hospitals picking up the 
added patient load. They do not have the manpower and resources to keep 
up and as a result are starting to make mistakes that puts their 
accreditation at risk. This has a ripple effect on so many.
    As a young woman growing up, I did not have the privilege of 
knowing where I came from and who I was as a young Lakota woman. Those 
teachings left when my mother left this world. I was taught otherwise 
by good intended people deciding for me what they thought was in my 
best interest. It was not until later in life I learned about my 
ancestors. How amazing of a people we are, what amazing gifts we have 
and what an amazing way of life I work toward everyday to get closer 
to. Many events that have taken place over the past 200 years created 
this ``perfect storm'' we live in today. The most important thing I 
have realized is only I can change what I do and only you can change 
what you do. So I ask you all to self reflect, be honest and sincerely 
hear and feel what I am saying. We have all had different experiences 
in our lives that mold the way we think and react. But I have searched 
and searched and I can not find anything that supports the lack of 
courtesy and respect that exists in our leadership today at all levels. 
We either can choose to continue with the same status quo and same 
practices or we can choose to change how we lead, how we treat one 
another, how we protect one another. I am respectfully asking each of 
you to put politics aside and look at our situation from your human 
side. I want for each of you the same as I want for my relatives. I do 
not expect anything less than you expect for your loved ones. For any 
of this to change in a meaningful way and sustain the changes, we have 
to all change what we are doing. We have to respect one another and 
move forward together with this in a good way. I thank you from the 
center of my heart for your advocacy, support, time and energy. I 
eagerly look forward to working together and using each other's 
strengths to strengthen each other's weaknesses.
    Lila Wopila Tanka (Thank you very much),
 Prepared Statement of Darlene M. Wilcox, Ph.D., LP, Licensed Clinical 
    I have been working with IHS for almost 10 years as a Mental Health 
professional. I am writing this as a Oglala Lakota/Sioux tribal member. 
I started out working at the Pine Ridge IHS service unit as a Mental 
Health Specialist in 2006.
    When I started there, I worked in an hostile environment. 
Behavioral Health staff did not get along. My supervisor treated me 
terribly, even though I was a tribal member and had worked really hard 
to be a psychologist. (I graduated from UND, Grand Forks, ND in 1999. I 
was a member of the Indians Into Medicine program and Indians into 
Psychology Doctoral Ed. (INPSYDE) program.) I tried to go through the 
union about my poor treatment by my supervisor but I was discouraged 
from going through with this process by a union representative.
    While at Pine Ridge I.H.S., I worked long hours, did walk ins and 
was on call at least 10 times per month. Many times, I would get called 
in to ER, 2 or 3 times per night. I was then expected to report to work 
at 8am and do a regular shift. I worked hard and studied long hours to 
become a licensed psychologist.
    I transferred to the Fort Defiance, AZ, Adolescent Psychiatric 
Unit. It was the only Adolescent Psychiatric Unit within IHS. While 
there, it was a wonderful experience, to work with a whole team of 
mental health professionals; 2 psychiatrists, 2 clinical psychologists, 
3 Social Workers, 2 Teachers, 2 Psychiatric nurse practitioners, Art 
Therapist, 3 traditional, Navajo medicine people, social service aides, 
one Behavioral Health Chief, as well as working with outpatient, mental 
health staff. We worked with 12 youth per 6 week cycle, in between 
cycles, we had program development type of activities, trainings and 
healing ceremonies for staff to prevent burn out and also protection 
ceremonies were done for staff.
    While there at Fort Defiance, AZ we were invited to go to my 
reservation, the Oglala Sioux Tribe at Pine Ridge, SD, to present on 
the Adolescent Psychiatric Unit. I traveled to Pine Ridge and Rapid 
City, SD and we met with many OST tribal organizations, I.H.S at Pine 
Ridge, the Oglala Sioux Tribe. They were very interested in starting a 
Adolescent Psychiatric Unit at the Pine Ridge IHS service unit. We were 
also invited to attend a local, Sundance ceremony. We attended and we 
were very much honored and blessed for being there.
    As follow up to these invitations, the Fort Defiance Indian 
Hospital invited the Oglala Lakota Nation to go to Fort Defiance, AZ to 
view the Adolescent Psychiatric Unit. A few of the tribal members, Pine 
Ridge high school counselors and Dr. Garcia, psychiatrist at Pine Ridge 
IHS did go to Fort Defiance Indian Hospital to visit and view the 
Adolescent Psychiatric Unit. They were taken into ceremony immediately 
and the Navajo Nation representative, the Fort Defiance CEO and board 
members and Adolescent Psychiatric Unit met with the SD visitors. The 
Oglala Lakota delegation were treated like royalty. The SD group talked 
about the problems they faced on a daily basis on the Pine Ridge 
reservation. A special ceremony was held for the SD staff that went to 
    As the result of these initial meetings, the Fort Defiance Indian 
Hospital, sent their business and billing staff to Rapid City, SD to 
provide the tribal and IHS service unit, valuable information on how to 
start their own Adolescent Psychiatric Unit. Fort Defiance Indian 
Hospital at that time, was making almost 9 million a year from federal, 
pass through monies and third party reimbursements for the Adolescent 
Psychiatric Unit. It cost 3 million to pay for the staff, so actually 
they made a profit of $6 million per year. The Fort Defiance Indian 
Hospital benefited tremendously from the Adolescent Psychiatric Unit.
    What stopped this endeavor from happening was the Behavioral Health 
leadership in 2010-2011, at the Aberdeen Area office. My Navajo 
supervisor, the Behavioral Health Chief (2011) heard from the 
Behavioral Health Director at IHS Headquarters: ``She said Aberdeen 
Area, was very upset with Fort Defiance, Adolescent Psychiatric Unit, 
for going to Pine Ridge to present on the adolescent psychiatric unit--
because Aberdeen Area office had plans of their own, to build a 
psychiatric unit at Rapid City.'' I said ``As an Oglala Lakota tribal 
member and Clinical psychologist, my tribe, the Oglala Lakota and Pine 
Ridge IHS and our Lakota traditional and spiritual healers and elders 
invited us. We didn't go there on our own, or because I am an Oglala 
Lakota/Sioux tribal member, they invited us and they want information 
to help the youth there.''
    I have worked at other IHS service units in the Great Plains Area, 
I have had positive and negative experiences. I have always have had a 
good relationship with my patients and tribes I have served.
    We do have educated, tribal people who are health professionals. We 
also have a lot of non-Indian, health professionals, who want to do 
things their way. I was informed by the tribal attorney that he has 
almost enough tribal people from the Crow Creek Sioux Tribe to file a 
class action, law suit again Fort Thompson Health Center, 
administration for discrimination against tribal employees.
    At Fort Thompson, they went through 7 or 8 Behavioral Health 
Directors within 5 years, about 7 acting before I started working 
there. I was met with a lot of resistance. There was a psychiatric 
nurse, who was acting before I started and she refused to attend my 
meetings, she was very non-compliant. I asked the CEO for help with 
this matter. He ignored me and let the psychiatric nurse get away with 
her unprofessional behavior. I left and heard later, the psychiatric 
nurse was again, acting, BH director. She had gotten into trouble for 
writing a prescription for her sister (non-native), her sister stole 
her prescription pad and wrote her self prescriptions. The SD Attorney 
General prosecuted the psychiatric nurse, she received a misdemeanor 
and was not disciplined by IHS and she is still the acting BH director.
    At Sisseton, SD, I witnessed and heard about a Clinical Director 
(2012-15), who chased away, most of the American Indian, medical 
doctors. She wrote them up for reasons that did not pertain to their 
practice. I applied there for a clinical psychologist position, she 
cancelled the position and it was reported to me later that she 
mentioned my name in a medical staff meeting that she did not want to 
hire me because I was using Indian Preference. She did that to another, 
American Indian woman psychologist who also applied at a different 
    I worked at the Kyle Health Center, from 2013-2015, during the 
suicide epidemic. What IHS HQs, did to address the issue, was to 
detail, mental health staff who were not able to work with the more 
complex cases. (CPS issues, developmental issues), they also detailed 
psychiatrists to administer medication via tele-psychiatry. I was the 
only psychologist working on the Pine Ridge, SD reservation for 2 years 
and 2 months. There was no housing there for me at Kyle Health Center. 
I had to commute 87 miles one way, each day to get to work. I also 
worked four, 10 hour days; I left my home at 6am each morning, I did 
not return home until 7:30 p.m. or 8 p.m. each night, depending on the 
weather. When I left there I was wore out, I was so tired from the long 
commute each day.
    In the short time I was there, I was able to complete over 100 
psychological evaluations, I referred them to a psychiatrist, 
psychiatric nurse practitioner for their medication if they needed to 
be on medication. When IHS detailed all the psychiatrists via tele-
behavioral health, less than 10 percent needed to be seen by the tele-
psychiatrists. Some of my patients did not want to be started on 
psychotropic medications, they wanted to get help via natural remedies; 
exercise, diet, traditional and cultural ceremonies, talk therapy.
    What the communities wanted was more mental health professionals 
who were able to go out to the cultural and spiritual camps, schools, 
district buildings, to do talking circles, grief groups, make home 
visits. They wanted activities for the youth such as jobs, educational 
opportunities, sport activities, safe houses for youth and elders.
    I do not see the Behavioral Health consultants meeting with the 
elders, community people to obtain their ideas for the youth on the 
reservations. The consultants tried to push their philosophies and 
ideas on to the Indian people. Their ideas did not apply to a rural 
    My reasons and rewards for working long hours and traveling long 
distances; is that I love my people. I committed myself to my people at 
a very young age, to get educated, to help my people in every way that 
I can. This is why I am here. You need to offer more incentives to the 
tribal, medical and mental health I.H.S. workers to help them buy their 
own houses so that they can stay and work on their own reservations. 
For those medical staff that have to commute, you need to develop a 
transit system so that they can ride it to work.
    You need to do the reservation wide, community needs assessments, 
you need to listen to the tribal voices. You need to have the respect 
and compassion necessary to hear those voices. Honor the people who do 
a good job. Hire the traditional and cultural healers at the Great 
Plains Area IHS service units, so that they can provide ceremony to the 
patients and staff like the Navajo Nation does. They provide healing 
services and they are able to do business so well, they are making a 
profit, so that they can continue to improve and expand their services.
    Thank you for your time and attention.
    Prepared Statement of Jane Dilldine, Supervisory General Supply 
                  Specialist, Pine Ridge IHS Hospital
    Good morning,
    I am a 29\1/2\ year employee with Exceptional Service at the Great 
Plains Area, currently serving as the Supervisory General supply 
Specialist at the Pine Ridge Service Unit. Prior to transferring to the 
Pine ridge Service Area, I serve as the Supply Management Specialist at 
the Area Office.
    Since transferred to Pine Ridge in 2003, I have been discriminated 
against, retaliated against, I have been placed on extended 
Administrative Leave, Transferred to the Wanblee Health Center, given 
letters or reprimand, directives, suspensions and currently one step 
away from being removed from service. Yet, during all the years that I 
have work for IHS including the years at Pine Ridge, the lowest PMAP 
rating I received was ``Achieved More Than Expected Results.
    In January 2014, on the day I returned from the first suspension, I 
was in a meeting with one of my staff that was requested by my 
supervisor Duane Ross. The employee had also filed an EEO complaint 
against Mr. Ross. During the meeting Mr. Ross confronted us for 
comments made to a EEO Manager. Mr. Ross stated ``You need to know that 
what you state to EEO is not confidential'' and ``Why did you say that 
I said `employee' could be fired''. The only statement I made during 
this meeting was that I stood by any statement I made to EEO. I was 
then suspended again because Mr. Ross reported that I called him a 
    This suspension was upheld by the Deputy Area Director, even though 
Mr. Ross admitted the he asked us these questions and both my statement 
and the employees statement which was provided stated the no one called 
him a liar. In my response I stated my belief that the suspension was 
in retaliation for my EEO Activity. The Deputy Area Director did not 
conduct a investigation into my allegations.
    In 2014 I received the ``Achieved More than Expected'' Results and 
in 2015 I received the Achieved Outstanding Results. If this is how the 
Great Plains Area treats their Outstanding employees, how do they treat 
their ``average'' employees. Is it any wonder that the Area cannot 
recruit or retain highly trained and qualified staff. And why there are 
so many vacancies in Critical Positions throughout the Area.
    I am, in my own humble way, asking you to read my story (see 
attached) and consider it during your investigation and hearing on the 
Great Plains Area Office.
    I authorize the Senate Committee access to my personnel record and 
any documents that would be needed to verify any statements I made in 
the attachment.
    Thank you in advance for your consideration.
  Prepared Statement of Hon. Marilynn Malerba, Chief, Mohegan Tribe; 
  Board Member of Self-Governance Communication and Education Tribal 
 Consortium; Chairwoman, IHS Tribal Self-Governance Advisory Committee 
    On behalf of the Self-Governance Communication & Education Tribal 
Consortium (SGCETC), \1\ I am pleased to formally submit this written 
testimony to support the ongoing efforts of the Indian Health Service 
(IHS). This testimony will highlight policy, legislative, budget, and 
administrative changes that would work to improve health care delivery 
for those that depend on medical and public health services from IHS, 
to raise their health status to the highest level possible and to 
ensure the success of the Indian Health Care System. I commend the 
Committee for hosting this opportunity to gather input from Tribal 
Leaders and Administrative officials to address critical concerns 
regarding the IHS.
    \1\ The Self-Governance Communication and Education Tribal 
Consortium consist of Tribal Leadership whose mission is to ensure that 
the implementation of the Tribal Self-Governance legislation and 
authorities in the Bureau of Indian Affairs (BIA) and Indian Health 
Service (IHS) are in compliance with the Tribal Self-Governance Program 
policies, regulations and guidelines.
    Self-Governance is a Tribally-driven, Congressional legislative 
option that recognizes the inherent right of Tribes, as sovereign 
nations, to negotiate annual appropriated funding and assume management 
and control of programs, services, functions and activities that were 
previously managed by the Federal government. It allows Tribes to 
determine their governmental priorities, redesign and create new 
programs and services and reallocate financial resources to more 
effectively and efficiently fit the needs of their Tribal citizens and 
communities. The growth and success of Self-Governance, within the IHS 
is best documented by the 351 Tribes currently participating in Self-
Governance compared to the 14 Tribes who initially signed agreements in 
1992. Together Self-Governance and Title I Contracting Tribes represent 
62 percent of Tribal governments who operate $1.8 billion in healthcare 
programs each year.
    Over the last two decades, Self-Governance Tribes have markedly 
improved the nation-to-nation relationship between the United States 
and Tribes. However, this success has required active engagement, 
cooperation and the collaboration of administrative officials across 
the Federal government, Congress, and Tribal Leadership. Improving 
patient care throughout the entire Indian Health Care System requires a 
similar approach. First, Congress must uphold its commitment to Tribal 
Nations by fully funding IHS. Without adequate funding the system 
cannot be expected to provide quality care to patients or to attract 
qualified, long-term providers and administrators. Second, the entire 
Federal system must work collaboratively to improve the conditions at 
Indian Health Service, Tribal and Urban (ITU) facilities within the 
Indian Health Care System. Lastly, Tribal Leaders must have a leading 
voice in decisions made regarding the health delivered in their 
    SGCETC proposes Congress focus its work in three areas: (1) 
stabilize and increase funding to IHS; (2) encourage administrative 
flexibility and collaboration; and, (3) adopt effective communication 
and partnership with Tribal Nations.
I. Stabilize and Increase Funding to the Indian Health Service
    Despite trust and treaty obligations to provide for the health care 
of the American Indian/Alaska Native (AI/AN) populations, Congress 
continues to severely underfund IHS without regard to meeting basic 
health care service needs for AI/AN and fulfilling requirements such as 
providing adequate health care facilities. Underfunding healthcare 
directly contributes to the poor health status and life expectancy of 
AI/AN. Within this overall context, SGCETC has identified the following 
top budget and related issues that would improve patient care by 
increasing appropriations and leveraging current opportunities:
    Protect the IHS budget from sequestration. Despite the 
unprecedented increase of 29 percent in the past 4 years, funding 
levels for AI/AN healthcare remain dangerously low. \2\ Tribal 
governments experienced severe budgetary cuts after the 2012 
sequester--which resulted in a decrease to the IHS budget of $220 
million. \3\ These cuts had a devastating impact on direct services 
provided to AI/AN patients, with an estimated elimination of 804,000 
outpatient visits and 3,000 inpatient visits. As Congressional members 
debate the FY 2017 appropriations, Self-Governance Tribes first, urge 
Congress to restore Tribal funding cuts and, second, to uphold the 
Tribal trust responsibility and amend the Budget Control Act of 2011 to 
exempt Tribal funding from future sequesters, budgetary reductions and/
or rescissions.
    \2\ National Congress of American Indians Policy Research Center. 
(2013). Geographic & demographic profile of Indian country.
    \3\ Native Care Act, H.R. 4843, 113th Congress (2013-2014) (2014).
    Support Advance Appropriations for IHS in the FY 2017 Budget 
Request. Since FY 1998, there has been only one year (FY 2006) when the 
Interior, Environment and Related Agencies budget, which contains the 
funding for IHS, has been enacted by the beginning of the fiscal year. 
Late funding creates significant challenges to Tribes and IHS provider 
budgeting, planning, recruitment, retention, provision of services, 
facility maintenance and construction efforts. Providing sufficient, 
timely, and predictable funding is needed to ensure the Federal 
government meets its obligation to provide health care for AI/AN 
people. Enacting advanced appropriations will ensure more stable 
funding and sustainable planning for the entire Indian Health Care 
system by appropriating funding two years in advance.
    End discretionary decisions within the IHS budget. Unlike other 
health programs such as Medicare and Medicaid, IHS is funded as a 
nondefense, discretionary line item, creating an inconsistent funding 
environment year-to-year and ignoring external factors that contribute 
to the recognized growing gap between IHS and other public health 
programs. \4\ Transferring the IHS budget to the mandatory side of the 
budget would adequately represent the trust and treaty responsibility 
due to AI/AN, while creating a consistent budget based on important 
factors such as population growth, inflation and evolving technology. 
    \4\ Moss, Margaret. P Ed. and Malerba, Marilynn. American Indian 
Health and Nursing. Springer Publishing NY, NY pp. 323-336.
    \5\ White, J. (1998). Entitlement budgeting vs. bureau budgeting. 
Public Administration Review, 58 (6), 510-521.
    Fully fund Indian Health Care Improvement Act (IHCIA) provisions 
related to patient care. Health reform represents a significant 
opportunity for Tribal and IHS programs to sustain, improve, and build 
innovative health systems in Tribal communities. However, to date, 
there are more than twenty-five (25) unfunded authorities in the Indian 
Health Care Improvement Act (IHCIA), each representing an unleveraged 
opportunity to increase and improve services for American Indians and 
Alaska Natives across the Nation. Therefore, successful implementation 
of the law is of great importance to Tribes and hinges on the full 
funding of the permanent reauthorization of the IHCIA and the 
overarching Affordable Care Act (ACA). The SGCETC respectfully requests 
funding increases to begin implementing the twenty-five unfunded 
authorities in IHCIA and countless others in the ACA.
    Fully support the IHS Information Technology System. The Resource 
and Patient Management System (RPMS) is the decentralized health 
information system used to manage both clinical and administrative 
information in IHS healthcare facilities. However, due to budget 
constraints and demands to meet growing industry and government 
standards, IHS has not been able to commit resources to update RPMS in 
every Area. Failure to maintain this system properly has resulted in 
lost revenue to IHS and Tribal facilities across the country. A short 
term influx in funding to bring RPMS up to industry standards in every 
area could result in more streamlined care as well as increase third-
party revenue to the Indian Health Care System.
    Invest in Self-Governance Planning and Negotiation Grants. More 
than two decades of Self-Governance in IHS has shown that Tribal 
governments can and often do deliver better quality care in a more 
efficient and culturally competent manner, improving the health and 
welfare of communities significantly. Congress should increase its 
support for Tribes wishing to plan, prepare, and negotiate for Self-
Governance programs. The easiest way to build the internal capacity for 
Tribes to make the transition into Self-Governance is to commit more 
Federal funds for planning and negotiation cooperative agreements. This 
year, due to inadequate funding, only five planning and two negotiation 
cooperative agreements were provided to a growing list of Tribes 
seeking alternative and innovative solutions to provide better care.
II. Encourage Administrative Flexibility and Collaboration
    Ultimately, improving patient care requires more than the provision 
of adequate funding. We must also embrace and advance innovative and 
collaborative approaches to providing programs and services in order to 
achieve sustainable healthcare. The Administration can take action to 
improve its business practices, open additional streams of revenue, and 
leverage funding opportunities that already exist within the Federal 
government to provide quality care, expand services, and hire qualified 
providers and administrators. However, each of these solutions requires 
Federal agencies across the entire government to allow greater 
flexibility and collaboration. SGCETC offers the following solution to 
administratively improve patient care:
    Expand the IHS-Veterans Administration Memorandum of Understanding 
to Include Purchase and Referred Care. When the IHS and the Department 
of Veterans Administration (VA) negotiated the first national 
agreement, required under the IHCIA, they only included reimbursement 
for direct care provided by IHS facilities. Failure to include 
Purchased and Referred Care (PRC) is a disservice to Veterans and does 
not adequately address the specialty care that is needed while imposing 
a financial burden on Tribal healthcare systems which provide eligible 
veterans care at its own expense. After two years of implementation and 
changes to the VA health care delivery, Self-Governance Tribes believe 
the time is right to revisit the reimbursement agreement and include 
    Enact Medicare-Like Rates for IHS outpatient services for ITU 
facilities. IHS, Tribes and Tribal organizations currently cap the 
rates they will pay for hospital services to what the Medicare program 
would pay for the same service (the ``Medicare-Like Rate'' or ``MLR''). 
Currently, this MLR cap applies only to hospital services, which 
represent a fraction of the services provided through PRC. In December 
of 2014, IHS proposed a rule to amend the current rule to apply 
Medicare methodology to all physicians, other health care professional 
services and non-hospital based services that are authorized for 
purchase by the IHS and Tribal PRC programs or urban Indian health 
programs. Tribes generally support the proposed rule with limited 
changes and provided recommendations to allow for the greatest 
flexibility. To date however, a final rule has not been published.
    Previously, Congress also proposed legislative fixes to amend 
Section 1866 of the Social Security Act (SSA) to expand application of 
the MLR Cap. It would direct the Secretary to issue new regulations to 
establish a payment rate cap applicable to medical and other health 
services in addition to the current SSA cap on services provided by 
hospitals. It would make the MLR cap apply to all Medicare-
participating providers and suppliers. Self-Governance Tribes support 
this legislative fix to leverage the limited resources provided to IHS, 
Tribal and Urban health programs.
    Bolster the recruitment and retention of qualified providers and 
administrators. Recruitment and retention of qualified health providers 
and administrators is at the crux of improving patient care. IHS, along 
with Federal partners such as the Departments of Housing and Urban 
Development (HUD) and Agriculture (USDA), the Health Resources and 
Services Administration (HRSA) and others, must adopt a reengineered 
business model that directly focuses on identifying the external 
factors and effective strategies that contribute to physician and 
administrator recruitment.
    Additionally, Congress could take steps to approve legislation that 
would amend the Internal Revenue Code to exclude from gross income, 
amounts received under the IHS Loan Repayment Program and the Indian 
Health Professions Scholarships Program, which are currently a drain on 
the appropriations extended to IHS.
    Support legislation to expand Self-Governance under a Demonstration 
Project within HHS, by amending the Indian Self-Determination and 
Education Assistance Act (ISDEAA). Title VI of the ISDEAA required the 
Secretary of Health and Human Services (HHS) to conduct a study to 
determine the feasibility of a Tribal Self-Governance demonstration 
project for appropriate HHS programs, services, functions, and 
activities (and portions thereof) in agencies other than IHS. HHS 
submitted the required report to Congress in March of 2003. The report 
concluded that the demonstration project was feasible. Although 
Congress has considered legislation to authorize a Self-Governance 
demonstration project, legislation to advance this initiative has not 
been enacted into law to date.
    HHS has more than 300 grants specifically available to Tribal 
governments. Yet, Tribes are unable to fully maximize these 
opportunities because they are often short-term or one-time sources of 
funding. Additionally, these opportunities often focus on prevention or 
treatment of the same health issues, such as suicide, substance abuse 
prevention, heart health, or diabetes, but cannot be leveraged together 
to provide holistic health care to AI/ANs. Distributing funding through 
grants does not fulfill the trusty responsibility and does not lead to 
improved, long-term health status indicators. Expanding a model with a 
proven track record, such as Self-Governance, would continue to improve 
the nation-to-nation relationship and allow Tribes to leverage funding 
from across HHS to support preventative and direct care, to enhance 
substance abuse and behavioral health services, and to manage their 
health systems similarly to other public and private entities.
    Tribal efforts to continue working on the expansion of Self-
Governance was recently realized in the transportation reauthorization 
legislation. P.L. 114-94, the Fixing America's Surface Transportation 
Act (FAST Act) made several important changes to the Tribal 
Transportation Program, most notably created a Department of 
Transportation (DOT) Tribal Self-Governance Program which extends many 
of the Self-Governance provisions of Title V of the Indian Self-
Determination and Education Assistance Act (ISDEAA) to DOT. The FAST 
Act also provides modest funding increases for the Tribal 
Transportation Program (TTP) and the Tribal Transit program as well as 
a number of technical changes to these programs. So why, after more 
than a decade of asking has HHS been so unwilling to advance the same 
opportunities for Self-Governance in HHS?
III. Adopt Effective Communication and Partnership with Tribal Nations
    During its sixty-year history as an agency committed to improving 
the health of American Indians and Alaska Natives, IHS has had many 
successes and downfalls. Like any other public or private organization, 
IHS will require consistent and transparent methods to evaluate and 
identify issues, to implement changes, and to respond to external, 
unknown factors. Instead of relying on Congressional action each time, 
the following recommendations should be adopted:
    Utilize formal and informal communication methods to encourage 
community partnership with Tribal Leaders. Delivering proper health 
care in Tribal communities requires true partnership between Tribal 
Leaders and agency officials. Since the Clinton Administration, 
Presidents have reaffirmed the responsibility of Federal agencies to 
consult with Tribal governments before taking actions that affect their 
communities. Though Tribal consultation is an excellent way to 
establish a set of principles, direction, or directly respond to a 
proposal, this formal communication does not allow for regular exchange 
regarding issues that arise outside of the formal policy process. 
Tribal Leaders maintain a close pulse on their community and the 
effects of proper health delivery. IHS should adopt methods to 
efficiently and effectively exchange information with Tribal Leaders in 
a manner that allows them to identify issues earlier and respond more 
    Institutionalize stakeholders throughout the Indian Health Care 
System. Another opportunity to tie Tribal communities to the 
performance of the Indian Health Care System is to regularly engage 
leadership in the administration and direction of local health 
facilities. IHS has adopted a process in other areas that allows Tribal 
Leaders and other experts to participate regularly in the governance of 
hospitals and clinics that impact the health of their citizens. 
Replication of this process would provide IHS with another avenue to 
hear from stakeholders and allow Tribes an opportunity to be part of 
the solution before issues negatively impact patient care.
    Direct IHS to develop an annual report which shows how well the 
Federal Government has upheld its Treaty Obligations and Trust 
Responsibilities to Tribes. Reporting on achievements is critical to 
winning and maintaining support. If the ``performance-based budgeting'' 
uses statements of missions, goals and objectives to explain why the 
money is spent, then similar objectives, goals and measures should be 
tied to the United States government honoring the treaties and 
fulfilling the trust responsibility. While our budgets remain at the 
discretion of Congress to sequester, decrease and eliminate services, 
we have no tools to leverage the broken promises to Indian people. 
There should be equal standards of performance and results to hold the 
United States accountable for not upholding the agreements between our 
nations and not honoring its word.
    In closing, SGCETC again thanks the Committee for the opportunity 
to submit testimony. We look forward to working with you to initiate 
positive changes that will improve the health and welfare of every 
Tribal citizen throughout Indian Country.
    My name is Steve L. Garreau and I want to tell you about what 
happened to me at the Eagle Butte IHS ER back in 2015.
    I went to the ER because I was having really bad nose bleeds and 
they would not stop. The ER doctor had them hold me down and she shoved 
a tube into the nostril that was bleeding and it was too big but she 
shoved it in any way and it hurt so bad. But after she had done this 
did she realize that it was to big and then she took it out and shoved 
a smaller one into my nostril. I do not normally holler from pain but 
when she shoved that big tube into my nostril, I hollered out in pain 
because it hurt that bad.
    Now as a result of the damage done to my nostril I have periods 
when I lose my sense of smell in it and it tends to discharge more than 
usual and I have headaches.
    They sent me to Rapid City and the ER doctor out there was really 
angry at what they did to me. He said that they tore up the inside of 
my nostril. He even wrote a statement about what they did to me. That 
statement is on file with Senator john Thune's office. A copy can be 
                                          Steven L. Garreau
    I am MeIda Garreau I am 85 years old and I live in Eagle Butte, 
South Dakota. I have been neglected by the Ii-IS clinic. I have seen so 
many Doctors and PA it is only to repeat over and over my condition and 
never get no satisfaction and my health deteriorates. I have cancer and 
in this cancer and it is so bad I can't think straight. I have this 
lump in my mouth for 12 years now. I keep telling the doctor and I 
continue to see the doctor on this lump but to no avail. They keep 
saying we will see you again all the time and then when it finally 
turned to cancer after a biopsy I've been really bad it came back again 
last month.
    My health deteriorated back in 1978 when I got a lump in my left 
side bottom jaw and when I check to see a doctor they slide me along no 
one cares to care unless it's a matter of death. Well, a Dr. Carlson 
kept seeing me every 3 or 4 months. He would say it is not growing and 
releases me. This went on till it turned into cancer. I was sent to 
Minnesota University Hospital in Minnesota the doctor removed a part of 
it cause the cancer wrapped around my jaw GOD! I don't want anyone to 
go through what I did.
    Finally a Dr. Gray sent me to Mayo Clinic, Rochester, MN. They did 
a major surgery and I can't eat just liquids am so hungry I am sad all 
the time.
    The cancer came back aggressively had surgery and 6 weeks of 
radiation. I am now waiting for an appointment to go back to Rochester, 
MN at the Mayo Clinic if I am cancer free. I am very fatigued so I stay 
in bed all the time. I also had cancer in my breast in 1994 and 1996 
because they didn't follow up on me.
                                              Melda Garreau
    My name is Brenda (Clown) Veit I am 58 years old.
    I kept going to IHS for over a year for my bones hurting. No 
arthritis I was told. My last visit was June 2015. My wrist was swollen 
and my bones were getting deformed. Still I was told nothing was wrong.
    I finally went to the Women's Health and they completed breast exam 
and immediately referred me out. I was given biopsy and diagnosed with 
4th stage cancer in August 2015. I have cancer in seven different 
    If blood work were done they could have caught it. I now have 
terminal cancer with a diagnosis over a year left.
                                                Brenda Veit
    IHS Incident on January 1, 2018
    On December 29, 2015 I hurt my back while cleaning seeing that I 
couldn't solve the problem of Pain myself I went into the ER. at the 
IHS hospital in Eagle Butte, South Dakota on January 1, 2016.
    I saw Dr. Mauricio Ferrel and he had an X-ray done on me. My pain 
level was at least a 9. While getting the X-ray the technician grabbed 
me by the ankles and pulled me down on the table to where he wanted me. 
Having had to hip replacements and the lower back pain this action 
caused me even more pain that made me cry. He could have told me to 
move down toward the end of the table instead of pulling me by the 
ankles I was in so much pain and I told the doctor what happened. I 
told him (the doctor) that you can't be pulling on a 78-year-old woman 
like that without something happening. Before leaving the hospital I 
was given a shot for pain but it did not help. The doctor refused to 
give me something else for the pain he explained that the hundred 
milligram of Celebrex that I am taking for my rheumatoid arthritis 
should be adequate. But it wasn't it drove me to see a doctor not 
connected with IHS to finally find relief.
                                      Ardis LeBeau Warcloud
    For 27 months my husband had total hip replacement at Black Hills 
surgery. Since that time he has been having swollen legs, knees and 
feet, severe pain in hip/leg area.
    He has been sent to Bismarck, ND, Sanford twice for misdiagnosed 
heart attack due to faulty CT scanner or blood test. Sanford has 
informed us that over ten patients were misdiagnosed for false alarm of 
heart attacks. We appreciate Eagle Butte IHS concern for my husband's 
heart but he was thoroughly tested and Sanford showed no blood clots 
either in legs, or heart, head nor chest areas.
    As his spouse, I am the opposite in regards to heart attacks. I 
have been diagnosed with cardiovascular disease and I have had two 
heart attacks in Arizona in IHS. I was sent via ambulance to Casa 
Grande hospital for treatment. Due to high charges by ambulance I have 
not been able to get Eagle Butte IHS to pay for $1,800.00 ambulance 
fees, MRI and CAT scan due to a truck running into the driver's side of 
my van. As I tried to hold on to the steering wheel my right shoulder 
was torn from bone to ligament, collarbone cracked, and resulted in 
shoulder cuff surgery, when no other doctor at IHS could diagnose my 
need for a shoulder cuff surgery two years after the surgery, a 
specialist in bone/joint surgery diagnosed and performed a shoulder 
cuff surgery two years after the truck accident. I have been in severe 
pain since the accident which occurred in Casa Grande, Arizona. I have 
been doing physical therapy for two years until this last PT therapist 
told me he cannot help me any further because he has no training in how 
to use the neck-spine stretcher machine.
    I was told that IHS cannot pay for my medical bills over 30 days. 
My medical bill occurred over 2 years ago. I had asked if they IHS can 
help me pay it but I was refused. I am requesting your assistance in 
having IHS pay this outstanding medical bill for me. Thank you for your 
attention into this matter.
                                   Mona Grey Bear Walks Out
    Concerning our IHS Health Facility at Eagle Butte, South Dakota. I 
would like you to know how much we appreciate this hospital. If not for 
this hospital, we would not have emergency or medical care for most 
people in this area. Had IHS not been here, I would have lost family 
members and friends to heart attacks, appendicitis, pneumonia, strokes, 
cancer, and car accidents. I am grateful beyond words.
    We have a wonderful staff at our IHS. Of course, there are 
occasional exceptions, but nothing is perfect in this world. As a rule, 
our medical staff and doctors are exceptional, they do everything 
humanly possible to help as many as they can. The problem is their 
hands are tied much of the time, because of funding. Doctors are forced 
to provide healthcare on the basis of most life-threatening leaving 
much preventive care undone.
    There are many stories and examples, but one that comes to mind is 
an 11 year old granddaughter. She was swinging when her flip-flop 
caught on something that turned her foot backward, and stabbed a large 
sliver into the arch of her foot. We removed the sliver, and soaked her 
foot in epsom salt, but she was still not able to put her weight on it, 
and was still complaining of pain, so we took her in, and she was given 
antibiotics and told to soak in epsom salt. It was x-rayed, but nothing 
could be seen. Two weeks later, it broke open and another piece of the 
sliver came out. We took her in, and were told to soak it more. Since 
that time, it has healed over, but there is a bright pink lump on her 
arch, since June 2014. It is unfortunate that her foot is not priority. 
I don't blame Doctors, I blame funding.
    My cousin was a diabetic on dialysis. He had trouble controlling 
his blood pressure and blood sugar, and when his blood sugar was 
finally stable; his insulin changed to a lower cost insulin, which made 
him sick, and caused his blood sugar to fluctuate again. Doesn't make 
sense to me. I understand cost cutting, but I think it's costing more 
in the long-term.
    It is too bad that people who have gone thru years of training, and 
have the ability to help others in need are stifled by pharmaceutical 
companies, insurance companies, and government budget cuts, which 
prevent them from doing what they have devoted a great deal of their 
lives of training to do. Unfortunately, that untrained people that 
control pharmaceutical companies, insurance companies, and government 
representatives, who have not taken an oath to save lives, have so much 
control over our health.
    It is my intent in this letter to voice my concerns, and do also 
ask that funding that in previous years has been subject to budget 
cuts, be restored to our IHS facility. Surely, funding services that 
have been in place providing services to their patients is at least as 
important as paying representatives of the people to force us to pay 
more of our earnings to our insurance companies for health and drug 
insurance, and giving them control as to where, when, who, and how we 
can be treated; which medications we receive, and what cost. I don't 
often seek medical treatment, I have never been able to afford medical 
insurance, but if I do ever seek medical attention, I prefer a Doctor 
to an insurance agent, or a drug manufacturer.
        Yours Truly,
                                       Georgina J. Red Bear
    Please, Please, read the grievance below and remember the dates are 
wrong but major issue is I was in a middle of an emergency and just 
brought my brother home few hours prior to the leave request that 
morning prior to start of my tour of duty to transport him to the IHS 
Hospital/primary care provider to re-do his labs due (hyperkalemia) and 
then re-assess him. Had that had happened like it should have I truly 
believe he would still be here. Everyone is telling me the opposite but 
he was only 47 and didn't my assistance prior to this incident. But 
because the supervisor had sent the upsetting text refusing my leave 
request my brother's attitude who was initially cooperative had took a 
turn and adopted the ``I don't want to be a burden'' theme and told me 
to leave him alone! he is fine! and denied all requests to go the 
hospital. Later that night, I called the ambulance he complaining of 
SOB and died in the ambulance. We were very close and I am in therapy 
praying for some type of closure. They didn't give me a new supervisor 
like I requested and forcing me to answer to her again without even an 
apology has made me angry. People in support of me said it would not do 
any good because it would not have any sincerity in it. I am very hurt 
and do not want to work here anymore under such inadequate supervision 
and taking it day by day hoping another job will appear soon that I 
would be able to apply for. Please make sure all supervisors are 
academically trained and up to par with their positions so a similar 
situation does not re-occur.
                                         Charlene M. Janis,

    From: Janis, Charlene (IHS/ABR/RCH)
    To: Bruce, Pauline

    Subject: RE: Stage 1 Griveance
    Thanks, I am so grateful and yes this my first day back. not the 
same! The dates need are what you said but other than that very true 
and I will keep in touch Pauline. A quick mention I am wondering if 
other supervisors are up to par with sick leave requests and able to 
recognize serious health conditions. I have a husband and with a 
defibrillator need someone like Lynn who competent to address and any 
serious issues with should they arise.
    I read that is Sioux Sans responsibility to ensure all supervisors 
are to be competent in everything and can be held liable for their 
misconduct one for making false statements via email or text or not 
recognizing serious medical condition a violation of the FMLA act.
                                          Charlene M. Janis

    From: Bruce, Pauline
    To: Janis, Charlene

    Subject: FW: Stage 1 Griveance
    Charlene: Providing you a copy of what I submitted (see below). I 
may not have dates correct but that's ok. I didn't want to make you go 
over the whole event again but I did state on or about so that leaves 
it open. I did not want to miss the timeframes so went ahead and filed. 
I will be away Monday and Tuesday next week but hope to touch base with 
you when I return.
    Let's see where this goes. Again, I'm so very, very sorry for your 
        Keeping you in prayer,
                                              Pauline Bruce

    From: Bruce, Pauline
    To: Alberta Bad Wound, Lynn Pourier

    Subject: Stage 1 Griveance

    Importance: High

    Grievant: Charlene Janis, Medical Records Tech


    On or about December 6th, BUE, Charlene Janis, requested leave to 
address an emergent issue with her brother's health. BUE, Charlene 
Janis is the custodian of said brother and is responsible for his care. 
Ms. Janis shared with her supervisor the critical health issues 
concerning her brother. Ms. Janis requested leave and supervisor denied 
and stated that she would be AWOL. Following that event BUE, Charlene 
Janis went to meet with supervisor to take in documentation of 
brother's discharge from hospital papers to verify the seriousness of 
his illness, brother was to go back the following morning. Supervisor 
was no where to be found to get approval and employee ultimately had to 
seek approval from second line supervisor, Lynn Pourer who approved 
leave without pay. BUE, Charlene Janis, was emotional, distraught and 
severely stressed and wanted to ensure that she received approval prior 
to being out of the office. Supervisor, Alberta Bad Wound, showed no 
compassion, concern nor did she offer her availability to assist BUE 
during this critical, emotional time. Brother of BUE, Charlene Janis 
passed away on December 7th, the following day in which employee was 
attempting to secure leave approval. BUE, Charlene Janis at this time 
is grieving the loss of her brother and the added emotional stress she 
was put through by her supervisor.
    Supervisor Alberta Bad Wound has violated Article 1, Section 7 and 
Section 16.


        1. BUE, Charlene Janis be assisted with processing appropriate 
        paperwork and approved for the Leave Share Program. 
        Notification of approval of Leave Share be sent to all 
        employees within IHS to seek leave donors to address the period 
        of time in which BUE, Charlene Janis needs to be away from duty 
        during this period of grief and time of healing.

        2. BUE, Charlene Janis, be referred to Employee Assistance 
        Counseling to allow her time and the opportunity to meet with a 
        grief counselor. Time allowed to attend counseling will be in 
        accordance with policy for EAP Counseling. Use of Official 

        3. BUE, Charlene Janis be assigned under the direct supervision 
        of Lynn Pourier, the second level supervisor who showed real 
        compassion and concern for the BUE during this difficult time.

        Respectfully Submitted,
                                              Pauline Bruce
                                 [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                 Prepared Statement of Kiros A.B. Auld
    My grandfather was an Urban Indian living and working in the 
Washington, D.C. area, hailing from a non-Federal Tribe. Despite his 
test scores, he was pulled out of school at the age of thirteen because 
``as a man'' it was time for him to ``pull his weight'' for the family 
and he was the darkest of his siblings. Outside of his unit in World 
War 2, you wouldn't have heard of him from deed or song. An old man 
working odds and ends, he found a sore on his foot that would not heal. 
Left untreated, gangrene followed, resulting in the doctors taking his 
foot. That wasn't enough to save him, so the doctors took more of his 
leg. Soon, the illness took his life. I don't expect people to care 
about what happens to Indians from non-acknowledged tribes, so maybe a 
recent example will make you reconsider whether this is your problem.
    A family friend who, unlike my grandfather, comes from a Tribe that 
is acknowledged by the Federal Government, traveled to the Nation's 
Capital to serve his community at an agency that fulfills trust 
responsibilities to Tribes and individuals. Back home, he is eligible 
for services at an Indian Health Services facility. Here in DC, he's an 
Urban Indian only eligible for services at Native American Lifelines, 
the closest health/dental provider accessible, but located in 
Baltimore, MD. He isn't a ``Big DC Indian,'' but he reports to a few.
    Now stop me if you've heard this one before. One day, he found a 
sore on his foot. Left untreated, he passed out on his way to a 
convenience store and awoke at the hospital. The infection was so 
severe that he lost his foot. His youth saved him from losing more than 
    In a sense, my grandfather was the lucky one, because in death, he 
escaped medical bills and the hard, expensive road to rehabilitation. 
Our friend is in store for all this without IHS support, which he would 
likely only have if he leaves his DC job and becomes another statistic 
back home. Despite coming here to serve his people, despite the history 
of Indians being drawn to our Capital to serve their Nations, and 
despite the Indians buried in the Congressional Cemetery, our ``Little 
DC Indian'' friend isn't going to get a dime from Indian Health Service 
because DC is somehow outside the coverage area.
    IHS was established to provide health benefits pursuant to Treaty 
Obligations that were bought, bled, and bargained for. Pursuant to 
self-determination imperatives that strengthen Tribal Sovereignty, IHS 
employees are often selected from the Tribal Communities receiving 
those services. After what I've seen for decades, after what I've heard 
from being a spouse and friend to IHS employees, and after the recent 
Senate hearings, I have to wonder then whether IHS treatment priorities 
from the point of view of those at the top concerns not Indians at the 
bottom, rather the ``bottoms'' of those at the top.
    Don't get me wrong, I appreciate when IHS provides quality care. 
Hell, if IHS was there for my mother as a little girl with an untreated 
ear infection, she would probably wouldn't have ended-up partially 
deaf. I wonder why, if even during an election year of all times, the 
bosses in D.C. won't just spare a staff member and a bit of metro fare 
to Rockville to put eyes and ears on what's going on at IHS 
Headquarters. I also wonder, as someone who isn't a Tribal Citizen of 
an Acknowledged Tribe, whether that lack of status makes me rate higher 
than the people IHS purportedly serves.
    Responding to an article about Senator Jon Tester's 2014 inquiries, 
I published a complaint about management at IHS HQ in Rockville, MD. I 
wrote in as ``Opechan,'' a default online handle I've used for over 
fifteen years. You might be familiar with it as ``/u/Opechan,'' founder 
and moderator of/r/IndianCountry, the most active Native American 
community on Reddit.com, the ninth most popular website in the U.S.
    This triggered a witch-hunt at IHS HQ and people were more 
concerned about ``who complained'' than the substance of the complaint. 
I expect people to again get defensive and focus on everything except 
whether care for Tribes and Urban Indians is a big enough priority 
around DC or in general, or whether those trusted with deciding how to 
provide that care are actually doing so or just nurturing public sector 
    I don't write this as a Tribal Citizen or employee, I write this as 
a U.S. citizen who wonders why tax dollars that should be going towards 
satisfying Treaty Obligations instead go towards settlement and 
promotions of bad high-level managers. I've wondered why, just outside 
of the Beltway, bad actors at IHS HQ fail upward and benefit from grade 
increases for performance without their HR settlements being taken into 
account. I understand the value of having an ``outside dog'' to scare 
away bad actors, but one does not bring it in for guests, especially if 
it's bitten members of the family and lacks house-training.
    Even if I wasn't Indian at all (and I am), would that make anything 
I, you, and yours have seen and said about IHS less true? Shouldn't 
this be easier for law makers to figure out, seeing as how it's 
happening just outside the Beltway? It's such low-hanging fruit; an 
easy win for an election year.
    I honestly don't know and I'm nobody really, but have you gotten 
the sore on your foot checked out?
    You should.
    And it probably shouldn't wait until you can afford airfare if you 
live off-rez, as most of us do.
    Public Healthcare Meeting--Cheyenne River Motel, Eagle Butte, SD.

    After 4\1/2\ years of a broken ribs, broken arm, and a result of 
weak bones, I fell and fractured my hip and a lot of pain and without 
offending or violation of pain management contract was not getting 
proper care. Some of the nine different PA so - called Indian Tribal 
Cultural Dr., I am left in the air without help. I live in a very high 
level of pain, and I am changing my Medicaid to someone who'll help me. 
I was told these medicines won't help me, so they hold out on 
medications, and tape gauze bandages from which we might be healed for 
pejuta wica, restored and protected. I know my life isn't going to be 
prolonged in good health, for the rest of my day wondering what the 
native people will do now that I am a diabetic. My culture, and 
descendant come in with other Indian Priority I and II list.
                                  Ethylene Buck Elk Thunder

    1) We want Doctors that are able to do their job independently, 
without having another Doctor oversee them. For example, I had an 
appointment with my Doctor, Dr. McLain, then a Nurse came in and said 
``Dr. McClain is needed in ER, and he has to admit a patient.'' Why is 
my Dr. getting pulled into this? The ER Doctors should be able to work 
independently, and they can't. they shouldn't be working in the ER 
    2) We need Doctors that know how to investigate with doing a 
complete physical, labs, patient history, etc. so that prompt diagnosis 
will happen. For example, it took June, July, August, and IHS didn't 
know why I couldn't walk. They just kept giving me pain medication 
after pain medication. Dr. Francine Mousseau yelled at me and my Mom 
because she said ``None of my providers want to see you! I don't want 
to see you, and Dr. Kahn don't want to see you.'' I said I have IHS 
eligibility. Then she went on to say ``the regional office said my 
hospital don't have to see you or help you.'' So people are being 
yelled at with no diagnosis given, wrong diagnosis, wrong medication, 
and being turned away.
    3) More Doctors for optometry, physical therapy, and diabetes. It's 
hard to get appointments, and then the Dr. or Therapist seems like they 
don't know what they are doing.
    4) Wrongful firing of people that are qualified to work there. 
Seems like they are letting a lot of ``brown or dark-skinned'' 
employees go, and sexual harassment to employees.
    To the Committee:
    I have worked as a clinical psychologist at IHS for sixteen years 
and at ``638'' tribal clinics for over three years. The problems 
identified by current and past hearings are accurate and, as you know, 
they persist. I would like to speak to the daily frustrations of 
treatment providers trying to provide good care to patients.
    Most of the IHS administrators at the top of the organization may 
be competent, as are most of the treatment providers who provide direct 
patient care. Unfortunately for tribal patients, that care is impeded 
by too many layers of managers who have priorities other than the 
mission of the agency. These mid-level managers seem to be invested in 
maintaining the status quo, not in challenging it in the interest of 
patients. And they will target for harassment employees who do speak up 
about deficiencies. The performance evaluation is their means for 
intimidating and silencing employees. That practice also serves to 
force out good treatment providers who don't want their personal and 
professional reputations damaged by negative performance ratings.
    I was gratified to hear the statements of Chairman Barrasso about 
the rampant intimidation and harassment of employees, nepotism, and 
moving incompetent managers around within the organization. I have 
witnessed these things for years. That is the culture in which we labor 
and which is so demoralizing. I'm at a point where I do not believe 
anything will change for the better without a dramatic re-organization 
and elimination of several layers of bureaucracy. The dollars saved 
could be re-directed toward paying for needed services for patients.
    Thank you for your continued efforts on behalf of Indian people.
                                   Louise Cenatiempo, Ph.D.
                                     Licensed Clinical Psychologist
                                 [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    I participated in the 2010 hearing by cooperating with the 
investigator Senator Dorgan had to Indian Health Employees and Indian 
people who used the services. I was employed at the Winnebago Indian 
Health Service Unit until May 5, 2015 where to repeated emails to 
supervisor and up the chain on the poor care given, and nurses who 
failed to carry out the doctors orders, and that I had a license which 
prohibits me from taking & carrying out nursing care from unlicensed 
persons, such as a Dentist, Pharmacist.
    I blew the whistle after numerous attempts for upper management to 
correct the unsafe practices, but was ignored, I contacted CMS after 
the dead of the male patient who died April 2014, I let all know I was 
going to report for the negligence in the poor care that resulted in 
the death of the 35 year old male.
    I even let the Great Plains Area Director Ronald Cornelius know 
through emails.
    End result I was fired for making or scheduling clinic appointments 
so all and any patient can access care. I also responded to an email 
that was sent out by the Dentist that included all medical and nursing 
staff. I asked 2 questions, I did leave the email as it was sent out 
which all who were included in the email seen my questions.
    Many at the facility did not know that Dr. Rodriquez was a Dentist 
who had no medical previleges and could not write orders or perform 
direct medical care on patients.
    I also sent Robert McSwain and email, and the corp officer who came 
to the meeting held on or around June or July in Sioux City Iowa. It 
did not matter, because I took my oath of employment serious to uphold 
the oath and the laws I was fired, to be made an example as stated in 
my termination letter.

    Why is it that the agency has fired federal employees for upholding 
the oath of office and supporting the constitution and state and 
federal laws have to waste government money to go to a EEO or MSPB 
    Tonie Greve RN had several exceptional PMAP, no problems other than 
sending email concerns about patient safety, and following the chain of 
command, only to be fired for bogus allegations of making clinic 
appointments for patients to access care, no federal or state or 
Winnebago regulation, policy violation? Why not give back my job as a 
clinical nurse who did great work performance?
    Janet Uheling RN who had nearly 25 years of clincal nursing 
experience, great PMAP ratings. She did nothing wrong, she saved the 
gentleman in April 2014 who was severely ill, did patient advocate, got 
the permanent medical provider to come to the Emergency Room to see and 
treat the patient. The patient died 4 days later, but through no wrong 
doing of Janet Uheling RN. Karen Riser fired her for not documenting 
the results of a nebulizer treatment results, which had good results, 
as patient was admitted and alive, until the other nurses failed him on 
the inpatient unit for giving poor care, and not contacting the medical 
provider per parameters, and for failing to give standards of care, and 
notification of patient's health deterioating.
    Mr. Robert McSwain stated he did not want to discuss due to 
employee rights and privacy rights, but I am Tonie Greve and I am the 
named representative for Ms. Janet Uheling RN.
    Karen Reiser was paid bonus and she failed to fulfill her job 
requirements, and performance. Trina Cleveland paid bonus she failed to 
fulfill her job requirements, Dr. Jose Rodriguez Dentist a commission 
corp officer who failed to fulfill his job duties and performance below 
standards. Mr. Ronald Cornelius knew of these problems yet ignored due 
to his personal friendships, instead of doing a complete unbiased 
investigation, instead he had the federal employees who upheld their 
oath of office fired instead of correcting the substandard care and 
poor job performers who continued to keep job after failing patients 
with standards or above standards of care.
    I want my job back, and my name cleared, and just work as I took 
the oath to uphold. Janet Uheling wants her job back as she did not 
violate any policy, regulation, but saved a patient, The nurses who 
failed the male patient still have their jobs, and still giving poor 
care at the Winnebago Indian Health Service Unit.
    This request is not abnormal, but seems fair request as I have had 
exception PMAPs, came to work daily, performed all duties required as a 
qualified nurse. I did leave and get a job in the private sector as a 
higher ranking and management position as Assistant Director of Nurses 
and helped that facility win awards for Standards of Care and 
participated in CIMRO standards, along with great plains but in the 
private sector. I left this job as I want to serve the Indian People as 
I am an enrolled AMerican Indian. I am willing to relocate if it is due 
to having family members in several of the Great Plains Tribes. I am 
asking for location in Pheonix area as I know no persons, have no 
family member in that area. I am willing to drop the MSPB hearing.
    Mr. McSwain has the information, and e-mails that I have sent to 
him and to the members of the Indian Senate Committee members.

    After reviewing the whole senate hearing that was conducted 2/3/
2016, I have to write this letter.
    1. Master, Bacholor, Medical Degree means nothing if you dont have 
the experience, this is the problem when hiring medical personnel.
    2. When there are qualified staff hired with experience and want to 
implement positive change, training they are ignored, and told ``No''.
    3. When a medical doctor, PA, NP tells a nurse to carry out an 
order, but they refuse, that medical staff should be able to write an 
complaint, and that nurse no matter who he/she is or related to should 
be disciplined immediately. Given training if they don't know and PIP 
for year to make sure the mistake does not happen again. In 2004 that 
was the policy when I started at the Agency, and believe me it took 
only 1 mistake, then I reviewed all the policies, regulations. I never 
repeated the mistake again.
    4. If you don't train properly, or nurses refuse to attend 
trainings then they should be let go, as they are part of the problem. 
Same for Medical Staff. Medicine changes each year sometimes more 
    5. ER/LR need to have medical background or the training so they 
will know if a staff is upholding the medical license they hold, rather 
than being called insubordinate. This will help determine if deliberate 
mistakes, or refusals to go outside scope of medical practice/license 
is prohibited.
    6. Supervisors who have clicks and know that some staff refuse to 
fulfill the vision & mission but turn blind eye. Remove that supervisor 
don't promote or move to another facility. (Karen Reiser, Trina 
Cleveland, Miguel Fernandez, Jose Rodriques, Samir Joshi, Nancy 
Freemont, Deb Saunsoci) to name a few.
    7. Nurse Educator is given more authority to issue letters to 
employees who fail to attend mandatory trainings, and give to 
supervisors to issue discipline, if that supervisor refuses the Nurse 
Educator is given the autonomy to go to the next in line to have that 
supervisor disciplined for failing to adhere to the vision & mission.
    8. Transparency, meaning real transparency where one can report 
without reprisals. This was how it was back in 204 at Winnebago, but 
changed after 2012.
    9. Allow all medical staff to be allowed medical training. (each 
year money was put aside but only a few were allowed) if all medical 
staff given opportunity to further education and return to give the 
training to others will retain that education and shared with others. 
THis was how it was handled back in 2004 at the Winnebago Facility. It 
stopped in 2009. This would show how well funds are being spent.
    10. PMAP should be made each year that represents the Job 
Description of each individual, each department they are employed in. 
Right now the PMAP are generic and some if they have friends in 
supervisory positions get rated above the standards, which do not 
reflect the actual job performed.
    11. Show employees who go above and beyond recognition, not the 
same employees over and over who get preference because of friendships.
    12. Annual in person training from Great Plains ER/LR and Human 
Resources on expectations, regulations, policy. Doing computer training 
which can be falsely done is harming the education purposes.
    I was preceptored by Gloria Thomas who is a great nurse at 
winnebago who was a supervisor who made sure all under her supervision 
was taught and educated upon hire and every quarter for the first year. 
I am only a product from a mentor who loves the medical profession, 
loved the supervisory position and fulfilled the vision & mission at 
the Winnebago Facility. I was one of the original nurses trained in 
this manner, and only expected others to follow.
    13.when a nurse is the charge nurse (why have supervisor) who sits 
in an office and not come out to the floor to see what is going on, 
what needs attention for patient care, flow of clinic, what needs other 
areas need for nursing staff. Give that charge nurse the autonomy to 
fulfill her duties assigned to help with patient care, patient flow, 
patient safety.
    I hope I did not submit too much information on how to correct the 
                                            Tonie Greve, RN
    In 2010-2011 I was experiencing fatigue and heart flutters as well 
as continuing to gain weight. Being tired constantly I thought maybe I 
could be anemic, making an appointment to have my iron level checked at 
the Eagle Butte Indian Health Service Out-Patient clinic. Kathy Zambo 
my provider listened to my symptoms then had blood drawn to see where 
my levels where.
    Later that evening she called, informing me that my iron levels 
were within normal limits. She also stated that my thyroid was 
functioning at a 0.00. She informed me that she would be submitting a 
referral to have me visit with an Endocrinologist in Bismarck. I was 
then referred to Dr. Ahmed.
    At my first appointment in Bismarck Dr. Ahmed performed various 
tests on my mobility as well as examining my thyroid. He concluded that 
I most likely suffered from Graves Disease and would be providing me 
with medication that would hopefully kick start my thyroid back into 
working order. Taking the medication (methamazole) for about 3 weeks I 
experienced an allergic reaction to the medication and was immediately 
taken off and prescribed another medication that is not for long term 
use as it begins to affect white blood cells and can affect your liver. 
I took the medication for approximately a year before being scheduled 
to undergo thyroid ablation with radioactive iodine.
    After the radiation treatment I was scheduled to return to check my 
thyroid levels every 4-6 weeks in order to begin the replacement 
hormone for my thyroid. On the 3rd month of having my levels checked 
there had not been any change, Dr. Rauta stated that at the next test 
if it continued to not level out I would need to undergo another 
radiation treatment.
    Finally, my thyroid began to respond after the third or fourth 
month and I was placed on a high dosage of the replacement hormone. Dr. 
Rauta wanted me to have my levels checked every 4-6 weeks again to 
ensure that I was being prescribed a proper dosage. In requesting the 
needed referrals I began to experience denials from Contract health 
stating that I could be seen within the IHS clinic by other providers 
one being Dr. Siddiqui who eventually stated that he felt I should 
continue my follow up appointments with Dr. Rauta in Bismarck as he is 
the physician who ordered the radiation treatment and knew my case the 
best. My referrals were continued to be denied.
    In the beginning of taking the replacement hormone I was prescribed 
a 150mg tablet but over time it was gradually reduced due to my thyroid 
reacting positively to the radiation treatment. I have not requested 
any further follow up in Bismarck as my symptoms have been steady at 
the level I am taking now which is an 88mg table 6 times a week.
                                                Jackie Dunn
                                 [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    To whom it may concern:
    My name is Willard Black Cat. I am an enrolled member of the Oglala 
Sioux Lakota and have resided on Pine Ridge Reservation my whole life. 
I am an elder, now presently in the hospital in Rapid City, South 
Dakota. A close friend, who is my medical power of attorney and has 
been supporting me during recent surgeries, is writing this letter for 
me (Rev. Janet Weber).
    I have many complaints over the years about my health care at IHS. 
I am diabetic and an amputee. It is a hardship for me to even get to 
the hospital, where I have to wait many long hours to be seen by a 
doctor. Sometimes I even have an appointment and when I get there I am 
told the doctor is not there, so I travelled for nothing. Sometimes I 
am there all day with no food, then it is very late and the CHR people 
have gone home and I have no ride home. I am an amputee and have no 
    Some of the doctors are nice, but almost every time I go to the 
hospital for a check up, I get a different doctor, sometimes they don't 
speak English too good. They don't know me or my history. All my 
friends and relatives have the same complaints about IHS. Every month 
my medications change completely. I got very sick on some of the 
medicines. Some affected my mind and I became suicidal and was 
hospitalized. My diabetes medicine Metformin got me sick too. The 
needle injections in my stomach made big bruises and hard lumps. 
Finally I got the easy 'pen' insulin, but then I was told to stop using 
this too. The medications change all the time and it is confusing. 
Also, the medical transport van to dialysis and the hospital sometimes 
does not show up. A few times also I fell in the van and broke ribs 
because the drivers do not always help me get in and out with my 
    The most recent problem I had was with my foot, which started over 
the summer of 2015. I went to the hospital a few times with pain. They 
gave me ointment and gauze and sent me home. Things got really bad and 
I went to the IHS Pine Ridge Hospital in an ambulance and a few other 
visits. They wrapped it and sent me home. The pain was so bad I could 
not sleep for weeks. Why did they not give me a referral to a doctor in 
Rapid City? This finally did happen. I went to a doctor specialist in 
Rapid City on Jan. 8, 2016. He told me I now had gangrene and I would 
need an amputation. (I lost my other leg last year 2015).
    I am now in Rapid City Regional hospital since early January. I had 
stents put in my leg and they had to amputated all my toes and graft my 
heel. Why did Pine Ridge IHS wait so long--they never helped me and now 
I lost part of my foot. Here is a picture of my foot when I got to see 
the specialist in Rapid City on January 8th, 2016. Pine Ridge IHS saw 
this earlier and did nothing. This is malpractice if you ask me.
    I have applied for residency in the new Oglala Sioux Lakota Nursing 
Home that is due to open in White Clay, Nebraska in April. I pray to 
God that this place will be giving us elders the good care that we 
need, and will be better than the IHS Hospital.
    Thank you for trying to fix this broken situation--the Lakota 
people have suffered enough for too many generations.
        Yours Truly,
                                          Willard Black Cat
    This is my son, Eric Dickson Keefe.(Pictures retained in the 
Committee files) The IHS RN Debbie Knisipel, who was publicly seen 
barging into my private home, before the FBI or CI even had a chance to 
get their to conduct a homicide, spat out at me preniciously, ``It was 
just a baby!!'' Due to Debbie's visit I was forced to settle; rather 
than go to court. Without a warrant Mrs. Knispel conducted an illegal 
search, seized an item that was in a closed cabinet, tampered with it, 
demanded my bodily fluids (and certainly would have provided herself 
with the opportunity to tamper with that), falsified the medical 
records, and generally impeded a homicide investigation!
    My son was sent to the mortician and procedures were preformed 
potentially loosing evidence before he was sent to autopsy. I still 
have some of Eric's blood that may be tested for any medications. I 
also have the dress I was wearing when Eric left this world. It has not 
been washed and is stained with his breast milk that kept coming during 
the hours he was dying. It may be tested for anything in my system. Dr. 
Lehman was upstairs and did not come down during the time he knew Eric 
was dying. Why did this so-called good man not come down? Instead, he 
sent a spy posing as a mourner to come prey upon me; not to pray with 
    Is it standard practice for an Indian Health Employee to come into 
our private homes (uninvited) during a time when evidence should have 
been secured by the proper authorities?! Dr. Douglas Dixon Lehman, the 
doctor who had performed Eric's circumcision and then immediately 
released us with no post period of observation, wrote to me encouraging 
me to continue to speak to Debbie.
    For it not been for Mrs. Knispel's visit their would have been no 
reason for me not to go to trial. I did not go to Rosebud Indian Health 
Service in the mistaken belief that I was engaging in ``welfare''. I 
went believing that according to the Ft. Laramie Treaty and Snyder Act 
that health care is what we got in leiu of the millions of acres of 
land and mineral rights given up.
    I have been pursuing an attorney; to no avail, to pursue criminal 
charges against Mrs. Knispel. I was told by one, ``I litigate for 
money; not the moral high ground.'' The fact of the matter is that I 
can prove some of Mrs. Knispel's lies, which is immensely disturbing 
and spiritually repugnant.
    To make matters worse Josh Verges of the Sioux Falls Argus leader 
published the following article:
    No where in any legal documents filed by my attorneys does indicate 
that ``Once discharged, his mother gave him Motrin and Tylenol for the 
pain.'' I made a request to Mr. Verges and the editor of the Sioux 
Falls Argus Leader to retract this story...they never did. Mr. Verges 
let me know that since I did not speak to him he had to explain what 
happened. What he wrote NEVER occurred. This is a slanderous and 
libelous news story, which is detrimental to all boys being circumcised 
and all patients at IHS. I am working towards all beings having 
affordable, honest, quality, and accountable health care. Why did Mr. 
Verges fail to explain how Dr. Lehman breached the standard of care? 
IHS is using his news story to bolster their faulting me.
    For almost everyday since June 19, 2008 I have either sat in the 
Evergreen Cemetery in Wood, SD or driven by it begging my God for some 
truth and justice. Eric's earthly suffering and death should not be in 
vain. Something good should come from it.
    I beg of you to look further into what happened to my most precious 
to overcome this iniquity. Something has to be legally done about that 
RN and to provide for the integrity of the investigations of these 
deaths, so justice may prevail.
                                    Mrs. Mary Aurelia Keefe

Rosebud South Dakota couple files lawsuit over circumcision death
    Category: Crime, Justice, Courts and Lawsuits, Pierre, South Dakota 
(AP) 10-09
    A Wood couple has filed a lawsuit over the death of their 6-week-
old son, who died after being circumcised at a hospital on the Rosebud 
Indian reservation.
    The lawsuit filed during September in federal court says Eric Keefe 
was circumcised at Indian Health Service Hospital on June 13, 2008. 
Once discharged, his mother gave him Motrin and Tylenol for the pain. 
He died the next day of massive blood loss.
    Forrest and Mary Keefe say in court documents the hospital failed 
to instruct them on what pain medications to give the boy.
    The couple is seeking $2 million from the Federal Government for 
personal injury and wrongful death.
Circumcision Death Case Settles for $230,000
    April 8th, 2011 by Dan Bollinger
    Native American Boy Bleeds to Death
    The lawsuit involving a South Dakota Native American infant, Eric 
Dickson Keefe, from the Rosebud Indian Reservation, who bled to death 
from a circumcision in 2008, was settled this week for $230,000. The 
case involved an Indian Health Service doctor who circumcised the child 
at the end of the working day allowing for no period of post-surgical 
observation. Testimony showed the mother faced a long drive home on 
rural roads with other children in her care.
    ``This was sheer negligence and an ethical failure to consider the 
risk,'' says George C. Denniston, MD, MPH, President of Doctors 
Opposing Circumcision, a physicians' group based in Seattle, 
Washington, which assisted with the case. ``Circumcision is unnecessary 
surgery, which the parents are never told holds a risk of death for 
their child.''
    Keefe bled to death during the night from his open circumcision 
wound in June, 2008. Medical professionals say that the loss of only 
two and one-half ounces of blood can cause the death of even a large 
eight-pound infant. ``That amount of blood, just a few drops per hour, 
was easily hidden in the super-absorbent disposable diaper baby Keefe 
was diapered with.'' notes Denniston, ``Parents are never told about 
that risk.''
    Doctors Opposing Circumcision has provided expert advice for 
numerous circumcision death cases. ``Exsanguination, or bleeding to 
death, is hard to detect,'' says Denniston, ``since the child slips 
away quietly, and no one wants to disturb what appears to be a sleeping 
    Death from circumcision is relatively rare, although a recent study 
estimates that around 117 children in the United States die each year 
from circumcision. ``These are entirely avoidable deaths,'' says 
Denniston, ``caused by a pointless surgery that the child would never 
choose for himself.''
    Dear Senate Committee on Indian Affairs Panel,
    As I am writing this, I am hearing a story on my local radio about 
the life expectancy of Native Americans in MT being 20 years shorter 
than those of white Montanans. I am thinking about an announcement at 
community gathering in Browning last year where it was announced that 
over 50 percent of mothers are using some kind of drug during their 
pregnancy. Over the past several months, my husband, a teacher at the 
alternative high school in Browning has been learning about ACE scores 
and that his students are disproportionately affected by traumatic 
events in their lives that have the potential to irreversibly alter 
their ability to cope with school, work, and leave them more vulnerable 
to acute and chronic disease. Our Native communities are hurting in 
disproportionate ways for which we can not expect an underfunded and 
under-resourced Indian Health Service to take the complete fall. I do 
believe that IHS is doing what it can with the resources it has. One of 
the few things that we are very proud of at Blackfeet Community 
Hospital, is our Baby-friendly designation status to assist mothers and 
families to get breastfeeding off to successful start. We are one of 
two hospitals in the state of MT to achieve this. IHS is capable of 
great things. It is capable of being a leader in Native communities to 
make lives healthier for Native people, but it needs significant 
resources and reform. I left the IHS for many reasons, but one of the 
main reasons being lack of good leadership and support at my local 
level. I dearly admired and respected our local leadership team, but 
many of them were terribly overworked and often not provided with the 
type of training and support necessary to successfully do their job.
    I hope that tomorrow's hearing is ripe with ideas and support for 
improving this system. I truly believe that it has immense potential, 
but needs the support of the congress and the American people to demand 
that it is no longer ignored or passed over.
    Senators Tester and Daines, thank you for being a part of this 
important committee and supporting Native lives and communities in 
Montana and across the country.
                                              Kirsten Krane
    I am writing in hopes that there will be a thorough investigation 
into the staffing practices of the Phoenix Area Office. It seems as 
though the service unit I work at in Yuma, Arizona has plenty of funds 
to over staff and hire Commission Officers at almost 3 times the rate 
it would cost to hire civilians, who are just as qualified.
    It's disturbing to know that the disregard for the patients who 
suffer the highest rates of amputations from diabetes yet they are 
being denied necessary health care because of lack of funds.
    It doesn't take a Harvard trained accountant to do the math in this 
case. Every time I see a new Officer hired, I immediately think, ``And 
we can't afford health care for the tribal peoples but we can afford to 
over staff and hire expensive Corp Officers.'' We have an over 
abundance of Nurses and Pharmacists who are also Commission Corp. The 
Acting Clinical Director is a Nurse Practitioner. We have been without 
a CEO: for almost a year now and a Clinical Director a year. This 
concerns me because the longer those positions are left vacant the 
longer it will take to fill them.
    I need to mention that, a retired Corp Officer, Dr. Robert Harry, 
is kept on contract by the Phoenix Area Office to oversee troubled 
service units. Dr. Harry is often referred to as the ``Cut Man.'' I was 
told he is used like a ``Neighborhood Bully'' to hone in on Native 
Americans, female staff members to create a ``Hostile/Oppressive work 
place.'' I have to say he is good at it.
    I have heard him say he is in his 80's and that made me realize 
that's why he repeats himself several times, forgets what he told you 
to do and makes management decisions based on gossip and hear say. I 
question the validity of his position as ``Acting CEO'' when he is on 
contract. He says he has authority to make decisions on staff matters. 
I know Dr. Harry is very partial to hiring Commission Corp officers but 
wont allow essential medications and referral services for the 
    I am the Public Health Educator and I have not been allowed to 
spend any of the funds that were sent to Yuma from Portland Area 
Office.The funds are not part of the Yuma Service Unit budget yet I 
have not been allowed to order so much as a pen in almost a year. I 
believe, Dr. Harry makes certain that my job is difficult to perform 
without any supplies to do so. I further conclude Dr. Harry is trying 
to make my job miserable in hopes I will resign!
    You can contact me in my office. I am. an enrolled member of the 
Rockyboy Chippewa Cree Tribe of Montana and I am an Indian Health 
Service Scholarship Awardee.
    Thank you for any attention you can devote to the issues I have 
    The ``Good Ole Boys Syndrome'' seems to be very active in the 
Phoenix Area.
                                      Sarah Schmasow BS, MS
    The following narrative is, to the best of our recollection and 
records, representative of the problems our office has encountered in 
trying to receive payment for $9,271.00 in medical services provided in 
September, 2015 to a single patient:
    9/18/15: A patient was referred to Scott Eccarius, MD though the 
Rapid City Regional Hospital (RCRH) Emergency Department (ED). He 
received a call that Friday morning at 0650 to consult on the patient 
in the ED. He saw him and determined that he needed surgery to repair 
multiple lacerations involving the patient's left eye and left upper 
and eyelid from multiple stabbings earlier that morning. Patient also 
had 20+ non-life-threatening stab wounds elsewhere.
    Dr. Eccarius spoke with the patient's father by phone that morning 
before surgery and received consent for treatment as the patient had 
significant injuries and ethanol intoxication precluding obtaining 
informed consent from the patient.
    Patient was prepped for surgery and underwent 4-5 hours of surgery 
to repair an extensive scleral laceration, full-thickness left upper 
lid laceration and full-thickness left lower lid laceration.
    Dr. Eccarius spoke to patient's mother right after surgery and 
explained what we had done and the profound nature of her son's 
    Patient stayed at RCRH overnight and was discharged by Dr. Eccarius 
the next day (Saturday).
    9/21/15: The patient was, apparently, an enrolled member and 
eligible for IHS services. We called Sioux San IHS Hospital to 
determine if we could get a purchase order for the above services. Our 
office was told by Loydell at Sioux San that they would have to speak 
with the patient. Called the number we had for patient. We talked to a 
family member about the importance of getting patient to Sioux San to 
get the purchase order for care.
    9/24/15: Patient returned to the clinic for a post-operative check 
up. Dr. Eccarius recommended that the patient be seen by a retinal 
specialist to care for the left eye, as to avoid developing vision loss 
in the right eye (sympathetic ophthalmia). The window of time to 
eliminate/reduce the chance of that developing is roughly 14 days from 
the time of injury. The `clock was ticking' and we had no success in 
reaching the patient.
    Patient was advised of the need for him to go to Sioux San to sign 
the necessary paperwork for the purchase order. He said he was going to 
try to get a ride.
    9/28/15: Patient was a no-show to the appointment with the retinal 
specialist. Patient was called by our office as well as the retinal 
specialist's office to reschedule. He rescheduled for 10/05/15. Again, 
we stressed the importance of checking in with Sioux San so they could 
authorize a purchase order, as well as the importance of keeping his 
    10/5/15: Patient was again a no-show for the retinal specialist's 
    10/7/15: Dr. Eccarius sent a certified letter to the patient's last 
known address detailing the missed appointments, the need for making 
these appointments, and the need for making contact with Sioux San.
    10/20/15: Received the certified letter back marked ``attempted not 
known''. Eccarius Eye Clinic billing staff called the motel where the 
patient had been residing and where the letter was sent. We were told 
that he, his mother, and his girlfriend (all of our next-of-kin 
contacts) had been kicked out of that residence due to non-payment 
    10/28/15: Patient's account was turned over to an outside 
collection agency.
    10/30/15: Collection agency sent letter to patient.
    11/11/15: Collection agency called patient.
    11/13/15: Collection agency sent letter to patient.
    Mid-December: Dr. Eccarius contacted Sen. Thune's office regarding 
the roadblocks encountered in dealing with the IHS system with respect 
to this case.
    Mid-December: Dr. Eccarius received a call from and spoke with a 
top-ranking IHS official in Aberdeen, SD.
    12/17/15: Dr. Eccarius called Sioux San hospital and talked to Rick 
Sorenson, CEO. He said that we were too late for claim filing 
deadlines, but that if we got a signature from the patient, we could 
appeal the denial for payment. Rick explained that if we had an 
address, they (Sioux San) would go as far as knocking on his door to 
obtain a signature. Dr. Eccarius was also informed by Loydell at Sioux 
San that patient had non-paid IHS claims to providers dating back to 
2014. She offered to `deny them' and suggested that we could then send 
him to collections; she was informed that we already had. Dr. Eccarius 
left a voicemail message for the billing supervisor at Sioux San, 
Brenda, to call him back to discuss the case (she related that she 
never received the voicemail).
    12/21/15: Left message for billing specialist at Sioux San, Brenda, 
to call us back if they had heard from the patient. We left her the 
updated address that a family member of the patient had given us. We 
did not hear back from her until her 12/31/15 call.
    12/22/15: Collection agency called patient.
    12/23/15: Called the collection agency and asked that they escalate 
this case. Gave them the updated phone number and address that the 
family member had given us. Collection agency attempted to call patient 
3 times, and also sent a letter.
    12/28/15: Collection agency called patient.
    12/29/15: Collection agency called patient.
    12/30/15: Left message for billing specialist at Sioux San, Brenda, 
to call us back if they had heard from the patient.
    12/31/15: Brenda called back, and said they were still working to 
find a valid address for the patient.
    Late December, 2015: Numerous attempts were made to make phone 
contact patient's girlfriend, mother, and father to locate the patient- 
all without success.
    1/7/16: Collection agency called patient.
    1/13/16: Collection agency called patient.
    1/15/16: Jeannie Hovland from Sen. Thune's office called to update 
me on the situation.
    1/15/16: Collection agency called patient.
    1/18/16: Collection agency called patient.
    1/18/16: Eccarius Eye Clinic found out that the patient was 
currently in the Pennington County Jail. We immediately called Sioux 
San and spoke to the secretary in Mr. Sorenson's office because they 
had previously said they would obtain patient's signature if they could 
determine where he was. We were told by Sioux San that they never ``go 
and get a signature from the patient''. We left a message to speak 
directly to Rick, since he had extended the offer.
    1/19/16: Talked with Jeannie Hovland who facilitated a call-back 
from Sioux San.
    1/19/16: Mr. Sorenson called back to let our office know that, 
``someone from his security team would go to the jail, and get the 
necessary paperwork for the purchase order to be signed''.
    1/20/16: Left message for Rick to call if he received necessary 
signature. Our office has not heard back from Rick or Brenda whether 
they were able to make contact with the patient or not.
    1/22/16: Spoke with Jeannie Hovland with Sen. Thune's office. She 
had also spoken to Rick Sorenson and was advised that due to the delay 
in receiving the signature (not for a lack of effort on the part of the 
Eccarius Eye Clinic) an appeal would have to be made to the national 
IHS office.
    1/26/16: Called collection agency. The agent said they have not 
talked to patient. They have called several times, and made contact 
with patient's girlfriend, but they have never been able to speak with 
the patient directly. They will attempt to call patient again today.
    Our local IHS system is not set up to address the problems of a 
very challenging population, in our experience. It relies heavily on 
patient responsibility and, in turn, places undue financial and 
collection burdens on its providers. Furthermore, there appears to be 
few incentives/penalties built into the current system for either the 
patient or the IHS system to pay providers. In fact, it seems to be 
just the opposite: uncompensated providers, who have already rendered 
care, are artificially shoring up IHS budgets.
    Dear Senate Committee on Indian Affairs:
    I am a member of the Kickapoo Tribe of Oklahoma and have been a 
beneficiary of Indian Health Service (IHS) my entire life. My 
experience includes working in Indian Health for over three decades and 
I now serve my people as the Director of the Kickapoo Health Center. 
Thank you for the opportunity to submit comments on the topic of 
addressing critical concerns on Indian health.
    While IHS has been, and continues to be, grossly underfunded, the 
care that I and my family have received as beneficiaries of IHS has 
been life-saving. I'm quite aware that services offered and the care 
provided could be improved--for any health system, not just IHS. The 
program's that IHS has implemented to care for our people, such as the 
patient-centered home medical model, IPC and the Special Diabetes 
Program for Indians (SDPI) is very successful and has made great 
strides in the overall system. As a matter of fact, the United States 
Renal Data System 2015 Annual Data Report (hhtp://www.usrds.org/
adr.aspx) has published data related to the impact of IHS and the 
SDPI's efforts in Indian Country. Both end-stage renal disease (ESRD) 
incidence and prevalence in American Indians have continued to decline. 
Even more notable, is that these improvement are surpassing all other 
U.S. racial groups.
    Seeing as my father had ESRD and his health suffered due to 
complications of diabetes, this news is quite refreshing. Please know 
that there are MANY positive outcomes in IHS. I know, first-hand, of 
the quality and passion that IHS has for our people. I am encouraged by 
the support Indian health and SDPI has from Representative Tom Cole. 
Hopefully others in Congress can follow his lead.
        Thank you,
                                              Gloria Anico,
      Kickapoo Elder Health Director, Kickapoo Tribal Health Center
    My name is Mr. Francis Archambeau, and I am the former 
Classification Officer for the Aberdeen & Bemidji Areas. I have been 
listening to the hearings regarding the great plains area.
    I hope that I am not out of line as I am a former IHS employee, but 
I feel I must speak up regarding the problems in the Aberdeen Area.
    I retired in February of 2007, but I was the Classification Officer 
from 1991 to September 2005. I retired about the same time as the 
former Area Director Don Lee. Other good managers have since retired.
    Since Mr. Lee and myself retired, I have heard some alarming 
stories regarding the position classification program and staffing 
program which are situated in the Personnel (HR) office.
    Classification: Management, including Charlene Red Thunder, former 
Area Director, Ms. Geri Fox (HR), Ms. Alice Lafontaine (HR) and other 
high level management began to abuse the position classification 
function. Super grades were ordered by Ms. Fox, and Ms. Lafontaine in 
collaboration with Ms. Red Thunder to reward friends and relatives.
    These high grades are paid for by our tax dollars. Dollars that 
could be directed to patient care. The Area Office has too many 
deputies, full assistants and glorified secretary positions that were 
created to reward these friends and relatives.
    Solutions: The Human Resources Division including staffing and 
classification should receive intense oversight by an outside entity to 
ensure integrity of these programs.
    Staffing: It has been rumored that due to the same ``rewarding of 
friends or relatives'' that the IHS merit promotion plan is not being 
followed, and that some employees/persons may not even be eligible for 
positions, but were placed on selection certificates. My most recent 
memory of the staffing function in Aberdeen is that they create a merit 
promotion file when filling positions, but that file is shredded after 
one year. Should anyone wish to contest the filling of a position, 
there would be no record of that process.
    Solutions: Again, an outside entity should oversee this process to 
ensure fairness as described in the merit promotion plan. Merit 
promotion files should be required to be maintained for up to six 
    Other abuses in the HR office and in conjunction with management 
direction are cash awards. Supervisors and managers are receiving 
awards, but not the worker who accomplishes the work. Ron Cornelius 
received a very large cash award recently, but nobody seems to know 
what it was for.
    Customer service to IHS employees from the HR office is practically 
    Final Statement: Each administrative program should be thoroughly 
reviewed and corrective action plans be implemented. Performance of all 
managers at the Division level and above should be reviewed, corrected 
or the managers should be reassigned or retired. We used to review 
administrative programs annually, but I am not sure if this is done 
    Employees are afraid to speak up. Managers have ordered staff not 
to say anything if they are questioned by investigators.
    The personnel office is only a part of the problem. There are other 
organizations in the Area Office that are a problem. However, I believe 
the problem begins at the top. As service unit personnel hear about 
what is going on in the Area Office, there is a negative effect.
    It is unfortunate that many of our tribal members have died due to 
lack of proper care and treatment. This is long overdue and has been a 
topic of controversy for many years--it just did not start five years 
ago. We all know that IHS provides substandard care to tribal members. 
The IHS facilities have rotating doors for their employees and do not 
promote continuity in quality health care.
    There have been many occurrences that tribal members health care 
was not a high priority to IHS. The IHS Staff are the priority. It's 
obvious--look at our facilities--cheap not adequate to serve the 
    The federal government has a TRUST REPSONSIBILITY to provide health 
care to tribal members, however that has been the unaddressed issue for 
many years.
    There was mention of SELF-DETERMINATION on the part of the Tribes 
in the Great Plains, unfortunately tribal leaders do not have the 
business savvy to operate this type of operation especially because of 
the consistent under-funded specifically for our health care in 
general. IHS should downsize and reorganize to decease the 
administrative overhead throughout the organization.
                                          Bonita Morin, MSW
     Community Research Liaison, Cankdeska Cikana Community College
    My testimony of incidences of medical malpractice at IHS:
    I was given an IUD and hormones at the same time causing unceasing 
bleeding had to go to the ER in Florida.
    I broke my foot went to the er no exray tech sent home no 
treatment. Went back to IHS it was already mending no referral to fix 
it. Had to rebreak it myself to get it set could not walk on it or get 
it into a shoe. No referral out. Emergency room has long waits and they 
forget about you a lot of the time. I also had a hysterectomy through 
IHS and am now having bladder issues. Referral denied because its not 
life or limb . I need a referral to a Urologist. Picked up meds for a 
diabetic no needles included. Got a prescription for a sever eat 
infection took 4 days to get the meds in then they mysteriously found 
them. All this is incompetence and mismanagement. Considering getting 
and attorney. It would be a great service to our people if these things 
no longer occurred. Thank you.
    To you, my very best wishes.
                                             Connie Corwitt
    I am forwarding this information as my testimony to how management 
conducts business at Fort Yuma Service Unit. The Acting CEO, Dr. Harry 
is a crony of Phoenix Area Office. He is a long time retired 
Commissioned Corp Officer and Dentist. I have been told he is in his 
80's. I have seen him going through garbage cans in the clinic and 
staff break rooms. He asks the same questions, or re-tell stories he 
already mentioned. It has been my experience with the Indian Health 
Service that Corp Officers are hired without competition. They are 
rehired back after retirement without competition to work as a 
civilian( cronyism?) or Contractor. The Federal Policy for retirement 
is 70 years old unless there is some kind of special permission granted 
to work beyond the retirement age requirement.
    It is a fact that Corp Officers are very expensive to employ when 
there are civilians available who cost about half the amount. This 
practice of unnecessary hiring Corp Officers consumes a huge amount of 
resources that could be better spent on direct patient care.

                                             Sarah Schmasow
                                                          Yuma, AZ.
Dr. Russell,
Chief Medical Officer,
Phoenix Area Indian Health Service,
Phoenix, Arizona.

Dear Dr. Russell,

    I would like to report the ongoing issues at Fort Yuma Service that 
I believe are a result of some preconceived notions and hear say about 
my job duties/performance. The action taken against me has created a 
``hostile work environment.'' I have had to endure the shadow cast over 
me that I believe was created by Ms. Amy Hamlet, Helen Safford, 
Shannon, Beyale, Commission Corp Officer, and Robert Harry Acting CEO, 
Fort Yuma.
    The first incident is when I was at a Health Educators meeting at 
Phoenix Area Office in June 2015. Ms Shannon, Beyale was rude, 
disrespectful and appeared agitated when I would participate in the 
discussions. She would not allow me to do my presentation of my 
activities at Fort Yuma. The other three Health Educators were allowed 
to take up almost the entire time for their presentations. I was left 
with maybe 5 minutes. When I started my presentation, Ms. Beyale cut me 
off abruptly saying Dr. Mac Intyre was scheduled to do a presentation 
on ``Historical Trauma''. Ms. Beyale said I would be allowed to finish 
my presentation later and that never happened. Ms. Beyale appeared 
hostile and disgusted when I talked about historical trauma and 
utilizing Native American approaches to healing.
    I was purposely ignored during the entire meeting and the other 3 
health educators participated fully in the discussions. I was excluded 
from the free time activities too with the group.
    When I returned to Yuma, I was told that someone from Area Office 
called and said I wasn't prepared for my presentation and I had left 
early one day. I explained, to my Supervisor, Cynthia, Long that I had 
a unexpected medical issue and had to take my granddaughter to her 
medical appointment. I took sick leave for the 90 minutes I left the 
    I am not quite sure how Ms. Amerita ,Hamlet, Corp Officer became 
aware of the situation but after ,my supervisor told me Ms. Helen, 
Safford had shared this information with Ms. Hamlet. Ms. Hamlet told me 
that she was not sure how Ms, Safford got the information and that 
someone from Area Office was hating on me.'' The only person who I 
deduced might be responsible was Ms Beyale. I didn't report Ms, Beyale 
because I was concerned she might retaliate if I reported her 
disrespectful and hostile behavior towards me. I let this go but now I 
am experiencing the racist and discriminatory treatment by Ms. Beyale 
and Robert Harry.
    I have always been respectful to Ms. Beyale. She is 20 plus years 
my junior. I am also aware the Commission Corp Officers are held to a 
very high standard of conduct which in my case Ms. Beyale doesn't apply 
when she interacts with me.
    I am now faced with the recent encounter with Ms. Beyale during a 
site visit to Fort Yuma Service Unit. It was my understanding, Ms. 
Beyale's role is to act as a Consultant and Advisor to help me with the 
Health Education Program. That didn't happen because Ms. Beyale 
appeared to have a hidden agenda that I later realized after her 
outburst of shouting at me while we were alone. She told me in a very 
hostile loud voice of disgust, she was tired of hearing about the 
Beading Therapy and my mentions of Historical Trauma! My approach to 
Health Education is culture based which is reflected in the Mission 
Statement of the Indian Health Service to provide Culturally Sensitive 
    Ms. Beyale's response was perplexing to me because when the AAAHC 
came to do the site visit this past September 2015, my Health Education 
Approach got the highest praise! My approach is from Native American 
Traditional thought and practice.
    For some reason Ms. Beyale is downright hateful that I utilize Bead 
Work as a means and antidote to address stress and substance abuse 
issues. My Beading Therapy class was stopped by the Acting CEO, Mr. 
Harry for some mysterious reason without explanation.
    Ms. Beyale email to Robert Harry, Acting CEO, stated I wasn't 
responding to her request for a date to do a site visit. I explained 
and apologized for the delay but it takes time to make all the 
arrangements to visit with all the programs I work with in the two 
tribal communities I work with.
    I proposed that we could meet in February because I had a 
commitment to train the Cocopah ADAP Staff and the January date her and 
Mr. Harry agreed on wasn't going to work. I believe Ms. Beyale's 
motives for emailing Mr. Harry was intended to damage me by creating a 
hostile work environment and suspicion of my activities.
    Ms. Beyale waited about 8 days before she would respond to the 
alternative date. When she did email me back she cc's my Supervisor and 
Mr. Harry. If Ms. Beyale would allow me to communicate with the chain 
of command on my own, would be a more respectful approach. When she 
cc's other in her emails to me can be misleading and can be concluded 
that I am being dishonest with my supervisor and Acting CEO. This 
results in creating a Hostile Work environment for me.
    Ms Beyale went into Mr. Harry's office and closed the door and came 
out after several minutes to join the meeting I was in. Before Ms. 
Beyale verbally attacked me, she was invited to sit in on the Sexual 
Assault Team meeting I had to attend before leaving on the planned 
    After about 15 minutes into the meeting Ms. Beyale had a 
disinterested demeanor, pulls a bag of carrots out of her back pack and 
starts eating. We all know how loud it is to chew raw carrots. I chose 
to ignore her loud chewing and participated in the meeting. We are not 
allowed to eat in the workplace when it's not a lunch or rest break.
    When I was ready to take Ms. Beyale on the tour of the programs I 
work with she indicated she didn't want to in spite of her email 
demanding a detailed agenda, prior to her arrival. I sent her a 
detailed agenda of the afternoon activities and cc it to Mr. Harry and 
Cynthia Long.
    Again, I was not allowed the full benefit of a program 
presentation! She did not want to hear about the abrupt directive by 
Mr. Harry gave me to not conduct any Beading Therapy anywhere on Indian 
Health Service Property. When I tried to tell Ms. Beyale about the 
issues preventing me from doing a good job, i.e. not allowed ordering 
supplies for almost a year and unanswered questions and lack of 
supervision she was not interested.
    All funds for health education was given to Yuma from Phoenix Area 
Office and now Portland Area. Ms. Beyale warned me, ``you won't be able 
to spend these funds before they take them back because of the fiscal 
year ending and the approving officials were too backed up.'' I 
replied, then what good is it to send the money if I can' spend it 
down? I ultimately, wrote up a plan to have a series of professional 
speakers come to train the staff and community on Diabetes. This plan 
was never acted upon so at the least minute, I came up with a plan to 
spend down the funds rather than send it back. I requested that all 
staff be allowed to attend the Annual Diabetes Conference in San Diego. 
This effort was approved. I need to mention, Ms. Safford was the Acting 
CEO during this timeframe and she is also Ms. Beyale's direct 
    Ms. Beyale, I believe, was aware or should have been, I had no 
budget for Health Education in 2015 or 2916. This lack of funds has 
negatively impacted Health Education. Mr. Joe Law from Portland Area 
did however send me $10,000 for 2016 but I am not allowed to spend 
those funds either. Dr. Berkley made a statement long ago that I never 
forgot, ``If you have no budget, you have no mission.'' Given that 
realization you can imagine how I have managed to do my job.
    Further, my supervisor suggested since Mr. Harry would not allow me 
the preapproved comp time to conduct the staff stress management 
program. Ms. Long suggested I come in later.
    However, when I followed Ms., Long's directive, Mr. Harry came to 
the room where we meet and pretended to be looking through a box of 
chocolates on the table. He asked me what I was doing. I replied that 
my Beading Class meets on Wednesdays 5-7 pm. He said, ``Did your 
supervisor tell you I won't approve comp time?'' ``I responded, she 
said to just come in later and I did.'' The next day Ms. Long came to 
tell me Mr. Harry directed her to tell me that I had to request 2 hours 
of my annual leave to cover coming in 2 hours late. I did as directed 
until I could file a grievance or EEOC complaint.
    While I met alone, behind closed doors, with Ms. Beyale, she was 
across the desk from me glaring at me. I asked her, ``Why she looked so 
angry at me?'' She was shaking, teeth clenched when she responded, ``I 
am so tired of hearing about the beadwork and historical trauma!'' She 
went on to say the other Health Educators didn't want to hear about it 
either from me. So, why is it ok for a Non-Indian (Dr. MacIntyre 
retired Corp Officer/friend of Ms. Beyale) to talk about it and not me? 
She responded, that's all you talk about.'' I replied, because this is 
at the root of most of the health issues Native Americans have.
    The Beading Therapy has a successful track record in attracting 
    Ms. Beyale's behavior toward me was hostile and I requested that it 
might be better to have someone else come to work with me since she 
can't keep her personal feelings against me out the work we needed to 
get done.
    I asked, Ms. Beyale who her supervisor is but she would not tell 
me. I did find out that Ms. Safford is. I asked Ms. Beyale to wait 
until my supervisor joined us but with a look of disgust, grabbed her 
back pack, abruptly walked across the room to Mr. Harrys' office and 
sat down smiling sarcastically at me.
    I told Mr. Harry he needs to get someone else more impartial to 
oversee Health Education because Ms. Beyale can't be civil to me.
    I was so upset afterwards, I had a Nurse check my blood pressure, 
seen a provider and went home on sick leave. I am at home now still 
feeling the effects of the horrible treatment. Ms. Beyale's behavior is 
outrageous, unprofessional, abusive, and uncalled for!
    After realizing all the connections between Mr. Harry, Ms. Safford, 
Amy Hamlet and Ms. Beyale, I noticed how my position was being 
undermined and sabotaged! This conduct, I believe constitutes 
discrimination, retaliation and cronyism.
    There are Federal Laws that protect the employees from this type of 
treatment. I believe, Ms. Hamlet is aware I wrote a formal complaint 
against her and I spoke personally with Dr. Russell regarding her 
    I have given Ms. Beyale every opportunity to be fair with me but 
apparently she can't. I suggest that Mr. Joe Law, Acting Health 
Education Director help me with the Health Education program.
    Lastly, just as a mention, the Beading Therapy is in the process of 
being accepted as a best practice for Native Americans. When I 
mentioned to Ms. Beyale about this she was clearly disinterested and 
    I have to also point out, that almost simultaneously, there was a 
hearing going on in DC with the Indian Health Service Officials and the 
Senate Committee on Indian Affairs. There was extensive testimony on 
Historical Trauma by Indian Health Service officials and Cronyism.
    So, I really am at a loss, why Ms. Beyale is so hateful to me when 
I mention it. Her conduct and influence she has with Mr. Harry has 
created a substantial amount of duress, stress and Hostile work 
environment for me. I am home today on sick leave because I was so 
shocked and upset how Ms. Beyale treated me.
    Furthermore, the series of events have the appearance of 
Discrimination against Native American Culture and retaliation.
    I am requesting a full investigation into this matter and that I am 
offered immediate relief i.e. Administrative Leave from work until this 
matter is addressed.
    Senate Committee on Indian Affairs--Thank you for taking time from 
your busy schedule to conduct hearings on the Indian Health Services. 
We are in Albuquerque, NM 87114. Attached are writings done on 
discrepancies existing within the Indian Health Service Areas. All us 
Indian people hear is, we cannot do this due to budgetary shortfall. 
This statement is not true as Congress and the Presidents budget always 
include increase in the budget. If we can help further, please call on 
us. Frank and Corie Moran Adakai. Thank you so much for reading the 

January 31, 2016
Headquarters Office Indian Health Services.

    This letter is to address a very serious existing situation and 
affecting patients in a very harmful manner. The continued practice of 
IHS physicians, without hesitation, of prescribing Narcotics based 
Prescription Drugs to ease the pain or ailment, has to come to a stop 
immediately. This practice is just a short term fix. It is a known fact 
that as soon as the prescription drug wears off, the pain still being 
there, the individual resorts to popping some more Narcotic based drugs 
to ease the pain. In the meantime, individuals on pain medication 
becomes addicted and absolutely cannot live without it. The Indian 
Health Services (IHS) physicians should establish other alternatives 
such as consulting with a Pain Management Specialist to pin point the 
real cause of the pain. Once this is done, proper treatment can be 
identified. Within the past week, the Congressional officials sent out 
communication to their constituents advising them to sign a petition. 
Some pharmaceutical companies are buying up existing drugs, often times 
cheap generic ones, and hiking up their prices by large amounts to 
increase profit margins. In one of the worst cases, a pharmaceutical 
CEO bought a drug that retailed for $13.50 per tablet and raised it to 
$750 almost overnight.
    These increasing prices come with repercussions for New Mexico's 
most vulnerable. It was reported that 540 drugs covered by Medicare 
Part D increased at least 25 percent in cost-per-tablet in a year.
    In our state, where 255,414 seniors are enrolled in Medicare Part 
D, you can imagine the financial toll these price hikes take. If this 
so, is IHS ready to pay the increased amount?
    The issue at hand is the prescription of Narcotic based drugs being 
prescribed by the Indian Health physicians to patients. Every day you 
see individuals walking out of the IHS Pharmacy with two or three bags 
of prescription drugs. Most of the prescription is Narcotic based 
drugs. We all know this is a short term fix. The real cause of the pain 
or ailment is completely overlooked. In our immediate family we have 
actually experienced the tragic aftermath of Narcotic based drugs for 
pain prescribed for over thirty years, by the Indian Health Services 
physician. Our immediate family was very concerned over this long 
period of time, until in August of 2015, we did something about this. 
The IHS physicians in Belcourt, North Dakota were excellent in quickly 
acknowledging the problem, and doing something about it. During the 
treatment of our family member, they terminated the constant use of 
Narcotic based prescription drug. During the process, our family member 
went through the immediate after effect of withdrawal. It was not a 
very nice sight to see. The physicians started working with our family 
member towards further identifying what was actually causing the pain. 
Presently, our family member is under the care of Pain Management 
    Therefore, again, we are officially and respectfully asking Indian 
Health Services seriously consider reverting to working with Pain 
Management Specialist, and not continue to prescribe Narcotic Based 
Prescription Drugs.

November 1, 2015--Document Number: 161-QASU-126--Chart: 48470 AIH
    Pursuant to 42 CFR 136.25, this appeal is being filed.
    On October 20, 2015 we received a letter signed by CDR John Rael. 
The letter received outlined the following; Contract Health Services 
request for services on October 19, 2015. Request received October 8, 
2015 and was for NM ORTHO ASSOC & NM SPINE.
    Request had been received to authorize payment for Medical 
Services. Careful review of Contract Rules and Regulations was 
supposedly done and decision made that ALBUQUERQUE INDIAN HEALTH CTR 
will not authorize payment for the following reasons:
    Lives outside Local CHS Area. Not eligible for Contract Health 
Services (CHS) because you do not live on the reservation and do not 
maintain close economic and social ties with the local tribe(s) for 
which the reservation was established. Close ties include marriage, 
employment or tribal certification (per 42 Code of Federal Regulations 
36.23 (1986).
    Reference was also made IHS records show that we have health care 
coverage/resources (such as private insurance, Medicare, Medicaid 
available to pay for this medical care. (see 42 Code of Federal 
Regulations 36.61c (1990).
    The letter further stated: Any unpaid balances should be promptly 
submitted to the Indian Health Service Contract health Service Office 
for review.
    It also states: If you have received a denial letter, but your 
alternate resources have not yet been billed or paid, you are not 
necessarily being denied authorization for PRC payment. The IHS is 
coordinating your benefits and waiting to receive notification of the 
remaining approved medical costs.
    We do take exceptions to this denial letter for the following 
    1. Discrimination--We are solely being discriminated against by the 
very entity directed to provide health services to all Indian people. 
We feel strongly the Treaty signed between Indian people and United 
States clearly states that the Treaty will provide health services 
along with other services. No where in the Treaty does it state that 
certain class of individual Indian people will be denied payment for 
health services.
    2. There are over five hundred Indian Tribes within the United 
States who receive benefits from the U.S. Federal Government through 
federal appropriation.
    Just like any other programs and organizations, Indian Health 
Services uses the most recent census of population as justification to 
seek federal dollars. We, even though we reside within an Urban 
setting, are counted and our numbers are used as justification.
    3. Many of us decided to leave the Reservation to seek better 
educational and employment opportunities. Many of us are retired from 
what employment we were involved with. Many of us have used what we 
learned from the white people.
    They use to tell us, ``SAVE FOR A RAINY DAY''. Many of us used that 
principle statement and that is how we were able to save our money, 
invest, and bought homes and land in an urban setting. We just did not 
stand in line waiting for a free hand-out. Many of us thought about our 
family and procured Insurance and Health Benefits. But still yet we are 
    4. The following statements contained in the letter are erroneous: 
do not maintain close economic and social ties with the local tribe(s) 
for which the reservation was established. Close ties include marriage, 
employment or tribal certification.
    We have maintained and still are maintaining close economic and 
social ties with the local tribe(s). This is done for many years 
through the facilitation and consultant work we do and have done with 
the local tribes, Navajo to the west and the Pueblos up and down the 
Rio Grande. The patient, Corie Moran Adakai is married to a Navajo and 
has been and going on 53 years. Corie Moran Adakai is an enrolled 
member of the Ojibwa Tribe of Turtle Mountain Agency and does have an 
enrollment number. This should satisfy employment and tribal 
certification questions.
    5. The letter contains references to the Code of Federal 
Regulation. The regulations cited are not law per se. It is only 
regulations and can always be changed as needed. Times are changing and 
there is constant progress.
    If references are made to citations within the CFR, then a copy of 
the applicable CFR should accompany the letter. In this way, a review 
can be made by the person who the denial letter was sent to. Of course, 
not everyone understands terminologies used in the CFR.
    6. The following statement also contains errors and is totally 
misconception: IHS records show that we have health care coverage/
resources (such as private insurance, Medicare, Medicaid available to 
pay for this medical care.
    We do have private health coverage and Medicare. We are not 
eligible for Medicaid, therefore, we do not have coverage under this 
provision. The medical records should be revised to reflect this.
    7. The denial letter is very confusing and the writer is talking 
from both sides of the mouth. The letter stated: Any unpaid balances 
should be promptly submitted to the Indian Health Service Contract 
health Service Office for review.
    If you have received a denial letter, but your alternate resources 
have not yet been billed or paid, you are not necessarily being denied 
authorization for PRC payment. The IHS is coordinating your benefits 
and waiting to receive notification of the remaining approved medical 
    Our question is: Is the payment going to be made by IHS or not? I 
know this is a form letter and it should be reviewed and updated 
reflecting changes to our concerns and questions.
                                         Corie Moran Adakai
    I'm 63 years old and an elder of the Cheyenne River Sioux Tribe in 
Eagle Butte, SD. Forty one years of public services work and still 
working. My concern is the competency of the Indian Health Services 
management people particularly a CEO at Eagle Butte. An individual with 
NO medical background nor employment in the health or medical fields. 
No college degree? I've known this CEO when he was a rookie in law 
enforcement back in the late 1980's and I think he's served a few 
positions of work in the criminal justice system including Chief of 
Police for the local Tribe and possible management positions in the BIA 
system. Up upon a couple of years ago or so I was informed that he was 
the current CEO of the local Indian Health hospital. I just about fell 
out of my chair when I heard this.
    I was visiting with a professional friend of mine who's husband 
recently retired from the criminal justice field after forty years or 
so who had management experiences in that particular field. I asked her 
how she would feel if her husband went and applied for the CEO position 
in their local City's big hospital. She said it would be a joke and 
that he would never qualify for that position and would not be stupid 
enough to think he would be eligible for that position in a different 
professional field. I then told her what happened at Eagle Butte with 
the Indian Health Services in hiring this new CEO. She was shocked and 
appalled and felt for our Native people as she heard so much negativity 
about the Indian Health Services management issues.
    For me and my personal medical issues getting services from this 
local hospital, I have absolutely NO confidence and comfort in the 
hospital's management here at all. I personally know at least three 
people who had EEO grievances or complaints against its local 
management. Also the nepotism here at the hospital plus the hiring of 
people with no college degrees, professional experiences, etc. I 
personally know of one person highly qualified who was passed over to 
hire one of the management's team members relative into that particular 
                                               Daryl Lebeau
    Dear Senators,
    I am a physician/psychiatrist currently working in the Indian 
Health Service, and have been here for 3\1/2\ years.
    The Indian Health Service is inefficient, bureaucratic, outdated, 
suffers from poor leadership, and low moral.
    Many of the problems with the Phoenix Veterans Administration (VA) 
Hospital are problems at the Phoenix Indian Medical Center/IHS 
hospital, and the IHS in general.
    My recommendation is for eligible Native Americans to be offered a 
choice of private health insurance plans, such as the Affordable Care 
Act provides, by which Native Americans and their families could obtain 
a health insurance plan that suits them, is more efficient, and could 
provide quicker service of their health care needs.
    The current system of the IHS providing clinics, hospitals would be 
slowly phased out. This would provide a cost savings to the government 
and taxpayers.
                                       Daniel Coulter, M.D.
    Dear Senate Committee
    The IHS is disproportionately overburdened, serving such a high 
risk population in many remote and underprivileged areas, yet seriously 
underfunded. Sadly, the IHS does not receive due credit and 
consideration for the excellent work that they do.
    Between 2012 and 2014, all 13 of the IHS' birthing facilities 
gained the WHO's prestigious Baby-Friendly designation. Baby-Friendly 
is an international designation earned by over 20,000 hospitals 
worldwide, yet fewer than 10 percent of U.S. facilities are designated, 
compared to 100 percent of IHS facilities. BFHI promotes optimal, 
evidence-based care for mothers and infants, and each hospital is 
designated by Baby-Friendly USA, an external organization performing an 
onsite assessment. IHS had the U.S.' first Baby-Friendly hospitals in 
Arizona, New Mexico, North Dakota, Oklahoma, and South Dakota. Early 
promotion and support for breastfeeding, a major component of Baby-
Friendly status, is critical in AI/AN populations where obesity and 
diabetes are high. As highlighted by the Lancet's January 2016 Global 
Series on Breastfeeding, human milk offers strong protection against 
these conditions, and breastfeeding could save 800,000 infant lives per 
year worldwide, if practiced at the same level it is practiced in IHS 
    Please respect and honor this outstanding IHS achievement which 
took place under the medical leadership of Dr Susan Karol; an active, 
inspirational CMO for the Agency.
                              Anne Merewood Ph.D MPH IBCLC,
    Consultant to the Indian Health Service Associate Professor of 
        Pediatrics, Boston University School of Medicine Associate 
 Professor of Community Health Sciences, BU School of Public Health
    I understand people are passed over for positions--but I also know 
Mr. Cornelius has been penalizing me professionally since he swept the 
embezzlement under the rug.
    Also--a woman in our department harassed me outside of the office 
and brought that to the workplace. She had children with the Personnel 
Officer at the time, Mr. David Azure who was friends with the Executive 
Officer, Tony Peterson and also friends with the Finance officer at the 
time, Mr. Edmigio Violanta. Ms. Picotte would harass me outside of work 
and then come here and use her position with these men to try to get me 
    Each time I applied for a position Mr. Cornelius brought this woman 
up and he put her on my resume every application thereafter.
    Twenty years later that woman has six kids with five different men 
and is no better life situation today than she was in 1994.
    My husband of 25 years and I bought a newly built home almost 
eleven years ago and have one gainfully employed son in graduate school 
and another on his third year of college.
    When I applied for the next position in my career ladder after 
working 1900 hours of overtime to reduce cash I was passed over and 
asked in my interview how my past relationship with Ms. Picotte would 
affect my ability to do my job. Ms. Allery then denied asking the 
question--and destroyed evidence? She had two pieces of paper with 
questions written on them and she was taking notes as I was answering 
    Rather than go on and on--I will stop there--Never did Ms. Picotte 
and her harassment affect my ability to excel in my position. And if it 
did--why was I rated Exceptional for all those years? And given awards 
and QSIs for my performance.
    Ms. Allery was the Budget Officer for several years and prefaced 
every meeting with me and the Accounts Payable Supervisor and the 
Accounts Receivable Supervisor with ``I don't know what you do in your 
section but. . . .'' Not to mention she was selecting for a position 
when she herself was retiring.
    Ms. Mary Godfrey did the same 2 years later. . . 
    I fear Retaliation.
                                          Kathleen Bankston
    I am in full agreement with the delegation from I believe Rosebud 
in their testimonies regarding Robert McSwain's inability to address 
critical reports attesting the critical needs and conditions of Indian 
Health Service Units not only in the Great Plains Region, but across 
Indian Country and after seeing his person, he need to retire. He looks 
overly tired and appears very uninterested. Senator Byron Dorgan's 68-
page Report of 2010 addressing the critical conditions of all the Great 
Plain's Regional IHS was brought to the attention of McSwain in my 
letter addressing the Standing Rock Sioux Tribal Council's requesting 
its current CEO, Jana Gipp be placed replacing Winona Stabler without 
competition. I provide much documentation on my opposition to this 
practice, however, never received a response. All to the Great Plains 
Regional's Chairman's Health Board without a response. There is no 
monitoring or follow up by those contracting officers or employees 
whose responsibility is to provide technical assistance. And Yes, there 
is reprisal to employees who dare to speak out about deficiencies 
witnessed. McSwain lied. Since a majority of the Tribal Councils across 
Indian Country are corrupt and visionless, there is a dire need to get 
down to the grassroots people for identification of crucial health 
needs. The overload of programs on our reservation are only to provide 
salaries for those occupying these programs who are usually family 
members, relatives or friends of the tribal council so unqualified for 
the programs they are servicing. This has been a pattern of practice 
for decades and will not be eliminated overnight. Now that federal 
funding cuts are being manifested tribal councils will be forced to 
view its defiiencies and its resources to meet its memberships' medical 
needs and find out its resources are now limited. The health conditions 
of the poor are devastating and inhumane on our reservations, and this 
is a fact. The tribal councils are incompetent as well. Senator Thune 
needs to hear from the grassroots now either through hearings, phone, 
emails or regular postal mails. Some of our membership are threatened 
to sign up under the Affordable Health Care Act or its IRS refund will 
be withheld. This is ridiculous! The current employees of all IHS needs 
to be assessed with background checks for drugs and other unethical 
practices. *
    * Attachments have been retained in the Committee files.
                                                Lena Toledo
    Senate Committee on Indian Affairs
    My name is Brandon Gypsy Wanna. I am employed by the Sisseton 
Wahpeton Oyate of the Lake Traverse Reservation. I work in our 
Community Health Education Program as the Wellness Coordinator. I know 
many people in the world go without health care because they can't 
afford it; I am thankful to have the Indian Health Service. However, 
this doesn't mean we should have inadequate care.
    Below I have listed what I feel should be known about the Woodrow 
Wilson Keeble Memorial Health Care Center. (IHS, Sisseton Service Unit)
    Patients are not informed about what laboratory tests are being 
ordered on them; especially the HIV screening tests. As part of my job, 
I organize screening events in the community. At these events several 
people have informed me they were already screened at IHS and they 
found out about it from Pharmacy when they were picking up medication 
refills. I wrote a formal complaint about this issue. I received a 
repsonse stating that all people are told exactly what tests are being 
ordered for them. However, months later, I am still getting reports 
from people that they aren't told what lab tests are being ordered.
    Many Native employees are being ``forced'' out because supervisors 
and administrative staff create and/or foster a hostile work 
environment and harass the native employees. Native employees are 
scrutinized on attendance, leave, breaks, etc. Often, the supervisors 
are getting advice from the area office.
    Current native employees are afraid to speak up about wrongs they 
see. I know of at least 2 people that followed the process of filing a 
complaint on either their co-workers or supervisor. Both were fired. 
They filed wrongful termination and of couse won their cases, however, 
the conditions at the facility still have NOT changed. They are still 
working in a hostile environment. The supervisors of these employees 
were never reprimanded and one got promoted to the area office.
    Thank you for your time and allowing me to submit my letter.
                                        Brandon Gypsy Wanna
    First I want to share with the committee that I am a dedicated 
employee of the Great Plains IHS, a veteran of the US Army, 
Commissioned Officer of the South Dakota Veteran's Commission, and a 
proud Lakota enrolled in the Cheyenne River Sioux Tribe.
    Ever since I could remember, our people encouraged us to leave the 
reservation, get an education and come back to help our Tribe. With 
that said, I did just that. I joined the US Army and served my country. 
I attended college and received my Bachelor's in Business 
Administration with a focus in Marketing and then went on to earn my 
Master of Management/HR Management. I started working for the Bureau of 
Indian Affairs as the Administrative Officer and then I moved into 
Indian Health Service as a Contract specialist. I then moved into 
another area of Office of Tribal Programs as a Health System 
    Before taking on the position in the Office of Tribal Programs, I 
was assured that if I enjoyed working with Tribes and helping them that 
this was the direction to take. I was told that this position was 
important as we would act as the liaison between the IHS and the 
Tribes. How awesome was that? I love working with our people, and I 
love the fact that I can make a difference. This of course has not been 
the case. Our office is supposed to support the Tribes in their efforts 
to 638. We receive proposals, resolutions, request for additional 
funding and in turn we are to provide assistance or respond with a 
declination. In my opinion, we have failed, miserably. I was given the 
task of responding to letters received that were over two years old! 
Some of those letters are still sitting with no signature. A family 
wrote a letter of complaint in regards to being declined for direct 
services. These letters are now going on three years old. The Area 
Director letter is yet to be mailed to the family. This is only one 
example. We have 90 days to respond to a proposal mailed in by the 
Tribe. Many times we miss the deadline and if the Tribe doesn't follow 
up, it slips through the cracks. If not, we have to send out funding 
that may not fit the criteria because we are tardy in our response 
time. This happens over and over. Who audits the Area office? I do not 
see an audit of whether or not we are following the law. I cannot 
submit the letter as evidence do to privacy, but the committee sure can 
come and ask during their investigation.
    I have been in my current position for almost three years. My 
supervisor holds a high school diploma and my second line supervisor 
holds a GED. They have wrapped themselves up in a fictitious world of 
their own which includes their rules. Although they have years of 
``experience,'' their experience has not impressed me. They take their 
time in responding to the Tribes' needs, and they protect their jobs by 
not doing what they were hired to do. They were hired to support the 
Tribes and help the Tribes become self supporting. Instead of doing 
this, they stand in the way of progress. They avoid Tribal needs and 
give the Tribes the ``run around.'' I have sat and observed their 
unprofessional behavior. I have been told to add ``fluff'' to letters. 
These 1-2 page responses to Tribes only add confusion. Many Tribes just 
give up because the hassle becomes time consuming.
    Currently I have a sexual harassment, hostile work environment and 
retaliation claim against my supervisor Sandy Nelson and the former 
Area Director Ron Cornelius. I have attached my last pre-hearing report 
for EEOC No. 443-2015-00088X, Agency No. HHS-IHS-0290-2014 and the 
current retaliation documents that occurred in December 2015. *
    * The information referred to has been retained in the Committee 
    For almost two years I have sat here putting up with continued 
retaliation and a hostile work environment. I have two written, 
unjustified reprimands that sit in my personnel folder that will sit 
for a total of two years. I provided rebuttals on the reprimands but 
not once did I receive a response from Mr. Nelson. In all of my career, 
I have never received a written reprimand, in a matter of six months 
following my EEO formal complaint, I received two. I have continued to 
decline in my personnel evaluations. My supervisor has increased 
percentages to over 90 percent just in order for me to pass at an 
acceptable level. If I wasn't passing with less than 90 percent, how am 
I to perform over 90 percent. It is called setting me up for failure. 
The attached documents will give you a very small insight to the broken 
EEO process. Every day I come to work and an unhealthy environment. Why 
do I stay? I have a family to support and as I sit here tortured daily, 
I job search for a better place, a place where the stress level has to 
be a lot lower. I have been ``black listed.'' I have had interview 
after interview with no job offers. I had no problem with getting jobs 
in the past, after all, I do hold three college degrees, and I bring a 
wealth of experience any position. All I can assume is that my 
personnel file must contain something in regards to my recent EEO 
activity. For over two years, this haunts me and follows me. My 
supervising staff treat me like a receptionist. I write correspondence 
letters and forward emails mostly. I am happy that I am well versed in 
MS Outlook. Needless to say, I have been trying to find a way out of 
this position for a long time. I will continue to search daily for an 
opportunity and hope that one day a prospective employer will see the 
potential I hold. I am a hard worker and feel that I am dedicated. At 
one time, I was a loyal employee. I cannot say I am that now, not in 
Indian Health Service. Mr. Cornelius, former Area Director of the Great 
Plains, was an enabler and the HHS zero tolerance policy on retaliation 
and sexual harassment is just words. No meaning behind them as managers 
are not penalized for their actions. Heather McClane once worked at the 
Great Plains Area. I heard that she recommended the removal of Richard 
Huff for HIPAA violations. Ron Cornelius retaliated against her and 
took job duties away and gave them to Rachel Atkins. Randy Jordan and 
his girlfriend were resolutioned out by the Winnebago/Omaha Tribe but 
were given jobs at the Area office. Randy Jordan is a GS-15 who reports 
to a GS-14. Teresa Poignee, his girlfriend failed to make the panel for 
a IT position. Scott Anderson, former IHS employee in charge of the IT 
department, refused to hire Teresa in the position. Richard Huff took 
away Scott's hiring authority and took it upon himself to hire Teresa 
in a position she does not qualify for. Ron Cornelius retaliated 
against Mr. Anderson, instructed him to move from Sioux Falls to 
Aberdeen where he and his family resides. Mr. Anderson went on terminal 
leave and applied for retirement. His last day was his first day in the 
Aberdeen office. Only lower level staff are harassed, retaliated 
against or worse, fired for their actions. There are reasons why there 
are problems in the field. It begins with the behavior at the Area 
office and the unethical behavior of staff in administrative positions.
    I watched the Senate Hearing and couldn't help but cry at the 
stories I have heard. My father passed recently but suffered years and 
years of being misdiagnosed at the Indian Health Service. I lived back 
on the reservation for a short time. I could have used the Indian 
Health Service instead of paying for insurance, but I did not. I paid 
for insurance as I was aware of the care that IHS provides. Going for 
an immunization or a common cold was the most I could trust the 
facility. My life and lives of my family are too important not put all 
my faith in IHS.
    I see that my problems are small in comparison to others who have 
lost loved ones in the Indian Health Service because of misdiagnosis or 
improper medical care at a facility. I shared my personal experiences 
to prove the issues are deeper than the Senate Committee knows. To 
solve these issues, the Senate Committee has to make change at the 
highest level of administration. Those like my supervisor who come to 
work when he feels like it, makes sexual comments at females, carries 
on with unprofessional behavior and doesn't do his job. The Indian 
Health Service needs to be proactive in hiring educated individuals in 
positions of GS-9 or higher. IHS needs to stop hiring high school 
graduates in positions of power. The problems will not stop in the 
field because the decision made in the Area office are not on the same 
level of those in the private sector. A secretary in the Aberdeen IHS 
can be paid over $90k a year, and I am almost certain they have no 
education to back that salary up. People in the private sector with 
degrees don't make that much money. I have seen time after time the 
jobs that have been created for area staff. Rhonda Webb, Special 
Assistant to the Area Director, holds such a position. She is a 
licensed cosmetologist yet she made the panel for a GS-14 making over 
$97k a year. I know plenty of hairdressers who don't make a third of 
that. The job was created for her and many others who made the panel, 
who hold higher education degrees, were passed up. No interviews were 
conducted. Why? Because this job didn't have an education requirement. 
Like many other GS-14s and higher, you just have to know the right 
people to move up in the IHS. These uneducated individuals never had to 
take an English writing class, MS Excel class, MS Word class, the list 
goes on, but yet, they hold a dream job with benefits and high paying 
salaries. I personally have taught my co-worker, who has been in the 
government for over 30 years, how to set up a reoccurring meeting 
request in MS Outlook. This is high school 101 and she has no clue. 
Yet, she is in charge of working on audits with Tribes. She is a GS-12, 
step 10.
    I work in a department where I am not allowed to even talk to 
members of the Tribes without be scolded or verbally reprimanded. How 
can I provide services to the Tribes if I am not allowed to talk to the 
Tribes? I know many people from the Tribes. I grew up on a reservation 
and experienced the many hardships that people face today. Indian 
Health Service was my medical provider my entire life. Luckily for me, 
I didn't have major health issues. Before we can fix problems at the 
local agencies, we need to clean up our Area office. Find out the real 
issues and find out how staff are treated. I have attached an example 
of a form of dictatorship in an email for the committee to review. Upon 
my arrival back into the office from leave, I received an email that 
was disturbing to me. I was also told that I am not allowed to 
``share'' outside of the department. This email stated that we were not 
allowed to enter the Area Director's office without an appointment. 
This was the new ``Office of the Area Director Protocol.'' It is 
apparent that the Area office lacks knowledge of the definition of 
transparency. The atmosphere in Indian Health service is scary and a 
part of me is scared to send this testimony, but I feel it is 
important. It is important that he committee understand the foundation 
that has been created. I have only worked in IHS going on four years 
and it has always been this way. Let's find a way to clean up 
administration first and clean out the bad apples. If you don't get rid 
of the rotten apples, you will not see an improvement in any area of 
the Indian Health Service.
    Thank you for allowing me to send in my documents. I am positive I 
missed something but am open to discussing or answering questions.
                                            Kella With Horn
    To Whom It May Concern:
    In regards to the Re-examining the Substandard Quality of Indian 
Health Care in the Great Plains; I listened to all the sessions and 
felt compelled to remark on what had been discussed.
    I am an Alaskan Native, I am an enrolled (descendant) member of 
Calista Incorporated and Cook Inlet Regional Incorporated (CIRI) 
descendant who received exemplary care at the Alaska Native Medical 
Center as run by the Alaska Native Tribal Health Consortium (ANHTC). As 
someone who worked for IHS in the past and someone who has friends who 
work for IHS or who receive care through the IHS facilities other than 
the Alaska Native Medical Center, I can honestly say that if I needed 
care through IHS in any area other than ANMC, I would willingly go into 
debt before being seen at any of the facilities that are in the Lower 
48. I place a high value on my life and I feel that IHS does not place 
that same value on my life in regards to my healthcare.
    Although I do know that the Great Plains Area needs quality 
physicians and nurses and needs to bring the hospitals out from under 
immediate jeopardy; did no one think to mention that some of the 
problems that have led to the issues at Great Plains Area starts with 
the lack of training that ALL staff do not receive?
    It takes months to become hired through the Indian Health Service. 
One applies for a position through USAJobs.gov or through the IHS 
website, then one must wait anywhere from two weeks to six weeks until 
the closing date of the position before one is notified if one has been 
referred to the deciding official. Another two to six weeks before one 
is notified that one has been approved for an interview. Why? Because a 
panel must be put together that includes at least three or more 
individuals who have the same or slightly higher (or lower) 
qualifications for the position advertised and that all individuals 
must have proven that they are either American Indian/Alaskan Native 
through the B.I.A. Approved Form 4432.
    Once one is interviewed, it takes another two to six weeks before 
one is contacted by a member of Human Resources that they have been 
chosen for the position. Once one accepts the position; an immediate 
barrage of paperwork is either emailed to them or faxed; or they must 
pick up and then fill out immediately and return immediately to the HR 
Department before one can report to their duty station. This paperwork 
is sent to the individual with little to no help from the HR 
Department. Once the paperwork is approved, one is told where to report 
and whom to report to.
    One shows up on their first day, eager to make a difference in the 
healthcare quality of the service unit or at the area headquarters and 
they are given little to no TRAINING. The eager individual is expected 
to ``hit the ground running, do not ask questions and don't make 
waves.'' They are not given time to learn the systems that they are 
expected to use such as the Electronic Health Records (EHR). If they do 
receive training, it is very limited and in a rushed fashion, such as 
30 minutes on the ``ins and outs'' of the EHR from the Clinical 
Applications Coordinator (CAC), they are not shown how to access the 
Indian Health Manual, nor given any desk manuals or reference manuals 
that pertain to their position. If they ask for a copy of their 
position description, they are told they don't need a copy. They are 
expected to know everything they need to know about their position from 
the moment that they clock in.
    This applies to ALL STAFF to include the nurses and physicians; how 
are they to know the IHS EHR if they are not trained on how to use it? 
How are they to know that they must provide clinical documentation on 
every patient and that they must finish and correct any notes if they 
are not trained on the system? When they ask for help or information; 
they are informed that they should know how to do their jobs and just 
``deal with it.''
    Staff are treated with contempt, lack of respect and they have no 
one that they can turn to for help; how can we expect to help care for 
all American Indians/Alaskan Natives if they are not given the training 
that they need or how to report issues without fear of retaliation? 
Fear of retaliation is very common and not just limited to one area. 
What happens when contract doctors leave because their contracts ended, 
they get their pay, which they are not supposed to receive until all 
their notes are completed. It leaves patient care and patient safety 
severely lacking, it leads to medical charts being incomplete which 
puts patients at risk. That is not acceptable; for anyone whether they 
are native or non-native.
    Please, before more money is spent on hiring doctors, physician 
assistants, nurses; and the accompanying support staff are hired; 
please ensure that the PROPER TRAINING has and is taking place. Lack of 
adequate training results in unprofessional standards of care. Training 
in customer care, proper documentation, policies and procedures should 
be standard when an individual is hired, no matter the position. 
Training is essential to ensure that all who receive care through 
Indian Health Services are given the best care in the nation.
        Thank you,
                                              Laurel Austin
                                 [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    FACT: The GP Area Office has made it a common practice of recycling 
field operations staff from one ihs field site to another and sometimes 
these staff are discretely allowed to telework and or occupy 
unclassified duties at locations of their choice.
    Question. Why are these employees allowed to float from location to 
location without being held accountable for their lack of performance 
or leadership at their pay grade?
    FACT: The Billings, Bemidji and Great Plains areas combined their 
Human Resources departments and staff to improve the hiring process for 
all three locations. The GPA created a Administrative Security Division 
that was to expedite the background checking process to assist with 
improving the hiring process also. There are currently HR field staff 
that should be performing this work locally and all field supervisor's 
are required to complete approximately 80 percent of the HR process as 
instructed by GPA HR staff. When the capital HR system goes down which 
is frequently, field staff are told the HR process is on hold until the 
system comes back on line.
    Question. What improvements in HR and ASD have been made? How long 
does it take to get a position advertised? How long does it take to 
complete a background check or verify credentials? Does IHS have a 
backup plan or process when the HR Capital system goes down in order to 
keep the HR process moving? Do we need these departments at the area 
level and or would the anticipated services be better suited at the 
field sites?
    FACT: The Great Plains Area has been informing field sites the GPA 
has a full time physician recruiter, whom is allowed to telework from 
their home. GPA staff have consistently pointed out that this recruiter 
has brought many new physicians on board within the GP Area.
    Question. Who are these new physicians and where have they been 
hired and placed?
    FACT: The Great Plains Administration is always informing on 
memo's, email announcements, etc., the fact that they are a TRANSPARENT 
    Question. What is the GPA's definition of transparency? Does the 
support staff in the area office feel they are afforded organizational 
transparency? Does the field sites fell they are afforded 
organizational transparency? How many official EEO, Union and 
Administrative Grievances has the GPA been investigated for in the last 
ten years? How many have been settled in favor of the IHS in the last 
ten years? How many were settled in favor of the complainant in the 
last ten years? How much money has been paid out by the GPA in the last 
ten years as a result of the out comes?
    MAIN Question. Mr. Cornelius, Do you feel the great plains area 
really needs a great plains area office if this is the type of 
leadership and guidance that you and your staff make available?
                                             Scott Sorensen
   Response to Written Questions Submitted by Hon. James Lankford to 
                              Andy Slavitt
    Many small businesses that supply home medical equipment to their 
communities, a significant portion of which are seniors and thus 
Medicare beneficiaries, are struggling to continue doing business 
because of losing bids during Round 2 of the DMEPOS competitive bidding 
program. You may be aware that, of the bid winners, several of the 
``new'' DME suppliers doing business in Oklahoma are from out-of- 
state. Oklahoma is now being threatened with an access problem to 
quality, local suppliers with which communities are familiar. During my 
travels across our state, I am hearing that many of the small, family-
owned businesses that have been able to keep their doors open despite 
losing out in the Round 2 bidding process are now the subject of an 
audit by either a Recovery Audit Contractor (RAC) or a Zone Program 
Integrity Contractor (ZPIC). I am told that the combination of the 
losing bid followed by the daunting reality of audit compliance and 
reimbursement withholding is a knockout punch for those businesses who 
have managed to hold on post-bid loss.

    Question. What resources, programs, or funding opportunities are 
available for small businesses--specifically those in the durable 
medical equipment space -who failed to secure a winning bid under 
DMEPOS competitive bidding program, and are now the target of a CMS 
audit, either through a RAC or a ZPIC audit?

    Question. What can CMS do administratively to avoid putting DME 
businesses in this dangerous position?

    Answer. Medicare's Durable Medical Equipment, Prosthetics, 
Orthotics, and Supplies (DMEPOS) Competitive Bidding program has been 
in effect since 2011 and is an essential tool to help Medicare set 
appropriate payment rates for DMEPOS items, save money for 
beneficiaries and taxpayers, and ensure access to quality items. Prior 
to the DMEPOS Competitive Bidding Program, Medicare paid for these 
DMEPOS items using a fee schedule that is generally based on historic 
supplier charges from the 1980s. Numerous studies from the Department 
of Health and Human Services' Office of Inspector General \1\ and the 
Government Accountability Office \2\ have shown these fee schedule 
prices to be excessive, and taxpayers and Medicare beneficiaries bear 
the burden of these excessive payments.
    \1\ See, for example, Comparison of Prices for Negative Pressure 
Wound Therapy Pumps, OEI-02-07-00660, March 2009; Power Wheelchairs in 
the Medicare Program: Supplier Acquisition Costs and Services, OEI-04-
07-00400, August 2009; Medicare Home Oxygen Equipment: Cost and 
Servicing, OEI-09-04-00420, September 2006.
    \2\ See, for example, Competitive Bidding for Medical Equipment and 
Supplies Could Reduce Program Payments, but Adequate Oversight Is 
Critical, GAO-08-767T, May 2008; Need to Overhaul Costly Payment System 
for Medical Equipment and Supplies, HEHS-98-102, May 1998.
    Under the program, DMEPOS suppliers compete to become Medicare 
contract suppliers by submitting bids to furnish certain items in 
competitive bidding areas (CBAs). After the first two years of Round 2 
and the national mail-order programs (July 1, 2013-June 30, 2015), 
Medicare has saved approximately $3.6 billion while health monitoring 
data indicate that its implementation is going smoothly. There have 
been few inquiries or complaints and our real-time monitoring system 
has shown no negative impact on beneficiary health outcomes.
    CMS is required by law to recompete contracts under the DMEPOS 
Competitive Bidding Program at least once every three years. The Round 
2 and national mail-order program contract periods expire on June 30, 
2016. Round 2 Recompete and the national mail-order recompete contracts 
are scheduled to become effective on July 1, 2016, and will expire on 
December 31, 2018.
    During the implementation of this program, CMS adopted numerous 
strategies to ensure small suppliers have the opportunity to be 
considered for participation in the program. For example:

   CMS worked in close collaboration with the Small Business 
        Administration to develop a new, more appropriate definition of 
        ``small supplier'' for this program. Under this definition, a 
        small supplier is a supplier that generates gross revenues of 
        $3.5 million or less in annual receipts including Medicare and 
        non-Medicare revenue rather than the definition used by the 
        Small Business Administration of 6.5 million. We believe that 
        this $3.5 million standard is representative of small suppliers 
        that provide DMEPOS to Medicare beneficiaries.

   Further, recognizing that it may be difficult for small 
        suppliers to furnish all the product categories under the 
        program, suppliers are not required to submit bids for all 
        product categories. The final regulation implementing the 
        program allows small suppliers to join together in ``networks'' 
        in order to meet the requirement to serve the entire 
        competitive bidding area.

   The program attempts to have at least 30 percent of contract 
        suppliers be small suppliers. During bid evaluation, qualified 
        suppliers that meet all program eligibility requirements and 
        whose composite bids are less than or equal to the pivotal bid 
        will be offered a contract to participate in the Medicare 
        DMEPOS Competitive Bidding Program. If there are not enough 
        small suppliers at or below the pivotal bid to meet the small 
        supplier target, additional contracts are offered to qualified 
        small suppliers. Contracts are offered until the 30 percent 
        target is reached or there are no more qualified small 
        suppliers for that product category in that competitive bidding 

   The financial standards and associated information 
        collection that suppliers must adhere to as part of the bidding 
        process were crafted in a way that considers small suppliers' 
        business practices and constraints. We have limited the number 
        of financial documents that a supplier must submit so that the 
        submission of this information will be less burdensome for all 
        suppliers, including small suppliers. We believe we have 
        balanced the needs of small suppliers and the needs of 
        beneficiaries in requesting documents that will provide us with 
        sufficient information to determine the financial soundness of 
        a supplier.

    CMS continues to identify program integrity as a top priority and 
strives to be a good steward of taxpayer dollars. We believe the 
statutorily required Medicare Fee-for-Service Recovery Audit Program is 
a valuable tool to reduce improper payments. Ongoing enhancements to 
the Recovery Audit Program allow CMS to use Recovery Auditors 
effectively by identifying and correcting improper payments according 
to a risk-based strategy. At the same time, these enhancements will 
increase transparency, improve provider fairness, and lead to improved 
communication between providers and Recovery Auditors. For example, 
Recovery Auditors must wait 30 days to allow for a discussion request 
before sending the claim to the MAC for adjustment. Providers can be 
assured that modifications to the improper payment determination will 
be made prior to the claim being sent for adjustment. Recovery Auditors 
also have 30 days to complete complex reviews and notify providers of 
their findings, which provides more immediate feedback to the provider 
on the outcome of their reviews. In addition, CMS instructed the 
Recovery Auditors to incrementally apply the additional documentation 
request limits to new providers under review to ensure that a new 
provider is able to respond to the request timely and with current 
staffing levels. \3\
    \3\ See Recent Updates to the Recovery Audit Program: https://
    The Recovery Audit Program uses techniques similar to commercial 
sector recovery auditing principles, such as using data analysis to 
identify improperly paid claims, requesting medical documentation to 
help identify possible improper payments, affording debtors a dispute 
or appeals process, and establishing recovery/collection processes. In 
addition, also similar to commercial sector recovery auditing, Recovery 
Auditors are paid on a contingency fee basis and must pay back 
contingency fees for review determinations that are overturned on 
    CMS is continuously working to improve collaboration between review 
contractors to promote accurate and efficient reviews of Medicare 
claims while reducing provider burden and ensuring beneficiary access 
to needed services. We encourage providers to work with the Recovery 
Auditors or Zone Program Integrity Contractors during the course of any 
reviews. Letters sent to providers when overpayments are identified 
include information on the potential for an Extended Repayment 
     Response to Written Questions Submitted by Hon. John Thune to 
                           Robert G. Mcswain
    Question 1. What percentage of appropriated funds is used for 
administrative costs throughout the entire Indian Health Service (IHS)?
    Answer. The total Fiscal Year (FY) 2015 appropriation for IHS was 
$4.6 billion, of which $3 billion (65 percent) was allocated to Tribes 
for them to run their own health care operations and $1.6 billion (35 
percent) remained at IHS for federally operated health programs. Of the 
$1.6 billion Federal allocation, $191 million or approximately 12 
percent was spent on administrative type costs such as: program 
services, information management/technical support, patient accounts/
business office, financial management, personnel management, and 
systems development.
    The $191 million relates to the administration of Federal programs 
IHS-wide only and therefore, does not include administrative costs 
incurred by Tribes or Contract Support Costs. IHS remains committed to 
good stewardship of Federal funds and to directing resources to 
activities, including essential administrative type activities, 
necessary for the provision of quality health care to American Indians 
and Alaska Natives.
    Question 1a. In the Great Plains Area?
    Answer. In FY 2015, the Great Plains Area's appropriated budget 
authority was $382 million, of which $113 million (30 percent) was 
allocated to Tribes to run their own health care operations and the 
remaining $268 million (70 percent) was used for federally operated 
health care programs. Of the $268 million Federal Great Plains Area 
allocation, $29 million (11 percent) was spent on administrative type 
costs. These figures relate to the administration of Federal programs 
Area-wide only and do not include administrative costs incurred by 
Tribes or Contract Support Costs. IHS remains committed to good 
stewardship of Federal funds and to directing resources to activities, 
including essential administrative type activities, necessary for the 
provision of quality health care to American Indians and Alaska 

    Question 2. In response to the 2011 Program Integrity Coordinating 
Council recommendations, which was formed to follow up on the 2010 
Senate Committee on Indian Affairs report ``In Critical Condition: The 
Urgent Need to Reform the Indian Health Service's Aberdeen Area,'' the 
then Aberdeen Area IHS stated ``Hospital CEOs are being held 
responsible for ensuring that Accreditation Specialist/QAPI 
Coordinators submit a Service Unit CMS Matrix to the Deputy Area 
Director-Field Operations by the 30th of each month outlining the level 
of compliance with CMS Conditions of Participation.'' Please provide 
the committee with copies of any and all of the above mentioned reports 
on file at either the Great Plains Area office or with IHS 
    Answer. The agency would be happy to work with the staff separately 
on the document request.

    Question 3. How many IHS Equal Employee Opportunity (EEO) 
complaints are filed in the Great Plains Area?
    Answer. For FY 2015, there were 56 EEO complaints filed in 
connection with the Great Plains Area.

    Question 3a. How does this number compare with the other IHS Areas?
    Answer. For FY 2015, there were a total of 79 EEO complaints filed 
in connection with the other IHS areas combined.

    Question 4. Additional, the 2010 Committee report indicated that 
IHS repeatedly used transfers, reassignments, details, or lengthy 
administrative leave to deal with employees who had a record of 
misconduct or poor performance. Since 2010, how many transfers, 
reassignments, details, or lengthy administrative leave have been used 
in the Great Plains Area?
    Answer. During FY 2010--FY 2015, the Great Plains Area processed 
324 reassignments, 109 transfers, and 229 details. In addition, nine 
employees were placed on Administrative Leave.

    Question 4a. Of that amount, how many employees have had a record 
of misconduct or poor performance?
    Answer. Of the Great Plains Area employees identified above, seven 
have a record of misconduct or poor performance.

    Question 5. Great Plains Area IHS facilities have, and continue to 
be, cited for leaving prescription medications unlocked and in patient 
access areas. What has IHS done to ensure that the correct process for 
prescription medication storage is being followed?
    Answer. IHS is committed to ensuring proper controls over 
pharmaceuticals. IHS has developed new procedures related to controlled 
medications intended to improve control of pharmaceuticals. The new 
procedures include enhanced security during ordering, receipt, storage 
within the pharmacy, and storage outside of the pharmacy, as well as 
the requirement for security features such as automated dispensing 
machines, pharmacy locks, and video cameras. The processes also require 
IHS pharmacies to submit monthly reports on inventories of schedule II 
controlled substances, quarterly audits for schedule III-V controlled 
substances, and an annual physical audit on inventories of all schedule 
II-V controlled substances that must be conducted by a senior level 
pharmacist from outside the service unit. IHS reports to State 
Prescription Drug Monitoring Programs (PDMPs) in 26 States and is 
working in collaboration with other States where there are issues with 
either privacy requirements, licensure requirements, or health 
management systems that IHS does not have access to. IHS will continue 
to work to identify new strategies to further improve its policies and 
procedures in this area.

    Question 5a. What changes can be made to ensure long-term 
    Answer. See above.

    Question 6. In the Consolidated Appropriations Act, 2016 (P.L. 114-
113), Congress appropriated $2 million to assist with accreditation 
issues at IHS facilities. Have these funds been allocated? If so, on 
what date were they allocated?
    Answer. Yes, funds were allotted to the Great Plains Area Office on 
March 8, 2016.

    Question 6a. Additionally, please provide a spending plan for how 
these funds will be used.
    Answer. The spending plan for the $2 million included: $426,886 to 
Omaha-Winnebago; $910,313 to Pine Ridge; and $662,801 to Rosebud to 
purchase central monitoring systems for all three facilities and a 
laparoscopic tower at Rosebud. The laparoscopic/arthroscopic tower is 
installed and in use at Rosebud. The Rosebud central monitoring system 
has been purchased and will be installed in October 2016 with a ``go 
live'' date scheduled for November 2016. For both the Omaha-Winnebago 
Hospital and the Pine Ridge Hospital the purchases are in the 
procurement process and it is expected that both will have purchase 
orders issued by the end of September 2016.

    Question 7. In 2013, then Acting Director of the IHS Yvette 
Roubideaux had indicated that a feasibility study was conducted that 
justified the Great Plains Area decision to relocate its information 
technology department from Sioux Falls, South Dakota, to Aberdeen, 
South Dakota. Please provide the committee with a copy of that study.
    Answer. A potential relocation of the information technology 
department from Sioux Falls, South Dakota to the Great Plains Area 
Office (GPA) in Aberdeen, South Dakota was contemplated by the GPA but, 
after conducting a reasonable search, we have not located any 
information regarding the existence of a formal plan/study to relocate 
the GPA Office of Information Technology (OIT) Department, including 
any evidence that such a study was conducted by OIT or submitted to 
Headquarters OIT for review.

    Question 8. IHS facilities are now automatically designated as 
Health Professional Shortage Areas. What steps are HRSA and IHS taking 
to increase the number of eligible health professionals serving in IHS 
    Answer. Having Health Professional Shortage Area (HPSA) Site Scores 
and an up-to-date National Health Service Corps (NHSC) Jobs Center site 
profile is essential to attracting NHSC scholarship and loan repayment 
participants. The IHS Office of Human Resources (OHR) and HRSA's Bureau 
of Health Workforce (BHW) Shortage Designation Branch and Division of 
Regional Operations are working together to identify IHS federal 
facilities needing HPSA Site Score or NHSC Jobs Center site profile 
updates. HRSA's BHW prepared information and web presentations on the 
need for and how to update HPSA scores and NHSC Jobs Center site 
profiles. This information was widely distributed to IHS Federal 
facilities. IHS OHR also developed and distributed a fact sheet 
detailing how to update HPSA scores and NHSC Jobs Center site profiles.
    HRSA BHW also conducts 1,100 to 1,200 site visits annually to NHSC 
sites, including IHS and Tribal facilities. On these visits, HRSA staff 
meet with CEOs, recruiters and Human Resources staff; conduct oversite 
and compliance activities; meet with NHSC scholars and loan repayment 
recipients; and provide technical assistance to sites (e.g., assisting 
in updating NHSC Jobs Center site profiles).
    IHS and HRSA continue to promote IHS facilities as service sites 
for NHSC scholarship and loan repayment recipients. As of January 2016, 
there were 396 NHSC loan repayment and 22 NHSC scholarship participants 
at IHS and Tribal sites (including 20 in the Great Plains Area).
    IHS is also working with the U.S. Public Health Service 
Commissioned Corps to increase the number of applicants to the 
Commissioned Corps who begin their Corps careers with an assignment in 
the IHS.
    HRSA hosted a NHSC Facebook Chat titled ``Finding Primary Care Jobs 
at High-Need Locations'' on February 3, 2016. IHS recruiters, including 
one from the Great Plains Area, participated in this live chat session. 
Another Virtual Job Fair is being planned with IHS and other American 
Indian Health Facilities, highlighting current job vacancies.

    Question 9. What strategies are the IHS and HRSA implementing to 
increase recruitment and retention of top quality health care 
    Answer. The need to recruit and retain highly qualified health care 
professionals to serve Indian communities is of critical importance to 
IHS and our Tribal and Urban Indian program partners. Collaboration 
with HRSA programs is a key to our success. IHS and HRSA work 
collaboratively to promote virtual events for both agencies. IHS 
facilities will participate in four NHSC Virtual Job Fairs in calendar 
year 2016. HRSA and IHS are working to promote the HRSA Nurse Corps. In 
February 2016, there were 13 Nurse Corps loan repayment participants 
and five Nurse Corps scholarship recipients working at IHS and Tribal 
facilities. IHS is also developing materials to promote the State Loan 
Repayment Program.
    The IHS has developed many materials to assist Clinical Directors, 
CEOs and others in recruitment and retention of health care providers. 
These materials are posted on the IHS Retention website at http://
www.ihs.gov/retention/. HRSA also assists IHS with retention of NHSC 
and Nurse Corps providers. HRSA provides the contact information for 
providers and information on when the provider's scholarship or loan 
repayment service commitment will be completed. This allows IHS 
managers and Area Office staff to follow-up with providers to work on 
retaining the provider at the current facility or at another IHS site.
    IHS is working to address these shortages using existing 
authorities for incentives to assist in the recruitment and retention 
of health professionals including:

   Title 5 and Title 38 Special Salary Rates
   Title 38 Physician and Dentist Pay (PDP)
   The 3Rs (recruitment, retention, and relocation incentives)
   Use of service credit to increase annual leave.

    Title 38 Special Salary Rates have allowed IHS facilities to offer 
pay that is closer to what health care providers would receive in the 
private sector. Title 38 PDP allows IHS to hire specialists, such as 
orthopedic surgeons, that would otherwise not consider IHS employment.

    Question 10. In addition to health care providers, there is also a 
need for top quality hospital administrators to properly manage and 
reduce bureaucracy at facilities in the Great Plains Area. What 
programs and resources are available to recruit the best hospital 
administrators to IHS facilities?
    Answer. Attracting and retaining highly qualified and effective 
Chief Executive Officers and other senior administrative leaders at IHS 
and Tribal facilities is essential to the success of Indian health care 
programs. Attracting these individuals to small hospitals and health 
centers in rural and remote locations is an ongoing challenge. IHS is 
able to offer incentives for these leadership positions including 
recruitment, relocation and retention incentives, service credit for 
annual leave, and setting pay above the minimum rate using the superior 
qualifications and special needs pay-setting authority.
    IHS has previously worked to promote from within for hospital 
administrator positions. Currently under review is the potential of 
developing additional career ladder opportunities as well as cross-
training and more robust administrator developmental programs. The 
Public Health Service Commissioned Corps provides an additional 
resource for hospital administrators, on a limited scale.

    Question 10a. Do you need additional authorities to recruit 
hospital administrators or can existing authorities be used?
    Answer. The IHS Loan Repayment Program (LRP) is a valuable tool for 
recruiting and retaining healthcare professionals. The LRP currently 
requires participants to serve their obligated full-time clinical 
practice of such individual's profession. Because health professionals 
appointed to purely administrative positions do not engage in full-time 
clinical practice, they cannot benefit from the current LRP. 
Additionally, the Internal Revenue Service has determined that IHS loan 
repayment/scholarship awards are taxable, reducing their value. The 
President's Budget contains two legislative proposals that address 
these problems. We look forward to working with this Committee and to 
answer any questions or provide any technical assistance you may need.

    Question 11. What steps has IHS taken to include Tribal 
Governmental participation in the governing boards of the IHS 
facilities in the Great Plains Area?
    Answer. IHS is committed to working in consultation with Tribes, 
including those in the Great Plains Area. It is the IHS policy that 
consultation with Indian tribes occurs to the extent practicable and 
permitted by law before any action is taken that will significantly 
affect such Indian tribes. This means that it is IHS' expectation and 
the governing board's obligation to engage affected tribes to ensure 
meaningful and timely input.
    It is important to note the IHS Director does not have the ability 
to delegate it's authority to run IHS facilities to individuals 
(elected tribal officials and other health care experts) who would not 
be accountable to IHS, the agency responsible for running the 
hospitals. Without clear authority, we cannot ensure IHS hospitals will 
meet the Centers for Medicare and Medicaid Services (CMS) 
accreditation. Moreover, governance board authority is extensive, and 
would include implementation of procedures for employee recruitment, 
hiring, supervision, and dismissal, and requiring hospital CEOs report 
to the board. Specifically, the inclusion of elected tribal officials 
and hospital administration experts outside the IHS system on governing 
boards raises legal concerns regarding inherently Federal functions, 
including the supervision of Federal employees by non-Federal 
employees, the sharing of confidential information, and conflicts of 
interest. In addition, at a time when several IHS hospitals need to be 
completely reorganized to maintain CMS accreditation, it is essential 
that authority over the operation of all hospitals remains clear and 
that IHS has the ability to affect change as needed.

    Question 12. What steps is the IHS taking to ensure that patients 
in the Great Plains Area understand the difference between a medical 
referral for which no Purchased/Referred Care authorization for payment 
is made, and referrals where payment has been authorized?
    Answer. To ensure that patients clearly understand the different 
types of referrals, IHS is developing outreach activities and training 
materials to ensure Purchased and Referred Care (PRC) patients and 
providers are aware of program requirements. Program materials will 
identify and explain the difference between medical referrals and PRC 
referrals authorized for payment. Staff will also incorporate this 
language into their daily use so patients and providers become 
accustomed to and recognize the difference in referrals.
    The Great Plains Area Office also developed a ``Basic PRC 
Requirements'' sheet that was sent to all PRC staff at the service 
units with the intent of offering patients an outline of basic 
eligibility requirements and includes the PRC contact information at 
the service unit.

    Question 13. GAO Report 14-57 recommended that the IHS separate 
reporting referrals from self-referrals and revise related to 
Government Performance Results Act reporting measures. What steps is 
IHS taking to implement that recommendation?
    Answer. IHS is working to implement GAO's recommendation. As 
recommended by GAO-14-57 Report (Indian Health Service: Opportunities 
May Exist to Improve the Contract Health Services Program), and with 
HHS concurrence in GAO-14-57 Appendix 1, the Office of Resource Access 
and Partnerships is developing the following two measures that will 
begin baseline reporting in calendar year 2016. PRC-2 will track IHS 
PRC referrals made by IHS providers and PRC-3 will track PRC self-
referrals where patients present to emergency rooms or urgent care 
facilities outside of IHS.
    The recommendation refers to timeliness for processing provider 
payments. The only self-referrals that will be tracked are those that 
are approved for PRC payment. No PRC payments are made for self-
referrals that are denied. Self-referrals occur when patients visit a 
non-IHS facility for care without pre-authorization, so approved self-
referrals will be tracked and denied self-referrals will not be 

    Question 14. What steps is IHS taking to negotiate contracts to 
provide transportation/ambulance/air ambulance services in the Great 
Plains Area?
    Answer. IHS is committed to providing adequate access to these 
services in the Great Plains Area. The Great Plains Area Contracting 
Office has negotiated agreements at rates for 10 percent above the 
Medicaid rates for two contracts that are in place to service the Area.

   The Eagle Air Med Corporation contract provides air 
        transportation to the Great Plains Area IHS, utilized for the 
        purchase of emergency air transport for medical necessitates 
        throughout the GPA IHS service area.

   Period of performance for Air Methods Corporation/Black 
        Hills Life Flight is May 15, 2015 through May 15, 2016 with 
        four one-year options--May 15, 2016 through May 14, 2017, May 
        15, 2017 through May 14, 2018, May 15, 2018 through May 14, 
        2019, May 15, 2019 through May 14, 2020

    Question 15. What strategies does IHS have in place to streamline 
the submission of third party claims and ensure that payment is 
received in a timely manner in the Great Plains Area?
    Answer. IHS is committed to facilitating the submission and payment 
of third party claims. The Great Plains Area is implementing a number 
of strategies to improve billing and payment for services delivered to 
patients with third party resources. We are working wherever possible 
to implement electronic submission of claims and transfer of payments, 
either directly or through a commercial clearinghouse. In addition, the 
Great Plains Area is working to implement strategies intended to 
monitor the billing process so as to quickly identify and remedy 
potential backlogs. IHS is committed to continuing to review and 
strengthen its procedures in this area.