    [Senate Hearing 114-522]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 114-522

       IMPROVING ACCOUNTABILITY AND QUALITY OF CARE AT THE INDIAN HEALTH
                            SERVICE THROUGH S. 2953

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

                                 FIELD HEARING

                                   before the

                          COMMITTEE ON INDIAN AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 JUNE 17, 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
    MIKE CRAPO, Idaho
    JERRY MORAN, Kansas
         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

                                  ----------
                                                                       Page
    Field Hearing held on June 17, 2016..............................     1
    Statement of Senator Barrasso....................................     1
    Statement of Senator Rounds......................................     6
    Statement of Senator Thume.......................................     4

                                   Witnesses

    Bear Shield, Hon. William, Chairman, Rosebud Sioux Tribal Health
      Board..........................................................    15
    Bohlen, Stacy A., Executive Director, National Indian Health
      Board..........................................................    24
        Prepared statement...........................................    27
    Blueshield, Ardell, Health Director, Spirit Lake Tribe...........    21
        Prepared statement...........................................    22
    Noem, Hon. Kristi Lynn, U.S. Representative from South Dakota....     7
    Stabler, Wehnona, CEO, Carl T. Curtis Health and Education
      Center, Omaha Tribe of Nebraska................................    17
        Prepared statement...........................................    19
    Wakefield, Mary, Ph.D., R.N., Acting Deputy Secretary, U.S.
      Department of Health and Human Services; accompanied by Mary
      Smith, Principal Deputy Director, Indian Health Service........     9
        Prepared statement...........................................    11

                                    Appendix

    Grundmann, Susan T., Chairman, U.S. Merit Systems Protection
      Board (MSPB), prepared statement...............................    52
    Lerner, Hon. Carolyn N., Special Counsel, U.S. Office of Special
      Counsel, prepared statement....................................    49
    Response to written questions submitted by Hon. Mike Rounds to
      Mary Wakefield.................................................   100
    Spotted Eagle, Faith, Treaty Chairwoman, Yankton Sioux/
      Ihanktonwan Tribe, prepared statement..........................    49
    Steele, Hon. John Yellow Bird, President, Oglala Sioux Tribe,
      prepared statement.............................................    63
    Stier, Max, President/CEO, Partnership for Public Service,
      prepared statement.............................................    56
    United South and Eastern Tribes Sovereignty Protection Fund,
      prepared statement.............................................    73
    Yankton Sioux Tribe, prepared statement..........................    76

    Additional information submitted for the record

       IMPROVING ACCOUNTABILITY AND QUALITY OF CARE AT THE INDIAN HEALTH
                            SERVICE THROUGH S. 2953

                                  ----------

                             FRIDAY, JUNE 17, 2016

                                           U.S. Senate,
                                   Committee on Indian Affairs,
                                                        Rapid City, SD.
        The Committee met, pursuant to notice, at 10:30 a.m. in the
    Central High School Auditorium, Hon. John Barrasso, Chairman of
    the Committee, presiding.
        [Opening prayer, by Robert Flying Hawk spoken in Lakota.]

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

        The Chairman. Well, good morning, everyone, and welcome to
    this oversight legislative hearing on improving accountability
    and quality of care at the Indian Health Service, and we have a
    piece of legislation to do that. I'm John Barrasso. I'm a
    physician from Wyoming. I'm also the United States Senator from
    Wyoming and Chairman of the Senate Indian Affairs Committee,
    and I'm delighted to be here with Senator Thune, Senator
    Rounds, and Congresswoman Noem, who have worked tirelessly on
    this effort and I'm so happy that you've all joined us today.
        The first order of business this morning is to recognize
    the tribal leaders here today. I'd like to thank all of them
    for your continued leadership and your dedication to making
    your people stronger and healthier. The progress we've made so
    far is a direct result of your hard work and the feedback, and
    I greatly appreciate the important role you've played in this
    entire process.
        So I look forward to working with each and every one of you
    to improve the legislation that's before us today and to move
    it forward for the betterment of Indian health in this region
    and for the entire country.
        Now, I know our work isn't finished, and I'd also like to
    thank, obviously, the congressional delegation of South Dakota
    for its significant dedication to Indian health and providing
    us with a warm welcome here in Rapid City today. And, of
    course, we want to thank our friends here at Central High
    School for hosting us.
        Today the Committee is basically examining one specific
    piece of legislation called S. 2953, the Indian Health Service
    Accountability Act.
        So let me just stop there and ask if you or your family
    relies on the Indian Health Service for medical care, please
    stand.
        [Members of the audience stood.]
        This is why we are here today. This is why we're here
    today. For everyone standing, for all of the IHS patients, we
    must get this right. We cannot accept failure or complacency,
    and, as a doctor, I know that quality health care is about
    putting the patient first. This is the mentality we need to see
    at every level of the Indian Health Service, and I thank each
    and every one of you for being here today.
        So on May 19th Senator Thune and I introduced a piece of
    legislation, S. 2953, the Indian Health Service Accountability
    Act. Senator Rounds is also a cosponsor. Congresswoman Noem is
    also working on similar legislation in the House.
        This Committee held an oversight hearing, a listening
    session, on February 3rd. We examined what we saw as
    substandard quality of Indian health care in the Great Plains
    Area. Many of you were part of that hearing, the listening
    session we held in Washington D.C.
        What was clear from listening to each and every one of you
    was the tremendous amount of pain and frustration that you have
    had with the Indian Health Service. You shared many tragic
    stories, tragic events with the Committee that day, and the sad
    reality is that many of these problems were identified, that we
    identified earlier this past year, were also identified in 2010
    when Senator Dorgan from North Dakota was chairman of the
    Committee and he did his report. So some of these problems I
    believe have gotten worse, new issues have developed over time,
    and, as you all recall his words, the services provided by the
    Indian Health Service as malpractice, and I stand by those
    words.
        As a physician for more than 20 years I know this can only
    be rectified by significant improvements in delivering
    medicine, accountability, transparency and compassion for
    patients. And I see people on the panel shaking their head yes.
    So the bill that Senator Thune and I introduced does just that.
        This bill, the Indian Health Service Accountability Act, is
    the critical first step on the road to reform because it
    targets the issues we believe are at the core of the
    dysfunction of the Indian Health Service. It will lay a sound
    foundation for the Indian Health Service to actually deliver
    the health care that tribal members need and deserve.
        Now before going any further, I want to emphasize that this
    bill will basically bring together what we've heard from you,
    the problems that you say are there and the solutions that
    you've all shared as ways to fix them. All the provisions in
    this Indian Health Service Accountability Act are tied directly
    to the feedback that we have already received from you. So this
    bill is really a series of solutions designed to solve specific
    problems.
        For example, the Indian Health Service Accountability Act
    will provide expanded removal and disciplinary authority for
    the Indian Health Service to ensure that it has all the tools
    it needs to address problem employees. This expanded authority
    enhances accountability and transparency within the Indian
    Health Service to better reporting mechanisms and increased
    compliance. We've also heard the Indian tribes describe a lack
    of basic tribal consultation. We heard it then and we heard it
    this morning in our listening session. We heard it yesterday.
    This legislation will increase consultation between the Indian
    Health Service and tribes and require this consultation be
    meaningful and timely. It would also ensure that the basic
    budget and spending information is available to the tribe. We
    heard about that this morning. And also available to Congress
    so the Indian Health Service funds are spent on patient care
    instead of union settlements that you brought up today.
        To address severe staffing shortfalls, this legislation
    would enhance the Indian Health Service's ability to recruit
    and retain qualified employees by offering more incentives to
    work in Indian country. The bill will also reward employees who
    deliver quality care and innovative ideas to the tribal
    communities that they serve.
        The bill includes a number of provisions that will help
    determine housing needs and staffing needs in the agency so
    that we are all in a position to make informed decisions about
    what resources are needed and how they should be spent.
        The Indian Health Service Accountability Act will increase
    patient safety through quality measures and monitoring, and
    requires regular oversight by other Health and Human Services
    agencies. Among other things, it would help ensure that cases
    don't fall through the cracks by requiring HHS's Inspector
    General to investigate suspect patient deaths.
        This bill will also help ensure that Indian Health Service
    employees who see something wrong feel comfortable coming
    forward to report problems. Increasing accountability and
    transparency will help ensure the problems are resolved rather
    than repeated and covered up. That's what we need to do to
    improve patient safety and quality of care.
        So this legislation of the Indian Health Service
    Accountability Act is a step in the right direction. Too many
    lives have been lost that could have been saved, and it's my
    hope the administration listens and responds to testimony today
    so that one day these tribes can trust and again seek services
    from a well- functioning Indian Health Service hospital in all
    areas of the country.
        So the feedback we receive today will help the Indian
    Health Service Accountability Act and will make it stronger
    before we consider it in our Committee in Washington.
        I would also like have it known the Human Services Deputy
    Secretary, Mary Wakefield, made the trip to South Dakota. Dr.
    Wakefield, I know you had a scheduling conflict earlier and you
    cleared the calendar so you could be here to attend the hearing
    today and I'm grateful you've done that.
        So I appreciate your attention to this important matter,
    and thank you for coming here to testify, but also I want to
    take a break from me talking and turn this over to Senator
    Thune for an opening statement.
        Senator Thune.

                     STATEMENT OF HON. JOHN THUNE,
                     U.S. SENATOR FROM SOUTH DAKOTA

        Senator Thune. Well, thank you, Mr. Chairman, for holding
    this important hearing in South Dakota, and I want to speak out
    to the commission and those who are affected most by the Indian
    Health Services and those are who are part of the communities.
    I also want to thank Chairman Barrasso, who has been terrific
    on these issues, and, as he mentioned, we had a hearing back in
    February. This is a follow-up hearing to that, but, most
    importantly, right here in South Dakota where we will hear
    directly from people who are impacted.
        And it's nice having someone like Senator Barrasso chairing
    the Indian Affairs Committee as a neighbor of Wyoming so he
    understands our issues. He also, as he said, is a physician, an
    orthopedic surgeon, so those of us in our 50s who are always
    looking for medical advice in the Senate turn to him quite
    often. He doesn't do surgery----
        The Chairman. Free advice.
        Senator Thune. Yes, that's right. That's the best type of
    advice.
        He doesn't do surgeries in the cloak room, and a lot of
    times I'm told, take two aspirin.
        But, anyway, it's great to have somebody with his
    background and expertise addressing issues to health care.
        The reason that we're doing this, and, you know, we held,
    what I feel, was a very necessary oversight hearing back in
    February regarding the chronic failures of the IHS, failures
    that, frankly, are just unacceptable; and, you know, we heard
    some pretty stunning stories, and at that time I think you, Mr.
    Chairman, heard the same stories, and Senator Rounds
    participated in that hearing along with us heard, and you
    continued that oversight into an agency that seemingly just
    doesn't have accountability to anyone.
        CMS's findings, as terrible and horrific as they were,
    brought forth evidence of reprehensible practices that were
    occurring at the Indian Health Service. Practices that did not
    match information that was provided to members of Congress,
    including myself. CMS's findings have, once again, provided a
    public window in these facilities to view the substandard care
    that's being delivered to our states by its citizens. The
    stories have been detailed time and again, and it's time to
    take action.
        After these reports were released in the hearing in
    February, Chairman Barrasso and I immediately began to explore
    ways to reform the agency. The result of our efforts, combined
    with tribal input, culminated with the introduction of the IHS
    Accountability Act of 2016, which attempts to tackle this
    crisis from all sides.
        Senator Rounds was very active in that process and is also
    a cosponsor of the legislation. The legislation which we are
    here to discuss today increases accountability, improves hiring
    practices, enhances recruitment and retention, protects
    whistle-blowers, increases fiscal accountability and creates
    greater transparency of the agency.
        In an effort to improve accountability, the legislation
    provides the Secretary of Health and Human Services with a
    streamlined ability to remove underperforming managers and
    executives. As I've said many times, leadership starts at the
    top, and if IHS leaders are a barrier to delivering quality
    care, then they should look for another job, not simply be
    moved to a different area.
        While we need strong leadership, it is also no secret that
    providing care in remote rural locations is difficult, which is
    why we have included provisions to streamline hiring demands
    and incentivize improvement of providers. One of the largest
    fears of change currently plaguing IHS is the lack of
    transparency. Unfortunately, IHS is simply unable to answer
    straightforward questions regarding funding allocations and
    outlays.
        For example, the agency estimates that it spends $50
    million a year in the Great Plains Area on temporary, non-full-
    time staff. What the agency does not know is whether that
    number is accurate and how much it would save IHS if they were
    able to achieve permanent staffing, and full-time employees.
        What's even more troubling is the question of where the
    agency is taking this money from in order to paper over this
    problem. This brings me to our bill's next point, fiscal
    transparency and long-term planning. Our legislation requires
    IHS to issue spending reports to tribes and to Congress and
    requires the agency to release a staffing plan. Creating a
    spending plan is essential to understanding exactly how IHS
    allocates funding, not only nationally, but within each area.
        Last, and most importantly, we want to ensure increased
    tribal consultation when IHS hires senior staff. One of the
    major complaints that we hear constantly from tribes is the
    lack of meaningful consultation.
        I hope to continue discussions regarding what meaningful
    consultation means to our tribal members and what we can do to
    improve it. While there's no doubt that more oversight is
    necessary and will be conducted, today's hearing allows us the
    opportunity to explore changes to this failing agency, and
    provides us with chance, with input from our clients, to change
    the status quo.
        I'd like to acknowledge and thank the administration's
    willingness to work with us and to engage with us on these
    issues and look forward to continued collaboration.
        I also want to thank, particularly, our tribal leaders,
    tribal representatives, and the individuals who reached out
    with their concerns and solutions for IHS. Your continued input
    and suggestions are still needed, and I am committed, along
    with the delegation, Senator Rounds and Congresswoman Noem and
    others who want to take on this battle with us to working with
    you to bring forth positive solutions.
        So thank you, Mr. Chairman, for being here in South Dakota.
    Thank you for bringing the Indian Affairs Committee to this
    state and to giving intense focus to the issue, and, frankly,
    to something that has become and reached, I think, a crisis
    stage and desperately demands a solution. Thank you.
        The Chairman. Thank you, Senator Thune, for your thoughtful
    leadership.
        Senator Rounds.

                    STATEMENT OF HON. MIKE ROUNDS,
                     U.S. SENATOR FROM SOUTH DAKOTA

        Senator Rounds. Thank you, Mr. Chairman. First, let me just
    say to the Chairman, I most certainly appreciate you taking the
    time to hold today's field hearing in South Dakota where our
    tribal members are all too familiar with the failures of the
    Indian Health Service. I'd also like to thank Senator Thune and
    Congresswoman Kristi Noem for their tireless work to address
    the problems plaguing IHS.
        In South Dakota we know all too well of these ongoing
    problems. Nearly every week, if not every day, our newspaper
    headlines tell the tale of new problems. Let me just read you
    some of the headlines that we've seen in just the last month:
    IHS Hospital in Immediate Jeopardy; Feds Deal Blow to Rosebud
    IHS Hospital; Man Won't Return to, As He Quotes, Death
    Hospital; Tribal Leaders Say They Were Left Out of IHS Call For
    Help; Health Care Crisis Hits South Dakota Reservations.
        I can spend my entire time reading headlines, but it's
    important to understand the impact that it's having on real
    people, our tribal members. The Great Plains Area IHS, which
    covers South Dakota, North Dakota, Nebraska, and Iowa, has the
    second highest mortality rate among all IHS regions. We also
    have the highest diabetes death rate. It's five times the U.S.
    average, almost double the average among all IHS regions. Our
    life expectancy rate is the lowest of all IHS regions at 68.1
    years. Compare this to the U.S. average of 77.7 years.
        It is clear the IHS is failing our tribal members who are
    suffering and even dying due to this inadequate and disgraceful
    care. As we all know, Rosebud has had its emergency department
    on diversion status for 195 days as of today, meaning tribal
    members are having to drive over 50 miles to receive emergency
    care. The same is true with their OB and surgical departments
    as well. These circumstances are going to continue to occur
    until we demand thorough review and reform of IHS. We need an
    independent audit.
        I had the opportunity to deal with the Great Plains Tribal
    Chairman's Association in April. We discussed an in-depth
    analysis on IHS and my office researched in an attempt to seek
    answers and gain a better understanding. We talked about the
    administrative imbalance, that there are 15,000 employees at
    IHS, only 750 doctors, yet nearly 4,000 are administrative
    medical billers.
        We also found that IHS employees and administrators can't
    explain or don't understand their own budget. After reviewing
    the data with me, the Great Plains Tribal Chairman voted on a
    resolution that supported an audit of the IHS. The IHS needs
    major reform. More taxpayer money won't solve the dysfunction
    because what IHS lacks is an efficient system and
    accountability.
        Consider this: If the President proposed and Congress
    supported doubling the IHS budget, based on IHS's current
    template, they would have 20,000 administrative employees,
    7,400 bureaucrats billing Medicaid, and still only 1500
    doctors. The imbalance and priorities would still exist, just
    at a greater level.
        From my standpoint, investing more taxpayer money in a
    dysfunctional system will only compound the problem. This is a
    serious issue that requires tangible solutions, not mandates.
    There are significant administrative management, financial
    management, and quality of care issues that must be addressed.
    Today's hearing will help us better understand where the
    problems lie and steps forward to fix these problems.
        Once again, we need the audit. Ultimately, today's hearing
    is to fix the poor quality of health care for our people. IHS
    will never be able to deliver quality timely care the federal
    government has a trust responsibility to deliver without broad
    reforms.
        I want to take this opportunity to thank Chairman Barrasso,
    Senator Thune, and Representative Noem for being here today,
    and also their ongoing work to address these issues. Thank you,
    Mr. Chairman.
        The Chairman. Well, thank you, Senator Rounds, for your
    leadership and for your intense focus on this. We're very
    grateful.
        Now Representative Noem.

     STATEMENT OF HON. KRISTI LYNN NOEM, U.S. REPRESENTATIVE FROM
                              SOUTH DAKOTA

        Congresswoman Noem. Thank you, Chairman Barrasso, and the
    Committee, and I appreciate your input today and this
    opportunity to attend today's hearing. I'm a member of the
    House, and, obviously, this is a Senate Committee Hearing, so
    it is very humbling to be a part of this process and to be
    invited to join the group at the table today and listening to
    our testimony that we'll hear.
        I also thank Senators Thune and Rounds for being great
    partners in having ongoing monitoring of HHS, IHS, CMS as we've
    gone through this crisis and over the years as we've dealt with
    this before, as well.
        Thank you all for coming here to testify today. Mr. Bear
    Shield, you've been very candid with me and you always speak
    with great truthfulness, and I know that the words that you
    speak are factual and very helpful to me when I've been dealing
    with drafting legislation and hearing the testimony of your
    tribe. The frank analysis that you gave me is extremely
    helpful.
        And, Dr. Wakefield, I do appreciate you making this a
    priority. It certainly is for all of us here at the table, and
    the fact that you came here today means a lot.
        Ms. Stabler, Ms. Blue Shield, Ms. Bohlen, thank you, as
    well, for coming. It's just wonderful. And, Ms. Smith, thank
    you for being here, as well. I wasn't quite sure that you'd
    make it, and I'm glad that you have. It means the world to me
    that you recognize how important this is.
        And I'm grateful that we're all here today to shed some
    light on the ongoing tribal health care crisis that we have
    going on in South Dakota, but, frankly, throughout Great Plains
    regions with tribes that include Nebraska, as well. We need
    comprehensive reform, and, frankly, I'm just going to put it
    very simply, I believe that IHS should get out of the hospital
    business. I think they're terrible at it. I don't think they
    know what they're doing.
        [Audience applause.]
        I believe this for two different reasons. First, as
    everyone in this room is aware, the medical care that we
    receive at IHS in the Great Plains region is like getting
    health care in a third-world country. The mismanagement of
    fiscal stability that is lacking in the area and the agency
    have just completely eliminated my confidence in the agency.
        We found that the agency is devoid of transparency and
    openness. We found it keeps patients and tribal leaders in the
    dark. It's extremely discouraging to me and it's incredibly
    difficult to get answers to the simplest questions.
        For example, IHS told us that it needs more people. We
    asked them how many employees the IHS needs and were told by
    the agency that it has no way of finding out this information.
    How do you make a request without knowing what you're
    requesting?
        And if you're a tribal leader, timely and accurate
    information is even harder to come by. To give one recent
    example, IHS notified Great Plains Tribal Leadership of an
    important conference call regarding the contracting problem by
    attending a Microsoft Outlook meeting invitation 1 hour before
    the call was to begin.
        Now we all describe the term ``tribal consultation''
    differently, but I tell you that is certainly not it.
        On my most recent visit down to the Rosebud hospital, which
    was just a couple weeks ago, every single conversation that I
    had, those people are sick and tired of the decades of
    corruption, the mismanagement, and the life-threatening care
    provided by Indian Health Services. They're done with the
    bureaucratic mess, and that they are tired of watching
    underperforming employees risk their lives of brothers and
    sisters and family.
        Enough is enough, and that's what we're here to talk about
    today. What do we do when enough is enough? For years IHS has
    been asked to make improvements. Congress has increased the
    agency's funding nearly every year that I've been in office,
    and yet the situation is as bad as it's been. And let me be
    very clear, I do believe that Native American health care is
    underfunded, but I also believe that money is not going to fix
    the broken management system that we have in the Great Plains
    region. So let's talk about solutions.
        I thank the Chairman and the Senators for introducing the
    IHS Accountability Act in the Senate. Like the bill that I
    introduced in the House, this legislation attacks serious
    personnel problems that are flooding IHS, including the
    agency's hiring, firing, and disciplinary practices. It also
    includes many incentives for improvement and retention of high-
    quality employees.
        My bipartisan Health Act that I've introduced in the House
    has many sponsors on it already. We'll be having a hearing in
    the coming weeks, but it also takes a similar approach, but I
    also added something that is a third rail of delivering high-
    quality health care to people in Indian country. It's the
    Purchase/Referred program, and we've already talked about that
    today when we had some questions from tribal leaders. Don't get
    sick after June has become a common phrase in Indian country.
    And it's because purchase referred care program runs out of
    money in June every year, and after that the only way that
    you're going to get any kind of treatment or care is if you're
    dying or losing a limb in Indian country. It's unacceptable.
    It's jeopardized tribal members' lives, personal well-being, as
    well as their financial health.
        The reforms in my bill ensures that funding is fairly
    distributed among tribal communities and ensures that South
    Dakotans can get the care that they need.
        So, Mr. Chairman, I am encouraged by the fact that we've
    already got broad agreement between the House and the Senate on
    solutions that remediates these problems. I'm looking forward
    to working with you and my delegation colleagues in the House,
    Natural Resources Committee, the Energy and Commerce Committee,
    Ways and Means Committee in uniting to approach this and unite
    to find a solution so we can put it on the President's desk.
    And that's what I fully intend to do is to get solutions signed
    into law so we can fix this problem. I yield back and I want to
    thank you again for allowing me to participate today.
        The Chairman. Thank you, Congresswoman Noem. Ladies and
    Gentlemen, there are 100 United States Senators. You've got
    three of us here. There are 435 members in the House of
    Representatives and I will tell you, people of South Dakota,
    you are looking at somebody who shows incredible leadership and
    a very forceful voice in the House of Representatives. Thank
    you very much, Congresswoman Noem.
        Now our witnesses. We are going to start with Mary
    Wakefield, who is also a Ph.D., but also a registered nurse.
    She's the acting Deputy Secretary of the U.S. Department of
    Health and Human Services from Washington D.C. I just want to
    remind all witnesses that your full written testimony will be
    made part of the hearing record, so we want to please keep your
    statements to 5 minutes or less so that we may have time for
    questioning.
        And I look forward to hearing your testimony. Let's us
    start with you.

           STATEMENT OF MARY WAKEFIELD, Ph.D., R.N., ACTING
    DEPUTY SECRETARY, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES;
                      ACCOMPANIED BY MARY SMITH,
            PRINCIPAL DEPUTY DIRECTOR, INDIAN HEALTH SERVICE

        Dr. Wakefield. Thank you very much, Mr. Chairman, Senator
    Thune, Senator Rounds, Congresswoman Noem. Thank you for the
    opportunity to participate in today's very important hearing on
    the IHS Accountability Act of 2016.
        I wanted to say at the outset of this hearing that we, in
    the administration, certainly share the goals reflected in your
    legislation. Your focus on accountability, strengthening the
    workforce, and improving the quality of our native communities
    that we serve are extremely important and we share those goals.
    Each goal that's reflected in your bill is important, as we
    confront acute and chronic problems like those that we are
    facing right now in some of our facilities here in the Great
    Plains Area, which are, in no small part, due to the product of
    longstanding issues.
        Today, under our current leadership, it is not business as
    usual at Indian Health Service, and with support from the
    Department of Health and Human Services we are doing critically
    important work on moving aggressively to strengthen the
    delivery of quality care at IHS facilities long term, while at
    the same time working to address immediate short-term needs.
        Four months ago Secretary Burwell created the Executive
    Council on Quality Care, and she asked me to lead this effort.
    I come from the Great Plains. I'm from North Dakota, which I
    say softly here in the Great State of South Dakota. But I have
    some firsthand knowledge of the challenges facing Indian
    Country, and I view the responsibilities the secretary gave me
    as incredibly important and as an opportunity to make
    meaningful and needed changes.
        The council, the executive council, includes some of HHS's
    top management and program experts, and together we are taking
    a deep look at longstanding obstacles like workforce retention,
    providing housing, care quality, and even the organization
    structure of the IHS, itself. With executive council engagement
    and support, IHS is applying a five-part strategy to create
    lasting change.
        First, we're focusing on surfacing problems and addressing
    them as quickly as we can with the resources that we have. One
    effort underway is IHS's system-wide survey initiative that
    includes all of its direct service hospitals.
        Second, we are focused on strengthening health care
    services to patients and communities. Recruiting and retaining
    health care providers is one of our biggest challenges. In the
    short-term we have already deployed more than two dozen U.S.
    Public Health Service Commissioned Corps clinicians to the
    Great Plains area. And right now, for example, we have the
    National Institute of Health helping IHS implement innovative
    nursing recruitment strategies.
        In addition, I do want to mention today that it is through
    the work of the Executive Council that we have identified an
    additional approximately $50 million in funding for Indian
    Health Service to help strengthen service delivery, the second
    goal over the long term. About 30 million of those dollars will
    support much-needed projects right here in South Dakota. This
    funding will be applied to some of the biggest needs, such as
    construction for provider housing. Lack of housing is a
    longstanding obstacle to recruiting and retaining staff.
        IHS will also be able to purchase equipment to make much
    needed IT upgrades, including to enhance hospital telehealth in
    historically hard to access specialties.
        As part of a long-term strategy we are working to find new
    ways to recruit and train more individuals with connections to
    the communities that IHS serves, and also connecting those with
    demonstrated commitment to service.
        For example, we're now recruiting committed U.S. clinicians
    to the Peace Corps, as well as a Global Health Services
    program. It's a new initiative.
        Third, we're focused on strengthening area management
    through a number of strategies, from improving recruitment
    efforts for area directors to IHS's recently announced
    consultation around the organization and structure of the Great
    Plains Area office.
        Fourth, we are infusing substantial quality expertise into
    the IHS system. IHS has joined with CMS supported hospital
    engagement network which shares approaches that we know improve
    care quality. Going forward CMS is in the process of
    contracting this fall for the first quality improvement
    organization that will focus exclusively on strengthening
    quality of care within IHS hospitals.
        And, fifth, we're working to collaborate with local
    resources. Local communities are valuable sources of expertise
    and collaboration. We plan to work with leaders from tribal
    colleges to other academic institutions, as well as regional
    health providers to further develop health care workers and
    services.
        We also know that the health of communities is tied to the
    health of the local economy, and that's why we're committed to
    doing what we can to advance the success of small businesses in
    the tribal communities. I've asked our HHS Department Office of
    Small and Disadvantaged Business working in cooperation with
    the U.S. Small Business Administration to coordinate technical
    assistance events for small businesses that are owned by Native
    American Indian Tribes and the native community at large. One
    of these is planned to occur here in South Dakota.
        As I mentioned, we know the health of our community is tied
    to the health of our local economy.
        IHS and all of HHS are committed to working hard to make
    meaningful and measurable progress. We've taken significant
    steps since the last hearing, and there is much more work
    ahead, including intense work ongoing now to strengthen and
    stabilize the hospitals in South Dakota and Nebraska.
        We look forward to addressing these challenges and making
    meaningful progress in partnership with you and the tribal
    leadership. Thank you.
        [The prepared statement of Ms. Wakefield follows:]

       Prepared Statement of Mary Wakefield, Ph.D., R.N., Acting Deputy
    Secretary, U.S. Department of Health and Human Services; accompanied by
          Mary Smith, Principal Deputy Director, Indian Health Service
    Introduction
        Good morning. Chairman Barrasso and Members of the Committee, thank
    you for the invitation to join you today here in Rapid City, South
    Dakota and to testify on S. 2953, the IHS Accountability Act of 2016.
    We would like to start by thanking you and Senator Thune for your
    leadership on the Committee and for elevating the importance of
    delivering quality care through the Indian Health Service. This
    Committee, IHS, and HHS share a common goal of providing consistent,
    quality health care to the American Indian and Alaska Native
    communities we serve. The Administration has concerns with some
    provisions in S. 2953 as drafted and looks forward to working with the
    Committee to improve the bill as it moves through the legislative
    process.
        Earlier this year, we strengthened and refocused our resources
    within the Department as part of an aggressive strategy to improve the
    overall quality of care in the Great Plains Area, and across the
    country. HHS and IHS are working to instill a culture of quality care
    and accountability across the agency. We are committed to hearing
    directly from you and the communities we serve to focus sharply on how
    to best improve access to quality health care and most importantly
    improve the health status of American Indian and Alaska Native families
    and communities.
        To be clear, the acute problems we are seeing right now are largely
    tied to chronic, longstanding issues, often spanning decades.
    Recognizing that, the focus of our work this year is to move
    aggressively to develop both systemic changes even while we're
    addressing immediate, short-term needs. We have significant efforts
    underway on both fronts.
        With new leadership at IHS, we are not accepting business as usual.
    IHS's Principal Deputy Director, Mary Smith, has made it crystal clear
    that change is the new status quo at IHS. And the leadership at HHS is
    reinforcing and amplifying that message. Under her leadership, IHS is
    changing the way it approaches long-standing challenges. IHS is working
    to reengineer its human resources, create an organizational structure
    that supports sustained improvement and accountability, and is focused
    on strengthening its financial management infrastructure.
        To ensure that dependable, quality care is delivered consistently
    across IHS facilities, three months ago, Secretary Burwell created the
    Executive Council on Quality Care and asked Acting Deputy Secretary
    Wakefield to lead it. This council includes senior executives from
    across HHS and thus draws on expertise from across the Department. We
    have some of HHS's top managers, clinicians, and program experts taking
    a fresh look at long-standing obstacles like workforce supply, housing,
    challenges to delivering quality of care, and addressing key operations
    issues. The council ensures that we are leveraging all the resources we
    can on behalf of American Indian families and communities.
        Through the work of this Council, in tandem with IHS, for the past
    two months, we have been engaging our work through a five-prong
    strategy to address these challenges--many of the same obstacles like
    sufficient workforce, personnel issues, and care quality, that your
    legislation seeks to address. With this strategy, IHS and the
    Department are working to (1) surface existing problems so that we can
    work to resolve them; (2) improve service delivery; (3) strengthen IHS
    Area management; (4) infuse quality expertise; and (5) engage with
    local resources.
    Surfacing Problems
        First, we are assessing and surfacing problems so that we can work
    to resolve them. We are taking a very close look at the quality of care
    delivered through direct service hospitals at IHS facilities across the
    Great Plains Area as well as throughout across Indian Country. We want
    to affirm and support facilities that are delivering quality care and
    work closely with facilities that need improvement. It is important
    that IHS leadership from headquarters to Area offices work closely with
    both tribal leadership and direct service hospitals in a transparent
    way that encourages open information exchange about improvement
    opportunities. We know from decades of experience across the health
    care continuum, that problems that are not acknowledged and fixed put
    even more patients at risk. For the past 20 years, health care systems
    across the nation have been embracing new models of improvement, and it
    is that orientation that we are working to further strengthen with in
    IHS through the assets of IHS and other divisions in HHS.
        For example, IHS is beginning a system-wide mock survey initiative
    at all 27 of its hospitals to assess compliance with CMS Conditions of
    Participation and readiness for re-accreditation. These mock surveys
    will be conducted by survey teams from outside each respective Area to
    reduce potential bias. The new mock survey initiative is being
    coordinated through the IHS Quality Consortium as a unified effort to
    reinforce standardization of processes. We are beginning in the Great
    Plains Area with assessments and, when appropriate, interventions
    through the provision of on-site assistance to hospital staff. Although
    some direct service hospitals currently conduct self-assessments, IHS
    is standardizing and improving this process so that all Direct Service
    hospitals receive an assessment within the next three months and
    performance data tracked, not just at individual facilities but across
    all facilities.
        Through this and other targeted strategies, IHS will move from
    being reactive to proactive in identifying and addressing performance
    issues early. Our first efforts were piloted May 10, 2016, at the
    Rosebud Hospital and we will continue to do quality surveys at all
    direct service hospitals, excluding those that have been surveyed in
    the past year or are scheduled to be formally surveyed through other
    mechanisms during this timeframe. When our survey teams identify
    problems, we will work swiftly to address these local problems and work
    to put systems changes in place to resolve the problems. Additionally,
    best practices that are identified will be shared across IHS
    facilities.
        Another example of surfacing and addressing problems is IHS'
    enhanced drug testing interim policy. This policy was released on June
    6th and focuses on drug testing based on reasonable suspicion, and
    expands the HHS drug testing policy that already applies to IHS
    employees. The interim policy provides guidance to supervisors and
    managers on drug testing based on a reasonable suspicion of drug use.
    This effort was informed by tribal leaders' calls for additional IHS
    administrative actions in this area.
    Improve Service Delivery
        Second, we are working to improve service delivery by focusing on
    workforce and clinical support infrastructure.
    Workforce
        The IHS continues to face significant workforce challenges with a
    chronic shortage of health care providers. While we have immediate
    steps to address some local shortages and are in the process of adding
    more, such as telemedicine, these longstanding challenges require
    building up and expanding the training and deployment pipelines and
    full use of innovative approaches to delivering care. In the near-term,
    with Secretary Burwell, Deputy Secretary Wakefield, and the U.S.
    Surgeon General's support, over two dozen Commissioned Corps clinicians
    have been deployed for temporary placements into the Great Plains
    hospitals with CMS findings. In addition, NIH has been helping IHS
    deploy strategies it has used to recruit nurses into its clinical
    program. These include providing new recruitment language and accessing
    web-based resumes of South Dakota nurses for the IHS, as well as using
    new web-based places to advertise. IHS is also revising position
    descriptions and deploying more comprehensive recruitment plans around
    key positions, in an effort to recruit a greater number of qualified
    candidates. IHS is also deploying Title 38 pay increases for high-
    demand clinicians and has established eligibility for payment of
    relocation expenses for GS-12 and lower graded clinical positions.
    However, even with these and a number of other strategies that have
    been deployed during the past two months or that are in development
    right now, there is still much more work that needs to be done to
    attract and retain an adequate health care workforce. Some of these
    changes will require legislative action. In addition, we are working
    with OPM, OMB, and other affected agencies to explore ways to enhance
    our current flexibilities. We are also are combining efforts that
    leverage collaboration between tribal, public, and private academic
    institutions.
        One of the most challenging areas to support is the availability of
    emergency services, particularly in the Great Plains Area. Because of
    this, on May 17, 2016, IHS initiated a new strategy through a contract
    award to provide both emergency department staffing and operations
    support and management services at three hospitals: Rosebud Hospital
    and Pine Ridge Hospital in South Dakota and Omaha Winnebago Hospital in
    Nebraska. This will provide health care in these hospital emergency
    rooms while IHS reviews the administrative and clinical operations of
    its facilities across the region to develop long-term solutions. IHS's
    leadership both in the hospitals and at headquarters have direct
    oversight of this contractor and is responsible for holding this
    contractor accountable for providing consistent quality health care.
    However, because this is a new approach to Emergency Department
    staffing and management combined, a team of clinicians and attorneys,
    as well as the CEOs of the facilities, are tracking this initiative
    weekly to ensure that performance expectations are met.
        As part of a longer term strategy, we are reexamining the
    scholarship and loan repayments program to make sure that we are
    maximizing their impact and we are introducing other new strategies as
    well. We are working with the Peace Corps' Global Health Services
    program that fields clinicians to areas of critical workforce needs and
    most immediately, we are building communication channels about service
    to Indian Country to 60 returning volunteers. By the end of this month
    for example, 60 returning volunteers will be learning about
    opportunities to work in direct service IHS hospitals even as we are
    engaging other longer term communication strategies with the broader
    Global Health Services program. Additionally, the U.S. Public Health
    Service Commissioned Corps has prioritized new officers to IHS with a
    particular focus on the Great Plains Area.
        On a related front, on June 1st, IHS proposed to expand its
    community health aide program and is slated to engage consultation with
    tribal leaders over the next months on this expanded effort. This
    important proposed change would bring more health workers directly into
    American Indian and Alaska Native communities.
    Infrastructure
        In addition to addressing workforce challenges, the IHS is trying
    to lessen the loads on our emergency departments by establishing
    alternative avenues of care, such as urgent care clinics and telehealth
    services. IHS is working aggressively to reopen the Rosebud Emergency
    Department as soon as it is safe for the patients. In the meantime, in
    order to fill the temporary gap, the IHS has re-purposed existing
    ambulatory care space into an Urgent Care clinic staffed with emergency
    department and ambulatory providers. Given the types of illnesses that
    individuals present with to the Rosebud Emergency Department, the
    Urgent Care clinic can manage the majority of these non-emergent care
    needs.
        Specialty services like behavioral health, cardiology, and diabetes
    care can be difficult to find in rural areas. IHS will also be using
    telehealth contracts to bring specialty services into the communities
    where individuals live so they do not need to travel. IHS issued a
    Telemedicine Request for Proposal on May 5, 2016. Proposals were
    originally due June 6, 2016; however, at the request of prospective
    bidders for more time to prepare comprehensive proposals, IHS extended
    the deadline to respond by 30 days.
    Strengthening Area Management
        Third, we are working to strengthen area management. While we
    support the workforce at each hospital, we are also taking a broader
    view to strengthen Great Plains Area management through the temporary
    deployment of high-quality managers from within other areas of IHS as
    well as deploying HHS experts to both IHS headquarters and the field to
    assist with finance, contracting, and management functions. IHS also
    established a Human Resources (HR) Steering Committee, which provides
    oversight and guidance on the implementation of system-wide HR
    improvements in IHS.
        As part of these efforts, Rear Admiral Kevin Meeks spent three
    months leading the Area Office. Captain Christopher Buchanan joined the
    Great Plains Area leadership team in May and is serving as the Acting
    Director of the Great Plains Area Office. Captain Buchanan has
    extensive expertise working with complex health systems which are IHS
    directly-operated facilities as well as tribally-managed programs
    assumed under the authority of the Indian Self-Determination and
    Education Assistance Act. In the longer term, the IHS is actively
    looking to find the best possible candidate for the Great Plains Area
    Director position. We revised technical qualification requirements for
    the position description in order to attract a broader pool of well
    qualified candidates. We have also implemented a stronger search
    committee process for recruiting highly qualified managers and
    executives. This committee is charged with candidate outreach,
    assessment, and vetting. IHS is also more widely advertising vacancies
    through federal, state, and non-profit partners, and is actively
    seeking additional venues to help attract a broad and diverse applicant
    pool. Additionally, going forward, we have expanded tribal
    participation in filling vacant Area Director positions and members of
    a tribe from each area will, for the first time, play a role in these
    search committees at the outset of the hiring process on these key
    positions.
        Finally, IHS recently announced conducting a 90-day consultation
    with Tribal leaders to discuss the organization and operation of the
    Great Plains Area Office, to, in partnership with the Tribes, identify
    new approaches to better support patients and tribal community health
    in the Area.
    Infusing Quality Expertise
        Fourth, we are infusing substantial quality expertise into
    informing and improving care quality in direct service facilities. In
    partnership with CMS, we have launched a Hospital Engagement Network
    (HEN) to provide evidence-based efforts in quality improvement. As we
    announced on May 13, 2016, the Premier HEN is now available to all IHS
    direct service facilities and focuses on quality improvement methods
    intended to reduce avoidable readmissions and hospital acquired
    conditions (e.g. central line blood infections, pressure ulcers, falls,
    etc.). Hospitals in the network share successful practices and lessons
    learned to accelerate learning and change. The HEN will prioritize
    working with the three Great Plains Area hospitals and is currently
    working with each hospital to schedule onsite meetings.
        Additionally, we are bringing in targeted quality improvement
    assistance through CMS' . Quality Improvement Organization (QIO)
    infrastructure (QIO). Among other support and training functions, QIOs
    assist with root cause analysis of identified problems, assists with
    the development of improvement plans, establish baseline data, and
    monitor data to ensure improvement plans are successful and
    improvements are sustained over time. Also through Secretary Burwell's
    Executive Council on Quality Care, HHS is deploying quality experts, as
    needed, from throughout the Department to consult with and help our IHS
    direct service hospitals that are currently out of compliance with CMS
    Conditions of Participation and to monitor progress as the facilities
    come into compliance.
    Engaging Local Resources
        And fifth, we aim to engage more robustly with local resources. We
    know that, in addition to our strong partnerships with Tribes and their
    leadership, local academic and health systems organizations can be
    valuable sources of expertise and partnership. We intend to strengthen
    our relationships with local and regional health care systems, local
    colleges and universities and tribal colleges, direct service hospital
    leadership and tribal leadership to build stronger academic pipelines
    and health care connections to ensure we are working collaboratively
    and effectively to produce health related workers and health care
    services.
        We also recognize that the health of communities is tied to the
    economic health of communities. Rates of unemployment and poverty
    matter. Consequently we are committed to advancing the success of small
    businesses in tribal communities. The Department's Office of Small and
    Disadvantaged Business Utilization, in collaboration with the U.S.
    Small Business Administration, is working to coordinate meetings with
    tribal leaders and small businesses owned by Native Americans, Indian
    Tribes, and the Native American community at large.
        Our team plans to have these meetings in or near the 12 Indian
    Health Service Area Offices and the events will focus on how to
    effectively pursue contract opportunities with HHS, IHS, and other
    Federal Agencies.
    Strengthening IHS
        We have been working to address challenges using new approaches on
    our end. First, we appreciate the authority we already have to use the
    pay flexibilities under chapter 74 of title 38. We are working with
    OPM, OMB, and other affected agencies to explore ways to enhance our
    current authorities to provide more tools to recruit and retain high
    quality staff.
        Second, we are seeking tax treatment, similar to the treatment
    provided to recipients of National Health Service Corps (NHSC) and
    Armed Forces Health Professions scholarships. Currently, IHS loan
    repayment/scholarship awards are taxable, reducing their value. In
    contrast, participants in the NHSC scholarship program and Armed Forces
    Health Professions may exclude scholarship amounts used for qualifying
    expenses from income, and participants in the NHSC loan program may
    exclude any loan amounts repaid on their behalf from income. We
    recommend adopting the Administration's Fiscal Year 2017 Budget
    proposal which would conform the tax treatment of IHS repayments/
    scholarships to the tax treatment for NHSC and Armed Forces Health
    Professions repayments/scholarships.
        Third, the Indian Health Care Improvement Act requires employees
    who receive IHS scholarships or loan repayments to provide clinical
    services on a full-time basis. However, the Affordable Care Act permits
    certain NHSC loan repayment and scholarship recipients to satisfy their
    service obligations through half-time clinical practice for double the
    amount of time or, for NHSC loan repayment recipients, to accept half
    the loan repayment award amount in exchange for a two-year service
    obligation. We would like similar flexibility.
        Being able to access resources is key to amplifying our work. It is
    critically important that we receive the funding the President
    requested in his Fiscal Year (FY) 2017 Budget, which includes: an
    increase of $159 million above FY 2016 to fund medical inflation, pay
    costs, and accommodate population growth for direct health care
    services; an increase of $20 million for health information technology
    to fund the development, modernization, and enhancement of IHS'
    critical health information technology systems; $2 million to create a
    new program which will focus on reducing medical errors that adversely
    affect patients; and $12 million specifically for staff quarters at
    current facilities, in addition to staff quarters associated with new
    facilities.
    Conclusion
        Our entire Department is committed to making meaningful and
    measurable progress in the way that IHS delivers care. While the
    Administration has concerns about this bill, we look forward to working
    with the Committee to improve it as it moves through the legislative
    process. Thank you, and we are happy to take your questions.

        The Chairman. Thanks so much for your testimony. I
    appreciate you being here and making the trip. Thank you.
        Let me just now turn to the honorable William Bear Shield,
    who is the Chairman of the Rosebud Sioux Tribal Health Board of
    South Dakota.

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

        Mr. Bear Shield. Good morning. Thank you, Chairman
    Barrasso. Good morning, Senator Thune, Senator Rounds,
    Representative Noem. Thank you for the kind words.
        First of all, I want to say [phrase in Lakota.] Welcome to
    the Hesapa Senate Indian Affairs Committee. It is the home of
    the great Sioux nation; Mount Rushmore; and, more importantly,
    Crazy Horse monument, which is our fierce warrior.
        As Chairman Barrasso has said, I'm also a member of the
    Rosebud Sioux Tribe. I serve as our chairman of our health
    board committee there. I'm also the chairman of Unified Tribal
    Health Board here for people that utilize Sioux San Hospital.
    I'm also vice chairman of the Great Plains Tribal Chairman's
    Health Board here.
        As you're aware, Rosebud IHS hospital has been the subject
    to multiple CMS findings that have left our hospital without
    emergency rooms since December 15, 2015 resulting in a CMS
    notification to terminate the hospital's provider agreement
    effective March 16, 2016, and as recently as this past week we
    learned that our tribal members who need surgical and health
    care services are now required to be diverted to other
    facilities.
        I would like to thank you for your commitment and your
    actions in assisting the Rosebud Sioux Tribe, and not only
    other tribes of the Great Plains to address these issues. Many
    of you visited Rosebud and have shown a sincere interest in
    finding a solution, and we can only do that working as a team.
        We believe in the IHS Accountability Act, along with
    Senator Rounds calling for an internal audit, and
    Representative Noem's bill to accept tribes from the ACA
    employer mandate are important steps towards improving health
    care for Indian people in the Great Plains.
        The IHS Accountability Act of 2016 calls for fiscal
    accountability. We ask that the legislation includes a
    prohibition of the IHS from using the third-party revenue to
    settle any types of litigation.
        Recently IHS used over $900,000 of Rosebud IHS third-party
    billing to pay a national labor claims settlement.
    Additionally, we ask this Committee's support and of the Great
    Plains tribes' requests to IHS for a comprehensive budget of
    the area office, including tribal shares so that the Great
    Plains tribes, with the assistance of the Great Plains Tribal
    Chairman's Health Board can begin developing an alternative
    model to the area office.
        We also believe that fiscal accountability must include
    adequate funding to ensure success. The Rosebud Sioux Tribe is
    currently teamed with capable health care management to pursue
    the sole source contracting of the Rosebud Indian Health
    management positions. However, when we informed IHS
    headquarters of this intent, we were told that the tribe could
    not sole source the proposed contract. When, in fact, didn't
    they do the same thing when they awarded the contract for the
    ED?
        We ask this Committee to recognize that Rosebud and other
    tribes that want to assume programs right now are working under
    a handicap because the funding stream from third party have
    been disrupted and the costs have gone due to increased efforts
    to assume compliance.
        Furthermore, we also need meaningful and productive
    consultation, which is currently absent.
        We ask that Congress support and encourage tribal
    assumptions by creating a pool of funds to offset these
    challenges immediately so that the tribes do not have to use
    its own resources to overcome the deficits IHS causes.
        Funding will also be needed to support increased
    recruitment and retention. They should also be able to have the
    tribes utilize and assume IHS programs since they are affected.
    We are aware that there is no changing the past, but we hope
    that the proposed legislation supported by adequate funding, we
    can all move forward in a positive way to provide quality
    health care as our ancestors envisioned upon signing of our
    treaties.
        Thank you again for your efforts on behalf of the Rosebud
    Sioux tribe and other tribes of the Great Plains. We look
    forward to continuing participation and partnership to drive
    these changes forward.
        The Chairman. Thank you for your testimony and sharing that
    with us.
        We're next going to turn to Wehnona Stabler, who's the
    Tribal Health Director from the Omaha Tribe of Nebraska.

     STATEMENT OF WEHNONA STABLER, CEO, CARL T. CURTIS HEALTH AND
                   EDUCATION CENTER, OMAHA TRIBE OF
                                NEBRASKA

        Ms. Stabler. Yes, good morning. I'd like to say thank you
    to my Tribal Council this morning that has accompanied me, and
    my nephew who said a little prayer this morning. I want to
    thank him.
        I'm not here representing the council, though. I'm here
    representing the many patients that suffer, and one recently
    who has died. A 40-year-old that went to the Omaha Winnebago
    hospital, 9 miles up the road. We were promised in the treaty
    that's provided, and she went in and she was a diabetic. It was
    clearly recorded. Nobody ever checked her blood sugar. Sent her
    home, next day she came in with 1,500 and she died.
        So in February when I testified, I wanted to relay the
    suffering; and yesterday I had to cry at the end of the day. It
    was one after the other after the other. And so, this morning I
    wanted to have the right words to say to you, but it's very
    difficult because these are people that I know. These are
    relatives that I'm going to watch these children grow up
    without a mother. Her daughter just graduated from high school.
    I almost sent it to all the IHS people, you should have seen
    what she wrote. I'm not sharing this with my mother, and it was
    a simple finger stick. And they're spending $6 million to buy a
    central monitoring system for our ER's, but if the people
    aren't there to push the buttons and to do the readings, this
    is what's happening today still in our hospitals.
        And I left the Indian Health Service after 31 years because
    I could not be a part. I could not be a part of a system that
    was failing my people. And I see this every day. And we're
    trying our best, and I have to thank CMS for doing their job.
    It seemed like they were trying to go around the systems. They
    were trying to figure out ways to not comply, instead of just
    giving us what we deserve and what we've already paid for, and
    what has been promised to the Omahas by the treaty.
        We have five treaties with the government. We are the
    indigenous tribe there. We've always been a very peaceful tribe
    on the river, never declared the government as an enemy, but I
    am right now doing that because I've been in this battle for a
    long time, and we're losing it. We're losing it.
        And the reality is they want the tribes to take it over,
    but the Omahas have done this for 38 years. We have a public
    law 93-638 contract. We've done everything except ER and
    inpatient care. Those are the two services, ER and inpatient
    care, that we rely on IHS for and they've failed us miserably.
        So I do thank CMS for doing their job. And it is not a
    mission impossible, you know. I run three hospitals for IHS and
    numerous clinics when I was at the Pine Ridge service unit
    recently, like three and a half years ago we removed the
    immediate jeopardy. But it takes a CEO that will go into the
    ER. And I had a new area director tell me in February CEO's
    should not have to go into the emergency room.
        I'm sorry. That was a necessity for me to do that to make
    sure those contract doctors, which are still in our ER's, give
    our patients the care they deserve. Nurses won't do it. Other
    staff won't do it. Doctors won't listen to people.
        Doctor, you know we were sent a dentist when we were
    failing. A dentist from Pine Ridge as our medical officer.
        You, as an orthopedic surgeon, know that there's no board
    certified ER doc that's going to listen to a dentist. That is
    the reality, but yet they argued with me every meeting and said
    it was legal. But we don't care if it's legal. We want the
    right thing to be done for us.
        So today I'm here representing those people that have not
    had a voice, or just take that care and never say anything. Sit
    all day and wait in those hospitals for care, and then sent
    home with Motrin. Those are the people that I'm here for today.
        And I have to say that this is a start, that you are
    building a beginning. Because you know what? When you asked
    that question, I stood up; chairman stood up; Ardell stood up;
    but none of the IHS people stood up. They don't get their care
    from IHS.
        As a CEO, that's the first thing I did, I made a chart. I
    thought if I'm going to be the CEO of this hospital or clinic,
    I need to get my care here. I need to be satisfied. If I go
    there, then I know what's happening in that facility. And I
    expect the best for the patients that I serve.
        This is why I'm sitting here today. I'm from Nebraska, and
    I don't have a representative at this table, so I'm depending
    on this Senate Committee investigation to move our voices
    forward. The bill is great. It's a start. There are some
    missing pieces, though, and I would just like to ask you to
    consider, including telemedicine, because the states are trying
    to figure out how to bill and how to set things up. But
    telemedicine would be an answer to these remote areas, and we
    would have access to board certified ER physician if we had
    telemedicine, rather than mid-level contractors or mid-level
    M.D.'s that they're contractors for a reason, you know.
    Otherwise they'd be in full-time positions somewhere. They all
    have their quirks.
        Also, quarters, even though we've given up our quarters at
    Omaha Winnebago hospital, we need them to recruit. Consider
    funding that. So that's a part of your bill, but broaden it for
    the ones that have given up their quarters. Give us a second
    chance to rethink that for recruitment efforts.
        We need authorities like the V.A. has, two-year funding.
    And president Steele talked about that this morning. We're
    still suffering from the shutdowns. We shouldn't have been shut
    down. We shouldn't have been included in that. All these things
    that the V.A.--we're the first Americans and they're our
    veterans and we have high, high rates, and there's veterans
    still in my tribe and so, oftentimes, I send them to the V.A.
    because, unfortunately, they get better care there. That should
    not be the case. Our vets and us should be on the same playing
    field, I believe all the authorities that the VA has, we should
    too.
        So what's the next step? I think the audit, because we need
    to know where our money is. We don't know. They don't share
    that information with us. There is no transparency when you
    start talking about funding. Those old accounts, those old
    discretionaries, where are they? We see things that the money
    is allocated, but they're not even in existence, so we know
    there's money available.
        So the audit would be the next step, and then include us
    throughout these processes. The tribes have been left out.
    We're the patients. We're the stakeholders. Include us through
    the whole. So I think that would be the next step.
        And then I'm going to start to close my comments, but I
    have to say I have to put it back on Congress, if Congress
    would fund us at 100 percent. We're only funded at 50, 40, 30
    percent. You can go to any facility, they don't have 100
    percent funding.
        [Applause.]
        Thank you.
        This is why we're having to deal with CMS. If we were
    funded at 100 percent, you know, we would not have to do third-
    party billing. But, again, I thank CMS for being here and
    keeping us accountable for patient care issues. But fund us at
    100 percent and uphold our treaty rights. I ask HHS and IHS,
    please uphold our treaty rights.
        [Applause.]
        Keep us, the patients, at the center of all your decisions
    and actions. Keep us in mind. We're real people.
        Yesterday the man could barely stand. Did you see him? He
    was sweating and he just got out of the hospital, but he felt
    so strongly. He stood there for almost 20 minutes at the podium
    relaying his barriers and all the things that went wrong with
    his care. And I thought for sure he was going to pass out, but
    that's the kind of passion, and I think I even have PTSD from
    running three hospitals for a little bit. This is why we get so
    passionate, and if we cry and we carry on it's because we have
    that inside us, you know. We give up a lot for this. We're just
    asking. And so I thank you all for the opportunity today and
    may God be with you.
        [The prepared statement of Ms. Stabler follows:]

     Prepared Statement of Wehnona Stabler, CEO, Carl T. Curtis Health And
                   Education Center, Omaha Tribe of Nebraska
        Good morning esteemed members of the Senate Select Committee on
    Indian Affairs. My name is Wehnona Stabler and I am the Chief Executive
    Officer of the Omaha Tribe of Nebraska's Carl T. Curtis Health Center
    and an enrolled member of the Omaha Tribe.
        We operate Indian Health Service (IHS) programs, which are crucial
    to our tribal members. In addition to providing needed services, these
    programs offer sorely needed employment for both Indian and non-
    Indians. These programs are offered 365 days a year using federal funds
    and our limited tribal income, with very little assistance from the
    State of Nebraska. Current and past IHS funding has never met our full
    basic needs and that leads me into my initial, general comments about
    the matter at hand.
        I understand that the IHS Accountability Act does not include more
    funding for our troubled facilities in the Great Plains Region. But it
    should. In sum, for too long, faced with federal shortfalls, IHS has
    leaned on the states and CMS to fund its operations. And while I
    appreciate the intent of the Accountability Act--and will speak to its
    provisions--I believe Congress needs to be held accountable too. So
    let's not stop here.
        Turning to the Accountability Act, I will begin with Section 3,
    regarding removal of IHS employees based on performance or misconduct.
    As a former employee of IHS, I personally welcome--and my Tribe
    welcomes--this language that fast tracks IHS' authority to fire or
    demote underperforming employees while also not allowing an individual
    transferred to a general schedule position or a reduction in pay grade
    to be placed on administrative or paid leave unless they're performing
    a primary or alternative primary duty. However, I submit that for the
    sake of transparency, Notice of the Personnel Action and of the results
    of employee appeals should also be submitted to the Tribes within the
    respective IHS service area
        Section 4 concerns improvements in hiring practices. Here, the
    proposed direct hiring authority is welcome, so too, are the provisions
    requiring tribal consultation. However, with regard to the required GAO
    report relating to staffing needs, I note the report to be submitted by
    the Comptroller General includes an assessment of the use of
    independent contractors instead of full time equivalent employees, yet
    lacks any required analysis of the fiscal impact of such use of
    independent contractors. In my experience, the expense of hiring
    independent contractors is far more than use of FTE. Accordingly, such
    analysis should be included.
        Moreover, based on experience with the Omaha-Winnebago Hospital, I
    have concerns regarding what I will call the ``recycling'' of the
    independent contractors. For example, ``AB Staffing'' recently entered
    into a contract with IHS to run the Emergency Department at the Omaha-
    Winnebago Hospital. This is the same company that was at the helm when
    the hospital was terminated by CMS. In fact, their role has been
    expanded to include nursing. Why bring back a company that was part of
    the problem?
        Section 5 regards Incentives for Recruitment and Retention. My
    comments concern the requirement that the GAO provide a report on IHS
    professional housing needs and the housing plan to be submitted by the
    Secretary based on that report. The draft bill proposes that the GAO
    has up to a year to provide the report and up to another year for the
    housing plan to be submitted to Congress. Given that Congress may take
    another year--if not years--to act, I suggest the respective reports
    should have a deadline of six months; that is, the report by IHS is due
    within six months of the passage of the bill and the subsequent report
    to Congress should be due within six months of the GAO report.
        Next, I turn to Section 9: Fiscal Accountability. Section 9 (c)
    calls for status reports to be provided by the Secretary each quarter
    of a fiscal year describing the expenditures, outlays, transfers,
    reprogramming, obligations, and other spending of each level of the
    Service, including the headquarters, each Area office, each Service
    unit, and each facility to governmental entities, including tribes. I
    suggest this report should include a report detailing when, how, and
    for what purposes funds were diverted from one service unit to another.
    For example, additional funds were diverted to the hospitals with CMS
    issues in the amount of $60 million: O/W Hospital, Pine Ridge and
    Rosebud. But instead of consulting with the Tribes, IHS decided to
    purchase a Central Monitoring Unit for the Emergency Departments at
    each hospital. The question the Omaha's have is ``Will this machine do
    finger sticks?'' and the answer is ``NO''. We ask that question because
    we had a 40-year-old Diabetic die and no one ever checked her blood
    sugar. We do not need new gadgets if we have no qualified staff to
    operate them; we need permanent Board Certified, compassionate
    providers and staff to take care of us. The O/W Hospital is all we
    have.
        Finally, Section 10 addresses Transparency and Accountability for
    Patient Safety. This section requires the Secretary to post surveys,
    reports and other CMS materials relating to patient safety on websites
    of IHS operated hospitals and clinics. Section 10 (b) makes CMS
    responsible for conducting surveys at least every two years to assess
    the compliance of each hospital or skilled nursing facility of IHS and
    publish the results on the same websites. The Omaha Tribe strongly
    suggests that CMS should further be responsible for immediately
    publishing to those websites any citations issued by CMS to an IHS
    facility stating that the facility is in ``Immediate Jeopardy''.
        Thank you for allowing me this time to speak. The Omaha Tribe will
    continue to stand ready to improve IHS as a partner to see the Quality
    of Care finally realized.

        The Chairman. Thank you so much, Ms. Stabler. You started
    by saying that yesterday, as we were listening, that you hoped
    you would be able to find your words, and I think we all agree
    that you have most certainly found your words.
        Next we're going to hear from Ms. Ardell Blueshield, who's
    the Tribal Health Director from the Spirit Lake Tribal Health
    in North Dakota.

      STATEMENT OF ARDELL BLUESHIELD, HEALTH DIRECTOR, SPIRT LAKE
                                 TRIBE

        Ms. Blueshield. Good morning, Mr. Chairman, and members of
    the Committee. I am honored to be here today to discuss the
    Spirit Lake Tribe's recent assumption of the Spirit Lake Health
    Center in Forth Totten, North Dakota from Indian Health
    Service.
        We are proud to be the first tribe in the Great Plains Area
    area to exercise our self-governance rights to provide for our
    people's health care. In response to patient concerns and after
    conducting a patient survey and numerous community meetings,
    the tribe decided, in 2015, to assume operation of the Spirit
    Lake Health Center. The tribe and IHS concluded negotiations in
    early May, and the compact and funding agreement became
    effective June 1st of this year.
        I want to add that the complaints that we received, the
    responses of them were long waiting times, they wanted more
    providers, there was no patient transportation, and they wanted
    more services at the clinic. But it fell on deaf ears.
        So the council, the Tribal Council, and the people were
    tired of it, so they wanted to do this. They wanted to take the
    health care into their own hands. For a smooth transition, the
    tribe offered IHS employees the option to continue to work at
    the health center under the interpersonal agreements with IHS,
    and 48 IHS employees are detailed to the health center under
    these agreements.
        The tribe hired a chief executive officer and is working
    hard to fill the 24 vacancies inherited from IHS. The tribe is
    actively recruiting, including a job fair held just this week.
    The tribe's goal is to have a single integrated system of care
    for its tribal citizens using the flexibility of self-
    governance to tailor health programs to address the specific
    needs of our communities. The tribe has only begun its journey
    over its health care and its future, but it is excited about
    the opportunities and promise afforded by self-governance to
    improve health care for its people.
        The tribe would like to express its gratitude to Indian
    Health Service in the Area Office, and the Office of Tribal
    Self-Governance for their technical assistance and cooperation
    as the tribe gathered information and negotiated the agreement.
    The tribe looks forward to a collaborative relationship for the
    future to provide the highest quality health care for our
    people. We deserve it. We deserve everything that everybody
    else has.
        I offer a few reflections based on the tribe's experience
    to date. The Spirit Lake Tribe found a tribal survey to be a
    useful tool to learn about patient experiences at the Spirit
    Lake Health Center. The Tribe intends to continue the use of
    surveys in order to evaluate the health care programs and
    services that it provides. We recommend that IHS increase its
    use of surveys.
        The tribe also recommends that IHS expand its efforts to
    interact with tribal government of the communities which it
    serves through regular meetings, consultations, and a tribal
    liaison function at the service unit level.
        At the time when we took it over, that we have that and it
    needs to be stronger in all Indian Country. The provisions in
    Section 4 of S. 2953 requiring consultation with affected
    tribes regarding certain IHS personnel decisions are consistent
    with this recommendation and the tribe's experience. Enhanced
    communication between IHS and tribal government will improve
    accountability, IHS responsiveness to local needs, and the
    quality of care.
        The tribe also believes that Section 5, provisions for
    incentives for improvement and retention of IHS employees would
    be beneficial.
        The reasons for the tribe's decision to assume the Spirit
    Lake Health Center includes the tribe's greater ability,
    compared with IHS, to develop packages of compensation and
    other employment terms to attract and retain quality medical
    providers and other staff. Section 5 appears to improve IHS's
    flexibility in this regard as well.
        I thank the Committee for inviting me to give testimony
    this morning today. Thank you.
        [The prepared statement of Ms. Blueshield follows:]

     Prepared Statement of Ardell Blueshield, Health Director, Spirit Lake
                                     Tribe
        Chairman Barraso, Vice-Chairman Tester and Members of the
    Committee,
        I am honored to be here today to discuss the Spirit Lake Tribe's
    recent assumption of the Spirit Lake Health Center in Fort Totten,
    North Dakota from Indian Health Service. On June 1 the Tribe assumed
    the Health Center under the self-governance provisions in Title V of
    the Indian Self-Determination and Education Assistance Act. We are
    proud to be the first Tribe in the Great Plains Area to enter into the
    Indian Health Service Tribal Self-Governance Program and to exercise
    our sovereign rights to provide for our people's health care under
    self-governance.
        The people of the Spirit Lake Tribe are Dakota. The Spirit Lake
    Reservation is comprised of approximately 405 square miles in eastern
    North Dakota and has four districts: Mission District (St. Michaels),
    Woodlake District (Tokio), Fort Totten District, and Crowhill District.
    The total population of the Reservation is 4,238 of whom 3,794 are
    tribal members. The total tribal enrollment is 7,839. According to
    recent census data, the economic conditions on the Reservation are
    difficult, with per capita income totaling only 37 percent of the
    statewide average and 35 percent of the national average, and 47.8
    percent of reservation residents and 57 percent of children on the
    reservation living below the poverty level. The Spirit Lake community
    faces a number of health care challenges, including a high rate of
    diabetes. A 2015 community assessment found health care needs were
    eight of the community's top ten needs, in particular behavioral health
    issues and chronic disease.
        The Spirit Lake Health Center is an outpatient facility on the
    Spirit Lake Reservation with over 70 staff positions serving IHS
    beneficiaries. Until June 1 IHS operated the Health Center. In recent
    years the Tribe noticed an increase in dissatisfaction among patients
    of the Health Center. In early 2015 the Tribe began evaluating whether
    it should assume administration of the Health Center under the Indian
    Self-Determination and Education Assistance Act. The Tribe conducted
    numerous community meetings in 2015 and 2016 to receive input from
    tribal members about the care provided at the Health Center and to
    discuss possible tribal assumption of the Health Center. The Tribe
    developed a patient survey and circulated it among patients. The
    results of that survey confirmed dissatisfaction with customer service
    and the care provided at the Health Center. The survey results also
    reflected concerns about the number of physicians and other providers
    available at the Health Center to serve patients and limited patient
    transportation services. In addition to the patient complaints, the
    Tribe was concerned about the high vacancy rate among IHS staff of the
    Health Center.
        For many years, the Spirit Lake Tribe has operated a number of
    health programs under Title I of the Indian Self-Determination and
    Education Assistance Act, including programs addressing mental health,
    diabetes, women's health, alcohol and substance abuse, public health,
    community health, environmental health, and emergency medical services.
    Assuming the Health Center would facilitate integration of the Tribe's
    programs with care provided at the Health Center.
        The IHS Office of Tribal Self-Governance confirmed that the Tribe
    was eligible for self-governance, and the Tribe determined to assume
    the Health Center. The Tribe and IHS concluded negotiations in early
    May 2016, the Compact and Funding Agreement for the Tribe's existing
    Title I programs and the assumption of the Health Center was approved
    later in the month, and they became effective June 1, 2016.
        In order to ensure the smoothest possible transition, the Tribe
    offered the current IHS employees the option to continue to work at the
    Health Center under Intergovernmental Personnel Act agreements or
    Memoranda of Agreement (for Commissioned Corps officers). As a result,
    48 IHS employees are detailed to the Health Center under such
    agreements. The Tribe has hired a Chief Executive Officer of the Health
    Center and is working hard to fill the 24 vacancies inherited from IHS.
    The Tribe is actively engaged in recruitment activities, including a
    job fair held just this week.
        The Tribe's goal is to have a single integrated system of care for
    its tribal citizens. The Spirit Lake Tribe believes that it can use the
    flexibility of self-governance to redesign the health care programs and
    funding at the Spirit Lake Health Center in order to address the
    specific needs of our community and to be accountable to tribal
    citizens in a way that IHS cannot. The Tribe has only begun its journey
    to assume greater control over its health programs and its future, but
    it is excited about the opportunities and promise afforded by self-
    governance to improve health care for its people.
        While it has not been easy, the Tribe would like to express its
    gratitude to Indian Health Service, in the Area Office and
    Headquarters, particularly the Office of Tribal Self-Governance, for
    their technical assistance and cooperation as the Tribe gathered
    information about the Health Center and negotiated the Compact and
    Funding Agreement. The Tribe looks forward to a collaborative
    relationship with IHS in the future to provide the highest quality
    health care for our people.
        I offer a few reflections based on the Tribe's experience to date.
        The Spirit Lake Tribe found the tribal survey to be a useful tool
    to learn about patient experiences at the Spirit Lake Health Center.
    The Tribe intends to continue to use surveys in order to evaluate the
    health care programs and services that it provides. We recommend that
    IHS increase its use of surveys.
        The Tribe also recommends that IHS expand its efforts to interact
    with tribal government of the communities which it serves, through
    regular meetings, consultations and a tribal liaison function at the
    Service Unit level.
        The Tribe is still reviewing S. 2953 and reserves the right to
    submit additional comments later. However, in light of the Tribe's
    experience, I offer comment on certain provisions. For example, Section
    4 would provide that before appointing, hiring, promoting or
    transferring a candidate to a senior position or a management position
    in an Area office or Service unit, IHS must, except in certain
    emergencies, consult with affected Indian tribes. The Tribe believes
    that this provision would be an improvement as it would enhance
    information provided to tribal government about important personnel
    decisions affecting the health care program serving the tribal
    community. Such communication between IHS and the tribal government
    representing the patients whom IHS serves should improve
    accountability, IHS responsiveness to local needs and the quality of
    care. The Tribe recommends that the Committee and IHS continue to
    search for ways to incorporate tribal input into IHS decisionmaking.
        The Tribe also believes that the provisions in Section 5 for
    incentives for recruitment and retention, including authority for
    granting or rescinding bonuses to promote patient safety, employee
    performance or for recruitment, performance-based retention bonuses,
    and reimbursement to employees of relocation costs, would be
    beneficial. The reasons for the Tribe's decision to assume the Spirit
    Lake Health Center include the Tribe's greater ability--compared with
    IHS--to develop packages of compensation and other employment terms to
    attract and retain quality medical providers and other staff. Section 5
    appears like to improve IHS's flexibility in this regard as well. The
    Tribe is studying the proposed changes regarding the pay scale for IHS
    providers.
        I thank the Committee for inviting me to give testimony today. I am
    available to answer questions.

        The Chairman. And thank you very much, Ms. Blueshield.
        Now we turn to Ms. Stacy Bohlen, who is the Executive
    Director of the National Indian Health Board in Washington D.C.

      STATEMENT OF STACY A. BOHLEN, EXECUTIVE DIRECTOR, NATIONAL
                          INDIAN HEALTH BOARD

        Ms. Bohlen. Thank you, Mr. Chairman, and members of the
    Committee, and Congresswoman Noem. My native name is [spoke in
    Lakota.] and that name means turtle woman, and that name
    carries responsibility to speak the truth for all people, and
    it's with that being that I'm very honored to be here today on
    behalf of the National Indian Health Board. Thank you for
    inviting us to be here.
        I'm a member of the Sault Sainte Marie Tribe Chippewa
    Indians from Michigan, but my father was born and raised here
    in Milbank and Crow, South Dakota. I spent most of my childhood
    here in South Dakota, so I have a strong-rooted affinity in my
    heart for the place and the people here.
        The National Indian Health Board is a nonprofit
    organization. It serves all 567 federally-recognized tribes to
    provide policy analysis and advocacy for all of the tribes of
    this nation. It was founded by the tribes to serve as one voice
    affirming and empowering American Indian an Alaskan Native
    peoples, to protect and improve health, reduce health
    disparities, and ensure the Federal Government upholds its
    trust responsibilities for the health care of our people.
        Unfortunately, we're all here today because of long-
    standing systemic issues within the Indian Health Service that
    have led to crises situation in the Great Plains, but other
    crises in other areas are on the cusp of showing themselves, as
    well, and it is from a national perspective that I believe that
    the NIHB was asked to be here.
        Now that we are in a crisis situation, we believe there are
    two separate courses of action that must be taken. First and
    for most, immediate corrective action must be taken to rectify
    the closing and cutting off of IHS services so that there are
    no more unnecessary deaths of our people in this region or
    anywhere in this country. Once this crisis is stabilized, we
    must address the fundamental and systemic issues that have been
    occurring within the agency for decades. These reforms may
    start in the Great Plains; however, they must be implemented
    nationally so that all tribes and tribal citizens receiving
    their health care from IHS are assured safe, reliable, and
    quality health services.
        The legislation proposed by Chairman Barrasso and Senator
    Thune, the Indian Health Service Accountability Act of 2016, is
    attempting to address long-standing tribal concerns and the
    move forward in attempt to improve the overall accountability
    and transparency of IHS. It is admirable and appreciated and
    necessary for staff. The spirit and intent of this legislation
    is clearly aimed at responding to the call of tribal leaders,
    patients, and families like all of those we heard yesterday and
    that we've heard down through the decades.
        Many folks here have already testified about a variety of
    concerns included in the NIHB testimony, so if you don't mind,
    I'm going to skip forward to a couple of things that I believe
    will add to the discussion.
        First of all, we believe that structure reform of the
    agency is needed. There are unique challenges to delivering
    health care in any rural setting in the United States. These
    include provider shortages, isolation, long travel distances,
    scarcity of specialty care, and under-resourced infrastructure.
    However, there are successfully run rural health care systems
    operating all over the United States. A pressing need and
    opportunity exists within the Indian health and it's many
    rural, geographically isolated hospitals and clinics to reform
    the structure in administration oversight of the service units
    and the area to more reflect what's happening in the private
    sector.
        Medicine is business. It is the business of medicine, and
    it works in many, many areas of this country. The examples are
    all around us of what is successful and what will work, and we,
    at NIHB, believe that IHS has the authority to innovate. There
    are dramatic efforts underway right now to reach for and
    achieve innovation and we encourage those to continue and be,
    perhaps, even more aggressive and more dramatic.
        While one element that is absolutely necessary to such an
    aspiration is a dramatic increase in the funding that is
    currently held by the Indian Health Service; however, that is
    hand in hand with adopting standard and generally accepted
    business practices throughout the service, and NIHB too,
    believes that creating partnerships with mainstream and private
    entities will help IHS improve operations and systems, and, in
    fact, provide a learning laboratory for system-wide reform.
        The National Rural Hospital Association, the American
    Hospital Association, and the many--wow, it really goes fast--
    sorry. That just took another 20 seconds off my time.
        The Chairman. Go ahead.
        Ms. Bohlen. Thank you, Senator. Sorry. Now I'm having a hot
    flash. Jeez.
        [Audience laughter.]
        Okay. All right. let's get back to it.
        Your bill, of course, mandates the Secretary of HHS to
    report each quarter of the fiscal year describing expenditures,
    outlays, transfers, programming obligations, and other spending
    at each level of the service to Congress, tribes and the IHS.
    It does not have substantive measures in place to ensure that
    the mismanagement of these resources does not continue.
        And, to make it quick, we believe at NIHB that these
    quarterly reports should have a few measurable standards that
    are transparent to everyone. The tribes can see them, where is
    the money going, where is the third-party billing coming in,
    where is it going out, where is the federal expenditure of
    dollars taking place, and what is being achieved with that
    outlay; quality assurance and transparency.
        Many reports attribute to deplorable quality of health care
    at IHS, to poor agency management at all levels. We know that
    the hiring decisions are often lengthy, and poor performing
    employees at both the service unit clinic, and hospital
    administration and headquarters are not terminated, but moved
    around or moved up. We know that this needs to be reformed,
    because without patients there's no hospital. That was a quote
    from a tribal leader during a town hall that IHS held earlier
    this year. Without the patients, there's no hospital. So the
    patients become so disenchanted with the system that they just
    won't go there, which is already widespread. You don't have a
    hospital, you don't have a system. You have a whole lot of
    people waiting until they are so sick that of the top five
    services that people come in for, septicemia is one of them.
    Because you're so sick by the time you go for care that it's
    like very, very, very, very serious.
        So I'm going to skip ahead to recruitment and retention of
    personnel. While we understand that it can be challenging to
    achieve this, we think that HHS has additional tools already at
    its disposal to do so. The proposed legislation at hand
    provides for improved incentives to recruit and retain a
    quality health care workforce. It begins to address setting
    competitive pay scales for IHS employees and so forth. But
    wouldn't it be something to imagine and possibly achieve in the
    housing shortages that we have to bring our doctors in.
        For example, a mainstream company like Walgreen's, which
    resides at the ``Corner of healthy and happy,'' to come
    forward, make it healthy and happy forgive me, as an example,
    what if we had the corner of healthy and happy at Pine Ridge
    and right in the middle of it the Walgreen's house of healing
    for doctors so that our tribes have a chance. That would be an
    interesting undertaking.
        Finally, many policy makers do not realize that the system
    of the United States that we employ to train medical residents,
    as well as dentists and some nurses, is an entitlement program
    paid for through Medicare called Graduate Medical Education.
    The GME program exceeds $15 billion annually. Congress capped
    the number of residency training positions in the United States
    as part of the Omnibus Budget Reconciliation Act of 1997.
    There's been some amendments since then to allow for more
    residency training; however, the limit never existed where
    there were never residency trainings or where they were trying
    to be built in a place that was medically underserved, that's
    Indian Country.
        Medical specialties remain highly motivated to increase the
    number of residency training positions within their various
    colleges and academies. That creates partnership opportunity. A
    win/win would be the potential, perhaps, for increasing the
    number of physicians serving in Indian Country to set aside
    some of the residency training positions, create new ones that
    can only be filled by people who will commit to working in
    Indian Country when they finish.
        I know you want to me to stop. I'm almost done. I swear. So
    let me finish.
        Here's the deal, and, Chairman, you're aware, as obviously
    an orthopedic surgeon who went to school 700 years, maybe a few
    less, but it probably felt like 700.
        So, the thing is, say a resident goes into family practice
    and it's a three-year internship, a three-year residency
    training program. The indirect medical costs, which is the
    majority of the money for that resident's training goes to the
    hospital. That would be a great thing for our facilities to
    have. You have ten residents, a hundred thousand dollars each,
    the indirect medical education comes into our system per
    placement or training, but in this scenario we're increasing
    the number of residency training positions working with
    American Academy of Orthopedic Surgeons, College of OBGYN,
    pediatrics, emergency physicians, they all want their residency
    positions to increase. So they come and they have residents who
    fulfill these American Indian and Alaskan Native positions with
    the stipulation that if they don't serve the exact number of
    years in Indian Country, that that residency training consumed
    and was paid for by the American people, they get to pay that
    money back to the United States and the institution gets to pay
    it back to the United States. That's pretty highly incentivized
    to be successful. Nobody wants to pay that back.
        So, sorry if I went a little over time. I'm past my time.
    There's words to be said by better people than me, so in close,
    thank you.
        [The prepared statement of Ms. Bohlen follows:]

      Prepared Statement of Stacy A. Bohlen, Executive Director, National
                              Indian Health Board
        Good morning, my name is Stacy Bohlen, and I am the Executive
    Director of the National Indian Health Board (NIHB). \1\ Chairman
    Barrasso, Vice Chairman Tester and Members of the Committee, thank you
    for holding this important hearing on ``Improving Accountability and
    Quality of Care at the Indian Health Service Through S. 2953''. And,
    furthermore, thank you for honoring the Tribal leaders and Tribal
    members of the Indian Health Service (IHS) Great Plains Service Area by
    traveling to their traditional lands to hold one of many hearings and
    meetings to examine the state of the Indian health system.
    ---------------------------------------------------------------------------
        \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 National Indian Health Board is a non-profit organization that
    serves all 567 federally recognized Tribes to provide policy analysis
    and advocacy, program development and assessment, and training and
    technical assistance in Indian healthcare and public health policy and
    programs. It is our mission to be the one voice affirming and
    empowering American Indian and Alaska Native (AI/AN) peoples to protect
    and improve health and reduce the health disparities our people face. I
    appreciate the opportunity to provide this testimony before the
    Committee today. The NIHB stands with and supports the Tribes of the
    Great Plains IHS Service Area in this time of crisis and I'll conclude
    my testimony today with specifics on what action NIHB is taking outside
    of working with both the Administration and Congress to do so. I am
    here today to offer the national perspective of all 567 federally
    recognized Indian Tribes--both those that receive direct services from
    the Indian Health Service, and those that have chosen to compact or
    contract with the Service to provide their own services.
        Unfortunately, we are all here today because of longstanding,
    systemic issues within the IHS that have lead to crises situations in
    the Great Plains Area. In the last year, several hospitals in this
    region have lost, (or received threats of revocation) their ability to
    bill Centers of Medicare and Medicaid Services (CMS) due to the failure
    of federally run sites to comply with basic safety and regulatory
    procedures. As early as this week, an IHS facility, the Rosebud
    Hospital on the Rosebud Sioux Reservation here in South Dakota, closed
    their surgical and obstetrics care services division. Now, patients
    seeking surgical and obstetrics care must go to privately owned
    facilities over 40-50 miles away. This is unacceptable.
        Many of the issues now coming to light are not new to American
    Indian and Alaska Natives that rely on the Indian Health Service as
    their primary source of health care and health information. At least
    five years ago then-Senator Dorgan released a report exposing the
    chronic mismanagement occurring at both the IHS regional (Area office)
    level and the Headquarters level of the Agency. A 2011 report by a
    separate U.S. Department of Health and Human Services (HHS) task force
    specifically noted that: ``. . .the lack of an agency-wide, systematic
    approach makes it virtually impossible to hold managers and staff
    accountable for performance and to correct problems before they reach
    crisis proportions.''
        Now that we are in such crises situations there must be two
    separate courses of action taken. First and foremost, immediate
    corrective action must be taken to rectify the closing and cutting of
    IHS services so there are no more unnecessary deaths of our people in
    this region and nationally. Once the crisis is stabilized, we must then
    to address the fundamental and systemic issues that have been occurring
    within the agency for years. These reforms may start in the Great
    Plains Area; however, they must be implemented nationally so that all
    Tribes and Tribal citizens receiving their health care from IHS are
    assured safe, reliable and quality health service.
        The legislation proposed by Chairman Barrasso and Senator John
    Thune, S. 2953 ``The Indian Health Service Accountability Act of
    2016'', is attempting to address long-standing Tribal concerns about
    the IHS, and the move forward to attempt improving the overall
    accountability and transparency of the Indian Health Service is
    admirable and appreciated. The spirit and intent of this legislation is
    clearly aimed at responding to the call of Tribal leaders, patients and
    the families of those who have had adverse experiences within the IHS
    system. Significant and structural changes are needed and this this
    bill boldly steps into that arena as a first attempt to open the
    dialogue of change. We stand ready to work with the Committee as the
    bill is shaped and formed through a Tribally-engaged and informed
    process. During the years that Indian Country and Congress worked to
    achieve the reauthorization of the Indian Health Care Improvement Act
    (IHCIA) NIHB facilitated a national, Tribal Leader Lead committee on
    the IHCIA Reauthorization. Many of the details of this bill attempt to
    achieve reforms that will provide the Service with the authorizations
    they need to improve the quality and quantity of health care services
    delivered at IHS facilities. However, especially because this
    legislation proposes to amend IHCIA, it is the position of the National
    Indian Health Board that the bill must be vetted further with a process
    similar to that utilized during the IHCIA reauthorization. Resources
    will be required to facilitate such a process and the time is now to
    engage the Tribes and Tribal consumers of IHS services in order to
    achieve meaningful, lasting and effective reforms to the system set up
    to fulfill the Treaty and Trust promise and obligations of the Federal
    Government.
    Federal Trust Responsibility
        The federal trust responsibility for health is a sacred promise,
    grounded in law, which our ancestors made with the United States. In
    exchange for land and peaceful co-existence, American Indians and
    Alaska Natives were promised access to certain paybacks, including
    health care. Since the earliest days of the Republic, all branches of
    the federal government have acknowledged the nation's obligations to
    the Tribes and the special trust relationship between the United States
    and American Indians and Alaska Natives. The Snyder Act of 1921 (25 USC
    13) further affirmed this trust responsibility, as numerous other
    documents, pieces of legislation, and court cases have. As part of
    upholding its responsibility, the federal government created the Indian
    Health Service (IHS) and tasked the agency with providing health
    services to AI/ANs. Since its creation in 1955, IHS has worked to
    provide health care to Native people. As recently as 2010, when
    Congress renewed the Indian Health Care Improvement Act, it was
    legislatively affirmed that, ``it is the policy of this Nation, to
    ensure the highest possible health status for Indians. . .and to
    provide all resources necessary to effect that policy.'' \2\
    ---------------------------------------------------------------------------
        \2\ Indian Health Care Improvement Act,  103(2009).
    ---------------------------------------------------------------------------
    Disparities
        While some statistics have improved for American Indians and Alaska
    Natives over the years, they are still alarming and not improving fast
    enough. Still, across almost all diseases, American Indians and Alaska
    Native are at greater risk than other Americans. For example, American
    Indians and Alaska Natives are 520 percent more likely to suffer from
    alcohol-related deaths; 207 percent greater to die in motor vehicle
    crashes; and 177 percent more likely to die from complications due to
    diabetes. \3\ Most recently, a report has come out reporting that
    American Indian and Alaska Natives are disproportionately affected by
    the hepatitis C virus (HCV). Furthermore, Natives have the highest HCV-
    related mortality rate of any US racial or ethnic group--resulting in
    324 deaths in 2013. And, most devastatingly to our Tribal communities,
    suicide rates are nearly 50 percent higher in American Indian and
    Alaska Natives compared to non-Hispanic whites.
    ---------------------------------------------------------------------------
        \3\ Ibid, p 5.
    ---------------------------------------------------------------------------
        Although the statistics give an idea of the problem, behind each
    statistic is the story of an individual, a family and a community
    lacking access to adequate behavioral health and health care services
    or traditional healing practices, and traditional family models that
    have been interrupted by historically traumatic events. Devastating
    risks from historical trauma, poverty, and a lack of adequate treatment
    resources continue to plague Tribal communities. American Indians and
    Alaska Natives have a life expectancy 4.8 years less than other
    Americans. But in some areas, it is even lower. For instance, here in
    South Dakota, for white residents the median age is 81, compared to
    only 58 for American Indians.
        What more will it take for the U.S. government to fulfill its
    promise of providing the highest possible health status for Indians and
    to provide all resources necessary to effect that policy? How many more
    horror stories must we share, and how many more hearings like this must
    we endure? Clearly, the current system is not working. Our health care
    delivery is not even safe and reliable, let alone moving us toward the
    ``highest possible health status'' in Indian Country.
    Structural Reform
        There are unique challenges to delivering health care in any rural
    area, including provider shortages, isolation, long travel distances,
    scarcity of specialty care, and under-resourced infrastructure.
    However, there are successful rural health systems operating all around
    the country that are able to deliver especially innovative and locally
    responsive and coordinated care. A pressing need and opportunity exists
    within the Indian Health Service, and its many rural, geographically
    isolated hospitals and clinics, to reform the structure in
    administrative oversight of the Service Units and Service Area offices.
    We believe that rather than reinventing a health system out of whole
    cloth, or reform around the edges of a system desperately in need of
    dramatic and deep reforms, IHS should aspire to achieve parity with
    mainstream, successful medical and health systems. One element
    absolutely necessary to such an aspiration is dramatic increases in the
    current funding levels of the Indian Health Service; however, adopting
    standard and generally accepted business practices is also necessary.
    NIHB believes that creating partnerships with mainstream and private
    entities will help IHS improve operations and systems and perhaps
    provide a learning laboratory for system-wide reform. The Rural
    Hospital Association and the American Hospital Association are just two
    places to examine for potential collaboration and learning.
        While S. 2953 would mandate the Secretary of HHS to provide a
    report each quarter of a fiscal year describing expenditures, outlays,
    transfers, programming, obligations, and other spending of each level
    of the Service to Congress, Tribes and the IHS, it does not have
    substantive measures in place to ensure that the mismanagement of these
    resources does not continue. In May 2015, the then Acting Director of
    the IHS, Mr. Robert McSwain, wrote a Dear Tribal Leader Letter
    informing Tribes of a settlement IHS reached with employee unions,
    costing the Service a total of $80million. The settlement was reported
    to have resolved claims by IHS employees for overtime compensation for
    work they performed in federally operated hospitals, clinics and
    facilities--overtime work that was done to cover shifts in the health
    care facilities that would have otherwise gone uncovered and left
    countless American Indian and Alaska Native patients without care. The
    claims began being filed in 2008 and settlement awards covered several
    years of back-pay for this overtime work that employees performed due
    to long-term staffing shortages and general mismanagement of staff,
    facilities, and funding. A significant portion of the funding used for
    the settlement payment came from both third party collections and funds
    obligated for employee positions that went unfulfilled. The Dear Tribal
    Leader Letter stated, ``IHS is also working to address the management
    of overtime work performed by IHS employees.'', but as far as we know,
    no further action or reporting has occurred on this blatant malpractice
    that could have many unseen and unreported consequences on both
    employees and patients of the IHS. This failure to appropriately staff
    facilities and compensate employees shows a break down in the multi-
    layered administrative system within IHS. Both the local Service Unit
    and the Area Office would have had to have known that these issues
    persisted over several years, and yet, no immediate corrective action
    was taken to improve the quality of care provided or quality of
    workplace for employees at the facilities. More must be done to ensure
    accountability at both the Service Unit and the Area Office level of
    the Agency.
    Quality Assurance
        Many reports attribute the deplorable quality of care at IHS-
    operated facilities to poor agency management at all levels. We know
    that hiring decisions are often lengthy, and poor performing employees
    at both the service unit, clinic and hospital administration and
    Headquarters are not terminated, but rather moved to other positions
    within IHS--often to a position of equal or higher responsibility
    level. The cyclical chronic lack of funding and mismanagement of funds
    also means that managers are often doing more than one job, and
    managerial oversight of medical conditions is compromised. However, as
    the National Indian Health Board heard from Tribal leaders when
    visiting the Great Plains Area in April 2016, Tribal leaders and
    members acknowledge the staffing shortages and other issues, but
    consistently demand that focus remain on improving the quality of
    patient care, first and foremost. As one Tribal leader said during a
    town-hall style discussion with IHS leadership, ``Without patients,
    there is no hospital.''
        So, in addition to the staffing and accountability provisions
    included in the newly proposed legislation we are discussing here
    today, attention must also be directed at improving the quality of care
    provided at federally run IHS facilities. This can be done by
    strengthening agency-wide standards for hiring quality and qualified
    individuals who are capable of fulfilling the role as expected; for
    example, hiring a qualified Hospital Administrator to run a hospital or
    clinic and implementing quality and performance improvement measures
    from the top down. Quality would also be furthered through implementing
    and nurturing a culture and practice of Continuous Quality Improvement,
    management and supervisory training and setting performance benchmarks
    that are reviewed twice-yearly. If employees are not performing,
    generally accepted management practices and principals must be in
    place, respected and consistently upheld. Creating and sustaining a
    culture where quality and compassion are expected from all IHS
    employees is an absolute must.
        The IHS currently has a hospital and health center accreditation
    policy requiring facilities to comply with at least one of any
    nationally accepted accrediting or certifying bodies, such as the Joint
    Commission on Accreditation of Healthcare Organizations (JCAHO) or by
    the Accreditation Association for Ambulatory Health Care (AAAHC). The
    responsibility for assuring compliance rests with both the Area and
    Service Unit Director, who through this IHS policy, are required to
    report to IHS Headquarters annually on the status of compliance with
    their accrediting body. As we have seen in the closures of services and
    service units in the Great Plains Service Area, this current model of
    reporting is inadequate for ensuring that accreditation, and therefore,
    full ability to bill to private insurance, Medicaid, and Medicare
    remains intact. Therefore, these reports must be made transparent and
    public, perhaps posted quarterly on a web-based dashboard so that both
    lawmakers, Tribal leaders, patients and IHS may view them and assess
    the status of whether the facility is meeting quality and accreditation
    measures.
        Improving care delivery and reducing costs are critical in today's
    healthcare environment, especially in the underfunded Indian health
    system. There needs to be more accountability in the accrediting
    process and more measures put in place that will allow IHS facilities
    to more consistently assess and implement quality and performance
    improvements. There are resources both within the federal government
    and private sector that exist to assist in these processes. For
    example, the American Hospital Association's performance improvement
    entity, the Hospitals in Pursuit of Excellence, exists to accelerate
    performance improvement in hospitals around the nation, and has
    specific resources and support for rural hospitals and clinic--like so
    many in Indian Country are. The Health Resources and Services
    Administration (HRSA), another agency of the U.S. Department of Health
    and Human Services, is the primary federal agency for improving health
    and achieving health equity through access to quality services, a
    skilled health workforce and innovative programs. More intentional
    partnership and sharing of resources between HRSA and the IHS could aid
    in improving access to care for American Indian and Alaska Native
    patients and retaining skilled health professionals in Tribal
    communities. Overall, we know the hospitals and health systems that
    make quality and performance improvement a high priority will be
    rewarded with improved efficiency, better patient outcomes, and the
    ability to attract and retain the best people.
    Recruiting and Retention of Personnel
        While we understand that it can be challenging to recruit medical
    professionals and health administrators to remote areas, it is critical
    that IHS, and other related agencies within HHS, employ all tools at
    their disposal to do so.
        The proposed legislation at hand, provides for improved incentives
    to recruit and retain a quality health care workforce. It begins to
    address setting competitive pay scales for IHS employees that would be
    comparable to other physicians, dentists, nurses, and other health
    professionals, and the bill also attempts to address housing issues
    that Tribes and the agency have long said deters qualified medical
    professionals from moving into remote locations to work at IHS.
    However, while the bill seeks to provide housing vouchers and
    relocation assistance to new employees, it does not fully address the
    lack of housing available in these areas. It is often not just the cost
    of housing that deters employees, but the lack of nearby housing
    available. To rectify this, there will need to be further collaboration
    among the Tribes, government agencies such as HHS and the U.S.
    Department of Housing and Urban Development (HUD), and Congress to make
    investments in housing so that people working in IHS facilities have
    adequate housing. It is also critical to provide support for schools so
    that the families of medical providers will have access to adequate
    educational opportunities. Public/private partnerships should be sought
    as an innovative solution, rather than just assuming it cannot be done.
    Wouldn't it be something to imagine and possibly achieve, for example,
    a Walgreen's House of Health housing health care providers at the
    ``Corner of Happy and Healthy'' on the Pidge Ridge or Rosebud Indian
    Reservation?
        Many policymakers do not realize that the system the United States
    employs to train medical residents, as well as dentists and some
    nurses, is through an entitlement program, Graduate Medical Education,
    within Medicare. The GME program exceeds $15 billion annually. Congress
    capped the number of residency training positions in the United States
    as part of the Omnibus Budget Reconciliation Act of 1997. Since 1997,
    several legislative amendments and changes have occurred to make slight
    increases and variances on the resident limit; however, the medical
    specialties remain highly motivated to increase the number of residency
    training positions within their various colleges and academies. One
    potential opportunity to increase the number of physicians serving in
    Indian Country is to set aside a certain number of new residency
    training positions for those willing to serve in Indian Country. The
    number of years of service in Indian Country following completion of
    residency training would be equal to the number of years the resident
    took to complete the residency. In states like Connecticut, where
    residency training positions are approximately $155.000 per resident
    per year, that is an astonishing incentive to complete service to
    Indian Country. Likewise, since most of the GME funding is in Indirect
    Medical Education expenses--paid directly to the training institution,
    perhaps a similar incentive could attach to the training institute if
    the resident does not fulfill the commitment. Further, there are very
    limited numbers of residency training programs in IHS facilities--and
    among the exceptions to the caps on new residency positions is if the
    new program were to be in a rural or medically underserved community or
    if a residency training program has never before existed in the
    training center. The Secretary of Health and Human Service has the
    authority to approve such growth: indeed, is this not the very
    definition of Indian Country?
        We must also 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. The S. 2953 bill
    does not address this issue, despite the Agency having asked for years
    to have similar authorizations as the National Health Service Corps in
    order to recruit qualified health professionals to work in Indian
    Country.
        Likewise, one of the inherent flaws in the Indian Health system is
    the lack of qualified hospital administrators and lack of basic
    business acumen in the management, leadership and operation of health
    systems. We, therefore, also advocate for measures to recruit, retain
    and fund students to enter Masters of Business Administration, Hospital
    Administration and related professions necessary to any chance of
    achieving and sustaining meaningful reforms in the IHS system.
        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. 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 obstacles. In
    addition to the compensation incentives outlined in the proposed
    legislation, the Administration needs to engage Tribes in the process
    of onboarding new physicians and health professionals, to create a more
    welcoming environment that makes both the new employees, and the Tribal
    members and patients feel safe and a part of the community.
        Additionally, a long-term solution to addressing American Indian
    and Alaska Native health disparities lies in investing in our youth. We
    can improve the future of the Indian health care workforce by
    developing a culturally and linguistically competent workforce of
    Native health professionals and administrators. We know that AI/AN
    providers are more likely to remain in their own communities long-term
    and to provide culturally appropriate care. Therefore, Congress and the
    Service should prioritize resources and relationship building with
    academic institutions and national health professional organizations to
    engage Native youth in cultivating interest and capability in pursuing
    medical and health professions.
    Medical Literacy for Patients, Patient Advocacy
        According to the National Assessment of Adult Literacy, only 12
    percent of the U.S. population has a proficient health literacy level,
    and a total of 25 percent of American Indian and Alaska Native
    respondents scored at a ``below basic'' level. A white paper published
    by the IHS Health Literacy Workgroup in 2009 stated, ``While low health
    literacy affects people from all facets of life, it is
    disproportionately burdensome on vulnerable populations, such as
    American Indian and Alaska Native people and their elders. Persons with
    limited health literacy skills make greater use of services designed to
    treat complications of disease and less use of services designed to
    prevent complications.'' The Agency for Health Care Research and
    Quality further reports that low health literacy is linked to higher
    risk of death and more emergency room visits and hospitalizations.
        Given the disproportionate levels of low health literacy in AI/AN
    communities, and its direct impact on health outcomes and need for
    care, it is clear that more resources and training are needed within
    the Indian health system to improve patients' understanding of their
    own health and health care delivery. As well, those currently receiving
    their health care from IHS are the 3d Generation being cared for within
    this system. It is very important that such individuals have a scope of
    perception that includes what an average American expects from a
    medical encounter in mainstream America. Only then will patients within
    the IHS system have a clear understanding of their rights within the
    health system. And NIHB believes that Americans, including American
    Indian and Alaska Natives, have health care rights and among those
    rights is engaging in one's own personal health advocacy in a
    meaningful and informed manner. NIHB believes it is the right entity to
    engage in a national health literacy campaign with American Indians and
    Alaska Natives and requests support from Congress to undertake this
    crucial initiative.
        Finally, we have heard numerous reports from patients who are
    afraid to report their negative patient encounters for fear of
    retaliation against themselves or their families. We believe it is
    vital to have a safe method for patients to share their comments and
    experiences with the IHS system. Therefore, we believe a system that
    values feedback to improve the patient experience is a necessary
    component of quality. An anonymous, third party service that engages
    IHS patients about their care experiences would offer very valuable
    insights to inform the quality improvement process.
    In Conclusion
        The National Indian Health Board stands with and supports the
    Tribes of the Great Plains IHS Service Area in this time of crisis. The
    NIHB will continue to work on behalf of all Tribes, in coordination
    with both the Administration and Congress, to rectify these
    longstanding, unacceptable conditions of health care delivery at IHS
    federally run hospitals and clinics. As evidenced by the stories I and
    others have and will share today, areas most in need of improvement
    include funding, staffing, culturally appropriate care, and most
    importantly, health outcomes.
        We are pleased that the Senate Committee on Indian Affairs, and
    other legislators in both the House and Senate, have heard our stories
    and are now taking real, actionable steps to correct the issues within
    IHS that have been worsening over the past decade. In addition to
    Senator Barrasso and Senator Thune's Indian Health Service
    Accountability Act of 2016, several other bills to address
    accountability and transparency within the IHS have been introduced in
    the past several weeks. Most notably, the Helping Ensure
    Accountability, Leadership, and Trust in Tribal Healthcare (HEALTTH)
    Act (H.R. 5406) introduced on June 8, 2016 by Representative Kristi
    Noem (R-SD) that seeks to address many of the same issues as S. 2953
    such as fiscal accountability, transparency of funding and compliance
    surveys, lack of quality of care, and mismanagement of resources.
        The National Indian Health Board will be convening a special task
    force to further study the systemic challenges of the IHS, and make
    policy recommendations for long-term, sustainable reform of IHS. We are
    eager to work with this Committee and other policymakers to continue
    building on the legislation proposed and to meaningfully engage Tribal
    leaders, members and allies in these efforts to ensure truly holistic
    and appropriate reforms to the Indian health system.
        Finally, because this legislation seeks to amend the Indian Health
    Care Improvement Act, the National Indian Health Board would like to
    take this opportunity to remind the Committee that the Indian Health
    Care Improvement Reauthorization and Extension Act (S. 1790, enacted in
    H.R. 3590) permanently reauthorized and made several amendments to the
    Indian Health Care Improvement Act (IHCIA). Numerous provisions of S.
    1790 have not yet been fully implemented. Below is a summary of the
    progress in implementing these provisions. Without full funding and
    implementation the strides we have already made to achieve quality
    improvement remain unfulfilled.

        Attachment

       i. indian health manpower--67 percent of provisions not yet fully
                                  implemented
        Sec. 119. Community Health Aide Program--Authorizes the Secretary
    to establish a national Community Health Aide Program (CHAP).--
    Sufficient funds not yet appropriated.
        Sec. 123. Health Professional Chronic Shortage Demonstration
    Project--Authorizes demonstration programs for Indian health programs
    to address chronic health professional shortages.--Sufficient funds not
    yet appropriated.

    ii. health services--47 percent of provisions not yet fully implemented
        Sec. 106. Continuing Education Allowances--Authorizes new education
    allowances and stipends for professional development.--Sufficient funds
    not yet appropriated.
        Sec. 201. Indian Health Care Improvement Fund--Authorizes
    expenditure of funds to address health status and resource
    deficiencies, in consultation with tribes.--After consultation, IHS
    decided to make no change in use of funds at this time.
        Sec. 204. Diabetes Prevention, Treatment, and Control--Authorizes
    dialysis programs.--Sufficient funds not yet appropriated.
        Sec. 205. Other Authority for Provision of Services--Authorizes new
    programs including hospice care, long-term care, and home- and
    community-based care.--Sufficient funds not yet appropriated for long
    term care programs.
        Sec. 209. Behavioral Health Training and Community Education
    Programs--Requires IHS and DOI to identify staff positions whose
    qualifications should include behavioral health training and to provide
    such training or funds to complete such training.--Identification of
    positions has occurred, but IHS and DOI have lacked funds to provide
    required training.
        Sec. 217. American Indians into Psychology Program--Increases
    institutions to be awarded grants.--Sufficient funding not yet
    appropriated for additional grants.
        Sec. 218. Prevention, Control, and Elimination of Communicable and
    Infectious Diseases--Authorizes new grants and demonstration
    projects.--Sufficient funds not yet appropriated.
        Sec. 223. Offices of Indian Men's Health and Indian Women's
    Health--Authorizes establishment of office on Indian men's health,
    maintains authorization of office on Indian women's health.--New
    offices have not yet been created due to lack of funds.
        iii. health facilities 43--percent of provisions not yet fully
                                  implemented
        Sec. 307. Indian Health Care Delivery Demonstration Projects--
    Authorizes demonstration projects to test new models/means of health
    care delivery.--Sufficient funds not yet appropriated.
        Sec. 312. Indian Country Modular Component Facilities Demonstration
    Program--Directs the Secretary to establish a demonstration program
    with no less than 3 grants for modular facilities.--IHS has not yet
    established the program due to lack of funds.
        Sec. 313. Mobile Health Stations Demonstration Program--Directs the
    Secretary to establish a demonstration program with at least 3 mobile
    health station projects.--IHS has not yet established the program due
    to lack of funds.
     iv. access to health services--11 percent of provisions not yet fully
                                  implemented
        Sec. 404. Grants and Contracts to Facilitate Outreach, Enrollment,
    and Coverage Under Social Security Act and Other Programs--Directs IHS
    to make grants or enter contracts with tribes and tribal organizations
    to assist in enrolling Indians in Social Security Act and other health
    benefit programs--IHS has not yet established the grants due to lack of
    funds.
      v. urban indians--67 percent of provisions not yet fully implemented
        Sec. 509. Facilities Renovation--Authorizes funds for construction
    or expansion.--Sufficient funds not yet appropriated.
        Sec. 515. Expand Program Authority for Urban Indian Organizations--
    Authorizes programs for urban Indian organizations regarding
    communicable disease and behavioral health.--Sufficient funds not yet
    appropriated.
        Sec. 516. Community Health Representatives--Authorizes Community
    Health Representative program to train and employ Indians to provide
    services.--Sufficient funds not yet appropriated.
        Sec. 517-18. Use of Federal Government Facilities and Sources of
    Supply; Health Information Technology--Authorizes access to federal
    property to meet needs of urban Indian organizations.--Protocols
    developed, but property transfer costs require additional funding.
            --Authorizes grants to develop, adopt, and implement health
            information technology.--Sufficient funds not yet appropriated.
    vi. organizational improvements--0 percent of provisions not yet fully
                                  implemented
        vii. behavioral health--57 percent of provisions not yet fully
                                  implemented
        Sec. 702. Behavioral Health prevention and Treatment Services--
    Authorizes programs to create a comprehensive continuum of care.--
    Sufficient funds not yet appropriated.
        Sec. 704. Comprehensive Behavioral Health Prevention and Treatment
    Program--Authorizes expanded behavioral health prevention and treatment
    programs, including detoxification, community-based rehabilitation, and
    other programs.--Sufficient funds not yet appropriated.
        Sec. 705. Mental Health Technician Program--Directs IHS to
    establish a mental health technician program.--IHS has yet not
    established the program due to lack of funds.
        Sec. 707. Indian Women Treatment Programs--Authorizes grants to
    develop and implement programs specifically addressing the cultural,
    historical, social, and childcare needs of Indian women.--Sufficient
    funds not yet appropriated.
        Sec. 708. Indian Youth Program--Authorizes expansion of
    detoxification programs.--Sufficient funds not yet appropriated.
        Sec. 709. Inpatient and Community Health Facilities Design,
    Construction, and Staffing--Authorizes construction and staffing for
    one inpatient mental health care facility per IHS Area.--Sufficient
    funds not yet appropriated.
        Sec. 710. Training and Community Education--Directs Secretary, in
    cooperation with Interior, to develop and implement or assist tribes
    and tribal organizations in developing and implementing community
    education program for tribal leadership.--Comprehensive community
    education program has not been implemented due to lack of funds,
    although IHS and agencies do provide some trainings.
        Sec. 711. Behavioral Health Program--Authorizes new competitive
    grant program for innovative community-based behavioral health
    programs.--Sufficient funds not yet appropriated.
        Sec. 712. Fetal Alcohol Spectrum Disorders--Authorizes new
    comprehensive training for fetal alcohol spectrum disorders.--
    Sufficient funds not yet appropriated.
        Sec. 713. Child Sexual Abuse and Prevention Treatment Programs--
    Authorized new regional demonstration projects and treatment
    programs.--Sufficient funds not yet appropriated.
        Sec. 715. Behavioral Health Research--Authorizes grants to research
    Indian behavioral health issues, including causes of youth suicides--
    Sufficient funds not yet appropriated.
        Sec. 723. Indian Youth Tele-Mental Health Demonstration Project--
    Authorizes new demonstration projects to develop tele-mental health
    approaches to youth suicide and other problems.--Sufficient funds not
    yet appropriated.
     viii. miscellaneous--9 percent of provisions not yet fully implemented
        Sec. 808A. North Dakota and South Dakota as Contract Health Service
    Delivery Areas--Provides that North Dakota and South Dakota shall be
    designated as a contract health service delivery area.--IHS has not yet
    implemented citing lack of funds.

        The Chairman. Well, thank you very much.
        Dr. Wakefield, I appreciated the fact that you listened
    closely to each person's testimony, and I can see that you were
    watching closely as to what was happening. The concern that I
    have, and it was mentioned at the hearing back in February, we
    visited about how apalled people were to learn that the acting
    Chief Medical Officer, Susie Carol, statements came up in the
    Committee about babies being born on the bathroom floor and it
    was an unfortunate situation.
        And the other thing that came up in the Committee was the
    fact that we heard people who maybe shouldn't be working within
    the system simply just get moved, get shuffled around from one
    place to another place. And I recently learned that this doctor
    had been appointed by HHS to be the Chief Medical Officer
    through the Great Plains Area, so I think we're all worried
    about tribal consultation and accountability and, you know, the
    tribes weren't consulted on that decision to kind of move a
    person from one place to another within the region when, you
    know, there were real concerns about the person and their
    performance.
        Dr. Wakefield. I cannot speak to the specific question that
    you asked about tribal consultation with regard to that
    individual. I can say that we have--we certainly have been
    focusing intensively on improving accountability using our
    performance evaluation structures that we have for evaluating
    our personnel in IHS.
        And to give you one example, we have embedded within our
    performance appraisals our annual evaluations of the
    individuals that are working in the Great Plains Area
    expectations that, in the hospitals where they work, they are
    held responsible for meeting conditions of participation, for
    example, that are the CMS's conditions of participation.
        The accountability piece that you've identified in your
    bill, we certainly agree, is extremely important and we have
    other strategies we talked about, to hold providers
    accountable, as a whole. I'll stop there.
        The Chairman. The concern that we've heard in D.C. and in
    talking with people here today and yesterday, as well, is a
    performance approval, if the people who are judging the
    performance are not actually the patients and the families who
    are being taken care of under that system, where there's just
    one provider saying, you're real good, and then the other
    provider saying, you're really good, that doesn't give the
    accountability that, I think, we're looking for.
        Performance approval, in my mind, should have members of
    the tribe, the patients, consulted as well, and that was very
    much a concern.
        [Audience applause.]
        Dr. Wakefield. Thank you for that recommendation. We'll be
    happy to take that into consideration and see how we can
    incorporate exactly patient feedback back into the processes.
        The Chairman. I think it's critical. There was another
    provision of the bill that talked about how unobligated funds
    would be used, and one provision says the secretary shall only
    use unobligated funds from the fiscal year to support patient
    care specifically. And I think you raised that, Ms. Stabler,
    costs of central medical equipment, purchase of preferred care,
    purchase approved by the secretary after consultation with the
    appropriate tribe. I'm sure you support that you use that money
    in that way.
        The concern that Ms. Stabler raised earlier had to do with
    there was a settlement where HHS allowed $80 million in Indian
    Health Service funds to be used for union settlements. That the
    money came from funds allocated for staffing needs and for
    patient care. To make matters of even greater concern to all of
    us is the attorneys, you know, get a percentage of settlement.
    The attorneys in this settlement got an estimated $20 million
    that should have been used for patient care.
        In the meanwhile you have hospitals in the Great Plaines
    that are understaffed, lack of basic medical equipment, the
    patients are dying, and my question is are tribes consulted on
    those sorts of decisions to take that kind of money away from
    the patient care to be used for a union settlement and their
    lawyers?
        Dr. Wakefield. So it's you, Senator, you, Mr. Chairman,
    have raised with us the need that you've identified and
    expressed to me very directly for IHS to be more forthcoming in
    terms of additional consultation. As a matter of fact, other
    members of this panel, Senator Thune, Senator Rounds, Congress-
    woman Noem have all expressed concern about and interest in IHS
    engaging in more robust and more frequent consultation.
        Based on the conversations that I've had with each of you,
    because you've made that very clear to me. I've taken your
    recommendations back. I've shared them with Mary Smith and they
    are advancing strategies to accomplish just that.
        We've also heard the same from tribal leadership. Between
    what we've heard from you and also tribal leadership, it is
    clear to us that there's more to be done in terms of improved
    consultation. I would say Mary Smith has been in the Great
    Plains Area, specifically in South Dakota now. This is her
    third trip here. She's engaged in a number of consultations
    with the Great Plains Area tribal leadership.
        Having said that, it's clear there's more that we need to
    do on all of our parts in terms of engaging consultation, and
    you, Mr. Chairman, have made that clear to us. I take that
    recommendation seriously, and we are acting on it.
        The Chairman. Thank you. Ms. Bohlen, I don't know if there
    was some additional things that you wanted to get out that you
    didn't feel you had the chance to, but I just feel--I'm so
    impressed with your testimony. You talked about what must be
    done to ensure accountability.
        Ms. Bohlen. Yes, sir.
        The Chairman. And you see it as somebody being born and
    raised here, but also what you do in Washington and across the
    country. But we want this bill to be as strong as possible.
        So, for the record, could you expand on some specifics that
    you might have that we could do with this bill to be sure that
    the dollars are getting to the patients who need it? Do you
    have additional thoughts?
        Ms. Bohlen. Yes, sir, I do. May I share something else
    first?
        The Chairman. Go ahead, yes.
        Ms. Bohlen. I wanted to, especially in this setting, I
    wanted to acknowledge Congresswoman Noem for alleviation of the
    employer mandate from the tribes. That bill never would have
    gotten through Weighs and Means this week without her and input
    from the tribes and I want to make sure to mention that
    acknowledgement. Thank you, Congresswoman Noem.
        Congresswoman Noem. I appreciate that. Thank you.
        Ms. Bohlen. Accountability, one of the things that we say,
    if you can't measure it, you can't manage it. And with the
    ongoing research that all of us have been doing to try to find
    good answers for IHS in the future, before we can even get to
    the point of accountability, we have to know what we're talking
    about.
        The audit that Senator Thune has been discussing, and all
    of you have been discussing, is essential to that being
    possible. Once we can get our arms around what it is that we--
    you know, measuring what it is that we're talking about, we'll
    be able to better manage it.
        I will share with you that the National Indian Health Board
    also believes that the tribe needs to be engaged in all of the
    decisionmaking about their health care and their dollars. The
    third-party billing revenue in 2015 from the Great Plains was
    $134 million. The Great Plains tribes, largely through Medicaid
    and Medicare, and about 33 million from third-party billing
    came through because the tenacity of the tribes to use that
    opportunity as additional income and resources and, as the
    questions have implied, they are not always able to be part of
    the decisionmaking in making sure that those dollars are spent
    the way they'd like to see them spent.
        We believe that there should be some medical literacy
    training that goes on in Indian Country. For three generations
    the IHS has been the only health system that many people in
    Indian Country are familiar with, and in order for tribes to be
    able to uniquely engage in their own decisions and their own
    care, we believe there has to be more light brought to bear on
    what the law is, how it works, what their rights are, what all
    the cards are that are on the table, because if you don't know
    what all the pieces are on each side of the table, you're not
    playing the same game.
        So we believe that given disproportionate levels of low
    literacy in Indian Country, that it has direct impact on the
    health outcomes and their need for care, and it is absolutely
    clear that more resources and training are needed within the
    Indian Health system to improve the patients' understanding of
    their own health care and their own health delivery system.
        One of the other stories that we consistently hear is that
    patients--I stumbled upon this when I was invited to Winnebago
    in 2014 to meet with their Tribal Council and learned what was
    going on, and one of the things that was the most resonating
    for me at that time was when council members said they are
    afraid to speak up, because if they speak up, they will not get
    health care and neither will their families.
        Well, there's an easy way around that. We know that one of
    the greatest quality improvement measures is patient direct
    surveying. My tribe, the Sault Sioux St. Marie tribe, uses a
    company in Ann Arbor, Michigan. It's a private third-party that
    keeps patient confidentiality, and after every patient
    encounter, those patients are called and surveyed about their
    experience.
        If we had a system like that where the patients could
    engage in a safe way, where they really felt that they could
    talk freely, we would probably find out some good things that
    are happening, too. So, you know, those kind of efforts to
    increase transparency, increase knowledge base of the tribes,
    empower tribes to be able to make their own decisions, and
    nothing empowers like knowledge. Open up the data to the tribes
    so they can see what is here and be a true partner with the
    tribes and understand that at the end of the day it is their
    people and their health that is at stake. Thank you.
        The Chairman. Thank you very much. Senator Thune.
        Senator Thune. Thank you, Mr. Chairman. And, again, thank
    you all to our panelists who were here today for sharing their
    insights.
        And, you know, the one thing, I guess, that I've, in
    looking at these issues, have sort of concluded is that--and we
    were talking earlier this morning in an earlier meeting Evie
    Espinosa, who is the Tribal Health Director for the Rosebud
    Sioux Tribe was talking about is that the psychological toll
    that the negativity surrounding these stories and this
    narrative just perpetuates year after year after year, the
    effect that has on people. And what I concluded is we can't fix
    the problem here by a tweak here or a fine tune here. This
    requires systemic change. You can't fix this by changing the
    oil and replacing the tires. We need a whole new car. I mean,
    the problems that are here are very deep seated. They are
    fundamental, and they require something that really does
    represent systemic change.
        And so the Chairman, in listening to everybody this morning
    and others who have shared with us over the past several
    months, try to get at in this bill, and, again, it's a starting
    point, some of those issues. You know, for one, how do we get
    change? We start with leadership, making it easier to replace
    leadership; to get medical professionals who are willing to
    serve and recruit and retain reservation hiring incentives,
    bonuses, competitive pay, temporary housing and housing costs,
    that sort of thing. Getting accountability both on the spending
    side, on the staffing side, so people know where money's going.
    I mean, $80 million. $80 million, Mr. Chairman, that went for
    litigation that was taken from patient care in the Great Plains
    Area. $6.2 million came out of this region and a million out of
    Rosebud. 1.3 out of Pine Ridge. That just can't continue. And
    so there's got to be the fiscal accountability piece of this.
        There's got to be whistleblower protection so when things
    go wrong and people report it, they aren't retaliated against,
    which is what you were getting at.
        [Audience applause.]
        And there's got to be the consultation, which my impression
    is, just doesn't and hasn't existed in the past. And so, I
    mean, these are big systemic things that we need to do to fix
    this problem.
        And, unfortunately, It took a crisis to kind of get us to
    this point, and, unfortunately, IHS has not been transparent
    and they have not been forthcoming about these issues, and
    they've asked these questions in the recent past and not gotten
    straight answers.
        And so December 5th of last year, IHS had conversations
    with my staff in which they said that everything is okay, the
    problems have been abated. That very day, later that day, we
    got notified that CMS had put the Rosebud Emergency Department
    on emergency status. There is a huge disconnect in
    communication.
        So I guess I want to just, Mr. Bear Shield, ask you in the
    course of last six or seven months, because we had this
    conversation, we had it several times, but we had this
    conversation in February, has consultation improved between the
    tribes and IHS?
        Mr. Bear Shield. First of all, getting back to, real quick,
    to the Act, before I forget, I'd really like to give thanks to
    the people sitting behind you, the staff. They've really done a
    great job coming to the tribe, getting to the tribe,
    everything--Ms. Noem's and your bills are exactly what we've
    been telling them, and a big thank you to them. Every morning I
    usually wake up to text or e-mails from them.
        But, Senator Thune, getting back to your question, you
    know, I have a hard time trying to--every time I--every day I
    pray and think that it's getting better. Something is going to
    break today where things are going to get better, and then it
    doesn't. You know, take for instance these contracts that were
    let out over for consultation for our ED. There's a young lady
    that has been calling me, asking me, a reporter, and I was at
    home and she calls me one day to--she says, Mr. Bear Shield,
    what do you think of the contracting company that contracted
    your ER? And I said, What? I said, What do you know? I'm sure
    you probably know more than I do.
        So then I call Ms. Espinosa and I say, Hey, have you heard?
    She said, Yeah, it's on the news, you know. And I'm not--the
    Chairman, Mr. Kindle and Ms. Espinosa and myself, we're usually
    the first ones to know, but that's the kind of stuff that still
    goes on today.
        And you know what Ms. Stabler and Ms. Blueshield and Ms.
    Bohlen were saying about, you know, contracts, there's some up
    and coming and we really need to be a part of. You know, we
    need to get away from this type of consultation which
    definitely isn't in our favor, you know. We've got the
    telehealth coming, we've got the sole sources sought, you know,
    five positions within IHS facilities, you know, we need help
    with those because the tribes need to be involved in those.
        And not only that, we send e-mails and calls up the line
    and they're not getting answered back.
        And even with Sioux San's current situation, we don't know
    what's going on there. You know, the last we knew that they
    worked out a--they got off immediate jeopardy status and they
    are working on an SIA agreement, I guess, and corrective action
    plan or what have you, but we sent e-mails also asking, you
    know, what's the status, and how can we assist and we need to
    be involved there. Rosebud, Pine Ridge, and Cheyenne River
    being the governing body there, you know, it concerns us. It's
    always concerned us.
        So, it isn't there. You know, on the tribe's part, ever
    since the last hearing, and you heard them, you know, just like
    today, we just heard that, you know, communities are important
    to us. Well, if that was the case, why didn't they let South
    Dakota providers in on the ED contract, you know?
        That doesn't make no sense to me.
        So, you know, with that being said now, I'm very confident
    that these bills will pass. Once they're passed and part of the
    law, the shoe needs to go on the other foot this time. We do
    not need IHS to define what that bill means to the tribes.
    Tribes need to define to them. They say, This is our bill, this
    is what this means to us.
        The Chairman. Thank you, Mr. Bear Shield.
        Senator Thune. So I'll assume the same as Ms. Blueshield,
    that the similar type of experiences on the consultation issue,
    but I guess what I would say, Secretary Wakefield and Ms.
    Smith, to that point there's got to be a way in which we can
    create a mechanism formalized so that consultation can take
    place. And the bill requires when it comes to major hires, if
    it's an area director or service unit, that there's
    consultation with the tribes, but I'm looking to you. We, I
    think, are all looking to you to work with us and with the
    tribes to create a way in which that happens so that we don't
    get these news bulletins about a contractor being hired and,
    frankly, a contractor that is, sounds like, from all we've been
    able to ascertain, pretty suspect based on the record with
    regard to previous work they've done for the tribes.
        And so that being said, I would just say to all of you,
    and, again, CMS, IHS are both under and that they seem to be
    operating on very different tracks, and where is the
    coordination, the conversations and consultation that we need
    to have; and, please, I would just say to you, I know the time
    is up, but work with us on getting that coordinated.
        Ms. Blueshield.
        Ms. Blueshield. When I was putting this together, I was
    thinking about everything that happened, all the years, and I
    thought, you know what? Why isn't there a tribal liaison or
    somebody that's in between the IHS and the people and the
    Tribal Council, and why isn't there somebody that advocates for
    us, that can explain things to the Tribal Council, or they can
    bring a message to the Tribal Council from IHS or somebody from
    IHS or something. But that was what was missing in our clinic
    and the things that we were doing, because we e-mailed all the
    time. I mean, we had phone calls, and once in a while we had
    somebody come and meet with us, but I think initially having
    somebody that was an advocate that could go both ways and talk
    to both sides, somebody in the middle that could be objective
    would be a possibility.
        The Chairman. Senator Rounds.
        Senator Rounds. Thank you, Mr. Chairman. And let me just
    share with everybody one of the rules in the Senate in terms of
    presenting testimony. When we ask questions, that we're
    normally limited by Committee to 5 minutes to do it, and so I
    would just thank the Chairman for the understanding and
    patience as each of us have kind of worked our way through. So
    thank you, Mr. Chairman, for that.
        Dr. Wakefield, I want to just preface my questions to you
    with this. Currently we're still experiencing underfunding with
    IHS and so forth, and I spoke earlier about the fact that I
    want the money to go in and get results. I want it to go
    directly to places where it's going to help people, but let me
    just put into perspective just exactly what we're talking about
    in terms of underfunding. At the federal level right now, the
    Bureau of Prisons currently spends about $5,100 per inmate on
    health care. Through IHS we spend $3,099, or about $2,000 less
    per individual on IHS funding than we do for the inmates in the
    Bureau of Prisons, and so we recognize that there is a
    discrepancy here in terms of focus.
        But at the same time if you put more money into this
    process and we don't know where it's going, and if we can't
    point to where it's being used successfully, then we're not
    going to get the results we want and we'll end up with more
    problems than we've got right now. In fact, I know you're
    aware, because we discussed this previously, Dr. Wakefield came
    in and spoke with all of us, we had a very good meeting, and
    there were several things that we committed at that time. I
    just want to walk through this in the public record on this.
        You're aware, because we discussed previously, but, again,
    I would like to raise my concerns about the financial
    discrepancies in the Department of Health and Human Services
    fiscal year budget specifically over IHS. The FY 17 budget
    intended to spend $40 million more on tribally operated
    facilities compared to federally operated facilities in the
    Great Plains Area. Given the Great Plains Area only has 17
    tribally operated facilities versus 35 federally operated, I
    repeatedly asked for explanation. Although my office has never
    received a response, we found that your website published a
    correction indicating that you had misreported the
    appropriation amount the IHS facilities in the Great Plains
    Area by $80 million. Now this is disturbing.
        If your budget analyst and your IHS national directors and
    your agency officials did not notice these very extreme
    inaccuracies, how do acting directors, some of who only have
    three months on the job, have any understanding on how to
    distribute this money between the 52 facilities when there are
    inaccuracies in your annually published budget of at least
    funds of as much as $80 million?
        And just as a real quick follow-up, would you, once again,
    commit to that independent audit to make sure that IHS can
    developed a transparent, clear and accurate budget?
        Dr. Wakefield. Thank you very much, Senator. And I said it
    at the very beginning, but, again, I want to tell you how much
    we appreciate the administration's intense interest and focus
    and leadership of the Chairman and of the three
    representatives, the members of Congress from South Dakota. You
    have been focused so intensively on ensuring access to quality
    care for American Indian populations and we appreciate the
    working relationship that we have with you to achieve a shared
    goal. So thank you for your willingness to spend time with me
    as we work through what are very significant challenges.
        In terms of the specific issues that you've raised, I would
    defer to Mary Smith about that because you raised that with me
    and that brought back immediately, the information was updated
    on that website after you flagged it. Thank you for flagging
    it. And, in addition to an audit, as we had discussed, you've
    raised that with me when we met. I said to you then, and I'll
    say it again for public record, you're certainly welcome to
    that. In the five-part strategy that we shared with you and
    Mary shared with the Great Plains Area leaders, the very first
    part of that five-part strategy is on our expectation to
    improve our transparency. It's critically important that we
    surface problems and that we work immediately to address those
    problems with the resources that we have.
        Transparency also involves consultation, which all of you
    have spoke about and we're trying to drive forward in a much
    more meaningful way than we have historically. So I agree with
    you about welcoming the audit. That's part of transparency, and
    we will do our level best, as we have been and continue to
    drive strategies forward that inprove surfacing problems and
    immediately addressing them.
        Senator Rounds. Let me just follow up on that then, please.
    We're talking about improving accountability at IHS. You've
    already heard a number of questions about CMS issues and our
    region's staffing concerns. While I certainly echo the
    concerns, we want to remain consistent through all these, the
    IHS inadequacies, poor communication, and literally no
    consultation.
        I want to illustrate this for you just in terms of what
    we've learned so far. The Great Plains Area IHS leadership
    hosted a call on December 4th regarding Pine Ridge and Rosebud
    CMS issues. Within three hours of the call, IHS sent out a
    press release outlying upcoming Rosebud Emergency Department
    diversion. Despite knowing that diversion was a possibility,
    IHS did not notify tribal leadership until they were issuing
    the press release.
        Secondly, with the revolving door of Great Plains Area
    directors, IHS has not been forthcoming about changes. Ron
    Cornelius was reassigned without notice hours before the
    February 3rd Senate Committee Indian Affairs hearing. When Rear
    Admiral Meeks signed on to serve as acting director, his
    commitment was for three months, but the tribes were not told
    this until his final days.
        We were pleased when IHS Principal Deputy Director Mary
    Smith, who is here with us today, visited South Dakota hoping
    for true discussion and consultation. Director Smith explicitly
    mentioned the means for better communication and promised
    improvement. Unfortunately, while you were here making that
    promise, the Emergency Department RFP had been issued; however,
    our tribes in South Dakotas three major health care systems,
    were not properly notified, did not receive timely responses to
    inquiries, and simply did not have enough information to
    consider these major contracts.
        A month after Director Smith's visit, local media outlets
    reported that another Great Plains Area hospital, Sioux San,
    was facing CMS violations. This newspaper headline came after
    days of tribes inquiring to IHS officials about such rumors,
    but our tribal leaders never received a response.
        So I'd like your commitment to reforming the culture in IHS
    to insisting that agency leaders treat their constituency with
    the dignity and the respect that they deserve. Do I have a
    commitment? And if I do have that commitment, I'd like you to
    share with us how you would execute it to make this change.
        Ms. Smith. Thank you, Chairman Barrasso, Senator Thune,
    Senator Rounds, and Congresswoman Noem. I really appreciate the
    opportunity and your interest and your leadership on bringing
    this field hearing today. I also want to thank all the tribal
    leaders and everyone here today to address this important
    issue. To me, there's nothing more important than health care
    in Indian Country.
        We've heard a lot of issues discussed today, and I know one
    of the issues, Senator Rounds, that you're raising is the issue
    of being transparent and open communication, and I fully agree
    with you on that. And, obviously, you know, there are more
    things we need to do, and I guess, you know, you asked how
    would we do that.
        The first thing I want to do is reach out to you all and
    the tribes, I think that open and honest communication occurs
    not only just with our tribal partners, the people we serve,
    but also Congress. And so I guess we are happy to continue
    talking with both the tribal leaders and yourselves as to what
    would be meaningful communication to you, because you do have
    my commitment that we will do whatever it takes to ensure that
    you get the information and we have the dialogue with you to do
    this.
        Senator Rounds. Mr. Chairman, you've been very kind with
    your time, and let me just finish with this very quickly. It
    seems like every time we have an emergency that comes up and
    there's an obvious layout program, we find out more things are
    a problem and it brings in the public attention, but what we
    end up doing is we provided a band-aid. In December we provided
    spending $2 million to go directly into the contracting work.
    What I think we have to do is to focus on the long-term issues
    surrounding IHS and provide more transparency so the tribes can
    actually make a decision about whether they want IHS to provide
    the services directly or if they want to look at doing
    independent activity among the tribes, themselves. And the only
    way that that's going to happen, I believe, is if we simply
    have systemically in place a plan that does not let us get
    focused on the emergency only, and let the big picture get
    away.
        And this time, unlike previous attempts, I think you're
    going to find that Congress is not going to let this get away
    again, and that we're going to continue to ask the hard
    questions and refocus on whether or not the job is getting
    done.
        [Audience applause.]
        The Chairman. Congresswoman Noem--I know you all have
    questions--but you can go ahead at this time.
        Congresswoman Noem. Thank you. I appreciate that, Mr.
    Chairman. And I've got a lot of questions so we're going to
    move kind of fast. I hope your answers are brief, but factual,
    if that's okay, and I will do that as well.
        Willy, we talked about before the culture that's ongoing
    within IHS, the fear, nepotism, corruption, and we can make a
    lot of changes in legislation, but it's hard to change
    attitudes and character in office. And, Willy, could you just
    speak a little bit about what that--in reality that is, because
    we have protection in U.S. law for whistle blowers, but,
    frankly, I have had whistle blowers contact my office that are
    scared of retaliation when they tell the truth about what's
    going on in IHS.
        So I want Willy to tell us a little bit about some of the
    culture that they see in IHS facilities and what it means to
    people, and then I want to get your commitment that whistle
    blowers will be protected and that there is not an environment
    of retaliation within IHS.
        Willy, do you have anything you can share with us about
    what it's like?
        Mr. Bear Shield. The other day I know we had visited--you
    know, backing up even to Chairman Barrasso's initial statement
    about the whole issue with the Indian Health Service, Mr.
    Andrews, your chief staffer came and visited a coalition of
    large tribes two weeks after initially hearing a representative
    of our tribe was there, Chairman Old Coyote from Crow Agency
    Montana Senate of Indian Affairs Committee for their work in
    coming to the Great Plains and having the hearing, but he said,
    Don't stop there. Come to the Billings area because the same
    thing is happening there. So I'm telling you how widespread it
    is.
        Now going back to Ms. Noem, there was an individual that
    came from there, you know, a provider in the past that had told
    me that, you know, he tried to make some changes himself, as a
    provider within the IHS system, and he pretty much got ran out
    of town. Work started getting audited, he was hounded, you
    know, quite often concerning his work because of the issues
    that he brought up, and he said ever since that day he's been
    afraid to do that.
        You know, the culture of people I do know. I think they may
    have--I was told the other day that, you know, they were going
    to make a video for recruiting or retention or a brochure, what
    have you. I don't know what people said, but, you know, I know
    tribal members, I think, that work in the facility weren't
    asked to be a part of it, but I do hope that they brought up
    our culture, our community, those type of issues because we are
    a very proud people, you know, rich in land and also in our own
    culture, and we're very proud of that fact.
        Going back to the initial questions of some of the
    disparity and frustration that this has caused us since we've
    been on diversion status, I do know I had an elder, his
    daughter called me from Valentine, and he said, Call Willy Bear
    Shield. I'm having a heart attack. He told me that I'll
    probably have to pay for it. This is even after December 5th,
    after Mr. Cornelius reporting this, I specifically stood up,
    and he was standing behind me in Tribal Council chambers, and I
    said, Okay, for the record, does this mean everything will get
    paid for while we're on this diversion status, and I mean
    everything? If they can't be fixed in Rosebud, no matter where
    you're sent, it's going to be paid for? And he said, Yes.
        So now we're running into purchase referred care dollars
    that aren't there. So what does that mean? And this elder
    gentleman just said, I don't want you kids to be riddled with a
    flight bill if I die anyway, so I'm not going to go. So I just
    said, Go, we'll take care of it. We'll take care of it. So
    those kind of issues.
        We have people that--even Chairman Flying Hawk, the other
    day at a chairman's association meeting, you know, they have a
    hard time waiting until the community hospital or clinic opens
    up so they get referred just across town because it's not going
    to get paid for there either. So there's a lot of issues. Even
    these people know about it, and it's disheartening to them to
    get their health care or even think about it.
        Congresswoman Noem. Thank you. Well, I appreciate that
    Senator Thune's bill, he has some more whistle blower
    protections, and I just I want everyone to know, and I want you
    to know that we're obviously aware that there are people scared
    of retaliation. And I want your commitment that we won't see
    that while we're going through this emergency situation. People
    are willing to tell the truth about what's really going on in
    facilities.
        Dr. Wakefield. Congresswoman, this is critically important.
    We cannot surface problems----
        Congresswoman Noem. Right.
        Dr. Wakefield. Right, if people are uncomfortable with
    flagging those problems for us. We cannot solve those problems
    if people don't identify them so that we can begin to work to
    address them. Under Mary Smith's leadership we are committed
    wholly to a culture that is designed to improve transparency
    with the expectation that people are supported in bringing
    their concerns, problems, challenges forward. Whistle blower
    protection isn't an option, it's an obligation.
        Congresswoman Noem. Thank you.
        Dr. Wakefield. It is critically important to control--
    [Applause.] we're totally supportive of that, and, in fact, I
    would just say that HHS and IHS have recently wrote to Office
    of Inspector General on facets of this very issue. Through Mary
    Smith's leadership, she recently released a memo to all staff
    of IHS, not just the supervisors, but the employees, as well,
    basically letting them know it's not an option, it's an
    obligation that if you see examples of waste, fraud, abuse, we
    expect you to report them and to feel comfortable to report
    them to the IG.
        Congresswoman Noem. Thank you.
        Dr. Wakefield. And we provide them the information about
    who called and----
        Congresswoman Noem. Could you quickly tell me why AB
    Staffing, which was considered for the contract, when their
    employees were previously a part of the problems that were
    ongoing in these facilities, why were they----
        [Applause.]
        Dr. Wakefield. So what I can tell you, first of all, is
    that obviously Emergency Department Services are critically
    important and----
        Congresswoman Noem. But some of the same employees are even
    in the positions, and that's what I really don't really
    understand is that if you continue working with a company that
    has failed us in the past and you put them on an even playing
    field with other contracting firms and allowed them to have a
    position to come in and bid for these contracts--my legislation
    deals in changing the contracting process, which I think needs
    to happen. I think we've discussed long-term contracts with
    local providers that understand the challenges of servicing
    health care and serving people in rural America, and especially
    in rural South Dakota. I'd much rather see Avera, Sanford,
    Rapid City Regional Health in these hospitals than AB Staffing
    solutions.
        [Applause.]
        So I just want to question why there is not a red flag at
    any point with you when somebody fails and has a problem that
    we don't kick them out of the pool of people who can bid for
    contracts?
        Dr. Wakefield. First of all, with regard to ED, you did
    flag for us, you and I had that conversation and you directed--
    --
        Congresswoman Noem. But I didn't really get an answer on
    what happens, I mean, when people fail --
        Dr. Wakefield. You flagged for me the importance of
    engaging and ensuring that local, regional facilities have an
    opportunity to bid on contracts, and certainly that was the
    case with the ED contract. Part of the challenge was the lack
    of familiarity that that opportunity was even available, I
    think, was part of the issue here, and so what you saw
    certainly with the telemedicine contract was additional efforts
    to share the information about the availability of that bidding
    process.
        Having said that, the federal procurement process that we
    are required to follow was followed in the awarding of that
    contract, so I can tell you that, because I went back to ensure
    that that process was followed.
        With regard to the specifics of that contract, I would ask
    Mary to speak to that. But I can tell you on the front end that
    the expectations around the awarding of contracts, those
    policies and procedures were followed. That, I can assure you
    of.
        Congresswoman Noem. I'll just close with this, that I also
    understand that IHS relies on a Norwegian accrediting body, DNV
    GL, to maintain your accreditation at some of these hospitals
    throughout the region and it includes Pine Ridge, Rosebud, and
    Sioux San, and I know many of the witnesses here today
    reference CMS for finding problems and I think they deserve to
    know why their accrediting body has clearly failed in the past.
        Has IHS, CMS, HHS, and you can respond--I know I'm out of
    time--you can respond to me later about this, but I want to
    know if you had conversations with DNV GL regarding the
    accreditation issues at these Great Plains hospitals, because I
    want to know whether they visited these facilities or did they
    come ever to these facilities and do a proper accreditation
    program, and will IHS's contract with DNV GL, will it expire,
    and will you renew it, because they've obviously failed, and I
    need to know if you'll consider changing to something like a
    joint commission on these accreditation processes. But I'll
    leave it at that. Thank you.
        The Chairman. Thank you. In addition to our follow-up
    questions, the tribes have asked for a copy of the contract.
    And can we get it from you, a copy of the contracts?
        Ms. Stabler. We were told we had to follow them. We think
    we should have a copy though.
        The Chairman. We all think we should have a copy.
        Dr. Wakefield. Mr. Chairman, yes. Yes is the answer to
    that. There is a process with which we can make the contract
    available, yes. Yes, there is a way to get.
        The Chairman. But will we be able to use that process to
    actually successfully get a copy of it or not?
        Dr. Wakefield. Yes.
        The Chairman. Thank you.
        Senator Thune. Chairman Barrasso, one quick follow-up on
    that point. And I fully appreciate the fact, Secretary
    Wakefield, that you followed the protocols and whatever the
    bidding requirements to award that contract, but, my gosh,
    there has got to be some recognition of past performance. I
    mean, if what we hear from the tribes is true about the
    contractor, how could you contemplate reissuing a contract?
    Even if it meets the, you know, that just, to me, it's almost
    incomprehensible.
        [Applause.]
        The Chairman. Senator Rounds.
        Senator Rounds. Just to clarify the Chairman's request. The
    contracts that are there that the tribes have not been able to
    get, how long will it take for this Committee to receive those
    copies of the contracts?
        Ms. Smith. It's my understanding that the Committee has
    already received a copy of the contract, and we are happy to
    provide them to the tribes after the request is made as
    expeditiously as possible within a few days.
        Dr. Wakefield. So, bottom line, Mr. Chairman, we'll make
    those contract copies available to you. But because they are
    contracts, there is an additional step that outside groups need
    to go through. It's a requirement, but they absolutely can be
    made available, and we'll work with the individuals for
    requesting them to ensure that they know what that process is,
    and I will commit that we will expedite that process.
        The Chairman. Thank you. I appreciate that commitment.
    Members of the Committee--yes, I'm sorry, Mr. Bear Shield.
        Mr. Bear Shield. One more thing, I guess, we'd like to know
    if we're going to be a part of upcoming contracting, the
    telehealth, the positions of the sources sought, five
    positions, you know, I guess, we need to enter that for the
    record if we're going to be able to have a say-so in those, and
    those need to be immediate. I mean, because if you can have a
    mediocre provider sitting somewhere, all he has to do is push a
    button and he could be hooked up to Sioux Falls or Rapid City
    somewhere and at least get a second opinion and save lives.
        The Chairman. And that's exactly why we're here today.
    That's why we've written this piece of legislation on improving
    accountability. We want all of these things, is why we asked
    the specifics of what do we need to put in here so you get
    everything you need. That's why we've come here today. That's
    why we've had the listening sessions. We want to get all of
    that and we want to get it into the law.
        Mr. Bear Shield. And, lastly, we just heard them say
    they're committed to waste, fraud, and abuse. I guess if that's
    the case, you helped the Great Plains Tribal Chairman's
    Association and Health Board, they just passed a resolution,
    you know, for years we've been saying we don't get any
    leadership or technical assistance out of the area office. We
    want to do away with that. That money needs to come down to the
    local units and go to health care for the people, and we'll
    just deal with the headquarters. Thank you.
        The Chairman. Yes, Ms. Bohlen.
        Ms. Bohlen. Mr. Chairman, I know you're not supposed to
    speak impromptu at these kind of things, but I can't fight my
    nature. So the National Indian Health Board has believed that
    the $80 million that was used on third-party revenues to pay
    off the legal settlement that should have maybe come from the
    Department of Justice instead of the third-party billing, is
    there any way to try to get the money back?
        [Applause.]
        Could you maybe look at a process for which maybe that cost
    could be shifted to DOJ and the tribes could recapture that $80
    million?
        The Chairman. We'll certainly have to look into that.
        Ms. Bohlen. Thank you, sir.
        The Chairman. I appreciate everyone who has come out to be
    with us today. Thank you. Thank you so very much for coming,
    and yesterday, and sharing your stories. The hearing record is
    going to be open for another two weeks--we may ask you to come
    up with your input to some additional questions, we're going
    ask that you provide and get to those and so I want to thank
    all the witnesses for coming, for traveling here from so many
    different places, but I want to thank the audience as well, the
    Senators; the dedicated members of the South Dakota;
    congressional delegation, Senator Thune, Senator Rounds,
    Congresswoman Noem. Thank you so much with all of your help,
    and thank you.
        With that, this hearing is adjourned.
        [Whereupon, at 12:25m., the hearing concluded.]

                                A P P E N D I X

      Prepared Statement of Hon. Carolyn N. Lerner, Special Counsel, U.S.
                           Office of Special Counsel
        Chairman Barrasso, Ranking Member Tester, and Members of the
    Committee:
        Thank you for the opportunity to submit written testimony on behalf
    of the Office of Special Counsel (OSC). OSC protects the merit system
    for over 2 million civilian employees in the federal government, with a
    particular focus on investigating and prosecuting allegations of
    whistleblower retaliation. We appreciate the Committee's efforts to
    support whistleblowers and promote accountability within the Indian
    Health Service (IHS), and we offer the following views on S. 2953, the
    Indian Health Service Accountability Act (``the Act'').
        Section 6 of the Act establishes a new ``mandatory reporting''
    procedure for IHS employees who witness retaliation or other
    misconduct. This new mandatory reporting procedure will restrict,
    rather than expand, existing channels for whistleblower disclosures.
    Under current law, IHS employees may choose to disclose information
    directly to their chain of command, to an Inspector General, to OSC, or
    through other avenues. Employees should have the flexibility, as they
    do under current law, to determine the best avenue for making a
    disclosure. However, Section 6 would require IHS employees to disclose
    the information to an official designated by the Secretary of Health
    and Human Services (HHS). Section 6's procedure does not include rules
    on confidentiality for the designated HHS official, and does not
    clearly define the terms that trigger the automatic reporting
    requirement to HHS. As stated, since IHS employees can already disclose
    information directly to the OIG, the benefit of establishing a new
    designated official to forward employee reports to the OIG is unclear.
    Reinforcing the existing channels for reporting concerns will result in
    better protections and outcomes for IHS whistleblowers. It would be
    appropriate to require HHS or IHS to provide additional information to
    IHS employees on available options for reporting wrongdoing.
        Additionally, Section 3 of the Act establishes a new process for
    the removal of IHS employees based on performance or misconduct. We
    understand that the intent of this provision is to promote
    accountability within IHS by providing the Secretary of HHS with an
    additional, expedited process for disciplining IHS employees. We note,
    however, that the new process is modeled, without modification, on a
    similar provision adopted by Congress to discipline senior executives
    within the Department of Veterans Affairs (VA). The VA provision has
    been subject to constitutional attack in federal court. The
    constitutional challenge has significantly delayed final resolution of
    disciplinary actions taken against senior VA officials. If the goal of
    this legislation is to expedite disciplinary actions against IHS
    employees, the Committee may wish to consider modifying the provision
    to ensure the constitutionality of the process.
                                     ______

     Prepared Statement of Faith Spotted Eagle, Treaty Chairwoman, Yankton
                            Sioux/Ihanktonwan Tribe
    Introduction
        The elected Treaty Committee, the formal elected officials of the
    Business and Claims Committee; the Tribal Chairman, Robert Flying Hawk;
    and Michael Horned Eagle, Wagner Service Unit Director have all
    established a positive partnership consistent with the mission of the
    Indian Health Service to raise the physical, mental, social and
    spiritual health, of American Indians and Alaska Natives to the highest
    level possible, and in this case the Yankton Sioux Reservation in the
    Aberdeen Area Healthy Service Unit. This partnership must remind us of
    the Indian Health Service priorities which are supported by the
    foundation of treaty rights delineating delivery of health, education
    and welfare to Native nations. These agency priorities are:

       Renew and strengthen partnerships with tribes and Urban
            Indian Healthy Programs

       Improve the Indian Health Service

       Improve the quality and access to care

       Ensure that work is transparent, accountable, fair and
            inclusive

    Treaty rights and trust responsibility
        As clearly outlined in the Position statement of the National
    Congress of American Indians regarding health care; the treaties signed
    by the Native nations created the clear trust responsibility of the
    government to the individual Nations in health care on what we call
    Turtle Island, or in this case the United States, located on Indigenous
    lands.
        When the Treaty of 1858 was signed under duress by the Yankton, it
    created the current reservation; the boundaries of which have been even
    further diminished by state and county action in an attempt to
    disestablish the reservation. The descendants of these immigrant
    families have short memories, as the Yankton shared our land with them
    to an extreme. The Supreme Court declined to hear the disestalishment
    case; thus the Yankton have retained their boundaries in a close call.
    However, despite the sad history of treaties, it was clear that treaty
    signatories had future generations in mind, by essentially creating a
    form of pre-paid health care. For this promise of health, education and
    welfare the Yankton signators essentially granted almost the entire
    half of eastern South Dakota to the US and immigrants through the Dawes
    Act, the Treaty of 1858 and the 1894 Act. In later years, the Pipestone
    Quarry was also lost; although guaranteed in the 1858 Treaty.
        In the case of the Yankton/Ihanktonwan; there were three large land
    actions which almost decimated the Yankton.

       The first was the coerced Treaty of 1858, which was signed
            under duress and military captivity with the coming of Ft.
            Randall. Prior to the signing of this Treaty, the tribes domain
            was greater than 11 million. Per the 1858 Treaty, the tribe
            ceded more than 11 million acres. The Yankton retained a
            reduced amount of 430,400 acres which was further reduced by
            subsequent US government actions.

       Following the cessions of the 1894 Act, the reservations was
            reduced to 262,300 acres. The 1894 Act was designed to obtain
            more Indian land even after treaties were done away with by the
            US government.

       The Pick Sloan Act took even more land from the Yanktons and
            destroyed highly productive farmlands on the Missouri River and
            created further homelessness. Only recently has legislation
            occurred to try to correct this.

       The tribe now has a mere 37,600 acres held in trust.

        In light of the tremendous land losses and subsequent impact of
    historical trauma faced by our people through impacts of attempted
    assimilation; it is even more important that these historical
    sacrifices receive justice through quality health care for not only
    future generations but a population made vulnerable through cultural
    loss and infrastructure destruction. It is obvious that the massive
    historical trauma inflicted on the Yankton and Native nations has
    resulted in stress related diseases such as cancer, diabetes and lupus.
    Now we have the opportunity to right these human rights infringements
    and wrongs and create just health care, funded at an effective level.
    Challenges faced by the Wagner Service Unit

       Inadequate staff composition and staff to cover an extremely
            large population area: The Unit website states that the Wagner
            location provides care from 7 am--11 pm; with 6 Primary Care
            Providers and 2 PA-C's. Although it is located on the Yankton
            Sioux Reservation, it provides services to patients from
            surrounding reservations and communities throughout South
            Dakota, Iowa, Minnesota and Nebraska. Unit director Mike Horned
            Eagle, has stated to us that the largest population area that
            Wagner provides service to is Sioux Falls, SD which is two
            hours ago. He also stated that each month, the unit has 39,000
            contacts which is totally overwhelming when compared to
            funding, staff and capability. This creates added stress to a
            small system and can set up scenarios of vulnerability for an
            overloaded system.

       Need for full emergency room: In past years, Wagner had a
            full fledged emergency room, however due to Indian Health
            actions and lack of congressional funding and support, this
            ended. Currently what exists is an urgent care unit. Recently
            the writer of this testimony had a first-hand experience at the
            urgent care unit this June 2016, when a young relative was
            taken in for an impending miscarriage. It took 45 minutes for
            the doctor to arrive; it took another 50 minutes for staff to
            arrive to do bloodwork and start the analysis machines and
            another 45 minutes for the ambulance to arrive and another hour
            to transport the young mother to Sacred Heart hospital in
            Yankton, SD; not counting how much it took for intake at the
            receiving facility. The mother subsequently suffered a
            miscarriage. This is a systemic problem, not necessarily always
            a staff problem although they could be related due to low
            levels of funding.

       The Wagner Unit Diabetes Program has identified 634
            diabetics receiving care at this clinic. This is roughly 20
            percent of an on-reservation population of approximately 3000
            rounded up to the nearest thousand out of a total Yankton/
            Ihanktonwan Sioux Tribal population of 9,000 again rounded off
            at the nearest thousand according to the tribal enrollment
            office. The current staffing could be potentially detailed to
            care only for the high number of diabetics who usually have
            systemic health problems way beyond high blood sugar.

       The National Center for Health Workforce Analysis has
            identified that among rural residents, there are
            proportionately more providers in occupations that require
            fewer years of education and training than providers in
            occupations which require more years of expertise. For example
            there are EMT's and paramedics per capita residing in rural as
            opposed to urban areas, and more physicians and surgeons per
            capita residing in urban as opposed to rural areas. This is
            already a problem for rural areas such as the Yankton
            Reservation.

       The same data center has identified that prison populations
            receive better care than Indian Health service populations,
            further compromising the future of our children, elders and
            families.

       Increased Indian Health Service funding has to be a priority
            to meet the treaty rights of Native nations. In the current
            situation, priority is given to those suffering from potential
            loss of life and limb, thus compromising preventive health care
            which in the long run will save money.

       Increased use of meth amphetamines and prescriptions are
            contributing to early organ, teeth and systemic failure. This
            is a national epidemic that has special consequences for an
            already rural compromised locale that has high poverty rates.

    Strengths of the Wagner Unit

       This past spring, the Yankton Sioux Tribe is very proud of
            its partnership with Indian Health and other providers with the
            opening of a ground breaking local dialysis unit adjacent to
            the Indian Health Service Clinic. This has taken years to
            develop and funding must continue.

       The Wagner Unit has developed a competent systemic track
            record of cooperative billing via medicare/Medicaid and other
            sources. They are to be commended for maintaining but further
            funding must continue for updated software and input staff who
            are always at a shortage, thus creating staff stress.

       The Director, Mike Horned Eagle has developed a positive
            working relationship with the Ihanktonwan/Yankton leadership
            and is willing to jointly partake in the following
            recommendations and plan.

    Proposed Basic Plan for Solution Improvement at the Wagner Unit
        The answer is those who have an emic perspective on what is needed,
    or those who are intimate users of the system being examined that will
    be impacted by the Indian Health Care Improvement bill.

            1. Tribal users of the Wagner IHS Clinic are ideally situated
            to provide problem areas they experience and solutions they
            propose and these should be documented. Importantly, their
            perspective on local IHS Wagner staff members is needed because
            they can identify who is helpful and who embodies the mission
            of the IHS.
            Therefore, a focus group of 10 diverse IHS Wagner users should
            be convened to list problems/concerns. Also, to identify a list
            of 10 IHS Wagner staff they perceive as most helpful and
            dedicated to the mission.

            2. A focus group of 10 IHS Wagner staff will be convened as
            identified by the Tribal user group. They too will identify the
            top problem areas they see from the inside perspective on
            service delivery. In addition, they will identify what they
            perceive as priority solutions.

            3. A report will be completed by the IHS Wagner Facility
            Director to delineate his inside or emic perspective on
            solutions.

            4. An appropriate tribal member from Yankton should lead the
            IHS consumer group with staff support to document notes and
            generate a qualitative report , which would be determined by
            the leadership team of Mr. Horned Eagle, Treaty Committee and
            Business and Claims Committee.

            5. An appropriate outside healthcare professional should lead
            the IHS staff group along with a Yankton Tribal Member.

            6. The appropriate healthcare professional can generate the
            final report to Senator Thune and the tribe, determined by the
            tribal leadership team who will then present the findings in
            hearings to the Ihanktonwan/Yankton Sioux Tribe.

            7. All parties, with the strong support of Thune to seek
            restoration of funding for a FULL FLEDGED EMERGENCY ROOM AT THE
            WAGNER UNIT, TO PREVENT FURTHER UNTIMELY DEATHS.

            8. We will provide joint leadership from the tribe, Senator
            Thune, the Chairman, the Treaty Committee and the Business and
            Claims Committee to revisit and clearly define and explore the
            best benefits for both parties in regard to the Veteran's
            Administration and Indian Health Service and seek technical
            assistance from the Veteran's Administration for a more
            balanced relationship. At the current time, the Wagner Unit is
            giving more than receiving from the VA.

            9. Senator Thune will take actions to obtain appropriate
            funding to implement the findings. The IHS Wagner Facility
            Director will measure the outcomes and providing follow
            reporting per protocol. This is encouraged by Mr. Thune's
            statement below.

            10. Lastly, we strongly urge Senator Thune to seek INCREASED
            NEW FUNDING TO ACCOMPLISH THE PROPOSED FOLLOWING THREE ITEMS IN
            THE NEW LEGISLATION AND THAT THEY NOT BE FUNDED BY EXISTING
            LEVELS, WHICH ARE INADEQUATE FOR ALL OTHER AREAS.

         Improving protections for employees who report violations
            of patient safety requirements.

         Mandating that the secretary of HHS provide timely Indian
            Health Service spending reports to Congress; and

         Ensuring the Inspector General of HHS investigates patient
            deaths in which the Indian Health Service is alleged to be
            involved.

        ``. . .We need a willing partner at IHS who takes these issues as
    seriously as I do. As far as I'm concerned, this conversation is far
    from over.''
        A part of this conversation can be an emic viewpoint from those who
    receive healthcare services and those who deliver them. This is
    organizational wisdom from a Dakota culturally based foundation.
                                     ______

    Prepared Statement of Susan T. Grundmann, Chairman, U.S. Merit Systems
                            Protection Board (MSPB)
        Chairman Barrasso, Vice Chairman Tester, and distinguished Members
    of the United States Senate Committee on Indian Affairs. Thank you for
    the invitation to present a written statement on behalf of the United
    States Merit Systems Protection Board (MSPB) in connection with the
    Committee's June 17, 2016 hearing entitled: ``Improving Accountability
    and Quality of Care at the Indian Health Service through S. 2953.''
        As an initial matter, I would like to note that under statute, MSPB
    is prohibited from providing advisory opinions on any hypothetical or
    future personnel action within the executive branch of the federal
    government. 5 U.S.C.  1204(h) (``The Board shall not issue advisory
    opinions.''). Accordingly, this statement should not be construed as an
    indication of how I, any other presidentially appointed, Senate-
    confirmed Member of the Merit Systems Protection Board (``Board''), or
    an MSPB administrative judge would rule in any pending or future matter
    before the agency. Moreover, during my time as Chairman, MSPB has not
    taken policy positions on legislation pending before Congress.
    Generally, I view MSPB's role in the federal civil service as an
    independent adjudicator of appeals in accordance with legislation
    passed by Congress and signed into law by the president. Accordingly, I
    would respectfully request that the Committee consider the substance of
    my statement to be technical in nature.
    MSPB's Adjudication Function
        MSPB's views on S. 2953--the Indian Health Service Accountability
    Act of 2016, or the ``IHS Accountability Act of 2016''--derive from its
    statutory responsibility to adjudicate appeals filed by federal
    employees in connection with certain adverse employment actions.
    Generally, after a federal agency imposes an adverse personnel action
    upon a federal employee, such as removal or demotion, and the federal
    employee chooses to exercise his or her statutory right to file an
    appeal with MSPB, MSPB will begin the adjudication process. In the case
    of a federal employee who is removed from his or her position, that
    individual is no longer employed by the federal government, and is not
    receiving pay at the time he or she files an appeal with MSPB or at any
    point during the subsequent MSPB adjudication process.
        Once an appeal is filed, an MSPB administrative judge \1\ in one of
    MSPB's regional or field offices will first determine whether MSPB has
    jurisdiction to adjudicate the appeal. If MSPB has jurisdiction, the
    administrative judge may conduct a hearing on the merits and then issue
    an initial decision addressing the federal agency's case and the
    appellant's defenses and claims. Thereafter, either the appellant or
    the named federal agency may file a petition for review of the MSPB
    administrative judge's initial decision to the three-Member Board. The
    Board Members constitute an administrative appellate body that reviews
    the administrative judge's decision and issues a final decision of the
    MSPB. Both the Board Members and MSPB administrative judges adjudicate
    appeals in accordance with statutory law, federal regulations,
    precedent from United States federal courts, including the Supreme
    Court of the United States and the United States Court of Appeals for
    the Federal Circuit, and MSPB precedent.
    ---------------------------------------------------------------------------
        \1\ MSPB administrative judges are federal employees under the
    General Schedule System employed by MSPB. They are not ``administrative
    law judges'' appointed under 5 U.S.C.  3105 nor federal judges.
    ---------------------------------------------------------------------------
    Requirements of S. 2953
        S. 2953 contains language that is virtually identical to Section
    707 of the Veterans Access, Choice, and Accountability Act of 2014
    (``the 2014 Act''), which was enacted into law and became effective in
    August 2014. (Public Law No. 113-146). In pertinent part, S. 2953 would
    allow the Secretary of Health and Human Services (``Secretary''),
    acting through the Director of Service, to remove, demote, or transfer
    employees, including Senior Executive Service (``SES'') employees, of
    the Indian Health Service (``Service'') if the Secretary determines the
    performance or misconduct of the employee warrants such a personnel
    action. Specifically, S. 2953 would allow the Secretary to take the
    following personnel actions:

       Remove the employee from the civil service altogether;

       Regarding SES employees, transfer the employee from the SES
            to a position in the General Schedule at any grade of the
            General Schedule for which the employee is qualified and that
            the Secretary determines is appropriate; and

       Regarding managers and supervisors, reduce the grade of
            these employees to any other grade for which the employee is
            qualified and the Secretary determines is appropriate.

        With respect to the above-referenced personnel actions, S. 2953
    provides that ``the procedures under chapters 43 and 75 of title 5,
    United States Code, shall not apply.'' \2\ Instead, S. 2953 provides
    that ``before an employee may be subject to a personnel action. he or
    she must be provided with: (1) written notice of the proposed personnel
    action not less than 10 days before the personnel action is taken; and
    (2) an ``opportunity and reasonable time'' to answer orally or in
    writing. Finally, with respect to SES employees who are transferred to
    a General Schedule position and managers/supervisors whose grades have
    been reduced, S. 2953 provides that they may not be placed on
    administrative leave or ``any other category of paid leave'' \3\ during
    the period during which an MSPB appeal is ongoing.
    ---------------------------------------------------------------------------
        \2\ Under 5 U.S.C.  7513(b)(1)-(4) and (d), a federal employee
    against whom certain adverse actions are proposed is generally entitled
    to: 1) at least 30 days advance written notice stating the specific
    reasons for the federal agency's proposed action; 2) not less than 7
    days to respond to the proposed adverse action; 3) be represented by an
    attorney or other representative before the federal agency; 4) a
    written decision and the specific reasons therefor by the federal
    agency; and 5) file an appeal to MSPB under 5 U.S.C.  7701. Under 5
    U.S.C.  4303(b)(1), a federal employee who is subject to removal or a
    reduction in grade for unacceptable performance is generally entitled
    to: 1) at least 30 days advance written notice of the federal agency's
    proposed action identifying certain information; 2) be represented by
    an attorney or other representative before the federal agency; 3) a
    reasonable time to answer orally and in writing to the proposed adverse
    action; 4) a written decision by the federal agency specifying the
    instances of unacceptable performance which has been concurred in by an
    employee who is in a higher position that proposes the removal or
    reduction in grade; and 5) appeal to MSPB under 5 U.S.C.  7701.
    Moreover, under 5 U.S.C.  4302(b)(5), before a federal agency can take
    a personnel action based on performance, the employee whose performance
    is in question shall be provided an opportunity to improve his or her
    unacceptable performance.
        \3\ This provision appears to prohibit a federal employee from
    using any accrued annual or sick leave if he or she chooses exercise
    his or her right to appeal the adverse action of a transfer or
    demotion. Unlike employees who are removed from the civil service,
    employees who are transferred and/or demoted remain federal employees
    during the pendency of an MSPB appeal. Thus, this provision would
    appear to prohibit a federal employee from using leave which he or she
    has earned and--in most circumstances--is entitled to use, while
    employed. It is also possible that this provision could have a chilling
    effect on employees who seek to file MSPB appeals, per their statutory
    rights.
    ---------------------------------------------------------------------------
    Expedited MSPB Appeal Rights Under S. 2953
        Employees who are either removed or demoted by the Secretary may
    appeal that personnel action to MSPB ``under section 7701 of title 5.''
    Any appeal must be filed with MSPB ``not later than seven days after
    the date of the personnel action'' \4\ and the MSPB will be required to
    refer the appeal to an ``administrative law judge'' \5\ for
    adjudication. An administrative law judge would be required to issue a
    decision ``not later than 21 days after the date of the appeal,'' and
    that decision ``shall be final'' and not subject to further review,
    either by the Board or a United States federal court. In the event that
    an administrative law judge does not issue a final decision within 21
    days, the decision of the Secretary to remove or demote the employee
    becomes final and the employee has no further right to appeal.
    ---------------------------------------------------------------------------
        \4\ Generally, under current law, an appeal must be filed at MSPB
    no later than 30 days after the effective date, if any, of the action
    being appealed, or 30 days after the date of the appellant's receipt of
    the agency's decision, whichever is later. 5 C.F.R.  1201.22(b).
        \5\ MSPB does not directly employ any administrative law judges,
    but can retain the services of administrative law judges via service
    contracts with other federal agencies. Thus, if S. 2953 were to become
    law, and MSPB were required to retain the services of administrative
    law judges to adjudicate appeals covered by this legislation--instead
    of using MSPB administrative judges--MSPB would likely incur
    significant operating costs. Moreover, MSPB has no supervisory
    authority over administrative law judges and could not ensure that they
    issue final decisions within 21 days. MSPB recommends amending S. 2953
    to address this matter.
    ---------------------------------------------------------------------------
    Possible Constitutional Defects of S. 2953
        In May 2015, MSPB released a study \6\ entitled: What is Due
    Process in Federal Civil Service Employment? The report provides an
    overview of current civil service laws for adverse actions and, perhaps
    more importantly, the history and considerations behind the formation
    of those laws. It also explains why, according to the Supreme Court of
    the United States, the Constitution requires that any system which
    provides that a public employee may only be removed for specified
    causes must also include an opportunity for the employee--prior to his
    or her termination--to be made aware of the charges the employer will
    make, present a defense to those charges, and appeal the removal
    decision to an impartial adjudicator. We encourage Members of the
    Committee and their staff who have interest in these issues to read
    this report. \7\
    ---------------------------------------------------------------------------
        \6\ In addition to adjudicating appeals filed by federal employees,
    MSPB is required under statute to: Conduct, from time to time, special
    studies relating to the civil service and to the other merit systems in
    the executive branch, and report to the President and to Congress as to
    whether the public interest in a civil service free of prohibited
    personnel practices is being adequately protected. 5 U.S.C.
    1204(a)(3).
        \7\ This report can be found at: http://www.mspb.gov/netsearch/
    viewdocs.aspx?docnumber=1166935&version=1171499&application=ACROBAT
    ---------------------------------------------------------------------------
        In the landmark decision of Cleveland Board of Education v.
    Loudermill, 470 U.S. 532 (1985) the Supreme Court held that while
    Congress (through statutes) or the president (through executive orders)
    may decide whether to grant protections to employees, they lack the
    authority to decide whether they will grant due process rights once
    those protections are granted. Stated differently, when Congress
    establishes the circumstances under which employees may be removed from
    positions (such as for misconduct or malfeasance), employees have a
    property interest in those positions. Loudermill, 470 U.S. at 538-39.
    \8\ Specifically, the Loudermill Court stated:
    ---------------------------------------------------------------------------
        \8\ The Loudermill case involved a state employee, not a federal
    employee. Nevertheless, while the Federal Government is covered by the
    Fifth Amendment and the states by the Fourteenth Amendment, the effect
    is the same. See Lachance v. Erickson, 522 U.S. 262, 266 (1998); Stone
    v. Federal Deposit Insurance Corp., 179 F.3d 1368, 1375-76 (Fed. Cir.
    1999).

             Property cannot be defined by the procedures provided for its
            deprivation any more than can life or liberty. The right to due
            process is conferred, not by legislative grace, but by
            constitutional guarantee. While the legislature may elect not
            to confer a property interest in public employment, it may not
            constitutionally authorize the deprivation of such an interest,
    ---------------------------------------------------------------------------
            once conferred, without the appropriate procedural safeguards.

            Id. at 541.

        The Court explained that the ``root requirement'' of the Due
    Process Clause is that ``an individual be given an opportunity for a
    hearing before he is deprived of any significant property interest,''
    and that ``this principle requires some kind of a hearing prior to the
    discharge of an employee who has a constitutionally protected property
    interest in his employment.'' Id. at 542.
        According to the Court, one reason for this due process right is
    the possibility that ``[e]ven where the facts are clear, the
    appropriateness or necessity of the discharge may not be; in such
    cases, the only meaningful opportunity to invoke the discretion of the
    decisionmaker is likely to be before the termination takes effect.''
    Id. at 542. The Court further held that ``the right to a hearing does
    not depend on a demonstration of certain success.'' Id. at 544.
        I further note that the requirements of the Constitution have
    shaped the rules under which federal agencies may take adverse actions
    against federal employees, as explained by the Supreme Court, U.S.
    Courts of Appeal, and U.S. District Courts. Accordingly, should
    Congress consider modifications to these rules, many of which have been
    in place for more than one hundred years, MSPB respectfully submits
    that the discussion be an informed one, and that all Constitutional
    requirements be considered.
        As stated above, S. 2953 provides ten days' notice to an employee
    prior to a personnel action, a ``reasonable time'' to respond, and the
    right to an expedited appeal at MSPB. Whether these rights--taken as a
    whole--satisfy constitutional due process requirements would depend on
    the various factors and the circumstances of a given appeal, and it
    would be inappropriate for me to address that issue here. I note,
    however, that the constitutionality of Section 707 of the 2014 Veterans
    Access, Choice, and Accountability Act is currently the subject of
    litigation at the United States Court of Appeals for the Federal
    Circuit. Helman v. Dep't. of Veterans Affairs, Case No. 15-3086 (Fed.
    Cir. 2015). The plaintiff in that litigation is alleging that Section
    707 is unconstitutional primarily on two grounds:

       By permitting the Department to remove a tenured federal
            employee without any pre-removal notice or an opportunity to
            respond, and by severely limiting post-removal appeal rights,
            Section 707 violates an employee's right to constitutional due
            process as articulated by the Supreme Court; and

       By removing the Board from the MSPB appellate review process
            and permitting MSPB administrative judges to make a final
            decision binding an executive branch agency which is not
            reviewable by a presidential appointee, Section 707 violates
            the Appointments Clause contained in Article II, Section 2 of
            the United States Constitution.

        Significantly, on June 1, 2016, the United States Department of
    Justice filed a brief with the Federal Circuit in Helman stating that
    it was declining to defend the constitutionality of the provision of
    Section 707 that removed the Board members from the MSPB adjudication
    process and permitted MSPB administrative judges to have final
    decisionmaking authority in appeals on behalf of the MSPB. According to
    the Department of Justice, the ``final authority to interpret and apply
    the civil service laws of the United States'' must remain in the hands
    of officials properly appointed under the Appointments Clause of
    Article II of the Constitution. It noted that MSPB administrative
    judges are ``regular government employees'' who--under the 2014 Act--
    are provided ``the significant authority'' that is properly exercised
    by the presidentially-appointed, Senate-confirmed ``members of the
    Merit Systems Protection Board.'' Consequently, the Department of
    Justice moved the Federal Circuit to declare that provision of law
    invalid and remand Ms. Helman's appeal back to MSPB for further
    proceedings. On June 17, 2016, the Department of Veterans Affairs
    announced that it would no longer use the personnel authority provided
    by the 2014 Act as a result of the Department of Justice's
    determination that the above-referenced provision of the Act was
    unconstitutional.
        Finally, I note that the provision of S. 2953 that states that the
    Secretary's decision with respect to the personnel action in question
    becomes ``final'' in the event that an administrative law judge does
    not issue a decision within 21 days may very well be on weak
    constitutional footing. This provision could be interpreted to suggest
    that a federal employee--who unquestionably possesses a federal
    property interest in his or her federal employment -loses his or her
    right to due process if the MSPB (a government actor) fails to hold a
    hearing and issue a final decision within 21 days.
        In Logan v. Zimmerman Brush Co., 455 U.S. 422 (1982), the Supreme
    Court noted that ``the Due Process Clause grants the aggrieved party
    the opportunity to present his case and have its merits fairly judged.
    Thus it has become a truism that `some form of hearing' is required
    before the owner is finally deprived of a protected property
    interest.'' Id. at 433, citing Board of Regents v. Roth, 408 U.S. 564,
    570-571, n.8. The Logan Court considered whether Mr. Logan lost his due
    process right to a hearing and final decision on his claims because the
    State of Illinois failed--through its own fault--to comply with a 120
    day procedural requirement required under Illinois statute. It held
    that he did not.
        The Court emphasized that the Fourteenth Amendment requires ``an
    opportunity. . . .granted at meaningful time and in a meaningful
    manner. . . .for a hearing appropriate to the nature of the case.'' Id.
    at 437 (internal citations omitted) (emphasis added). Thus, under
    Logan, an individual who possesses a federal property interest in his
    or her federal employment must be provided a meaningful hearing prior
    to that deprivation of that property, and the failure of a government
    actor to comply with certain procedural requirements--such as a time
    requirement in connection with a hearing--likely does not eliminate
    that individual's constitutional rights. In light of Logan, I urge the
    Committee to consider whether any time limit with respect to the
    issuance of a final MSPB decision is proper.
    Permitting Appeals to MSPB ``Under 5 U.S.C.  7701"
        Similar to the 2014 Act, S. 2953 would permit covered employees to
    appeal to MSPB ``under 5 U.S.C.  7701.'' Section 7701 of title 5,
    United States Code, provides in pertinent part that ``the decision of
    an agency shall be sustained. . . only if the agency's decision. . . is
    supported by a preponderance of the evidence.'' 5 U.S.C.
    7701(c)(1)(B). The term ``preponderance of the evidence'' is defined as
    ``the degree of relevant evidence that a reasonable person, considering
    the record as a whole, would accept as sufficient to find that a
    contested fact is more likely to be true than untrue.'' 5 C.F.R.
    1201.4(q).
        Additionally, 5 U.S.C.  7701(c)(2)(B) provides that ``an agency's
    decision may not be sustained. . .if the employee or applicant for
    employment shows that the decision was based on any prohibited
    personnel practice described in section 2302(b) [of title 5, United
    States Code].'' Among the ``prohibited personnel practices'' described
    in section 2302(b) are illegal discrimination, 5 U.S.C.
    2302(b)(1)(A)-(E), coercion of political activity or reprisal for
    refusal to engage in political activity, 5 U.S.C.  2302(b)(3), and
    reprisal for lawful ``whistleblowing,'' 5 U.S.C.  2302(b)(8). Thus, if
    such issues are raised by appellants as defenses in appeals filed
    pursuant to the language contained in S. 2953, MSPB administrative
    judges will be required under law to consider those defenses--which
    often are fact intensive and complicated--prior to issuing a final
    decision within 21 days.
        This concludes my written statement. I am happy to address any
    questions for the record that Members of the Committee may have.
                                     ______

    Prepared Statement of Max Stier, President/CEO, Partnership for Public
                                    Service
        Chairman Barrasso, Vice Chairman Tester, Members of the Senate
    Committee on Indian Affairs, thank you for the opportunity to provide a
    statement for the record on S. 2953, the Indian Health Service
    Accountability Act of 2016.
        I am Max Stier, President and CEO of the Partnership for Public
    Service. The Partnership is a nonpartisan, nonprofit organization
    dedicated to revitalizing our federal government by inspiring a new
    generation to enter public service and transforming the way government
    works. We believe that making our government more efficient, effective,
    and accountable begins with smart hiring practices, engaged employees
    and strong, competent leaders. Congress has entrusted the Indian Health
    Service (IHS) with making good our country's obligations to native
    peoples. If the agency is to do so, it must be able to recruit, hire
    and retain talented employees, hold those employees accountable for
    their performance, and provide them with the resources and tools to
    necessary to achieve their unique and rewarding mission of delivering
    quality health care to American Indians and Alaska Natives. In this
    statement, I will focus on the proposed legislation's accountability,
    performance and hiring provisions.
        The good news is that, as a whole, employees of the Indian Health
    Service are highly connected to the mission of the agency, as measured
    by the Partnership's, Best Places to Work in the Federal Government
    rankings. \1\ The rankings, based on data from the Federal Employee
    Viewpoint Survey (FEVS) administered by the Office of Personnel
    Management (OPM), are the most comprehensive and authoritative rating
    of employee satisfaction and commitment in the federal government. They
    consist of an ``index score'', which measures employees' satisfaction
    and commitment, and 10 ``workplace categories'' which measure
    employees' views on particular aspects of the workplace. In 2015, IHS
    scored 79.9 out of 100 in the workplace category of ``Employee Skill-
    Mission Match'', which measures the extent to which employees feel that
    the agency uses their skills and talents effectively. \2\ The category
    also assesses the level of which employees get satisfaction from their
    work and understand how their jobs are relevant to the organizational
    mission. This score was relatively high with a ranking of 57 out of 319
    ranked agency subcomponents, putting the IHS in the group's top
    quartile. According to the 2015 FEVS, IHS employees also score above
    government as a whole on specific questions including ``I like the kind
    of work I do,'' and ``My talents are well used in the workplace.''
    ---------------------------------------------------------------------------
        \1\ The Best Places to Work in the Federal Government rankings are
    produced in partnership with Deloitte Consulting.
        \2\ ``Department of Health and Human Services.'' Best Places to
    Work in the Federal Government. Accessed June 24, 2016. http://
    bestplacestowork.org/BPTW/rankings/detail/HE37.
    ---------------------------------------------------------------------------
        The Indian Health Service faces challenges as well. The agency
    scored near the bottom of all agencies in the workplace categories of
    ``Effective Leadership'', ``Teamwork'', and ``Support for Diversity.''
    \3\ The IHS ranked 301 out of 318 agency subcomponents in employee
    views of leadership, 317 out of 319 in employee views of teamwork in
    their agency and 313 out of 319 in employee views of how their agency
    promotes and respects diversity. These data are consistent with the
    findings of the Committee's 2010 report, ``In Critical Condition: The
    Urgent Need to Reform the Indian Health Service's Aberdeen Area'' as
    well as more recent investigations. \4\ Particularly troubling is how
    poorly the IHS fares in the category of ``Effective Leadership'' and
    especially the subcategory measuring employee opinions of their
    immediate supervisor, including how well supervisors give employees the
    opportunity to demonstrate leadership, support employee development,
    and provide worthwhile feedback about job performance. The
    Partnership's research has consistently found that employee views of
    leadership are the single biggest driver of satisfaction with their
    organization. The IHS ranked 315 out of 318 subcomponents with a score
    of 53.2 out of 100 in the ``Effective Leadership: Supervisors''
    subcategory. To put this in context, the highest scoring subcomponent
    in this subcategory in 2015 was the Federal Energy Regulatory
    Commission's Office of the General Counsel with a score of 86.1. \5\
    The state of leadership at the Indian Health Service should, therefore,
    continue to be a priority for this Committee. The IHS significantly
    underperforms government as a whole in positive responses to FEVS
    questions including ``Supervisors work well with employees of different
    backgrounds'', ``I have trust and confidence in my supervisor'', ``My
    supervisor treats me with respect'', and ``Employees in my work unit
    share job knowledge with each other.'' In the overall measure of
    employee satisfaction and commitment, the Indian Health Service ranked
    248 out of 320 total agency subcomponents with an index score of 54.5.
    \6\
    ---------------------------------------------------------------------------
        \3\ The workplace category of ``Effective Leadership'' measures the
    extent to which employees believe leadership at all levels of the
    organization generates motivation and commitment, encourages integrity
    and manages people fairly, while also promoting the professional
    development, creativity and empowerment of employees. ``Teamwork''
    measures the extent to which employees believe they communicate
    effectively both inside and outside their team organizations, creating
    a friendly work atmosphere and producing high-quality work products.
    The ``Support for Diversity'' category measures the extent to which
    employees believe that actions and policies of leadership and
    management promote and respect diversity.
        \4\ United States of America. United States Senate Committee on
    Indian Affairs. In Critical Condition: The Urgent Need to Reform the
    Indian Health Service's Aberdeen Area. Washington, DC: United States
    Senate Committee on Indian Affairs, 2010.
        \5\ ``Department of Health and Human Services.'' Best Places to
    Work in the Federal Government. Accessed June 24, 2016. http://
    bestplacestowork.org/BPTW/rankings/detail/HE37.
        \6\ Ibid.
    ---------------------------------------------------------------------------
        This committee is right to be troubled by the reports coming out of
    particular Indian Health Service facilities, and the Partnership shares
    your concern. It is unfortunate that the actions of a few can do so
    much to tarnish the work of the many thousands of employees who have
    dedicated their careers to serving Native communities. However, firing
    a few bad actors is not a long-term solution to systemic management
    problems; the IHS will never be able to fire its way to excellence. The
    Partnership believes that the most effective way to address the
    performance and talent challenges of the IHS and other agencies is a
    comprehensive overhaul of the civil service system, and we outlined a
    framework to achieve this goal in 2014. \7\ We understand that this
    kind of reform is outside the committee's purview. In its absence,
    there is still much you can do to hold poor performers accountable, as
    well as attract new talent, reward and recognize the best employees,
    and set them up for success without jeopardizing due process or moving
    towards an ``at-will'' system of employment that would undermine our
    non-political civil service.
    ---------------------------------------------------------------------------
        \7\ United States of America. Congressional Research Service. The
    Indian Health Service (IHS): An Overview. By Elayne J. Heisler.
    Washington, DC: Congressional Reserach Service, 2016.
    ---------------------------------------------------------------------------
    Faster Firing Is Not the Answer
        The goal of an accountable and well-equipped Indian Health Service
    workforce is an important one. As the Committee considers the Indian
    Health Service Accountability Act of 2016, we urge you to think
    carefully about whether these proposed changes to due process and
    employment rights are the best way to achieve this goal. In the
    Partnership's view, they are not the answer; in fact, the changes
    considered here may have unintended consequences that reduce protection
    for whistleblowers and diminish incentives for experienced and
    dedicated employees to join an agency already struggling to recruit the
    talent it needs. Though well intentioned, S. 2953 severely undermines
    due process protections for employees and could lead to removals for
    partisan or discriminatory reasons.
        We believe strongly that the Indian Health Service has the
    authorities needed to take corrective action, up to and including
    removing an employee from the civil service when warranted. If it is to
    tackle these problems in a sustainable and lasting way, the IHS needs
    empowered managers who are willing to take action to deal with poor
    performers and senior leadership and human resources staff willing to
    support them. The agency also needs employees who are engaged in the
    work and mission of their agency, communicate effectively, and work
    together toward common goals.
        While accomplishing these things will take time, there is much that
    the Committee can do to move the Indian Health Service in the right
    direction. For example, requiring more training on the disciplinary
    process and how to deal with poor performers would better equip
    frontline managers and supervisors to manage the performance of their
    employees and engage in difficult conversations that many now choose to
    avoid. This training should include how to motivate, engage and reward
    employees. Managers should then be held accountable for the performance
    of their employees and their efforts to keep their teams satisfied and
    engaged. The Committee should also strengthen the probationary period
    at the IHS for both frontline employees and new supervisors and
    managers. In the federal government, newly-hired employees and new
    supervisors undergo a probationary period, typically of one year, to
    evaluate the employee's conduct and performance to determine if the
    employee's appointment to the civil service should become final. \8\ In
    the IHS, as in most other federal agencies, the probationary period is
    considered a formality rather than an extension of the assessment
    process as it was originally intended to be. \9\ By requiring
    supervisors to make an affirmative decision to keep an employee past
    the employee's probationary period, you can ensure agencies are using
    this time to evaluate new employees and determine whether they have
    earned a permanent place in the workforce.
    ---------------------------------------------------------------------------
        \8\ United States of America. Merit Systems Protection Board. The
    Probationary Period: A Critical Assessment Opportunity. Washington, DC:
    Merit Systems Protection Board, 2005. i.
        \9\ Ibid ii.
    ---------------------------------------------------------------------------
        Finally, the Committee should require the Indian Health Service to
    collect and report data on disciplinary process outcomes. Significant
    changes to the law should be based on measurable data rather than on
    anecdotes and individual cases. It is critically important that in
    considering further legislative changes, the Committee takes care to
    make reforms after fully deliberating their potential impact. The
    Committee can better understand the disciplinary process at the IHS by
    requiring the agency to report on the number of disciplinary actions
    proposed, the result of those actions, the average length of the
    disciplinary process, the extent to which administrative leave is used
    in disciplinary cases, and the number of decisions overturned or
    settled. These data would allow the IHS and the Committee to understand
    better the state of the disciplinary process, process outcomes, and
    where breakdowns occur, and could inform future oversight. We would be
    pleased to provide legislative language to the Committee to this
    effect.
    Recommendations
        Beyond the ideas offered above, I include here several additional
    recommendations for improving S. 2953 as currently drafted:

       Handle Appeals at the Level of the Full Merit Systems
            Protection Board--Employees and executives slated for demotion
            or removal under the Indian Health Service Accountability Act
            of 2016 would have their appeal heard by an MSPB administrative
            law judge (ALJ). Such an appeals structure is problematic. As a
            recent decision by the U.S. Department of Justice (DOJ)
            relating to nearly identical language in Section 707 of the
            Veterans Access, Choice, and Accountability Act of 2014 found
            that vesting final decisionmaking authority in an ALJ violates
            the Constitution's Appointments Clause and is, therefore,
            invalid. \10\ Given this recent decision, we recommend amending
            the language in S. 2953 to send appeals to the full Merit
            Systems Protection Board. This change will sidestep the current
            legal challenges as well as bring to bear greater resources in
            the adjudication of IHS appeals.
    ---------------------------------------------------------------------------
        \10\ ``Helman v. Department of Veterans Affairs, No. 15-3086 (Fed.
    Cir.).'' Loretta E. Lynch to Patricia Bryan, Senate Legal Counsel. May
    31, 2016. Office of the Attorney General, Washington, DC.

       Align Accountability Provisions with Current Law--We believe
            the bill can better address concerns over fairness through
            greater alignment with existing law. First, an employee facing
            a major adverse action such as demotion and removal from the
            civil service should have 30 rather than ten days of written
            notice. This change would align the bill with current law and
            provide employees more time to prepare a meaningful response to
            the agency's action. \11\ Second, the language granting the
            Secretary authority to remove an employee from the civil
            service, if the Secretary determines that the performance or
            misconduct of the employee warrants removal, should be amended
            to state that the personnel action will promote the efficiency
            of the service. This addition will align the bill with current
            statute. \12\
    ---------------------------------------------------------------------------
        \11\ 5 U.S. Code  7513
        \12\ Ibid.

       Provide More Flexibility in the Use of Administrative
            Leave--The Act states that the agency cannot place an employee
            appealing a personnel action on administrative leave. We
            recommend changing this language to allow the agency to place
            an employee on administrative leave with the approval of the
            Director of the Indian Health Service. There may be rare
            instances when it makes sense to use administrative leave, such
            as if an employee poses a threat to themselves or other
            employees, if their presence would result in loss or damage to
            government property, or if the employee otherwise jeopardizes
            legitimate government interests. It also may be appropriate to
            remove an employee from the worksite in situations where an
            investigation is taking place and the agency does not have all
            the facts. In any case, the use of leave should be limited and
    ---------------------------------------------------------------------------
            transparent.

       Sharing of Senior Executive Personnel Files Raises Privacy
            Concerns--We are concerned that language in Section 4 of the
            proposed legislation making available a senior executive's
            employment record to tribal organizations may present privacy
            concerns. Further, the knowledge that individuals from outside
            the agency will review an executive's records may lead to a
            reduced willingness on the part of managers to put clear and
            candid information in files. We do recognize, however, the
            importance of transparency with the customers of the IHS, and
            urge the Committee to consider alternate ways to transmit and
            share information about the senior executives responsible for
            leading Area offices or Service units with tribes in a manner
            that does not compromise privacy.

       Require a Performance Plan for the Director of the Indian
            Health Service and Other Political Appointees--Career employees
            and executives undergo a performance planning and appraisal
            process every year. Political appointees should be required to
            participate in a similar process. For example, as the highest
            level of leadership in the Indian Health Service, the Director
            plays a crucial role in providing leadership and setting
            priorities. In 2015, the Indian Health Service ranked just 271
            out of 318 agency subcomponents in employee satisfaction with
            senior leaders. Appraising political leadership on and holding
            senior leaders accountable for setting expectations and
            developing an empowered and engaged workforce can improve
            satisfaction and help accountability cascade throughout the
            organization. Leaders should be rated on efforts to promote
            best practices and efforts to recruit, select and retain
            talent, engage and motivate employees, train and develop future
            leaders, and hold managers accountable for managing performance
            and dealing with poor performers.
    Hiring Reforms are a Good Start, and the Committee Should Go Further
        We are pleased to see the Committee demonstrate a strong commitment
    to addressing the Indian Health Service's long-standing workforce
    challenges. Inspiring and hiring a new generation into public service
    is a core part of the Partnership's mission; we believe agencies must
    have a more flexible and responsive hiring process that more
    effectively locates and assesses talent. For this reason, we believe
    the ideal solution is comprehensive hiring reform that places agencies
    on a level playing field with each other and, to the extent possible,
    with the private sector. Hiring improvements should be combined with
    marketbased compensation that grants agencies the flexibility to set
    salaries the way any private sector organization would. While the
    Indian Health Service is not alone in its struggles to recruit, hire
    and retain specialized talent--organizations such as the Department of
    Veterans Affairs face similar difficulties--its challenges are
    nonetheless significant and require action.
        The Indian Health Service faces two major hurdles in bringing in
    the talent it needs: recruiting medical professionals to remote
    locations and compensation below comparable private sector levels. The
    numbers paint an alarming picture of the Indian Health Service's
    success in addressing these challenges. GAO's March 2016 report, Indian
    Health Service: Actions Needed to Improve Oversight of Patient Wait
    Times, reported that according to the IHS 2016 budget justification,
    the agency had over 1,550 healthcare professional vacancies in the
    system. \13\ In testimony before this Committee in February, Robert
    McSwain, Principal Deputy Director of the Indian Health Service,
    reported that the Great Plains Area is facing a physician vacancy rate
    of 37 percent. \14\ In 2014, the system-wide vacancy rate for
    physicians and nurses was 20 percent, and 650 separate IHS facilities
    reported provider shortages. \15\ On the compensation side, the IHS
    starting salary is roughly a third of what providers can earn
    elsewhere. \16\ And while IHS offers some loan repayment and
    scholarship programs for medical professionals, they are underfunded
    and underutilized; in fiscal year 2014, over 500 applications for loan
    repayments were denied due to \17\ limited funds. \18\
    ---------------------------------------------------------------------------
        \13\ United States of America. Government Accountability Office.
    Indian Health Service: Actions Needed to Improve Oversight of Patient
    Wait Times. Washington, DC: Government Accountability Office, 2016. 21.
        \14\ ``Reexamining the Substandard Quality of Indian Health Care in
    the Great Plains'', 114th Cong., 9 (2016) (testimony of Robert McSwain,
    Principal Deputy Director, Indian Health Service).
        \15\ United States of America. Congressional Research Service. The
    Indian Health Service (IHS): An Overview. By Elayne J. Heisler.
    Washington, DC: Congressional Reserach Service, 2016.
        \16\ United States of America. Government Accountability Office.
    Indian Health Service: Actions Needed to Improve Oversight of Patient
    Wait Times. Washington, DC: Government Accountability Office, 2016. 23.
        \17\ United States of America. Government Accountability Office.
    Health Care Workforce: Federally Funded Training Programs in Fiscal
    Year 2012. Washington, DC: Government Accountability Office, 2016. 21.
        \18\ United States of America. Government Accountability Office.
    Indian Health Service: Actions Needed to Improve Oversight of Patient
    Wait Times. Washington, DC: Government Accountability Office, 2016. 23.
    ---------------------------------------------------------------------------
        The Indian Health Service faces recruitment and hiring difficulties
    by nature of the location of its facilities and compensation structure,
    but the agency's hiring process exacerbates these challenges. A 2011
    report by Merritt Hawkins found that ``paperwork/red tape'' was the
    factor having the most negative effect on clinician turnover at IHS
    facilities. \19\ The Department of Health and Human Services FY 2016
    Annual Performance Plan and Report stated that the IHS average time to
    hire was 114 days as of 2014. GAO found that at one Navajo area
    facility, the length of the hiring process averaged 190 days, with some
    hires taking as long as 738 days. \20\ These figures are well above the
    target of 80 days laid out by the administration as part of its 2010
    hiring reform effort. \21\ The most recent FEVS data shows that only
    just over a third of IHS employees believe their work unit can recruit
    people with the right skills--below the government-wide score. IHS is
    reportedly working to re-engineer its human resources, deploy new
    strategies and tools to recruit medical professionals, and better
    utilize external partners to build its workforce. \22\ These are, taken
    together, an important step in the right direction, and we encourage
    the Committee to maintain its focus on the organization's human capital
    needs.
    ---------------------------------------------------------------------------
        \19\ 2011 Clinical Staffing and Recruiting Survey. Report. Merritt
    Hawkins. Rockville, MD: Indian Health Service, 2011.
        \20\ United States of America. Government Accountability Office.
    Indian Health Service: Actions Needed to Improve Oversight of Patient
    Wait Times. Washington, DC: Government Accountability Office, 2016. 23.
        \21\ ``Human Capital Management Hiring Reform.'' U.S. Office of
    Personnel Management. Accessed June 27, 2016. https://www.opm.gov/
    policy-data-oversight/human-capital-management/hiring-reform/
    #url=Hiring.
        \22\ ``Improving Accountability and Quality of Care at the Indian
    Health Service Through S.2953'', 114th Cong., 11 (2016) (testimony of
    Mary Smith, Principal Deputy Director, Indian Health Service).
    ---------------------------------------------------------------------------
        The Indian Health Service Accountability Act of 2016 includes some
    important and meaningful reforms that we believe will have a positive
    impact on the agency's outstanding recruitment and hiring challenges.
    In particular, we applaud the Committee for authorizing direct hiring
    at the Indian Health Service and expanding market pay under Title 38 to
    IHS medical professionals. The Partnership advocated for both reforms
    in our 2014 civil service reform report. Allowing the IHS to request
    waivers for Indian Preference if the agency cannot otherwise access the
    talent it needs is also a good idea, and the Committee should consider
    offering this flexibility to other agencies, such as the Bureau of
    Indian Education, with similar recruitment and hiring difficulties. The
    additional recruitment and relocation incentives should be helpful
    tools as well.
        To further improve the bill's hiring provisions, we urge you to
    think about what more can be done. We recommend the Committee consider
    language allowing the IHS to rehire former employees noncompetitively
    at any grade for which they qualify. Currently, agencies can only
    reinstate former employees at the last grade they held or below. This
    limited reinstatement authority means that qualified medical
    professionals who have left the agency and gained valuable experience
    outside of government may not be considered for noncompetitive
    reinstatement to a higher grade. It is in the government's interest to
    allow the IHS to have this option as an additional weapon in its
    arsenal to recruit former employees who may otherwise not return to
    federal service. Finally, the IHS should work with OPM to figure out
    how the agency can utilize the Competitive Service Act of 2015, enacted
    into law earlier this year, to reach talented individuals who were
    interviewed and rated by other agencies but not hired. This law gives
    the IHS the ability to access a broad pool of vetted talent from across
    government.
    Recommendations
        In addition to the ideas offered above, we would like to make the
    following recommendations to strengthen the recruitment, hiring and
    retention provisions of S.2953:

       Expand upon GAO Report on IHS Staffing Needs--The
            Partnership supports the bill's provision requiring a GAO
            report on Indian Health Service staffing needs. Making
            wellinformed decisions about how to address IHS workforce
            challenges requires accurate and up-todate information. Towards
            this end, we believe GAO's report could be made even more
            useful. The Committee should request that the report also look
            at current legislative and regulatory barriers to more
            effective hiring at the IHS, current demographics of the
            organization's workforce, use of existing recruitment and
            retention tools and the state of workforce and succession
            planning at the agency. Specifically, does the IHS know who in
            the workforce is most likely to leave, what actions the agency
            is taking to address skills gaps and retain key talent, and
            what the agency is doing to transfer institutional knowledge?

       Use the IHS Staffing Plan as an Accountability Mechanism--
            Requiring the agency to develop a plan to address its staffing
            needs is a useful initial step. We believe the Committee can
            increase the value of this plan further. First, the IHS should
            be required to deliver the report within three to six months of
            the completion of GAO's study, rather than a full year. Given
            the need for drastic and immediate change at the IHS, a year is
            simply too long to wait. Second, the report should be recurring
            either for a set number of years or until the agency reaches a
            milestone determined by the Committee. Regular reporting on the
            recruiting, hiring and retention strategies of the IHS,
            combined with data on the agency's success in meeting the goals
            it has set for itself, will act as a meaningful measure of
            accountability both for the organization and for this
            Committee. The IHS staffing plan should also include, in
            addition to the responses to GAO's recommendations, how the IHS
            plans to work with other federal agencies and external
            organizations to improve recruitment and hiring, an evaluation
            of the agency's success in meeting hiring goals, and how the
            organization will utilize local talent sources. The IHS is
            reportedly looking at how to do these things already, and
            should integrate this information into into the staffing plan.
            \23\
    ---------------------------------------------------------------------------
        \23\ Ibid.

       Implement an Exit Survey at the IHS--One of the best ways an
            agency can inform its recruitment and retention strategies is
            to understand why employees are leaving in the first place. We
            believe a voluntary exit survey would provide the IHS with
            useful data to help it retain key talent. These data should
            then be made available to all IHS human resources staff and
            hiring managers. IHS could also be required to report survey
            data to the Committee and held accountable for taking actions
    ---------------------------------------------------------------------------
            to improve.

       Collect Data on Hiring Process Outcomes--If the Indian
            Health Service is to improve its hiring process, it must be
            able to measure outcomes and hold itself accountable for
            improvement. There are several sets of data which the
            Partnership believes are key to the IHS wrapping its arms
            around the state of its hiring process: information on the use
            of special hiring authorities and flexibilities, time-to-hire
            data disaggregated by internal and external hires, manager
            satisfaction with the quality of applicants and new hires, and
            satisfaction of applicants and new hires with the hiring
            process. The IHS should ensure that this data is being
            collected and shared consistently, and is being used to make
            meaningful process improvements. The IHS is reportedly taking
            proactive steps to ensure broad and diverse applicant pools,
            and we believe this data will greatly enhance that effort. \24\
    ---------------------------------------------------------------------------
        \24\ Ibid.

       Provide Training to Managers and Supervisors on Hiring
            Authorities and Flexibilities--The Committee should consider
            language requiring training for both human resources staff and
            hiring managers on how to use these new tools, as well as how
            to maximize current authorities and navigate Indian Preference,
            to enhance the effectiveness of its hiring process. As part of
            this, the agency should identify ways that it will educate its
            staff on how to improve recruitment and hiring practices. OPM's
            ``Hiring Excellence'' campaign is already traveling the country
            offering in-person and virtual sessions to help federal
            agencies ``foster collaboration and the strategic use of
            recruitment and hiring tools.'' \25\ However, given the unique
            nature of the Service's work and its many agency-specific
            hiring authorities, additional training and education for
            employees would be warranted. Managers should then be held
            accountable for their efforts to bring talent into the
            organization; other agencies, such as the National Protection
            and Programs Directorate within the Department of Homeland
            Security, already do this.
    ---------------------------------------------------------------------------
        \25\ ``Hiring Excellence.'' U.S. Office of Personnel Management.
    Accessed June 24, 2016. http://www.opm.gov/policy-data-oversight/
    hiring-information/hiring-excellence/.

       Better Utilize Student Interns as a Pipeline for Entry-Level
            Talent--According to data from the OPM FedScope database, just
            under seven percent of IHS employees are under the age of 30.
            \26\ Compare this to the US workforce as a whole, in which
            workers under 30 make up 23 percent of the total. \27\ The
            Pathways internship programs, created in 2010, allow agencies
            like the Indian Health Service to noncompetitively convert
            program participants to full-time federal employment from any
            federal agency as long as the individual meets the eligibility
            requirements for conversion. Given this authority, we recommend
            that the IHS work with the Department of Health and Human
            Resources and other agencies to create lists or platforms that
            allow it to access this talent pool. The Committee should also
            codify Pathways conversion authority for third-party and unpaid
            interns in undergraduate and graduate programs at the IHS. As
            of now, interns hired to work in government agencies through
            third-parties like the Washington Internships for Native
            Students Summer program hosted by American University can only
            credit half their hours towards conversion to a full-time
            position, despite the fact that they are performing
            substantially the same work; unpaid interns receive no credit
            at all towards conversion. The Committee should also look at
            expanding AmeriCorps noncompetitive hiring eligibility to
            encourage former AmeriCorps members to join IHS. Each of these
            reforms would expand the pipeline of proven entry-level talent
            entering the IHS and are especially critical given the overall
            lack of young talent at the agency.
    ---------------------------------------------------------------------------
        \26\ ``U.S. Office of Personnel Management--Ensuring the Federal
    Government Has an Effective Civilian Workforce.'' FedScope Home Page.
    Accessed June 24, 2016. https://www.fedscope.opm.gov/.
        \27\ Rein, Lisa. ``Millennials Exit the Federal Workforce as
    Government Jobs Lose Their Allure.'' The Washington Post. 16 Dec. 2014.
    Web. 2016.
    ---------------------------------------------------------------------------
        Chairman Barrasso, Vice Chairman Tester, Members of the Committee,
    thank you for providing me the opportunity to share the views of the
    Partnership for Public Service on this important piece of legislation.
    I look forward to further engagement with this Committee on how to
    strengthen the workforce of the Indian Health Service.
                                     ______

     Prepared Statement of Hon. John Yellow Bird Steele, President, Oglala
                                  Sioux Tribe

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

     Prepared Statement of the United South and Eastern Tribes Sovereignty
                                Protection Fund
        The United South and Eastern Tribes Sovereignty Protection Fund
    (USET SPF) is pleased to provide the Senate Committee on Indian Affairs
    (SCIA) with the following testimony for the record of its June 16,
    2016, field hearing on, ``Improving Accountability and Quality of Care
    at the Indian Health Service through S. 2953.'' USET SPF acknowledges
    the long standing and systemic challenges faced in the Great Plains
    Area and throughout the Indian Health System. We appreciate the
    Committee's commitment to addressing issues in the Great Plains Area
    and throughout the IHS with the introduction of S. 2953, and offer
    section by section recommendations to further strengthen the provisions
    of the bill. USET SPF maintains, however, that until Congress fully
    funds the Indian Health Service (IHS), the Indian Health System will
    never be able to fully overcome its challenges. While USET SPF supports
    the intent of S. 2953, The Indian Health Service Accountability Act of
    2016, we reiterate the obligation of Congress to meet its trust
    responsibility by providing full funding to IHS and support additional
    innovative legislative solutions to improve the Indian Health System.
        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 Indian Health Service, 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 SPF member Tribal Nations 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).
    ---------------------------------------------------------------------------
    Uphold the Federal Trust Responsibility to Tribal Nations
        We again remind SCIA that through the permanent reauthorization of
    the Indian Health Care Improvement Act, ``Congress declare[d] that it
    is the policy of this Nation, in fulfillment of its special trust
    responsibilities and legal obligations to Indians to ensure the highest
    possible health status for Indians and urban Indians and to provide all
    resources necessary to effect that policy.'' As long as IHS is so
    dramatically underfunded, the root causes of the failures in the Great
    Plains will not be addressed, and Congress will not live up to its own
    stated policy and responsibilities. USET SPF urges this Committee to
    consider carefully the level of funding it will support for IHS and its
    impact on the Agency's ability to provide quality care as it considers
    S. 2953. Further, we recommend the inclusion of language directing the
    IHS to request a budget that is reflective of its full demonstrated
    financial need, as this is the only way to determine the amount of
    resources required to deliver comprehensive and quality care. USET SPF
    remains 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.
    Need for Tribal Consultation
        We agree with members of the Committee and with Tribal witnesses
    calling for increased transparency and accountability within the IHS.
    We are very concerned that conditions in the Great Plains area have
    resulted in severe gaps in access to care for American Indian/Alaska
    Native (AI/AN) patients. These gaps in access will only continue to
    widen the disparity in health status between AI/AN and the general U.S.
    population if not addressed. While we seek comprehensive solutions to
    the complex and multifaceted issues within the Indian Health System, we
    seek the empowerment of Tribal Nations in decisions regarding health
    care. We request that additional language be inserted into S.2953
    requiring Tribal consultation on all provisions of the law, as it is
    implemented. On-going, meaningful Tribal consultation is essential to
    mitigating current challenges, preventing future crises, and increasing
    the health status of AI/AN.
    Implement Advance Appropriations for the IHS
        In order to address the challenges facing health care delivery in
    Indian Country, SCIA should work to ensure funding is received on time
    by authorizing advance appropriations for IHS.
        On top of chronic underfunding, IHS and Tribal Nations 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. 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 challenges in providing adequate salaries and hiring of
    qualified professionals.
        As this Committee seeks to improve IHS' ability to attract and
    retain quality employees, USET SPF urges the inclusions of language
    that would extend advance appropriations to the IHS.
    Addressing Health Professional Shortages in the Indian Health System
        One of the major ways that the IHS and Tribal Nations seek to
    combat persistent provider shortages is through the IHS Scholarship
    Program and Loan Repayment Program (LRP). Although these programs have
    helped to increase the amount of provider placements in the Indian
    Health System, they are significantly limited by the level of funding
    available to make awards and by the treatment of these awards under the
    Internal Revenue Service Tax Code. In FY 2015, a total of 1,211 health
    professionals including physicians and behavioral health providers
    received IHS loan repayment. During the same fiscal year, the LRP was
    unable to provide loan repayment funding to 613 health professionals
    who applied for funding, of which only 200 still accepted employment at
    an IHS or Tribally Operated Health facility. IHS estimates that it
    would need an additional $30.39 million to fund all the health
    professional applicants from that year.
        Additionally, payments to Indian health care providers through the
    LRP and IHS Scholarship are currently considered taxable income under
    the Internal Revenue Service (IRS) Tax Code for awardees. However, an
    exemption exists for benefits paid to providers under similar programs
    like the Armed Forces Health Professions Scholarships and loan
    repayment under the National Health Service Corps. S.2953, as written,
    does not address this discrepancy. We request that language be included
    in the S.2953 to create parity for IHS with other federal health
    professions incentive programs and provide IHS with the greatest amount
    of tools to recruit quality providers.
        Finally, we request that additional funding be made available to
    assist in the recruitment AI/AN health professionals from within local
    Tribal communities. We believe that the best way to care for our
    citizens is to ensure that health professionals are deeply connected to
    the communities they serve. In order to promote pathways to increase
    AI/ANs entering health professions, we request additional funding,
    beyond the IHS' Budget Request, be made available for the American
    Indians into Nursing Program, Indians into Medicine (INMED) program and
    American Indians into Psychology Program.
    Section-by-Section Comments
        In addition to urging the inclusion of the above proposals, USET
    SPF provides several recommendations to strengthen the existing
    provisions of S.2953. If implemented together, we believe that the IHS
    and Tribal Nations can begin to make gains in the quality of care
    delivered through the Indian Health System and improve AI/AN patient
    outcomes.
    Sec. 3. Removal of Indian Health Service Employees Based on Performance
            or Misconduct
        We support strengthening the Secretary's authority to remove or
    demote IHS employees based on performance or misconduct. We also
    support the ``Employment Record Transparency'' language which will
    ensure that prior employee personnel actions are adequately notated and
    considered in future hiring processes. However, in addition to
    Congressional leadership, Tribal Leadership must also be notified when
    employees within their Service Area become subject to a personnel
    action. In Section 3 under Sec. 603(d), we recommend inserting ``Tribal
    Governments located in the affected service area''. Increasing
    transparency and access to information for Tribal Nations will be
    essential to rebuilding the confidence and trust in the IHS.
    Sec. 4. Improvements in Hiring Practices
        We recommend adding additional language to the ``Notice of Removal
    Based on Performance or Misconduct'' in Section 4 which would broaden
    access to records, available to Tribal Governments upon request, to
    include all clinical IHS employees. As the draft is currently written,
    access to personnel records is limited to Senior Executive, manager and
    supervisor level positions. Increasing transparency and access to
    records including clinical positions will allow Tribal Nations to have
    greater knowledge about and confidence in the clinicians delivering
    care to their citizens.
    Sec. 5 Incentives for Recruitment and Retention
        While USET SPF agrees that addressing the provider shortages across
    Indian Country requires innovative solutions and incentives, the IHS is
    not equipped to implement these initiatives without additional
    appropriations. With IHS funded at 59 percent of demonstrated need, any
    mandate to provide housing vouchers, relocation costs, or increase pay
    scales must be funded using patient care dollars. While the attraction
    of qualified staff is critically important, it must not be done by
    diverting precious resources from health care services. For this
    reason, we request that S. 2953 include additional funding to support
    these incentives without impacting patient care.
    Sec. 10. Transparency and Accountability for Patient Safety
        USET SPF has concerns regarding the lack of specificity in Section
    10, as well as its feasibility. Although we support transparency and
    accountability in patient care, we believe that requiring an
    investigation of all patient deaths, ``in which the Service is alleged
    to be involved by act or omission,'' is unnecessary and will merely
    result in an investigations backlog. Due to the risks inherent to the
    delivery of medical care, patient death is a sad reality for all
    medical systems, with many patient deaths occurring through no fault of
    the provider or facility. We urge SCIA to consider narrowing the
    language of Section 10 to require an investigation only into deaths
    where there is an allegation of negligence or malpractice on the part
    of the IHS. In addition, we seek additional Tribal consultation on this
    section, in particular, to assist in providing further clarity on the
    criteria for investigation.
    Conclusion
        USET SPF appreciates SCIA's efforts to seek solutions to the long-
    standing challenges within the Indian Health System. However, we note
    the initiatives proposed in S. 2953 do not address the root cause of
    these issues: the chronic underfunding of the IHS. Only when Congress
    acts to uphold the federal trust responsibility by providing full
    funding and parity for the Agency will the Indian Health System be
    equipped to provide an adequate level of care to AI/AN people.
    Nonetheless, with some targeted changes, we believe that S. 2953 could
    be an important step in this direction. We appreciate the opportunity
    to provide comments on this bill and look forward to an ongoing
    dialogue to address the complex challenges of health care delivery in
    Indian Country.
                                     ______

                 Prepared Statement of the Yankton Sioux Tribe

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                                           June 5, 2016
    To whom it may concern/Health Committee:

        I had a stroke in fall of 2011 while at work at the IHS hospital,
    and immediately walked over to the emergency room department. I was
    immediately assessed by a CNA named Jody and in a room when, one of the
    nurses by the name of Tess Conroy told the nurse to move me. CNA Jody
    told nurse Conroy that I was having stroke like symptoms and nurse
    Conroy got mad at her. All this happened in front of patients. I was
    walked over to the nurses' station and sat in the doctor's office.
    There wasn't any equipment in there to help me if I needed any kind of
    medical care. This was at the demand of nurse Conroy, I WILL NEVER
    FORGET HER SAYING; ``she's not having a stroke, move her.'' I knew I
    had to act quickly and my aunt who was there at the time drove me to
    Rapid City Regional Hospital. I am glad that I left the emergency room
    department because my situation was caught in time. I did have a stroke
    and can prove it with my medical records. At the time I also worked
    there in medical records and I had to put my two weeks' notice in due
    to horrible treatment, nepotism, moral and ethical treatment on behalf
    of my supervisor and other IHS staff. I can truly say that filing a
    complaint against Tess Conroy because of the malpractice during that
    time ended in back lash as an employee working there. My then Manager
    Lynn Pouirer and acting Supervisor Alberta Bad Wound found every way to
    punish me through out that year. For example I was asked more than once
    what my education was. . .I knew very well, if you are my supervisor
    you have access to my employee records and you know I have a Bachelors
    degree. I was literally picked on; I tried every avenue to protect
    myself. I know now that the protocol put in place is void and useless
    if you are filing complaints and sending them into Aberdeen where your
    supervisor has more friends and extended family. The system does not
    work when you have people in place that sabotage the proper protocol of
    filing a complaint. I literally had to make a choice of being stress
    free and healthy to prevent another stroke from stress. They are all
    close friends or relatives, I just had to make the choice to win when
    it came to my health and loose when it came to financial stability. I
    was extremely hesitant to even write a statement only because nothing
    has been rectified or done. Statements, complaints are filed for action
    to be taken and then the employee or patient has hope that they will be
    justified in some way. Sadly in most cases it is not. I could have died
    due to negligence on the choice of the nurse; I walked away from a good
    paying job, because that nurse is very close friends with my manager
    and supervisor. After this statement that I am writing I greatly hope
    it will help to change how employees are trained, and how employees are
    treated by upper management, this will definitely change how patients
    are treated and the type of care they receive. This is my experience as
    an employee and patient of IHS hospital in Rapid City, SD.
            Thank you
                                     Trivia Afraid of Lightning
                                     ______

    Good afternoon, my name is Linda Green,

        A few years ago, (2012-2014) I worked at Soiux San Hospital in the
    Patient Registration Dept., I worked with a woman by the name of, Patty
    Bissonette, we got along very well at first, but as the months went on
    I noticed she didn't like very many people and it was either because of
    their race and the past she had with them, some were because they were
    dated her ex-boyfriend. So one day I asked if she could please keep her
    opionions to herself, I explained to her that we were there because of
    the patients and not ourselves. This is one of the trainings that we
    had to take, to be professional, kind and put the patient before
    ourselves and that not to be racist or discriminate against anyone,
    because of their color, origin or sex. Well from time on I was on her
    bad side. There was another employee that had started and she was very
    good at doing her job and right away she noticed how, Patty's, work
    ethics were and wrote her up every time, Patty, made a mistake or
    discriminated against a patient, and when several attempts of going to
    the supervisor, we had a supervisor by then, his name was, Monte
    Gonzalez, and he was also getting tired of, Patty, for awhile then when
    the employee who had issues with, Patty, finally filed an EEO and
    somehow I got involved in it and when the Mediators came I was also
    told by our supervisor to attend the EEO as well since I had issues
    with her, but I did talk to the supervisor about, Patty, being racist
    and rude to certain patients so I guess this was the reason I was told
    to attend to resolve all the issues at once. But after that all hell
    broke loose, Patty, got worse with her attitude, the supervisor took
    her side and although I didn't really have a lot of issues with her,
    the supervisor and the business office manager, Colleen Steele, who was
    also the supervisors relative and Patty's best friend, all clicked
    together and started trying to make me do things that I knew if I did I
    would either get reprimanded and probably terminated, which they
    attempted to do anyway. So this woman, Patty, does not like me at all,
    was telling people after I left Sioux San that I was fired because I
    was stupid, dumb, didn't know how to do my job and how she hated me so
    much that she could choke the hell outta me. These are the reasons that
    I do not go to Sioux San for my appts or to get my medicines. I had a
    stroke in Spet of 2015 and had a second one in Jan of 2016, which the
    neurologists said was not a new stroke but was not going to rule out
    that it was not as troke because I had all the same symptoms.
        so anyway I had an appt at Sioux San Indian Hospital on 05/08/2016,
    it was a friday, I was running a little late so I called to ask if my
    sister could check me in and the woman that answered the phone did not
    identify herself, she said, ``appointment desk'', not a ``good
    afternoon'' or ``how can I help you?'', so I just continued and
    Identified myself so she would know who I was and told her that I had
    an appt and was running so I wanted to know what my appt was? the phone
    was dead for a few seconds, longer than usual, so I said ``hello?'' and
    she responded, ``I'm right here!'' with attitude, so I said ``oh I just
    thought I got disconnected'', again no response in any way, then she
    said, ``your appt is at Sioux San Indian Hospital, Rapid City South
    Dakota @ 4pm (and I think it was a little later than that), so I said
    ``ok thank you'' and was going to ask if my sister would be able check
    me in and she hung up very hard because I heard a very loud click, so I
    told my sister that she just hung up, without any ``have a good day or
    is there anything else that I can help you with?'' I was shocked at her
    attitude and how unprofessional and rude she was, but I had to call
    again to make sure that it was ok for my sister to check me in, at the
    time I had an injured foot and was getting around very slow so I needed
    all the help I could get, so I called her back knowing what was going
    to happen. So I tried again and she answered the phone again so I asked
    her if she was the lady that I spoke to a few minutes ago, I Identified
    myself again and she said ``yeah!'', again with attitude, so I asked
    what her name was and she said ``Patty!'' so I said ``thank you'' and
    before I could say anything, she hung up again! same as before, no
    ``have a good day, good bye or is there anything else I could help you
    with?'' no apologies what so ever. So I asked my sister if she would
    come in with me to check in, in case she got an attitude with me, I was
    kind of nervous but I had to see a Dr or PA so we both went in and she
    was gone, her chair was turned like she ran out or something, her chair
    wasn't pushed in, it was turned facing the door, so I checked in with
    the man that was there, Humphrey Long, I knew the man so when I walked
    in he was laughing but I didn't know why? he was then only one in the
    office area, we made small talk, being cordial, and when I was finished
    checking in, I asked for a complaint form, he showed me where they
    were, so I took one, went about my way, a few days later the following
    week, I asked an ex co-worker if she could take the form in for me, I
    didn't want to face, Patty, in case she was in the area, then I was
    told by same ex co-worker that I should go in and speak to supervisor
    in person to make sure that something was being done about it so I went
    in later that week and I visited the supervisor, she said at the time
    that, that, Patty, came in on monday, first thing in the morning and
    she had complained about how I harassed her and intimidated her when i
    worked with her and she was in fear of her safety so she went to the
    security office and they sat and watched me as I went in to check in
    for my appt and that they watched me as I went up to the third floor.
    But the supervisor said that it was my word against hers and that she
    couldn't really do anything about it but that she had a talk with her
    and then she asked what I wanted done about her?. . ..isn't it her job
    to take care of that kind of issues and make the place a peaceful,
    relaxing, comfortable place for the patient to come and get their
    medical issues taken care of? This woman had so many complaints wrote
    up on her that she shouldn't even be allowed to come near the place,
    shes very hateful, unprofessional and rude. I need to see a Dr or PA
    again to refill some of my meds but I'm very hesitant because I don't
    want the security sitting there watching my every move, I'm not a
    violent person, I was very kind to the patients when I worked there, as
    a matter of fact they were some of the people that told me back that
    Patty would talk about me when they asked where I was. There are some
    patients that she talked about when they would leave after they checked
    in for their appts. This woman needs to be made accountable for her
    work and watched very closely. There are other issues and I'm hoping
    that these people will take the time to send their complaints.
            Sincerely,
                                                    Linda Green
                                                         Hill City, SD.
                                     ______

        I live on crow creek IF YOUR NOT RELATED TO AN EMPLOYEE YOU GET
    PICKED ON IBILLED FOR REFERRALS. CONSTANTLY HARASSED GOD FOR BID IF YOU
    NEED PAIN CARE. THEY ARE DRUG TESTED SOME OF THEM AREALLY MAJOR PILL
    HEADS. CONTRACT HEALTH I'D JOKE RUN BY DECISIONS MADE BY A HIGH SCHOOL
    GRADUATE NO OTHER COLLEGE EDUCATION MAKING MAJOR HEALTH ISSUES SHE HAS
    NO CLUE WE SUFFER GET RID OF BERNIE LONG, ROBERT DOUVILLE, PHARMACY
    DIRECTOR GREY. WHERE IS HIPPA ENFORCED ALL GOSSIP. IT'S SAD WE HAVE SO
    MANY MISDIAGNOSED.
                                                    Janice Howe
                                     ______

                                                     07/02/2016
    Dear Sirs,

        My name is Randy St.Pierre and I have been an IHS employee at the
    Winnebago IHS hospital and most recently at the Rapid City IHS
    hospital. I just wanted to add my impressions and some of the
    experiences I have had while working in IHS and also being a patient at
    these hospitals. First of all I want to share a little of my
    background, I am 55 years old and am from Yankton SD originally
    currently living in Rapid City SD. At the present time I am not an
    employee at the Rapid City facility. I left in February of 2016. I am a
    Native American although I am not considered Native by some because my
    mother was Caucasian. While working in the IHS system I worked as a
    Medical Laboratory Technician (laboratory) and this involved working
    with many in the facility, particularly the medical staff. I finished
    my Bachelor's degree in 2015 in Hospital Administration and Management
    and am halfway through a Master's degree in Human Resources and
    Management. I wanted to work in IHS in the administrative area when I
    started my degree several years back but after dealing with
    administration in both the Aberdeen area and the Rapid City Hospital I
    have changed my mind because of the problems that plagues these
    offices. In my opinion there are many but not all that are there only
    to get a paycheck and do not care about anything else. While working at
    both the Winnebago and Rapid City facilities I would have to make calls
    to the Aberdeen area offices several times a year and I can probably
    count on one hand how many times I was actually able to talk to a
    person there. And leaving voice mails would also be problematic since
    rarely would they respond to your voice mails including emails. When
    there was something urgent that needed to be done I would have to have
    my supervisor call or email and even he had trouble getting through to
    someone. The same goes for the local administrative offices at the
    hospital, the staff would rarely take your calls.
        The point that has been made about trying to get rid of people is
    well known in IHS, an employee can almost get away with almost anything
    and never get fired, in the 9 years I was employed at IHS I never once
    saw anyone get fired except for myself. I will give a short synopsis of
    the event that led up to my termination at Winnebago. The laboratory
    had a lab aid that was Native American from the Winnebago tribe and I
    was warned when I started there that his brother was on the tribal
    council so you shouldn't upset him. Anyway, I was also told that he did
    not like any Natives that were not from the Winnebago tribe which I
    found out quickly as he would berate me in front of the lab staff, even
    during our lab meetings. I took a complaint to the EEOC in Aberdeen and
    it took them about a year to finally send someone down to investigate
    and in a meeting with myself and the EEOC person and the Hospital CEO
    which the CEO stated that this was the first he had heard of this
    ``untrue'' he had been aware of the complaints for over a year and
    everyone in the lab said there was no problem. So this goes on for
    another year when one day the lab aid pushes me off a chair and I go to
    the lab supervisor and he just tells me to forget about it, I was so
    upset I walked out and went home, the following day when I returned I
    was told I was being fired for going AWOL. I was actually not that
    upset because I was finally not having to endure the constant abuse
    from a fellow worker. I filed for workmen's comp and was denied because
    I was fired so I took it to court in Omaha NE and provided my testimony
    and won the case because no one from Winnebago came to the hearing. I
    was never bitter about this because I was never so glad to get out of a
    job that was so stressful every day.
        I do not agree with those that say that IHS needs more funding, I
    believe they are funded well enough they just don't use the funds that
    they do receive in a way that is in the best interests of the people.
    And as for the employees, there are a lot of good people working in IHS
    but unfortunately, there are also a lot of those that should not be
    there. I have seen it numerous times that when a person becomes such a
    problem that they have to do something about them they don't fire them
    they just transfer them to another facility. What a great way to solve
    a problem, this wouldn't fly in the private sector.
        And finally, about the care that the people receive at IHS, I do
    believe for the most part they do get very good care but it does depend
    on the provider and the staff. The problem I have seen with the
    providers, Drs and PA's is that they seem to not be very good at their
    jobs. I firmly believe that some if not many of these providers are
    those that have trouble in the private sector so they go into IHS where
    if they become a problem the hospital just transfers them to another
    facility or in most cases does not renew their short term contracts and
    they just go to another IHS facility. There are a great many providers
    that I have worked with over the years that are very good but
    unfortunately they are in the minority.
        There is so much more I could say about IHS although I don't want
    you to get the impression that I hate it because it is a very good
    service to the Native population. I just believe that if there was more
    accountability and not the attitude that you can never get fired from
    IHS then more of those people would be put in a position to be more
    accountable not only to their fellow workers but also the IHS system as
    a whole. In about a year when I finish my Master's degree program I
    will then reevaluate whether or not I want to pursue a career in the
    IHS system, I hope that I can.
                                                Randy St.Pierre
                                                        Rapid City, SD.
                                     ______

    Dear respected members of our South Dakota community,

        In 2008, I finished my master's in healthcare administration and
    management. Eager to work back home I applied for a position with the
    nascent diabetes prevention program through the IHS. I applied
    repeatedly and left many messages to the program managers via email and
    telephone. I never heard anything back. The following year I read in
    the Rapid City Journal that those in charge of starting the program
    were embezzling funds. I am only writing this to add a single voice to
    the problem, and share some of my frustration that many younger people
    feel about the state of the state.
            Respectfully,
                                                   Andrew Slama
                                     ______

        We have the same problem on the white earth res in Minnesota they
    say we might have to pay fore any of res medical treatment as they
    might not have the funds to pay.
                                                    Leroy Story
                                     ______

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

        Response to Written Questions Submitted by Hon. Mike Rounds to
                                 Mary Wakefield
    Tribal/Residual Shares for Great Plains Area
        Questions 1, 2, 3a. Can you tell us when you would be able to
    provide our tribal leaders with information about the potential
    allocation of shares for the Great Plains Area? Why isn't this
    information public already? Is there a reason you are withholding this
    information or that it is not transparent?
        Answer. Consistent with the IHS Tribal Consultation policy, the
    Great Plains Area (GPA) consults annually on the IHS budget formulation
    activities and includes Tribal representation from the GPA in the IHS
    Budget Formulation Workgroup. In these meetings, IHS openly discusses
    and shares information related to IHS headquarters, Area, and program
    or Service Unit level budgets with the tribes. These consultations and
    meetings may include other topic areas, such as IHS investments,
    initiatives, human capital, etc. The availability of information may
    vary depending on the timing of annual appropriation bills or other
    actions impacting federal appropriations. This information cannot be
    shared until the full-year appropriations bill is enacted.
        In addition to these recurring meetings, in April and May of 2016,
    the GPA Office held meetings to specifically provide technical
    assistance related to tribal shares, as defined by the Indian Self-
    Determination and Education Assistance Act (ISDEAA) (25 U.S.C. 5301 et
    seq.), with the GPA Tribal Leaders and their subject matter experts. On
    March 23, 2016, invitations to attend these meetings were sent to all
    tribes in the GPA for those tribal consultation topics that are
    relevant to the respective tribes. For example, the IHS held a GPA
    Tribal Leaders Briefing in Sioux Falls, South Dakota on April 5-7, 2016
    to provide an update on the progress addressing the delivery of health
    care services in the GPA, and to provide an opportunity for Tribal
    Leaders to voice their specific concerns. IHS provided a summary of
    this briefing to GPA Tribal Leaders via letter dated May 9, 2016.
        Throughout the year and at the request of a Tribe, the GPA met on
    an individual basis with several Tribes to provide tribal shares
    information and ISDEAA technical assistance. IHS informed Tribes that
    they may contact the GPA Office, the Office of Direct Service &
    Contracting Tribes or the Office of Tribal Self-Governance at
    headquarters to schedule individual technical assistance meetings.

        Question 3b. Why would tribes need to use FOIA to request this
    info?
        Answer. The IHS makes every effort to maintain a clear balance
    between transparency and information sharing as it relates to
    applicable requirements for protecting privacy. In general, information
    regarding tribal shares and residual is shared annually or through
    individual technical assistance as noted above. In addition, IHS
    provides information relating to budgets, initiatives, and updates to
    Tribes on an on-going basis throughout the year through various forums
    from Tribal advisory committees, workgroups, and boards to press
    releases, letters to Tribal Leaders, and Congressional reports. The IHS
    values transparency in parallel to its stewardship duty of safeguarding
    records and data. As a general practice, when information is not
    publically available, IHS adheres to the requirements of the Freedom of
    Information Act (FOIA).

        Question 4. Shouldn't this information be based upon how the Great
    Plains Area's budget is distributed today and isn't that information
    readily available to you?
        Answer. The Indian Health Service, in consultation with tribes, has
    developed formulas for distribution of HQ, Area, and Service Unit
    funding known as ``tribal shares tables.'' These formulas are not based
    on actual expenditures from year to year. This was deliberate because
    tribes wanted the formulas set in order to ensure predictability in
    funding to continue to allow tribes to exercise self-determination in
    how they receive healthcare. This allows tribes to make their
    determinations continue to either receive services directly from the
    Indian Health Service or through an ISDEAA contract based on the tribal
    needs.
        This residual amount is described here in an April 1995
    communication:

        https://www.ihs.gov/ihm/
    index.cfm?module=dsp_ihm_sgm_main&sgm=ihm_sgm_9502
        This provides a clear distinction between the funding a Tribe or
    Tribal organization is entitled to under the ISDEAA and the operational
    budgets of an IHS Area Office. A residual is portion of the IHS budget
    related to inherently federal functions necessary for the execution of
    the agency's programs and are not issued as shares to tribes. The split
    between residual and not inherently governmental funds are determined
    by IHS based on the legislative history of each appropriation act and
    executive branch wide definitions of inherently governmental functions.
        The IHS is committed to ensuring accurate financial information is
    shared in a timely and transparent manner, through consultative
    processes and efforts described above. One key driver of delay in
    getting information to the tribes is the annual appropriations process.
    IHS cannot provide final tribal share information until our
    appropriation is enacted by Congress. These bills have been delayed
    from mid-December to as late as mid-March. Once the bill is enacted,
    IHS can compare this to the planned President's Budget and determine
    the correct categorization for any new amounts, either eligible for
    tribal shares or designation as residual. This process involves review
    of the bills legislative history and potentially decisions issued by
    the IHS Director.

        Question 5. Are these shares the product of statute or
    administrative rule?
        Answer. The IHS implements the Indian Self-Determination and
    Education Assistance Act (ISDEAA), (25 U.S.C. 5301 et seq.), as
    amended, which recognizes the unique legal and political relationship
    between the United States and American Indian and Alaska Native
    peoples. Titles I and V of the ISDEAA provide Tribes the option to
    exercise the right to self-determination by assuming control and
    management of programs, services, functions, and activities (or
    portions thereof) previously administered by the Federal Government.
        Per the ISDEAA regulations, Tribal share means an Indian Tribe's
    portion of all funds and resources that support secretarial PSFAs that
    are not required by the Secretary for the performance of inherent
    Federal function. The ISDEAA regulations and Tribal Consultation (at
    Headquarters and Area levels) helped shape the methodologies utilized
    today. The methodologies range: (1) Direct Shares are precisely
    determined when financial accounts record actual spending for PSFAs for
    a Tribe, e.g. IHS funds at a local site serving one Tribe; (2) Program
    Measures may be calculated in proportion to workloads, services, or
    patient counts for each Tribe. These formulas are most common for PSFAs
    associated with the Office of Environmental Health and Engineering; and
    (3) Proxy formula that calculates shares in proportion to indirect
    measures such as user counts, number of Tribes, or other general
    distributive factors.

        Question 6. Information on tribal shares are already published in
    the annual budget book for 10 of the 12 IHS service areas. Why is this
    information not published for the Great Plains Area?
        Answer. The IHS Congressional Justification (CJ) includes self-
    governance funding tables. For the first time, a Tribe from the Great
    Plains Area successfully entered into a self-governance compact in
    2016, after the February 2016 publication of the FY 2017 CJ. Because of
    this, the Great Plains Area will be included in the self-governance
    funding tables in future years.
    Contracting/Staffing (Contracting/Quality Offices)
        We are frustrated by the lack of transparency, consultation and
    communication in the process for both issuing the RFP and selecting the
    vendor for the Winnebago/Omaha, Pine Ridge and Rosebud Emergency
    Departments. We believe that had there been more awareness that the RFP
    was issued and had IHS responded to the interested local health care
    providers, a local health care entity may have submitted a legitimate
    bid for consideration. Furthermore, we understand that AB Staffing
    Solutions has a mediocre to poor history at being able to staff IHS
    facilities in the past, specifically:

       The San Carlos Apache had AB Staffing at their facility in
            Arizona. AB Staffing did not meet the tribe's expectations and
            were fired.

       We have heard reports that AB Staffing supplied staff at our
            Pine Ridge and Rosebud facilities and that the staff members
            that AB Staffing supplied were responsible for the shortcomings
            and poor quality that led to the CMS violations.

       We have heard reports that AB Staffing regularly recruits
            health care professionals from global regions that do not have
            the same or equal quality medical training and certification
            standards as United States medical training and certification.

        Question 7. What information can you give me about your confidence
    in AB Staffing's ability to be successful in their contracts in the
    Great Plains Area?
        Answer. IHS is committed to providing quality care at its emergency
    facilities in the Great Plains Area. IHS is working to provide
    oversight and support to the contractor and to the hospitals served by
    the contractor to help facilitate a successful implementation. The
    challenges are complex in these specific areas of quality improvement.
    IHS is continually working to improve the quality of care provided at
    our facilities and to ensuring the improvements made can be sustained
    over time.

        Question 8. Ultimately, if they are not able to perform
    successfully, what recourse do our tribes have in canceling and
    rebidding the contracts?
        Answer. A recent modification has been issued to the AB Staffing
    contract to more clearly define requirements, provide additional
    qualifications for health care providers, and enhance contractor
    accountability. The modification also provided additional funding in
    order to recruit and retain quality personnel. Tribes with concerns
    about AB Staffing's performance should contact the Great Plains Areas
    Director who can notify the Contracting Officer's Representative (COR)
    for the contract and Indian Health Service will assess the situation
    and if appropriate, take action pursuant to the Federal Acquisition
    Regulations.
    Vacancy info (OHR)
        Of the 846 Healthcare Professionals in the Great Plains Area, only
    637 of those positions were filled at the time of the report this
    spring. This is a vacancy rate of 25 percent.

        Question 9. Presumably there is money allocated for the salaries of
    those positions that are not filled. How is that money allocated every
    year; is it redeployed and if so, how?
        Answer. Positions are funded through the annual appropriations
    allocated to the Area and each Service Unit. Third party collections
    within each Service Unit may also be used to fund healthcare positions.
    Any funds available due to vacancies are used for the provision of
    health care services including but not limited to medical supplies and
    equipment and temporary contracted healthcare providers.

        Question 10. Can you provide the vacancy rates/information as of
    June 17, 2016 for the Great Plains Area?
        Answer. As of June 15, 2016, total number of vacancies and the
    vacancy rates for IHS GPA are as follows:

       The total number of GPA positions was 2,782. Of the 2,782
            GPA positions 549 were vacant. Therefore, the overall vacancy
            rate for GPA was 20 percent (1936 total non-health professional
            positions and 846 health professional positions).

       The total number of health professional positions was 846.
            Of the 846 health professional positions 209 were vacant.
            Therefore, the vacancy rate for health professional positions
            was 25 percent. Health professional positions include, Medical
            Officers/Physicians, Nurses, CRNAs, Midwives, Nurse
            Practitioners, Dentists, Physician Assistants, and Pharmacists.

       The total number of non-health professional positions was
            1,936. Of the 1,936 non-health professional positions 340 were
            vacant. Therefore, the vacancy rate for non-health professional
            positions was 18 percent. Non-health professionals positions
            include, for example, medical support staff, Area Office, admin
            staff, custodians, clerks, Engineers, Behavioral Health, HR,
            Finance, Business Office, etc.).