[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.
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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\
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    \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
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    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:
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    \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.''
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    \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.
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    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\
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    \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.
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    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.
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    \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.
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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.
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    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\
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    \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 
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        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
                              
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                                 ______
                                 
 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.).