[Senate Hearing 114-441]
[From the U.S. Government Publishing Office]




 
     DEPARTMENT OF THE INTERIOR, ENVIRONMENT, AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2017

                              ----------                              


                        WEDNESDAY, MARCH 9, 2016

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.

    The subcommittee met at 10:03 a.m., in Room SD-124, Dirksen 
Senate Office Building, Hon. Lisa Murkowski (chairman) 
presiding.
    Present: Senators Murkowski, Cochran, Daines, Udall, 
Tester, and Merkley.

                         INDIAN HEALTH SERVICE

STATEMENT OF MARY SMITH, PRINCIPAL DEPUTY DIRECTOR
ACCOMPANIED BY:
        ELIZABETH FOWLER, DEPUTY DIRECTOR FOR MANAGEMENT OPERATIONS
        GARY HARTZ, DIRECTOR OF THE OFFICE OF ENVIRONMENTAL HEALTH AND 
            ENGINEERING

              OPENING STATEMENT OF SENATOR LISA MURKOWSKI

    Senator Murkowski. Good morning. We will call to order the 
Senate Appropriations Subcommittee on Interior, Environment, 
and Related Agencies.
    Today's hearing is on the fiscal year 2017 budget request 
for Indian Health Service (IHS).
    Before I begin my comments and welcoming, we do have the 
chairman of the full Committee on Appropriations. So at this 
time, Chairman Cochran, I would defer to you if you would like 
to make any opening comments.

                   STATEMENT OF SENATOR THAD COCHRAN

    Senator Cochran. Thank you, Madam Chair. I appreciate the 
recognition and to join you in welcoming our witnesses this 
morning, reviewing the budget request for the Indian Health 
Service. Specifically in our State of Mississippi, we're 
pleased to host the Mississippi Band of Choctaw Indians' state-
of-the-art medical center. It is a new health center, and I 
know that people are still getting adjusted to the fact that 
there's such a fine facility that is available for healthcare 
services for the Mississippi Band of Choctaw Indians in 
particular. I hope we can continue to stay in touch with the 
management of the hospital, and we hope we will learn from this 
hearing how it's being received and whether the needs are being 
met for appropriated dollars that are necessary.
    Thank you.
    Senator Murkowski. Thank you, Mr. Chairman.
    At this time, I again would like to welcome all.
    Today we will examine the budget request for Indian Health 
Service. I want to thank Mary Smith, the Principal Deputy 
Director for IHS, for appearing before us today.
    Ms. Smith was named to the top position at the agency just 
last week, so we wish you well. The head of the IHS, I think we 
recognize, is a tough job. It's a critical job for us in 
Alaska, where all of the healthcare for Native Alaskans is 
delivered through compacts between tribal organizations and the 
IHS.
    Ms. Smith is accompanied by Elizabeth Fowler, who is the 
Deputy Director for Management Operations, as well as Gary 
Hartz, Director of the Office of Environmental Health and 
Engineering. We welcome all of you.
    Last year we started what I hope will be a tradition. We 
held the first IHS budget hearing in over 5 years. These issues 
are too important in terms of your work to have such a lapse, 
so I'm pleased that we are having this hearing.
    With a budget of over $5 billion, a seemingly limitless 
number of needs for healthcare delivery for Native Americans, 
it's critical that this subcommittee exercise a strong 
oversight role to make sure scarce resources are spent as 
efficiently as possible. The IHS budget request for fiscal year 
2017 is $5.185 billion for programs within this subcommittee's 
jurisdiction. This is an increase of $377 million, or 8 
percent, above last year's enacted.
    There are worthy increases in this budget, including $82 
million for contract support costs. I'm pleased that this 
budget fully funds these costs and adopts the approach that I 
put forward in the Senate bill for fiscal year 2016, which 
establishes a separate indefinite appropriation for contract 
support costs to ensure these legal obligations are met and 
other programs will not be affected.
    Other important increases include $132 million to address 
the more than $2 billion backlog on the current healthcare 
facilities construction list, as well as $15 million for the 
substance abuse and suicide prevention program, with a 
particular focus on youth. I'm particularly interested in the 
initiatives in your budget to address substance abuse, suicide, 
and domestic violence. These are enormous problems within 
Indian Country and are particularly acute in Alaska.
    I think we look at the statistics and are just truly 
overwhelmed by them. One out of every three American Indian or 
Alaska Native women will be sexually assaulted in her lifetime. 
The alcohol-related death rate for Native Americans is six 
times greater than the rest of the population, and the suicide 
rate for 15 to 24-year-olds is 2.5 times the rate for other 
ethnicities.
    We've had a very courageous group of young people from 
Tanana, Alaska who have spoken out about these issues in their 
community over the past few years. They stood before several 
thousand Alaska Natives at our largest gathering at the Alaska 
Federation of Natives conference. They've written what is known 
as the Tanana Pledge to encourage Native Alaskans around the 
State to stand together against suicide, against substance 
abuse.
    It was just a few weeks ago there was an article in our 
newspaper and on the radio about dozens of young people from 
the village of Kwethluk who took a stand against alcohol and 
drugs in their community. They marched through the streets of 
the village with homemade signs basically saying enough is 
enough. So when your children stand in front of you, stand in 
front of the adults and say stop it, enough is enough, it is 
well past time to act.
    In an effort to push for more effective ways to address 
issues like suicide among Indian youth, I sent a letter last 
December to Secretary Burwell with 11 other senators, including 
our ranking member here, concerning the issue of complex 
trauma. In that letter we asked Department of Health and Human 
Services to develop a coordinated interagency approach that 
incorporates the growing evidence that complex childhood trauma 
is often the underlying cause of substance abuse and youth 
suicide.
    I see that your budget discusses trauma-informed care and 
indicates that the agency's mental health and social service 
program provides training and workforce development to IHS and 
tribal healthcare providers to incorporate culturally relevant 
and trauma-informed approaches.
    When we get to the time for questions, I'd like to learn 
more about what IHS and the Department of Health and Human 
Services as a whole are doing in this area. I think it's 
critical that we continue to make progress on these issues.
    And then finally, I'm very concerned with the situation 
that we have at the IHS Rosebud Hospital on the Rosebud Indian 
Reservation in South Dakota. Conditions at the hospital are so 
bad that IHS sent out a notice on March 1, indicating that the 
Center for Medicare and Medicaid Services will terminate its 
provider agreement with the hospital effective March 16. This 
means that IHS can no longer bill for Medicare and Medicaid 
services and that in many instances tribal members will have to 
travel long distances to get care.
    There have been cases reported in the press where employees 
at Rosebud were washing surgical instruments by hand because 
the hospital sterilization machine was broken for 6 months. 
Also, a case where staff members left a pregnant woman 
unattended and she delivered her premature baby on the floor of 
a hospital bathroom--absolutely, absolutely unacceptable.
    So we need to hear from you today what the Indian Health 
Service and Health and Human Services is doing to rectify this 
situation and when the hospital can restore its provider 
agreement with the Center for Medicare and Medicaid Services 
(CMS).
    So again, thank you for being here.
    I would now like to turn to my ranking member, Senator 
Udall, for his comments this morning.

                     STATEMENT OF SENATOR TOM UDALL

    Senator Udall. Thank you, Madam Chair.
    Let me also welcome Mary Smith, the new Principal Deputy 
Director of the Indian Health Service, to this hearing before 
the subcommittee. Deputy Director Smith, congratulations on 
your new leadership role within the agency. We're glad you're 
able to join us to share your perspective on the President's 
2017 budget request for the Indian Health Service and to hear 
from members of the subcommittee about our particular 
priorities for the Service and about its budget.
    I also want to welcome Elizabeth Fowler, Deputy Director 
for Management Operations, and Mr. Gary Hartz, Director of the 
Office of Environmental Health and Engineering. We appreciate 
you being here today and look forward to hearing from you.
    Before we turn to the 2017 budget, I want to thank Chairman 
Murkowski for working with me to produce a very solid budget 
for the Service this year. Overall, we were able to support a 
3.5 percent increase for the Service, including important 
investments in facilities and substance abuse treatment. I also 
want to applaud the Chairman for coming up with a more 
sustainable way to fund contract support costs so that these 
costs aren't funded at the expense of other programs.
    Madam Chairman, you've been a great champion for programs 
that are so critical to Native communities in both our States 
and throughout Indian Country, and I'm proud of this entire 
subcommittee and the effort it has made to fund tribal health 
programs and make them a priority.
    But more is clearly needed. Indian Country needs better 
access to clinical services. This is especially true for 
preventive care, and also for mental health and substance abuse 
programs. These are critical services. We want to see IHS build 
more hospitals and health clinics, and we need to make sure the 
agency has the right tools to staff its facilities with 
qualified doctors and nurses.
    All of these issues affect tribes in New Mexico. We see it 
in the lack of funding for substance abuse treatment in Gallup. 
We see it there in Gallup. We see it in the staffing shortages 
in Crownpoint, which forced the closure of emergency medical 
services last year. The challenges are very clear.
    So I look forward to hearing more about possible solutions. 
I also want to hear how the agency plans to address serious 
problems we're seeing in other areas, including in the Great 
Plains, as the Chairman has mentioned, where some IHS 
facilities are at risk of losing accreditation and have been 
forced to cut back vital medical services. This budget request 
takes on some of those challenges by requesting an 8 percent 
overall increase for the agency.
    It's going to be an uphill battle for this subcommittee to 
fully fund your proposal given the flat budget caps in 2017, 
but we will do everything we can to support you, Deputy 
Director Smith, and to support Indian Country. Your appearance 
today to share some of the details of the budget is critical to 
helping the subcommittee do its work.
    Again, congratulations on your new position, and thank you 
for providing testimony to us today.
    Senator Murkowski. Thank you, Senator Udall.
    With that, let us go to you, Ms. Smith. Welcome again, and 
I will repeat the ranking member's comments about 
congratulations for the appointment to this position.
    So if you would like to begin your comments, I understand 
that it will just be you testifying and that Ms. Fowler and Mr. 
Hartz are there to answer questions.
    Ms. Smith. Yes, that's correct.
    Senator Murkowski. Very good. If you can begin, please.

                    SUMMARY STATEMENT OF MARY SMITH

    Ms. Smith. Good morning. Thank you, Chair Murkowski and 
Ranking Member Udall, and all the members of the subcommittee, 
for allowing us to be here today to talk about the fiscal year 
2017 IHS budget request. As was mentioned, accompanying me 
today are Elizabeth Fowler, Deputy Director for Management 
Operations, and Gary Hartz, Director of the Office of 
Environmental Health and Engineering.
    I've only been in my job as Principal Deputy Director for a 
little over 1 week, and although I've been at the agency for a 
little bit longer, about 5 months in the role of Deputy 
Director, it has become quite clear to me that while the IHS is 
firmly committed to the mission of providing quality healthcare 
for American Indians and Alaska Natives, we face steep 
operational and quality of care challenges. This situation is 
unacceptable.
    I appear before you today to underscore my commitment to 
fixing these challenges, including those in the Great Plains, 
and the more systemic issues that we face at the agency such as 
staffing and housing. We are committed to fixing these issues 
not simply in the short term but so that these changes are 
sustainable over time. I and the rest of the team at IHS are 
committed to creating a culture of quality, leadership, and 
accountability. It is far from business as usual at IHS.
    With that preamble, I am pleased to present testimony on 
the President's proposed fiscal year 2017 budget for IHS, which 
will allow us to continue to make a difference in addressing 
our agency mission. I'm committed to working with our partners, 
including those on this subcommittee, to provide access to 
quality healthcare to Native Americans.
    The fiscal year 2017 President's budget proposes to 
increase the total IHS program budget to $6.6 billion, which 
will add $402 million to the fiscal year 2016 enacted funding 
level. If appropriated, this funding level would represent a 53 
percent increase in funding for the IHS since fiscal year 2008.
    The overall funding increases proposed in the President's 
budget are consistent with tribal priorities and would continue 
to address longstanding health disparities among American 
Indians and Alaska Natives compared to other Americans.
    Specific investments include expanding behavioral and 
mental health services, improving healthcare quality, capacity 
and workforce, and supporting self-determination by fully 
funding contract support costs.
    The President's budget proposal includes funding for pay 
costs, inflation, and population growth increases totaling $159 
million, which are critical to maintaining the budgets of IHS 
and tribal hospitals, clinics, and other programs at current-
year levels.
    The budget also includes program increases of $49 million, 
of which $46 million will be focused on critical behavioral 
health services, including generating indigenous substance 
abuse and suicide prevention projects to increase the number of 
child and adolescent behavioral professionals; continued 
integration between medical care, behavioral health, and tribal 
community organizations, and domestic violence prevention 
programming, to name a few.
    The budget also includes an HHS-wide, 2-year mandatory 
proposal to address mental and behavioral health. For the IHS, 
the proposal includes a new $15 million Tribal Crisis Response 
Fund which would allow IHS to expeditiously assist tribes 
experiencing behavioral health crises, and an additional $10 
million to increase the number of behavioral health 
professionals through the American Indians Into Psychology 
Program and IHS scholarships and loan repayment programs.
    The budget proposes an additional investment for healthcare 
information technology to fund improvement, enhanced 
modernization and security of health IT systems; and also $2 
million for IHS Quality Consortium, which will coordinate 
quality improvement activities among the 28 IHS hospitals, 
critical access hospitals, and the over 200 outpatient 
ambulatory clinics.
    The budget includes funds for infrastructure that is 
critical to healthcare delivery, including to fund additional 
staff for five newly-constructed facilities, for tribal clinic 
leases and maintenance costs, specifically in Alaska, and to 
address the backlog of $473 million at Federal and tribal 
facilities.
    In addition, the budget proposes funding of $12 million for 
the replacement and addition of new housing quarters in 
isolated and remote locations to enhance IHS recruitment and 
retention of healthcare professionals.
    As was mentioned, the budget supports self-determination by 
continuing the separate indefinite appropriation account for 
contract support costs through fiscal year 2017. Additionally, 
the budget proposes to reclassify contract support costs as a 
mandatory 3-year appropriation.
    Finally, I do want to acknowledge that we are working 
aggressively to address quality of care issues at our three 
facilities in the Great Plains. The challenges there are 
longstanding, especially around recruitment and retention of 
providers, but the deficiencies cited by CMS are unacceptable. 
We have an intense effort underway. We have brought in 
Commissioned Corps officers to help. We have the full support 
of the Department of Health and Human Services. We have 
established a Council on Quality, staffed by people throughout 
the Department of Health and Human Services, and we have 
established a new Deputy Director of Quality, who is Dorothy 
Dupree. We are working diligently to address those issues.
    We look forward to working in partnership with you to enact 
the President's budget, and I want to say that we take these 
challenges seriously, and you have my commitment that we will 
work tirelessly to make meaningful, measureable progress. Thank 
you so much.
    [The statement follows:]
                    Prepared Statement of Mary Smith
    Chairman and members of the subcommittee:

    Good morning. I am Mary Smith, Principal Deputy Director of the 
Indian Health Service (IHS). Accompanying me today are Elizabeth 
Fowler, Deputy Director for Management Operations, and Gary Hartz, 
Director of the Office of Environmental Health and Engineering. I am 
pleased to provide testimony on the proposed fiscal year 2017 
President's budget for the IHS, which will allow us to continue to make 
a difference in addressing our agency mission to raise the physical, 
mental, social, and spiritual health of American Indians and Alaska 
Natives (AI/ANs) to the highest level.
    The IHS is an agency within the Department of Health and Human 
Services (HHS) that provides a comprehensive health service delivery 
system for approximately 2.2 million AI/ANs from 567 federally 
recognized tribes in 36 States. The IHS system consists of 12 Area 
Offices, which are further divided into 170 Service Units that provide 
care at the local level. Health services are provided through 
facilities managed directly by the IHS, by tribes under authorities of 
the Indian Self-Determination and Education Assistance Act, through 
services purchased from private providers, and through Urban Indian 
Health Programs.
    As an agency we are committed to ensuring a healthier future for 
all AI/AN people, and the IHS budget is critical to our progress in 
accomplishing this. From fiscal year 2008 through fiscal year 2016, IHS 
appropriations have increased by 43 percent thanks in part to your 
subcommittee, and these investments are making a substantial impact in 
the quantity and quality of healthcare we are able to provide to AI/
ANs. The fiscal year 2017 President's budget proposes to increase the 
total IHS program level to $6.6 billion, which will add $402 million to 
the fiscal year 2016 enacted funding level, and if appropriated, this 
funding level would represent a 53 percent increase in funding for the 
IHS since fiscal year 2008.
    The overall funding increases proposed in the President's budget 
are consistent with tribal priorities and would continue to address 
long-standing health disparities among AI/AN, compared to other 
Americans. Specific investments include expanding behavioral and mental 
health services, improving healthcare quality, capacity, and workforce, 
supporting self-determination by fully funding Contract Support Costs 
(CSC) of tribes who manage their own programs, and ensuring increased 
healthcare access through addressing critical healthcare facilities 
infrastructure needs.
                   prioritizing health care services
    More specifically, the President's budget proposal includes funding 
for pay costs, inflation and population growth increases totaling $159 
million, which are critical to maintaining the budgets of our IHS and 
tribal hospitals, clinics and other programs at current year levels, 
and ensure continued support of services that are vital to improving 
health outcomes.
    The budget also includes program increases of $49 million to grow 
healthcare services by targeting funding increases to help close the 
gap in health disparities experienced by AI/AN and improve their 
overall health and well-being. Of the $49 million, $46 million will be 
focused on critical behavioral health services, including $15 million 
for Generation Indigenous substance abuse and suicide prevention 
projects to increase the number of child and adolescent behavioral 
professionals; $21 million to fund continued integration between 
medical care, behavioral health, and tribal community organizations to 
provide the entire spectrum of prevention to impact health outcomes; $4 
million to fund implementation of pilot projects for the Zero Suicide 
Initiative in IHS, Tribal, Urban (I/T/U) organizations; $2 million to 
fund a youth pilot project to provide a continuum of care for AI/AN 
youth after they are discharged and return home from Youth Regional 
Treatment Centers; and $4 million for domestic violence prevention to 
fund approximately 30 additional I/T/U organizations. And $3 million to 
expand services provided through the Catastrophic Health Emergency Fund 
and Urban Indian Health Programs.
             improving the quality of health care delivery
    The budget includes funding increases intended to strengthen the 
provision of high-quality care. The budget proposes an additional $20 
million for health information technology (IT) to fund improvement, 
enhancement, modernization, and security of health IT systems used for 
patient care data. And an additional $2 million for the IHS Quality 
Consortium, which will coordinate quality improvement activities among 
the 27 IHS Hospitals, Critical Access Hospitals and over 200 Outpatient 
Ambulatory Clinics to reduce hospital acquired conditions, avoidable 
readmissions, support the IHS Quality Consortium Work Plan with 
associated buildup of professional Quality staff and development of a 
National Quality Manager Council. Additionally, this funding would help 
to address recent standard of care issues at three of our Great Plains 
Area hospitals.
  increasing access to quality health care services through improved 
                             infrastructure
    The budget includes funds for infrastructure that is critical to 
healthcare delivery. Funding increases totaling $43 million are 
proposed as follows: $33 million to fund additional staff for five 
newly constructed facilities opening between 2016 and 2017, including 
three Joint Venture facilities where tribes funded the construction and 
equipment costs; $9 million for tribal clinic leases and maintenance 
costs, specifically where tribal space is ineligible for IHS 
Maintenance and Improvement funds, such as Village Built Clinics in 
Alaska; $.5 million to provide additional funds in reducing the 
maintenance backlog of $473 million at Federal and tribal facilities.
    In addition, a total budget of $133 million is proposed, (1) to 
complete construction of the Phoenix Indian Medical Center Northeast 
Ambulatory Care Center ($53 million), (2) to begin design of the White 
River Hospital ($15 million), (3) to continue construction of the Rapid 
City Health Center ($28 million), (4) to continue construction of the 
Dilkon Alternative Rural Health Center ($15 million), (5) to fund the 
Small Ambulatory Grants Program ($10 million), and (6) to fund the 
replacement and addition of new staffing quarters in isolated and 
remote locations to enhance IHS recruitment and retention of healthcare 
professionals ($12 million).
    Public and private collections represent a significant portion of 
IHS and tribal healthcare delivery budgets and are critical to support 
the IHS priority to improve the quality of and access to care. Third 
party collections from Medicare, Medicaid, the Veterans Health 
Administration, and private insurance allows IHS and contracting tribes 
to provide additional healthcare services, purchase new equipment, hire 
necessary medical staff, and make essential building improvements. IHS 
estimates that in fiscal year 2017 it will collect approximately $1.2 
billion in funds from Medicare, Medicaid, private insurance companies, 
and the Department of Veterans Affairs.
                  supporting indian self-determination
    The budget supports self-determination by continuing the separate 
indefinite appropriation account for CSC through fiscal year 2017. 
Additionally, the budget proposes to reclassify CSC as a mandatory, 3-
year appropriation in fiscal year 2018, with sufficient increases year 
over year to fully fund the estimated need for both the IHS and the 
Bureau of Indian Affairs. This funding approach continues the policy to 
fully fund CSC and helps to support self-determination.
        mandatory funding proposal for mental health initiatives
    The budget includes a HHS-wide 2-year mandatory proposal to address 
mental and behavioral health. For the IHS, the proposal includes a new 
$15 million Tribal Crisis Response Fund, which would allow the IHS to 
expeditiously assist tribes experiencing behavioral health crises, and 
an additional $10 million to increase the number of AI/AN behavioral 
health professionals through the American Indians into Psychology 
program and IHS scholarships and loan repayment programs.
                         legislative proposals
    I would also like to highlight two of our legislative proposals. 
First, IHS is seeking a consistent definition of ``Indian'' in the 
Affordable Care Act (ACA). Currently, the ACA includes different 
definitions of ``Indian'' when outlining eligibility requirements for 
certain coverage provisions. These definitions are not consistent with 
eligibility requirements used for delivery of other federally supported 
health services to AI/AN under Medicaid, the Children's Health 
Insurance Program, and the IHS. The budget proposes to standardize ACA 
definitions to ensure all AI/ANs will be treated equally with respect 
to the Act's coverage provisions, including access to qualified health 
plans with no cost sharing.
    IHS is also seeking permanent reauthorization of the Special 
Diabetes Program for Indians (SDPI). The SDPI grant program provides 
funding for diabetes treatment and prevention to approximately 301 I/T/
U health programs. Most recently, the SDPI has been reauthorized 
through September 2017. Reauthorization of the SDPI beyond fiscal year 
2017 will be required to continue progress in the prevention and 
treatment of diabetes in AI/AN communities. Permanent reauthorization 
allows the programs more continuity and the ability to plan more long 
term interventions and activities.
                         great plains hospitals
    Finally, I want to acknowledge that we are working aggressively 
with the full support of the HHS to address quality of care issues at 
three of our facilities in the Great Plains Area--Winnebago, Rosebud, 
and Pine Ridge. The challenges there are long-standing, especially 
around recruitment and retention of providers, but the deficiencies 
cited in the reports by the Centers for Medicare and Medicaid Services 
(CMS) are unacceptable. We have an intense effort underway right now 
through our corrective action plans to address the problems cited by 
CMS at these three hospitals. We brought in independent third-party 
reviewers to advise us on addressing the specific deficiencies found by 
CMS. The equipment identified in the CMS findings has already been 
replaced or procurement actions are underway. To further assist with 
addressing and implementing corrective actions, additional U.S. Public 
Health Service officers are supplementing IHS personnel in the Great 
Plains Area. I am also pleased to report that as part of our continuing 
workforce improvement efforts we recently received approval for an 
emergency department physicians' pay package. At the same time, we are 
working to improve communications with the tribes impacted. More 
broadly, we are redoubling their efforts to ensure that sustained, 
quality care is delivered consistently across IHS facilities. The HHS 
Secretary established the Executive Council on Quality Care, in which 
IHS is an active participant, and we are partnering with CMS to 
establish an agreement that will address systemic issues. As part of 
these longer-term efforts to make sustained change, we transformed our 
Hospital Consortium into a Quality Consortium and I have a new Deputy 
Director, Dorothy Dupree, who will work across the IHS to solely focus 
on quality improvement. We are also developing a strategic framework 
and sustainability plan for the Great Plains Area, in consultation with 
the tribes, that is agile and will be used to evaluate and ensure 
quality across the entire system.
    I close by emphasizing that even with all the challenges we face, I 
know that, working together throughout HHS, with our partners across 
Indian Country and in Congress, we can improve our Agency to better 
serve tribal communities. I appreciate all your efforts in helping us 
provide the best possible healthcare services to the people we serve, 
and in helping to ensure a healthier future for American Indians and 
Alaska Natives.
    Thank you and I am happy to answer any questions you may have.

    Senator Murkowski. Thank you, Ms. Smith. I appreciate your 
comments, and we will now move to questions from those of us 
here on the dais. It looks like the clock is 6 minutes.

                         CONTRACT SUPPORT COSTS

    Contract support costs, as you have mentioned and as I have 
mentioned that this has long been a priority of mine to make 
sure that full contract support costs are without question, and 
the separate appropriations account that we developed I think 
is going to be important to make sure that, again, we're honest 
with this, we're not taking from one account to help meet this 
obligation.
    You mentioned the mandatory 3-year approach here that you 
are laying out. Frequently we've seen the administration make 
some general statements about providing mandatory funding for 
certain programs, but then it never sends up the legislative 
proposal. Last week we talked about mandatory proposals by the 
administration for accounts like the Land and Water 
Conservation Fund (LWCF) and the National Parks, but there were 
no offsets for those.
    So a question for you this morning is whether or not you do 
plan to send the Congress the proposal for mandatory funding 
for contract support costs, and if so when, and then whether or 
not there will be any offset identified.
    Ms. Smith. Thank you, Senator Murkowski. Yes, we are 
committed to fully funding contract support costs. As you 
mentioned, in our fiscal year 2017 budget proposal we are 
proposing to make contract support costs mandatory for 3 years 
starting in fiscal year 2018, and we are committed to sending 
up language. We look forward to working with this subcommittee 
and others to provide language throughout the process.
    I will defer to Liz Fowler. I am not sure about the offset 
question.
    Senator Murkowski. Ms. Fowler.
    Ms. Fowler. Good morning. The overall President's budget 
takes care of the offset for all of the mandatory proposals 
that are in the President's budget request. There's not a one-
to-one offset within the IHS budget, so it's addressed by the 
President's budget overall.
    Senator Murkowski. Well, that may continue to be an issue. 
As you know, there have been many concerns raised by those of 
us that are looking at the President's budget and how they are 
proposing to address specific offsets. I have had a lot of 
constituents coming to me over the years expressing some 
frustration about contract support costs and, again, making 
sure that there is that full funding.
    So now we got to full funding, and the push has been can we 
make this mandatory? And I think it will be met with good news 
that the proposal is that we do see it on the mandatory side. 
But as we all know, this is the last year of a two-term 
President, and I think there are many that have said there has 
been time that was wasted here, and it's unfortunate that we're 
just seeing it on the way out.
    Now, I am told that the agency has still failed to settle 
about 30 percent of all the contract support cost claims filed 
against it by tribes, and this dates back many years. Where are 
you on prioritizing the conclusion of all the outstanding 
claims that are currently on file? If you can just give me an 
update on that.
    Ms. Smith. Yes. Thank you, Senator, for asking about the 
settling of the contract support cost claims. You are about 
right. My understanding is we have settled about 75 percent of 
those, and my understanding is that a majority of the remaining 
ones are ones for more recent years. So I understand that we 
have worked through the longer-standing disputes, and we are 
working on more recent cases as a general matter. So we are 
committed to continuing to resolve those and paying full 
contract support costs.
    Senator Murkowski. Who is in charge of executing that plan 
just in terms of making sure you move through as many of them 
as quickly as possible?
    Ms. Smith. I think that, obviously, as head of the agency, 
ultimate responsibility is with me. But I know that Ms. Fowler, 
in her role in Management and Operations, oversees and works 
very closely with our Office of General Counsel to ensure that 
these are a priority, and we continue to make progress on the 
settlements.
    Senator Murkowski. I know that that continues to be a very, 
very high priority.

                         VILLAGE BUILT CLINICS

    In my last minute here, I want to raise the issue of 
village-built clinics. As you know, this is an issue that I 
have raised for years with your predecessor and, quite 
honestly, gotten nowhere, gotten nowhere, which was very, very 
frustrating. Last year we were able to include $2 million to 
help address the issue of village-built clinics. We've got 
about 150 in my State, many of them being the only local 
options for any healthcare. Many have serious maintenance 
needs, and again the frustration was your predecessor said 
basically that the tribes are responsible for paying these 
costs out of other funds that they get from the Service. That 
just was not right.
    So again, we've got $2 million to help address it, but this 
issue I hear more from local folks than just about anything 
else when I'm out in the villages. So can you tell me how the 
agency plans to allocate these funds and when they will be 
distributed?
    Ms. Smith. Thanks, Senator, for that question. I'm glad you 
asked about it because one of the first things that I was 
looking into when I started last fall was I did see that you 
had spent over a year asking about this issue.
    Senator Murkowski. It was like every hearing on an annual 
basis.
    Ms. Smith. Yes, yes, and I read all your correspondence, 
and I started talking to people at the agency, including Ms. 
Fowler, and it seemed to me that there was a gap there of 
something that we needed to address.
    So we worked out a way--there's $2 million in the fiscal 
year 2016 budget, but I'm pleased to say also we have now 
created a line item in the fiscal year 2017 budget for $9 
million to fund clinics of this type. As you pointed out, a 
majority of them, I believe, are in Alaska, but I do believe 
there might be some in the other 48 States, and we wanted to 
make sure that everyone who was in this gap category would be 
covered.
    So with respect to the $2 million in the fiscal year 2016 
budget, we are going to start a tribal consultation to ensure 
that these funds are distributed where they're needed, and 
equitably. As you mentioned, there are quite a number of 
clinics in Alaska, and I have also personally read--I know the 
Alaska Health Board wrote a fantastic report just on the 
maintenance that's needed on these village-built clinics.
    So I know that our area director in Alaska will be doing a 
consultation to----
    Senator Murkowski. Will that be pretty soon, then?
    Ms. Smith. Yes, it will be soon.
    Senator Murkowski. All right. Well, we will look forward to 
that. I appreciate working with you on it. As you are aware, 
the need is great, and we appreciate the increase that we will 
see in this account.
    Let me turn to my ranking member.
    Okay, Senator Tester.
    Senator Tester. Thank you, Madam Chair, and I want to thank 
the ranking member for his courtesy.

                               IHS BUDGET

    There is an expectation that Indian Health Service provides 
the healthcare that we expect. It's a direct responsibility. 
We've heard issues of life and limb in the past where IHS has 
run out of money, and then there have been the issues with 
contract care that the Chairman brought up.
    This budget is increased by $377 million, which is a lot of 
money. But is it enough when you consider that IHS is currently 
at 50 percent of what we spend on veterans and probably the 
least amount of money we spend for healthcare of any group that 
the Federal Government supports? So tell me about this budget. 
Tell me where it's at. Tell me if it's adequate.
    Ms. Smith. Senator Tester, thanks so much for your 
question. As you mentioned, this budget has a total of $402 
million increase, and as I mentioned in my opening statement, 
if enacted, that would represent a 53 percent increase since 
fiscal year 2008.
    We believe that this budget is a strong budget put forth by 
the President that focuses on critical needs such as staffing, 
behavioral health issues, and critical needs in housing and 
facilities. So we do believe that it makes important progress.

                                STAFFING

    Senator Tester. Let's talk about staffing for a second, 
because that's a problem. What is the plan? What is the plan to 
get folks on and retain those folks?
    Ms. Smith. Thanks, Senator. Yes, what I want to say at the 
outset, and I want to be very honest with this committee, we, I 
think along with any agency that provides services in rural 
remote locations, we have problems with staffing, including 
recruiting and retaining staff, particularly medical staff.
    Senator Tester. That's correct. So what are we going to do 
about it?
    Ms. Smith. We have to have, I think, a multi-prong 
approach. So what we are doing, for instance in the Great 
Plains now, in the very short term we are working with 
deployments of Commissioned Corps. We are also looking into 
contracting for staffing, and then we are also working very 
vigorously on permanent staffing. Just last week, I'm pleased 
to report, we were able to get an approval and a pay package 
for emergency rooms so that we are able to pay more now.
    Senator Tester. So can I ask you, is what you pay your 
staff for equivalent capabilities competitive with the VA?
    Ms. Smith. Not in all instances, Senator, no.
    Senator Tester. And why is that?

                                TITLE 38

    Ms. Smith. We use Title 38, which is also the pay scale 
that VA uses. We have some of the authorities in the pay scale. 
We can pay certain special salaries. We can pay some market 
pay. But we don't have the full Title 38 authorities.
    Senator Tester. Have you guys made a recommendation to give 
yourselves some more flexibility in that area?
    Ms. Smith. We are discussing it and we have, like I said, 
done some proposals, and I know we are working on a number of 
items.

                                STAFFING

    Senator Tester. Look, healthcare in Indian Country is a 
great experience because you get to deal with a myriad of 
problems, but it's very difficult to get people to come if they 
know they've got to take a pay cut to come. So if you need 
flexibility, I wish the Department would make that 
recommendation to the Chair and ranking member so we could 
analyze that and maybe pursue it, and the same thing with the 
Indian Affairs Committee, Senator Barrasso and myself.

                           MEDICAID EXPANSION

    Let me talk about Medicaid expansion very quickly. Some 
States have done it, some States haven't. Montana just did it. 
I think it's a good thing. I think it's a good thing for Native 
Americans. This budget is for the whole country. Some States 
don't have Medicaid expansion. I understand that States that do 
have Medicaid expansion, these IHS dollars have been able to go 
further. Is that correct? Yes?
    Ms. Smith. Yes, that's correct, Senator.
    Senator Tester. So what about the States that don't have 
Medicaid expansion? What do we do about that from an Indian 
health standpoint? Because it appears to me we could have two 
classes of Native Americans out there.
    Ms. Smith. No, Senator, thanks so much for your question, 
and you are correct. I do think that in States where Medicaid 
has been expanded, we are able to leverage our dollars further, 
particularly with respect to our purchase referred care 
program, and your point is well taken. We do not want to create 
different classes of Native Americans because everyone who is 
eligible for IHS should receive the same standard of quality 
care.
    So I know we are working very intensely on that and making 
sure that the provider agreements we have create equity among 
the people that we serve.

                          THIRD-PARTY BILLING

    Senator Tester. Okay. How much success are you having with 
tribes and third-party billing? If they don't bill third party, 
then the dollars can't be extended out further. Are tribes on 
board with this or are they balking at it?
    Ms. Smith. You mean when they run their own program?
    Senator Tester. Yes, that's correct.
    Ms. Smith. I do believe that they are doing that, but we 
don't actually have a lot of information on which tribes run 
their programs.
    Senator Tester. All right. How about IHS themselves?
    Ms. Smith. Yes. Every year I think we have steadily 
increased our third-party billing, and we have adopted a number 
of practices at our business office that we are disseminating 
across the field to further leverage----
    Senator Tester. Do you have the figures on how much that 
third-party billing has brought into the program?
    Ms. Smith. Yes. I think for fiscal year 2017, I think we're 
estimated to be at about $1.2 billion of third-party billing.
    Senator Tester. And how much of that is your total budget, 
then?
    Ms. Smith. Our total budget is $6.5 billion, including the 
mandatory----
    Senator Tester. It's significant.
    Ms. Smith. Yes.
    Senator Tester. Okay. Thank you, Mary.
    Thank you, Madam Chairman.
    Thank you, ranking member.
    Senator Murkowski. Senator Daines.
    Senator Daines. Thank you, Madam Chair.
    It's very good to have you here today.

                          HEALTHCARE OUTCOMES

    Recently we had Jace Killsback from Indian Affairs 
Committee. He's Executive Health Manager for Northern Cheyenne 
Tribal Board of Health. In IHS testimony last month he said, 
and I quote, ``It has become normal and okay to be misdiagnosed 
and to wait until you're going to lose a leg or your life to 
receive the right healthcare that you need.''
    I know as I travel around Indian Country in Montana, there 
aren't a lot of folks back home that are real happy with the 
outcomes. We've heard a lot today about spending on various 
programs, not much on concrete outcomes for tribal communities.
    Just a question. What would you say are two or three of the 
most important metrics you look at in terms of outcomes in 
terms of improving Indian health that you evaluate here in 
terms of whether it's working or not?
    Ms. Smith. I think we have very important outcomes in 
several areas. One is I think we have made tremendous strides 
with addressing diabetes in Indian Country. The childhood 
obesity rate is going down, and also I think the incidence of 
Type II diabetes has stabilized over the past few years. That's 
one example.
    Senator Daines. If you were to try to take it up to the--I 
mean, you quote a couple where we have made some progress, but 
if you just kind of step back and try to evaluate the success 
or failures of a program, what are the top three outcomes you 
say really are good measures in terms of whether or not we're 
improving health in Indian Country?
    Ms. Smith. I think, Senator, one top-line measure would 
certainly be the overall life expectancy in Indian Country, 
where I think we've shown progress over the years, over a long 
term. That would be one high-level measure.
    Senator Daines. What else?
    Ms. Smith. I think looking at health disparities across 
other populations would be a good measure. I know that there 
has been some progress made, but more progress needs to be made 
on those health disparities.
    Senator Daines. My concern in looking at the testimony here 
is we've invested another $2 billion in IHS. It looks like 
round numbers here. You mentioned the 53 percent increase if 
funded at the President's request versus 2008. So if we put 
approximately $2 billion more, plus or minus the programs, and 
that's relative to about a $4 billion base, roughly, add 
another $2 billion, the question is what's improved because of 
that? I hear, again, a lot of concerns about outcomes in Indian 
Country. I don't hear a lot of feedback to say we're very 
pleased with IHS. To the contrary, I think virtually everywhere 
I go I hear about the challenges and the failures of the 
program.
    Ms. Smith. Yes, Senator, I share your concerns. I know that 
there are a lot of issues. I know that I have heard personally 
myself from a number of patients and people in tribal 
communities, but I do think there are a lot of dedicated people 
who work at IHS as well, and I know that there's also a lot of 
good work. But that's not to diminish the challenges that you 
are talking about.
    Senator Daines. My request would be when we look at 
budgets, of course you've got to look at where the spending is 
going to be, but also to bring the outcomes, bring the metrics. 
Let's go back to 2008, or let's say a 5-year timeline, are we 
getting better or not. What are the top three to five measures 
that really help us understand better is Indian health getting 
better or is it getting worse as we look at the investment 
choices and prioritizing on it.

                          ADMINISTRATIVE COSTS

    And along that line, when Dr. Roubideaux was here, she 
cited the IHS admin costs at around 10 to 11 percent of the 
total. It looks like now--well, let me ask you, what are the 
admin costs as a percentage of the overall budget for this 
year?
    Ms. Smith. I think the IHS-wide administrative costs are at 
12 percent, and then some of the areas are lower than that.
    Senator Daines. Overall. I'm just looking at what Dr. 
Roubideaux told us, the 12 percent. It looks like the 
percentage of administrative costs are actually going up versus 
going down. And typically when budgets are increasing 
oftentimes, because you have a bigger denominator, the admin 
costs will start going down. Having spent many, many years 
doing budgets in the private sector, why are admin costs going 
up?
    Ms. Smith. Senator, I'd have to look back at the number 
that Dr. Roubideaux gave you. I'm not aware that they're going 
up between 11 and 12, but we can certainly look at that, and I 
will say that we are committed to--I think your points are well 
taken. We are committed to ensuring that we are efficient in 
how we spend the funds and that we have deliverable outcomes 
and metrics and timelines for achieving results.
    Senator Daines. Yes, and part of the overall challenge 
here, I'd like to see some clear goals set, that we want to 
take admin costs as a percentage--if they're at 12 percent 
today, how do we get to 11 percent, 10 percent, and 9 percent 
over the course of the next 3 or 4 years? Because every dollar 
that's spent in admin arguably is a dollar getting taken out of 
the help that people here who need it the most in Indian 
Country.
    Ms. Smith. Yes, Senator, thank you so much, and we 
definitely can take a look at that. I share your thoughts on 
that.
    Senator Daines. And again, this is just my concern. This 
disproportionate spending on admin costs doesn't translate into 
better care in Indian Country. A recent study showed in Montana 
that white men live 19 years longer than American Indian men, 
and white women live 20 years longer than American Indian 
women. I know there are other factors involved, but I do 
believe it's unacceptable that we've reached disparities like 
these under the watch of IHS, and I urge you to address the 
real health challenges facing Indian Country and really turn 
the focus back to results versus just activities.
    Ms. Smith. Thank you, Senator, and I totally agree, and 
that is a point well taken.
    Senator Daines. All right. Thank you.
    Senator Murkowski. The ranking member has asked that we 
defer to Senator Merkley from Oregon.
    Senator Merkley. Thank you very much to the ranking member, 
I appreciate that.

                            HEALTHCARE COSTS

    I appreciate this conversation about the Indian Health 
Service. It certainly serves a vital role in many parts of my 
home State of Oregon. One thing I was looking at was a number I 
found very interesting, and that is the number that, per 
patient, the Indian Health Service spends about $3,100 compared 
to, say, Medicare, at almost $12,000, or the national average 
for those who are not in either Medicaid, Medicare, Veterans, 
et cetera, of about $8,100. So $3,100 sounds like a very low 
number.
    Is that so low in part because there are lots of folks who 
qualify who don't actually utilize the Indian Health Service, 
they live in urban areas and have other health service 
providers, or is that just a reflection of how desperately 
underfunded IHS is?
    Ms. Smith. Thank you, Senator. I think the number that you 
are referencing is the per capita funding for certain Federal 
programs that provide healthcare. The per capita funding for 
IHS is, as you correctly stated, about $3,100 per capita. I 
think the number is derived from our total population served, 
about 2.2 million, and then dividing out our budget. So I think 
that's how the number is derived.
    Senator Merkley. So of those 2.2 million who are eligible, 
how many in a given year utilize the IHS as their primary 
health provider?
    Ms. Smith. Senator, I would have to get back with you on 
that, but we're happy to provide an answer.
    [The information follows:]
    
    
    
    

 
 
 
1. $12,179--2014 AVERAGE MEDICARE BENEFIT PER ENROLLEE: Source--2015
 ANNUAL REPORT OF THE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL
 INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS;
 available at https://www.cms.gov/Research-Statistics-Data-and-Systems/
 Statistics-Trends-and-Reports/ReportsTrustPFunds/Downloads/TR2015.pdf
 in Table II.B1 Medicare Data for 2014, page 11.
 
2. $8,517--PROJECTED 2015 NATIONAL HEALTH CARE EXPENDITURES PER CAPITA:
 Source--Table 5 Personal Health Care Expenditures; Aggregate and per
 Capital Amounts, Percent Distribution and Annual Percent Change by
 Source of Funds: Calendar Years 2014-2024; available at https://
 www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
 Reports/NationalHealthExpendData/Downloads/Proj2014tables.zip.
 
3. $8,760--2015 CURRENT ESTIMATE OBLIGATIONS PER UNIQUE PATIENT: Source--
 Volume II--Medical Programs and Information Technology Programs--
 Congressional Submission, available http://www.va.gov/budget/docs/
 summary/FY2016-Volumell-MedicalProgramsAndInformationTechnology.pdf
 (page VHA-23).
 
4. $5,790--2011 MEDICAID SPENDING PER ENROLLEE. Spending per enrollee
 calculations includes both state and federal payments to Medicaid.
 These figures represent the average (mean) level of payments across all
 Medicaid enrollees, including those receiving full or partial Medicaid
 benefits, during federal fiscal year 2011, based on date of payment.
 Available at http://kff.org/medicaid/state-indicator/medicaid-spending-
 per-enrollee/.
 
5. $5,460--FDI BENCHMARK PER IHS USER (Interim Inflated to 2015): The
 ACA expands health care resources potentially available to AIANs. IHS'
 long standing methodology projecting per-capita resource needs has not
 yet incorporated these factors due to unavailable data. In the interim,
 the last benchmark was inflated to 2015 pending future methodological
 adjustments for ACA effects.
 
6. $3,136--2014 IHS MEDICAL CARE EXPENDITURES PER USER*: Source--IHS
 appropriations for 2015. Appropriations spent for personal health care
 services plus IHS collections from third parties are totaled and
 divided by 2015 user counts (1,613,450). IHS spends an additional $524
 per person for *OTHER public health, community programs, sanitation and
 environmental projects, education, and other purposes unrelated to
 personal medical care. An unknown additional amount of spending occurs
 outside the IHS system when patients obtain a portion of their medical
 services elsewhere, e.g. payments by private insurance, Medicare and
 Medicaid to non-IHS providers for services to Indians who also use the
 IHS.
------------------------------------------------------------------------
 
* Payments by other sources for medical services provided to AIANs
  outside IHS is unknown.


    Senator Merkley. That would be helpful to try to understand 
really how this compares to other healthcare settings.

                              TELEMEDICINE

    I wanted to turn to telemedicine. I believe that in Alaska, 
and the Chair will correct me if I'm wrong about this, that 
they have piloted the Dental Health Aide Therapist Program to 
provide telemedicine in dental care. This trains tribal members 
to become mid-level dental professionals, 2 years of training. 
It provides care such as oral exams, cleaning, fluoride 
treatments, sealants, x-rays, crowns, extractions, while doing 
it through a video conference with a dentist. Has this worked 
well in Alaska?
    Senator Murkowski. Well, I will let Ms. Smith speak to it. 
I think everything that you have said is correct, although the 
dental health therapists don't do the extractions necessarily, 
but it has proven to be phenomenally successful to get mid-
level providers out in areas where we would never find the full 
provider.
    Senator Merkley. Well, the reason I wanted to raise this is 
I'd heard rave reviews about Alaska, and Oregon is the first 
State outside of Alaska to provide this. I believe that we had 
to pass a State law to authorize it. Given the success and the 
cost-effectiveness of this, is this something that the Indian 
Health Service is hoping to expand substantially?
    Ms. Smith. Thank you, Senator, for your question. I agree 
with the premise of your question. I think they're doing some 
amazing, innovative things in Alaska and serving the community 
well, and this is one example. I think your question, you 
mentioned it in the dental context, but I think the premise of 
your question I think expands more broadly on how can we 
leverage resources and how can we leverage the use of 
telemedicine. I can tell you that we are very committed to 
doing that because, as was mentioned earlier, we have 
significant staffing challenges, and we have to think 
creatively, and everything has to be on the table. I think 
telemedicine is one of the ways, along with a lot of other 
things, that we can leverage those resources.
    I know that we are using telemedicine for behavioral 
health. We have the Telehealth Center of Excellence that's in 
partnership with the University of New Mexico, and we are doing 
several sites in the Great Plains, for instance. We actually 
just--we're going to do a telemedicine area-wide contract in 
the Great Plains that is in process now, and one of the things 
last week we actually had our budget formulation workgroups, 
and I think one of the things we would like to see on a going-
forward basis is a more concerted effort nationally to focus on 
telemedicine.
    Senator Merkley. Well, thank you. I think that's an area 
where we can help address some of the concerns that Senator 
Daines was mentioning in terms of how do we get more outcomes 
for the dollars invested.

                         CONTRACT SUPPORT COSTS

    I did want to ask about contract support costs. My 
understanding is that this budget line pays for tribes for 
things such as financial management accounting, training, 
program startup, but that pretty much it has had a substantial 
shortfall, and you're recommending an $82 million increase. Is 
that based on a certain percent of assistance to tribes for 
administrative overhead? How is that calculated, and how much 
of a difference will that make?
    Ms. Smith. Thanks, Senator. I will answer at a high level, 
and if you need more detail we're happy to get that to you. I 
understand that there was an estimate made in consultation with 
tribes, and after the Supreme Court's decision in Ramah we are 
obviously fully supportive of the full contract support costs, 
and I personally actually have spent a lot of time. We are 
actually going to be putting forth a new contract support cost 
policy this year with IHS. But I've spent a lot of time with 
the Contract Support Cost Working Group and I understand, even 
from our tribal partners, that the number that we have put 
forward is on the generous end of the estimate, and I do 
believe that it will fully fund contract support costs.
    Senator Merkley. Thank you very much, and thank you for 
your very--you said you hadn't been there that long, but you're 
presenting very thorough responses to all of our questions, and 
it gives me great confidence in IHS going forward. Thank you.
    Senator Murkowski. Thank you, Senator Merkley.
    Senator Udall.

                            SUBSTANCE ABUSE

    Senator Udall. Thank you, Madam Chair and Deputy Director 
Smith. I'm very pleased to see that you've included a 14 
percent increase for alcohol and substance abuse programs as 
part of your 2017 budget request. I've already had the chance 
to visit with you about a particular issue in New Mexico that 
has to do with the Gallup detox center. It's also called NCI 
(Na'nizhoozhi Center Inc.). I wanted to raise this issue again 
this morning and ask for your help.
    As I've mentioned, the center has been providing 
detoxification services to the Gallup community for more than 
20 years. In a community struggling to reduce exposure deaths 
related to alcohol and substance abuse, the services it 
provides literally mean the difference between life or death.
    Twenty-five people have died from alcohol-related exposure 
incidents between this winter and last winter, with the recent 
report of another death just 2 weeks ago. There were five 
deaths this January alone. According to the center's director, 
they have admitted more than 2,500 individuals since October 
2015, which is approximately 10 percent of the population of 
Gallup.
    The need is clearly there, and the community is desperate 
to maintain these life-saving services. Over the past few years 
NCI has lost some of the funding that it received from Indian 
Health Service and other sources, and the center has been on 
the brink of closure ever since.
    I'm grateful that the Indian Health Service just stepped up 
to the plate to provide some emergency funding to help keep the 
center open through June 30, funding that was particularly 
critical to keep it open through the coldest winter months, 
when the risk of weather-related deaths is the highest. But 
that's just a temporary fix, and we must do more.
    I want to work with all the partners involved with NCI, 
IHS, the tribe, the State and the city to come up with a plan 
to provide sustainable funding. Senator Heinrich and 
Congressman Ben Lujan have been great partners on this issue, 
and we have all been working together to find a way forward and 
to encourage communication between the local stakeholders.
    Can I have your commitment that you will work with me and 
with members of the delegation to develop a long-term plan to 
keep the center open so it can continue to provide essential 
services?
    Ms. Smith. Senator, first I want to thank you for your 
leadership and all that you've done to help that situation, and 
you do have my commitment. As we've talked about at this 
hearing, there are great issues of alcohol and substance abuse 
in Indian Country, and since we talked I've been thinking about 
this issue a lot, and to me it's similar to the village-built 
clinic. This is like a gap that we're not addressing, and I am 
committed to working with you to find a sustainable solution.
    Senator Udall. Thank you so much for that. We've talked 
specifically about the needs in Gallup, but obviously, as 
you've just said, substance abuse treatment is a critical need 
in many of our Native communities, and I continue to hear from 
tribal leaders in New Mexico, including the Mescalero Apache 
Tribe and others who are concerned for the well-being of their 
people. That's why I'm pleased to see we were able to provide a 
$10 million increase for alcohol and substance abuse treatment 
as part of the 2016 omnibus.
    Could you tell us more about how these increased funds will 
be used, what improvements in counseling and treatment services 
will these additional resources provide, and how soon will 
these improvements be available to tribes?

                           BEHAVIORAL HEALTH

    Ms. Smith. Thank you, Senator, so much for highlighting the 
great need we have for behavioral health issues in Indian 
Country, and we appreciate all your help and leadership on that 
issue.
    Our fiscal year 2017 budget, we actually have $46 million 
to focus on critical behavioral health needs. $15 million of 
that is for the generation of indigenous substance abuse and 
suicide prevention projects to increase the number of child and 
adolescent behavioral health professionals. We have $21 million 
to fund continuing integration of behavioral health services 
throughout our IHS system. We have $4 million to fund pilot 
projects for Zero Suicide Initiative. We have $2 million to 
fund another gap that I think we realized is for after-care, 
after people leave regional youth treatment centers. So we have 
a $2 million pilot project for that, and then we have $4 
million for domestic violence prevention to fund 30 additional 
organizations.
    Senator Udall. Are you able, when you ramp up like this, 
able to get the funds and the resources down to the ground 
quickly?
    Ms. Smith. I think we are able to do that. I know that even 
since the time that I've been at IHS, we have had a number of 
tribes who have had what I'll call behavioral health crises, 
and one of the things I know a number of us have been working 
on at IHS as well is that sometimes grant programs are timed a 
certain way and you cannot time when a behavioral health crisis 
happens. So one of the things that I am particularly excited 
about in our budget is we have $15 million for a new Tribal 
Crisis Response Fund so that those funds will be immediately 
available upon the request of a tribe when they're having a 
behavioral health crisis in their community.
    Senator Udall. Thank you very much.
    Thanks, Madam Chair.

                      SUICIDE AND SUBSTANCE ABUSE

    Senator Murkowski. Thank you, Senator Udall. I appreciate 
your focus on these issues of suicide, substance abuse. Know 
that this is something that I really want us to try to focus on 
within this IHS budget. I think there are so many other areas 
that we can look to. We're going to have a hearing this 
afternoon in Indian Affairs on the budget as it relates to 
Indian Affairs. I think about the job creation programs and the 
other things that we will do, education. But if, in fact, our 
Native peoples are not healthy, it makes it difficult to really 
be there to provide much else. So making sure that they have 
hope, that they do not view suicide as an answer or that they 
turn to substance abuse that not only takes them down but their 
families down and their whole communities is just so key.
    I mentioned complex trauma in my opening remarks. Your 
budget request talks briefly about it, but know that, again, 
that's something where we'd like to have better understanding.
    You mentioned this integrated approach to addressing 
primary healthcare, mental health and substance abuse 
disorders. I know that you have made some commitment to some of 
our tribes to perhaps come up to Alaska sometime this summer, 
but I do hope that you will take full advantage of visiting 
with the folks at South Central Foundation to really come to 
understand what they have done with the Nuka model, which is 
truly this integrated, whole-person approach to providing 
healthcare services. It's a model that is not only being built 
on within the State of Alaska but really around the country and 
as an international model. It's not too often that in Alaska we 
are leading the way in healthcare reform, but I view what 
Katherine Gottlieb and those at South Central have done over 
the years with the Nuka model as not only innovative and 
pioneering, it's the way of the future. I would certainly 
commend that to you as you're talking about this integrated 
approach.
    I mean, if you'd care to make any comments about that, I'm 
happy to hear them.
    Ms. Smith. Senator, I completely agree. Healthcare needs to 
be integrated in all facets of life, and it's family, tribe, 
and community. I look forward to a trip to Alaska. I'm 
committed, and I certainly look forward to learning more about 
that because I have heard of all the innovative things that are 
happening in Alaska and I hope to learn a lot and see if 
there's any way we can replicate some of those best practices 
elsewhere in the country. So, thank you so much.

                          DEFINITION OF INDIAN

    Senator Murkowski. We certainly believe we can, and we're 
ready to show you.
    Let me ask about a technical thing. This is the definition 
of ``Indian'' under the Affordable Care Act. We continue to 
hear the complaints about the inconsistent definition that is 
contained in that Act that has caused confusion and 
inconsistent treatment, unfortunately. A person who is an 
Indian for purposes of Indian Health Service programs and for 
Medicaid is not treated as an Indian for purposes of the ACA--
incredible. And yet we knew that this was an issue coming 
forward. The National Congress of American Indians (NCAI) 
weighed in, the National Indian Health Board, and yet the 
administration chose to interpret the legislation in a way that 
really created a problem.
    We believe that there is authority within the 
administration to grant regulatory waivers, but it hasn't taken 
action to ensure that the benefits of open enrollment and 
protection from cost-sharing would be available to all Indians. 
We asked the administration to fix this administratively, but 
they haven't. We included report language in the fiscal year 
2015 omnibus containing a directive to work together to 
establish a consistent definition of ``Indian'' for purposes of 
providing health benefits.
    What's the administration going to do this year to fix the 
problem? Because it really needs to be addressed.
    Ms. Smith. No. Thank you so much, Senator, for your 
leadership. I know you have also been advocating for this for a 
long time, and I have also looked into this since I've been 
there. The definition definitely should be consistent, and as 
part of our fiscal year 2017 budget proposal we have a 
legislative proposal to make the fix. I think there's been a 
determination that this needs to be done legislatively.
    Senator Murkowski. Well, I understand that. But I also 
understand that the ACA passed at the beginning of this 
administration. It is now the end of this administration. And I 
understand that it didn't come into play until a couple of 
years ago. But in the interim, again, you have American 
Indians, Alaska Natives that are just kind of caught in this 
back and forth. It was just so, so unnecessary.
    So I appreciate the administration coming forward and 
saying, well, now we think we need legislation. Before they 
were looking at administrative fixes. So I know that I'm just 
taking on the messenger here, but I think it needs to be made 
very clear that this became a problem when it didn't need to be 
a problem, and it could have been remedied. If the 
administration determined it needed legislation, we've been 
prepared to address it, and it's just been a failure, so know 
that it's been a priority.

                     PRIORITY LIST AND CONSTRUCTION

    Let me ask a question about two very small communities in 
Alaska, Gambell and Sevoonga. They are located on St. Lawrence 
Island out in the middle of the Bering Sea. You want to talk 
about remote, it does not get any more remote than Gambell and 
Sevoonga. They are communities that have roughly 700 people 
each. The only way you can get there is by airplane, and more 
often than not the weather is not very forgiving. The existing 
facilities are old, old, old and really rundown. I have seen 
the facility there at Sevoonga, but they are simply 
unacceptable in terms of their condition.
    The Norton Sound Health Corporation, along with some very 
dedicated folks from Gambell and Sevoonga, have tried to get 
Federal financing to construct new clinics. They were in to 
visit with me about a month ago. We sent a letter to the 
Department and were told that the current IHS healthcare 
facilities priority list has a $2 billion backlog of projects 
and that you can't add any new projects to the list, which for 
the people of Gambell and Sevoonga is incredible. You've got to 
be kidding me. There's no way to possibly provide some upgrades 
to a situation that is in desperate need.
    So, first of all, I want to know whether or not that is 
still your position, that they cannot be added to the list. And 
second, I want to ask about the small ambulatory clinic 
program. For the first time since 2008, the agency has 
requested funds for this program. There's $10 million in it. 
Would Gambell and Sevoonga be eligible for funding for this 
program if funds were to be provided? As you can probably 
understand, the people in these two communities are really most 
desperate and are seeking some answers. So if you could provide 
me something here today, that would be helpful.
    Ms. Smith. Thanks, Senator. I certainly can appreciate your 
frustration. I get frustrated, too. As you correctly mentioned, 
we have a list of priority projects that actually gets approved 
by Congress, and there is a $2 billion backlog. I wish that we 
had more flexibility with the list. Unfortunately, that's the 
way the system is set up. So I think adding to the list, we 
don't actually have flexibility at IHS. Congress dictates how 
we have to move through the list. So I appreciate your 
frustration.
    In terms of other options or trying to think creatively how 
to address this issue, and I know you've raised the small 
ambulatory clinic, if I may defer to Mr. Hartz to see IHS 
thoughts on that.
    Senator Murkowski. Mr. Hartz.

                        SMALL AMBULATORY PROGRAM

    Mr. Hartz. Thank you, Senator. The small ambulatory program 
is one of the programs to be considered for Sevoonga and 
Gambell. There are criteria, and we'd be happy to send in 
advance of even the solicitation, we would go ahead and send to 
Manilick what the criteria were when we last implemented the 
program so that they can get some idea of the specifics of 
that.
    Furthermore, we understand that those two locations are 
considering applying under the tribally built program for 
equipment, and they certainly would be strongly considered for 
equipment dollar support should they move forward as a tribally 
built facility.

                             JOINT VENTURE

    So there are some options available, and the most popular 
program is the JV, the joint venture program that's been 
utilized throughout Indian Country, and that would be another 
option should they consider the next solicitation.
    Senator Murkowski. Thank you, Mr. Hartz and Ms. Smith. Know 
that we will continue to try to work with you on this.
    Ms. Smith, I know it is a long way out of the path of 
Anchorage or Fairbanks where you will likely be, but I do think 
that when you visit it would be most important to get out to 
some of our smaller villages and see the needs and how 
isolation really makes imperative the need to have some 
facilities out there.
    Let me turn to my colleague here, Senator Udall.

                                STAFFING

    Senator Udall. Thank you, Madam Chair.
    Deputy Director Smith, New Mexico emergency medical 
services were halted last year at an IHS medical center in 
Crownpoint, New Mexico. This was due in part to staffing 
issues, though some emergency services were ultimately 
restored. I'm told the hospital is still unable to provide 
certain medical services like labor and delivery. My concerns 
about this situation are amplified by the problems that the 
service is having in other areas like the Great Plains, where 
multiple facilities are on the brink of losing their 
accreditation, and other tribes there have faced the loss of 
emergency services as well as substandard care.
    It goes without saying that patients deserve competent and 
timely care. It's absolutely intolerable for any IHS emergency 
facility to close for any amount of time, and cutbacks to 
essential services like obstetrics are also unacceptable.
    Can you talk about what the IHS is specifically doing to 
address staffing shortages at Crownpoint and other facilities 
in New Mexico?
    Ms. Smith. Thank you, Senator. Yes, we certainly agree with 
you on access to quality care and certain services being 
provided. I know that across the agency, including at 
Crownpoint, we are looking at staffing issues, like I said kind 
of in three simultaneous ways, in the short term, in the 
intermediate term and the longer-term sustainable solutions. So 
we are definitely working on that and it is certainly a 
priority for us.
    Senator Udall. And are you able to tell me today anything 
specific about Crownpoint, or would you rather do that----
    Ms. Smith. Yes, I have one specific. I know that the 
quarters are being upgraded out at Crownpoint, so I'm able to 
tell you that today.
    Senator Udall. Okay, thank you. Maybe you can update me on 
additional things in the record for specifically what we're 
doing out at Crownpoint.
    Ms. Smith. I certainly will.
    Senator Udall. On a related note, I'd like to raise the 
concerns I'm hearing about service reductions at the Santa Fe 
Indian Hospital. This is an issue that was brought to my 
attention recently by the Pueblo of Tesuque. Deputy Director 
Smith, I'd like to ask for your help in reviewing the situation 
with the hospital, and I'm going to ask you to provide some 
data for the record regarding services and staffing levels so 
that we can get to the bottom of these concerns. Would you work 
with me on this issue?
    Ms. Smith. Senator, we will certainly work with you and 
your staff on this issue and get you whatever answers and work 
together to find a solution. Thank you.
    Senator Udall. Great, thank you.

                   LOAN REPAYMENT AND STAFF QUARTERS

    On the issue of loan repayment and staff quarters and 
things like that, as you know the Indian Health Service 
currently spends an estimated 30 percent of its health 
professions account to pay taxes to the Federal Government, 
taking needed funding away from investments in skilled medical 
professionals. I've introduced a bill with the Chairman, 
Senator Murkowski, that will make the IHS Health Professions 
Awards Program exempt from a Federal income tax requirement, 
and I'm pleased to see that your budget includes a similar 
proposal.
    Can you talk about the importance of this specific issue 
for recruitment purposes? And if this proposal would be 
enacted, how many additional scholarships and loans could IHS 
provide with the existing resources?
    Ms. Smith. Thank you so much, Senator, and thank you so 
much for your leadership on this issue. All 100 percent of the 
dollars for both the scholarships and loans can go for the 
purposes for which they're intended rather than taxes. As you 
mentioned, we do support that proposal. I understand that if 
the proposal went forward, that would free up $11 million, $8 
million of it for loan repayment and $3 million for 
scholarships, and I think that would allow us to do 200 more 
loan recipients. So, thank you so much.
    Senator Udall. Well, we haven't gotten it done yet, but we 
look forward to working on this and actually accomplishing 
this. It helps a lot that the Chairman is also the chairman of 
the authorizing committee.

                        FACILITIES CONSTRUCTION

    I'm pleased that this subcommittee was able to provide $63 
million in new funds for construction and maintenance needs as 
part of the 2016 omnibus, and I'm pleased to see that you build 
on that request in your 2017 budget by asking for another 9 
percent increase. We really need these kinds of things to 
happen in Indian Country. The issue is particularly important 
to me because there are a number of tribal health facilities in 
New Mexico that have been waiting their turn on the IHS 
priority list for years. These include outpatient facilities in 
Alamo, Pueblo Pintado, and Albuquerque. And, of course, we also 
have the replacement of the Gallup hospital on the list.
    How long will it take at current funding levels to complete 
work on the current priority list? Is it fair to say that 
should additional resources become available, that you would be 
in a position to accelerate this timetable?
    Ms. Smith. Senator, thanks so much for your question. Yes, 
I do understand, I think. This is a ballpark estimate. I think 
it's in the nature of 18 to 20 years to fully fund all the 
needs that there would be, and certainly if there were more 
funding we would be able to do more projects.
    Senator Udall. And I understand that the Alamo facility is 
next up for funding on the priority list, but it's not part of 
your fiscal year 2017 request. What's the earliest we can 
expect to see funding for that project?
    Ms. Smith. I will defer to Mr. Hartz on this question.
    Mr. Hartz. Thank you, Senator. You are correct, it is the 
next project on the outpatient list. Based on the current level 
of funding, it would probably be reached within the next 2 
years.
    Senator Udall. Thank you.
    Maybe I'll come back with this one. Thank you, Madam Chair.
    Senator Murkowski. Thank you.

                        FACILITIES CONSTRUCTION

    I want to ask one more Alaska-specific question, and then I 
want to turn my attention to what I raised in my opening, which 
is the situation at Rosebud.
    But first, I want to ask specifically about Southeast 
Alaska. The Mount Edgecombe service unit is an area, it's about 
35,000 square miles but entirely tribally operated, mostly by 
the Southeast Alaska Regional Health Consortium, SEARHC. It is 
anchored by about a 70-year-old hospital there in Sitka that 
was built just after World War II by the War Department. It's 
in pretty tough shape. I will just tell you that. It's ill-
suited to the 21st century model of healthcare that's dominated 
by primary and ambulatory care facilities. What we have seen in 
Southeast in particular has been more facilities focused on 
localized care provided through 13 clinics serving 18 Alaska 
communities.
    What is Indian Health Service doing to collaborate with 
SEARHC in the development of a plan moving forward for how we 
provide for healthcare across Southeast Alaska, and then 
dealing with the situation with Mt. Edgecombe Hospital there 
and the deteriorating conditions? Is this on anybody's radar?
    Ms. Smith. Yes, Senator. Let me again defer to Mr. Hartz to 
speak to that issue.
    Senator Murkowski. Okay.
    Mr. Hartz. Thank you, Senator. You're taking me back a 
number of years because I worked in that service unit.
    Senator Murkowski. Ah, then you know well, you know well.
    Mr. Hartz. I know well that facility. I was stationed at 
the time in Ketchikan, so I got in there to work with Art 
Wallman, bless his heart, for many, many, many years.
    You are absolutely correct regarding the age and the 
condition of that facility. I know SEARHC has been a major 
force in all of Southeast Alaska in providing coordination for 
healthcare in the outlying areas and probably left that Federal 
facility pretty much intact.
    As was discussed earlier about the existing priority list, 
we have to work our way down through that. We have prepared, 
are prepared to implement a new priority system or a modified 
priority system to address the needs across Indian Country, and 
we will soon be providing a report to Congress talking about 
all of the needs in Indian Country. That's required of us every 
5 years. That facility, along with a number of others, even 
though not specifically identified, are part of that 
significant need in Indian Country.
    Upon working our way down further on that existing priority 
list, we would essentially then create a new list that would 
not last so many years. We would prioritize those that are of 
the highest rank and address them maybe over a 3-year period so 
we wouldn't have this ongoing list and reassess what's the 
greatest need in Indian Country as we move forward in 
healthcare facility construction.

                            ROSEBUD HOSPITAL

    Senator Murkowski. Well, thank you for that. It kind of 
dovetails with my questions here about the Rosebud Hospital. I 
indicated that the Center for Medicare and Medicaid Services 
(CMS) is intending to terminate the hospital provider agreement 
effective March 16, and I mentioned some of the issues, 
allegations concerning sanitary conditions, instances of drug 
theft, lack of infection control measures, clearly a 
fundamental lack of oversight within the hospital.
    So the question to you this morning is--I mean, I suppose 
we could talk about how we got here, but that's not our 
problem. What we really need to know is that there is a plan 
going forward. How does the agency intend to address this 
situation, and what management reforms or changes are being put 
in place as we go forward? Because I think we would all agree 
that this is simply not tolerable, it's not acceptable. If CMS 
does terminate, you've got individuals that are going to have 
to travel long distances to get urgent care that they would 
have received.
    This is not a tolerable situation. What are you doing?
    Ms. Smith. Thank you, Senator. I certainly agree, and I 
know that the team at IHS does as well. This is simply not 
tolerable, it's unacceptable. I do want to give you an update 
and then segue into what we are doing to address it.
    We did receive that notice from CMS with the potential 
termination date of March 16. At IHS we requested an extension 
on that date, which CMS has now granted. We requested an 
extension to be able to work with CMS collaboratively on what's 
called a Systems Improvement Agreement, and this type of 
agreement is different than the normal corrective action plans 
that are developed when you get these types of notices from CMS 
because they address systemic root-based causes for how the 
issues developed. They are very specific types of agreements 
that have, as I know was mentioned earlier in this hearing, 
measureable outcomes and timelines for when they will be 
addressed.
    So this agreement will address issues such as staffing, 
housing, and quality and compliance, and creating a culture of 
accountability and compliance and leadership, even leadership 
skills and issues with the governing board. So as we speak we 
are working very closely with CMS on developing such an 
agreement. It will involve a major commitment of time and 
resources and a new sense of leadership I think out at Rosebud 
Hospital. But that is our plan to address it.
    Senator Murkowski. So you sound relatively certain that the 
hospital provider agreement will not be terminated, that 
services will still continue as you are working through these 
issues; is that correct?
    Ms. Smith. Yes. So, just to be very clear, CMS has 
responded in writing that we're happy to give to any members of 
the subcommittee that we have an extension until May 16, a 
provisional period to work on the systems improvement 
agreement, and in the letter from CMS the agreement actually 
has to be entered into by April 29, because if we have not 
entered into the agreement by that point there's a 10-day 
notification period. So that is the extension we have been 
granted.
    Of course, I do want to make clear it's not only in the 
purview of IHS. CMS has to approve the agreement, and that 
would be part of the regulatory duties. But we are heartened 
that they are at least talking to us and working closely with 
us on this agreement.

                          PINE RIDGE HOSPITAL

    Senator Murkowski. Well, then let me ask about another, 
because I understand that CMS has raised similar questions with 
regards to Pine Ridge Hospital, also in South Dakota, and 
they've also received a termination letter. Is this the same 
situation where you're able to work something out with CMS? 
That's one question, but it really does beg the question as to 
whether or not we've got some systemic failures within IHS to 
have Rosebud and also Pine Ridge in this situation. Are there 
others that are also in a similarly precarious situation?
    Ms. Smith. Thank you, Senator. I guess what I'll say just 
as a general matter, we are committed to doing whatever it 
takes. This is not an option. We need to ensure that these 
hospitals are delivering quality care, and that is I think the 
top priority for all of us at the agency right now. But as you 
mentioned, I think there are systemic problems, not just at 
those hospitals but throughout our system, things that we've 
talked about in terms of staffing and housing. One of the 
things we are working on also is establishing a system of 
quality across the agency.
    With respect to Pine Ridge specifically, we did actually 
receive two notices from CMS. One was on the hospital, and one 
was on the emergency services. We did receive notice from CMS 
that with respect to the hospital we had met the requirements. 
We are still waiting on the emergency department, but we are 
committed to doing whatever it takes to ensure that these 
hospitals are providing quality care.
    Senator Murkowski. Very discouraging because, again, you 
don't get these notices unless there has been a long buildup, 
and what that long buildup means is that these people have been 
left behind, their health has potentially been compromised or 
put at risk. And again, it is just not acceptable.
    Senator Udall.
    Senator Udall. Great. Thank you, Madam Chair.

                   SANITATION FACILITIES CONSTRUCTION

    I just have one additional question on sanitation 
improvements. As you know, the subcommittee provided a 25 
percent increase there, and nearly half of all homes in Indian 
Country are in need of sanitation improvements. I frequently 
hear from the tribes in my State such as the Navajo Nation 
about the importance of these funds. The Nation is unique 
because the tribe is making its own aggressive investments to 
upgrade water infrastructure on the reservation, and they are 
particularly interested in leveraging IHS sanitation funds to 
provide service to their members.
    Can you talk about the progress you expect to make with the 
increased funds provided in the omnibus? How specifically are 
you working with tribes specifically like the Navajo Nation to 
ensure that the additional funds are being used strategically 
to take care of the most critical needs?
    Ms. Smith. Thank you, Senator, and thanks for the funding 
to address the urgent sanitation needs. We certainly agree with 
you, and I know we have another commitment in our fiscal fear 
2017 budget. With respect to the specific measures, I again 
will refer to my colleague, Mr. Hartz.
    Mr. Hartz. Thank you, Senator. First of all, I thank the 
subcommittee for the additional $20 million in fiscal year 
2016. Nationwide, that's going to provide over 3,000 additional 
homes with improved water and sewer facilities, or new water 
and sewer facilities, because there are many places where 
potable water is not available in the home as we know it.
    As far as the collaboration with the Navajo Nation, I guess 
I would say it's not unique because we do it with all tribes 
and all corporations across the country in providing water and 
sewer facilities, but it is unique from the standpoint of the 
Navajo Nation coming forward with such a substantial plan to 
support funding for projects on the sanitation facilities 
priority list. They have actually worked directly with our 
staff scattered around the Navajo reservation and the area 
office to look at the sanitation deficiency system, and they 
actually use that list, Senator, to start identifying how they 
would provide resources to projects.
    So I guess they're leveraging. It's kind of a mutual 
leveraging to see these projects be addressed and work down the 
list. My understanding is they're planning to address their 
contributions over the next 5 years, and even address the large 
infrastructure projects, large transmission mains where they 
really are very remote in parts of the Navajo reservation. It's 
always been a good relationship, and you touched my heart, just 
like Senator Murkowski did, because I started on the Navajo 
reservation.
    Senator Udall. That's great. A lot of challenges out there.
    Mr. Hartz. Absolutely.
    Senator Udall. But interesting things going on. Thank you 
very much.
    Thank you, Madam Chair.

                   SANITATION FACILITIES CONSTRUCTION

    Senator Murkowski. Thank you, Senator Udall.
    I will conclude my comments in thanking you all. You raised 
the issue, Senator Udall, about the water and sanitation, and I 
had an opportunity a few weeks ago to bring the Secretary of 
Energy and five of our colleagues to Bethel, Alaska in mid-
February, and then we went to the little community of 
Oscarville. Oscarville is about 80 people, and it's just down 
river, down the Kuskokwim River from Bethel. Out in that area, 
there are no roads. So in order for us to get there, we were 
going to take snow machines, but there wasn't enough snow 
cover, so we took trucks on the ice, which kind of freaked some 
of my colleagues out, but the ice was nice and thick.
    But we got to Oscarville, and Oscarville is a community 
that has no running water, it has no sanitation facility. Human 
waste disposal is through the honey bucket. Usually it's the 
younger kids in the family that are given the job of dumping 
the honey bucket outside and digging a pit and hoping it 
freezes over quick.
    Talking to the elementary school teacher there--there are 
only two teachers in the school. One is elementary and the 
other is everybody else. But she has five kids, and I asked 
her, how do you do the laundry for your family, and she very 
matter-of-factly described that during the summertime you just 
go down--usually it's the kids that haul the water up from the 
river. During the winter, when the ice is thick enough that you 
can drive your trucks on it, you chop ice and you put it on a 
sled and haul it up to the house and you heat it on the stove. 
Basically, it's no different than way back when. This is a 
community of Alaskans, of Americans who are figuring out how to 
deal with the challenges of the day-to-day world, trying to get 
Internet and broadband, but at the same time literally dumping 
their human waste in a pit, in a hole, and hauling their water 
from a river.
    So the issues of disease and the concerns that are 
associated when you cannot keep clean, when you do not have 
safe drinking water, when you just have a level of exposure, 
these are issues that are very close to my heart because there 
are far too many communities in my State and, unfortunately, 
still around the country where we have these issues.
    So know that I want to work with you on so many of them. 
And to those of you that work every day on these issues, know 
that we appreciate your work. We've got a lot to do in this 
area. But when I look at that segment of the Interior budget 
that you all represent through IHS, these are very serious 
commitments that we make to our Native peoples, that the 
healthcare that they receive will be good and adequate and 
equal. I think some of the questions that you heard raised here 
today suggest that that care is not yet adequate nor equal. So 
we've got a ways to go, but know that we're committed to doing 
that. We appreciate you being here.

                          SUBCOMMITTEE RECESS

    With that, we stand adjourned.
    [Whereupon, at 11:30 a.m., Wednesday, March 9, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]