[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
H.R. 2662, ``RESTORING ACCOUNTABILITY IN THE INDIAN HEALTH SERVICE ACT
OF 2017''
=======================================================================
LEGISLATIVE HEARING
before the
SUBCOMMITTEE ON INDIAN, INSULAR AND
ALASKA NATIVE AFFAIRS
of the
COMMITTEE ON NATURAL RESOURCES
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
Wednesday, June 21, 2017
__________
Serial No. 115-10
__________
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Committee address: http://naturalresources.house.gov
______
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COMMITTEE ON NATURAL RESOURCES
ROB BISHOP, UT, Chairman
RAUL M. GRIJALVA, AZ, Ranking Democratic Member
Don Young, AK Grace F. Napolitano, CA
Chairman Emeritus Madeleine Z. Bordallo, GU
Louie Gohmert, TX Jim Costa, CA
Vice Chairman Gregorio Kilili Camacho Sablan,
Doug Lamborn, CO CNMI
Robert J. Wittman, VA Niki Tsongas, MA
Tom McClintock, CA Jared Huffman, CA
Stevan Pearce, NM Vice Ranking Member
Glenn Thompson, PA Alan S. Lowenthal, CA
Paul A. Gosar, AZ Donald S. Beyer, Jr., VA
Raul R. Labrador, ID Norma J. Torres, CA
Scott R. Tipton, CO Ruben Gallego, AZ
Doug LaMalfa, CA Colleen Hanabusa, HI
Jeff Denham, CA Nanette Diaz Barragan, CA
Paul Cook, CA Darren Soto, FL
Bruce Westerman, AR Jimmy Panetta, CA
Garret Graves, LA A. Donald McEachin, VA
Jody B. Hice, GA Anthony G. Brown, MD
Aumua Amata Coleman Radewagen, AS Wm. Lacy Clay, MO
Darin LaHood, IL
Daniel Webster, FL
David Rouzer, NC
Jack Bergman, MI
Liz Cheney, WY
Mike Johnson, LA
Jenniffer Gonzalez-Colon, PR
Jason Knox, Chief of Staff
Lisa Pittman, Chief Counsel
David Watkins, Democratic Staff Director
------
SUBCOMMITTEE ON INDIAN, INSULAR AND ALASKA NATIVE AFFAIRS
DOUG LaMALFA, CA, Chairman
NORMA J. TORRES, CA, Ranking Democratic Member
Don Young, AK Madeleine Z. Bordallo, GU
Jeff Denham, CA Gregorio Kilili Camacho Sablan,
Paul Cook, CA CNMI
Aumua Amata Coleman Radewagen, AS Ruben Gallego, AZ
Darin LaHood, IL Darren Soto, FL
Jack Bergman, MI Colleen Hanabusa, HI
Jenniffer Gonzalez-Colon, PR Raul M. Grijalva, AZ, ex officio
Vice Chairman
Rob Bishop, UT, ex officio
------
CONTENTS
----------
Page
Hearing held on Wednesday, June 21, 2017......................... 1
Statement of Members:
LaMalfa, Hon. Doug, a Representative in Congress from the
State of California........................................ 1
Prepared statement of.................................... 2
Torres, Hon. Norma J., a Representative in Congress from the
State of California........................................ 3
Prepared statement of.................................... 4
Statement of Witnesses:
Buchanan, Chris, REHS, MPH, Rear Admiral, Assistant Surgeon
General, USPHS; Deputy Director, Indian Health Service,
Rockville, Maryland........................................ 10
Prepared statement of.................................... 11
Questions submitted for the record....................... 14
Joseph, Hon. Andy, Business Council Member, Confederated
Tribes of the Colville Reservation, Nespelem, Washington... 18
Prepared statement of.................................... 20
Kitcheyan, Victoria, Great Plains Area Representative,
National Indian Health Board, Washington, DC............... 26
Prepared statement of.................................... 28
Noem, Hon. Kristi L., a Representative in Congress from the
State of South Dakota...................................... 5
Prepared statement of.................................... 7
Shield, Hon. William Bear, Chairman, Rosebud Sioux Tribal
Health Board, Rosebud, South Dakota........................ 15
Prepared statement of.................................... 16
TwoBears, Robert, District V Representative, Ho-Chunk Nation
Legislature, Black River Falls, Wisconsin.................. 22
Prepared statement of.................................... 24
Additional Materials Submitted for the Record:
List of documents submitted for the record retained in the
Committee's official files................................. 39
LEGISLATIVE HEARING ON H.R. 2662, TO AMEND THE INDIAN HEALTH CARE
IMPROVEMENT ACT TO IMPROVE THE RECRUITMENT AND RETENTION OF EMPLOYEES
IN THE INDIAN HEALTH SERVICE, RESTORE ACCOUNTABILITY IN THE INDIAN
HEALTH SERVICE, IMPROVE HEALTH SERVICES, AND FOR OTHER PURPOSES,
``RESTORING ACCOUNTABILITY IN THE INDIAN HEALTH SERVICE ACT OF 2017''
----------
Wednesday, June 21, 2017
U.S. House of Representatives
Subcommittee on Indian, Insular and Alaska Native Affairs
Committee on Natural Resources
Washington, DC
----------
The Subcommittee met, pursuant to notice, at 2:48 p.m., in
room 1324, Longworth House Office Building, Hon. Doug LaMalfa
[Chairman of the Subcommittee] presiding.
Present: Representatives LaMalfa, Radewagen, Gonzalez-
Colon; and Torres.
Mr. LaMalfa. Good afternoon. The Subcommittee on Indian,
Insular and Alaska Native Affairs will come to order. The
Subcommittee is meeting today to hear testimony on H.R. 2662,
by Representative Kristi Noem, to amend the Indian Health Care
Improvement Act to improve the recruitment and retention of
employees in the Indian Health Service, restore accountability
in the Indian Health Service, improve health services, and for
other purposes; or known as the ``Restoring Accountability in
the Indian Health Service Act of 2017.''
Under Committee Rule 4(f), any oral opening statements at
hearings are limited to the Chairman, the Ranking Minority
Member, and the Vice Chair. This will allow us to hear from our
witnesses sooner, and help Members keep to their schedules.
Therefore, I ask unanimous consent that all other Members'
opening statements be made part of the hearing record if they
are submitted to the Subcommittee Clerk by 5:00 p.m. today.
Without objection, so ordered.
STATEMENT OF THE HON. DOUG LaMALFA, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Mr. LaMalfa. Today, we are here to take testimony on the
bill intended to address a severe problem in Indian Country.
Adequate health care is one of the most important issues to
American Indian and Alaska Natives; however, the IHS direct
care system is deficient, inadequate, and is simply failing
areas of the country that need help the most.
In 2010, a Senate investigation report brought to light
some very severe problems plaguing 1 of the 12 regions of the
IHS: the Great Plains area. After the report was released, the
agency repeatedly assured Congress that issues were being
addressed.
Then, in 2015, the same IHS region experienced the
termination of a provider agreement with Centers for Medicare
and Medicaid Services at the Winnebago IHS Hospital in
Nebraska. CMS found that repeated deficiencies at the hospital
``had caused actual harm and is likely to cause harm'' to
persons seeking examination or treatment.
Since 2015, the CMS has found deficiencies in other
hospitals in the Great Plains region. Emergency department
services have been diverted to hospitals that are 45 miles
away. This leaves some tribes asking not ``if,'' but ``when,''
other hospitals may lose CMS provider agreements.
Congress has continued to increase IHS funding almost each
year since 2010, and it continues to increase it. In Fiscal
Year 2014 and Fiscal Year 2015, Congress exceeded President
Obama's budget.
Since 2008, funding for the IHS has increased by more than
50 percent. The House's Fiscal Year 2017 proposal appropriation
is at approximately $1 billion over Fiscal Year 2010 levels,
yet the dangerous situation in the Great Plains area and the
staffing shortage problem throughout the 12 IHS areas continues
to exist, if not to grow.
In March of 2017, and despite funding increases, the
Government Accountability Office added Indian health care to
its biennial high-risk report for programs that are most
susceptible to waste, fraud, and abuse.
H.R. 2662, the Restoring Accountability in the Indian
Health Service Act, is intended to make reforms to the Indian
Health Service to help a broken system. This bill would amend
the Indian Health Care Improvement Act to improve the IHS by
reforming the agency's personnel processes, timeliness
standards, and other operations.
The bill also includes accountability language similar to
what Congress has enacted to help the Veterans Affairs
Administration make it easier to discipline and fire
underperforming employees.
The bill is a continuation of the work in the 114th
Congress found in H.R. 5406, Helping Ensure Accountability,
Leadership, and Trust in Tribal Healthcare Act, commonly known
as the ``HEALTTH Act.'' This bill does not fix every problem in
the IHS, however, it is a step in the right direction for
Indian Country.
I want to thank the sponsor of the bill and our witnesses
for being here today.
[The prepared statement of Mr. LaMalfa follows:]
Prepared Statement of the Hon. Doug LaMalfa, Chairman, Subcommittee on
Indian, Insular and Alaska Native Affairs
We are here today to take testimony on a bill intended to address a
severe problem in Indian Country. Adequate health care is one of the
most important issues to American Indian and Alaska Natives; however
the IHS direct care system is deficient, inadequate, and is simply
failing areas of the country that need help the most.
In 2010, a Senate investigation report brought to light some very
severe problems plaguing 1 of the 12 regions of the Indian Health
Service, the Great Plains area. After the report was released the
agency repeatedly assured Congress that issues were being addressed.
Then in 2015, the same IHS region experienced the termination of a
provider agreement with Centers for Medicare and Medicaid Services at
the Winnebago IHS Hospital Nebraska. CMS found that repeated
deficiencies at the hospital ``had caused actual harm and is likely to
cause harm'' to persons seeking examination or treatment.
Since 2015, CMS has found deficiencies in other hospitals in the
Great Plains region. Emergency Department services have been diverted
to hospitals that are 45 miles away. This leaves some tribes asking not
``if'' but ``when'' other hospitals may lose CMS provider agreements.
Congress has continued increase IHS funding almost each year since
the 2010, and it continues to increase. In FY14 and FY15, Congress
exceeded President Obama's budget.
Since 2008, funding for the Indian Health Service has increased by
more than 50 percent. The House's FY17 proposed appropriation is at
approximately $1 billion over FY10 levels, yet the dangerous situation
in the Great Plains area and the staffing shortage problem throughout
the 12 IHS areas continues to exist if not grow.
In March of 2017, and despite funding increases, the Government
Accountability office added Indian health care to its biennial high
risk report, for programs that are most susceptible to waste, fraud and
abuse.
H.R. 2662, the Restoring Accountability in the Indian Health
Service Act is intended to make reforms to the Indian Health Service to
help a broken system.
This bill would amend the Indian Health Care Improvement Act to
improve the Indian Health Service by reforming the agency's personnel
processes, timeliness standards, and other operations.
The bill also includes accountability language similar to what
Congress has enacted to help the Veterans Affairs Administration making
it easier to discipline and fire underperforming employees.
This bill is a continuation of the work in the 114th Congress found
in H.R. 5406, the Helping Ensure Accountability, Leadership, and Trust
in Tribal Healthcare Act, commonly known as the ``HEALTTH Act.''
This bill does not fix every problem in the IHS; however it is a
step in the right direction for Indian Country. I want to thank the
Sponsor of the bill and our witnesses for being here today.
______
Mr. LaMalfa. I would now like to recognize our Ranking
Member for any opening statement.
STATEMENT OF THE HON. NORMA J. TORRES, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Mrs. Torres. Thank you so much, Mr. Chairman, and good
afternoon to everyone here, and our witnesses.
Today is our opportunity to take a hard look at the current
state and possible future of health care in Indian Country.
American Indian and Alaska Native people have long
experienced health disparities when compared with other
Americans, including a lower life expectancy and higher rates
of disease. There are many reasons for this, but we know that
one of the factors has been the chronic underfunding of the
Indian Health Service. These issues have been brought back to
the forefront after what occurred with the Great Plains area
hospitals, but I worry that we will hear many of the same
stories from IHS facilities throughout the country.
The fact is that we cannot provide competent, quality
health care to Native American and Alaska Natives when we allow
inadequate facilities and substandard levels of care to
continue to exist. I am glad to have this discussion today,
because we need to start talking about permanent solutions that
will address the long-standing issues at IHS.
We have to acknowledge that to bring about true
transformation at IHS facilities, we need to start funding IHS
appropriately. IHS has been shamefully underfunded for years,
and the President's proposed Fiscal Year 2018 budget looks to
cut another $59 million.
Mr. Chairman, the hospitals are old, their technology is
outdated, and they face major hurdles when hiring and keeping
quality healthcare professionals.
So, yes, we do need reforms at IHS, but even with the best-
intentioned reforms, we will just be giving lip service if we
do not supply the funding to implement real change.
I want to thank our colleague, Representative Noem, for
bringing this legislation forward; and I thank all of our
witnesses for taking time today to share your thoughts on this
legislation.
Thank you, Mr. Chairman, and I yield back.
[The prepared statement of Mrs. Torres follows:]
Prepared Statement of the Hon. Norma J. Torres, Ranking Member,
Subcommittee on Indian, Insular and Alaska Native Affairs
Thank you, Mr. Chairman.
Today is our chance to take a hard look at the current state and
possible future of health care in Indian Country. American Indian and
Alaska Native people have long experienced health disparities when
compared with other Americans, including a lower life expectancy and
higher rates of diseases.
There are many reasons for this, but we know that one of the
factors has been the chronic underfunding of the Indian Health Service.
These issues have been brought back to the forefront after what
occurred with the Great Plains area hospitals, but I worry we'll hear
many of the same stories from IHS facilities throughout the country.
The fact is that we cannot provide competent, quality health care
to Native American and Alaska Natives when we allow inadequate
facilities and sub-standard levels of care to exist.
I'm glad to have this discussion today, because we need to start
talking about permanent solutions that will address the long-standing
issues at IHS. We have to acknowledge that to bring about a true
transformation at IHS facilities, we need to start funding IHS at an
appropriate level.
IHS has been shamefully underfunded for years, and the President's
proposed FY2018 budget looks to cut another $59 million.
Mr. Chairman, the hospitals are old, their technology is outdated,
and they face major hurtles when hiring and keeping quality healthcare
professionals. So, yes, we do need reforms at IHS, but even the best
intentioned reforms will just be lip service if we don't supply the
funding to implement real change. There are actual lives in the
balance, and they deserve better.
I want to thank our colleague Rep. Noem for bringing this
legislation forward, and I thank all our witnesses for taking the time
today to share your thoughts on this legislation.
Thank you Mr. Chairman, and I yield back.
______
Mr. LaMalfa. Thank you. It is now up to me to introduce our
witness for our first panel, the Honorable Kristi Noem, U.S.
Congresswoman for the state of South Dakota.
We remind the witness that under Committee Rules, there is
a 5-minute limit to the statement, but the entire statement
will appear in the record.
So, allow me to recognize you, Congresswoman Noem, for your
testimony. Thank you for appearing here.
STATEMENT OF THE HON. KRISTI L. NOEM, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF SOUTH DAKOTA
Mrs. Noem. Thank you, Chairman. And thank you also, Ranking
Member Torres, as well, and the rest of the members of the
Subcommittee, for allowing me to be here today to talk about
the Indian Health Service. Many of the items that you discussed
in your opening statements are very true. I couldn't find
anything in there that I would disagree with.
I do want to point out that we have increased funding for
Indian health services over many, many years. And since I have
been in Congress we have done that, but we still have not seen
improvements. In fact, the situation has only gotten worse. And
that is one of the reasons you have this bill before you today.
I appreciate the opportunity to talk about H.R. 2662. It is
the Restoring Accountability in the Indian Health Service Act.
And before I begin, I wanted to also inform you that yesterday
I was told the HHS senior staff are traveling to South Dakota
this week. They are going to visit the IHS hospital at the Pine
Ridge Indian Reservation, which is the home to the Oglala Sioux
Tribe.
That is one of the areas that has been the worst in the
Nation. The Great Plains District has been a disaster. We have
had third-world care being delivered there, and just a few
weeks ago I had asked Secretary Price for his leadership and
his help in addressing the situations that we are currently
facing. So, I want to thank him and his team for his quick
action in going there this week to look at the situation on the
ground. I look forward to working with them to find solutions
to the many issues that we face in Indian Country.
Now, turning to our hearing today, I personally thank the
witnesses who traveled here to Washington, DC to be at this
hearing, especially Mr. William Bear Shield from the Rosebud
Sioux Tribe. Mr. Bear Shield has testified before you before.
In fact, he was here to testify on the legislation that I had
last Congress. He is here to offer his critical insights into
what the situation is on the ground.
Last year, I, too, sat before this Subcommittee, testifying
on the same issue. I told you that the state of Indian health
care in South Dakota had fallen to emergency levels. Today, I
could report to you that in some areas we have seen a little
bit of progress, but it is not enough. We need to get help to
these people that are relying on this agency for health care,
and they are failing them dramatically.
Since this most recent crisis has begun, the Centers for
Medicare and Medicaid Services has found three IHS hospitals in
South Dakota to be deficient, which resulted in the closure of
two emergency rooms. One has since reopened, but nonetheless,
these closures have put a serious strain on local community
hospitals and has drastically curtailed access to care for my
constituents. Many of them are traveling much farther in
situations. In fact, I believe Mr. Bear Shield will talk today
about how they believe they have lost lives because of the
situation of IHS not delivering care that is needed.
And it is not just South Dakota that has been affected; it
is a nationwide issue. The hospital serving the Winnebago and
Omaha Tribes had its relationship with CMS almost completely
severed. And most recently, a hospital in Minnesota was cited
by CMS, as well. In fact, my constituents tell me that the only
reason that some IHS facilities are open today is because CMS
just hasn't visited them yet.
I am working hard to produce legislative solutions to this
problem. Last year, I introduced the Helping Ensure
Accountability, Leadership, and Trust in Tribal Healthcare Act,
and this Subcommittee held a hearing. Today the bill looks a
little bit different, and I will tell you why. It is because I
have worked together with my colleagues in the Senate to craft
a bill that includes elements of that bill that I had last
Congress, but also a bill that Senator Barrasso introduced last
year. His bill was called the IHS Accountability Act. The
result of our cooperation is identical bills in the House and
the Senate, and I am pleased that we are working together to
address the serious deficiencies in the agency.
The Restoring Accountability in the Indian Health Service
Act contains several meaningful provisions and ensures that the
agency's employees are held accountable.
For example, the bill requires regular reporting from IHS,
as well as GAO and the HHS Inspector General. New reporting is
going to be critical. In our discussions with IHS over the last
several years, the agency has been unable to even provide us
with basic data related to its regular operations, which seemed
pretty basic to us, but we realized they had not done any kind
of data collection or reporting. The reporting will ensure that
Congress has the information it needs to conduct oversight and
make good decisions in the future.
The bill also improves recruitment and retention by
allowing the agency to look at employees and how they get them
to come and serve at these facilities.
The bill also will help IHS attract new management talent
by allowing those managers to participate in the student loan
repayment program. This is just an overview, but the bill
contains several other provisions to improve patient care and
streamline IHS processes.
This bill, while important, I want to be clear is just a
first step. There is so much to do in Indian Country to address
substance abuse, domestic abuse, violent crime, child abuse,
and, most tragically, the youth suicide situation that we are
seeing in our tribes in South Dakota. Tribes in South Dakota
are affected by all of these issues, and I look forward to
working with you on them in the future.
Again, these are situations that, if they can't get basic
health care, you can see why none of the other needs are being
met. I want to get this right. I have already reached out to
HHS and IHS for technical assistance on this bill. So, that has
been done, and I have worked with stakeholders across Indian
Country--patients, tribal leaders, IHS employees, healthcare
providers, private hospitals--to submit testimony for the
record and give us feedback on the bill.
I am excited to work with you and our tribes and thank you
for the opportunity to discuss this bill with you today.
[The prepared statement of Mrs. Noem follows:]
Prepared Statement of the Hon. Kristi L. Noem, a Representative in
Congress from the State of South Dakota
Chairman LaMalfa, Ranking Member Torres, and members of the
Subcommittee, thank you for inviting me to testify at today's hearing
about my bill, H.R. 2662, the Restoring Accountability in the Indian
Health Service Act.
Before I begin, I want to inform you that I was notified yesterday
that HHS senior staff are traveling to South Dakota this week to visit
the IHS hospital at Pine Ridge, which is home to the Oglala Sioux
Tribe.
Just a few weeks ago, I asked Secretary Price for his leadership
and help in addressing this situation, and I thank him and his team for
their quick action. I look forward to working with Secretary Price and
the Administration on this and the many issues facing Indian Country.
Now, turning to our hearing today: I personally thank the witnesses
who traveled here to Washington, DC to testify today, especially Mr.
William Bear Shield of the Rosebud Sioux Tribe. Mr. Bear Shield
testified before you last year, and I am pleased he is here to offer
his critical insights.
Last year, I too, sat before this Subcommittee testifying on this
same issue. I told you that the state of Indian health care in South
Dakota had fallen to emergency levels. Today I can report to you that
some progress has been made, but it's not enough, and it's not
happening fast enough.
Since this most recent crisis began, the Centers for Medicare and
Medicaid Services has found three IHS hospitals in South Dakota to be
deficient, which resulted in the closure of two emergency rooms. One
has since reopened, but nevertheless, these closures have put serious
strain on local community hospitals and drastically curtailed access to
care for my constituents.
And it's not just South Dakota that is affected. This is a
nationwide issue.
The hospital serving the Winnebago and Omaha Tribes had its
relationship with CMS almost completely severed, and most recently, a
hospital in Minnesota was cited by CMS as well. In fact, my
constituents tell me that the only reason some IHS facilities remain
open today is because CMS just hasn't visited them yet.
I am working hard to produce legislative solutions to this problem.
Last year, I introduced the Helping Ensure Accountability, Leadership,
and Trust in Tribal Healthcare Act, and this Subcommittee held a
hearing on the bill. Today's bill looks slightly different.
That's because I have worked together with my colleagues in the
Senate to craft a bill that includes elements from my HEALTTH Act and a
bill Senator Barrasso introduced last year, the IHS Accountability Act.
The result of our cooperation is identical bills in both the House and
the Senate, and I am pleased that we are working together to address
the serious deficiencies in the agency.
The Restoring Accountability in the IHS Act contains several
meaningful provisions that would streamline the agency's bureaucracy
and ensure that the agency's employees are held accountable. For
example, the bill would require regular reporting from the IHS, as well
as GAO and the HHS Inspector General.
New reporting is critical. In our discussions with the IHS over the
past couple of years, the agency has been unable to provide us basic
data related to its regular operations. This reporting will ensure
Congress has all the information it needs to conduct thorough oversight
of the agency.
The bill would also improve recruitment and retention by allowing
the agency to offer more robust benefits for employees. The bill would
help the IHS attract new management talent by allowing managers to
participate in the student loan repayment program.
That's just an overview--the bill contains several other provisions
to improve patient care and streamline IHS processes.
This bill, while important, is only a first step. There's so much
more to do to in Indian Country to address substance abuse, domestic
abuse, violent crime, child abuse, and most tragically, youth suicide.
Tribes in South Dakota are affected by all of these issues and I look
forward to working with all of you on them in the future.
In closing, let me be clear: I want to get this right. I have
already reached out to HHS and IHS to obtain technical assistance for
this bill, and I hope to get it this week.
I encourage stakeholders across Indian Country--patients, tribal
leaders, IHS employees, healthcare providers, private hospitals--to
submit testimony for the record and give us feedback on the bill.
I am excited to work closely with the Committee, tribes, and other
stakeholders to pass this critical legislation. Thank you again for the
opportunity to discuss the Restoring Accountability in the IHS Act.
______
Mr. LaMalfa. Thank you, Mrs. Noem, for that. I appreciate
your testimony.
Would there be any questions of our panel up here? OK.
You do? OK. Recognizing our Vice Chair.
Miss Gonzalez-Colon. Thank you, Mr. Chairman. I want to
commend my colleague for her noteworthy efforts to deliver
improved health care to her constituents. Much of the IHS user
population struggles in accessing timely quality care.
While those facilities suffer from serious deficiencies
memorialized in the 2010 Dorgan Report, they are still having
those problems, and unfortunately, many of these challenges
continue. I look forward to addressing those issues in the next
panel.
I have just two questions for you. One is the interest of
H.R. 2662 to apply tribally operated facilities and recommend
that these facilities shall have the ability to opt in and opt
out of certain provisions of the bill. Do you think this bill
will make it available to opt in, opt out for certain services,
or not?
Mrs. Noem. It will be, and it allows us to really meet the
needs of those local communities that it is going to serve, and
give us the opportunity--some of the reforms that we put into
the legislation are ones that we have considered and debated
when it comes to reforms in the VA.
We looked at what was working there, as far as reforms. And
some of the same problems that we have had in the VA, we are
seeing in IHS as well. Some of them have to do with being able
to fire employees that were not doing their job. Some of them
had to do with recruitment issues that we are having. So, some
of those abilities, to bring reforms to that federally run
healthcare system of the VA, we put in this legislation as
well, to meet some of the reforms that we believe are necessary
within IHS.
Miss Gonzalez-Colon. I made that question because some of
the witnesses that are going to be here in the next panel just
expressed that option of having opt in or opt out. And as a
sponsor of the bill, I want to have your input about having
that option or not.
Mrs. Noem. Yes.
Miss Gonzalez-Colon. The other question is, the deputy
director of the Indian Health Service, Mr. Buchanan, mentions
in his testimony that Section 110 of the bill requires to
establish a tribal consultation policy. And he thinks that it
is unnecessary, because the IHS already has a tribal
consultation policy. What is your consideration?
Mrs. Noem. I would encourage you to ask the others who are
going to testify today about what consultation has been in the
past. They will tell you that there has been no consultation.
What IHS deems is called consultation with the tribe is non-
existent, so that is why it is required within the legislation,
so that we now, as Members of Congress--and it is in statute--
that oversight has to happen on how that consultation piece is
put into place, so that they have some input into what kind of
health care is delivered to their communities.
This is something that I have heard over and over, dozens
and dozens of times through the years, that IHS has ignored
many of the protocols that they have been encouraged to do, and
consultation is one of the biggest things that they have failed
at.
Miss Gonzalez-Colon. Thank you. I yield back the rest of my
time, Chairman.
Mr. LaMalfa. Thank you. Anybody else on the panel wish to
question?
OK. Well, Mrs. Noem, you have answered it very well. I see
a lot of parallels with the Veterans Administration and IHS
here, and so the reforms you are pushing for I hope can be a
template--one for the other--whichever one can get it done
sooner.
Is there anything else you would wish to elaborate on, on
that parallel there?
Mrs. Noem. Just the dire situation that we face. I would
encourage all of you, if you have the opportunity, to come to
the Great Plains region and see some of these facilities that
have been affected. It really is like delivering health care in
a third-world country. We have had babies born on the floor, we
have had providers delivering care while they are on alcohol or
drugs. We have had non-compliance on even just basic safety
issues.
And then we have no consistency in leadership or in
providers. And many employees are left--they are understaffed,
under-supported. And in the past, when we have given more money
to IHS, the problems still have not been fixed. I believe that
is why you see HHS on the ground today in South Dakota, because
even in light of what has happened in the last couple of years,
of shining some more light on this situation, IHS still has not
made the changes that they promised to us that they would make.
We held a hearing in South Dakota. We have had hearings
here. We have been extremely vocal about this. This is why you
see legislation today. We have tried to work with IHS in the
past, and that has failed, and that is why we are pushing to
have these reforms put in place. And listening to those who
will testify on the next panel is critically important for you
to get a clear picture as to the situation and the emergency
situation that we have on the ground. Thank you.
Mr. LaMalfa. All right. Congresswoman Noem, thank you for
again bringing this bill forward, and for your strong efforts
this year and last year in shining the light on this, and
working toward an important solution for, in some cases, a
pretty shameful situation.
Thank you, and we will go ahead and seat the next panel. If
you wish to stay along or do other duties--again, thank you for
being here.
[Pause.]
Mr. LaMalfa. OK, I will introduce our second panel of
witnesses as they come up to the dais.
We have Rear Admiral Chris Buchanan, who is Assistant
Surgeon General, U.S. Public Health Service, and the Deputy
Director of Indian Health Service; we have the Honorable
William Bear Shield, Chairman, Rosebud Sioux Tribal Health
Board; we have the Honorable Andy Joseph, Business Council
Member of the Confederated Tribes of the Colville Reservation;
Mr. Robert TwoBears, District V Representative, Ho-Chunk Nation
Legislature; and we have Ms. Victoria Kitcheyan, Great Plains
Area Representative, National Indian Health Board.
So, as you are seated, I will remind the witnesses again
that under our Committee Rules, oral statements are limited to
5 minutes. Their entire statement will appear in the hearing
record.
I think you all know the drill on the microphones, but they
are not automatic. You need to press the button when you begin
your testimony as we go down the line. A green light will turn
on, which will allow you 4 minutes. The yellow light will allow
you 1 additional minute, and your time will expire when the red
light comes on, which we ask you to sum up and complete.
We will have the entire panel give their testimony before
the questioning will happen for the panel, as well. So, the
Chair now recognizes Rear Admiral Buchanan to testify.
STATEMENT OF CHRIS BUCHANAN, REHS, MPH, REAR ADMIRAL, ASSISTANT
SURGEON GENERAL, USPHS; DEPUTY DIRECTOR, INDIAN HEALTH SERVICE
Admiral Buchanan. Good afternoon, Chairman LaMalfa, Ranking
Member Torres, and members of the Subcommittee, I am Chris
Buchanan, I am an enrolled member of the Seminole Nation of
Oklahoma, and Deputy Director of the Indian Health Service. I
am pleased to have the opportunity to testify before the
Subcommittee on H.R. 2662, the Restoring Accountability in the
Indian Health Service Act of 2017.
The mission of Indian Health Service, in partnership with
American Indians and Alaska Natives, is to raise the physical,
mental, social, and spiritual health of American Indians and
Alaska Natives to the highest level. Providing quality health
care is our highest priority. We share the urgency of
addressing the long-standing systemic problems that hamper our
ability to fully carry out the IHS mission.
In November of 2016, we launched our Quality Framework and
Implementation Plan to strengthen the quality of care that IHS
delivers to the patients we serve. Since November of 2016, IHS
has made substantial progress in implementing the Quality
Framework and addressing many of the challenges you have
identified in your proposed legislation.
The Quality Framework guides how we develop, implement, and
sustain an effective quality program that improves patient
experience and outcomes. We are doing this by strengthening our
organizational capacity, and ensuring the delivery of reliable,
high-quality health care at IHS direct-service facilities.
The new IHS credentialing system will streamline
credentialing and facilitate the hiring of qualified
practitioners, as well as privileging and performance
evaluations of IHS practitioners. It will allow the local and
area offices to perform these functions in alignment with the
Centers for Medicare and Medicaid Services' conditions of
participation, and accreditation standards for governance of
hospitals and ambulatory care facilities. We will pilot it in
four IHS areas in July, and implement it across the remaining
IHS areas by the end of 2017.
Ensuring timely access to care requires that we develop
standards for waiting times for appointments, as well as for
the time spent in providers' offices, and that we benchmark
against clear standards. Agency-wide standards for wait times
are also in development. To ensure accountability at the
highest level, and to improve transparency about access to and
quality of care, IHS is implementing a performance
accountability dashboard. This includes reporting on patient
wait times. Pilot testing of the dashboard and associated data
collection is targeted for this summer.
Strengthening governance and leadership at all levels of
IHS is essential for assuring quality health care. IHS now
requires a standardized governance process and use of a
standard governing board agenda across all IHS areas with
federally operated facilities.
The first leadership training class to prepare selected
individuals to serve in leadership positions at the service
unit, area, and headquarters levels was launched June 6, with
34 participants. IHS faces significant recruitment challenges
due to the remote, rural locations of our healthcare facilities
and area offices.
IHS is implementing various strategies to increase
recruitment and retention. Global recruitment is one strategy
that we have implemented for a streamlined approach to filling
critical provider vacancies at multiple locations. Applicants
only need to apply to a single vacancy announcement, and can be
considered for multiple positions throughout the country.
Recruiting for critical positions by using a single
announcement to recruit for multiple positions is showing
promise.
Now, IHS has priority access to new commissioned corps
applicants. This allows IHS to make first contact with these
applicants in efforts to recruit them to fill health
professional vacancies throughout IHS.
Also, IHS facilities can use the National Health Service
Corps scholarship and loan repayment incentives to recruit and
retain primary care providers. As of April 2017, 472 National
Health Service Corps recipients are currently part of our
workforce serving in IHS tribal and urban facilities. These
actions demonstrate that IHS is taking challenges seriously,
and is continuing to take assertive and proactive steps to
address them.
IHS is prepared to provide the Subcommittee technical
assistance on specific authorities proposed by H.R. 2662.
Despite all of the challenges, I am firmly committed to
improving quality, safety, and access to health care for
American Indians and Alaska Natives.
In collaboration with HHS, our partners across Indian
Country, and Congress, we look forward to working with the
Subcommittee on this legislation as it moves through the
legislative process, and I am happy to answer any questions the
Subcommittee may have. Thank you.
[The prepared statement of Admiral Buchanan follows:]
Prepared Statement of Chris Buchanan, R.E.H.S., M.P.H., Assistant
Surgeon General, USPHS; Deputy Director, Indian Health Service, U.S.
Department of Health and Human Services
Good afternoon, Chairman LaMalfa, Ranking Member Torres, and
members of the Subcommittee. I am Chris Buchanan, an enrolled member of
the Seminole Nation of Oklahoma and Deputy Director of the Indian
Health Service (IHS). I am pleased to have the opportunity to testify
before the House Natural Resources Committee's Subcommittee on Indian,
Insular and Alaska Native Affairs on H.R. 2662, the ``Restoring
Accountability in the Indian Health Service Act of 2017.'' I would like
to thank you, Chairman LaMalfa and members of the Subcommittee for
elevating the importance of delivering quality care through the IHS.
IHS plays a unique role in the Department of Health and Human
Services (HHS) because it was established to carry out the
responsibilities, authorities, and functions of the United States to
provide healthcare services to American Indians and Alaska Natives. The
mission of IHS, in partnership with American Indian and Alaska Native
people, is to raise the physical, mental, social, and spiritual health
of American Indians and Alaska Natives to the highest level. IHS
provides comprehensive health care delivery to approximately 2.2
million American Indians and Alaska Natives through 26 hospitals, 59
health centers, 32 health stations, and 9 school health centers. Tribes
also provide health care access through an additional 19 hospitals, 284
health centers, 163 Alaska Village Clinics, 79 health stations, and 8
school health centers.
Providing quality health care is our highest priority. We share the
urgency of addressing long-standing systemic problems that hamper our
ability to fully carry out the IHS mission. In November 2016, we
launched our 2016-2017 Quality Framework and Implementation Plan to
strengthen the quality of care that IHS delivers to the patients we
serve. Implementation of the Quality Framework is intended to
strengthen organizational capacity to improve quality of care, improve
our ability to meet and maintain accreditation for IHS direct-service
facilities, align service delivery processes to improve the patient
experience, ensure patient safety, and improve processes and strengthen
communications for early identification of risks. The Quality Framework
will be reviewed and updated at least annually in partnership with
tribes.
The HHS Executive Council on Quality Care (the Council), which was
stood up in November 2016, provides support to IHS by identifying and
facilitating collaborative, action-oriented approaches from across the
Department to address issues that affect the quality of health care
provided to American Indians and Alaska Natives we serve. The Council
includes leadership from 12 HHS Staff and Operating Divisions. The
Council's mission is to support IHS' efforts to develop, enact, and
sustain an effective quality program--to improve quality and patient
safety in the hospitals and clinics that IHS administers. This may
include providing technical assistance to bolster quality and safety,
identifying solutions to address workforce recruitment and retention
challenges, seeking creative solutions to infrastructure needs, and
enhancing stakeholder engagement. The Council partners with HHS
leadership and staff in policy implementation.
Since November 2016, IHS has made substantial progress in
implementing the Quality Framework and in addressing many of the
challenges you have identified in your proposed legislation.
strengthening organizational capacity
The Quality Framework guides how we develop, implement, and sustain
an effective quality program that improves patient experience and
outcomes. We are doing this by strengthening our organizational
capacity, and ensuring the delivery of reliable, high quality health
care at IHS direct-service facilities.
We recently awarded a contract for credentialing software that will
provide enhanced capabilities and standardize the credentialing process
across IHS. The new system will streamline credentialing and facilitate
the hiring of qualified practitioners as well as, privileging and
performance evaluations of IHS practitioners. This will help ensure the
quality and safety of care delivered in IHS Federal Government
hospitals and health centers. We are on course with the implementation
of this medical credentialing system. We expect to test it in four IHS
Areas in July 2017, and plan to implement it across the remaining IHS
Areas by the end of 2017. Our agency credentialing policy is in the
process of being updated.
Ensuring timely access to care requires that we develop standards
for waiting times for appointments, as well as for the time spent in
the provider's office, and that we benchmark against clear standards.
IHS Service Units currently collect patient wait time data to track the
patient care experience as part of the Improving Patient Care program.
Agency-wide standards for wait times are also in development. To ensure
accountability at the highest level, and to improve transparency about
access to and quality of care, IHS is implementing a performance
accountability dashboard. This includes reporting on patient wait
times. Pilot testing of the dashboard and associated data collection is
targeted for this summer.
Strengthening governance and leadership at all levels of the IHS
system is essential to assuring quality health care. IHS now requires a
standardized governance process and use of a standard governing board
agenda across all IHS Areas with federally operated facilities. The
first leadership training class to prepare selected individuals to
serve in leadership positions at the Service unit, Area, and
Headquarters levels was launched June 6 with 34 participants. In
addition, IHS has begun implementing a leadership coaching and
mentoring program in the Great Plains area as new leaders are
recruited.
workforce strategies
IHS faces significant recruitment challenges due to the remote,
rural location of our healthcare facilities and Area offices. To make a
career in IHS more attractive to modern healthcare practitioners, IHS
is implementing various strategies to increase recruitment and
retention. Global recruitment is one strategy we have implemented that
allows for a streamlined approach to filling critical provider
vacancies at multiple locations. Applicants only need to apply to a
single vacancy announcement and can be considered for multiple
positions throughout the country. Recruiting for critical positions by
using a single announcement to recruit for multiple positions is
showing promise.
IHS continues the successful partnership with the Office of the
Surgeon General to increase the recruitment and retention of
Commissioned Corps officers, and most recently the IHS has been given
priority access to new Commissioned Corps applicants. This allows IHS
to make the first contact with these applicants in an effort to recruit
them to fill health professional vacancies throughout IHS. This new
effort began in May, and we can provide periodic updates on this
effort. IHS also continues to partner with the National Health Service
Corps (NHSC). Use of NHSC allows IHS facilities to recruit and retain
primary care providers by using NHSC scholarship and loan repayment
incentives. As of April 2017, 472 NHSC recipients are currently part of
our workforce serving in IHS, tribal and urban facilities.
These actions demonstrate that IHS is taking its challenges
seriously, and is continuing to take assertive and proactive steps to
address them.
h.r. 2662
H.R. 2662 proposes specific authorities to aid us in elevating the
health of American Indians and Alaska Natives to the highest level. IHS
is prepared to provide the Subcommittee technical assistance on the
legislation and I would like to provide additional technical comments
on various sections of the bill.
Section 101 would address the need for IHS to offer more flexible
and competitive benefits to recruit employees by establishing a
comparable pay system as allowed under Chapter 74 of Title 38. IHS
appreciates the authority we already have to use the pay flexibilities
under Chapter 74 of Title 38. We are working with OPM, OMB, and other
affected agencies to explore ways to enhance utilization of our current
pay authorities to enhance our ability to recruit and retain high
quality staff.
Section 102 requires a Service-wide centralized credentialing
system to credential licensed health professionals who seek to provide
healthcare services at any Service facility. IHS supports the use of a
standard system for credentialing. We are implementing a national
system for credentialing as well as privileging and evaluating
performance of IHS practitioners. Our new system will allow the local
and/or Area offices to perform these functions in alignment with the
Centers for Medicare and Medicaid Services (CMS) Conditions of
Participation and external accreditation standards for governance of
hospitals and ambulatory care facilities.
Section 104 would make certain healthcare management or healthcare
executive positions eligible professions for loan repayment awards, in
exchange for non-clinical service obligations. Management expertise is
very important in a health system as large as IHS.
Section 106 addresses IHS authority to remove or demote employees.
IHS has existing authorities to implement adverse employment actions.
Section 107 requires IHS to develop and implement standards to
measure the timeliness of care at direct-service IHS facilities. As
described above, IHS is in the process of establishing agency-wide
standards for wait times to each federally operated service unit. A
process for uniform data collection and reporting is also being
established.
Section 108 adds specific requirements for implementation of annual
mandatory cultural competency training programs for IHS employees, and
other contracted employees engaged in direct patient care. Cultural
competency in the IHS workforce is essential to the provision of
quality care and is a requirement under the accreditation standards for
hospitals. I have recently issued direction for all IHS employees to
complete training, which will become an annual requirement.
Section 110 requires IHS to establish a tribal consultation policy.
The specific provision is unnecessary as IHS already has a tribal
consultation policy in place. The requirements for consultation are
contained in statutes and various Presidential Executive Orders
including: the Indian Self-Determination and Education Assistance Act,
Indian Health Care Improvement Act, Presidential Memoranda in 1994 and
2004, and Executive Orders in 1998 and 2000. It is the policy of HHS
and IHS that consultation with American Indian and Alaska Native tribes
will occur to the extent practicable and permitted by law before any
action is taken that will significantly affect Indian tribes. IHS is
committed to regular and meaningful tribal consultation and
collaboration as an essential element for a sound and productive
relationship with tribes.
Despite all of the challenges, I am firmly committed to improving
quality, safety, and access to health care for American Indians and
Alaska Natives, in collaboration with HHS, our partners across Indian
Country, and Congress. I appreciate all your efforts in helping us
provide the best possible healthcare services to the people we serve to
ensure a healthier future for all American Indians and Alaska Natives.
We look forward to working with the Subcommittee on this
legislation as it moves through the legislative process. Thank you for
your commitment to improving quality, safety, and access to health care
for American Indians and Alaska Natives. I am happy to answer any
questions the Subcommittee may have.
______
Questions Submitted for the Record by Rep. LaMalfa to RADM Chris
Buchanan, Deputy Director, Indian Health Service
Question 1. The Indian Health Service (IHS) operates the Joint
Venture Construction Program, allowing tribes to expend tribal,
private, or other available non-IHS funds to acquire or construct a
healthcare facility, usually clinics.
In exchange, IHS agrees to request congressional appropriations for
additional staff and operation costs to maintain the facility under a
no-cost lease for a minimum of 20 years.
While this program is yielding some success, funding for the
construction of healthcare facilities has been limited to clinics and
fails to address the challenge of providing physician care to those
areas of Indian Country which are most in need.
How would the IHS respond to the idea of modifying the Join Venture
model by tasking the Federal Government to build, perhaps with the
involvement of private investment, 20-30 bed micro hospitals and then
allowing willing tribes take on the task of equipping and staffing the
facility?
Answer. The current Joint Venture Construction Program (JVCP) is a
way for the IHS to bring new healthcare facilities into the IHS system.
Tribes strongly support the JVCP because it provides them the
opportunity to use their own capital on a one-time basis to acquire or
construct a facility. In exchange, IHS agrees to submit requests to
Congress for initial and recurring staffing and operation funding for
that facility. The last solicitation for the JVCP yielded 37
applications. Seven of those applicants were approved to proceed with
planning on variously sized ambulatory and inpatient facilities.
The IHS currently does not have the authority to fund construction
of Joint Venture Construction projects. If Congress provided IHS with
construction authority for such projects, it would likely impact IHS's
ability to fund the construction of other new and replacement
healthcare facilities that have been identified by the Secretary as
priorities under the Health Care Facility Priority System (HCFPS).
Generally, IHS appropriations for construction are limited to the
amounts required to construct new and replacement healthcare facilities
identified as HCFPS priorities.
The HCFPS list was last updated in 1992, identifying 27 facilities
that need to be completed before new facilities are added. Today, there
are 11 healthcare facilities that remain on the list that have either
received funds for design and construction or are waiting to be funded.
The rate of funding to date has been approximately one facility per
year. IHS funding the construction of other facilities would delay
continued progress on addressing the HCFPS list.
In summary, the IHS is open to working with tribal leaders to
explore how we can utilize existing authorities within the IHS and
other resources to maximize resources for Indian Country.
______
Miss. Gonzalez-Colon [presiding]. Thank you. Now the Chair
recognizes Chairman Bear Shield to testify.
STATEMENT OF THE HON. WILLIAM BEAR SHIELD, CHAIRMAN, ROSEBUD
SIOUX TRIBAL HEALTH BOARD, ROSEBUD, SOUTH DAKOTA
Mr. Shield. Good afternoon. Thank you, Committee, for once
again allowing me to be here to testify about H.R. 2662. I want
to acknowledge our South Dakota Congresswoman, Mrs. Kristi
Noem, and our gratitude for her reaching out to us on working
together on creating this legislation.
I am William Bear Shield, a member of the Rosebud Sioux
Tribal Council. I am also the Chairman of our Rosebud Sioux
Health Board and the Unified Health Board that serves the Sioux
San IHS Hospital in Rapid City, South Dakota, as well as the
Vice Chairman of our Great Plains Tribal Chairman's Health
Board, and I sit on the Health and Human Service's Secretary's
Tribal Advisory Committee.
The problems within IHS did not happen overnight. In fact,
in 2010, former U.S. Senator Dorgan from North Dakota released
the Dorgan Report that identified most of the same issues. The
difference is something is now being done to correct those
issues.
The fundamental problem found in the Dorgan Report in 2010
and the findings now before the House is IHS leadership was
failing then, as it is failing now. So, before I talk about
this bill, I first feel the need to stress the appointment of a
new principal director of IHS. The Rosebud Sioux Tribe has
endorsed a candidate that we believe will bring a new
perspective, and is not a member of PHS. We believe this is
necessary if the rebuilding of IHS is to have any change at
all.
We strongly urge the Members to press for the nomination of
a permanent director of IHS as soon as possible. Along with the
naming of a permanent director, the position must be given
authority to deal with rebuilding IHS, which H.R. 2662 does.
We feel that IHS needs a deputy secretary-level position at
the Health and Human Services level. It is appropriate and
necessary that tribal health care be given the priority and
status it deserves, and this helps in creating positive change.
As a starting point for commenting on any legislation, it
must be acknowledged that the current structure, systems, and
management of IHS are outdated, broken, and cannot be fixed. It
has reached a point where only adding tools and
responsibilities will not help. The IHS must be set aside and
be completely rebuilt from the ground up. If this is not the
view, we will be back here next year and in the following years
talking about the same issues and more tribal members will have
needlessly perished.
Specifically, it is our view that this legislation
accomplishes the following: This legislation respects our
treaty rights--this means always recognizing and affirming the
obligations of the U.S. Government to provide the highest
quality of health care to every tribal member.
This legislation allows the delivery of patient-focused
health care, and this should be the first and truly only
priority of IHS. Regardless of what may be said or reported,
this is not the case now and it has not been for a very long
time.
This legislation mandates the required meaningful
communication at all levels between the IHS and tribes. You may
hear that there is a consultation policy in place and that it
is working. It is not working, and I am here to tell you that.
Consultation only works when there is a direct and substantial
dialogue. It only works when the dialogue leads to better care,
solves real problems, and is accountable. Because of this, we
ask Congress to direct IHS to work with tribes, and we are
included in developing the consultation policies as directed in
the proposed legislation.
We applaud the task force set up by the House. It is our
hope that this signals the rebuilding efforts we advocate are
supported by the Members. We will work with the task force in
continuing to advocate for real, meaningful recommendations
that rebuild and strengthen IHS.
As we move forward, there are other areas we need to focus
on: Drug pricing--allow the IHS to use existing Federal
authority to negotiate prices to better deploy IHS budgeted
funds.
PRC--focus on better systems and processes, so that tribes
can access Medicaid and third-party dollars. We ask that
Congress work with us and the Centers for Medicare and Medicaid
Services to update a policy on funding 100 percent of funds for
Medicaid-eligible American Indians through the Indian Health
Service and/or tribes.
HIPAA changes--explore amendments to HIPAA that would give
access to records and accountability for all Indian healthcare
facilities and operations.
We would also favor the President using an Executive Order,
very like the one he issued for the VA. It could be possibly
titled, ``Improving Accountability and Whistleblower Protection
at IHS.''
Create a modern, state-of-the-art healthcare delivery and
administrative system for tribal health care. There are many
examples in the private sector and the direction the VA is
moving may be worth examining. At a minimum, modern systems
address credentialing, waiting times, and quality of service.
Miss Gonzalez-Colon. Chairman, could you summarize?
Mr. Shield. Yes. Last, again, it may be said that there are
plans being implemented to address this issue. How long has IHS
been in this planning mode? We still need to see that
implemented. When there are no leadership and no systems, plans
are all that can be talked about. We look forward to this bill
in changing those systems within IHS. Thank you.
[The prepared statement of Mr. Shield follows:]
Prepared Statement of Councilman William Bear Shield, Rosebud Sioux
Tribal Health Board
Thank you for inviting me to testify about H.R. 2662. I want to
acknowledge our South Dakota Congresswoman Kristi Noem, and give our
gratitude to her for reaching out to us on working together in creating
this legislation.
I am Willie Bear Shield. I am a member of the Rosebud Sioux Tribal
Council, I am also the Chairman of the Rosebud Sioux Health Board and
Unified Health Board that serves the Sioux San IHS Hospital in Rapid
City, South Dakota, as well as the Vice-Chairman of the Great Plains
Tribal Chairman's Health Board and I sit on the HHS Secretary's Tribal
Advisory Committee.
The problems within IHS did not happen overnight, in fact in 2010
former U.S. Senator Dorgan from North Dakota released the Dorgan report
that identified most of these same issues, the difference is something
is now being done to correct the problems.
The fundamental problem found in the Dorgan report in 2010 and the
findings now before the House is IHS, LEADERSHIP was failing then as it
is failing now. So, before I talk more about the bill, I feel the first
thing we must do is appoint a new Principle Director of IHS. The
Rosebud Sioux Tribe has endorsed a candidate that we believe will bring
a new perspective and is not a member of PHS. We believe this is
necessary if the rebuilding of IHS is to have any change at all.
We strongly urge the members to press for the nomination of a
permanent Director of IHS as soon as possible. Along with the naming of
a permanent Director, the position must be given authority to deal with
rebuilding IHS, which H.R. 2662 does. We feel that IHS needs a Deputy
Secretary level position at HHS. It is appropriate and necessary that
tribal health care be given the priority and status it deserves and
this helps in creating positive change.
As a starting point for commenting on any legislation it must be
acknowledged that the current structure, systems and management of IHS
are outdated, broken and cannot be fixed. It has reached a point where
only adding tools and responsibilities will not help. The IHS must be
set aside and be completely rebuilt from the ground up. If this is not
the view, we will be back here next year and the years following
talking about the same issues and more tribal members will have
needlessly died.
Specifically, it is our view that this legislation accomplishes the
following:
This legislation, Respects Treaty Rights--this means
always recognizing and affirming the obligations of the
U.S. Government to provide the highest quality health care
to every tribal member.
This legislation allows the delivery of patient focused
health care and this should be the first and truly only
priority of IHS. Regardless of what may be said or reported
this is not the case now and has not been for a very long
time.
This legislation mandates the required meaningful
communication at all levels between the IHS and tribes. You
may hear that there is a Consultation Policy in place and
that it is working. It is not working. Consultation only
works when there is a direct and substantial dialogue. It
only works when the dialogue leads to better care, solves
real problems and is accountable. Because of this we ask
Congress to direct IHS to work with tribes and we are
included in developing the consultation policies as
directed in the proposed legislation.
We applaud the task force set up by the House. It is our hope that
this signals the rebuilding efforts we advocate are supported by the
Members. We will work with the task force and continue to advocate for
real meaningful recommendations that rebuild and strengthen IHS.
As we move forward there are other areas we need to focus on:
Drug pricing--Allow the IHS to use existing Federal authority to
negotiate prices to better deploy IHS budgeted funds.
PRC--Focus on better systems and processes so that tribes can
access Medicaid and third-party money. We ask that Congress work with
us and the Centers for Medicare and Medicaid Services (CMS) to update a
policy on funding 100 percent of funds for Medicaid-eligible American
Indians through the Indian Health Service or tribes.
HIPPA changes--Explore amendments to HIPPA that would give access
to records and accountability for all Indian healthcare facilities and
operations.
We would also favor the President issuing an Executive Order very
like the one issued for the VA. It could be possibly titled, Improving
Accountability and Whistleblower Protection at IHS.
Create a modern state-of-the-art healthcare delivery and
administrative system for tribal health care. There are many examples
in the private sector and the direction the VA is moving may be worth
examining. At a minimum, modern systems address credentialing, wait
times and quality of service.
For example:
We all hear how terrible the credentialing systems are at
IHS. The reason is because of the lack of leadership
practically every service unit within IHS uses its own
method of credentialing. This means that a doctor at IHS
Pine Ridge cannot easily come to IHS Rosebud and provide
service. It may take 30, 60, 90 days or longer. Also, if a
bad doctor is moved out of any given IHS facility they can
be credentialed at another because of the lack of systems
that track and are accessible system wide in the IHS. An
$85 million contract does not solve this, because it
requires leadership to make it work.
At the Rosebud ER, and others, the lack of standing orders
and other processes that are standard in most every other
healthcare system in the United States has killed our
people. Let me explain--It is common and best practice for
an ER to have standing orders issued by a doctor. This
enable the staff to quickly treat and otherwise deal with
incidents. The orders follow well established medical
practice and allow staff to administer drugs and other
treatments if an attending or on call doctor is not
immediately available. This then allows for effective
service, evaluations, and assessments as well as saving
lives. Why is it that IHS leadership does not require that
this fundamental medical practice be implemented
everywhere? It is beyond me.
Again, it may be said that there are plans being implemented to
address this issue. How long has IHS been in the planning mode. When
there is no leadership and no systems--plans are all that can be talked
about!
Once again, I want to thank you for the opportunity to testify
before you and want to advise you that we strongly support this
legislation and ask that all Members of Congress do the same to start
the rebuilding of a broken system into one that provides quality health
care.
We strongly urge the Members to press for the nomination of a
permanent Director of IHS as soon as possible. Along with the naming of
a permanent Director, the position must be given authority to deal with
the rebuild. H.R. 2662 does some of that. Let me suggest that the IHS
needs a Deputy Secretary level position at HHS. It is appropriate and
necessary that tribal health care be given the priority and status it
deserves this change within HHS would bring.
As to the rebuild, we applaud the task force set up by the House of
Representatives. It is our hope that this signals the rebuilding
efforts we advocate are supported by the Members. We will work with the
task force and continue to advocate for real meaningful recommendations
that rebuild and strengthen IHS.
There are other areas for the Members to focus on:
Drug pricing--Allow the IHS to use existing Federal
authority to negotiate prices to better deploy IHS budgeted
funds.
PRC--Focus on better systems and processes so that tribes
can access Medicaid and third-party money.
HIPPA changes--Explore amendments to HIPPA that would give
access to records and accountability for all Indian
healthcare facilities and operations.
We recognize the provision of health care is complicated. We see
the national demand for change in delivery, service and financing of
the healthcare system. We ask that Members focus on the rebuilding of
the IHS as both a way to meet the obligations of the U.S. Government to
tribes and to make sure that tribes have a place at the table as the
overall national debate on health care moves forward.
______
Miss. Gonzalez-Colon. Thank you, Chairman. The Chair now
recognizes the Honorable Andy Joseph, Business Council Member
of the Confederated Tribes of the Colville Reservation.
STATEMENT OF THE HON. ANDY JOSEPH, BUSINESS COUNCIL MEMBER,
CONFEDERATED TRIBES OF THE COLVILLE RESERVATION, NESPELEM,
WASHINGTON
Mr. Joseph. Good afternoon, members of the Subcommittee.
[Speaking native language.] My name is Andy Joseph, Jr. I am a
member of the Colville Business Council, the governing body of
the Confederated Tribes of the Colville Reservation. I serve as
the Chair of the Council's Health and Human Services Committee.
H.R. 2662 addresses several long-standing problems with IHS
service. The Colville is a direct-service tribe, and the bill
would benefit us and other direct-service tribes in several
ways. We strongly support H.R. 2662 and urge the Committee to
move the legislation forward.
I would like to express the Colville Tribes' thanks to
Congresswoman Kristi Noem and her staff for their work in
developing this legislation. I would also like to thank this
Committee for its work in outreach on the bill.
Last year, your staff toured the health facilities on the
Colville Reservation and heard firsthand about the challenges
we face in providing care for our members. I would also like to
thank Rear Admiral Chris Buchanan for him and his staff who
came to our reservation and toured our clinics.
For decades, the Colville Tribes have endured chronically
low staffing levels. On December 17, 2013, the Colville
Business Council adopted a resolution declaring a state of
emergency because of IHS staffing shortages. After that
declaration, IHS calculated that the Colville Tribe service
unit had less than one-third of the required number of clinical
staff and only one-quarter of the required number of dental
staff.
For direct-service tribes, facility staffing ratios are
established when the initial IHS health facility opens for
operations. Those levels may increase slightly as the IHS base
budget increases, but they can never be brought anywhere close
to what is needed in modern times.
There are two ways for direct-service tribes to update
their staffing levels. One is to construct a new facility with
IHS funds under the Facility Construction Priority System. The
other is to build the facility using tribal funds under a joint
venture program. The priority list has been closed since 1992,
and applicants for joint venture programs are offered rarely
and are highly competitive.
Direct-service tribes that have not been able to update
their staffing ratios through these two IHS programs are frozen
in time for staffing purposes. For the Colville Tribes, this
historic staffing ratio dates back to 1938. That is when the
U.S. Public Health Service converted a Department of War
building for use as the Colville service unit's health clinic.
Former IHS officials have told us that this facility was
removed from the priority list in the 1980s because of its
historical significance. This building was used as a tribe's
primary health clinic until the tribe used its own tribal funds
to construct a new facility.
Staffing shortages increase the waiting times for patients
and have other consequences. Lack of staffing has also resulted
in fewer patient encounters. Fewer encounters means our user
population decreases, which means our allocation of purchased
and referred care funding decreases.
The staffing shortages have also driven our healthcare
providers to seek other employment. Many of their patients have
chronic illnesses that multiply the number of visits in their
annual workload. Despite increases in the IHS base budget in
recent years, the Colville Tribes' staffing ratios have not
improved. This is because the increases for IHS staffing in the
President's budget request are almost always earmarked to staff
new facilities that come on-line under the priority list or the
joint venture program.
For direct-service tribes like the Colville that have been
unable to build anything under these programs, our staffing
ratios are frozen in time. In our case, time was 70 years ago.
The staffing demonstration project in Section 109 would
provide a way to address these inequities. It would authorize
IHS to provide additional staffing resources to the Indian
Health Service units on a temporary basis. A deployment----
Miss Gonzalez-Colon. Mr. Joseph, can you summarize?
Mr. Joseph. Yes. I just have a couple more--this would
enable staffing to be self-sustaining and permanent.
Section 109 would address a much-needed void in the Indian
Health System. It would provide a path to direct-service tribes
with historically low staffing ratios to update their ratios.
This could be a model to address staffing inequities throughout
the IHS system for well-managed IHS service units.
My written testimony is in for the record. Thank you for
this time.
[The prepared statement of Mr. Joseph follows:]
Prepared Statement of the Honorable Andrew Joseph, Jr., Council Member,
Colville Business Council, Confederated Tribes of the Colville
Reservation
On behalf of the Confederated Tribes of the Colville Reservation
(``Colville Tribes'' or the ``CCT''), I thank you for this opportunity
to provide testimony on the ``Restoring Accountability in the Indian
Service Act of 2017,'' H.R. 2662.
My name is Andy Joseph, Jr., and I am a member of the Colville
Business Council, the governing body of the Colville Tribes, and serve
as the Chair of the Council's Human Services Committee. I also serve as
the President of the Portland Northwest Area Indian Health Board, which
has 43 federally recognized member tribes in Oregon, Washington and
Idaho and serves as the health advocacy organization for the Northwest
region. I provide this testimony in my capacity as a representative of
the Colville Tribes.
As an initial matter, I would like to express the Colville Tribes'
thanks to Congresswoman Kristi Noem and her staff for their work over
the past year in developing this legislation. I would also like to
thank the staff for this Committee, who toured the health facilities on
the Colville Reservation last year and heard directly from our staff
about the challenges they face in providing care to our members.
H.R. 2662 addresses several long-standing issues with the Indian
Health Service (``IHS'') and would benefit the Colville Tribes and
other tribes in many ways. The Colville Tribes supports H.R. 2662 and
urges the Committee to move the legislation forward through the
legislative process. We offer some specific recommendations on how the
bill can be clarified to garner even broader Indian Country support.
background on the colville tribes
The present-day Colville Reservation is approximately 1.4 million
acres and occupies a geographic area in north central Washington State
that is slightly larger than the state of Delaware. The Colville Tribes
has more than 9,500 enrolled members, about half of whom live on the
Colville Reservation. In terms of both land base and tribal membership,
the Colville Tribes is one of the largest Indian tribes in the Pacific
Northwest.
Most of the Colville Reservation is rural timberland and rangeland
and most residents live in one of four communities on the Reservation:
Nespelem, Omak, Keller, and Inchelium. The Colville Tribes has a large
IHS service area and these communities are separated by significant
drive times. The CCT's primary IHS facility is in Nespelem, WA, and
residents from Inchelium that require care must drive, in many cases,
more than 90 minutes through two mountain passes. Although the CCT has
contracted some discrete IHS activities under Pub. L. 93-638, the IHS
directly provides most of the healthcare services on the Colville
Reservation.
staffing inequities in the ihs system
The Colville Tribes has, for decades, endured chronically low
staffing levels. On December 17, 2013, the Colville Business Council
adopted a resolution declaring a state of emergency on the Colville
Reservation in response to immediate IHS staffing shortages and a large
number of current and forecasted vacancies. In response to a
congressional inquiry resulting from that declaration, the IHS
calculated that the Colville Service Unit had less than one-third of
the required number of clinical staff and only one-quarter of the
required number of dental staff.
For the Colville Tribes and similarly situated direct-service
tribes, facility staffing ratios are essentially set when the initial
IHS health facility opens for operation. These levels may increase
incrementally as the IHS base budget increases, but they can never be
brought anywhere close to what is needed in modern times.
The only way for a tribe to update its staffing levels to reflect
growth and modern health delivery needs is to either construct a new
facility with IHS funds under the Health Care Facility Construction
Priority List (``Priority List'') or construct a facility using tribal
funds under the Joint Venture construction program. The Priority List
has been closed since 1992 and solicitations for the Joint Venture
program are offered very infrequently and are extraordinarily
competitive.
Direct service tribes that have not been able to update their
staffing ratios through these two IHS programs are essentially frozen
in time for staffing ratio purposes. For the Colville Tribes, these
historic staffing ratios date back to the late 1930s when the U.S.
Public Health Service converted a Department of War building for use as
the Colville Service Unit's health clinic. This historic facility--
which the CCT understands from former IHS officials was removed from
the Priority List in the 1980s because of its historical significance--
was used as the CCT's primary health clinic until the CCT used its own
tribal funds to construct a new facility. That facility opened in June
2007.
Staffing shortages not only increase the wait times for patients,
but in the CCT's case, they have also had other consequences. Lack of
health providers has resulted in fewer patient encounters, which has
had a negative domino effect on the CCT's Purchased/Referred Care
funding and user population. The staffing shortages have also prompted
other healthcare providers to seek other employment because many of the
patients in their respective panels have chronic illnesses that
multiply the number of visits in their annual workloads.
Despite increases to the IHS's base budget in recent years, the
Colville Tribes' staffing ratios have not improved. This is because
increases for IHS staffing in the President's Budget request have been
earmarked to staff new facilities that come on-line that were
constructed under either the Priority List or the Joint Venture
programs. Again, for direct-service tribes like the CCT that have been
unable to build anything under those IHS construction programs, our
staffing ratios are frozen in time. In our case, the 1930s.
the section 109 staffing demonstration project provides an innovative
approach to addressing staffing inequities
The Staffing Demonstration Project in Section 109 would provide a
mechanism to address these inequities by authorizing the IHS to deploy
an infusion of staffing resources to federally managed IHS Service
Units. While temporary, the deployment of staff is intended to enable
Service Units to incorporate the additional staff into their billing
and collection processes to enable the staff to be self-sustaining and
permanent. The Staffing Demonstration Project could be funded
separately but, as drafted, it is intended to allow the IHS to utilize
carryover or other available funds.
Section 109 would address a much-needed void in the IHS system by
providing a path for tribes with historically low staffing ratios to
update those ratios. With the advances in opportunities for third party
billing in the last reauthorization of the Indian Health Care
Improvement Act, if successful, the Staffing Demonstration Project
could be a model to address staffing inequities throughout the IHS
system. We greatly appreciate that this language was included in the
bill and strongly support it.
other comments and recommendations
Although the CCT is primarily a direct-service tribe and most of
H.R. 2662 is intended to address issues applicable to direct-service
tribes, we recommend that language be added that clarifies the
applicability of H.R. 2662 to tribally operated facilities. We believe
that tribally operated facilities would likely want the opportunity to
opt-in to certain provisions of the Act, such as the parity in pay
requirements in Section 101, but might also want to opt out of certain
provisions as well. We encourage further discussion with tribes and
tribal organizations to clarify application of H.R. 2662 to tribally
operated facilities.
Sec. 101. Incentives for Recruitment and Retention
The Colville Tribes strongly supports Section 101, which would
direct the Secretary to establish a pay system for physicians,
dentists, nurses, and other healthcare professionals employed by the
IHS comparable to the pay provided by the Department of Veterans
Affairs. We also support authorizing the IHS to reimburse relocation
costs. Despite whatever recruiting challenges might exist, the IHS has
an obligation to provide adequate care to federally managed service
units. The Colville Service Unit is in a rural area and these tools are
necessary to attract and incentivize health providers to take jobs
there.
Sec. 102. Medical Credentialing System
This section would direct the Secretary to consult with Indian
tribes and any public or private association of medical providers,
government agencies, or relevant experts in developing an IHS-wide
credentialing system. While the CCT appreciates the need to standardize
credentialing, we are concerned that directing the Secretary to consult
with private associations may provide an opportunity for those
associations that do not share tribal goals to cause mischief or erect
barriers in developing credentialing standards.
Sec. 105. Improvements in Hiring Practices
Section 105 would amend the IHCIA to authorize the Secretary to
directly hire candidates to vacant positions within the IHS. The
section also directs the Secretary to notify each Indian tribe located
within a geographic Service Area and, in some instances, obtain a
waiver of Indian preference laws from each Indian tribe concerned. The
CCT is concerned about the directive for the Secretary to obtain a
waiver of Indian preference from tribes. We recommend additional
discussion on this provision with Indian tribes and tribal
organizations.
Sec. 106. Removal or Demotion of IHS Employees Based on Performance or
Misconduct
The Colville Tribes strongly supports this section. While the
Colville Service Unit has not experienced the personnel issues that
other IHS areas have reported regarding problem personnel, these tools
should be available for all IHS areas.
Sec. 202. Fiscal Accountability
The Colville Tribes strongly supports Section 202, which would
direct the Secretary to use unobligated or unexpended funding to
support essential medical equipment, purchased or referred care, or
staffing. The Colville Tribes is troubled by reports that the IHS has
carried over significant funds from year to year. The CCT was also
disturbed that in 2015, the IHS paid $80 million from funds that could
have otherwise been used for staffing to the Laborers' International
Union of North America to settle overtime claims.
There has long been a lack of transparency in how the IHS spends
its appropriated funds. Had Indian Country known that this $80 million
was available, it could have used it for needed programs and services.
The IHS needs congressional direction on how it should use unobligated
or unexpended funds and Section 202 is a good start.
Sec. 303. Reports by the Comptroller General
The Colville Tribes strongly supports Section 303, which would
direct the U.S. Comptroller General to develop and submit to Congress
three reports. With regard to the staffing report in Section 303(b)(2),
the CCT recommends additional specificity be added to ensure that the
formulas or methodologies that the IHS has previously used and
currently uses to assess staffing needs are identified in the report.
The Colville Tribes has received conflicting information from the IHS
about these issues in past years when it was attempting to ascertain
what its needed staffing levels should be.
This concludes my testimony. Thank you for allowing the Colville
Tribes to testify today. I would be happy to answer any questions that
the members of the Committee may have.
______
Miss Gonzalez-Colon. Thank you, Mr. Joseph. Now the Chair
recognized the Honorable Robert TwoBears.
STATEMENT OF TWO BEARS, ROBERT, DISTRICT V REPRESENTATIVE, HO-
CHUNK NATION LEGISLATURE, BLACK RIVER FALLS, WISCONSIN
Mr. TwoBears. I would like to thank you for the invitation
to appear before you today to discuss H.R. 2662, the Restoring
Accountability in the Indian Health Service Act of 2017.
My name is Robert TwoBears. I am a District V
Representative of the Ho-Chunk Nation Legislature. The Ho-Chunk
Nation has over 7,000 tribal members spread across 18 counties
in the state of Wisconsin. We have a diverse and strong tribal
economy that employs thousands of tribal members in the
surrounding communities.
The Nation operates two health facilities, one in Black
River Falls and one in Wisconsin Dells. The Black River Falls
facility has 23 exam rooms and 6 operatories. The Wisconsin
Dells facility has 11 exam rooms and 3 dental operatories.
The facilities in itself are very similar to community
health centers. They handle a pharmacy, optometry, and also
community health departments.
You have read our written statement, so I would just like
to highlight a few provisions the Nation believes are most
important.
Section 100 requires Indian Health Service doctors,
dentists, and other professionals have a pay parity and
relocation cost with their counterparts, similar to the
Department of Veterans Affairs.
Section 104 expands a loan repayment program for
administrators, health managers, and the like. These sections
will help attract and retain high-quality professionals to
Indian lands.
Section 109 would allow staffing demonstration pilot to
increase staffing resources for federally run health units with
an emphasis on those tribes that have contributed substantially
to the constrictions of the facility.
Last, a word about consultation. I know that there are two
different types of tribal consultations being considered under
this bill. Section 110--the first being the previous tribal
consultation, as mandated by the Indian Health Service, in
which Indian Health Service is utilized in dealing with the
Indian tribes. This policy was endorsed by Executive Orders and
formalized by CMS. The policy that Indian Health Service
utilizes requires tribes to be contacted, consulted at any
point during a rulemaking or Federal planning decision where a
tribe could be affected.
In his extended remarks on the final negotiated rulemaking
process on October 23, 1990, he indicated that this Act was not
intended to apply to policy decisions. I think early in the
earlier testimonies they were talking about consultations, and
I actually attended the consultation for the Midwest region. We
met with the Health and Human Services region, and we actually
have a work plan that we reviewed with the appropriate staff
from the region, CMS, Indian Health Service, HRSA, SAMHSA.
And just to really kind of clarify from a tribal
perspective is we talk about issues that are affecting the
tribes. When we were having these consultations, we sit in a
room similar to this. The tribes are on this side, similar to
this, and the Feds are on one side. And then we actually just
ask questions and look for guidance and assistance to help us
with some of our health disparities, whether it is substance
abuse, diabetes, and so forth.
But really, what doesn't happen is that when the tribes are
requesting this assistance, we just get the looks back from the
Feds, looking for us. So, in a sense they give us, the tribes,
an opportunity to talk about their issues. But on the back end
is we never get the answers that we are looking for.
So, in a sense, that consultation does work. We are at the
table with the appropriate people. As far as any actionable
items that we request back from the Feds, the tribes still have
that work plan in place, and it is never addressed.
This concludes my testimony. I will be happy to answer any
questions. Thank you.
[The prepared statement of Mr. TwoBears follows:]
Prepared Statement of the Honorable Robert TwoBears, Ho-Chunk Nation,
Legislative Representative, District V, Black River Falls, Wisconsin
Greetings Chairman LaMalfa, Ranking Member Torres, and esteemed
members of the Subcommittee. My name is Robert TwoBears, and once
again, I am one of the acting Legislative Representatives for District
V of the Ho-Chunk Nation (the ``Nation'').
Please allow me to extend some previous-stated background on the
Ho-Chunk Nation. The Nation has nearly 7,000 tribal members, and while
it does not have a reservation, its land base consists of trust lands
and fee simple lands spread across eighteen (18) counties in the state
of Wisconsin. The Nation also maintains fee simple lands in the states
of Minnesota and Illinois. Further, the Nation has a diverse economy
that includes forestry, gaming, agriculture services, and a number of
retail outlets. The Nation employs approximately 4,000 individuals, and
is the largest employer in Sauk and Jackson counties in Wisconsin. As a
Legislative Representative for District V of the Nation, I represent
the at-large tribal population residing outside of Wisconsin.
For years the Nation has received direct healthcare services from
the Indian Health Service (``IHS'') but recently, the Nation has
finalized negotiations with IHS under its annual funding agreement, and
now proudly operates its health facilities through the Self-Governance
Compact and Funding Agreement under Title V of the Indian Self-
Determination and Education Assistance Act (``ISDEAA'') 25 U.S.C.
Sec. 5381.
Again, we applaud H.R. 2662, ``Restoring Accountability in the
Indian Health Service Act of 2017'', as it provides workable measures
for the success and betterment of employee recruitment, employee
hiring, and employee retention in the Indian Health Service (``IHS'')
workforce. We again note that H.R. 2662 takes affirmative steps to
restore accountability in the standards and timeliness of care that IHS
provides to its Native People. A significant obstacle H.R. 2662
undertakes, which is essential to providing adequate health to Native
Americans, is imposing firmer reporting requirements for the Federal
Government to utilize, that if followed, would report with better
clarity and accuracy, on the true state of all Indian Health Service
Units.
Although not applicable to all service units, Section 833 of H.R.
2662, proposes the creation of a staffing demonstration project. This
project would provide federally managed service units with additional
staffing resources. The hope is, that in providing these additional
resources to a tribe, the additionally staffed service area will become
a self-sustaining source of revenue for the unit at the end of a 3-5
year period. The staffing demonstration project is ambitious, to say
the least, as it would indicate upon completion, whether giving tribes
additional staffing resources could generate sufficient service revenue
for the unit to retain the staffed service area on a permanent basis.
In essence, this is the start of a self-help formula for federally
managed tribal service units to identify their unmet needs, and then
seek to relieve those needs by placing government provided additional
staffing resources toward identified areas of concern, with the hoped-
for-wish that the provision of additional resources creates self-
sustaining sources of internal revenue. However, such a project cannot
be initiated and completed without appropriate tribal consultation.
In submitting testimony on H.R. 2662, the Nation is not in support
of H.R. 2662's amendment, as proposed under Section 834, to replace the
tribal consultation policy under Circular No. 2006-01 of IHS, with the
Negotiated Rulemaking Act of 1990. In providing health care to its
People, the Nation has consistently relied on the deictic channels of
communication as provided by the tribal consultation policy under
Circular No. 2006-01.
On September 1, 2016, the Nation submitted a Comment on the
Proposed Rule for ``Medicare Program: Payment Policies under the
Physician Fee Schedule and Other Revisions to Part B for CY 2017;
Proposed Expansion of Medicare Diabetes Prevention. The Nation urged
the Centers for Medicare and Medicaid Services (``CMS'') to take into
account the unique position of tribes, and requested that consultation
occur at all stages where there could be a substantial effect on a
tribe, which mirrors the standards as set forth under Circular No.
2006-01.
Whether any relief the Nation requested was provided, remains
undetermined, however the tribal consultation policy, as utilized by
the Service, provides the only viable notice to the Nation, and to all
tribes, to assert standing and express all and any concerns regarding
their health care as serviced by IHS and the Federal Government at
large.
Additionally, the Nation would like to remind the Committee that,
in his extended remarks on the Final Passage of the Negotiated
Rulemaking Act of 1990, Speaker Donald J. Pease, then stated that he
does not ``. . . intend that negotiated rulemaking be employed to
establish fundamental policy directives or to permit Federal agencies
to frustrate the will of the Congress.'' (See attached Exhibit A. Final
Passage of The Negotiated Rulemaking Act of 1990, 136 Cong Rec E 3414).
Speaker Donald J. Pease was the first to introduce the Negotiated
Rulemaking Act, and was a strong supporter of this legislation from its
creation to its enactment.
Given the special relationship that exists between tribes and the
Federal Government, as well as the promulgations long-established in
the then-titled Indian Health Care Improvement Act of 1976, as since
amended, Congress spoke quite clearly when it found that ``. . . a goal
of the United States is to provide the quantity and quality of health
services which will permit the health status of Indians to be raised to
the highest possible level and to encourage the maximum participation
of Indians in the planning and management of those services.''(See
attached Exhibit B. 94 P.L. 437, 90 Stat. 1400).
Although the Indian Health Care Improvement Act has undergone many
transformations since its inception, congressional intent for tribes to
be meaningfully engaged and consulted regarding their health services
as provided by the Federal Government, remains intact. Adopting the
Negotiated Rulemaking Act of 1990 to determine or guide tribal
consultation for services through IHS, under H.R. 2662, frustrates this
congressional intent, and is a misapplication of the legislative intent
of the Negotiated Rulemaking Act.
The Ho-Chunk Nation wishes for the tribal consultation policy under
Circular No. 2006-01 to remain and continue under H.R. 2662. Although
by no means perfect, this policy at the very least, recognizes and
meets the unique consultation needs of Indian tribes, as recognized by
Congress.
In considering the unique position of tribes, and the consequent
need for tribal consultation, the Nation wishes to expand its
commentary regarding the legislation's intent to increase physician
retention rate under the service by offering the following insight.
Upon reading H.R. 2662, and reviewing the testimony that was offered,
Executive Director of the Ho-Chunk Nation Department of Health, Ona M.
Garvin, found that physician retention rate in Indian Country would be
better served by IHS receiving and funding tribes with more monies to
hire physicians with a pay-rate that is commensurate with physicians in
private practice, specifically in the 330k-range.
Once again, I appreciate your kind invitation to testify and appear
before you to discuss the Ho-Chunk Nation's commentary regarding H.R.
2662, ``Restoring Accountability in the Indian Health Service Act of
2017.'' I would like to thank Congresswoman Kristi Noem for introducing
this important bill, as well as Chairman LaMalfa, the Full Committee,
Chairman Rob Bishop, and others, for co-sponsoring this proposed
legislation.
I look forward to working together with all concerned parties to
further ``Restoring Accountability in the Indian Health Service Act of
2017.'' Thank you again for this kind invitation to the Ho-Chunk Nation
to offer testimony on H.R. 2662.
*****
The following documents were submitted as supplements to Mr. TwoBears'
testimony. These documents are part of the hearing record and are being
retained in the Committee's official files:
--Exhibit A: Final Passage of The Negotiated Rulemaking Act of
1990, 136 Cong Rec E 3414
--Exhibit B. 94 P.L. 437, 90 Stat. 1400
______
Miss Gonzalez-Colon. I want to thank you, Representative
TwoBears, for your statement. Now the Chair recognizes Ms.
Victoria Kitcheyan, representative of the Great Plains Area
National Indian Health Board.
STATEMENT OF VICTORIA KITCHEYAN, GREAT PLAINS AREA
REPRESENTATIVE, NATIONAL INDIAN HEALTH BOARD, WASHINGTON, DC
Ms. Kitcheyan. Good afternoon, Committee members and
Ranking Member Torres. Thank you for the opportunity to offer
testimony on this important bill. My name is Victoria
Kitcheyan, and I serve as the Great Plains area rep for the
National Indian Health Board. I am also a Winnebago tribal
member and I serve on the Tribal Council as Treasurer.
We appreciate the commitment of this Committee to find
lasting solutions to the long-faced challenges in the health
care delivery in Indian Country. Legislative efforts to address
these issues should be conducted in conjunction with increased
oversight and scrutiny of the agency. We need to get this
right. I have heard from my colleagues today, and some of our
supportive representatives, that our people need help. And some
of the quality care issues found in my tribe and elsewhere
within the Great Plains have been going on for far too long.
But I want to, I guess, kindly remind the Committee that we
need to do this in tandem with all of Indian Country, because
this is going to affect us all. And we need to work together so
we have the best possible outcome and product for the whole IHS
agency and Indian Country. This includes making the legislation
work for direct-service tribes as well as self-governance
tribes, and we look forward to working with this Committee and
Indian Country in the coming weeks to further engage in this
consultation on the bill.
As I have shared in previous testimonies with this
Committee, as documented since 2007, that we have had these
demonstrated deficiencies in Winnebago. And it is our feeling
that these should not exist at any facility run by the Federal
Government. And Winnebago still remains the only Federal
facility to lose its CMS certification. We lost that in July of
2015. Two years later we are still without that certification.
Other tribes in our region continue to experience similar
circumstances, although they have not lost their certification.
So, we are looking for both long-term and short-term
solutions that would improve the quality of services delivered
at these IHS hospitals that would improve staffing and
management.
Though this bill addresses crucial care issues, it is
important that we consider that it will affect the whole Indian
healthcare system. For instance, savings clauses in the bill
should be more clear in how they intend to exempt self-
governance tribes.
There are a few other items in the legislation I would like
to address so that it works for all of us.
First and foremost, I again want to emphasize that
legislation should not be enacted without thorough input and
agreement of Indian Country. The legislation will affect
everyone, and we want to ensure that all voices are heard. This
remains a high priority for the National Indian Health Board.
There are many provisions that address new programs and
functions for IHS, which will be beneficial if they receive
adequate resources and oversight. We want to make sure that
this legislation put forward is something that is not going to
become an unfunded mandate. Many of the provisions within the
Indian Health Care Improvement Act passed 7 years ago remain to
be unfunded. So, I just ask that this bill be funded so that it
is not another broken promise to Indian Country.
NIHB also appreciates the intent to streamline the system
for licensed healthcare professionals' credentialing
procedures. However, we do not want that to be mistaken as the
replacement to providing permanent healthcare providers to the
tribes and the IHS. We are striving for permanent providers
here, and we just want to make sure that there is a commitment.
Tribes in some of the areas have already come up with some
creative solutions to gain that commitment at the local level,
and I think that there is value there, and we can mimic those
throughout Indian Country and replicate those models. We look
forward to further developing some of those concepts and
creative solutions to address the change that is much needed.
When it comes to hiring authorities outlined in the
legislation, NIHB appreciates the streamlining of Federal
hiring authority. However, we believe that changes to the
legislative language are needed to include more tribal input,
again, and most notably when it comes to waiving the Indian
hiring preference. And we want to make sure that that is not an
erosion of that as a distinct political people--it is important
that that stays intact.
Section 110 establishes rules regarding a tribal
consultation policy. We are in complete agreement that this
consultation policy needs to be strengthened so it is
meaningful for the tribes. And had this been done from the
beginning, many of the Great Plains issues and deficiencies may
have been identified sooner and not have risen to this crisis
level.
We believe increasing fiscal accountability for IHS
outlined in the bill makes sense. However, we want to make sure
that in Section 202, that the tribes are involved so that those
third-party revenue dollars are spent at the local level, so
the tribes can identify where those services are needed the
most.
Finally, we are glad to see some of the reporting
requirements outlined on the quality of care, but we also want
to include purchase-referred care. In addition, tribes should
have input on how those reports are released.
Again, we thank the Committee for its genuine interest to
elevate our problems--alleviate, not elevate--I think they have
been elevated. It is clear that management, recruitment,
accountability, and transparency are still issues within the
agency. I thank you for the increased efforts that this
Committee has made, so that the tribes can be consulted with
and we can make effective change for long-term care for Indian
tribes and Alaska Natives.
[The prepared statement of Ms. Kitcheyan follows:]
Prepared Statement of Victoria Kitcheyan, Great Plains Area
Representative, National Indian Health Board
Chairman LaMalfa, Ranking Member Torres and members of the
Committee, thank you for holding this hearing on this very important
piece of legislation. My name is Victoria Kitcheyan. I am a member of
the Winnebago Tribe of Nebraska and I currently serve as Treasurer of
the Winnebago Tribal Council. I also serve as the Great Plains Area
Representative of the National Indian Health Board. The National Indian
Health Board serves all 567 federally recognized tribal nations when it
comes to health. This means we serve both tribes who receive care
directly from the Indian Health Service (IHS) and those who operate
their health systems through self-governance compacts and contracts.
The Federal Government has a duty, agreed to long ago and
reaffirmed many times by all three branches of government, to provide
health care to tribes and their members throughout the country. Yet,
the Federal Government has never lived up to that trust responsibility
to provide adequate health services to our Nation's indigenous peoples.
Historical trauma, poverty, lack of access to healthy foods, loss of
culture and many other social, economic and environmental determinants
of health as well as lack of a developed public health infrastructure
in Indian Country all contribute to the poor state of American Indian
and Alaska Native (AI/AN) health. AI/ANs suffer some of the worst
health disparities of all Americans. We live 4.5 years less than other
Americans. In some states, life expectancy is 20 years less, and in
some counties, the disparity is even more severe. With these
statistics, it is unconscionable that some IHS-operated facilities
continue to deliver a poor quality of care to our people.
We appreciate the commitment of this Committee to find lasting
change at IHS which has long-faced challenges in the delivery of health
care. Legislative efforts to address these issues should be conducted
in tandem with increased oversight and scrutiny over the administration
of the delivery of care at service units operated by the Indian Health
Service. The current legal framework for IHS provides much of the
necessary guidelines for the operation of the agency.
While we appreciate the speed at which the House is considering the
legislation given the critical situation going on in the Great Plains
region, we need to make sure we get this right. It is true, our people
need help. These issues surrounding quality of care cannot go on any
longer. However, it is also important that these changes are
accompanied by input from all tribal nations to ensure the best
possible outcome and product. Tribes across the country would have
appreciated the time to review any draft legislative language before
H.R. 2662 was introduced. NIHB is ready and willing to lead a
legislative consultation on this bill and we intend to do so in the
coming weeks and months. This step must happen first before anything
can be enacted.
ihs hospital operations
Quality of care issues at IHS-operated hospitals and facilities are
well documented. Since at least 2007, the Winnebago IHS Hospital has
been operating with demonstrated deficiencies which should not exist at
any hospital in the United States. The Centers for Medicare and
Medicaid Services (CMS) deficiencies were so numerous and so life-
threatening that in July 2015 the IHS Hospital in Winnebago became what
still is, to the best of our knowledge, the only federally operated
hospital ever to lose its CMS certification. Other IHS facilities in
the Great Plains region such as Rosebud Indian Hospital and Pine Ridge
Hospital have been experiencing similar quality of care issues
throughout this time and are also under threat of decertification by
CMS. These facilities continue to have quality of care issues, and it
is unclear if the actions the agency has taken are substantially
improving the situation. This situation is especially troubling
considering the challenges that have been identified are not new. In
2010, for example, then-Chairman of the Senate Committee on Indian
Affairs, Byron Dorgan (D-ND) issued a report detailing issues in the
Great Plains area that sound similar to those still experienced today.
As recently as October 2016, the Department of Health and Human
Services' Office of the Inspector General published a report that
highlighted the long-standing challenges IHS-operated hospitals
experience across the system.\1\
---------------------------------------------------------------------------
\1\ Indian Health Service Hospitals: Longstanding Challenges
Warrant Focused Attention to Support Quality Care. Department of Health
and Human Services, Office of the Inspector General. October 2016. OEI-
06-14-00011, p. 14-15.
---------------------------------------------------------------------------
comments on h.r. 2662
Though we continue to express the need for more review and comment
by the tribes, we have some general areas of concern regarding the
proposed legislation. There are provisions in the bill that create new
programs and functions for the IHS, which will be beneficial if they
are actually funded. We want to make sure the legislation does not put
forward programs that become in essence unfunded mandates. We urge this
Committee to work with the Appropriations Committee to ensure that
these provisions are funded so they do not end up just being lip
service to tribal communities. The Indian Health Care Improvement Act
was permanently enacted in 2010 and contained many provisions designed
to modernize the provision of care, such as the development of new
health care delivery demonstration projects and expansion of the types
of health professionals available within the Indian health system. Yet
many of those provisions remain unimplemented due to lack of adequate
funding. We do not want to see the same type of thing happen with this
legislation. Congress cannot continue to starve the Indian health
system and expect major change.
About 60 percent of the IHS budget is delivered directly to the
tribes through contracts and compacts. We are concerned that the
proposed legislation does not do an adequate job of stating which
provisions of the legislation pertain to self-governance tribes and
which do not. The legislation provides a ``Savings Clause'' that
appears to ensure the legislation does not interfere with tribal
contracting or compacting. Yet the provision at 607(e) of the proposed
legislation is not clear on what provision or provisions that Savings
Clause language pertains. This language does not clearly state that the
provision it is contained in does not apply to tribal health programs.
Instead, it just states that it cannot be construed to interfere with
tribes' rights under the Indian Self-Determination and Education
Assistance Act (ISDEAA). If enacted, it is entirely possible that IHS
or others could interpret the operative position to apply to self-
governance tribes because, in their view, compliance with that
provision would not inhibit the authority of a tribe to exercise its
ISDEAA rights. As a result, we think it important that the rule of
construction be clarified throughout the bill so as to clearly state
that the provision does not apply to tribal health programs. Similarly,
we believe that language should be constructed in such a way that self-
governance tribes could opt into some of the provisions if they so
choose or would be eligible for new programs in the bill such as
liability protections for health professional volunteers as described
in Section 103.
NIHB understands the intent to make a streamlined system for
licensed healthcare professional credentialing procedures, including
volunteers, as outlined in Section 102 and provisions in Section 103
that support liability protections for health professional volunteers
at IHS that would allow for healthcare professionals who volunteer at
an IHS service unit to be considered an employee of the IHS in order to
receive liability protections.
However, we note that these provisions should not be considered a
substitute or final step for increasing available providers to the IHS
and tribes throughout the country. For example, NIHB and a large
majority of tribes support the expansion of the dental therapy model,
which was first brought to the United States by tribes in Alaska in
2004. It is a highly effective way to provide reliable, safe, and
quality dental care providers to underserved areas. We urge the
Committee to consider models such as these to address the chronic
staffing shortages in the Indian health system, rather than exclusively
relying on a patchwork of volunteers. Additionally, NIHB supports
provisions included in similar legislation introduced in the 114th
Congress (H.R. 5406) that would provide tax-exempt status for IHS
student loan repayment. Because IHS is paying the necessary taxes on
the loan payments to the medical professionals, this provision would
allow IHS to fund more medical professionals for loan repayment,
thereby increase the amount of practitioners in the IHS system.
Section 105 addresses improvement in hiring practices. While we
certainly agree that hiring practices need drastic improvement, we are
concerned that some of the proposals in the bill do not adequately
involve the tribes, which has been a central concern with some of the
issues in the Great Plains region. Furthermore, this provision
indicates that the Secretary has direct hire authority, but Tribal
Preference should not be ignored in this process. This provision of the
proposed legislation goes on to note that the Secretary shall notify
each tribe in the service area prior to the direct hire taking place
without further guidance on how or why. While notice is appreciated,
tribes should be able to file objections to any hire, especially if the
new hire is somebody who has been recycled through the system
previously and has not performed well with other tribes in the Region,
which has been a common practice at IHS. Last, this provision provides
that the Secretary may seek waivers to Indian preference from each
Indian tribe concerned if certain criteria are met. Tribes are
concerned about diminishing Indian preference in the hiring process.
Further, consultation on this provision is needed to ensure that IHS
receives a more streamlined hiring system, but also that Indian hiring
preference is respected across the agency, as is current practice.
We are pleased to see a provision addressing the Timeliness of Care
in Section 107. We believe that timeliness of care has been an issue
for many years and that additional standards to improve the reporting
and tracking of timeliness are necessary. It should be noted that
underfunding also contributes to the inadequate and untimely care.
There is currently a system in place that, if implemented, correctly
tracks these important care initiatives. However, if a region does
nothing to implement the current system or inadequate staffing impedes
the ability to track these initiatives, then it becomes a major
problem. We feel that additional congressional oversight over this
particular area may be necessary. Section 107 also states that
regulations and standards to measure the timeliness of the provisions
of healthcare services must be done within 180 days of the enactment of
this legislation. We are concerned that 180 days may not be enough time
to develop the regulations and standards if proper consultation with
the tribes is used to develop said regulations and standards. Last, we
request that any data gathered regarding the timeliness of care be
provided to the tribes as well as the Secretary.
NIHB believes that Section 108 regarding training programs in
tribal culture and history is of utmost importance. Meaningful cultural
training will help IHS employees as they learn the history and culture
of the people they are serving on a daily basis. We think this training
should be mandatory and it should not only include medical
professionals but also include all IHS employees from headquarters to
all staff at the service unit facilities, who have daily interaction
with Native American people. It would be even more useful if the
training was specifically developed by the tribes and was tailored
specifically for the tribes in the service area.
Section 110 establishes rules regarding a tribal consultation
policy. We are in complete agreement that a consultation policy should
exist and that tribes should have input into the way services are
provided to tribal communities. However, it is imperative that the
consultation policy developed under this section mandate to IHS staff
that consultation shall be more than simple lip service or a listening
session with the tribes. It should be viewed as a true partnership and
collaborative effort. Tribal input is key to IHS in providing high
quality services and must be taken seriously. The problems in the Great
Plains area would have never have risen to the current critical level
if there was true consultation and collaboration at every step in this
process; and these issues never would have received the attention they
have if not for tribal oversight and actions.
Fiscal accountability is never a bad thing, but the provision in
Section 202, subsection (b) that addresses the prioritization of
patient care is concerning due to the specific guidelines provided.
This section explains that IHS should only use certain dollars for
patient care directly and limits their use to essential medical
equipment; purchased/referred care; and staffing. While it is
understandable the agency should have more scrutiny over these funds,
we worry that the criteria may end up being too constraining. IHS
should consult with the tribes in their service area before making
decisions on what can be done with the funds pertaining to this
section. With consultation, the money can go to the most needed
programs in a particular service area.
Most of Title III of the proposed legislation outlines a series of
reports. One report that drew our attention was the Inspector General
reports on patient care in Section 304. We agree that reports on the
quality of care and patient harm at IHS are necessary. However, we want
to draw attention to the fact that many tribal members end up receiving
their care outside of the IHS system through the Purchased/Referred
Care program. For example, in South Dakota, approximately 70 percent of
care is referred outside of IHS facilities. It would be useful to also
have information on quality of care once a patient has left the IHS
facility as part of reporting. Additionally, we believe that any and
all reports that come as a result of this legislation be first shared
with the tribes for review and comment before they are made public.
Again, we thank the Committee for its genuine interest in trying to
alleviate problems within IHS. It is clear that management,
recruitment, accountability and transparency are all still issues that
need to be addressed at IHS-operated facilities. Real change and the
rebuilding of many of the areas in the Great Plains region cannot
happen without permanent qualified personnel and the funding necessary
to carry out the mission. However, we reiterate our request that
additional time be taken to review the legislation with Indian Country
before the legislation moves forward in the legislative process. It is
critical that we are able to more fully understand the implications of
the bill.
Legislation alone will not solve issues in the IHS. Proper training
of hospital staff costs money, new equipment costs money, and
recruitment under these circumstances is also going to cost money.
Correcting this situation is going to require a continuous team effort,
additional resources, and consistent congressional oversight of IHS
activity.
Thank you again for allowing me to testify, I will be happy to
answer any questions you may have.
______
Miss Gonzalez-Colon. Thank you, Ms. Kitcheyan. I want to
thank the panel for their testimony.
And I remind the Members that Committee Rule 3(d) imposes a
5-minute limit on questions. Right now the Chair will recognize
Members for questions, and I will recognize myself for 5
minutes.
First of all, I want to begin with you, our last witness.
You said about Section 110, regarding the consultation policy
with the IHS, you said that the fear that mandate will result
in lip service or listening sessions with the tribes, could you
provide more examples of, or specifics about what kind of
recommendation we can include in the bill to make that policy
be a true help to the Indian tribes?
Ms. Kitcheyan. Thank you for that question. We certainly
view consultation as our voice in the process, and we want to
be taken seriously. So, when the tribes, at a very
sophisticated level, engage with IHS and have the technical
assistance to ask the right questions, we expect an answer. And
there are many resources brought together from the tribes, from
the regional health boards, that bring that technical
assistance.
When we come to the meeting, we come prepared and ready to
engage. And when IHS comes, we just don't feel like they are
ready to truly engage with us, or we are not given the
information that we have asked for time and time again.
So, I would just cite that as an example that I have
experienced in the Great Plains. And some of it may come down
to some miscommunications. But all in all, I feel like the
tribes have put their best foot forward in gathering our issues
and our concerns that we need addressed and need answered
through data-driven information, not just, like, hey, we are
here, and to have some face-to-face----
Miss Gonzalez-Colon. Can you make specific recommendations
about exercise or initiatives that can truly make this a true
partnership? To enhance the bill we would need to have what
kind of experience or exercise, do you think, that will improve
that kind of relation?
You can provide that in writing after this hearing. You
don't have to write it right now. You may have some days to
provide that.
Ms. Kitcheyan. I just had a note from my colleague, and it
may sound crazy, but increased consultation on the
consultation, because we are not getting the answers, and it
feels like a press release when we engage in this consultation.
So, anything that is brought forward is not really factored
into the decision or the next roll-out. It is just they had to
do it, they checked that they engaged with the tribe.
I would just say this word ``meaningful'' is so overused,
but it needs to be meaningful to tribes so that they felt like
they were heard, and that whatever recommendations or input was
actually incorporated, not just dismissed.
Miss Gonzalez-Colon. Thank you. Question to Mr. Buchanan.
Section 202 of the bill will direct the Secretary of HHS to
use unobligated or unexpected funding to support essential
medical equipment, or refer care for staffing. This raises the
long-term issue of transparency on how IHS spends its
appropriated funds. Do you believe that IHS suffers from lack
of transparency?
Admiral Buchanan. With the budget, we are--with the
resources that we get, we are extremely prudent with those. We
try to manage those as best as we can, going forward. Is there
a specific question that I can----
Miss Gonzalez-Colon. I am just referring to Section 202, in
terms of the transparency of the use of those funds. I was
referring you about how you use the funds of the long-term
issue of the funding for the equipment. Do you have any
specific feedback of how this Committee can use or address the
transparency issue in IHS?
Admiral Buchanan. All right. As far as funding and
transparency, we look at all opportunities to provide
transparency related to funding and budget activities. A lot of
our funds and--are located on our IHS website. And we also have
other websites that they are located at.
We have been providing training across the agency by doing
some all-tribes calls so that we can explain where those funds
are located. We just recently held an all-tribes call--I
believe it was back in May--related to where you can find
those.
One of the things, kind of getting back to the tribal
consultation issues, is providing that information. For me it
is really technical; I have to rely on my experts to explain
that to me. So, providing information that is meaningful is one
of the goals that we have been trying to implement. And also
providing information at the local level that is meaningful and
useful. We are rolling out templates to provide information at
the local level so that we can have those communications with
the tribes on an ongoing basis.
Miss Gonzalez-Colon. Thank you. The Chair now recognizes
Ranking Member Torres.
Mrs. Torres. Thank you.
Mr. Buchanan, I would like to go back to what Ms. Victoria
Kitcheyan was talking about regarding what sounds like
wonderful meet-and-greet meetings, but with absolutely no
follow-up. Can you respond to that? What do you do? What is the
purpose of wasting time and money traveling and pretend that
you actually care about what they are saying to you, and there
is no followup from IHS?
Admiral Buchanan. Thank you for the question. Our tribal
consultation--we are committed to regular consultation----
Mrs. Torres. Well, that commitment hasn't shown, sir. It is
obvious to me by all of the witnesses that they have tried time
and time again to provide to you, to your department, feedback.
And yet that feedback has fallen to deaf ears.
Admiral Buchanan. I hear the concerns that you are
expressing. I hear the concerns that the tribes have expressed.
Meaningful consultation, I get that. The agency gets that.
We are open to improving. When we think we have consulted
enough, we know that we have not. We can always do better. We
can always continue to improve. We are open to revising our
consultation policy, going forward, hearing those concerns----
Mrs. Torres. How is this bill going to help you improve
what you haven't been able to improve to date?
Admiral Buchanan. Well, some of the things that we have
done to improve the consultation process is having all-tribes
calls, providing information and being more transparent.
With the Quality Framework and Implementation Plan, we have
identified five priority areas, specifically organizational
capacity, accreditation, patient experience, patient safety,
and last but not least is transparency and communication. So,
that is one of the priorities, going forward with IHS.
Mrs. Torres. Let's talk about Section 106. It is my
understanding that Section 106 of this bill is based on
language found in the Veterans Access Choice, an accountability
act of 2014. In May of this year, the U.S. Court of Appeals for
the Federal Circuit held that some provision from the 2014
statute to be unconstitutional.
In light of this ruling, how do you think enactment of
Section 106 would impact IHS?
Admiral Buchanan. I don't have the bill in front of me--106
specifically relates to?
Mrs. Torres. The authority for hiring and firing, or
dismissing personnel.
Admiral Buchanan. Right. We have lots of hiring
authorities, and we also have authorities in place that allow
us to discipline problem employees. But specifically, we have
15,000 employees across the agency that are hard-working
employees that are mission-focused related to Indian Health
Service. We have those authorities in place to address that----
Mrs. Torres. I understand that. In your statement you say
IHS has existing authorities to implement adverse employment
actions. I am reading that from your statement. Yet, what I am
telling you is that DoJ has already weighed in on this, stating
that they will not defend that position.
Could enactment of Section 106 open IHS up to potential
costly litigation that would further take away funding from the
program to defend?
Admiral Buchanan. Great question, a question for DoJ. DoJ
represents us in litigation issues, so I would have to defer to
DoJ.
Mrs. Torres. OK, because it could also lead to the
possibility of having the ongoing bad employees continue to
stay on the payroll. We don't want the bad employees, we want
to help recruit more people.
Walk me through that process. What are some of the
incentives to recruit new candidates? Have you met with HUD?
And I understand that housing is part of the problem. How
are you incorporating other agencies, and ensuring that you are
able to have proper housing for good candidates? I mean I don't
want to move to an area and bring children and a spouse if they
don't have proper housing for them. So, what incentives have
you provided?
Admiral Buchanan. Great question. Again, recruitment and
retention is a challenge, not only in Indian Health Service,
but rural America, rural healthcare systems across the country.
Some of the things that we have done specifically related
to housing, we have used models in other areas, and we are
incorporating those in places like the Great Plains,
specifically Rosebud----
Mrs. Torres. My time has expired. I hope that you would
follow up with a written statement on that.
Admiral Buchanan. Yes, ma'am. Sure will.
Mrs. Torres. I yield back.
Mr. LaMalfa [presiding]. Thank you. I will recognize myself
for up to 5 minutes here. Let me start with Admiral Buchanan.
I understand that when the South Dakota delegation met with
your predecessor and asked questions about staffing needs, the
agency was not able to produce reliable data on that. How do
you determine what staffing levels will be needed at the
facilities?
Admiral Buchanan. So, specifically related to staffing
levels at the facilities? Having been a former CEO, I would
know the staffing levels associated within my facility, within
Indian Health Service. We have a vacancy rate of 20 percent.
Some of the facilities that we are talking about today,
including Rosebud, we have vacancy levels at 22 percent. Pine
Ridge, we have vacancy levels at 22 percent. Rapid City, we
have 11 percent vacancy levels. Omaha Winnebago we have 29
percent vacancy levels--lots of those physicians, chief
executive officers, chief of nursing officers, operation
officers.
So, definitely a challenge. Recruitment and retention, as
Mrs. Torres had mentioned earlier, is a challenge across IHS in
our rural, remote locations.
Mr. LaMalfa. OK, thank you. Let me shift over to Andy
Joseph for a moment here.
Your testimony indicated that in 2013, IHS determined that
the Colville service unit had fewer than one-third of the
required number of clinical staff. Not just short 20 percent,
but that would be over 60 percent required number of clinical
staff, and one-quarter of the required number of dental staff.
Is that consistent with what we are understanding here? And
then, what is the effect on the Colville Reservation with that
kind of staffing?
Mr. Joseph. The effect is a lot of our patients that go
there, they have to wait for a chance to actually get in to see
one of the providers that we have. So, by not having the
providers there, they are not really getting the basic health
care needs taken care of.
And a lot of times what happens is our patients end up
really hurting, and they will go into emergency and find out
they might have Stage 3 or Stage 4 cancer, or they might be a
diabetic, or they might need some kind of surgery procedure
done, and then that ends up costing the government a whole lot
more money.
If we had the adequate amount of basic healthcare
providers, we would be able probably to keep our patients out
of the hospital.
So, what we are really looking at is staffing for basic
health care needs to keep us from burying our people. We have
lost so many of our people due to not having those needs and
going into emergency. Thank you.
Mr. LaMalfa. Thank you. So, you feel, according to your
testimony, that you really have about one-third of the required
staff. But Admiral Buchanan, do you know what that is,
specifically to Colville? Or is that kind of an average across
the region, when you said numbers between 20 to 29 percent
short of a full staff?
Admiral Buchanan. I do not have Colville-specific numbers
in front of me, but I am happy to provide those for the record.
Mr. LaMalfa. You believe that is probably likely, too, as
what Mr. Joseph is saying? It could be as low as one-third?
Admiral Buchanan. Not knowing specifically what Colville is
like, I----
Mr. LaMalfa. That is a problem at that kind of level.
Mr. Joseph. I could give you an example. One of our
districts, Omak District, was going to get a joint venture. If
we would have did a joint venture, that community, that
district, would have got 115 new staff that would have came
with that project. Right now, they are borrowing from our main
clinic, I believe, 12 or 13 staff. There are two doctors that
are there.
So, that is where the inequity is, I guess, for staffing.
We built three of our four clinics with our dollars, but have
never been given a staffing increase from clear back in the
1930s. So, it is based on our population back then, which was
probably about 3,000; now we are almost 10,000 members. So, the
user population goes backwards. It has been going that way with
Colville for quite a few years now.
Mr. LaMalfa. OK, thank you. My time has expired. If the
Committee cares to have a second round--oh, I am sorry, I need
to recognize Mrs. Radewagen on the first round. I was away for
a little bit. So, thank you, please, 5 minutes.
Mrs. Radewagen. I want to thank you, Chairman LaMalfa and
Ranking Member Torres, for holding this hearing. I especially
want to thank the panel for taking the time to be here today.
And I particularly want to acknowledge my colleague,
Representative Noem, for her bill, H.R. 2662. This much-needed
legislation will make important changes to the Indian Health
Service, and I look forward to seeing the bill added to the
markup schedule in the near future.
I have a couple of questions for you, Admiral Buchanan.
Your predecessor, Mary Smith, testified before this
Subcommittee last year about a previous version of the bill we
are considering today. In her testimony, she agreed to sign on
to a request to the HHS Inspector General to investigate the
deaths at Rosebud Hospital that occurred during the diversion.
Unfortunately, that never occurred.
Here is my question. Will you commit to helping Mrs. Noem
in co-signing a request to the HHS Inspector General to
investigate the deaths?
Admiral Buchanan. That is a great question. Actually,
Indian Health Service is already engaged with the Office of the
Inspector General. I am not able to comment much more because
of the investigation that is currently going on.
Mrs. Radewagen. Thank you. Admiral Buchanan, one of the
chief concerns about the situation at Pine Ridge Hospital is
that a revolving door of leadership staff has resulted in
inconsistent leadership, and led ultimately to the most recent
immediate jeopardy findings by CMS.
My question is how many CEOs has Pine Ridge had in the last
2 years? And does the facility now have permanent leadership?
Admiral Buchanan. Great question. I don't know the specific
number of CEOs we have had in the last 2 years. I was the
acting area director in the Great Plains. I can recall two in
hiring the permanent one, Mr. Mark Meersman, who is currently
the CEO at Pine Ridge.
Mrs. Radewagen. I would appreciate you following up and
getting that information to us.
And last, Admiral Buchanan, clearly our most immediate goal
in the Great Plains is to get these Federal facilities in a
state in which they are fully functional and safe. What is the
long-term goal in the Great Plains? What is our ultimate
aspiration beyond simply ensuring these facilities are safe?
Admiral Buchanan. Our ultimate goal is to provide good,
quality health care for the Great Plains area. Not only the
Great Plains area, but all of IHS areas. All of our patients
deserve that.
To meet the mission of Indian Health Service, to raise the
physical, mental, social, and spiritual health of American
Indians and Alaska Natives to the highest level is something
that all of our 15,000 employees are striving to do.
We are implementing the Quality Framework. That is our
long-range goal. In that framework, we have several things that
we are implementing that are related to this bill. Talking
about the credentialing aspect, we are going to be rolling that
out for pilot sites in July. A policy that is going to be
rolling out with that, also in July. So, we are excited about
that.
We will be establishing wait times. That was something that
was identified in some of the GAO reports and also in this
bill. So, we will be rolling those out, will definitely have
that in July, and we are excited about the progress that we are
making there.
That is not enough. I mean when we continue to, like I
mentioned earlier, think we are providing good-quality care, we
can always do better. So, that is the long-term goal, the
Quality Framework, providing performance metrics so that we can
measure if we are making true progress when we come to hearings
like this, when we meet with tribal leaders, to show them that
here are the areas that we are having challenges with, here are
the areas that we are improving with, get input at those local
levels.
Part of that framework is a governance process, where we
can meet on a regular basis to make sure that our health
centers and our hospitals are providing good, quality care to
our patients.
Mrs. Radewagen. Thank you, Mr. Chairman. I yield back.
Mr. LaMalfa. OK, thank you. You can hear the buzz. We are
going to have to go back for votes here any minute, but we can
go for a brief second round of questions or comments.
Let me go ahead and recognize our Ranking Member for the
second round, for a statement, and then----
Mrs. Torres. Thank you, Mr. Chairman. I simply want to say
that we have heard over and over in this meeting that there was
very little tribal consultation before introducing this
legislation. While there might have been some meet-and-greet
opportunities thereafter, the tribes still feel that they have
not been heard and their concerns have not been addressed or
even replied to, which means that you have not acknowledged
that they have real issues. And that is tragic.
Additionally, many of these new provisions in this bill
would require funding for implementation. Yet, there is no
authorized funding found anywhere in the bill; and, as I stated
in my opening statement, IHS is already chronically
underfunded, and we must not impose new unfunded mandates on
IHS or Indian Country.
As we know, many of the Indian Health Care Improvement Act
provisions from 2010 still remain unimplemented, due to lack of
adequate funding. Unless we want the same outcome for this
bill, we need to finally fund IHS at an appropriate level.
I would suggest that you sit down with rural communities,
counties, because they have a lot of the same issues, and try
to maximize funding so that you can address some of these
issues, if funding continues to be an issue for you.
Finally, let me say that I think that this bill is a good
starting point with some good provisions. And I want to again
thank Mrs. Noem for putting pressure on this issue. But we have
one chance at this, and we need to make sure that we get it
right this time.
So, before we move forward, I recommend that tribes be
consulted--and not just sitting down and meeting with them, but
actually listening to them. And not just the tribes that are
here today, but tribes across the country. Their ideas, they
have a lot of great ideas, and we need to hear them.
Then we can come back together, in a bipartisan fashion,
and amend this bill so that we have a workable solution. And I
look to you for this leadership. I yield back, Mr. Chairman,
thank you.
Mr. LaMalfa. Thank you. All right. I will wrap up with just
a couple more questions here. I want to come back to Admiral
Buchanan, please.
Do you have in place a reliable way to measure the number
of full-time equivalents needed at a given facility to meet the
need of that facility at this point? And please be brief,
because we have----
Admiral Buchanan. For sure. As Chair Joseph was talking
about, we use a process called, I believe, RRM. The acronym
escapes me right now, but it is a process that we typically use
to staff facilities, as he was referencing earlier.
Mr. LaMalfa. So, you believe that that method will be
accurate for the number of full-time equivalents that will be
needed as you work toward that?
Admiral Buchanan. We typically use that process when we
staff and build a new facility.
Mr. LaMalfa. OK. Let me jump to a couple more questions
here.
Chairman William Bear Shield--again, I have to go faster,
so maybe a little more yes or no, if you don't mind--would you
say that the Federal employees at the Rosebud Hospital are
accountable to you?
Mr. Shield. Excuse me?
Mr. LaMalfa. Are the Federal employees at the Rosebud
Hospital accountable?
Mr. Shield. There are several good employees, as was
pointed out, of Indian Health Service. As far as accountable,
there are still issues that were mentioned today with
credentialing. And the ones that need to be held accountable,
seemingly, are moved throughout the system.
Mr. LaMalfa. How would you feel about that at the Aberdeen
office? Are they accountable, on the ball for you?
Mr. Shield. Well, we have different issues with the
Aberdeen area office and, really, the need for it there. A lot
of decisions are not made there, they are made up at the
headquarters level. And----
Mr. LaMalfa. What is the relationship like with that area
office?
Mr. Shield. It all falls back on meaningful consultation.
Mr. LaMalfa. Yes.
Mr. Shield. And the non-existence of it. And it is hard to
win trust back when we are not afforded meaningful consultation
or our questions are not answered, especially when it comes to
the budget.
Mr. LaMalfa. OK, all right. Do you believe that the Federal
Government and its employees can effectively spend the dollars
that would improve patient care at this point? Do you see the
seeds of improvement?
Mr. Shield. Yes, I do, in a revamping of the whole system.
But it is going to take strong leadership, starting at the
Health and Human Services Secretary level and the incoming
Indian Health Director.
Mr. LaMalfa. OK, thank you. As was mentioned earlier, I
believe, in our Ranking Member's line of questioning, some
tribal leaders--this is for Ms. Kitcheyan--that the only reason
some IHS facilities in the Great Plains remain open--maybe that
was in Mrs. Noem's testimony, as well--is because CMS simply
has not visited them recently. Do you believe that is an
accurate statement?
Ms. Kitcheyan. I believe that is very accurate. I believe
across the whole country there are probably facilities that are
in jeopardy, and they just have not been identified yet. So,
our problem is not just in the Great Plains, it is agency-wide,
and that is why it is so important that the solutions that come
out of this bill are going to affect positive change across
Indian Country.
Mr. LaMalfa. OK. And the problems outlined earlier on a
more individual basis--Winnebago, Rosebud, et cetera--do you
think it is widespread across the entire Great Plains area?
Ms. Kitcheyan. Yes, I do. And we are finding that, as we
think we can look toward our area office for some of these
answers and solutions, we are finding, unfortunately, that that
capacity is not there. And I don't mean to be disrespectful to
our area office, but the tribes are very frustrated with the
services that are coming out of that to the extent that we want
to dismantle it. It is just not serving our needs.
Mr. LaMalfa. Yes, OK. That is unfortunate, but this
Committee is committed toward vastly improving the situation,
as Mrs. Noem is, and carrying the legislation, so I expect
positive results coming from our efforts here in the Committee,
and the Committee as a whole.
With that, again, the clock is running fast here, so I do
want to thank the panel for your travel, for your effort to be
here, and to share your important testimony with us today,
informing this Committee.
I would remind that the members of the Committee may have
additional questions for the witnesses, and we will ask you to
respond to those in writing later on. Under Committee Rule
3(o), members of the Committee must submit witness questions
within 3 business days following the hearing, and the hearing
record will be held open for 10 business days for these
responses.
If there is no further business, without objection, the
Subcommittee stands adjourned.
[Whereupon, at 4:06 p.m., the Subcommittee was adjourned.]
[LIST OF DOCUMENTS SUBMITTED FOR THE RECORD RETAINED IN THE COMMITTEE'S
OFFICIAL FILES]
-- Letter from Chairman William Bear Shield, Rosebud Sioux
Tribe to the Hon. Kristi Noem dated June 20, 2017.
Rep. Gosar Submission
-- Statement of the American Dental Association to the
Subcommittee on Indian, Insular and Alaska Native
Affairs on ``Restoring Accountability in the Indian
Health Service Act of 2017, H.R. 2662'' dated June
21, 2017.
Rep. Grijalva Submissions
-- Written Testimony of the Hon. W. Ron Allen, Chairman,
Self-Governance Communication & Education Tribal
Consortium and Tribal Chairman/CEO, Jamestown
S'Klallam Tribe to the House Committee on Natural
Resources, Subcommittee on Indian Insular and
Alaska Native Affairs. H.R. 2662, ``Restoring
Accountability in the Indian Health Service Act of
2017'' dated June 21, 2017.
-- Written Testimony of United South and Eastern Tribes
Sovereignty Protection Fund to the House Committee
on Natural Resources, Subcommittee on Indian,
Insular and Alaska Native Affairs on ``Restoring
Accountability in the Indian Health Service Act of
2017,'' dated July 5, 2017.
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