    [Senate Hearing 115-89]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 115-89

                         S. 1250, S. 1275, AND S. 1333

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

                                    HEARING

                                   BEFORE THE

                          COMMITTEE ON INDIAN AFFAIRS
                              UNITED STATES SENATE

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 JUNE 13, 2017

                                   __________

             Printed for the use of the Committee on Indian Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                       U.S. GOVERNMENT PUBLISHING OFFICE
    27-650 PDF                  WASHINGTON : 2017

    ----------------------------------------------------------------------------------------
    For sale by the Superintendent of Documents, U.S. Government Publishing Office,
    http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,
    U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free).
    E-mail, gpo@custhelp.com.

                          COMMITTEE ON INDIAN AFFAIRS

                      JOHN HOEVEN, North Dakota, Chairman
                      TOM UDALL, New Mexico, Vice Chairman
    JOHN BARRASSO, Wyoming               MARIA CANTWELL, Washington
    JOHN McCAIN, Arizona                 JON TESTER, Montana,
    LISA MURKOWSKI, Alaska               AL FRANKEN, Minnesota
    JAMES LANKFORD, Oklahoma             BRIAN SCHATZ, Hawaii
    STEVE DAINES, Montana                HEIDI HEITKAMP, North Dakota
    MIKE CRAPO, Idaho                    CATHERINE CORTEZ MASTO, Nevada
    JERRY MORAN, Kansas
         T. Michael Andrews, Majority Staff Director and Chief Counsel
           Jennifer Romero, Minority Staff Director and Chief Counsel

                               C O N T E N T S

                                  ----------
                                                                       Page
    Hearing held on June 13, 2017....................................     1
    Statement of Senator Barrasso....................................    11
    Statement of Senator Cortez Masto................................    10
    Statement of Senator Daines......................................    44
    Statement of Senator Franken.....................................     7
    Statement of Senator Heitkamp....................................     9
    Statement of Senator Hirono......................................     7
    Statement of Senator Hoeven......................................     1
    Statement of Senator Murkowski...................................     5
    Statement of Senator Schatz......................................     4
    Statement of Senator Tester......................................    49
    Statement of Senator Thune.......................................    51
    Statement of Senator Udall.......................................     3

                                   Witnesses

    Buchanan, Rear Admiral Chris, Acting Director, Indian Health
      Service, U.S. Department of Health and Human Services..........    12
        Prepared statement...........................................    14
    Charlie, Mark, President/CEO, Association of Village Council
      Presidents (AVCP) Regional Housing.............................    67
        Prepared statement...........................................    69
    Crowley, Dr. Joseph P., President-Elect, American Dental
      Association....................................................    22
        Prepared statement...........................................    23
    Difuntorum, Sami Jo, Chairwoman, National American Indian Housing
      Council........................................................    75
        Prepared statement...........................................    78
    Frechette, Heidi, Deputy Assistant Secretary, Office of Native
      American Programs, U.S. Department of Housing and Urban
      Development....................................................    54
        Prepared statement...........................................    56
    Harris, Dr. Keith, Director of Clinical Operations, Homeless
      Programs Office, U.S. Department of Veterans Affairs...........    59
        Prepared statement...........................................    61
    Kitcheyan, Hon. Victoria, Treasurer, Winnebago Tribe of Nebraska
      Tribal Council.................................................    16
        Prepared statement...........................................    18
    Onnen, Hon. Liana, Vice President, Southern Plains Region,
      National Congress of American Indians (NCAI)...................    63
        Prepared statement...........................................    65
    Stier, Max, President/CEO, Partnership for Public Service........    27
        Prepared statement...........................................    30

                                    Appendix

    Allen, Hon. W. Ron, Chairman, Self-Governance Communication &
      Education Tribal Consortium; Tribal Chairman/CEO, Jamestown
      S'Klallam Tribe, prepared statement............................    96
    American Academy of PAs, prepared statement......................    89
    Begaye, Hon. Russell, President, Navajo Nation and Jonathan Hale,
      Chairman, Health, Education & Human Services, Navajo Nation
      Council, joint prepared statement..............................   102
    Cladoosby, Hon. Brian, Chairman, Swinomish Indian Tribal
      Community, prepared statement..................................   123
    Danner, Robin Puanani, Chairman, Sovereign Councils of the
      Hawaiian Homeland Assembly (SCHHA), prepared statement.........   116
    Department of Hawaiian Home Lands, prepared statement............   107
    Gundersen Health System, prepared statement......................   124
    Hawaii Congressional Delegation, prepared statement..............    89
    Hodson, Mike, Chairman, Board of Commissioners, Homestead Housing
      Authority, prepared statement..................................   111
    Navajo Housing Authority Board of Commissioners, prepared
      statement......................................................    99
    Office of Hawaiian Affairs (OHA), prepared statement.............   112
    Response to written questions submitted by Hon. Jon Tester to:
        Heidi Frechette..............................................   130
        Dr. Keith Harris.............................................   125
    United South and Eastern Tribes Sovereignty Protection Fund,
      prepared statement.............................................   104
    United States Merit Systems Protection Board (MSPB), prepared
      statement......................................................    93
    Weston, Hon. Troy ``Scott'', President, Oglala Sioux Tribe,
      prepared statement.............................................   120
    Yazzie,Aneva J., CEO, Navajo Housing Authority, prepared
      statement......................................................    90

                         S. 1250, S. 1275, AND S. 1333

                                  ----------

                             TUESDAY, JUNE 13, 2017

                                           U.S. Senate,
                                   Committee on Indian Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 2:55 p.m. in room
    628, Dirksen Senate Office Building, Hon. John Hoeven,
    Chairman of the Committee, presiding.

                OPENING STATEMENT OF HON. JOHN HOEVEN,
                     U.S. SENATOR FROM NORTH DAKOTA

        The Chairman. I call the meeting to order.
        Today, the Committee will examine three bills in two
    panels: S. 1250, the restoring accountability to the Indian
    Health Service Act of 2017; S. 1275, the bringing useful
    initiatives to Indian land development or the BUILD Act; and S.
    1333, the Tribal HUD/VASH Act of 2017.
        Regarding Panel 1, on May 25, 2017, Senators Barrasso,
    Thune and I introduced S. 1250, the restoring accountability to
    the Indian Health Service Act of 2017. This bill is intended to
    increase transparency and accountability, improve patient
    safety and care, and boost recruitment and retention of
    employees to the IHS.
        We introduced this bill again this Congress to begin
    reversing years of poor health care delivery in some IHS
    facilities. A significant amount of work by the Committee with
    the agency, the Government Accountability Office and
    stakeholders, has been put into this bill and the predecessor
    bill introduced by then-Chairman Barrasso and Senators Thune,
    Rounds and McCain.
        Nearly one year ago in the last Congress on June 17, 2016,
    the Committee held a hearing on the predecessor bill, S. 2953.
    The Acting Deputy Secretary of the Department of Health and
    Human Services, Mary Wakefield, testified in support of some
    provision of the bill and gave suggestions on other provisions.
        The Committee favorably reported a substitute amendment to
    address the department's issues. Those changes are also
    reflected in this bill, along with a few additional provisions.
        I look forward to hearing from our witnesses today on this
    bill as well as improvements. I join everyone on the dais, that
    we can do better in providing health care to Native
    communities.
        As far as Panel 2, on May 25, 2017, I introduced S. 1275,
    the BUILD Act, to reauthorize the Native American Housing and
    Self Determination Act to eliminate duplicative bureaucracy,
    when multiple agencies are involved in a tribal housing
    project, and encourage new forms of investment by extending
    leaseholds on trust or restricted lands from 50 years to a
    maximum of 99 years.
        The bill is intended to improve housing conditions within
    tribal communities by providing greater tribal control over
    housing development on their lands. We all know what a pressing
    issue housing is on the reservation.
        This Committee has worked for several years to reauthorize
    the Native American Housing and Self Determination Act,
    NAHASDA, and improve housing conditions for Indian people.
    Prior bills have been held up in past Congresses with
    substantial effort into finding a path forward.
        This bill has been held up in the last Congress and the
    Congress prior to that. We would like to pass it.
        As I mentioned to the National American Indian Housing
    Council's Legislative Conference in February, the BUILD Act is
    the Chevy model of reauthorization. The engine of the BUILD Act
    is the reauthorization of the Indian Housing Block Grant which
    was the centerpiece of NAHASDA when it was first introduced and
    passed this body back in 1996.
        In previous versions of the NAHASDA reauthorization, there
    were over 20 different pieces of legislation included. Some of
    them are more controversial than others obviously, but some of
    the pieces included were lease requirements, program income,
    rental income caps, total development, maximum project costs,
    demonstration programs, limitation on use for the Cherokee
    Nation, the Native Hawaiian Block Grant and other aspects.
        Instead of just reintroducing all the past bills, I wanted
    to take a fresh look at getting a bill across the finish line.
    I know some of the members on the Committee have expressed
    their desire to include some of these previous positions in
    this bill, a different vehicle or a combination of both.
        With that, I am willing to work with any member here on
    finding a path forward. This is one of the reasons why I wanted
    to have a legislative hearing early on, as we are doing today,
    so we can roll up our sleeves and work towards finally getting
    these bills to the President's desk, only after giving everyone
    opportunity for meaningful input, not only in the housing bill
    but the other features I just covered.
        On June 12, 2017, Senators Tester, Isakson, Udall and
    myself introduced S. 1333, the Tribal HUD/VASH Act of 2017.
    This bill is intended to improve the Housing and Urban
    Development and Veterans Affairs support of housing programs.
        This program combines housing and choice of voucher rental
    assistance for homeless tribal veterans with case management
    and clinical services provided by the Veterans Administration
    through the Veterans Administration Medical Centers.
        The bill would authorize the Department of Housing and
    Urban Development and the VA to modify program administration
    to facilitate the recruitment of VA case managers and create a
    set aside for rental assistance. The bill would also require
    the program to be administered in accordance with the Native
    American Housing Assistance and Self Determination Act,
    NAHASDA. It would also mandate IHS work cooperatively to
    provide assistance as requested by HUD or the VA in carrying
    out the program.
        Finally, it would require review and a report by the
    agencies to be submitted to the congressional committees of
    jurisdiction.
        All three of these are important bills to help Indian
    people obtain critical services for health care and for
    housing. I look forward to hearing how we can best advance
    these measures and get them signed into law.
        The Native American people I think have the highest rate of
    service in our military of any group. We are talking about
    housing, health care and veterans.
        Before we turn to the witnesses, I would like to turn to
    the Vice Chairman for any comments that you may have, Senator
    Udall.

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

        Senator Udall. Thank you, Chairman Hoeven, for calling this
    legislative hearing today on S. 1250, S. 1275 and S. 1333.
        The issues presented in these bills are important to Indian
    Country and reflect our shared priorities on this Committee. In
    fact, each of the bills is important enough to merit its own
    hearing.
        S. 1250 would impose sweeping reforms on the Indian Health
    Service, S. 1275 would reauthorize certain housing programs
    created by the Native American Housing and Self Determination
    Act, while imposing changes to that law, training and technical
    assistance programs and environmental review processes; S. 1333
    would authorize the Tribal HUD/Veterans Affairs Supported
    Housing Program and ensure that our Native veterans receive the
    housing benefits they assuredly deserve.
        These bills would have real and long-lasting impacts on
    Indian Country and deserve a thorough vetting to ensure that
    the final product reflects the meaningful consideration of
    Indian Country's concerns.
        I encourage all stakeholders present at this hearing, as
    well as those listening online, to submit statements for the
    record. Your input matters.
        Touching briefly on S. 1250, I share the goals of achieving
    accountability, strengthening the workforce and improving
    quality of care at IHS. The health care crisis facing many IHS
    facilities in the Great Plains and throughout Indian Country is
    a concern this Committee takes very seriously.
        We must do more beyond tinkering with Federal employment
    law to address the need for transparency and quality assurance.
    We must also take care not to jettison well established,
    constitutional protections in the process of holding IHS
    leadership and staff accountable at every level.
        Let us not overlook the fact that for decades, tribal
    health care programs have been severely underfunded, which I
    believe has contributed greatly to the health care crisis we
    are in today. I look forward to working with Senator Barrasso
    and the Chairman to make sure this bill addresses IHS issues
    identified by all tribes and patients in an effective way.
        With regard to S. 1275, Mr. Chairman, you and I know that
    NAHASDA is critically important. The overwhelming need for
    adequate, safe and sanitary housing in all Native communities
    is well documented.
        That is just as true for Native Hawaiian homesteads as it
    is for reservations, pueblos and Alaska Native villages. Given
    that understanding, I was concerned to see that S. 1275 does
    not include a reauthorization of Title 8. I will defer to my
    colleague, Senator Schatz, to explain why carving out Native
    Hawaiian programs from this bill sets a dangerous precedent for
    his constituents and Indian Country as a whole. We must do all
    we can to make sure NAHASDA is fully reauthorized for all
    Native American communities that rely on its housing programs.
        Turning to Senator Tester's Tribal Veterans Housing bill, I
    am proud to join him, VA Committee Chair, Senator Isakson and
    Chairman Hoeven to sponsor this bill. It is a powerful message
    to bring together bipartisan leadership from two Senate
    committees in support of one goal, better serving Native
    veterans.
        S. 1333 represents all the good that can happen when
    members from both sides of the aisle listen to Indian Country
    and work together to advance tribal priorities. This body has a
    rich history of acknowledging that Native issues can rise above
    beltway party politics. Indeed, I am reminded this Committee
    accomplishes so much more when it works from the viewpoint that
    Indian issues are largely bipartisan.
        I look forward to continuing this tradition and honoring
    the special political and trust relationship the United States
    has with all its indigenous peoples. It is clear to me that any
    potential changes to the national policy regarding Medicaid and
    health insurance programs like those contained in the AHCA,
    will directly impact tribal communities and Native lives.
        For the record, I would like to urge the majority on all
    committees to follow regular order and to hold hearings and
    seek tribal consultation on any proposal that would cut access
    to life saving health care programs.
        With that, Mr. Chairman, I will yield back.
        The Chairman. Thank you, Senator Udall.
        I would invite any other comments at this point.
        Senator Schatz. Mr. Chairman?
        The Chairman. Senator Schatz.

                    STATEMENT OF HON. BRIAN SCHATZ,
                        U.S. SENATOR FROM HAWAII

        Senator Schatz. Thank you, Mr. Chairman.
        Thank you for the opportunity to talk about the impact of
    the BUILD Act. I have a few statements for the record from
    Native Hawaiian organizations and Native Hawaiian-serving
    organizations I would like to submit for the record.
        The Chairman. Without objection.
        Senator Schatz. Thank you.
        I would like to welcome leaders from the Hawaiian community
    including several members of the Office of Hawaiian Affairs in
    the audience today. They are here to represent the people who
    would suffer if the BUILD Act were to proceed. Several of them
    are direct beneficiaries.
        With us, we have Robin Danner, the Chairman of the
    Sovereign Councils of the Hawaiian Homelands Assembly; Coty-
    Lynne Haia, D.C. Bureau Chief for the Office of Hawaiian
    Affairs; Sheri-Ann Daniels, Executive Director, Papa Ola
    Lokahi; Kawika Riley, Chief Advocate for the Office of Hawaiian
    Affairs; and Timmy Wailehua, Operations Manager, Office of
    Hawaiian Affairs, Native Hawaiian Revolving Loan Fund. Thank
    you all for being here.
        The BUILD Act is a serious departure from the way this
    Committee does business and breaks our longstanding tradition
    of bipartisanship and standing together. Just last Congress,
    this Committee reported out a bipartisan NAHASDA
    reauthorization that included Native Hawaiians. Even the House
    passed a bipartisan NAHASDA reauthorization that included
    Native Hawaiians.
        The BUILD Act is a dramatic departure from the norm. By
    leaving out Native Hawaiians, this bill is an attack on my
    State and my people. It dishonors the legacies of Daniel K.
    Inouye and Daniel Akaka and threatens the future work of the
    Committee.
        The Committee has always been a bastion of bipartisanship.
    For decades, American Indians, Alaska Natives and Native
    Hawaiians have stood together on behalf of all Native people.
    We have had our challenges on the Floor and I am sure we will
    continue to face more but we have never faced this kind of
    attack in Committee.
        There is a reason for that. That is because most everything
    that comes out of the Committee depends on unanimous consent on
    the Floor. That is just how we work and how we get things done.
    That solidarity is being strained and it is unfortunate in the
    extreme. I worry it is the beginning of the end of the
    Committee's productivity.
        Serving Native Hawaiians is foundational to my service in
    the Senate. It is why I made Native Hawaiians the subject of my
    maiden speech on the Senate floor. It will be difficult to
    maintain the unanimity of this Committee's work, the work we
    rely on, when my people are being left out.
        I strongly urge this Committee to preserve the spirit of
    bipartisanship by changing course and including Native
    Hawaiians going forward.
        Thank you, Mr. Chairman.
        The Chairman. Are there other opening statements? Senator
    Murkowski.

                   STATEMENT OF HON. LISA MURKOWSKI,
                        U.S. SENATOR FROM ALASKA

        Senator Murkowski. Thank you, Mr. Chairman.
        I must first start by thanking the Committee for moving out
    S. 825, the Southeast Alaska Regional Health Consortium Land
    Transfer Act of 2017. I was not here but you did a fine job in
    moving that. I appreciate that. I know the people of SEARHC
    appreciate that as well.
        I want to thank you both for having this hearing today and
    focusing on some very foundational issues. As you mentioned,
    health care and housing our veterans really is so important.
        I would like to welcome Mark Charlie to the Committee
    today. Mark is Yupik. He is a member of the Native Village of
    Tununak. He serves as the present CEO of the Association of
    Village Council Presidents Regional Housing Authority in
    Bethel.
        As you will hear from Mark, AVCP Housing is the tribally-
    designated housing entity of southwest Alaska responsible for
    51 tribes. His team has a pretty tough job in providing housing
    in a very remote and very, very costly area where weather can
    be a deciding factor if you can even build or not in any given
    year.
        Today, Mark is going to be providing testimony on both the
    BUILD Act and on the Tribal HUD/VASH Act. This is a long way to
    come and I appreciate his willingness to be here. I do agree
    very strongly with Mark that we must find a way to reauthorize
    NAHASDA and continue to support this very important program.
        I want to tell my colleague from Hawaii that I remain
    dedicated and willing to work with him, with other members of
    the Committee and members of the Senate to try to find the best
    route to do this.
        As you noted, Senator Schatz, Alaska Natives and Native
    Hawaiians have been allies and friends in many different areas.
    Sometimes it can be difficult to work through the issues but I
    think continued effort, conversation, dialogue and a
    willingness to get there is important. Know that I remain
    dedicated to do just that. I think this is important to Alaska
    Natives, to those across Indian Country and certainly to Native
    Hawaiians.
        I also want to thank you, Senator Hoeven and Senator Udall,
    as well as Senators Isakson and Tester, for the work on the
    Tribal HUD/VASH Act. It is really an important program and one
    I would hope we can all get behind.
        We have run into some challenges in Alaska in
    implementation, so I hope we will hear from President Charlie,
    HUD and the VA on how we get there as well.
        Thank you again for the hearing and I thank all the
    witnesses for coming a long way and doing a good job.
        The Chairman. Thank you, Senator Murkowski, for your
    comments.
        I will turn to other opening statements in a moment but I
    want to respond to both Senator Schatz, and it seems
    appropriate following Senator Murkowski, as you are the Chair
    of the Subcommittee on Interior and EPA.
        We have included in the BUILD Act the things that we felt
    there was no objection to so that we would be able to move the
    bill. Left out are things where we have had objections. I am
    not opposed to adding things if we can get enough support to
    move the bill.
        As I said to Senator Schatz directly, I am certainly open
    to working with him and finding a way to advance the bill. Not
    only that, in fact, I have offered to you, Senator Schatz, in
    addition to moving the BUILD Act, that I would work with
    Senator Murkowski to get funding for Native Hawaiians through
    the appropriations bill. You and I are both members of the
    Appropriations Committee.
        I understand that is not exactly what you want but I just
    want to make sure the record is clear that I am trying to be of
    assistance and trying to get this legislation passed. If there
    is some way to do it, even in a multistep process, I am trying
    to work on that, including approaching Senator Murkowski about
    getting it funded through the appropriations process.
        Again, I am trying to solve the challenge we face in
    getting legislation advanced. As Senator Murkowski said, we
    will keep working on it but the NAHASDA bill, the BUILD Act, is
    $650 million for housing in Indian Country. It includes the
    Native Alaskans because of the status Native Alaskans have. We
    have a challenge and that has not been done yet for Native
    Hawaiians.
        I understand that you may perceive it differently. All I
    want to be clear on is that I am trying to find a way to
    advance the housing legislation and that I am open to ideas
    that enable us to do that. I know Senator Hirono is here to
    probably have the same discussion.
        I wanted to make that a part of the record. It seems timely
    because Senator Murkowski has been very helpful in saying if
    there is another way to solve this challenge, she is more than
    willing to help.
        Senator Murkowski. I might just note, Mr. Chairman, that
    your Ranking Member is also my Ranking Member on the Interior
    Appropriations Committee.
        The Chairman. I have always found him to be extremely
    helpful, so I am pretty sure he would roll up his sleeves and
    help as well.
        Senator Franken.

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

        Senator Franken. I would just like to associate myself with
    Senators Schatz and Murkowski. This covered Native Hawaiians
    before and I think it should do it again. I appreciate your
    willingness to work toward that end with both Senator Murkowski
    and Senator Udall. I trust that will get done.
        Thank you.
        The Chairman. Other opening statements?
        Senator Hirono. Mr. Chairman?
        The Chairman. Senator Hirono.

                  STATEMENT OF HON. MAZIE K. HIRONO,
                        U.S. SENATOR FROM HAWAII

        Senator Hirono. Thank you very much.
        I am not a member of this Committee. Thank you so much for
    allowing me the opportunity.
        This Committee holds important jurisdiction over matters
    involving indigenous people. I am here to speak against S. 1275
    in its current form. Our indigenous peoples are the American
    Indians, Alaska Natives and Native Hawaiians. These are our
    original peoples.
        As members of this Committee, you are aware of the
    experiences and challenges of Native peoples, including the
    history of decimation and prolonged subjugation by the Federal
    Government. This history is one of the reasons the Federal
    Government has enacted laws intended to help our indigenous
    peoples and recognize our government's trust responsibilities
    to them.
        While I am not a member of this Committee, I am here
    because the matters you are discussing today are very important
    for the Native Hawaiian community. I am here to share my
    serious concerns over the decision to exclude Native Hawaiian
    housing programs in S. 1275, the Bringing Useful Initiatives
    for Indian Land Development Act, also known as the BUILD Act.
        As this legislative vehicle to reauthorize the Native
    American Housing Assistance and Self Determination Act, also
    known as NAHASDA, the BUILD Act is an opportunity to support
    all Native communities.
        The BUILD Act, however, strips out Title 8, which includes
    the Native Hawaiian Housing Block Grant and 184(a), Native
    Hawaiian Home Loan Guarantee Programs. By omitting Native
    Hawaiian housing programs, the BUILD Act strikes a blow not
    only to the 37,000 Native Hawaiians who could directly benefit
    from their inclusion, but also strikes a blow to the over
    500,000 Native Hawaiians in our Country.
        This is about much more than just stripping out Native
    Hawaiian housing programs from a bill. At a time when we see us
    against them perspectives rising in our Country, we cannot
    allow divide and conquer tactics to undermine collaborative
    efforts to bring people together.
        Sadly, intended or not, the BUILD Act is an example of
    dividing Native peoples. This bill threatens strong alliances
    and partnerships Native communities have forged over decades. I
    understand suggestions have been made to Native tribes that
    supporting Native Hawaiian programs may jeopardize funding for
    their own programs.
        I strongly oppose those suggestions and I believe that
    dividing Native communities is, frankly, unconscionable. The
    history of our government's treatment of Native peoples is not
    a proud one. For Native Hawaiians, this includes illegal
    overthrow of the Hawaiian monarchy in 1893.
        Today, Native Hawaiians, like other Native peoples across
    the Country, continue to face high levels of poverty, lower
    educational attainment, and lack of affordable housing. For
    those who do not recognize Native Hawaiians as an indigenous
    people or oppose Native Hawaiian programs, I would ask that you
    learn more about their history and experiences.
        Today's hearing would have been an excellent opportunity
    for members of this Committee to learn more about Native
    Hawaiians, their history, and how Federal housing programs have
    made a real difference in their lives. Unfortunately, no Native
    Hawaiians or Native Hawaiian organizations were invited to
    testify on the BUILD Act, but they are here. They are sitting
    in the audience; they are watching; and they are listening.
        Many of you on the Committee are long-time advocates for
    indigenous peoples. You are aware of their history and why
    Congress enacted programs that promote better health, quality
    education, and access to housing for their communities,
    programs that provide opportunities for growth and sustained
    strength.
        Without these programs, the progress made in their
    communities would have been harder and taken longer to achieve.
    That is why reauthorization of NAHASDA, including Native
    Hawaiian housing programs, is so important.
        All of our Native people, American Indians, Alaska Natives
    and Native Hawaiians, should be treated with equal respect.
    That certainly extends to supporting programs that benefit all
    our Native peoples and communities.
        For these reasons, I ask this Committee to restore
    reauthorization for Native Hawaiian housing programs in
    NAHASDA. I ask you to do the right thing and welcome the
    opportunity to work with you to find a path forward.
        I would also like to submit a longer statement for the
    record on behalf of the Hawaiian Congressional Delegation
    signed by Senators Schatz and myself and Representatives
    Hanabusa and Gabbard in opposition to the BUILD Act in its
    current form.
        Mr. Chairman, I do thank you for your openness in going
    forward so that our Native peoples can be treated with the
    respect they deserve.
        The Chairman. Thank you, Senator Hirono.
        Again, I want to make clear that I am not holding it up. If
    we pass the bill out with it in, my expectation is, unless we
    can figure out something, we will end up with the same result
    we have had the last two Congresses, that we will move the bill
    out of Committee and that will be it.
        We were not able to move it across the floor in the last
    Congress or the Congress before, so I am trying to find a
    solution. We have not precluded not including it in the bill,
    we just have to find a way to move it forward or we are just
    going to move it out of Committee.
        I am very sensitive to Senator Schatz's talking about the
    bipartisanship of this Committee. I think that is very
    important. I want to do everything I can to preserve it, but we
    are confronted with the situation of having either a bill we
    can move out of Committee with the provision in but we cannot
    move across the floor or putting the provision in the bill in
    Committee but then we have to somehow figure out how we can
    advance it.
        That is why I offered the appropriations process but I am
    open to other ideas. Obviously, this is a work in progress. We
    are looking for solutions. Whoever has a great solution, as
    Ross Perot used to say, I am all ears.
        Senator Heitkamp.

                   STATEMENT OF HON. HEIDI HEITKAMP,
                     U.S. SENATOR FROM NORTH DAKOTA

        Senator Heitkamp. Mr. Chairman, thank you.
        I know the motivation here is to get a bill and to get a
    housing program and move it forward.
        Ben Franklin once famously said, ``If we don't all hang
    together, surely we will hang separately.'' I think NAHASDA and
    the Native Hawaiian provision has been a long history of
    weaving together a compromise. When we start pulling it apart,
    I can assure my good friends, Senator Hirono and Senator
    Schatz, will provide equal resistance to what we have seen in
    the last two Congresses if we exclude Native Hawaiians. We are
    between a rock and a hard place.
        I surely will do everything that I can. I think one of the
    most critical challenges we face in Indian Country, especially
    in our neck of the woods, is housing and the lack of
    affordable, quality, good housing. We should all be working
    together to prevent these problems in the future.
        Thank you, Mr. Chairman.
        The Chairman. That is it exactly, because we are talking
    about reauthorizing $650 million for housing in Indian Country.
    It is something we want to move. Figuring out how to do it is
    very important.
        Senator Cortez Masto. Mr. Chairman, if I may?
        The Chairman. Senator Cortez Masto.

               STATEMENT OF HON. CATHERINE CORTEZ MASTO,
                        U.S. SENATOR FROM NEVADA

        Senator Cortez Masto. Thank you.
        I appreciate the conversation and bipartisanship here. As a
    new member, you may not realize that although I represent
    Nevada, a desert State, believe it or not, Nevada is home to
    the largest number of Hawaiians in the Country outside of
    Hawaii. This is an important issue for my constituents and
    something I will be advocating for as well.
        I appreciate the opportunity to work with you to address
    the housing needs of my constituents in Nevada.
        The Chairman. Senator, are you saying that Hawaiians are
    coming to Nevada rather than Nevadans going to Hawaii? Is that
    what I heard you say?
        Senator Cortez Masto. Absolutely correct. There are a good
    number of them coming into southern Nevada, so much so that
    when Senator Schatz comes to Las Vegas, they recognize him more
    so than I think in his State. Yes, this is an important issue,
    I believe, for so many reasons. I look forward to the
    opportunity to work with you.
        Thank you.
        The Chairman. Senator Schatz.
        Senator Schatz. Thank you, Mr. Chairman. I will be really
    brief. I appreciate the conversation and the goodwill here.
        What Senator Heitkamp said is really exactly right which is
    that what we are doing here is trying to accommodate the fact
    that we cannot get cloture or we are not going to be able to
    get unanimous consent, because there will be members who will
    oppose NAHASDA on the basis of it including Native Hawaiians.
        I think it is really clear that you are not going to get
    unanimous consent for this bill on the basis of it not
    including Native Hawaiians. The solution, on the floor, is to
    get cloture. The way to get cloture is for us to work together
    on a bipartisan basis and get to 60.
        I will just add that because of the unique time we are in,
    normally the primary commodity in the Senate is Floor time, but
    the cupboard is bare. There is not a lot of legislation flying
    off the shelf. We are cooking up votes to come up with for
    Mondays and Wednesdays, a lot of assistant secretaries and a
    lot of judgeships that are going 93 to 5 and such.
        We actually, I think, have a pathway to get floor time for
    this. I know it will be an effort to get to 60, but with your
    support and Senator Murkowski, and I hope for Senator Sullivan
    and others support, we might be able to get to 60.
        The solution is not to accommodate one person's filibuster
    and force the other side to filibuster. I think we are between
    a rock and a hard place. The only solution is cloture. I think
    we can do it.
        The Chairman. I appreciate that. Again, we have not in the
    last two Congresses, but I am not ruling out any options at
    this point. We will keep working. Again, that is part of the
    reason we are having the early hearing so that we have more
    time to work on it.
        Senator Barrasso.

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

        Senator Barrasso. Thank you very much, Mr. Chairman.
        I appreciate your holding this hearing today to consider
    legislation on a number of topics, none more important than
    tribal health care.
        For decades, the Indian Health Service has failed to
    deliver even basic standards of care. In 2010, former Chairman
    Dorgan began an investigation that resulted in the infamous and
    often cited Dorgan Report.
        The issue of the Indian Health Service revealed widespread
    staffing issues, expired medical credentials, and we heard
    about exceptionally poor delivery of the services. These
    issues, reported more than seven years ago, still exist within
    the Indian Health Service.
        During my time as chairman of this Committee, we all spent
    a great deal of time working on issues related to the quality
    of care at the Indian Health Service. As both a doctor and a
    Senator, I find the level of dysfunction completely
    unacceptable.
        Not only does the United States Government have a trust
    responsibility that they much fulfill, but failures of the
    Indian Health Service should never result in the loss of life.
    Yet, stories of unnecessary patient deaths have dominated
    Indian Health Service oversight hearings for years.
        Ms. Kitcheyan, I appreciated hearing your story when you
    testified before this Committee last year. I appreciate you
    traveling here to be with us again today. Your story and those
    like it make it obvious why I joined with Senators Hoeven and
    Thune in introducing the bill before us today. Restoring
    accountability in the Indian Health Service is not just the
    name of the legislation, but also the goal of this Committee,
    in a bipartisan way, in any action we take related to health
    care.
        The bill addresses recruitment and retention of high
    quality staff. It addresses shortcomings in the process to
    remove problem staff, requires improvement of metrics that will
    measure Health Service delivery, and makes significant changes
    to credentialing to allow for better, faster patient treatment.
        Chairman Hoeven, I appreciate the leadership you and
    Senator Thune have shown on this issue over the years. The bill
    and the care it seeks to improve have real implications for
    daily life in Indian Country.
        Though there is no silver bullet, the need is clear. Across
    the Country, across the Country, interest in improving the
    Indian Health Service has led to countless comments on the bill
    so far, in addition to those we are here to receive today.
        I see suggestions for additional ways to address the many
    shortcomings at the agency and they continue to arrive. I look
    forward to working with you, the witnesses, and the
    Administration to advance meaningful change.
        Again, thank you, Senator Hoeven. Thank you to the
    witnesses for traveling to be with us today.
        The Chairman. Thank you, Senator Barrasso.
        Thank you for your work both as the former chairman of this
    Committee and also as a physician on this important issue and
    your commitment, which I think is such a huge priority, to
    strengthen IHS and provide better health care services
    throughout Indian Country.
        We have our first panel and will now ask for their
    testimony.
        Ranking Member, did you have anything else before we go to
    testimony?
        Senator Udall. No.`
        The Chairman. We will go to testimony.
        I want to welcome all of you. We have with us Rear Admiral
    Chris Buchanan, Acting Director, Indian Health Service, U.S.
    Department of Health and Human Services; the Honorable Victoria
    Kitcheyan, Tribal Council Treasurer, Winnebago Tribe of
    Nebraska; Dr. Joseph P. Crowley, President-Elect, American
    Dental Association; and Max Stier, President, Partnership for
    Public Service.
        Thanks to all of you for being here. Admiral, why don't you
    start?

      STATEMENT OF REAR ADMIRAL CHRIS BUCHANAN, ACTING DIRECTOR,
      INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN
                                SERVICES

        Mr. Buchanan. Good afternoon, Chairman Hoeven, Vice
    Chairman Udall, and members of the Committee.
        I am Chris Buchanan, an enrolled member of the Seminole
    Nation of Oklahoma. I am the Acting Director of the Indian
    Health Service. I am pleased to be here and have the
    opportunity to testify before the Senate Committee on Indian
    Affairs on S. 1250, the Restoring Accountability in the Indian
    Health Service Act of 2017.
        The mission of IHS, 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 longstanding,
    systemic problems that hamper our ability to fully carryout the
    IHS mission.
        In November 2016, we launched our Quality Framework and
    Implementation Plan to strengthen the quality of care that IHS
    delivers to patients we serve. Since November 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
    experiences and outcomes. We are doing this by strengthening
    the 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
    evaluation 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 in four IHS areas in July 2017 and implement
    it across the remaining IHS areas by the end of 2017.
        Ensuring timely access to care requires that we develop
    standards for wait times for appointments, as well as for time
    spent in the provider's 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. To
    improve transparency and access to quality of care, IHS is
    implementing a performance accountability dashboard. This
    includes reporting on patient wait times, pilot testing of
    dashboards and associated data collection is targeted for this
    summer.
        Strengthening governance and leadership at all levels of
    IHS is essential to ensure 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 on June 6 with
    34 participants.
        IHS faces significant recruitment challenges due to remote,
    rural locations of our health care facilities and area offices.
    IHS is implementing various strategies to increase recruitment
    and retention. Global recruitment is one strategy we have
    implemented for a streamlined approach to filling critical
    provider vacancies at multiple locations.
        Applicants only need to apply at 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 an effort to recruit and fill
    health professional vacancies throughout IHS.
        Also, IHS facilities can use the National Health Services
    Corps' scholarship and loan repayment incentive to recruit and
    retain primary care providers. 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. IHS is prepared to provide technical
    assistance on specific authorities proposed in S. 1250.
        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 Committee on this legislation as it
    moves through the legislative process.
        I am happy to answer any questions the Committee may have.
    Thank you.
        [The prepared statement of Mr. Buchanan follows:]

      Prepared Statement of Rear Admiral Chris Buchanan, Acting Director,
      Indian Health Service, U.S. Department of Health and Human Services
        Mr. Chairman and Members of the Committee:
        Good afternoon, Chairman Hoeven, Vice-Chairman Udall, and Members
    of the Committee. I am Chris Buchanan, an enrolled member of the
    Seminole Nation of Oklahoma and Acting Director of the Indian Health
    Service (IHS). I am pleased to have the opportunity to testify before
    the Senate Committee on Indian Affairs on S. 1250, the Restoring
    Accountability in the Indian Health Service Act of 2017. I would like
    to thank you, Chairman Hoeven, Vice-Chairman Udall, and Members of the
    Committee 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 healthcare delivery to approximately 2.2 million
    American Indians and Alaska Natives through 26 hospitals, 59 health
    centers, 32 health stations, and nine school health centers. Tribes
    also provide healthcare access through an additional 19 hospitals, 284
    health centers, 163 Alaska Village Clinics, 79 health stations, and
    eight school health centers.
        Providing quality healthcare is our highest priority. We share the
    urgency of addressing longstanding 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 healthcare
    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
    healthcare 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 healthcare. 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 6th 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.
    S. 1250
        S. 1250 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 Committee 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 & 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 healthcare 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 Committee on this legislation
    as it moves through the legislative process. Thank you for your
    commitment to improving quality, safety, and access to healthcare for
    American Indians and Alaska Natives. I am happy to answer any questions
    the Committee may have.

        The Chairman. Thank you, Admiral.
        Ms. Kitcheyan.

      STATEMENT OF HON. VICTORIA KITCHEYAN, TREASURER, WINNEBAGO
                    TRIBE OF NEBRASKA TRIBAL COUNCIL

        Ms. Kitcheyan. Good afternoon, Chairman Hoeven and Vice
    Chairman Udall.
        Thank you for the opportunity to testify today on S. 1250,
    the Restoring Accountability in the Indian Health Service Act.
        My name is Victoria Kitcheyan. I am a member of the
    Winnebago Tribe of Nebraska where I serve as Tribal Council
    Treasurer. I am also the Great Plains Area Rep to the National
    Indian Health Board. I will be making some national level
    comments on NIHB as well.
        The Winnebago Tribe and national Tribal advocates support
    the efforts of Congress to address the ongoing challenges for
    health delivery at the IHS-operated facilities. Legislative
    efforts to address these issues should be conducted in
    conjunction with the tribes. Increased oversight and scrutiny
    are essential to improving the service unit care.
        Essentially, we need to get this right. We are at a point
    where our people need help. Some of the quality care issues in
    the Great Plains and my tribe cannot be overlooked any further.
    It is important that we garner the voice of Indian Country and
    that we all have input on this legislation. The best outcome
    can only be derived from the tribes.
        We look forward to working with Indian Country in the
    coming months and weeks on how we can further have legislative
    consultation on this bill because it is going to affect all of
    us. We want to make sure that is a part of this process.
        I have shared in previous testimony with this Committee
    that the IHS hospital on my reservation has demonstrated
    deficiencies back to 2007. These deficiencies were so numerous,
    egregious and life threatening that in 2015, we lost our CMS
    certification. Two years later, we are still without that
    certification.
        Month after month this decertification is delayed due to
    lack of resources, key staff vacancies, and the lack of CMS-
    generated third party revenue is an additional strain on the
    service unit. In addition to the staffing challenges, this has
    kept the facility in dire constraint.
        It is important that the leadership roles be filled with
    qualified, permanent providers so that we can continue to offer
    the services the tribes need. It is this dedicated staff that
    we need to be committed to making these improvements that have
    been identified.
        It is this rolling of administrators and recycled employees
    from other Great Plains service units that are, in our opinion,
    dumped on one of the most dire service units. It is the
    unacceptable level of administration and this revolving door
    that has left area hospitals in the Great Plains continuing to
    suffer. The resources and continuity of leadership has been a
    problem.
        Given this critical state, we are much appreciative of this
    Committee taking the action to introduce S. 1250. However,
    there are a few items in this legislation that I want to
    address and make sure it works for everyone in Indian Country.
        As I mentioned before, the legislation should not be
    enacted without the proper consultation of all of Indian
    Country. This legislation is going to affect everyone, so we
    want everyone's voice to be a part of this. This is
    particularly important as a National Indian Health Board
    representative. We do not want to take down any other tribe in
    our path of turmoil. That is important to me as a rep and as a
    member of NIHB.
        Also, there are provisions in the bill that address new
    programs and functions in IHS. Although these would be
    beneficial, we need adequate oversight and funding to make
    these beneficial. We want to make sure that this is not just a
    program that becomes an unfunded mandate.
        This is very much true in the Indian Health Care
    Improvement Act which was implemented seven years ago and has
    yet to be fully funded. We do not want to make this another
    broken promise to Indian Country. We want this to be funded and
    be a real commitment to improving the health care.
        The Winnebago Tribe and NIHB also support the intent to
    make a streamlined system for licensed health care
    professionals, credentialing procedures, including volunteers.
    However, I want to note this is not the substitute or final
    step in increasing available, permanent, full-time providers in
    IHS and throughout Indian Country.
        Tribes in some areas have already come up with some very
    creative and innovative solutions to address this problem. We
    would like to replicate that model throughout Indian Country.
    We hope to discuss that more in the future and develop some
    creative solutions together.
        When it comes to hiring authorities outlined in the
    legislation, NIHB and the Winnebago are happy to see there is
    some streamlining of Federal hiring authority, but we believe
    this section needs more tribal input, especially when it comes
    to waiving Indian preference.
        Tribes need to have important input on that so that it
    becomes a tool and not so much the norm to Indian preference.
    More details are outlined in the testimony.
        Section 10 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 ways that will provide community input.
        If this had been done earlier, I think some of our issues
    at the local level may not have reached the levels they have.
        We strongly agree with increasing fiscal accountability
    measures in the bill. We hope we can modify the language,
    especially around third party revenue so that we can include
    the community input on where those monies should go. We should
    have access to that in the programs we know we need the most.
        Finally, we are glad to see the reporting requirements but
    we would also like to see those done in the purchased and
    referred care so that we can assure the quality through that
    process as well.
        Overall, this legislation is important and necessary. We
    thank this Committee for their genuine interest in being a
    partner to the tribes so that we can address the transparency,
    accountability, recruitment and management. All these continue
    to be a problem.
        I would like to plead with you that we cannot continue to
    starve the system and expect a different result.
        I thank you for this time. I am happy to answer any
    questions.
        [The prepared statement of Ms. Kitcheyan follows:]

      Prepared Statement of Hon. Victoria Kitcheyan, Treasurer, Winnebago
                        Tribe of Nebraska Tribal Council
        Good afternoon Mr. Chairman 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 and will offer
    national-level comments on behalf of NIHB as well. 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 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
    healthcare 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.
        The Winnebago Tribe and national Tribal advocates support the
    efforts of Congress to address the ongoing challenges for health
    delivery at the IHS-operated facilities. We appreciate the commitment
    of the Senate Committee on Indian Affairs to find real change.
    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 legal current framework for IHS provides much of the
    necessary guidelines for the operation of the agency.
        While we appreciate the speed at which the Senate 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. Some of the quality of care issues found at my Tribe
    and elsewhere in the Great Plains region cannot go on any longer.
    However, it is also important that these changes are accompanied by
    input from tribes across the country to ensure the best possible
    outcome and product. We think legislation is needed and would have
    appreciated an opportunity for the Winnebago Tribe and other tribes
    across the county to review any draft legislative language before S.
    1250 was introduced. NIHB is ready and willing to lead a legislative
    consultation on this bill and we intend to do so in throughout the
    coming weeks and months. This step must happen first before anything
    can be enacted.
    Winnebago IHS Hospital
        For those of you that may not know, the Winnebago Tribe is located
    in rural northeast Nebraska. The Tribe is served by a thirteen (13) bed
    Indian Health Service operated hospital, clinic and emergency room
    located on our Reservation. This hospital provides services to members
    of the Winnebago, Omaha, Ponca and Santee Sioux Tribes. It also
    provides services to a number of people from other tribes who reside in
    the area. Collectively, the hospital has a service population of
    approximately 10,000 people.
        As I have shared in previous testimony before this Committee, 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 have
    been experiencing similar quality of care issues throughout this time
    and are also under threat of decertification by CMS.
        Nearly two years have passed since the Winnebago Hospital lost its
    certification and IHS has yet to submit the application to CMS for
    recertification. Initially, the target date to apply for
    recertification was scheduled for October 2015. Since then, the date
    for submitting the application has been repeatedly delayed. It is an
    extremely frustrating situation and it is unacceptable that such a bad
    situation should take so long to correct. While the staff at the
    facility have been working hard to prepare for recertification and
    corrective action plans have been implemented, including multiple mock
    surveys, staff training and necessary policy changes, the fact remains
    that the facility continues to lack critical resources necessary to
    move forward.
        Senior officials at IHS have said that recertification at Winnebago
    is a top priority, but for some reason the practical resources to
    achieve this have not reached the ground level. The inability to
    generate necessary revenue from all third party sources has caused
    serious budget issues. The financial constraints in addition to
    staffing challenges have kept the facility in a dire situation. The
    Hospital Governing Body finally decided last month that the Hospital
    was ready for recertification. However, the application has not been
    submitted due to key staff vacancies including the CEO, Director of
    Nursing and Lab Supervisor. The fact that these vital positions are
    vacant is a huge indicator that the hospital is not adequately staffed
    to be ready for CMS review.
        Many of the situations that led to the Hospital losing its
    certification in the first place have also played a role in the delay
    to submit the application for recertification. For example, the Great
    Plains Region has operated under an Acting Regional Director for nearly
    one and a half years. At Winnebago, the hospital also operated with a
    series of Acting CEO's until a permanent hire was made approximately 6
    months ago. Both the Omaha and Winnebago Tribes have been very pleased
    with the progress he has made at the facility. Unfortunately, due to
    personal reasons, he is now resigning as the CEO and the position will
    be vacant once again later this month.
        These important leadership roles need to be filled by permanent,
    qualified and dedicated employees who have a vested interest making
    improvements. There have been instances where the IHS has continued to
    hire key personnel without any input from the Tribe and/or ``recycled''
    employees who were found to be unacceptable at other IHS hospitals in
    the Great Plains Region. A multi-million dollar staffing contract was
    awarded to a company previously used by IHS that had placed
    unsatisfactory employees in many of the Great Plains IHS hospitals.
    Finally, the federal hiring freeze implemented earlier this year caused
    great delays in filling critical positions. While waivers were
    eventually obtained for many positions, it is our understanding that
    some positions necessary for CMS certification remain under a freeze
    status. The hiring freeze is detrimental to the needs of our tribal
    members and others who rely on IHS for their healthcare.
        Many missteps could have been avoided by getting input from the
    Tribes and actually acting on that input. The Governing Body for the
    Winnebago Hospital was basically non-functional around the time of the
    loss of the CMS Certification. Although the Governing Body appears to
    be meeting more often, the tribal representatives have since lost their
    seats on the Governing Body since IHS deemed that the non-IHS members
    (Tribal Council representatives from the Winnebago Tribe and the Omaha
    Tribe) have no oversight over IHS and therefore should not be on the
    Board. This is ridiculous and counter-intuitive. Perhaps Tribal Council
    members have no ``authority'' over IHS, but they know their own
    communities and are more likely to have an interest in holding
    management accountable if their actions are not conducive to patient
    care or a well operated medical facility. We have already learned that
    IHS officials in the Great Plains region were not using their authority
    to police each other, which was another reason that led to the
    decertification in the first place.
        Although some IHS regions around the country seem to function
    better than others, the Great Plains Region has been problematic for
    years, despite several reports conducted by Congress and U.S.
    Government agencies. Many provisions contained within this proposed
    legislation are designed to correct some of the issues that plague the
    Winnebago Hospital and other IHS Hospitals within the region. I will
    now provide more specific comments on S. 1250 and how certain
    provisions will help the situation in Winnebago or how it might be
    amended to meet our specific needs.
    Comments on S. 1250
        First, we have some general areas of concern regarding the proposed
    legislation that we would like to stress. There are provisions in the
    bill that address 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 Appropriations
    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 the types of health professionals available within the Indian
    health system. Yet those provisions remained 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.
        The Winnebago Tribe is working its way toward self-governance, a
    status many other tribes throughout the country already have. In fact,
    about 60 percent of the IHS budget is delivered directly to the tribes
    through contracts and compacts. 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 that 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. Since we hope to be a
    self-governance tribe in the reasonably near future we would certainly
    appreciate some clarity regarding the application of this provision.
    The Winnebago Tribe and NIHB are happy to work with you on the drafting
    of that provision.
        The Winnebago Tribe and NIHB support the intent to make a
    streamlined system for licensed health care professional credentialing
    procedures, including volunteers, as outlined in Section 102. 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 the tribes fully 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.
        Section 105 addresses Improvement in Hiring Practices. While we
    certainly agree that hiring practices need drastic improvement we are
    not completely comfortable with the language in the proposed
    legislation. First, this provision indicates that the Secretary has
    direct hire authority, which in and of itself is not a bad idea.
    However, the Winnebago Tribe and NIHB want to make sure that Tribal
    Preference is not ignored in the direct hire authority. 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. While notice is appreciated, it would be useful if tribes could
    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. Lastly, this provision provides that the Secretary may seek
    waivers to Indian preference from each Indian tribe concerned if
    certain criteria are met. We understand that when there are no
    qualified ``Indian'' candidates or the Indian candidates have not
    performed well in the past, it may be appropriate to hire a non-Indian
    candidate. However, Tribes are concerned about diminishing Indian
    preference in the hiring process. This path should only be used in the
    most extreme circumstances and should be initiated by the Tribe(s)
    served by the facility in question.
        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 at
    the Winnebago Hospital 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 timely 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 health care 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.
    Lastly, we request that any data gathered regarding the timeliness of
    care be provided to the tribes as well as the Secretary.
        The Winnebago Tribe finds Section 108 regarding training programs
    in tribal culture and history to be of utmost importance. Meaningful
    cultural training can do nothing but 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 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 involved 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 issues with the
    Winnebago Hospital would have never have risen to the level that
    existed if there was true consultation and collaboration at every step
    in this process and they never would have received the attention it has
    if it were not for Tribal action.
        Fiscal accountability is never a bad thing as laid out in Section
    202, but the provision in subsection (b) that addresses the
    prioritization of patient care is somewhat troubling in its
    specificity. 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 we
    certainly appreciate the need for more scrutiny, we worry that the
    criteria may end up being too constraining on the programs. IHS should
    consult with the Tribes in their service area before they make
    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 areas.
        Most of Title III of the proposed legislation deals with a variety
    of reports. The one report that drew our attention was the Inspector
    General reports on patient care in Section 304. We definitely 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 and referred care program. For example, in South
    Dakota, approximately 70 percent of care 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 and is care for in an
    outside facility. We suggest that another subsection be added to
    Section 304 in order to address this issue.
        Overall, we think this proposed legislation is necessary and once
    again 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, most of which are covered in the proposed
    legislation. Nearly two years has passed since the CMS certification
    was terminated at the Winnebago Hospital and our CEO, Director of
    Nursing and Lab Director positions are once again vacant. As we have
    stated at prior hearings, real change and the rebuilding of the
    hospital cannot happen without permanent qualified personnel and the
    funding necessary to carry out the mission.
        Mr. Chairman, the Winnebago Tribe supports the passage of this
    legislation once the issues listed above are addressed and after
    thorough comment and review by Indian Country. As I stated last year at
    a hearing and this bears repeating, while everything in this bill is
    needed, legislation alone will not solve our problem. Proper training
    of hospital staff costs money, new equipment costs money, and
    recruitment under these circumstances is also going to cost money. We
    would consider the passage of this legislation an initial solid first
    step and implore you not to abandon us after this bill is passed.
    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.

        The Chairman. Thank you.
        Dr. Crowley.

     STATEMENT OF DR. JOSEPH P. CROWLEY, PRESIDENT-ELECT, AMERICAN
                           DENTAL ASSOCIATION

        Dr. Crowley. Thank you, Mr. Chairman.
        As stated, my name is Joe Crowley. I am President-elect of
    the American Dental Association and a practicing general
    dentist in Cincinnati, Ohio.
        The ADA supports the ``medical credentialing system''
    provision (section 102) of the S. 1250, ``Restoring
    Accountability in the Indian Health Service Act of 2017.''
        The provision calls for the IHS to implement a centralized
    credentialing system to licensed health care professionals who
    seek to provide health care services at any IHS facility. A
    central credentialing system would benefit both the
    practitioners and the IHS.
        According to former and current IHS area dental chiefs, the
    credentialing process easily takes eight to twelve hours of
    staff time at local service unit levels at a cost of about
    $1,000 per application. The current credentialing process makes
    it difficult for the Service to timely fill dental vacancies.
    It serves as a disincentive to those who want to contract IHS
    or volunteer their services.
        As an example, a private sector dentist in Mayville, North
    Dakota, who currently contracts with the Spirit Lake
    Reservation in Fort Totten, said that his IHS paperwork was
    much more difficult and much more extensive than the paperwork
    for his hospital privileging credentials.
        In 2012, despite the best efforts of the South Dakota
    Dental Association and Delta Dental of South Dakota to place
    volunteers in IHS dental clinics, the time-consuming
    credentialing process proved too large a barrier to overcome
    for all but two pediatric dentists. There were 70 volunteers
    who started that application.
        The Dental Association ultimately abandoned this project
    and established a partnership with the Jesuit Mission on the
    Rosebud Reservation just eight miles down the road from the IHS
    facility where the two pediatric dentists worked. This speaks
    to the issue raised by the current credentialing services and
    it can be corrected with the language in this bill today.
        As my testimony details, many of the Federal services
    currently operate centralized credentialing services. The IHS
    dental officers that the ADA spoke with suggested that the IHS
    would benefit from a centralized credentialing unit with the
    proper technology that enabled applicants to upload documents
    similar to the other Federal services.
        The good news is that it appears IHS is making progress in
    centralizing the credentialing process according to the
    November 2016 press release from the agency. The ADA recommends
    that the IHS agency be encouraged to support continuing down
    this path with adequate funding in its project. In addition,
    the ADA encourages this Committee to ask the Indian Health
    Service to provide an update on the status of this new
    credentialing process.
        Mr. Chairman, I would also like to point out that the ADA
    is currently supporting implementation of a ten-year health and
    wellness plan which includes oral health and is designed to
    reduce oral disease by 50 percent among the Navajo tribal
    communities. This will be done by developing a foundation of
    prevention, early detection and treatment of dental disease and
    utilizing the interprofessional models of care, while providing
    timely and accessible oral health care.
        This model is being considered by other Indian Nations in
    Arizona and Washington State tribes. Centralizing the
    credentialing process will facilitate these efforts by getting
    more dentists into IHS and tribal clinics. Having more dentists
    available to provide care will also greatly enhance access to
    oral health care services as shown in the Navajo Health Plan.
    It builds capacity utilizing existing resources, including
    their Community Health Representatives and the ADA community
    Delta health coordinators.
        Mr. Chairman, thank you for this opportunity to share with
    you and the members of the Committee why the ADA supports the
    medical credentialing system provisions of S. 1250.
        I would be pleased to answer any questions.
        [The prepared statement of Dr. Crowley follows:]

    Prepared Statement of Dr. Joseph P. Crowley, President-Elect, American
                               Dental Association
        My name is Dr. Joseph P. Crowley, president-elect of the American
    Dental Association (ADA) and a practicing general dentist from
    Cincinnati, Ohio. The ADA represents over 161,000 dentists nationwide,
    including many dentists working in the federal dental services, such as
    the Indian Health Service (IHS), as both U.S. Public Health Service
    commissioned officers and civil servants.
        The ADA supports the ``medical credentialing system'' provision
    (section 102) of the ``Restoring Accountability in the Indian Health
    Service Act of 2017'' (S. 1250) that calls for the IHS to implement a
    Service-wide centralized credentialing system to credential licensed
    health care professionals who seek to provide health care services at
    any IHS facility.
    Need for Centralized Credentialing
        Based on discussions with current and former IHS officials and a
    number of private sector dentists and state dental associations who
    have had experience with the credentialing process at various IHS
    facilities, the ADA believes a centralized credentialing system would
    benefit both practitioners and the IHS.
        According to former and current IHS area dental chiefs,
    credentialing is handled at the service unit level and generally
    assigned to a clerical employee. The credentialing process easily takes
    8-12 hours of staff time for a full-time dentist, a part-time dentist,
    or a volunteer. Because of the challenges associated with this process
    and the cost (estimated to be about $1,000 per applicant), IHS dental
    chiefs do not put a high priority on recruiting volunteers, especially
    if they only have a limited block of time to devote to the assignment.
        A private-sector dentist from Mayville, N.D., Dr. Rob Lauf,
    currently contracts with the Spirit Lake Reservation in Fort Totten,
    N.D. He describes the credentialing process as ``arduous,'' noting that
    the IHS paperwork far exceeded the amount of paperwork required for his
    hospital privileging credentials. Despite this administrative burden,
    Dr. Lauf sees that the dental need is very apparent and he intends to
    continue to provide services. The most recent credentialing guide
    published by IHS is 74 pages long with one short paragraph on volunteer
    credentialing, which focuses solely on residencies through medical
    schools.
        In 2012, the South Dakota Dental Association (SDDA), working with
    Delta Dental of South Dakota, made a serious attempt at placing
    volunteers in IHS dental clinics. The SDDA surveyed its membership of
    400 practicing dentists and approximately 70 indicated a willingness to
    volunteer or contract with IHS. All of these dentists were sent the IHS
    credentialing packet and the instructions needed to complete them. Due
    in part to the fact that the packet is quite large and intimidating for
    the uninitiated, out of the 70 dentists who indicated interest in
    volunteering ultimately only two members, both pediatric dentists,
    became credentialed to work in an IHS facility. SDDA ultimately
    abandoned this project and established a partnership with the Jesuit
    Mission on the Rosebud Reservation, just eight miles down the road from
    the facility where the two pediatric dentists volunteered. In order to
    volunteer at the Mission, dentists must only have a current license to
    practice dentistry in South Dakota or, if they are from outside of the
    state, obtain a volunteer license issued by the South Dakota State
    Board of Dentistry. Of course, private charities are not subject to the
    same quality control constraints as those placed on federal facilities.
    This example is cited merely as a means of showing that many dentists
    are more than willing to help address the oral health care needs of the
    American Indian/Alaska Native population and that streamlining the
    credentialing process will facilitate those efforts.
        In fact, the IHS dental officers that the ADA spoke with suggested
    that the IHS would benefit from a centralized credentialing unit with
    the proper technology that enabled applicants to upload documents. This
    would allow for the appropriate primary source verification of dental
    education, license verification, and National Practitioner Databank
    checks to be conducted in a timely manner, saving significant work at
    the service unit level.
    Federal Agencies with Centralized Credentialing
        The ADA inquired about centralized credentialing and privileging
    among the federal services. All three of the military services and the
    U.S. Coast Guard use the Centralized Credentials & Quality Assurance
    System (CCQAS).
        According to information provided by the Coast Guard and verified
    by the Army, Navy and Air Force:

             The Centralized Credentials & Quality Assurance System is a
            standard Department of Defense (DOD) system jointly undertaken,
            operated, and controlled by the Army, Navy, and Air Force
            medical departments within the overall corporate sponsorship
            and policies of the Office of the Assistant Secretary of
            Defense for Health Affairs. The Defense Health Services System
            is responsible for the development, deployment, and maintenance
            of credentialing and quality policies. CCQAS is a Web-based
            worldwide credentialing, privileging, risk management, and
            adverse actions application that supports medical personnel
            readiness.

             This centralized system enables the military medical community
            to electronically manage provider credentialing and
            privileging, malpractice and disability claims, and adverse
            action investigations of diverse, multi-disciplinary health
            care professionals and their support personnel at all levels of
            the Department of Defense.

             The system provides the following features:

          Maintains and tracks the credentials and privileging
            history of all military and civilian health care providers,
            including Active Duty, Reserves, and National Guard.

          Contains comprehensive provider demographic, specialty,
            licensing, training, education, privileges, assignment history,
            and provider photographs for identification purposes.

          Enables providers to complete and submit an application
            for clinical privileges online.

          Automates the online review and approval of a provider's
            application for initial and renewal of privileges.

          Expedites the transfer of provider credentialing and
            privileging information for temporary change of assignment or
            Permanent Change of Station.

        As noted in the last bullet, each facility is still charged with
    the responsibility for actually granting privileges to a provider when
    assigned to that facility either temporarily or permanently.
        According to Dr. Patricia Arola, Assistant Under Secretary for
    Health for Dentistry, within the U.S. Department of Veterans Affairs
    (VA), ``Centralization of the privileging process has been on the wish
    list for years; but unfortunately, the process remains local. There is,
    however, a repository for credentialing information called VetPro,
    which allows for online entry of information by providers and
    credentialing staff.'' It appears that this particular VA process is
    similar to but distinct from the DOD centralized credentialing and
    privileging system.
    IHS Making Progress toward Centralized Credentialing
        The good news is that it appears that the IHS is making progress on
    the centralized credentialing issue and should be encouraged and
    supported to continue down this path with adequate funding for its
    project. The Office of Human Resources at the IHS is spearheading this
    initiative, based a November 16, 2016, press release, titled ``Indian
    Health Service (IHS) Quality Framework, 2016-2017'' at: https://
    www.ihs.gov/newsroom/includes/themes/newihstheme/display_objects/
    documents/IHS_2016-2017_QualityFramework.PDF.
        As you can see, the first order of business in this plan was to
    assign a key leader (https://www.ihs.gov/aboutihs/keyleaders/) as the
    Deputy Director for Quality Health Care. Mr. Jonathan Merrell, RN, BSN
    MBA has been assigned these duties in an acting role.
        In the press release cited above, the IHS addresses the centralized
    credentialing issue in Objective 1B: Standardize Governance:
    Standardizing and strengthening governance processes and structures
    promotes reliability, consistency, and management excellence while
    emphasizing quality improvement as an Agency priority.

        A standard governing body structure will be developed to
            improve planning and oversight processes while ensuring that
            all Direct Service facilities are meeting external
            accreditation and certification Governance requirements.

        IHS will support a central repository of key IHS policies
            and procedures accessible to each Area Office and Service Unit
            to ensure consistency across the Agency and enable easy access
            to, and version control of, current policies and procedures.
            This effort will include a review of policies and procedures to
            reduce variation across the Agency.

        IHS will standardize the credentialing business process and
            implement a single credentialing software system for Direct
            Service facilities. IHS will automate business processes where
            possible and review, update, and simplify credentialing and
            privileging policies and procedures. Training and technical
            assistance will be provided to staff. The Quality Office will
            provide operational support and oversight to ensure system-wide
            high quality credentialing processes and procedures.

        The ADA encourages the Committee to ask the Indian Health Service
    to provide an update on its implementation of the Quality Framework,
    including implementing the credentialing business process. It is
    important to ensure there are adequate funds available to complete this
    initiative. As the committee knows, the IHS has approximately 100
    funded dental vacancies at the time of this testimony. Other
    disciplines, such as nursing and medical, have similar recruitment
    challenges. Streamlining the credentialing process could help fill
    those vacancies with quality health care professionals in a timely,
    efficient manner.
    Improving Oral Health in Tribal Communities
        Working closely with Navajo tribal leaders, the ADA is currently
    supporting implementation of a 10 Year Health and Wellness Plan, which
    includes oral health and is designed to reduce oral disease by 50
    percent among the Navajo tribal communities. This will be done by
    developing a foundation of prevention, early detection and treatment of
    dental disease, and utilizing interprofessional models of care, while
    providing timely and accessible oral health services. This model is
    being considered by other Arizona and Washington State tribes.
    Centralizing the credentialing process will facilitate these efforts by
    getting more dentists into IHS and tribal clinics.
        Having more dentists available to provide care will also greatly
    enhance access to oral health services as the Navajo Health Plan builds
    capacity utilizing existing resources, namely Community Health
    Representatives (CHRs). Utilizing both the Smiles for Life oral health
    curriculum and educating a number of Navajo CHRs and dental assistants
    with Community Dental Health Coordinator (CDHC) certification will
    enable greater community outreach, community education, and preventive
    services. The role of a CDHC is threefold: educating the community
    about the importance of oral health to overall health across the
    lifespan; providing limited preventive services, such as fluoride
    varnish and dental sealants; and connecting the community to oral
    health teams that can provide needed dental treatment. CDHCs work in
    inner cities, remote rural areas and Native American lands. Most grew
    up in these communities, allowing them, through cultural competence, to
    better understand the problems that limit access to dental care.
        A September 2013 evaluation of 88 case studies of the CDHC program
    conducted by the ADA verified the real world value of the CDHC in
    making the dental team more efficient and effective. Screenings, dental
    education and certain preventive services were delivered by the CDHC
    and an increasing number of individuals needing dental care did not
    ``fall through the cracks'' of a complicated delivery system.
        Before the end of this summer, the CDHC program will have over 100
    graduates working in 21 states. This includes 16 CDHCs working in
    tribal facilities, including clinics serving the Chickasaw Nation
    Division of Health, Wewaka Indian Health, and the Muskogee Creek Nation
    in the Oklahoma City area. And more are being trained. For example,
    four additional Navajo CHRs are being trained at the Central Community
    College in New Mexico. These four will soon join two Navajo CDHCs
    serving in Fort Defiance on the Navajo Reservation. Following the lead
    of the Navajo Nation, the Chickasaw Nation is working on a grant to
    begin a CDHC program with Pontotoc Technical College.
        Mr. Chairman, thank you for this opportunity to share with you and
    the members of the committee why the ADA supports the medical
    credentialing system provision of S. 1250, which calls for the IHS to
    implement a Service-wide centralized credentialing system.
        Attachments

           Arizona Tribal Communities Oral Health Plan Offering--2016
    Making Oral Health a Priority
        Goal: Reduce incidence of oral disease by 50 percent among the
    Arizona Tribal Communities by developing a foundation of prevention,
    early detection and treatment of dental disease, and utilizing
    Interprofessional models of care, while providing timely and accessible
    referral services.
    Practical Goals Across the Lifespan

        Every individual will have access to the benefits of water
            fluoridation

        Every pregnant woman will have a healthy mouth

        Every child will start kindergarten cavity free

        Every individual with a chronic disease such as diabetes or
            hypertension will have oral health as an integral part of their
            disease management

        Every elder will have access to dentures or other tooth
            replacement options

    Objectives to Achieve Practical Goals

        Establish collaboration between dental and medical services

        Build grassroots support for oral health throughout tribal
            leadership

        Build a collaborative relationship with organized dentistry

        Establish/enhance strong, sustainable community oral health
            prevention programs

        Establish/enhance electronic health record for tribal
            individuals that incorporates medical, dental and behavioral
            health data

        Build relationships with dental industry and research
            entities

        Promote health literacy for sustainable results of health
            improvement actions

        Incorporate Community Dental Health Coordinators (CDHCs)
            into tribal health clinics and communities

        Develop awareness and encouragement to pursue oral health
            careers for teens and young adults

    Action Steps
    Building Capacity

        Work with Tribal Community Health Representatives to become
            CDHCs

        Recruit students for dental school careers

        Actively work with local dental offices to expand access
            for tribal oral health care

        Create ``on the job'' training for high school students to
            learn dental assisting skills

        Promote interdisciplinary approach to improve Native
            American health care:

          Establish a dental home by age 1

          Provide mouthguards for athletes

          Establish oral health protocols for pregnant women, young
            children and individuals living with chronic diseases

    Building Infrastructure

        Establish reliable data and surveillance to support health
            improvement efforts

        Coordinate research efforts building upon relevant
            historical data and medical surveys

        Educate physicians to enter oral health findings into
            shared health record and educate patients on the value of oral
            health to overall health

        Educate oral health professionals to promote overall
            prevention efforts, such as hypertension and cancer screenings,
            immunizations and good nutrition

    Building Community

        Incorporate CDHCs into existing CHR programs

        Build upon existing efforts to integrate oral health
            education into WIC, Early Health Start, Head Start and
            elementary education programs

        Expand community prevention programs for tobacco cessation,
            school-based sealant programs, and oral cancer screening events

        Raise awareness of oral health value through events for
            tribal populations

    Building Partnerships

        Contract with local dentists in order to expand oral health
            access without expense of additional ``brick and mortar''
            expansion

        Participate in Local and State Oral Health Coalition
            meetings

        Enhance the voice of Native Americans to advocate to the
            Indian Health Service for oral health improvement initiatives

        Encourage the dental industry to contribute materials to
            support/sustain oral health activities to improve tribal oral
            health

        The Chairman. Thank you, Doctor.
        Mr. Stier.

     STATEMENT OF MAX STIER, PRESIDENT/CEO, PARTNERSHIP FOR PUBLIC
                                SERVICE

        Mr. Stier. Thank you very much, Mr. Chairman, Mr. Vice
    Chairman, and Senator Heitkamp.
        It is a great pleasure to be here. You are focusing on a
    very important issue. I would like to put this in context,
    however. The problems you are seeing at IHS are not unique to
    IHS. They actually exist across the Federal Government.
        My proposition to you would be, learn from what else is
    going on in the Federal Government. Don't see this as an
    insulated, isolated example. There is a lot of learning to be
    done. Senator Heitkamp has done some very important work on
    some broader changes.
        Senator Udall, you said let us not tinker around the edges.
    Tinkering is not going to get you what you want. If you want to
    have better quality service, you are going to have to do a lot
    more. You are going to have to fix the system that was designed
    for a different era and a different age.
        Let us look at the data. It is devastating. IHS hospital
    rates, physician vacancy rates are at 33 percent; 1,550 health
    care professional vacancies exist across the system. Only 38.3
    percent of the IHS employees believe that their work unit can
    recruit people with the right skills.
        Only 7.3 percent of the employees there are actually under
    the age of 30. Nearly three-quarters of the employees do not
    believe that steps are taken to deal with poor performers. This
    is a real problem. You are focusing on something important but
    I would propose to you that there are better ways for you to
    fix these issues.
        You have jurisdiction for IHS. I think there are some key
    things you can do around the areas of hiring and accountability
    that would be much more powerful. Let us start with
    accountability.
        You are on a path now that the Veterans Affairs Committee
    has been down for more time than you have. I would propose to
    you that you look to see what kind of changes they have made.
    The provisions you have on accountability are Version 1.0 from
    the Veteran Affairs Committee. They are beyond that. I would
    take a look at the things they are doing already. Let me point
    out four particular opportunities to promote accountability
    that I think will do more.
        First and foremost, you have to understand what the problem
    is. One of the real problems is that employees who are
    excellent technical experts are promoted to management because
    that is the only way for them to be promoted.
        One solution is, have dual tracks where you can have
    expertise that are technical experts that get promoted through
    the system that they don't have to go into management in order
    to move up in the system.
        Second, we have a probation period in the Federal
    Government, typically a year long. A lot of folks point at it
    to say it doesn't work, they want to extend it. The problem is
    it doesn't work. Why doesn't it work? Because managers don't
    use it appropriately. They don't actually decide whether an
    employee deserves non-probationary status.
        My proposition to you would be to flip the presumption.
    Today, if you are a Federal employee, you have been there for a
    year, you automatically become non-probationary. I would say it
    should be the opposite. You are not actually non-probationary
    unless the manager who is supervising you determines that you
    are right for the job. Put the burden on the manager.
        The same goes for the manager. If you are put into
    management, you have a probation period of a year. You should
    not stay in management unless your supervisory affirmatively
    decides that you are doing that job well and then you become
    non-probationary for that position. That is the second point.
        Third, we need to do more training for managers. Right now,
    people are made managers but not helped in any way to actually
    do the difficult and different things they have to do as
    managers.
        Fourth, I think you have to hold leadership accountable.
    There is a performance plan requirement for the head of the
    Indian Health Service. My view is I don't know where that
    performance plan is. It ought to include the management
    functions of running the organization.
        Let me move to hiring. One, we need to focus more on the
    entry level side on student level talent. The Federal
    Government does not do the most basic thing that every other
    private sector organization does which his to see student
    interns as a primary way of bringing talent in at the entry
    level. It doesn't happen. A lot more could be done on that.
        Secondly, we have a pay system that was designed in 1949.
    That is not a pay system that is designed for today's world. We
    need more market sensitive pay. Again, look at the VA. It is
    not just enough to duplicate Title 38.
        You need to think about what kind of pay you need to get
    the right talent into the jobs. It is not just the doctors; it
    is actually the leaders of the hospitals and the medical
    directors for the system, the same problems you see at the VA.
        Then you are going to have to evaluate the impact of the
    authorities and flexibilities that already exist that
    oftentimes are not used. The bottom line is you have a lot of
    talented people. The system is failing them.
        Finally, you do need more data. I propose that you really
    need a dashboard that has four critical elements around quality
    of care to health outcomes, number one; number two, what is
    customer service perspective; number three is the employee
    voice which you have which is very powerful. I think you can
    look at that more. Fourth obviously is fiscal prudence because
    there are only so many resources to get this done.
        I work at the Partnership for Public Service. I should say
    at the front end, it is a non-partisan, non-profit
    organization. We would be pleased to help in any way we can.
    There is a lot you can do. I am glad you are focusing on it.
        Thank you very much.
        [The prepared statement of Mr. Stier follows:]

    Prepared Statement of Max Stier, President/CEO, Partnership for Public
                                    Service
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        The Chairman. Thank you for being here and for your
    testimony. We really appreciate it.
        I will turn to the Ranking Member and see if you would like
    to begin the questions.
        Senator Udall. As we all heard at the last hearing,
    Medicaid billing accounts for a substantial part of IHS
    funding. That means the loss of CMS certification is both a
    safety concern and a funding issue.
        The Committee frequently receives status updates on the
    IHS-CMS system improvement agreements for the three South
    Dakota facilities placed on probation last Congress. The
    Committee has heard very little about the efforts to regain
    accreditation at the Omaha Winnebago. Omaha Winnebago tribal
    leaders, like Ms. Kitcheyan, report that they have similarly
    received few updates.
        What is the current CMS accreditation status of the Omaha
    Winnebago IHS facility, Admiral Buchanan?
        Mr. Buchanan. Currently, it remains unchanged. As mentioned
    earlier, it has been about two years since the certification
    was lost.
        One of the challenges we have had has been locating a
    senior leader for that position, a CEO position. We were able
    to locate a senior leader to operate the Omaha Winnebago
    Hospital and with input from the Winnebago Tribe and the Omaha
    Tribe, that person was selected, brought onboard and started
    implementing changes.
        As I understand, he has been holding regular meetings with
    the tribes, both Omaha and Winnebago, to provide those regular
    updates.
        Some of the challenges continue to be the leadership
    positions. Some of our key positions there still remain vacant.
    I recently heard that the CEO we hired will be resigning at the
    end of the month. That could pose a continual challenge going
    forward.
        Senator Udall. Do you have a timeline for getting them back
    up and getting accreditation?
        Mr. Buchanan. We have been working continuously to try to
    get that timeline. It continues to move. Specifically, as new
    leaders come in, we want to apply for that certification when
    it is safe to do so. The next step in the process is to bring
    in a contractor such as Joint Commission Resources to evaluate
    and see where we are. That has been the next step. That is
    where we are.
        Senator Udall. Admiral, you are very aware that Medicaid
    and Medicare, if these facilities are in a status where they
    don't get those, that hurts the ability to their offering
    health care to a significant degree. It is very important to
    try to make sure we get them off that list and up and running,
    as you are well aware.
        Identifying and removing bad IHS employees is certainly an
    issue this Committee has heard about for some time but I really
    want to use this hearing today to drill down and make sure we
    are addressing the root cause.
        This question is to Mr. Stier. Mr. Stier, has your
    organization done any sort of analysis of how many IHS
    employees are reinstated through the MSPB appeal? When you
    mentioned leadership, you have heard we don't have leadership
    at one of these facilities or more. We don't have leadership
    today of the overall IHS in terms of a permanent person. We
    have the very well qualified gentleman here but he is in an
    acting capacity. Do you believe it is important to get full-
    time leadership rather than an acting person?
        Mr. Stier. Senator, there is no question that it is
    critical to get full-time leadership at IHS. I have no doubt
    that Acting Director Buchanan is terrific but the reality is,
    when you are in an acting status, it is impossible to really do
    the job in the same way.
        My analogy is the substitute teacher. You can be an
    excellent educator but the reality is that you are not
    perceived as having that long-term authority and it is very
    difficult to do the job as well as you might.
        It is also true, we just heard from testimony now that they
    are missing a CEO in a critical place. That kind of leadership
    vacancy is incredibly debilitating and fundamental to all of
    these issues.
        Figuring out how to deal with that, I would propose that a
    more market sensitive pay system would be one way of getting at
    that in a bigger way, again very much analogous to what the VA
    is experiencing as well.
        On the issue you raised directly about the Merit Systems
    Protection Board, the reality is the agency wins in the vast
    number of times. Only 2.1 percent of the cases actually get
    reversed in favor of the employee. That is not where the real
    issue is.
        Federal employees themselves, three-quarters of them at
    IHS, will tell you that poor performers are not dealt with. The
    problem is not creating rules to fire them faster, in fact,
    that will actually have unintended negative consequences, but
    the problem is trying to improve the management, the
    leadership. That is where you will get real improvement.
        That has not been done in the way that it needs to be. Your
    Committee could do it.
        Senator Udall. Thank you.
        I yield back, Mr. Chairman.
        The Chairman. Senator Heitkamp.
        Senator Heitkamp. Thank you, Mr. Chairman, for letting us
    go ahead of you.
        First, Mr. Stier, thank you so much for the plug for the
    work we are doing over in Homeland Security and Government
    Affairs. Senator Lankford, who is also a member of this
    Committee, and I have really made this a major initiative. We
    appreciate your support but I think there are other lessons we
    are learning that can be applied here equally.
        I really appreciate your reference to our bill. I think it
    can, in fact, provide that support on hiring but we also have a
    supervisory training bill that I think can also be
    extraordinarily helpful. Could you comment on that?
        Mr. Stier. Yes, absolutely, I think you are entirely
    correct.
        These problems are the same across the board. You have
    general jurisdiction. Obviously, it is great that this
    Committee is focusing on the particular agencies over which it
    has oversight.
        The training piece is fundamental. Right now, we put great
    people in place without the tools they actually need to do
    their jobs well. The first thing that gets cut in these
    agencies is the training and development budgets. There really
    isn't the kind of investment or requirements around managers
    that I think is necessary to actually see improvements in
    productivity and outcomes for the people being served.
        I think you are very much on the right track in the work
    you are doing. I think there ought to be, again, sort of
    alignment across the board with the efforts being done.
        Senator Heitkamp. Admiral Buchanan, before she left her
    post, Mary Wakefield, who was the Deputy Secretary for HHS,
    performed a lot of hours of review of the problems we have at
    HHS or at the Indian Health Service. Where is that work? We
    don't really need legislation for you guys to fix this. It is
    important to send a message that you guys can fix this on your
    own. I am appalled that the Winnebago Tribe still does not have
    a facility that is CMS-certified. That is not acceptable.
        Where are those initiatives? Have you benchmarked them? Why
    haven't those initiatives been carried out to the point where
    we could see the Winnebago of Nebraska actually having a full
    service medical facility?
        Mr. Buchanan. I heard the comments down the line related to
    acting. This is actually personal to me.
        I am a member of the Seminole Nation of Oklahoma, having
    been born in an IHS hospital, with family members that work at
    IHS. I hear Ms. Kitcheyan, a friend of mine, experiencing the
    issues at Omaha Winnebago Hospital and having worked there for
    three weeks to get an idea of what the conditions were and the
    challenges at Omaha Winnebago, this is truly personal.
        I respect the acting questions but I have family members
    that rely on the IHS system. I have family members who work in
    the system, so I hear your concerns and the issues you are
    raising.
        We are working hard to make those changes. One of the
    things that Ms. Wakefield developed, and the former
    Administration, was something we implemented in November 2016.
    It is the Quality Framework and Implementation Plan. That is
    the culmination of all the activities and recommendations of
    experts where the goal is to provide top quality health care
    and get back the trust of the tribes related to those issues.
        We have specifically identified five priority areas going
    forward: organizational capacity, accreditation, getting back
    the accreditation for the Omaha Winnebago Hospital, doing that
    specifically with contracting to get one contractor to accredit
    all of our IHS hospitals across the Country. That is one
    avenue.
        Senator Heitkamp. I just think this Committee would
    benefit. Maybe there are some changes we should make to those
    plans, but it would benefit from an analysis of where we were
    at the end of that survey, where we are headed going forward,
    and what additional tools does Indian Health believe they need
    to meet quality standards.
        I think it is not just about discipline. No discipline in
    the world is going to prevent a CEO from resigning literally
    weeks after the CEO took the job.
        Finally, I want to speak to Ms. Kitcheyan. How has this
    really affected the availability of health care for your tribe?
        Ms. Kitcheyan. It has impacted the services at the service
    unit. Without that third-party revenue, which makes it enough,
    the services are weakened, the reputation is poor and the PRC,
    the preferred care dollars, are minimal.
        We were at Level 1 for a while. I think now they are down
    to Level 2. Many of the services aren't available at the
    service unit so they are referred out. If you are only referred
    out, life or limb, there are many people who are sick and have
    chronic conditions that are not life or limb and continue to
    suffer. It is an essential piece of the operating revenue, this
    third-party revenue.
        I also want to mention that we are also without our
    Director of Nursing and our lab supervisor, two essential
    pieces along with this CEO. I guess I have to acknowledge our
    Acting Area Director, again another acting role, in getting the
    job posted.
        We have to celebrate our success where we can celebrate it,
    but that is such a small thing that we are happy it was posted
    in a timely manner. We are trying and they are trying as well
    but it is just not successful. It is very frustrating to lose
    these administrators in whom we put our confidence. We
    understand people have their lives and have to leave these
    positions, but we are not making any progress in these two
    years. I wish I could tell you differently.
        Senator Heitkamp. I think this Committee shares that
    frustration that we aren't making progress. We need benchmarks
    and then levels of accountability. Without it, I don't see this
    getting better.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator Heitkamp.
        Senator Cortez Masto.
        Senator Cortez Masto. Thank you, Mr. Chairman. Thank you to
    the panel members. I appreciate you being here.
        Ms. Kitcheyan, let me just follow up because I also was
    concerned with what I was hearing regarding on what is going on
    with your community. You addressed some concerns with S. 1250,
    one being that Indian Country should be consulted because they
    are going to be impacted within its entirety.
        The need for adequate funding and oversight for new
    programs and no under-funded mandates, I agree with you. I
    don't like unfunded mandates or unintended consequences.
        Then, you talked about tribal best practices for retaining
    providers. Are there models out there? Are there things we
    should be looking at as we look to retain our providers in our
    tribal communities that you can cite?
        Ms. Kitcheyan. I wasn't so much talking about the retention
    of employees, but innovative programs such as the dental health
    therapy program in the Alaska area that has been successful
    with recruiting permanent, local providers who are more like a
    long-term solution than short-term volunteers who are not going
    to be sustained or circle back.
        Senator Cortez Masto. Models that we should be looking to
    for recruitment?
        Ms. Kitcheyan. We should be looking, at the local level, at
    programs such as the Alaska Native Dental Health Therapy
    Program which has been successful for that area and models like
    that which can mimicked throughout Indian Country.
        Senator Cortez Masto. Thank you. I appreciate that.
        Ms. Kitcheyan. We are looking for sustainable change for
    our communities.
        Senator Cortez Masto. Mr. Stier, thank you for being here
    as well.
        In your testimony, you acknowledged the Committee's focus
    on the workforce challenges facing IHS. You said in your
    statement, ``The myriad of challenges that confront the IHS are
    the result of both a broader Federal civil service system that
    is poorly suited to the needs of the modern health care
    delivery system.''
        I agree that we need some fundamental reforms in our
    delivery system. What do you think is the biggest exterior
    challenge to our leadership that is causing such a high
    turnover rate?
        Mr. Stier. I think there are so many different pieces to
    this but I think it would be best to think about how must the
    Federal Government stop being an island, an insulated and
    isolated institution and adopt practices that are now the norms
    in the private sector.
        When I say that, I mean very fundamentally the pay system.
    It was a pay system that was designed literally in 1949 and
    intended for a government that was almost, in large majority, a
    clerical workforce. Now it is a professional workforce.
        When you think about the challenges of hiring what is
    already a short supply set of professionals in areas that are
    very difficult to recruit for in rural and remote areas, I
    think it is really important to make sure IHS has the same
    tools that the best in class in the private sector has.
        That means finding market sensitive pay, in particular, not
    just for the physicians. Again, I think of the comparison to
    the Veterans Affairs problems, and they are very much the same
    thing. They have the same kinds of issues, especially in remote
    and rural areas.
        I think one issue they face is it is very hard to recruit
    CEOs, hospital directors, people who are phenomenal
    administrators that are fundamental to the success of those
    institutions.
        If you ask me what the largest factor is right now, it is a
    system that doesn't offer the same kinds of tools to the
    government that the best in class in the private sector has. If
    you have those, then IHS will beat anyone out there.
        What is amazing when you look at the data, what the
    employees have to say is, you have a workforce that is
    fundamentally charged up about its mission; they care about
    what they are doing. You hear that from Director Buchanan. He
    cares about what he wants. That is something private sector
    employees would die for, that kind of intensity of mission
    commitment.
        What they don't have is the right tools. That is one thing
    you can give.
        Senator Cortez Masto. Thank you. I appreciate that.
        I have one final question. Because I am new to the
    Committee, I am going to focus this on Admiral Buchanan. I am
    curious how you would handle this.
        I was the Attorney General in Nevada for eight years. As
    part of that work, I represented the State agencies. Anytime
    there was legislation passed, we helped them to interpret it
    and address unfunded mandates, unintended consequences, and
    also, constitutionality provisions.
        I understand, after reading through everything, there is a
    concern with Section 106 in S. 1250. That particular section
    has been held unconstitutional by the U.S. Court of Appeals for
    the Federal Circuit in Helman v. Department of Veterans
    Affairs.
        If that provision is still in the bill as we pass it, how
    would you address the constitutionality provision in Section
    106 that has been held unconstitutional by the court?
        Mr. Buchanan. That is a great question.
        At the Indian Health Service, we defer to the Department of
    Justice for court issues and litigation. We would typically
    defer to them.
        Senator Cortez Masto. To legal counsel, similar to what I
    addressed. Thank you for that.
        Mr. Chairman, as a new member, I don't know how this would
    normally be handled, but I would love an opportunity to address
    that provision if it has truly been held unconstitutional by
    the courts, how that normally would be handled in the
    Committee, and that process.
        Thank you to the panel members. I appreciate the comments
    made today.
        Thank you, Mr. Chairman.
        The Chairman. Senator Daines.

                    STATEMENT OF HON. STEVE DAINES,
                       U.S. SENATOR FROM MONTANA

        Senator Daines. Thank you, Mr. Chairman and Ranking Member
    Udall.
        I think it is pretty clear from what we have heard today,
    as well as what I hear as I jump in my Ford pickup and drive
    all across Montana and Indian Country, that the Indian Health
    Service isn't working.
        However, across the Country, we see large, complex health
    systems that are deploying the principles of improvement
    science to improve the quality of care and health outcomes. One
    mechanism to do so is through the Collaborative Improvement and
    Innovation Networks, also known as CoIIN, whereby these
    multidisciplinary teams of Federal, State and local leaders
    work together to tackle a common problem.
        IHS has certainly been a common problem for Montana's
    Native American communities. I cannot tell you how many hours,
    if you are a member of the United States Senate and you come
    from Indian Country, you spend time engaging and sitting down
    with tribes and you get an earful. As soon as your left ear is
    full, your right ear gets full in terms of the challenges we
    face right now in IHS.
        Admiral Buchanan, I believe you are familiar with the CoIIN
    model. I understand IHS has been participating in the HHS
    Health Resources and Services Administration's CoIIN design to
    prevent infant mortality, an important place to start. How has
    the participation of IHS in that CoIIN improved infant
    mortality rates in Indian Country?
        Mr. Buchanan. IHS has been using elements of the CoIIN
    model through NOAs and IPAs for a very long time. The Indian
    Health Service has partnered with HRSA in partnerships related
    to the infant mortality CoIIN with the goal of preventing and
    reducing American Indian and Alaska Native infant mortalities.
        We have implemented the recommended strategies that are
    culturally appropriate with the pre-natal and post-natal
    education activities. I can provide additional details for the
    record if you like.
        Senator Daines. Admiral, can you think of any other
    specific trends you are seeing in Indian health where a CoIIN
    might be able to address it?
        Mr. Buchanan. There are some other activities we have been
    doing. One that comes to mind right off the bat is the Special
    Diabetes Program for Indians where we provided funding to NCAI,
    I believe, of $1 million or so where they work with a TRAIL
    program to implement something similar to the CoIIN model you
    are referencing.
        Senator Daines. Thank you, Admiral.
        Ms. Kitcheyan, among the reforms in the system included in
    the Restoring Accountability in the Indian Health Service Act,
    I know you found the expansion of training for IHS personnel in
    tribal cultural and history to be ``of utmost importance'' just
    as it is to the Montana tribal leaders with whom I consulted on
    this legislation.
        Could you share with this Committee why you believe that is
    important?
        Ms. Kitcheyan. It is important that the IHS personnel,
    whether it be the providers or the administrators, have the
    proper cultural sensitivity training when they engage with the
    tribal community.
        One of the things I want to impress upon this Committee is
    that it is not going to be a one size fits all model. We need
    to design these cultural sensitivity programs that are distinct
    to the Nation that this provider or administrator will be
    working in.
        That is one of the challenges with solutions for Indian
    Country. It is like this pan-Indian idea that they want to roll
    out to every tribe. We find it does not fit for every tribe. We
    have to have respect for that distinct Nation and their
    cultural norms, especially with the elders and some of the lady
    relatives and things that are appropriate and inappropriate in
    our communities. I will just leave you with that.
        Senator Daines. Would you say then it would also be
    beneficial to train new medical personnel on the unique
    history? I am using the words unique history and culture of
    each tribal community in which they serve prior to beginning
    the work at an IHS facility?
        Ms. Kitcheyan. Yes. Thank you. I think that is an amazing
    suggestion. It is only fair to the provider as well, in order
    them to feel like they are fully prepared to engage with the
    tribal community and patient.
        Senator Daines. It seems like a tool in an on-boarding
    process. You get off to a much better start if you have some
    those issues trained ahead of time.
        Ms. Kitcheyan. Right, and that might help with the
    retention so that the provider feels they know where they are
    going and they would, I feel, be further embraced by the
    community if they had that respect and effort into learning
    about the people.
        Senator Daines. I am out of time but it is good to hear. I
    would be interested in exploring that concept in working with
    the tribal leaders back in Montana, as well as with my
    colleagues here in the Committee, as well as with IHS.
        Thank you.
        Ms. Kitcheyan. Thank you.
        The Chairman. Dr. Crowley, in S. 1250, we are trying to
    come up with a simplified, uniform credentialing process so
    that dentists who are willing to volunteer can go out and
    provide services on the reservation. What recommendations do
    you have for us?
        The Dental Association and dentists have approached me and
    they are willing to do this. I think it is a remarkable
    opportunity and there is an incredible need out there. How do
    we make sure that we set up a system that gets them
    credentialed and gets them out there helping in Indian Country?
        Dr. Crowley. Thank you, Senator. I thought you were going
    to let me off the hook.
        The Chairman. No, sir.
        [Laughter.]
        Dr. Crowley. I think the model is there. The other Federal
    services have a credentialing service that is national that
    goes to simplification, using online means and they can get all
    the data they need with licensing, the national databank,
    issues and any other education issues they need. It can be done
    in a simple and fast way through online credentialing.
        The Chairman. Who administers that?
        Dr. Crowley. Maybe the Admiral would know but it is the
    Federal service, the Army, Navy, Coast Guard, I think the
    Veterans Service. I think they use that service now as they
    credential. It is a much more condensed, abbreviated, quicker
    pathway to get the information they need to accredit someone
    they want to bring onto their service.
        The Chairman. IHS could plug into that system?
        Dr. Crowley. The Admiral may be able to answer whether
    there is a plug-in to that but I certainly think there is a
    model there.
        The Chairman. You would be willing to work with us and IHS
    to try to plug-in to that type of model?
        Dr. Crowley. Most certainly. If I can speak to a higher
    level of what you have said, the millennials in dentistry are
    almost half of our dentists now. Our dentist millennials are
    just like the other millennials. They take social
    responsibility seriously. They want to reach out; they want to
    do good.
        To have the availability to be able to quickly go
    someplace, coupled with the fact that the dental students today
    graduate with more debt than any professional in the Country,
    and the fact they have loan payment systems, it certainly is an
    eye opener for these young people to combine their social
    consciousness with the ability to get a job that they can go
    help people.
        We also know the Indian Nations have the highest amount of
    dental disease as any of our population. The care needs to be
    there. We have to get the model there to help them prevent this
    disease. You cannot treat your way out of it.
        I think our system where we are working with our CDHCs, we
    are going in with the Navajos and bringing young people to the
    table to help educate so they can go back to their populations
    and be a culturally competent person from the get-go on how we
    are treating prevention of oral disease and access to work with
    others and collaborate with our other health care professionals
    to bring oral care to the level it needs to be with the Indian
    population.
        Getting the dentists there is critical. This credentialing
    would simplify that tremendously. I think you would see very
    good results because of that.
        The Chairman. I really appreciative of the Dental
    Association and individual dentists. Their willingness to do
    this is just an incredible opportunity. It is something we need
    to put in place as soon as we can.
        I would ask Admiral for your commitment to work with the
    Dental Association to effectuate that type of credentialing
    process so that we can get these dentists out there doing the
    good work they are willing to do.
        Mr. Buchanan. That is a great question and I am happy to
    work with the Committee, with Mr. Crowley and Mr. Stier on the
    issues they have raised.
        I wanted to provide a quick update on the credentialing
    process. We recently awarded a contract for a national
    credentialing system. We are excited about that. We are rolling
    that out to four pilot sites across IHS through July. All of
    our facilities will be on that credentialing system and all of
    our areas will have that by the end of the year.
        We are excited that it will streamline and standardize the
    process. As a former CEO and former area director, I know what
    it takes to go through the credentialing process for a
    provider. It is a huge binder and lots of checks, making sure
    the provider has the training, credentials, and checking
    databases. That is just for one provider. That goes on for a
    long time.
        Those documents get rolled up to the area office. My chief
    medical officer and I will review those. We will signoff. It is
    a cumbersome process. Putting it in an electronic format, as
    discussed, is a goal that we are implementing now. We
    definitely will be happy to work with the Committee.
        The Chairman. How long will it take to get that in place
    and working?
        Mr. Buchanan. We have awarded it and have pilots going out
    right now. We have updated our policies. Of course, with
    government agencies, you have to create policy and guidance on
    how to operate the credentialing system. That is in place and
    it is going through clearance right now.
        Dr. Crowley. Senator, if I may. I promise that the American
    Dental Association will work with the Admiral and IHS to move
    this forward. We will get out the message to the dentists of
    America that this opportunity exists for them to help in this
    process.
        The Chairman. I very much appreciate that, Doctor. Do you
    have a time frame to have it activated?
        Mr. Buchanan. We do. By the end of July, we will have it
    going. It is actually in process right now.
        The Chairman. The end of July?
        Mr. Buchanan. Yes.
        The Chairman. Good. I thank you both.
        Ms. Kitcheyan.
        Ms. Kitcheyan. I am sorry, I have to make a comment.
        Although I appreciate the partnership that is being
    garnered right now, Indian Country does not need more short-
    term providers. That is not a long-term solution. With all due
    respect to the panel, I just have to voice that.
        The Chairman. It is not mutually exclusive of long-term
    solutions. It would be in addition to that.
        Ms. Kitcheyan. There are some creative solutions happening
    within Indian Country that I would like the Committee to
    consider. It is just that we don't need more short-term,
    revolving doors in Indian Country in terms of chronic oral
    health. We already have that problem on the other side of the
    aisle. I just want to make that comment so it is clear that
    Indian Country wants sustainable solutions, not short-term
    volunteers.
        The Chairman. Absolutely. Thank you.
        At this point, I am going to turn over the gavel to Senator
    Murkowski to preside. Senator Udall also had some more
    questions. I am turning it over to you.
        Senator Murkowski. [Presiding]. Thank you.
        I have what is not really a question. I apologize that I
    was not able to hear the full testimony.
        Ms. Kitcheyan, you mentioned some of the innovative
    solutions that are out there. In Alaska, we led on the middle
    level provider, the dental health therapist, and the DHATS
    Program that I think for many years was viewed as far too
    experimental, that we would see poor health outcomes, and that
    it was less than acceptable care.
        The reality was that getting dentists full-time out to our
    villages was just not going to happen. We did have a great many
    dentists who were very generous with their time who would
    literally volunteer to come out for a month or six weeks in the
    summer.
        However, that meant for a family in a village to wait a
    full year when your child needed dental care and when you
    needed dental care. Then when the dentist did come, they
    literally worked around the clock to provide for the needs.
        What we have been able to do with the DHATS Program, I
    think has been viewed as a model, as remarkable and as a
    response that was generated by the extraordinary need. What has
    been very heartwarming to me is to see how over the years, the
    Dental Association has come to accept, I think is a fair word,
    that the level of service that has been provided has been
    important.
        We now have preventative care being given in our villages
    when we had nothing before. It is being done by local people
    who, when you are in the grocery store and you see an eight-
    year old, say, how is that flossing coming? That is kind of a
    reminder instead of waiting and hoping you will have a dentist
    who actually comes to your village that year.
        Being innovative is important. Longer term solutions are
    important. I think in Alaska we have clearly seen the proven
    success of mid-level providers.
        The Chairman did not give me a list but I am told that
    Senator Tester has a question.

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

        Senator Tester. Boy, do I ever. Thank you, Madam Chair.
        Admiral Buchanan, what is the biggest challenge IHS has?
    You have been onboard since when, January. What is the biggest
    challenge it has, in your opinion?
        Mr. Buchanan. Recruiting and retention of qualified
    providers in rural and remote areas.
        Senator Tester. The budget is not a problem?
        Mr. Buchanan. We are very effective with the resources that
    we have.
        Senator Tester. You understand that we pay more money for
    health care for prisoners and our prison system than we do for
    folks in Indian Country?
        Mr. Buchanan. I have seen those reports.
        Senator Tester. So you are saying we are spending too much
    money on prisoners?
        Mr. Buchanan. I did not say that.
        Senator Tester. I will tell you that I think IHS has a huge
    problem. That problem is you are dealing with rural areas of
    this Country where, quite frankly, it is hard to get people
    because it is tough work, number one, and very challenging
    work, number two.
        I think it is very difficult to keep people when the
    budget, before ACA, what was the term they used, ``If you
    weren't going to die, you ran out of time.'' I think that is a
    huge problem.
        The question becomes, you are low on staff, right, just
    like the private sector, just like the VA, and cannot get
    enough doctors or nurses. What are you doing about that? How
    long does it take you to hire somebody in the VA?
        Mr. Buchanan. It depends.
        Senator Tester. Not the VA, IHS.
        Mr. Buchanan. I understand. I want to comment a little bit
    to Senator Murkowski's comments related to the Alaska issues
    related to DHATS and some other providers.
        Last week, I had the opportunity to visit Alaska. I was
    invited by some of the chiefs to see some of the innovative
    activities going on. I would be remiss if I did not mention
    Allakaket Village, Rampart, Marshall, and Bethel, Alaska where
    they are implementing the DHAT Program and providing the
    training with some truly innovative ways in Alaska in truly
    challenging conditions. Hats off to them.
        We are looking at those as opportunities to move those
    types of activities forward specifically with developing work
    groups related to those mid-level activities. That is something
    we are actually doing and will be implementing very soon in the
    near future.
        Of course, recruitment and retention is a huge challenge.
    The time that it takes to get a physician onboard can depend.
    We have implemented the Global Recruitment Initiative where you
    can announce in one location for a physician and that
    announcement can go across IHS to a field where that physician
    wants to go.
        To answer your question, we have been able to get a
    physician on as quickly as 60 days.
        Senator Tester. Sixty days if they were within the VA. What
    if they are not within the VA?
        Mr. Buchanan. That is within IHS.
        Senator Tester. I mean within IHS. What if they are not
    within IHS?
        Mr. Buchanan. That is actually them coming in off the
    street into the Indian Health Service.
        Senator Tester. You can get them hired in 60 days? That is
    not bad.
        Have you guys implemented any best practices since you have
    been head of the IHS?
        Mr. Buchanan. Specifically related to recruitment and
    retention?
        Senator Tester. Specifically recruited to patient care,
    because I think that also impacts recruitment and retention.
        Mr. Buchanan. Quality is at the focus of everything we do.
    The quality framework is something we have been implementing. I
    mentioned one of the items, the credentialing software program
    that we have rolled out. Patient wait times is another activity
    where we have identified a standard that is going through our
    process to formalize. We will have those by July.
        We have been implementing telemedicine that recently rolled
    out in the Great Plains starting with Pine Ridge and Rosebud.
    Eagle Butte is also on the list and scheduled to roll out
    today. We have done several things.
        Senator Tester. That is great. What is your wait time
    standard?
        Mr. Buchanan. Wait time standard, I have yet to see the
    document. It is working its way through the process.
        Senator Tester. We would love to have that as soon as you
    get it.
        Lastly, this is for Dr. Crowley and Mr. Stier, very quickly
    because I am out of time.
        Could you give me your top recommendations on how we can
    recruit better folks to the IHS, whether dentists, MDs or
    whatever?
        Dr. Crowley. From my perspective, for dentistry, it is to
    make it easy for the dentists to get there and actually hire
    them and bring them on board to do the work.
        Senator Tester. In a timely manner, you are talking about?
        Dr. Crowley. Yes.
        Mr. Stier. My recommendation would be to focus at the top.
    Make sure that you actually give IHS the tools to recruit the
    CEOs and the hospital directors they need. They can then do the
    recruiting for the physicians and other staff that they need.
    If you do not have the people at the top, nothing else
    underneath is going to work the way you want it to.
        Senator Tester. Very good.
        I want to thank you all for your work. I can tell you that
    IHS has been a failure, quite frankly. We have had a couple
    different Administrations; this is the third one, since I have
    been in the Senate.
        One of the best things that transpired for Native Americans
    is Medicaid expansion because it freed up some money for IHS
    and helped move the ball forward for people who were not making
    enough money to be able to afford health insurance.
        As we approach taking up a health care bill a week from
    Monday, as I see a budget that is about $300 million short, I
    might be off on that, I think we have some tough decisions to
    make here. I do not know if we can make them and actually
    accomplish the trust responsibilities we have for our Native
    Americans across this Country.
        Rear Admiral, I think everyone on this Committee is more
    than happy to work with you, but you cannot get blood out of a
    turnip.
        Thank you.
        Senator Murkowski. Thank you, Senator Tester.
        I think Senator Udall and I are both looking at one another
    as the appropriators on the Interior Appropriations that has
    the oversight of IHS. I think we want to continue to try to do
    right by these budgets. You mentioned it is tough but we have
    an obligation here.
        Senator Thune.

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

        Senator Thune. Thank you, Madam Chair.
        I thank you and Senator Udall for your indulgence and
    letting me briefly join the Committee. This is an issue in
    which, as you know, I have a great interest. It has a profound
    impact on our State of South Dakota. Thank you for giving me a
    chance to ask a couple of questions.
        I just want to echo what Senator Tester said and say it as
    plainly as possible. That is that the Indian Health Service
    just continues to underperform. The consequences continue to
    negatively impact the quality of care, with sometimes
    devastating consequences.
        What we see is taxpayer dollars get wasted and patients are
    put at risk. We have significant problems at the facilities in
    South Dakota. Even after two IHS facilities had entered systems
    improvement agreements with CMS, they continue to find serious
    deficiencies at both facilities.
        These systemic problems are what prompted Senators
    Barrasso, Hoeven and I to introduce the Restoring
    Accountability in the IHS Act, one of the issues we are here to
    discuss today.
        It is long past time to address the problems with IHS. They
    have been identified time and time and time again. This bill is
    aimed at giving the Indian Health Service and the tribes the
    tools they need to provide quality care for patients.
        Our tribes deserve better than the status quo. This
    hearing, I think, is an important first step in getting these
    reforms passed through Congress and hopefully to the
    President's desk for his signature.
        I want to ask, if I might, Director Buchanan, a question
    that has to do deal with what is going on in South Dakota as I
    referenced earlier. I appreciate the IHS's efforts to address
    these systemic issues but it seems to me that what my
    colleagues and I are told by IHS often does not match what is
    happening on the ground.
        You mentioned in your testimony that ``In November 2016,
    IHS launched the Quality Framework and Implementation Plan to
    strengthen the quality of care and organizational capacity.''
    Yet in April, 12 months after the Rosebud and Pine Ridge IHS
    facilities entered into their systemic improvement agreement
    with CMS, unannounced CMS site visits found both facilities out
    of compliance for failures within the governing body and the
    quality assessment and performance improvement programs. Even
    more concerning is feedback from my staff and what I hear from
    Pine Ridge and Rosebud tribal members that the quality of care
    has not improved and, in some cases, has gotten worse.
        My question is, how can we trust IHS in addressing these
    issues when CMS site visits and tribal members consistently say
    otherwise?
        Mr. Buchanan. That is a great point. I acknowledge the
    concerns that you bring up. We are implementing the quality
    framework going forward specifically related to organizational
    capacity which is one of our priorities.
        The other priority is transparency and accountability,
    communications with the tribe, which I believe we have
    increased even more so, and accreditation, trying to maintain
    that going forward. We have been doing several things to make
    those changes to be more long term going forward.
        Implementing the quality framework, putting area quality
    assurance officers at the area level, at the service unit
    levels, is another activity we have done. We have doubled our
    efforts by bringing folks from other areas to assist.
        As to Ms. Kitcheyan's point, we do not want short-term
    fixes. We want them to be sustained over a long period of time.
        Senator Thune. One of the things you state in your
    testimony is ``IHS is committed to regular, meaningful tribal
    consultation and collaboration for a sound and productive
    relationship with the tribes.'' That is your quote.
        We continually hear that there is a lack of consultation.
    It is a complaint I deal with all the time, as does my staff.
    What steps are you taking, in the midst of this mess that we
    have in South Dakota, to consult with and hear from the tribes
    when it comes to some of the issues we have raised about
    quality?
        Mr. Buchanan. We have created a template. One of the things
    that comes to mind is the request for budgets, financial
    documents, and those sorts of things. As the area director when
    I was in the Great Plains, I provided those documents, what I
    thought, at least twice to all the tribal leaders in the Great
    Plains. There was obviously a breakdown in communication.
        Specifically related to the budget issue, we have created a
    template that we were utilizing for not only the Great Plains
    but throughout IHS. It is a template of those financial
    documents so that we can standardize those and be streamlined.
        Some of the other things we are doing is we have had all
    tribes calls where if an issue is brought up and there are
    questions, whether related to the budget, we provide budget 101
    to increase those communications and transparencies.
        When an issue was raised regarding the budget, the $300
    million decrease in the budget, we reached out to all the
    tribes and had a call to explain the $300 million reduction and
    also where that information can be found on websites across the
    agency.
        Senator Thune. Madam Chair, I want to be respectful with
    the Committee's time so I have other questions I would like to
    submit for the record.
        I just want to say that I hope this Committee can move
    quickly on this legislation being discussed today. I think
    there are some steps in here that will help enormously with
    some of the issues I identified, certainly with respect to the
    Great Plains tribal issues but hopefully all across the
    Country.
        Thank you for the time.
        Senator Murkowski. Thank you, Senator Thune.
        Senator Udall.
        Senator Udall. Thank you. I have just a couple of quick
    questions.
        Ms. Kitcheyan, last year when you testified before this
    Committee you told us, ``Employees need to be held accountable
    for their actions. No longer can IHS continue to protect, cover
    up, shuffle, transfer or perpetuate incompetency.'' That is
    your quote.
        Is it your opinion that the employee accountability problem
    at IHS stems from fired employees gaming the appeals process
    and being reinstated or in the alternative, do you believe it
    comes from a failure of IHS to formally identify and take
    action against bad employees?
        Ms. Kitcheyan. I believe it is the failure to take action
    against bad employees. For so long, there was this system, I
    know we have used the term ``cronyism'' where they protected
    one another. Bad nurses protected other bad nurses.
        It had become so egregious that there was just a culture of
    that amongst my service unit. It is that cronyism that led to
    some of the deficiencies in patient care because things had
    become so acceptable because you could just cover it up.
        I would say it is directly tied to the relationships they
    had amongst each other that it never reached area or
    headquarters.
        Senator Udall. Thank you for that answer.
        At our last hearing, I mentioned the Democratic members of
    this Committee sent a letter to President Trump urging him to
    exempt Indian programs from a February hiring freeze. Mr.
    Buchanan, I then asked you if IHS was being impacted by the
    subsequent ``reduction in force'' planning ordered by the
    President. You stated it was not.
        However, in her testimony today, Ms. Kitcheyan states,
    ``While hiring freeze waivers were eventually obtained for many
    IHS positions, it is our understanding that some positions
    necessary for CMS certification remain under freeze status.''
        Mr. Buchanan, what is the current hiring status of the IHS?
    This is really a yes or no answer. Are all critical medical
    vacancies being actively and expeditiously filled?
        Mr. Buchanan. Yes, sir.
        Senator Udall. Thank you very much.
        Thank you, Madam Chair.
        Senator Murkowski. Thank you.
        We do have a second panel we would like to go to. If there
    are no further questions, we thank each of you for your
    testimony here this afternoon and invite the second panel to
    come before the Committee. We appreciate the patience of each
    of you in spending time with us.
        This afternoon we will hear from Heidi Frechette, Deputy
    Assistant Secretary, Office of Native American Programs, U.S.
    Department of Housing and Urban Development here in Washington;
    Dr. Keith Harris, Director of Clinical Operations, Homeless
    Programs Office, U.S. Department of Veterans Affairs here in
    Washington; The Honorable Liana Onnen, Area Vice President,
    Southern Plains Region, National Congress of American Indians
    also here in Washington; and our long traveler, my friend, Mr.
    Mark Charlie, President/CEO, AVCP Regional Housing Authority
    located in Bethel, Alaska. I think you get the prize for
    traveling the farthest. We appreciate your making the trip to
    be here. The panel is rounded out by Sami Jo Difuntorum,
    Chairwoman, National American Indian Housing Council here in
    Washington, D.C.
        Ms. Frechette, would you begin your testimony. We would ask
    that you please limit your testimony to no more than five
    minutes. Your full statement will be incorporated as part of
    the record.

            STATEMENT OF HEIDI FRECHETTE, DEPUTY ASSISTANT
    SECRETARY, OFFICE OF NATIVE AMERICAN PROGRAMS, U.S. DEPARTMENT
                    OF HOUSING AND URBAN DEVELOPMENT

        Ms. Frechette. [Greeting in native tongue.] Hello and thank
    you.
        My name is Heidi Frechette. I am the Deputy Assistant
    Secretary for Native American Programs at the Department of
    Housing and Urban Development.
        Thank you, Chairman Hoeven and Senator Murkowski as well as
    Vice Chairman Udall, and members of the Committee, for this
    opportunity to discuss Senate Bill 1275, the BUIILD Act, and
    Senate Bill 1333, The Tribal HUD-VASH Act of 2017.
        I also wish to say thank you to the Committee staff for
    coordinating the hearing and their ongoing engagement with HUD
    on many Native American issues.
        I am honored and humbled to testify with this esteemed
    panel of tribal leaders, tribal advocates and the Department of
    Veterans Affairs. As a career SES at HUD, I administer the
    largest national Indian housing programs and work closely with
    tribal leaders, tribally-designated housing authorizes known as
    TDHEs and tribal housing departments who are doing amazing and
    innovative work in their communities.
        Since I began my tenure in June 2016, I have visited Native
    communities in most of your States to discuss the issues and
    challenges tribes face and to hear directly from the tribal
    leaders on what HUD can do to strengthen Indian housing
    programs.
        Today, one out of every four Native Americans lives in
    poverty, including more than one-third of all Native American
    children. Given these grave statistics, HUD looks forward to
    working with Congress on the reauthorization of the Native
    American Housing Assistance and Self-Determination Act known as
    NAHASDA, which authorizes the single largest source of Federal
    funding for housing in Indian Country.
        Tribes have made great strides under NAHASDA and a recently
    published Indian Housing Needs Study concluded NAHASDA works.
    Under NAHASDA, tribes have produced more housing units per year
    and have produced better housing, housing tailored for local
    conditions, customs and climates.
        NAHASDA supports the government-to-government relationship
    between the Federal Government and tribal governments. It
    recognizes tribal sovereignty by providing flexibility and
    local control so that each tribe can decide how to best address
    the unique housing and community needs.
        NAHASDA funds are often used as seed money to leverage
    funding for new construction and rehabilitation. Last week, I
    had the honor of visiting the San Felipe Pueblo in New Mexico.
    The TDHE used their $500,000 annual IHB block grant, HUD's
    Title VI Loan Guarantee Program and HUD's Section 184 Program
    to attract an additional $5 million in funding to construct a
    new housing subdivision.
        There are examples like this from tribes across the
    Country. Tribes are leveraging NAHASDA dollars and utilizing
    other programs such as low income housing tax credits to
    address their housing needs.
        The BUILD Act, in addition to reauthorizing NAHASDA, also
    seeks to streamline the environmental review process, authorize
    technical assistance funding for a broader range of TA
    providers and reauthorize the HUD Section 184 Program, which is
    a home loan program and is the largest mortgage program for
    Native American families. HUD looks forward to working with the
    Committee on this bill.
        Senate Bill 1333, the Tribal HUD-VASH Act of 2017,
    permanently authorizes the current pilot program that HUD is
    conducting in conjunction with the VA which has made great
    strides in housing Native veterans in Indian Country. The
    Tribal HUD-VASH pilot was authorized to reach eligible veterans
    who were unable to access the general HUD-VASH Program because
    they were Native and lived on Indian lands.
        As of June 1, the Tribal HUD-VASH Demonstration Program has
    housed 103 veterans in tribal areas. Tribal HUD-VASH has real
    tangible impacts on veterans' lives. One veteran in the program
    struggled with substance abuse for many years. Through Tribal
    HUD-VASH, she accessed safe and affordable housing along with
    support services to help her combat her addiction.
        This alone is amazing. However, equally amazing is to see
    how her neighboring veterans check in on her and help protect
    her sobriety by preventing contact from people who come around
    and try to trigger a relapse. She is now employed and is
    maintaining her sobriety.
        At Standing Rock, North Dakota, veterans are being housed
    in Title VI-financed units and the Black Feet Tribe of Montana
    is finishing construction of 50 new units, 20 of which will be
    new units, new project-based Tribal HUD-VASH units.
        We can see the difference Tribal HUD-VASH is making in the
    lives of individual veterans. HUD is committed to serving this
    population. We look forward to working with Congress, VA and
    IHS to ensure that they are well served.
        In closing, HUD's Indian housing programs do more than just
    build homes. They bring hope to communities. Last week, I
    visited a tribe and was invited into a new home of a mother and
    her four children.
        Often on my visits to tribal communities, I am shown vacant
    units so that we do not disturb families in their homes. I was
    surprised this mother was so insistent that we visit her house.
    When we arrived, we were welcomed by the grandmother because
    the mother was at work. The grandmother was accompanied by her
    eight-year old granddaughter who was out of school for the
    summer.
        It was so moving to see how happy and excited this young
    girl was as she moved out of overcrowded conditions. She
    insisted on giving me a tour of her new home. She was
    particularly proud to show me her new bedroom which she pointed
    out she did not have to share with her three little brothers.
    That was very important to her.
        Senator Murkowski. Ms. Frechette, if you can wrap up, you
    are well over your time. I am sorry because it is a very
    compelling story.
        Ms. Frechette. I will hurry.
        As I left, I thanked the grandmother for hosting us and she
    gave me a hug and thanked me for the hope and opportunities the
    HUD programs provide. That is the gist of why we do what we do.
    I was encouraged by the difference the tribe made, the TDHE
    made and is making in the lives of people utilizing HUD
    programs.
        Thank you. It was an honor to appear before you. I am happy
    to answer any questions you may have.
        [The prepared statement of Ms. Frechette follows:]

      Prepared Statement of Heidi Frechette, Deputy Assistant Secretary,
      Office of Native American Programs, U.S. Department of Housing and
                                     Urban
                                  Development
        Thank you Chairman Hoeven, Vice Chairman Udall, and Members of the
    Committee, for this opportunity to discuss Senate bill 1275, ``Bringing
    Useful Initiatives for Indian Land Development Act'' (BUIILD Act), and
    Senate bill 1333, ``Tribal HUD-VASH Act of 2017'', providing rental
    assistance to Indian veterans who are experiencing or at-risk of
    homelessness through the tribal Department of Housing and Urban
    Development--Department of Veterans Affairs Supportive Housing Program
    (Tribal HUD-VASH). I also wish to acknowledge and thank the Committee's
    staff, not only for coordinating this hearing, but also for their
    ongoing engagement with HUD staff on the many issues that impact the
    Native American communities across our nation.
        As the Deputy Assistant Secretary for Native American Programs, I
    have had the opportunity to visit Native communities to learn first-
    hand about the issues and challenges the tribes face, and to hear
    directly from tribal leaders what we need to do to strengthen and
    improve HUD's policies and programs for Native Americans. Far too many
    Native American communities struggle with severely overcrowded housing,
    affordable housing shortages, substandard living conditions, and
    significant barriers to economic opportunity.
        Today, one out of every four Native Americans lives in poverty--
    including more than one-third of all Native American children. Far too
    many families live in unacceptable circumstances and face a future that
    lacks educational and economic opportunity. In the last 14 years (2003-
    2016), the number of low-income families in the Indian Housing Block
    Grant (IHBG) formula areas grew by 44 percent and now exceeds 322,000
    families. The number of overcrowded households, or households without
    adequate kitchens or plumbing, grew by 23 percent to over 111,000
    families. Finally, the number of families with severe housing costs
    grew by 58 percent to over 66,000 families.
        To put these numbers in greater perspective, American Indian and
    Alaska Native people living in tribal areas in 2006-2010 had a poverty
    rate and an unemployment rate that were approximately twice as high as
    those rates for non-Indians nationally. American Indian and Alaska
    Native people in large tribal areas were more than 8 times as likely to
    live in housing that was overcrowded, and more than 6 times as likely
    to live in housing that did not have adequate plumbing facilities than
    the national average.
        HUD looks forward to working with Congress on reauthorization of
    the Native American Housing Assistance and Self-Determination Act
    (NAHASDA), which authorizes the single largest source of Federal
    funding for housing in Indian Country. Tribes have made great strides
    under this legislation. The recently published Housing Needs of
    American Indians and Alaska Natives in Tribal Areas, the product of a
    congressionally mandated, multi-year study of housing needs and
    conditions in Indian Country concluded, ``. . .tribes have demonstrated
    the capacity to construct and rehabilitate housing for low-income
    families at substantial levels under the NAHASDA framework.'' Since
    1998, under NAHASDA, tribes have not only produced more housing units
    per year, but they have produced better housing-housing that is
    tailored for local conditions, customs, and climates. Tribes also use
    the flexible block grant in many different and innovative ways to
    address unique local needs, such as assisting college students with
    housing, counseling prospective homeowners, providing self-sufficiency
    training to residents, and maintaining critical community
    infrastructure.
        NAHASDA supports the government-to-government relationship between
    the Federal Government and tribal governments, established by long-
    standing treaties, court decisions, statutes, Executive Orders and the
    United States Constitution. NAHASDA recognizes the importance of tribal
    sovereignty and is designed to provide flexibility and local control,
    so that each tribe can decide how best to address its unique housing
    needs and economic priorities.
        Since 2014, HUD has led a workgroup of several Federal agencies to
    develop a coordinated environmental review process for housing and
    housing-related infrastructure in Indian Country, as directed by the
    report of the Senate Appropriations Committee. HUD issued a Final
    Report on the workgroup's activities in December 2015. The Final Report
    and its recommendations would not have been possible without the
    invaluable input of numerous tribal leaders and Indian communities. The
    workgroup interviewed tribes and tribally designated housing entities
    (TDHEs) about their existing environmental review processes. Tribes and
    TDHEs participated in a series of briefings and listening sessions
    around the country to explain this effort and discuss their concerns
    and suggestions. Additionally, two formal tribal consultations were
    held to discuss findings, seek feedback, and garner additional
    information regarding processes and barriers. HUD is very grateful to
    those who generously gave, and continue to give, their time and
    attention to this effort.
        The Final Report made several recommendations, including measures
    that could be taken to coordinate agencies' environmental review
    processes within existing frameworks and processes. The workgroup
    continues to meet to implement the recommendations of the Final Report.
    The workgroup is finalizing a Memorandum of Understanding to encourage
    the use of National Environmental Policy Act efficiency tools, and is
    drafting an implementation plan that puts forth action items derived
    from the recommendations of the final report and tribal consultation.
    The goal of the workgroup is to facilitate a more efficient
    environmental review process by being responsive to the Final Report
    recommendations, and to the continued input of tribal leaders.
        The BUIILD Act would expand tribes' ability to assume
    responsibility for environmental review, decisionmaking, and action to
    include all federal agency funded actions associated with a NAHASDA
    section 202 funded project. This would facilitate a more efficient
    environmental review process since tribes are already authorized to
    complete the review process on behalf of HUD, which is typically the
    largest source of funding for these projects. The environmental review
    would include the HUD review requirements, plus any additional laws and
    authorities that are required for the other funding agencies.
        Additionally the BUIILD Act provides that Indian Housing Block
    Grant (IHBG) funds may be used to meet matching or cost participation
    requirements of other Federal and non-Federal programs; as well as
    extend the maximum period that trust or restricted Indian lands can be
    leased for residential purposes from 50 years to 99 years. We look
    forward to working with Congress to develop these ideas.
        HUD recognizes the importance of assisting tribes and their housing
    entities to increase their capacity and technical expertise. HUD is
    committed to exploring ways to use its technical assistance to help
    tribes enhance their development efforts and to better leverage the
    assistance they receive through the dissemination of successful tribal
    strategies that meet the urgent housing needs of tribal communities.
    The BUIILD Act would authorize technical assistance funding to a
    broader range of TA providers than is currently authorized by NAHASDA.
        The BUIILD Act provides continued authorization of the Section 184
    Indian Home Loan Guarantee Program. HUD continues to be the largest
    single source of financing for housing in tribal communities. The
    Section 184 program is the primary vehicle to access mortgage capital
    in Indian communities. As of December 31, 2016, the program has
    guaranteed a cumulative total of 36,324 loans with a principal balance
    of more than $6 billion. In January 2017, as part of the
    congressionally mandated Assessment of American Indian, Alaska Native,
    and Native Hawaiian Housing Needs, HUD published, Mortgage Lending on
    Tribal Land: A Report from the Assessment of American Indian, Alaska
    Native, and Native Hawaiian Housing Needs. The report finds that the
    Section 184 program successfully eliminates the functional market
    barrier to private lending presented by tribal trust land.
        The Section 184 program is the primary vehicle to access mortgage
    capital in Indian communities. The program helps tribes promote the
    development of sustainable reservation communities by making
    homeownership a realistic option for tribal members. It provides access
    to market-rate, private mortgage capital, and is not subject to income
    restrictions. The Section 184 program does not have minimum
    requirements for credit scores, and allows for alternative forms of
    credit and non-traditional income to address specific issues within the
    Native American communities. The program gives Native Americans from
    across the income spectrum the choice of living in their native
    community. In addition to individual Indians, tribes and tribally
    designated housing entities (TDHE) are eligible borrowers. This benefit
    of the program makes it possible for tribes and TDHEs to address
    housing shortages by developing and financing rental housing or by
    promoting homeownership opportunities for tribal members through lease
    purchase programs.
        As of June 1, 2017, the Tribal HUD-VASH demonstration program has
    housed 103 veterans in tribal areas who were homeless or at-risk of
    becoming homeless. Approximately 201 Native American veterans are in
    case management with VA and may soon receive housing assistance under
    this program. Tribal HUD-VASH is an offshoot of the standard HUD-VASH
    program, which has been successful in many communities across the
    country but unable to reach eligible Native American veterans living on
    tribal lands, largely because tribes and TDHEs were not eligible to
    administer the program. HUD is committed to serving this population and
    looks forward to working with Congress to ensure they are well-served.
        HUD has been working tirelessly with VA to coordinate services and
    case management with housing. The program is housing families and
    helping veterans struggling with substance abuse and other mental
    health issues. One of the first veterans who was housed and received
    supportive services was a female veteran with a young daughter living
    in a trailer in severely overcrowded conditions. She and her daughter
    moved into their new home and for the first time in her life her
    daughter had her own room and a quiet place to do her homework.
        Another very moving story is about a veteran who had struggled with
    substance abuse for many years. Through Tribal HUD-VASH she was able to
    access safe affordable housing and support services to help her combat
    her addiction. The other veterans living nearby looked out for her and
    protected her sobriety by helping prevent contact from people who might
    trigger a relapse. She now is employed and is maintaining her sobriety.
        Some of the challenges HUD and VA have faced in implementation are
    identifying adequate housing stock and locating veterans who are
    eligible for and need access to the HUD-VASH program. Given the overall
    shortage of housing units in Indian County and the limited number of
    private rental units, many tribes have found it difficult to find units
    for their veterans and are using their own NAHASDA housing stock to
    house the veterans. While this approach provides a home for a Veteran
    who has experienced homelessness, it does not create a net increase in
    the number of affordable housing options available to tribal members
    and means that the unit is not available as an opportunity for another
    household on the tribe's waiting list. Attempts to house veterans in
    private rental units near tribal lands are mixed. Some veterans,
    predominately younger veterans, are willing to move off tribal lands to
    obtain housing. Many, especially elderly veterans, are not willing to
    leave their community to obtain housing.
        Some tribes are using project-based rental subsidies to develop new
    units; however, many are reluctant to leverage the funding provided by
    the program for new units since the program continues to be a
    ``demonstration.''
        Finding eligible veterans who are experiencing or at-risk of
    homelessness in Indian Country can be difficult because they are often
    in overcrowded and transient situations. In Indian Country, there are
    rarely emergency shelters for people who are experiencing homelessness
    which can be used as a way to identify homeless veterans. There are
    also typically few people experiencing unsheltered homelessness in
    Indian Country, as community members take in veterans experiencing
    homelessness, oftentimes creating overcrowded situations, and those
    veterans often have to ``couch surf'' from one family member's home to
    another.
        To fully leverage Senate bill 1333, HUD seeks to strengthen its
    partnership with the Indian Health Service (IHS), and continue to work
    with VA to better identify veterans experiencing homelessness in Indian
    Country. IHS serves eligible American Indian/Alaska Native veterans in
    IHS operated health care facilities and programs. Through an agreement
    between IHS and VA's Veterans Health Administration, VA reimburses IHS
    for the direct health care services of these veterans. An enhanced
    partnership could help identify eligible veterans by linking veterans
    who are being served by IHS health facilities with the Tribal HUD-VASH
    program. Another potential outcome of an IHS, HUD, and VA partnership
    is to explore the possibility of using IHS's telemedicine network to
    deliver VA case management to more remote locations.
        In conclusion, HUD's Indian Housing programs, including IHBG,
    Section 184, and the Tribal HUD-VASH program are all successful
    examples of federal programs that provide local choice, under
    streamlined governmental requirements, and leverage private market
    investment while respecting tribal self-governance.
        Thank you again for this opportunity to appear before you today. I
    would be happy to answer any questions you may have.

        Senator Murkowski. Dr. Harris.

    STATEMENT OF DR. KEITH HARRIS, DIRECTOR OF CLINICAL OPERATIONS,
                    HOMELESS PROGRAMS OFFICE, U.S.
                     DEPARTMENT OF VETERANS AFFAIRS

        Dr. Harris. Thank you, Madam Chair Murkowski, Vice Chair
    Udall and members of the Committee.
        I want to thank you for the opportunity to discuss the
    Tribal HUD-VASH Act of 2017 and our experience at VA of
    implementing this demonstration program.
        I would like to begin by stating emphatically it remains a
    key priority for VA to end veteran homelessness, especially as
    it applies to our homeless and at risk Native Americans living
    in their tribal communities.
        I think my comments will be most useful if I focus on VA's
    experience in implementing the demonstration program, some
    lessons learned there, as well as how they might apply to the
    new bill.
        The current status, as you just heard in testimony, there
    are approximately 200 veterans in their demonstration program
    now, 103 of them as of June 1, are housed. The remainder, about
    two-thirds, are essentially holding a voucher as we would say
    in the standard program and the remaining one-third entered
    into case management and were referred to the tribal housing
    authority.
        I want to speak to VA hiring and case management. I know
    that is an interest, especially in Alaska, of the Committee and
    I assume of my fellow panel members.
        Of the 25 active sites, 21 have a case manager onboard
    either through VA hiring or contract. Two others have been
    selected and are in the on-boarding process and/or moving to
    their location. That leaves two vacancies. One is in Montana
    and the other, as you know, Senator Murkowski, is in Bethel,
    Alaska.
        In both of those remaining cases, they have been very
    difficult to fill because of the remote nature of the location.
    I am pleased to report a couple of things. One is that both
    medical centers have agreed to search for broader disciplines
    than social work only. They are looking at licensed marriage
    and family therapists, for instance, and clinical mental health
    counselors.
        Both medical centers have also, at our urging, agreed to
    introduce recruitment incentives into the recruitment process.
    I am very pleased to say I actually just today authorized
    funding from our office for both recruitment incentives and
    permanent change of station to Bethel. We are hopeful that by
    broadening the disciplines and increasing the incentives, we
    can get those positions filled.
        All medical centers are also working on providing temporary
    case management in the case of vacancies so that we can move
    veterans forward in the program even in those areas.
        I wanted to touch on a couple of lessons we have learned.
    First is, partnership is necessary and critical in this
    program. We have an excellent collaborative relationship with
    our partners at HUD; within VA, with the Office of Government
    and Tribal Relations; and certainly, with all of the tribes we
    have worked with.
        This has been particularly important in developing new
    policies. We built this program from the ground up. There are
    differences in this model and some of the rules with tribal
    entities especially regarding substance use. There is a lot of
    work and a lot of negotiation around that. Partnership has been
    excellent.
        On the flip side, despite a lot of work, I think on both
    sides, we were unable to achieve a partnership with IHS to
    enter an agency agreement. We worked for several months on
    that. I am pleased to see language in the bill bringing IHS
    back to the table. We are excited to work with them and hope to
    achieve further partnership with them as this program expands.
        I will touch on other challenges just briefly. People are
    well aware of this already. Housing stock is a very difficult
    challenge, especially on reservations. Finding eligible
    veterans is a challenge both at a macro and micro level. It is
    difficult to quantify need. The typical way is the Federal
    Government does this through its standard PIT count, point in
    time count, and it doesn't necessarily work or apply on Federal
    lands.
        At a micro level, some of the tribes and some of the
    medical centers have had trouble finding enough eligible
    veterans for this program. I know that VA hiring, especially in
    remote areas, is particularly challenging.
        I just want share really quickly, I reviewed feedback from
    all the medical centers running this program. It really was
    striking to me the number of them that noted the value and
    importance of permanent housing and the case management tied to
    that.
        We have seen many stories of people gaining employment,
    education or training, family reunification and stabilization
    of mental health and substance use symptoms. I think it is a
    testament to the housing, first, the model this program was
    based on and I think it is great evidence for continuing and
    expanding it in the future.
        Thank you very much for the opportunity today. I look
    forward to any questions.
        [The prepared statement of Dr. Harris follows:]

         Prepared Statement of Dr. Keith Harris, Director of Clinical
       Operations, Homeless Programs Office, U.S. Department of Veterans
                                    Affairs
        Good afternoon, Chairman Hoeven, Vice Chairman Udall, and
    distinguished Members of the Committee. Thank you for the opportunity
    to discuss the Department of Veterans Affairs' (VA) efforts to end
    homelessness among Veterans and specifically Native American Veterans,
    including legislation regarding the U.S. Department of Housing and
    Urban Development-VA Supportive Housing (HUD-VASH) Program.
    Unfortunately, VA did not receive the draft bill regarding this program
    in sufficient time to fully coordinate views on the bill. We will
    follow up with the Committee as quickly as possible to provide comments
    on the draft bill.
        Ending homelessness among all Veterans, including Native American
    Veterans, is a VA priority. The HUD-VASH Program is a collaborative
    program between HUD and VA which combines HUD housing choice vouchers
    with VA supportive services to help Veterans experiencing homelessness
    and their families find and sustain permanent housing. Through public
    housing authorities, HUD provides rental assistance vouchers for
    privately owned housing to Veterans eligible for VA healthcare services
    who are experiencing homelessness. VA case managers connect these
    Veterans with support services such as health care, mental health
    treatment, and substance use counseling to help them in their recovery
    process and with their ability to maintain housing in the community.
    Among the VA programs addressing Veteran homelessness, HUD-VASH enrolls
    the largest number and largest percentage of Veterans who have
    experienced long-term or repeated homelessness. Since 2008, HUD-VASH
    has admitted over 180,000 homeless Veterans to case management.
        Historically, legal rules have prevented Tribes or Tribally
    Designated Housing Entities (TDHE) from participating in the HUD-VASH
    program. In December 2014, Congress authorized funding for a Tribal
    HUD-VASH demonstration program, which targets housing and supportive
    services to Native American Veterans who are homeless or at risk of
    homelessness and who are living on or near a reservation or other
    Indian areas. Under the first-ever Tribal HUD-VASH Program, 26 tribes
    share $5.9 million in funding for rental assistance. Case management
    and supportive services are primarily provided by VA for participating
    Native American Veterans.
        Tribal HUD-VASH is modeled on the standard HUD-VASH program, which
    combines HUD rental assistance for homeless Veterans with VA case
    management and clinical services. In the program's first year, HUD and
    VA are working to implement the program and have begun to lease the 500
    housing subsidies allocated for the demonstration program and to
    provide supportive services. Some of the rental assistance will be used
    as project based unit subsidies, supporting development of affordable
    housing stock on tribal lands. Consistent with other project based
    housing, some of these units are in development or otherwise not yet
    active.
    Implementation of Tribal HUD-VASH
        Tribal HUD-VASH is a program that requires strong collaborative and
    coordinated efforts from the involved partners, including VA, HUD, the
    tribes and tribal housing authorities, as well as the tribal Veterans
    Service Officers and other community partners. In implementing this
    program, VA and tribal entities havedeveloped policies and procedures
    related to assessment, screening, referral, and entry into the program,
    and have worked together to identify and engage eligible Veterans.
    Community partnerships are needed to ensure that additional resources
    are available for supports that VA is not able to provide, such as
    services for the Veteran's family members.
        When a potentially eligible Veteran is identified, VA conducts the
    initial screening to determine if the Veteran meets basic eligibility
    criteria, including determination of homelessness or at risk of
    homelessness status, eligibility for VA health care, and the clinical
    need for case management services. As in the standard HUD-VASH program,
    eligible Veterans must agree to participate in VA case management to
    receive Tribal HUD-VASH assistance as one of the eligibility criteria,
    particularly as this program provides permanent supportive housing, not
    housing only. The tribally designated housing entity (TDHE) makes its
    own eligibility determination after VA referral. TDHE eligibility
    includes meeting Native American criteria, income threshold, and state
    lifetime sex offender prohibitions.
        Goals of Tribal HUD-VASH include improved physical and/or mental
    health, employment, education, and/or goals the Veteran chooses for
    himself/herself. Substance use can have a significant impact on
    Veterans' ability to achieve and sustain housing stability and related
    goals, addressing substance use is a significant focus of the services
    provided to Veterans within the Tribal HUD-VASH program. Through
    Veteran-centered services, HUD-VASH case managers support Veterans to
    achieve their goals regarding substance use and recovery, and Veterans
    are provided access to VA behavioral health care services and substance
    use treatment.
        Tribes and TDHEs deliver tenant- or project-based rental assistance
    to eligible Native American Veterans who have been screened for
    eligibility by VA and the Tribe or TDHE. VA prioritizes eligible Native
    American Veterans with the greatest need for case management. VA must
    document the assessment and screening process in the Veteran's medical
    record and in VA's Homeless Operations Management and Evaluation System
    (HOMES). The tribe or TDHE must maintain written documentation of all
    referrals and housing eligibility screening in the Veteran's file, as
    well as electronically report participant data as required in the
    Federal Register implementation notice, Vol. 80, No. 203. VA may
    provide case management services directly or via contract with a Tribal
    health care provider for service delivery. A Tribe or TDHE may partner
    with VA to provide office space for the VA case manager, or VA, in
    coordination with the Tribe, or TDHE may partner with IHS to provide
    space for VA case management at an IHS facility. Services may include
    substance use treatment, mental health care, health care, job training,
    and education about tenancy rights and responsibilities.
        Similar to the standard HUD-VASH program, Native Americans are
    housed under Tribal HUD-VASH based on a Housing First approach. This
    means that Veterans are provided housing assistance, along with case
    management and supportive services to foster long-term stability to
    prevent a return to homelessness. Housing First provides immediate
    access to housing without prerequisites, such as sobriety or the
    demonstrated absence of current substance use. This approach targets
    those who are homeless and have complex clinical needs. There are two
    main components to Housing First: permanent housing and wrap around
    services to support continued tenancy. Housing First uses a treatment
    philosophy that is consumer-directed and Veteran-centric.
        Housing First is a research-based approach based on the premise
    that supportive services are more effective when the daily stress of
    being homeless is relieved. The key principles of Housing First as it
    is applied under HUD-VASH policy are: respect, warmth, and compassion
    for all Veterans; Veteran choice and self-determination; a recovery-
    oriented approach; and utilization of Harm Reduction strategies to
    assist Veterans to understand and reduce the impact any substance use
    may be having on their housing stability and the achievement of their
    goals.
        Informed by the evidence that housing stability enhances the
    ability of Veterans to seek and engage in appropriate health and
    behavioral health care services including substance use treatment,
    Housing First approaches do not require sobriety as a precondition for
    obtaining or sustaining tenancy, and such criteria are not required
    within leases. With a focus on Veteran-driven services, mandatory
    testing for substance use is not implemented, but assisting Veterans to
    achieve and sustain recovery is a significant focus of the case
    management and other supportive services delivered, and Veterans are
    linked to appropriate treatment and behavioral health care services as
    needed. VA and tribal grantees work together to establish eligibility,
    case management, outreach strategies and next steps. All partners work
    to develop processes that obtain and sustain housing for eligible
    Veterans. Every partner provides points of contact for all involved
    agencies. Additionally, VA and tribal grantees work with community
    agencies such as tribal Veterans' services/offices, tribal law
    enforcement, health agencies, drug and alcohol service providers, and
    others to let them know about this potential resource for Native
    American Veterans who are homeless or at risk of homelessness.
        Eligible Native American Veterans and their families pay no more
    than 30 percent of their monthly-adjusted income, as outlined in the
    Tribal HUD-VASH implementation notice. Tribes or TDHEs pay the
    difference between the rent and the Veteran's rent contribution with
    the Tribal HUD-VASH rental assistance. Tribes or TDHEs may also
    negotiate the inclusion of utilities in payment contracts with housing
    owners. Funds may cover any additional costs related to housing Native
    American Veterans under this program.
        To date, Tribal HUD-VASH has 103 Veterans housed, with another 98
    Veterans currently enrolled and in the process of becoming housed. Many
    of these Veterans are married or have children residing with them. In
    addition, several Veterans have engaged in employment opportunities, or
    have enrolled in education or training programs, now that they are
    housed.
        With regard to other bills on the agenda, S. 1250, the Restoring
    Accountability in the Indian Health Service Act of 2017, we defer to
    the Department of Health and Human Services, Indian Health Service, for
    views and comments. We note for that same bill certain portions of the
    text reflects the language in 38 U.S.C.  713(e), the constitutionality
    of which was successfully challenged in Helman v. Department of
    Veterans Affairs, case 2015-3085 (Fed. Cir. May 9, 2017). We defer to
    the Department of Justice for further comment on that issue. We defer
    to the Department of Housing and Urban Development with respect to S.
    1275, the Bringing Useful Initiatives for Indian Land Development Act
    of 2017 or BUIILD Act of 2017.
        VA remains steadfast in our commitment to end homelessness among
    all Veterans, no matter their circumstance or background, with
    recognition of the special efforts needed to reach especially
    vulnerable Native American Veteran populations. We are fortunate to
    have robust partnerships with HUD, other Federal agencies, and tribal
    organizations in that effort. Thank you and I look forward to your
    questions.

        Senator Murkowski. Thank you, Dr. Harris.
        Ms. Onnen, welcome.

    STATEMENT OF HON. LIANA ONNEN, VICE PRESIDENT, SOUTHERN PLAINS
          REGION, NATIONAL CONGRESS OF AMERICAN INDIANS (NCAI)

        Ms. Onnen. Good afternoon, Madam Chairwoman, Mr. Vice Chair
    and members of the Committee.
        My name is Liana Onnen. I am an Area Vice President for the
    National Congress of American Indians, Chairwoman of the
    Prairie Band Potawatomi Nation, and a former housing director
    for my tribe.
        I want to thank you for holding this important hearing and
    allowing me to testify specifically on two important pieces of
    legislation that will address housing issues throughout Indian
    Country.
        The first bill focuses on reauthorization of the Native
    American Housing Assistance and Self-Determination Act which
    has not been reauthorized since 2013. The second addresses the
    important issue of providing housing opportunities for our
    Native veterans.
        The housing needs in Indian Country are great. I would even
    say that the lack of housing is at a crisis point. I know this
    because in Indian Country, we are well aware of the lack of
    basic housing in our communities.
        We are aware of the overcrowding that often means multiple
    families are living under one roof in a three-bedroom house. We
    know that in many of our communities, we lack the basic
    infrastructure to provide for housing, even when we can afford
    to build the houses.
        At NCAI, we have long advocated for increased attention to
    housing programs. We have long supported reauthorization of
    NAHASDA but we are also aware that to truly address the housing
    needs in tribal communities, we also need to look at innovative
    ways to not only address the basic needs of our tribal
    citizens, but also to provide homes for teachers, public safety
    professionals and health care providers. It is not possible for
    us to recruit and retain these vital services to our
    communities if we lack basic housing.
        The recently released Housing Needs Assessment highlighted
    the housing needs we are addressing today. That report, based
    on a small sampling of individual households, tribes, tribally-
    designated housing entities, and Native Hawaiians focused on
    three factors: one, demographics, social and economic
    conditions; two, housing conditions and needs; and three,
    housing policies and programs.
        That study is beneficial to illustrate the need in Indian
    Country, but it was only a small sampling, so we strongly
    recommend that Congress request a more comprehensive study of
    the housing needs in tribal communities. Without accurate data
    about the true need, we will continue to be under funded.
        You and your colleagues in Congress rely on data to show
    need and more importantly, to show results when scarce Federal
    funding is provided to Federal programs. The NAHASDA funding
    has been stagnant for nearly a decade, while the housing need
    only continues to grow.
        NCAI supports the reauthorization of NAHASDA as well as the
    comprehensive review of other programs and innovative ways to
    address the housing needs in tribal communities. We stand ready
    to assist you in engaging tribal leaders across Indian Country
    to bring solutions to housing needs.
        NCAI's membership has strongly supported reauthorization of
    NAHASDA and passed a resolution to that effect at our 2013 mid-
    year conference in Reno. That resolution is entitled, Support
    for the Immediate Reauthorization of the Native American
    Housing Assistance and Self-Determination Act.
        NCAI resolutions remain the standing policy of NCAI until
    withdrawn or modified by subsequent resolution. Therefore, we
    continue to strongly advocate for reauthorization of NAHASDA
    during this Congress.
        NCAI also has a resolution passed during the same mid-year
    conference that supports reauthorization of the Native Hawaiian
    programs as part of the overall NAHASDA reauthorization.
    Support reauthorization of the Title VIII part of the overall
    reauthorization of NAHASDA programs is the name of that
    resolution.
        NCAI's membership has also strongly spoken on the need to
    ensure that any overall reauthorization also includes the
    Native Hawaiian programs. This is important to our membership
    because the housing needs of our Native Hawaiian brothers and
    sisters are just as critical as those throughout Indian
    Country.
        There are other provisions contained in the bill that NCAI
    will seek additional tribal input on. NCAI is encouraged that
    the bill contains provisions to streamline NEPA requirements by
    affirming a lead agency to assist tribes and remove
    bureaucratic hurdles for environmental reviews. NCAI is
    consulting with tribal leaders this week to seek their views on
    this provision.
        In addition, we are seeking additional tribal input on the
    99-year leasehold interest in trust or restricted land for
    housing purposes. We are encouraging this Committee to consult
    with tribes so that we can ensure this provision would not
    create unintended hardship for tribes at the end of these
    leasing terms.
        In closing, I would again like to thank you for allowing
    NCAI to be here to discuss the housing needs in Indian Country.
    We stand ready to assist you as this legislation moves forward
    for consideration by this Committee and this Congress.
        I am happy to answer any questions you may have.
        [The prepared statement of Ms. Onnen follows:]

    Prepared Statement of Hon. Liana Onnen, Vice President, Southern Plains
              Region, National Congress of American Indians (NCAI)
        Good Afternoon. On behalf of the National Congress of American
    Indians (NCAI), I would like to thank the Chairman Hoeven, Vice-
    Chairman Udall and other distinguished members of the Committee for the
    opportunity to provide testimony about our views on S. 1275, and HUD-
    VASH. NCAI is the oldest and largest national organization representing
    American Indian and Alaska Native tribal governments in the United
    States. We are steadfastly dedicated to protecting the rights of tribal
    governments and the achievement of self-determination and self-
    sufficiency. NCAI looks forward to working with this Committee to
    ensure that the recommendations from the Committee's hearing process
    today take into account the unique needs of Indian Country.
        NCAI has been working diligently with tribal governments and other
    national tribal organizations to find solutions to protect and improve
    the infrastructure, health and welfare of Indian Country.
    Reauthorization of housing programs for tribal governments and citizens
    is a key component of meeting the infrastructure needs of tribal
    communities.
        The accessibility and condition of housing and other related
    physical infrastructure needed in American Indian, Alaska Native and
    Native Hawaiian communities continues to lag far behind that in all
    other segments of the U.S. population. Providing quality and safe
    housing within tribal communities for members and essential employees
    is crucial for the health and welfare of those communities. Without a
    vibrant housing sector, tribal governments cannot recruit or retain
    essential employees such as doctors and nurses, law enforcement
    personnel and teachers who are vital to ensuring the health, safety and
    education of their members and a thriving community. Moreover, given
    the shortage of supply and problem of undersized homes for Indian
    households, many families are forced to live in overcrowded conditions
    that negatively impact the lives of Native families, children and
    elders virtually all areas of their lives.
    S. 1275: Bringing Useful Initiatives for Indian Land Development Act of
            2017
        NCAI agrees with and is willing to work with the Committee on the
    reauthorization of NAHASDA. NCAI's comments regarding S. 1275, Bringing
    Useful Initiatives for Indian Land Development Act of 2017 (Build Act
    of 2017) are outlined below by Section.
    Section 2: Environmental Review
        Tribes have requested a streamlined approach to NEPA requirements
    that are already authorized in statute, and request identification of a
    lead agency when there are multiple federal agencies in one project. It
    has been difficult to get the federal agencies to remove the barriers
    that keep their work in silos and to agree to accept the review and
    determination of another agency. HUD issued a notice entitled PIH-
    201622 Environmental Review Requirements for Public Housing Agencies
    that aims to implement a lead agency for environmental review to
    address the inter-agency coordination.
        NCAI is encouraged that this section affirms the lead agency
    provision and allows the governmental review requirements to be
    satisfied by the tribe or its tribal housing authority. NCAI will
    review this provision as drafted with tribes at our mid-year conference
    this week and we will be glad to share the comments we receive with the
    Committee.
    Section 4: 99-Year Leasehold Interest in Trust or Restricted land for
            Housing Proposes
        The legislation authorizes all tribal trust or restricted lands to
    be leased for up to 99 years for residential purposes and NCAI urges
    further consultation with tribal leaders on this issue. Before 1955,
    except in rare and localized circumstances (for example, Salamanca and
    the congressional villages on the Seneca Nation's Allegany
    Reservation), surface leasing of Indian lands had been limited to 5- or
    10-year periods, which are appropriate for agricultural leases, but not
    for commercial, residential, industrial and other uses promising major
    economic returns. In 1955, Congress passed a statute (now codified as
    25 U.S.C. 415) allowing all tribes and individual Indians to lease
    trust and restricted lands for up to 25 years, with the possibility of
    an additional renewal term of 25 years while retaining shorter limits
    for agricultural leases. Amendments to the 1955 Act have allowed longer
    lease terms for business purposes, usually up to 99 years, for over two
    dozen specified tribes.
        We urge further consultation with tribal leaders on the concept of
    99 year leasing for residential purposes, particularly where large
    tracts of land could be leased for non-Indian residential leasing. Even
    if a 99 year lease may be authorized, the Tribe should retain the right
    to a term of less than 99 years.
    Section 6: Loan Guarantees for Indian Housing
        NCAI supports the reauthorization of Section 184, and it is vital
    for Congress to continue this program which increases tribal
    homeownership. However, the Committee needs to be aware of the small
    percentages of acquiring home loans on Indian reservation land.
        Native Community Development Financial Institutions, or CDFIs, are
    critical to closing the homeownership gap in tribal communities. A
    recently released study Access to Capital and Credit in Native
    Communities concluded that Native people residing in tribal communities
    ``who wish to buy a home. . .have much better options now than they did
    [in 2001]: they have access to a [Native CDFI] that can help them
    realize their ambitions.''
        Loan guarantees enable Native CDFIs to leverage the financing
    necessary to provide low-interest mortgage loans to Native people who
    otherwise would not have any other affordable options. Native CDFIs
    also provide mortgage loan recipients with credit counseling, home
    ownership preparedness training, and the ongoing support they need to
    stay in the homes that they purchase.
    Section 7: Leveraging
        NCAI supports the clarification that all NAHASDA funds meet the
    full faith and credit for leveraging funding from other federal
    programs and is essential to the leveraging needs in Indian Country.
    Native Hawaiian Housing Programs
        As much as the need for housing is a priority for Indian Country,
    NCAI is concerned with the S. 1275, the Build Act, because this
    proposed legislation leaves out the Native Hawaiian Housing Block Grant
    and Native Hawaiian Guarantee Home Loan Programs within the NAHASDA
    reauthorization title. The exclusion of the Native Hawaiian housing
    programs sets a harmful precedent for federal programs serving American
    Indians, Alaska Natives, and Native Hawaiians. NCAI stands with our
    Native Hawaiian brothers and sisters and requests the committee to
    include Native Hawaiians in the NAHASDA Reauthorization. Please refer
    to NCAI's resolution #REN-13-017, Support Reauthorization of Title VIII
    Part of the Overall Reauthorization of NAHASDA Programs.
    Housing Needs Assessment
        Earlier this year, the U.S. Department of Housing and Urban
    Development (HUD) released a study entitled, ``Housing Needs of
    American Indians and Alaska Natives in Tribal Areas: A Report From the
    Assessment of American Indian, Alaska Native, and Native Hawaiian
    Housing Needs.'' This report provided the results of a multi-year study
    based on interviews of individual households, tribes and Tribally
    Designated Housing Entities (TDHE), and Native Hawaiians. The report
    focused on three factors related to housing needs: (1) demographic,
    social and economic conditions; (2) housing conditions and needs; and
    (3) housing policies and programs.
        The study confirmed what we already know about the needs and
    barriers to adequate housing in Indian Country. The main housing needs
    are tied to: structural deficiencies (i.e. plumbing, kitchen, heating
    and electrical); inadequate housing conditions; overcrowding; and the
    need for Congress to provide funding that will enable, and not hinder,
    tribes from meeting the needs for their communities. According to the
    study, 33,000 new housing units are needed to alleviate housing
    overcrowding and an additional 35,000 housing units are needed to
    replace existing housing units in severe condition. The estimate to
    construct new and replace existing housing totals over $33 billion
    (based on a HUD calculation of the average construction costs of a
    three-bedroom house).
        NCAI encourages Congress to work with tribal governments to find
    solutions to ensure adequate funding and oversight that enables tribes
    and federal agencies to have the data and other resources needed to
    truly determine the need for housing throughout Indian Country. We are
    confident that once there is consistent housing needs data, it will
    provide much needed information that shows the relative housing needs
    and tribal government accountability. This report is the only current
    study that identifies the data, information and needs of housing in
    Indian Country. However, the study was limited in scope, and the
    comprehensive needs in Indian Country have yet to be determined. this
    needs data will enable this Committee and Indian Country to advocate
    for the appropriations and policy considerations necessary to bring
    adequate housing to Indian Country.
    S. ___ HUD/VA Veterans Affairs Supporting Housing, and for other
            purposes
        NCAI and its members strongly support the Tribal HUD-Veterans
    Affairs Supportive Housing Program (HUD-VASH) program and expansion of
    HUD-VASH on tribal lands. American Indians serve in their country's
    armed forces in greater numbers per capita than any other racial and
    ethnic group, and they have served with distinction in every major
    conflict for over 200 years. Homelessness among Native Veterans is a
    serious issue throughout Indian Country. However, the current HUD-VASH
    program does not include its impact on tribal lands. In 2015, the HUD-
    VASH demonstration program was created to address at-risk and homeless
    Veterans on tribal lands. For the first time, tribes and tribal
    Veterans organization were eligible to apply for HUD-VASH funding.
    Funding for the HUD-VASH program increased from $5.9 million to its
    current funding level of $7 million for enacted FY 2017.
        The HUD-VASH program is a successful program nationwide. However,
    without providing funding for tribes, it is virtually impossible for
    tribes to utilize this program. Tribes request the same opportunity
    given to all of America's local municipal governments. According to a
    2016 HUD Annual Report on Homelessness that estimated the number of
    homeless Veterans, ``the remaining five percent were of Native
    Americans, Pacific Islander, or Asian descent.'' Please refer to NCAI
    resolution # ECWS-14-001, Support for Indian Veterans Housing Rental
    Assistance Demonstration Program in the Native American Housing and
    Self-Determination on Act Reauthorization.
    Conclusion
        NCAI thanks the Committee for its commitment to the important goals
    of tribal self-determination through flexible and effective housing
    policy for American Indians, Alaska Natives, Native Hawaiians and
    Native Veterans. We look forward to working with the Committee to take
    the necessary steps to support tribes as they improve the housing
    conditions in their communities and to effectively respond to the
    changing economic environment.

        Senator Murkowski. Thank you, Ms. Onnen.
        Mr. Charlie, welcome to the Committee.

               STATEMENT OF MARK CHARLIE, PRESIDENT/CEO,
           ASSOCIATION OF VILLAGE COUNCIL PRESIDENTS (AVCP)
                            REGIONAL HOUSING

        Mr. Charlie. Good afternoon, Chairman and other members of
    the Committee. Thank you for the opportunity to appear.
        In respect of time, I offer my full written testimony to
    the Committee for the record.
        My name is Mark Charlie. I am a Yupik Eskimo and an
    enrolled member of the Native Village of Tununak. I have the
    privilege and honor of serving as the President and CEO of the
    Association of Village Council Presidents Regional Housing
    Authority.
        AVCP RHA is the regional housing authority for the AVCP
    region in Southwest Alaska and the Tribally Designated Housing
    Entity for 51 tribes out of 56 in our region. We are also one
    of the three PTHEs participating in the Tribal HUD-VASH
    Program.
        As you know, housing conditions in Native communities
    remain far worse than those of non-Native communities. Housing
    conditions in Native communities are five times more likely to
    have plumbing deficiencies, six times more likely to have
    heating deficiencies, and seven times more likely to be
    overcrowded.
        Substandard and overcrowded housing conditions imperils
    Native communities and exposes Native families to health,
    social, and economic conditions that impede their ability to
    become permanently self sufficient. A recent HUD study
    estimates that 68 new homes are needed in tribal communities
    and that figure does not include estimates for much of Alaska.
        Although our housing needs remain substantial, NAHASDA has
    had a profoundly positive impact in Native communities. Tribes
    have used block grant funding to build, acquire, and renovate
    more than 123 homes and to operate and maintain 43,000 homes
    built before NAHASDA as well as potential thousands of
    additional homes built since NAHASDA.
        Today, IHBG remains the single most critical tool for
    developing safe, affordable housing in Native communities.
    Thank you, Chairman Hoeven, for introducing the BUILD Act which
    represents a streamlined effort to reauthorize the Indian Block
    Grant. Passage of the BUILD Act is a critical step toward
    ensuring that the good work being done by tribal housing
    programs will continue.
        Unfortunately, reauthorizing IHGB is not enough. As noted
    in HUD's recent report, flat funding and inflation have
    seriously eroded the purchasing power of the IHGB Program.
    Without additional appropriations, development in Native
    communities will decline. This is, in part, due to higher
    development costs, but also because tribes must use a large
    portion of the IHGB to support the housing we have built.
        Without reasonable funding adjustment, development activity
    will continue to decline and Native families will fall further
    behind their non-Native counterparts.
        Allow me to turn to the Tribal HUD-VASH Demonstration
    Program.
        We in Alaska admit to being frustrated by the program's
    slow implementation. However, we see the program's potential
    since one region in our State has begun implementing the
    program.
        In one instance, a program participant Native veteran had a
    serious medical issue that required immediate attention and was
    taken to a hospital emergency room. He was admitted and treated
    and that veteran has recovered.
        An innovative aspect of the Tribal HUD-VASH Demonstration
    Program is that it allows tribes to serve both Native veterans
    and their families. This approach respects traditional family
    structures and empowers tribes to reunite veterans with their
    families, to find permanent housing for a Native veteran and
    his family of five including three young children.
        The veteran's wife had been battling a serious illness.
    Sadly, she died soon after her family moved into their new
    home. Before she passed away, she expressed happiness and
    relief that her family had found a safe place to live.
        External barriers have made achieving the program's
    potential difficult. Two Tribal HUD-VASH recipients in Alaska
    continue to struggle with implementation. In our experience,
    the primary barriers to VA credentialing requirements exceed
    those of similar positions in many communities for case
    managers making it difficult to recruit case managers.
        We believe VA and HUD have the authority to reconsider the
    VA's credentialing requirements. If not, we would appreciate
    congressional efforts to give the agencies that flexibility.
        We have reviewed the recently circulated Tribal HUD-VASH
    bill and believe it will have a positive impact on tribal
    communities. It would enhance program stability and give tribes
    the opportunity to engage in direct consultation with VA
    leadership about barriers to program implementation.
        On behalf of The Association of Village Council Presidents,
    The Association of Alaska Housing Authorities, and tribes
    across the United States, thank you for your efforts to improve
    housing conditions in tribal communities and for the privilege
    of speaking with you today.
        [The prepared statement of Mr. Charlie follows:]

       Prepared Statement of Mark Charlie, President/CEO, Association of
               Village Council Presidents (AVCP) Regional Housing
        Good afternoon Chairman Hoeven, Vice-Chairman Udall, and
    distinguished members of the Senate Committee on Indian Affairs. Thank
    you for the opportunity to appear today as the Committee examines two
    bills intended to strengthen American Indian and Alaska Native
    communities and improve housing conditions for Native families.
        My name is Mark Charlie. I am a Yupik Eskimo and an enrolled member
    of Native Village of Tununak. I serve as the President and CEO of the
    Association of Village Council Presidents Regional Housing Authority
    (AVCP RHA). AVCP RHA is the regional housing authority for the AVCP
    region in Southwest Alaska and the Tribally Designated Housing Entity
    for 51 tribes. The AVCP region, approximately the size of the state of
    Illinois, has 48 remote communities. Access to our region is by air
    year round and by barge from May to October. Use of a barge is mainly
    for delivery of building materials and petroleum (heating fuel and
    gasoline).
        The AVCP region is home to many thousands of Alaska Native people.
    Many of our families lack safe and decent housing or housing that is
    affordable. Unfortunately, this problem is not isolated to the AVCP
    region but is experienced in the remainder of Alaska and throughout
    Indian country.
    S. 1275 (The Build Act) and NAHASDA
    Housing Needs in Native Communities
        In January 2017, HUD published the results of a comprehensive
    national study on the housing needs of American Indians and Alaska
    Natives living in tribal communities. The study confirmed that the
    housing problems experienced by Native peoples in tribal areas are
    extremely severe and considerably worse than the housing conditions of
    non-Native populations.
        For example, the study found that physical deficiencies in
    plumbing, kitchen, heating, electrical, and maintenance issues were
    found in 23 percent of households in tribal areas but only five percent
    of U.S. households overall. Compared to the general population, homes
    in Native communities are five times more likely to have plumbing
    deficiencies, six times more likely to have heating deficiencies, and
    seven times more likely to be overcrowded. The study estimated that
    between 42,000 and 85,000 Native Americans are ``doubled up,'' meaning
    that they live with family or friends because they have no place else
    to stay and would otherwise reside in a homeless shelter or on the
    streets.
        HUD's report, Housing Needs of American Indians and Alaska Natives
    in Tribal Areas, estimates that 68,000 units of new affordable housing
    are needed to replace substandard or overcrowded units in tribal
    communities nationwide. Further, the Report estimates that an
    additional 30,000 homes in tribal communities are candidates for
    rehabilitation. It must be noted that these figures do not capture the
    housing needs of all Indian areas served by tribal housing providers,
    including significant portions of the Alaska Native population. While
    we applaud HUD's diligent efforts to quantify and describe the housing
    needs of Alaska Native and American Indian people, the Association of
    Alaska Housing Authorities estimates that the methodology used by the
    study team has caused housing needs in Alaska to be underrepresented by
    thousands of units.
        The availability of safe, affordable housing is crucial for the
    survival of Native cultures. Tribal communities that lack decent
    housing often cannot recruit the health care providers, law enforcement
    officers, and teachers needed to ensure the health, safety, and
    education of their tribal members. Substandard housing also negatively
    impacts health and wellness outcomes for the families who live in them.
    The World Health Organization has identified respiratory and
    cardiovascular disease stemming from poor indoor air quality and the
    spread of communicable disease due to poor living conditions as key
    health risks caused by substandard housing.
        In rural Alaska, respiratory diseases are responsible for two-
    thirds of child hospitalizations. Recently, a study evaluated the
    effect of home ventilation improvements on 68 homes in eight villages
    in Southwest Alaska, having a combined population of 211 children. When
    outcomes were monitored one year later, hospitalizations had decreased
    from ten cases to zero, health clinic visits had decreased from 36 to
    12, and school absences had decreased from 18 to three.
        There remains a significant disparity in housing conditions for
    Alaska Native and American Indian people compared to non-Native
    populations in the United States. This inequtiy imperils Native
    communities and exposes Native families to health, social, and economic
    conditions that impede their ability to achieve permanent self-
    sufficiency. For these reasons, federal investment in housing programs
    for low-income Alaska Native and American Indian families remains of
    critical importance.
    The Native American Housing Assistance and Self-Determination Act
            (NAHASDA)
        Prior to NAHASDA, housing assistance for Alaska Natives and
    American Indians was provided by various programs under the Housing Act
    of 1937 and other legislation. While these programs provided a broad
    range of assistance, they were administratively cumbersome and
    inefficient when used in tribal communities. They required separate
    applications and program administration, and eligibility requirements
    differed from one program to the next. The programs were an extension
    of urban-oriented housing programs and failed to recognize the unique
    social, cultural, and economic needs of Alaska Native and American
    Indian communities.
        In 1994, HUD articulated its intent to strengthen the unique
    government-to-government relationship between the United States and
    federally recognized Native American tribes and Alaska Native villages.
    This created momentum toward the development of NAHASDA, which was
    introduced in the U.S. House of Representatives by Congressman Rick
    Lazio. In his remarks, Congressman Lazio explained:

             Tribal governments and housing authorities should also have
            the ability and responsibility to strategically plan their own
            communities' development, focusing on the long-term health of
            the community and the results of their work, not over burdened
            by excessive regulation. Providing the maximum amount of
            flexibility in the use of housing dollars, within strict
            accountability standards, is not only a further affirmation of
            the self-determination of tribes, it allows for innovation and
            local problem-solving capabilities that are crucial to the
            success of any community-based strategy.

        Congress enacted NAHASDA in 1996, establishing an Indian Housing
    Block Grant (IHBG) program specifically for the benefit of Alaska
    Native and American Indian communities. NAHASDA represents an
    affirmation of the unique relationship between the Federal government
    and Indian tribes. Acknowledging the Federal government's trust
    obligation to promote the wellbeing of Native peoples, it for the first
    time addressed the distinct affordable housing needs of low-income
    Alaska Natives and American Indians. NAHASDA authorizes tribes to
    address their specific housing needs using the strategies that are most
    effective in their own tribal communities, rather than strategies
    mandated by federal officials working in offices thousands of miles
    away.
        Although our housing needs remain substantial, NAHASDA has had a
    profoundly positive impact in American Indian and Alaska Native
    communities. Recipients have used IHBG funding to build, acquire, or
    rehabilitate more than 123,000 homes. We have developed new housing;
    modernized, weatherized, and rehabilitated old homes; provided rental
    assistance; created home loan programs; delivered housing and financial
    literacy counseling; offered down payment assistance; prevented crime;
    and revitalized blighted communities. In addition, tribes continue to
    operate, maintain, and renovate about 43,000 homes developed under the
    1937 Housing Act and the tens of thousands of additional homes that we
    have built since the passage of NAHASDA. HUD's recent report on Native
    American housing needs confirms that NAHASDA has enabled tribal housing
    providers to match or exceed the rate of housing production under
    previous HUD programs.
        The Indian Housing Block Grant remains the single most significant
    source of funding for affordable housing in Alaska Native and American
    Indian areas. The program helps to stabilize Native communities and
    makes it easier to grow their economies. Although HUD monitors grantees
    to ensure compliance with applicable statutes and regulations, the
    flexibility inherent in NAHASDA also allows tribes to design, develop,
    and operate the affordable housing programs that best address their
    local needs.
        Support for NAHASDA is strong throughout Indian Country. According
    to the Government Accountability Office, 89 percent of tribal housing
    providers hold positive views toward the effectiveness of NAHASDA.
    IHBG Case Study--Hooper Bay, Alaska
        The village of Hooper Bay is located in remote western Alaska. In
    2006, the village was ravaged by a fire, which destroyed 15 acres of
    the old section of town, including 13 residential homes, six units of
    teacher housing, the grocery store, the school, the water and sewer
    treatment plant, warehouses, food caches, and vital equipment such as
    boats, outboard motors, and snow machines. As the TDHE for Hooper Bay,
    AVCP RHA began to identify solutions to rebuild. One potential solution
    was the use of Low Income Housing Tax Credits (LIHTC), but at the time
    AVCP RHA did not have experience developing or operating LIHTC
    properties.
        We reached out to Cook Inlet Housing Authority, a tribal housing
    provider that had the necessary experience. Together, our two
    organizations secured an allocation of Low Income Housing Tax Credits,
    sold the credits to an investor to generate equity for the project, and
    built a 19-unit apartment building for a community in the midst of a
    housing crisis.
        The Hooper Bay partnership between AVCP Regional Housing Authority
    and Cook Inlet Housing demonstrates the importance of leveraging both
    money and capacity. Our investment of IHBG funds, which were just 13
    percent of the total project cost, made it possible to secure other
    sources, including tax credit equity, while our willingness to
    collaborate produced timely results and a mutually beneficial
    relationship that continues to this day.
    HUD Section 184 Loan Guarantee Program
        The Section 184 Loan Guarantee Program was created by the Housing
    and Community Development Act of 1992 to address the lack of mortgage
    lending and homeownership in Native communities. The program offers a
    loan guarantee to private lenders, who then make mortgage loans to
    American Indian and Alaska Native families, tribes, and Tribally
    Designated Housing Entities. As of March 2016, the Section 184 program
    has guaranteed over 33,000 loans, representing over $5.4 billion
    dollars in increased capital into Native American Communities.
        Several characteristics of the Section 184 loan guarantee make it a
    particularly powerful leveraging tool. For example, new construction
    can be financed with a ``single close'' loan that provides permanent
    guaranteed financing before construction begins. This eliminates the
    need to procure separate construction financing, which typically
    carries a high interest rate. Additionally, the required down payment
    (2.25 percent) is achievable for both families and smaller tribal
    entities that may not have the financial capacity to make a large down
    payment. Because there are no income limitations for the 184 program,
    tribes are also able to serve a broader range of families and build
    healthier, more economically diverse tribal communities.
    Positive Impact of the BUILD Act
        On behalf of AVCP RHA and the Association of Alaska Housing
    Authorities, thank you, Chairman Hoeven, for introducing S. 1275, the
    BUILD Act. The BUILD Act represents a streamlined effort to reauthorize
    the single most critical tool for developing safe, affordable housing
    in Alaska Native and American Indian communities--the Indian Housing
    Block Grant.
        When the IHBG operates under an expired authorization the
    unintended result is that potential investors in Native housing
    developments become anxious. Frequently, their investments are
    predicated on the assumption that IHBG funding will be available in the
    long-term, often to subsidize property operations in future years.
    Extended periods of expired authorization send the message that
    Congress is not an enthusiastic investor in the IHBG program, despite
    its historical success. This uncertainty worries some potential housing
    investors and makes them reluctant to invest in Alaska Native and
    American Indian communities. Passage of the BUILD Act will resolve this
    issue. Further, we deeply appreciate the extended period of
    authorization for the IHBG in the BUILD Act, which run through 2025.
        AVCP RHA is also pleased that the BUILD Act will reauthorize the
    HUD Section 184 program for the same extended period. Reauthorization
    of the Section 184 program sends a clear message that Congress is
    committed to meeting its trust obligations to Alaska Native and
    American Indian tribes, and will continue to encourage private
    investors to deploy capital to Native communities.
    IHBG Funding
        Reauthorizing the Indian Housing Block Grant program is critical.
    However, the potential impact of NAHASDA has been undercut by flat
    funding over nearly twenty years. HUD's recent report on Native
    American housing needs noted, ``Congress has provided a fairly
    consistent level of funding for the [IHBG] in nominal terms, but this
    flow has been seriously eroded by inflation.''
        Without additional appropriations to inflation-proof the IHBG
    program, the amount of new affordable housing developed in Alaska
    Native and American Indian communities is likely to decline in future
    years. This is in part attributable to higher development costs, but it
    is also because tribes must now use a more significant portion of their
    grants to support the housing they previously developed. Because
    NAHASDA severely limits the rents recipients can charge under the IHBG
    program, many tribes must use more of their annual housing block grant
    to fund the operations of existing housing. In other words, IHBG
    recipients are increasingly focused on just keeping the lights on.
        Without a reasonable adjustment to IHBG funding, development
    activity under the IHBG program will continue to slow and families in
    Native American communities will fall farther behind their non-Native
    counterparts. On behalf of AVCP RHA and the Association of Alaska
    Housing Authorities, I implore the members of this Committee to educate
    Senate appropriators regarding the critical importance of adequately
    funding the Indian Housing Block Grant program.
    Tribal HUD-VASH Demonstration Program
        In January 2015, HUD and the VA announced a demonstration program
    to offer rental assistance and supportive services to Native American
    veterans who experience or are at risk of experiencing homelessness.
    One year later, in January 2016, HUD and the VA awarded $5.9 million to
    26 tribes, effectively launching the Tribal HUD-VASH demonstration
    program.
    Tribal HUD-VASH Successes and Program Potential
        The demonstration program has faced challenges during initial
    implementation, which are described below. However, the Tribal HUD-VASH
    has tremendous potential. With a few sensible adjustments, the program
    has the ability to permanently change the lives of Alaska Native and
    American Indian veterans and their families, lifting them from
    homelessness or near homelessness and offering them permanent access to
    safe, stable housing.
        Three Alaska tribes were selected to participate in the Tribal HUD-
    VASH demonstration program:

        The Association of Village Council Presidents Regional
            Housing Authority is headquartered in Bethel, Alaska, and
            serves 51 tribes in 48 remote communities spread over an area
            of Western Alaska the size of the state of Illinois.

        Tlingit and Haida Regional Housing Authority (THRHA),
            headquartered in Juneau, Alaska, serves Alaska Native people
            living in twelve Southeast Alaska tribal communities and
            Juneau. Similar to AVCP RHA, the communities THRHA serves are
            inaccessible from the road system and spread over a vast
            geographic area.

        Cook Inlet Housing Authority is headquartered in Anchorage,
            Alaska. In addition to serving Alaska Native and American
            Indian people in Alaska's largest urban center, Cook Inlet
            Housing provides housing assistance in tribal communities
            scattered throughout Southcentral Alaska.

        In Alaska, one of the three tribes selected to participate in the
    Tribal HUD-VASH program has begun placing veterans in stable housing.
    Cook Inlet Housing Authority, based in Anchorage, has benefitted from
    access to a qualified and credentialed workforce, as described below,
    and its Tribal HUD-VASH program has begun to realize the outcomes
    Congress intended when it authorized the Tribal HUD-VASH demonstration.
        To date, Cook Inlet Housing has issued all twenty of its tribal
    HUD-VASH vouchers to Alaska Native veterans. They have been able to
    secure housing for nine veteran families totaling 23 individuals, and
    they anticipate that the remaining 11 Native veteran households will be
    housed this summer and early fall.
        Cook Inlet Housing has found that the impact of the Tribal HUD-VASH
    program goes beyond simply sheltering Alaska Native and American Indian
    veterans. For example, it has already helped to stabilize the health of
    Native veterans. Cook Inlet Housing was able to find housing for
    ``James,'' a 75-year-old veteran who had been homeless for many years.
    Once James was housed, his VA case manager was able to arrange personal
    care services that help James meet his basic needs, including eating,
    bathing, and dressing. In another instance, the Tribal HUD VASH case
    manager realized during an appointment that ``Susan,'' a female
    veteran, had a serious medical issue that required immediate attention.
    The case manager took Susan to a hospital emergency room, where she was
    admitted and treated. Susan has since recovered.
        One of the most innovative aspects of the Tribal HUD-VASH
    demonstration program is that program eligibility is sensibly expanded.
    Whereas the traditional VASH program limits eligibility to chronically
    homeless veterans, the Tribal HUD-VASH demonstration program allows
    tribes to serve Native veterans who are homeless or at risk of
    homelessness, as well as their families. This approach respects
    traditional Alaska Native and American Indian family structures and
    empowers tribes to reunite veterans who lack stable housing with their
    families. This program flexibility has led to several noteworthy
    success stories in Alaska's Cook Inlet region:

        Cook Inlet Housing received an inquiry from ``Steven,'' a
            veteran whose family spanned three generations, including a
            grandmother, Steven and his wife, and their five children.
            Their eight-person family was living with another three-person
            family in a small two-bedroom home. Cook Inlet Housing was able
            to qualify Steven and his family under the Tribal HUD-VASH
            program, and they have since relocated to a larger four-bedroom
            duplex.

        ``Mark,'' an Alaska Native veteran, was referred to Cook
            Inlet Housing's Tribal HUD-VASH program after being homeless
            for some time. He was determined to be eligible, which allowed
            him to reconnect with his family, including his young child.
            Mark's family has been reunified and is now the recipient of a
            Tribal HUD-VASH voucher for a two-bedroom home.

        Cook Inlet Housing was able to find housing for a Native
            Veteran and his family of five, which includes three young
            children. The veteran's wife, ``Karen,'' had been battling a
            serious illness, and sadly, she died soon after her family
            moved in to their new home. Before she passed away, Karen told
            the Tribal HUD-VASH case manager that she was happy her family
            had found a safe place to live and that it gave her peace of
            mind in the end.

        As these stories demonstrate, the Tribal HUD-VASH program has the
    potential to truly and permanently change the lives of homeless and at-
    risk Native veterans and their families. However, external barriers
    have made achieving the program's potential difficult for many tribes.
    Tribal HUD-VASH Program Barriers
        Two of the three Tribal HUD-VASH demonstration program participants
    in Alaska continue to struggle with program implementation. My
    organization, AVCP Regional Housing Authority, has been unable to
    deploy our vouchers, and in Southeast Alaska, Tlingit and Haida
    Regional Housing Authority has also been unable to deploy its vouchers.
    Even Cook Inlet Housing Authority, based in Anchorage, experienced a
    lengthy delay before eventual deployment.
        The primary barrier to the timely deployment of Tribal HUD-VASH
    vouchers in Alaska has been the process of filling the required case
    management positions under VA specifications. When the VA hires a case
    manager, it does so under Office of Personnel Management classification
    0185 (Social Worker). That classification requires a ``master's degree
    in social work.'' In Alaska, however, most non-institutional case
    management is performed by clinical associates--people with knowledge
    of community resources and the training to work with the focus
    population but who do not necessarily have a graduate degree in a
    clinical mental health professional field. Put simply, the VA's
    required case management credentials exceed those required for
    comparable positions in Alaska, and they have made it extremely
    difficult to recruit qualified case managers for the Tribal HUD-VASH
    demonstration program.
        This issue became apparent to Alaska's Tribal HUD-VASH recipients
    in the early months of 2016, after the VA notified us that it would not
    provide case management services directly. Instead, the VA required the
    three Alaska recipients to secure independently contracted case
    management services.
        After months of exhaustive efforts, none of the three Alaska Tribal
    HUD-VASH recipients were able to identify any organization willing to
    provide case management services under the VA's contract
    specifications. One of the primary reasons potential contractors cited
    for declining to participate in the program was the VA's credential
    requirements for case managers. One large, extremely capable tribal
    healthcare organization considered the VA's educational and licensure
    requirements to be unnecessary, unduly restrictive, and out of
    alignment with professional standards in Alaska.
        In July 2016, the VA recognized that the three Alaska Tribal HUD-
    VASH recipients had exhausted all reasonable efforts to secure third-
    party case management services under the VA's contract specifications
    and informed the recipients that it would fill the case management
    positions internally within the VA. However, like the recipients
    themselves, the VA found it difficult to recruit case managers with the
    VA's preferred credentials. In September 2016, the Alaska VA was able
    to leverage staff time from other VA programs to begin providing part-
    time case management services in the Cook Inlet Region, and in November
    2016, the VA was finally able to hire a full-time case manager position
    for Cook Inlet Housing's tribal HUD-VASH program.
        In Southeast Alaska, THRHA located a counselor who it believed
    would be a suitable case manager. The individual held a master's degree
    in secondary education, was a licensed professional and chemical
    dependency counselor, and had received a statewide Counselor of the
    Year Award. Because the candidate's master's degree was not in ``social
    work,'' the VA informed THRHA that he could not be hired.
        Another candidate for the THRHA case manager position subsequently
    began the VA's vetting process this spring. However, the VA's
    recruitment, credentialing, boarding, and offer process can be
    cumbersome, and the candidate has not yet been hired. THRHA and the
    Alaska VA are hopeful that the VA will be able to make a final offer to
    the candidate by mid-June. Once a hire is made and a case manager
    begins work, THRHA can finally begin connecting homeless Alaska Native
    Veterans with the case management services that will help prepare them
    to transition into permanent housing.
        Sadly, in the AVCP region of Southwestern Alaska, little progress
    has been made toward the hiring of a VA case manager. We credit the VA
    with recently adding Licensed Professional Mental Health Counselors and
    Licensed Marriage and Family Therapists to the list of licensed
    professionals it will deem to meet their credential requirements.
    However, we are not optimistic that this step will be sufficient to
    secure the case management services that our homeless veterans so
    desperately need in order to access the Tribal HUD-VASH demonstration
    program.
        We believe that there is more that the VA and HUD can do to address
    this significant impediment to implementation. The simplest solution
    would be for the VA to proactively reconsider its credential
    requirements and more appropriately align them with the professional
    standards for ``clinical associates,'' para-professionals who
    frequently provide case management services in many communities.
        Alternatively, Congress could explicitly require the VA to waive or
    specify reasonable alternative requirements for its case management
    credentials. When Congress authorized the Tribal HUD-VASH demonstration
    via P.L. 113-235, it required that the program be modeled after the
    general HUD-VASH program, but ``with necessary and appropriate
    adjustments for Native American grant recipients and veterans.''
    Congress further required that HUD, in coordination with the VA,
    ``ensure the effective delivery of supportive services to Native
    American veterans that are homeless or at-risk of homelessness. . .''
    When Tribal VASH recipients, because of their remoteness, economic
    conditions or other factors, do not have access to personnel meeting
    the VA's case manager credentials, the VA should be compelled to adjust
    those credentials to align them with the standard qualifications of
    other positions, such as clinical associates, that capably perform case
    management functions in similar communities.
    Draft Tribal HUD-VASH Bill
        I appreciate the opportunity to review and offer comment regarding
    the recently circulated draft Tribal HUD-VASH bill. We in Alaska
    believe the draft bill would, if passed, have a positive impact on
    tribal communities by strengthening the Tribal HUD VASH Program.
        The draft bill would enhance program stability by setting aside a
    small portion of the funding provided for the general HUD-VASH Program
    on a permanent basis. Veteran families that have been successfully
    housed under the Tribal HUD-VASH demonstration would be at less risk of
    losing their assistance and once again struggling to find safe,
    affordable housing. Additionally, the added sense of program permanency
    could make it easier to attract qualified case managers, who may be
    less concerned that their position will evaporate at the conclusion of
    the Tribal HUD-VASH demonstration.
        The draft bill also requires consultation between HUD, the VA, the
    Tribal HUD-VASH recipients, and other appropriate tribal organizations
    on program design. The three Alaska recipients, as well as the
    Association of Alaska Housing Authorities, would welcome the
    opportunity to share our observations and recommendations with high-
    level leadership from the VA, in particular. While we have expressed
    our thoughts and concerns to the Alaska VA Healthcare System, it can
    sometimes be difficult for local VA officials to communicate our local
    perspective to VA leadership at the national level. We believe that the
    opportunity to engage in direct tribal consultation with the VA will
    prove beneficial to all stakeholders.
        Finally, we appreciate that the draft bill includes provisions that
    give administrative flexibility to HUD and the VA. These provisions
    empower HUD and the VA to make necessary and appropriate modifications
    to the program after engaging in consultation with recipients and
    tribal organizations. Additionally, HUD is provided authorization to
    waive or specify alternative requirements for any provision of law when
    doing so is necessary for the effective delivery and administration of
    rental assistance under the Tribal HUD-VASH program. Provisions of this
    nature leave open the possibility that HUD and VA will help address
    future issues that impact program implementation without the need for a
    legislative fix.
    Conclusion
        Housing conditions in Alaska Native and American Indian communities
    remain far worse than the conditions experienced by America's non-
    Native populations. This persistent inequtiy imperils Native
    communities and exposes Native families to health, social, and economic
    conditions that present a barrier to the attainment permanent self-
    sufficiency.
        The Indian Housing Block Grant program has successfully empowered
    tribes to address their housing conditions using strategies developed
    and implemented at the local level. S. 1275, the BUILD Act, would
    reauthorize the IHBG, a critical step toward ensuring that the good
    work being done by tribal housing providers will continue. However,
    simply reauthorizing the IHBG is not enough. Without a reasonable
    funding adjustment, development activity under the IHBG program will
    continue to slow and families in Native American communities will fall
    farther behind their non-Native counterparts.
        In Alaska, we admit to being frustrated by the unacceptably slow
    implementation of the Tribal HUD-VASH program. However, we are also
    beginning to see the program's impacts in one region of our state, and
    the outcomes have been impressive. We believe that the primary barrier
    to program implementation in many Native communities has been the VA's
    credential requirements for case managers, which exceed those required
    for comparable positions in many communities and make it extremely
    difficult to recruit qualified case management personnel.
        It appears that the current legislative authorization for the
    Tribal HUD-VASH demonstration program allows the VA and HUD to
    reconsider the VA's credential requirements for case managers and more
    appropriately align them with the professional standards for ``clinical
    associates,'' which frequently provide case management services in many
    communities. Alternatively, Congress could explicitly require the VA to
    waive or specify reasonable alternative requirements for its case
    management credentials.
        Finally, we in Alaska believe the draft Tribal HUD-VASH bill would,
    if passed, have a positive impact on tribal communities by
    strengthening the Tribal HUD VASH Program. It would enhance program
    stability and provide the opportunity for recipients to engage in
    direct tribal consultation with the VA about current barriers to
    program implementation.
        On behalf of The Association of Village Council Presidents, The
    Association of Alaska Housing Authorities, and tribes across the United
    States, thank you for your efforts to improve housing conditions in
    tribal communities and for the privilege of speaking with you today.

        Senator Murkowski. Thank you. Again, thank you for coming
    so far to provide your testimony today.
        Ms. Difuntorum. I hope I am pronouncing that correctly.
        Ms. Difuntorum. That is about as close as it gets.

    STATEMENT OF SAMI JO DIFUNTORUM, CHAIRWOMAN, NATIONAL AMERICAN
                         INDIAN HOUSING COUNCIL

        Ms. Difuntorum. Good afternoon.
        My name is Sami Jo Difuntorum. I am the Chairwoman of the
    National American Indian Housing Council. I am a member of the
    Kwekaeke Band of Shasta Indians of California, and I am the
    Housing Director for the Confederated Tribes of Siletz Indians
    in the beautiful State of Oregon.
        I appreciate the opportunity to testify before you today. I
    would like to thank Chairman Hoeven, Ranking Member Udall and
    members of the Committee for having this hearing today and for
    staying engaged on tribal housing issues.
        The NAIHC is comprised of 267 voting members that represent
    nearly 471 tribes and tribally-designated housing entities
    across the United States. We were established 43 years ago and
    our core functions are advocacy and capacity building to our
    training and technical assistance program.
        In addition to the comments I will make today, I have
    submitted a formal written statement for the record. Today, I
    want to focus on the two bills I have been asked to speak about
    and discuss a tribal housing issue we have identified with the
    new Administration.
        First, with respect to S. 1275, the BUILD Act, I would like
    to thank Senator Hoeven for introducing the bill and for
    focusing on NAHASDA reauthorization. I would also like to thank
    Committee staff. We have had several reauthorization bills
    introduced in the last couple of sessions to no avail. I was
    encouraged to hear people on the Committee commit to working
    together to get this done this year. I hope that happens.
        To be clear, NAIHC supported the past reauthorization
    efforts that included Title VIII and will continue to advocate
    for Title VIII reauthorization. I am encouraged that members of
    the Committee pledged to one another to find a solution to
    reauthorize or authorize Title VIII. Whether it is in NAHASDA
    or not, I do not know, but I am encouraged with the commitment
    of the people on the Committee to do that.
        There are a number of things that we really like in the
    bill. We strongly support reauthorization of both the Indian
    Housing Block Grant and the 184 Loan Guarantee Program, the
    backbone of tribal housing programs across the Country. The
    Indian Housing Block Grant Program is the third largest source
    of Federal funds on Indian reservations and the primary source
    for Indian housing development.
        We also support the longer, seven-year authorization. As
    you can tell by how long it has taken to not get it authorized
    so far, it would be nice not to have this pressure every five
    years.
        The environmental review process, as in the past, we
    supported provisions to streamline environment reviews. The
    BUILD Act has a provision that goes in the right direction. We
    think it could be a little bit better. We are committed to
    helping work on refining that a little bit.
        Section 703, as I mentioned before, capacity building, is
    one of the core functions of NAIHC. We are mainly concerned
    that the BUILD Act proposes to change Section 703 Training and
    Technical Assistance provisions.
        As part of negotiations in 2000, tribal leadership
    understood the need for quality training and technical
    assistance in housing programs. Tribal leaders also understood
    that for T/TA to be effective, it should be delivered by an
    organization that represents and understands housing issues and
    the complexity of housing development on tribal lands.
        The provisions of the BUILD Act would strip away the
    requirements that the T/TA be provided by an organization
    knowledgeable in tribal housing. We don't think that is in
    Indian Country's best interest. Tribes have not asked for this
    change and, frankly, we don't support it.
        There are a number of provisions that the BUILD Act leaves
    out that we would like to see enacted. If you get to the point
    that you are looking at mark up, obviously, we would like to
    see Title VIII enacted, Title VIII authorized in some way,
    shape or form. We would like to see elevation of the ONAP that
    position to an assistant secretary position. That was in S. 710
    introduced in the last Congress by then-Chairman Barrasso.
        We think it is important to elevate Indian Country to where
    it needs to be within HUD and some relief from the 30 percent
    rule. It is not part of the BUILD Act so I am not going belabor
    the discussion here, but that is something we have worked very
    hard on for a number of years to try and get some change and
    relief. We hope, going forward, that is a discussion we can
    take up with all of you.
        We support the efforts of all members of the Committee and
    Congress to reach these goals and we stand ready to work with
    each of you to secure their inclusion and passage of the BUILD
    Act.
        I am already out of time. I thought I was talking fast.
        The Chairman. [Presiding]. You are doing just fine.
        Ms. Difuntorum. Thank you.
        With respect to the HUD-VASH bill, NAIHC generally supports
    efforts to improve housing conditions and opportunities for
    Native veterans. We believe the HUD-VASH Program is a step in
    the right direction.
        We support making HUD-VASH a permanent program and we also
    support the provision within the larger HUD-VASH Program for a
    five percent minimum set aside for Indian Country. Every time
    we have a conference, I ask people in the room how many of you
    have veterans on your reservation. Every single person in the
    room raises their hand. All tribes have vets and we have
    homeless vets.
        We think expansion of this program is really important. I
    think it is doing a lot of good in Indian Country.
        Funding is the last issue on which I want to touch. I
    realize this is not an appropriations hearing or an
    appropriations committee, but I would be remiss in my duty as
    chairwoman if I did not bring this up.
        The President's budget request proposes to reduce the
    Indian Housing Block Grant by $54 million from the 2017 enacted
    level. That is 30 percent. That would be devastating to tribes.
    It zeroes out the Native Hawaiian Block Grant entirely.
        I know a lot of people on this Committee are also on
    appropriations committees, so I want you to think about this
    when you start doing appropriations work.
        It completely eliminates the Community Development Block
    Grant. The Indian Community Development Block Grant is a
    component of the larger CDBG. If that goes away, ICDBG goes
    away. That is one of our primary mechanisms and funding streams
    for developing infrastructure on tribal land. I hope those of
    you who are part of appropriations will take a close look at
    that.
        Earlier this year, a HUD Needs Assessment Study showed
    tribal rates of substandard housing and overcrowded homes well
    in excess of the national average. This is not new. This isn't
    news.
        The report indicates that 68,000 new units are needed in
    Indian Country. I would suggest that is probably a low
    estimate. We have a lot of hidden homeless not on the radar a
    lot of the time.
        We recognize the budget constraints the Federal Government
    is in. However, that does not diminish the trust and treaty
    responsibilities the United States has towards tribes. Tribal
    programs have been operating with severe unmet needs for
    decades. Tribal programs are certainly not the cause of this
    Country's fiscal issues and cuts to these programs should
    certainly not be a part of any solution.
        I would like to thank the Committee again for its attention
    to tribal housing. Thank you, Chairman Hoeven, for introducing
    the BUILD Act. I look forward to answering any questions you
    have before I have to leave for the airport.
        Thank you.
        [The prepared statement of Ms. Difuntorum follows:]

    Prepared Statement of Sami Jo Difuntorum, Chairwoman, National American
                             Indian Housing Council
        Good Afternoon. My name is Sami Jo Difuntorum, and I am the
    Chairwoman of the National American Indian Housing Council. I am a
    member of the Kwekaeke Band of Shasta Indians of California, and I am
    currently the Executive Director of the Siletz Tribal Housing
    Department in Oregon. I would like to thank Chairman Hoeven, Ranking
    Member Udall and committee members for having this hearing today and
    for staying engaged on tribal housing issues.
        The NAIHC is comprised of 255 voting members that represent nearly
    470 tribes and tribally-designated housing entities across the United
    States. The NAIHC was established 43 years ago to advocate on behalf of
    tribal housing programs and now also provides vital training and
    technical assistance to increase the managerial and administrative
    capacity of tribal housing programs.
    Background on the National American Indian Housing Council
        The NAIHC was founded in 1974 and for over four decades has
    provided invaluable Training and Technical Assistance (T&TA) to all
    tribes and tribal housing entities; provided information to Congress
    regarding the issues and challenges that tribes face in their housing,
    infrastructure, and community development efforts; and worked with key
    federal agencies to ensure their effectiveness in native communities.
    Overall, NAIHC's primary mission is to support tribal housing entities
    in their efforts to provide safe, decent, affordable, and culturally
    appropriate housing for Native people.
        The membership of NAIHC is comprised of 255 members representing
    478 \1\ tribes and tribal housing organizations. NAIHC's membership
    includes tribes and groups throughout the United States, including
    Alaska and Hawaii. Every member of this Committee serves constituents
    that are members of NAIHC. Our members are deeply appreciative of the
    consistent leadership this Committee provides in Congress related to
    issues affecting tribal communities.
    ---------------------------------------------------------------------------
        \1\ There are 567 federally recognized Indian tribes and Alaska
    Native villages in the United States, all of which are eligible for
    membership in NAIHC. Other NAIHC members include state-recognized
    tribes eligible for housing assistance under the 1937 Housing Act and
    that were subsequently grandfathered in under the Native American
    Housing Assistance and Self-Determination Act of 1996, and the
    Department of Hawaiian Home Lands, the state agency that administers
    the Native Hawaiian Housing Block Grant program.
    ---------------------------------------------------------------------------
    Profile of Indian Country
        There are 567 federally-recognized Indian tribes in the United
    States. Despite progress over the last few decades, many tribal
    communities continue to suffer from some of the highest unemployment
    and poverty rates in the United States. Historically, Native Americans
    in the United States have experienced higher rates of substandard
    housing and overcrowded homes than other demographics.
        The U.S. Census Bureau reported in the 2015 American Community
    Survey that American Indians and Alaska Natives were almost twice as
    likely to live in poverty as the rest of the population--26.6 percent
    compared with 14.7 percent. The median income for an American Indian
    Alaska Native household is 31 percent less than the national average
    ($38,530 versus $55,775)
        In addition, overcrowding, substandard housing, and homelessness
    are far more common in Native American communities. In January of this
    year, the Department of Housing and Urban Development (HUD) published
    an updated housing needs assessment. According to the assessment, 5.6
    percent of homes on Native American lands lacked complete plumbing and
    6.6 percent lacked complete kitchens. These are nearly four times than
    the national average, which saw rates of 1.3 percent and 1.7 percent,
    respectively. The assessment found that 12 percent of tribal homes
    lacked sufficient heating.
        The assessment also highlighted the issue of overcrowded homes in
    Indian Country, finding that 15.9 percent of tribal homes were
    overcrowded, compared to only 2.2 percent of homes nationally. The
    assessment concluded that to alleviate the substandard and overcrowded
    homes in Indian Country, 68,000 new units need to be built.
        Since NAHASDA was enacted, tribes have built over 37,000 new units
    according to HUD. However, as the IHBG appropriations have remained
    level for a number of years, inflation has diminished the purchasing
    power of those dollars, and new unit construction has diminished as
    tribes focus their efforts on unit rehabilitation. While averaging over
    2,400 new unit construction between FY2007 and 2010, new unit
    construction has dropped in recent years with only 2,000 new units
    between 2011 and 2014, and HUD estimating less than 1,000 new units in
    future years as tribes maintain existing housing stock.
    S. 1275, the Bringing Useful Initiatives for Indian Land Development
            Act of 2017
        First and foremost, the NAIHC would like to thank Senator Hoeven
    for introducing S. 1275 and for focusing on NAHASDA reauthorization.
    This is the fourth year now that the program has been left
    unauthorized, and our membership continues to grow more concerned as
    discussions in Washington, DC focus on cutting spending and eliminating
    unauthorized programs.
        While NAHASDA may be currently unauthorized, the United States'
    trust and treaty responsibilities towards Native peoples remain and
    will not go away. The members of this Committee know these commitments
    well and NAIHC is very appreciative of all your efforts in supporting
    tribal programs and tribal self-determination.
        There are a number of provisions in S. 1275 that NAIHC supports,
    and the following section-by-section outlines area we support and those
    with which we have concerns.
    Section 3 and 6: Reauthorizations of the IHBG and 184 Loan Guarantee
            Programs
        NAIHC strongly supports the re-authorization of both the Indian
    Housing Block Grant and the 184 Loan Guarantee program. We also support
    the longer term of authorization of 7 years, as it recognizes the
    complexity in reauthorizing these types of programs.
    Section 2: Environment Reviews
        As in the past, NAIHC supports provisions to streamline
    environmental reviews. Completing multiple reviews adds additional time
    and cost to housing projects that are already complex enough due to the
    number of parties involved in tribal projects. Section 2 of the BUIILD
    Act would eliminate some of those costs and delays. While NAIHC
    believes the language could be further simplified, we understand the
    provisions in the BUIILD Act were crafted to address practical concerns
    expressed by HUD. We would be happy to offer further technical
    assistance to ensure the provisions are effective.
    Section 5: Training and Technical Assistance
        The NAIHC remains concerned that the BUIILD Act proposes changes to
    the NAHASDA section 703 Training and Technical Assistance (T/TA)
    provisions. As part of the original negotiations leading up to
    NAHASDA's enactment, tribal leadership understood the need for a
    national organization to provide quality technical assistance and
    training opportunities to tribal housing programs. Tribal leaders also
    understood that for the T/TA to be effective it should be delivered by
    an organization that specifically understands tribal housing issues and
    the complexity of housing development on tribal lands.
        Furthermore, tribal leadership negotiated the provision with the
    understanding that the funds would come out of the Indian Housing Block
    Grant, which would otherwise go directly to tribal housing programs.
    Without a mandate from tribal leaders to change these provisions, NAIHC
    cannot support a change that would open up funds from the Indian
    Housing Block Grant to organizations that do not have a strong
    background or specific expertise in tribal housing, which the BUIILD
    Act does not currently require.
        If a consensus of tribal leaders indicates that the current
    language of section 703 is no longer useful in fulfilling the T/TA
    needs of tribal housing programs, NAIHC would support such a change.
    But until that happens, we would ask members of this Committee to leave
    section 703 of NAHASDA unaltered.
    Section 7: Leveraging
        NAIHC supports the provision that clarifies that NAHASDA funds can
    be used to meet matching or cost-sharing requirements of other federal
    or non-federal programs. This provision is common in other tribal self-
    determination programs, and provides tribes greater flexibility and
    leveraging opportunities.
    Other NAHASDA provisions
        S. 1275 represents a departure from past NAHASDA reauthorization
    efforts in that it leaves out many provisions found in past bills in an
    effort to secure passage. However, it is unclear at this time to NAIHC
    that the changes found in the BUIILD Act provide a clearer path to
    enactment.
        In particular, the BUIILD Act does not include a reauthorization
    for Title VIII programs for Native Hawaiians. Past versions of NAHASDA
    reauthorization bills included reauthorization of these programs.
    Notably in the 114th Congress, both H.R. 360, which passed out of the
    House of Representatives, and S. 710, introduced by Senator Barrasso
    and reported unanimously out of this Committee, contained language
    reauthorizing Title VIII.
        In December of last year, NAIHC provided a letter to Congress that
    indicated it could support a bill that only reauthorized the Indian
    Housing Block Grant. However, that approach contemplated a two-prong
    approach where a second more substantive and thorough tribal housing
    bill (likely including Title VIII programs) would also be developed and
    moved forward. NAIHC is concerned that we have not seen movement on the
    second prong of that approach, and are worried the lack of such
    progress will diminish broader Congressional support of the BUIILD Act
    itself.
        To be clear, NAIHC supports reauthorization of IHBG,
    reauthorization of Title VIII Native Hawaiian housing assistance
    programs, and a host of other tribal housing related provisions. We
    support the efforts of all members of this Committee and Congress to
    reach those goals, and stand ready to work with each of you to secure
    their inclusion and passage in the BUIILD Act or other legislative
    vehicle.
    S. ___, the HUD-VASH bill
        NAIHC has not been able to fully analyze S. ___ but generally
    supports efforts to improve housing conditions and opportunities for
    Native American veterans. In addition to making the HUD-VASH program
    permanent, the draft bill appears to provide the Secretaries of HUD and
    the VA the necessary flexibility to improve implementation of HUD-VASH
    on tribal lands.
        Two of the primary concerns that NAIHC has heard regarding HUD-VASH
    implementation are the lack of case managers the VA can identify
    willing to work in tribal areas, and the restrictions placed on certain
    tribal housing units by HUD that make them ineligible for VASH
    vouchers. The flexibility provided to the agencies by the bill could
    allow the VA and HUD to address these concerns. However, the
    restrictions on certain tribal housing units being eligible for VASH
    vouchers could be addressed more directly in the bill, as we believe
    HUD has too narrowly restricted which tribal housing units should be
    eligible. Many communities have housing shortages, and limiting the
    housing stock that can be used in the tribal HUD-VASH program forces
    some of the participating tribes to house their tribal veterans in
    nearby urban areas, rather than the tribal community as intended by the
    program.
        While that concludes NAIHC's statement on the bills placed on
    today's hearing agenda, the NAIHC believes it must raise the issue of
    several troubling developments made by the new Administration.
    Concerns with the Administration's FY 2017 Omnibus Signing Statement
        On May 5, when President Trump signed into law the FY 2017 omnibus
    spending bill, the President issued a signing statement that
    characterized the ``Native American Housing Block Grants'' as quote ``a
    program that allocated benefits on the basis of race.''
        All of the members of this Committee know full well that tribal
    programs are not based on race, but on the political relationship that
    have existed between Native peoples and the United States for over two
    hundred years.
        The relationship is grounded in the United States Constitution and
    treaties, Congressional statutes and numerous Supreme Court decisions.
    So we ask that members of Congress work with the new Administration to
    ensure it knows the history and importance of tribal programs.
        There are numerous Supreme Court cases that can be cited upholding
    this principle of federal Indian Law and countless legal articles that
    chronicle this background. NAIHC is happy to provide documentation to
    the Committee if necessary, but believes the question is well settled
    and did not see the need to include such information here.
    Concerns with the Administration's FY 2018 Budget Proposal
        While the signing statement could be dismissed as not fully
    understanding the background of federal Indian law, the
    Administration's FY 2018 funding proposals is much more concerning. In
    short, NAIHC believes that the budget, if enacted, would devastate
    tribal housing programs across the country.
        The budget provides substantial cuts or completely eliminates the
    Community Development Block Grant at HUD, the CDFI Fund at Treasury,
    and Rural Development programs at the USDA.
        The proposed budget would also cut the Indian Housing Block Grant
    to $600 million, which is essentially the same level of funding tribal
    housing programs received in 1996. However adjusting for inflation, the
    proposal represents a cut of about one-third compared to 1996 funding
    levels.
        The HUD tribal housing needs assessment released in January showed
    that tribes have rates of substandard housing and overcrowded homes
    well in excess of the national average. The report indicated that
    68,000 new units are needed in Indian Country. As the ability of tribes
    to develop new housing units has diminished in the last few years due
    to inflation, the problem cannot be compounded by the severe program
    funding cuts proposed in the Administration's FY 2018 budget.
        NAIHC asks that members of this Committee, particularly those who
    also sit on the Appropriations Committee, support adequate funding of
    the Indian Housing Block Grant and other tribal housing programs.
    Funding the IHBG at $900 million would provide tribes relatively the
    same purchasing power it had in 1996 and NAIHC requests no less than
    $700 million for FY 2018. Congress should also reject the proposed cuts
    to the other programs listed above, as they provide tribes additional
    resources for their housing programs. Funding tribal housing programs
    not only fulfills Congressional trust and treaty responsibilities, but
    does so in a way that spurs economic development, creates jobs and
    builds credit in tribal communities.

        The Chairman. Thank you for your outstanding testimony. I
    thought yours was excellent and I am sorry I missed some of the
    others. I do thank all of you very much for being here.
        Madam Chairwoman, in previous Indian Affairs Committee
    hearings, we had one entitled, Accessing Capital in Indian
    Country. Witnesses from NAIHC provided testimony recommending
    that NAHASDA dollars, the BUILD dollars, should be allowed for
    leveraging investment opportunities in Indian Country,
    combining and leveraging those investments.
        We have included some of those leveraging authorities. I am
    just wondering if you think that would be helpful in terms of
    the housing challenges?
        Ms. Difuntorum. Chairman Hoeven, the short answer is yes. I
    do think that would be helpful. I also think being able to use
    Indian Housing Block Grant dollars for matching funds, which is
    a provision in the BUILD Act, would help us to leverage as
    well.
        The Chairman. You mentioned the appropriations process. I
    am on appropriations and yes, we have a lot of work to do
    there. We will be hard at work.
        Also, do you think the HUD-VASH bill addresses some of the
    problems the National American Indian Housing Council has heard
    from the tribes, the feedback they are getting? Are we getting
    to some of their priorities and concerns?
        Ms. Difuntorum. I do think so. There are two concerns I
    consistently hear from our membership. One is the education
    level required for the counselors in remote areas. It is very
    difficult to get people with Master's degrees as counselors. I
    think Alaska had suggested maybe remote counseling and lowering
    the requirement to Bachelor degrees. I think that is helpful.
        The other that surfaced recently, I have only heard from
    one of our members, is that they cannot use the HUD-VASH in
    what we call formula current assistance stock which is our 37
    Act units. I have not been able to delve into that and it is
    not addressed in the BUILD Act. Ms. Frechette might be able to
    speak to that.
        The Chairman. I am going to turn to her next and ask that.
        I also want to ask about the remote counseling. Is anyone
    doing that? If so, how is it working? How can we try to
    implement something like that? You express a very real
    challenge. Maybe the telecounseling is something that can be
    done. Are you doing it and, if so, how do you think it is
    working? What can we do to try to make it work?
        Ms. Frechette. I will invite Keith to comment on this also
    because he is in charge of the case management.
        This is an opportunity that we see in the Indian Health
    Service to become a strong partner with VA and HUD, to look at
    ways to use their telemedicine system. This is something we
    have talked about for a while. We would be able to access folks
    in rural and remote areas.
        The Chairman. Has anyone done it?
        Ms. Frechette. We have with telemedicine but I don't know
    about case management.
        The Chairman. No, I mean counseling, particularly in regard
    to veterans in remote areas and so forth?
        Dr. Harris. Not in the tribal programs specifically. We
    have done it more generally in HUD-VASH. Telemedicine and tele-
    mental health are both big pushes.
        The Chairman. You have not done it in the tribal community?
        Dr. Harris. Not in the tribal community. It is one of the
    things we wanted to try.
        The Chairman. Do you have the ability to do it in any
    tribal community?
        Dr. Harris. It requires infrastructure. That is one of the
    things we are hoping to get from IHS in an interagency
    agreement. We hope to restart those conversations but certainly
    we could.
        The Chairman. You could maybe link with VA and IHS to try
    to do it?
        Dr. Harris. Yes.
        The Chairman. It seems like that would be a really good
    idea, would it not?
        Dr. Harris. That is the goal.
        The Chairman. It would pose some challenges also because it
    is challenging work, right? You would have to figure out how to
    do it so it is sensitive and effective and you get some kind of
    feedback as to whether you are accomplishing something.
        Dr. Harris. That is right.
        The Chairman. It is such a challenge in these remote areas.
    It is not easily solvable either in terms of time and
    resources, getting people in place, and going where you need to
    go. It seems to me this is something we need to really pursue.
        Senator Schatz.
        Senator Schatz. Thank you, Mr. Chairman.
        This is a question for all witnesses. I will start on my
    left and go down the line.
        If this bill marked up in Committee, the BUILD Act, would
    any of you object to an amendment that included Native
    Hawaiians?
        Ms. Frechette. Thank you for your question. I am career
    staff at HUD, so I don't comment on what vehicles are
    appropriate and stuff like that.
        Senator Schatz. Dr. Harris?
        Dr. Harris. The same answer, unfortunately. Sorry, sir.
        Ms. Onnen. I am within CAI, and you missed part of my
    testimony, but we would support that.
        Senator Schatz. Thank you.
        Mr. Charlie. We would support that.
        Ms. Difuntorum. We support authorization of Title VIII. If
    it happens through Committee, we would support that.
        Senator Schatz. Thank you.
        The next question is for NCAI and Ms. Onnen.
        For decades, as you know, Native communities have stood
    together fighting off divide and conquer. Could you give us a
    little bit of historical context for why this bill is a
    departure from the way we have done business both on the
    Committee with NCAI and Native communities generally?
        Ms. Onnen. I think what I could comment on is our concern
    at NCAI about the legal precedent this would set. We have
    always worked in partnership with the Native Hawaiian
    community. It has a special political and trust relationship
    with the United States and it has been reaffirmed through
    Congress through over 150 statutes, as well as the message it
    sends.
        I think the concern is the message it sends by condoning
    separate treatment of Native communities by this Committee. I
    think that is our concern at NCAI.
        Senator Schatz. Thank you very much.
        Ms. Difuntorum, am I getting your name right?
        Ms. Difuntorum. Yes, thank you.
        Senator Schatz. I have good staff.
        You have Native Hawaiian members, right?
        Ms. Difuntorum. Members?
        Senator Schatz. Of your housing council?
        Ms. Difuntorum. Let me answer that. The Department of
    Hawaiian Homelands is the voting member and we also have an
    associate member which is a different level. That is the way
    our by-laws read. The short answer is yes, but it is a bit more
    complicated than that.
        Senator Schatz. Could you quickly elucidate what the impact
    would be for the Department of Hawaiian Homelands' Hawaiian
    housing generally if this bill were to be enacted without
    taking care of Native Hawaiians? What would be the impact of
    passing NAHASDA without including Hawaiians?
        Ms. Difuntorum. I don't know that means; there would not be
    funding or the Native Hawaiian Housing Block Grant Program.
    That is the piece that would be devastated. On a political
    level, I think it is a very different question for Hawaiians in
    general. I am sure you know the answer to that. It is in
    everyone's best interest to include them in reauthorization.
    Does that answer your question?
        Senator Schatz. Yes, thank you.
        Thank you, Mr. Chairman.
        The Chairman. Vice Chairman Udall.
        Senator Udall. Thank you, Mr. Chairman.
        President Trump's recent signing statement called into
    doubt the legality of Federal housing programs for Native
    Americans, Alaska Natives and Native Hawaiians. He also
    questioned the constitutionality of Native Hawaiian and Alaska
    Native education programs.
        For Mr. Charlie, as an Alaska Native leader, are you
    concerned about the President's statement questioning the
    legality of programs benefitting Alaska Natives and Native
    Hawaiians?
        Mr. Charlie. Yes, I am.
        Senator Udall. Are you similarly concerned that it supports
    the idea that Alaska Natives and Native Hawaiians have weaker
    claims to the Federal trust responsibility than American
    Indians?
        Mr. Charlie. The way I understand your question, yes, I
    think it weakens that responsibility, that understanding, that
    relationship.
        Senator Udall. You believe it weakens the trust
    responsibility to those tribes?
        Mr. Charlie. Yes.
        Senator Udall. Ms. Onnen, you represent the oldest, largest
    and most representative tribal organization in the Country. I
    understand that NCAI has a resolution supporting the
    reauthorization of the Native Hawaiian Housing Block Grant
    Program as a part of the overall reauthorization of NAHASDA, is
    that correct?
        Ms. Onnen. That is correct.
        Senator Udall. Why did your organization take such a strong
    position and why hasn't it changed its position?
        Ms. Onnen. I think the answer to that question is very
    similar to the answer that I just gave. We are concerned about
    the message that it may send by condoning separate treatment of
    different Native communities within the United States.
        It begins, in essence, to create potential classes of
    Native Americans. I think that is a concern at NCAI. The
    membership has stood behind the Native Hawaiians and the
    reauthorization of that piece. We have discussed this a couple
    times at our conventions and that stance has not yet changed.
    The resolution on file from 2013 stands and that is where we
    stand right now.
        Senator Udall. Thank you.
        Ms. Difuntorum, you represent the housing interests of more
    than 277 tribally-designated housing entities providing housing
    services to approximately 450 tribes, Alaska Natives and Native
    Hawaiians.
        Your organization has a resolution supporting the
    reauthorization of the Native Hawaiian Housing Block Grant
    Program as part of the overall reauthorization of NAHASDA. Do
    you stand by this resolution?
        Ms. Difuntorum. Yes.
        Senator Udall. Thank you.
        ABCP is a member of your organization. So are the
    Department of Hawaiian Homelands and the Hawaiian Homestead
    Community Development Corporation. Does it concern you that S.
    1275 seeks to divide the interests of your membership?
        Ms. Difuntorum. Was that a question for me? I am sorry.
        Senator Udall. Yes, that was.
        Ms. Difuntorum. I am sorry, would you repeat the question?
    I thought you were talking to Mark Charlie.
        Senator Udall. No. ABCP is a member of your organization.
    So are the Department of Hawaiian Homelands and the Hawaiian
    Homestead Community Development Corporation. Does it concern
    you that S. 1275 seeks to divide the interests of your
    membership?
        Ms. Difuntorum. I wouldn't characterize it quite like that.
        Senator Udall. How would you characterize it?
        Ms. Difuntorum. I would say, again, Committee staff has
    worked very hard for several sessions of Congress to get a
    reauthorization bill, including Title VIII. We support
    authorization of Title VIII even though they have never been
    authorized under a NAHASDA reauthorization, right? Everybody
    knows that.
        We support the Hawaiian program. Chairman Hoeven spoke to
    this at the very beginning in his opening remarks that there
    has not been any success in getting any authorization done.
    Unfortunately, Title VIII has been a big barrier. That does not
    mean that we do not support authorization of that program. We
    do and if there is a way to do NAHASDA and have Title VIII
    included, absolutely, we support that.
        I do not know if that answers your question but that is our
    position. We support including Title VIII if we can get
    reauthorization done in its entirety with Title VIII intact,
    absolutely we would support that.
        Senator Udall. Let me ask it just a little bit differently.
    Would you support passage of a NAHASDA reauthorization bill
    that does not include Native Hawaiian housing programs?
        Ms. Difuntorum. Okay, that is a different question. What I
    am going to say is I do not think that is a fair question to
    ask me. The Department of Hawaiian Homelands is a member of the
    Housing Council. We also have a lot of other members and I
    would really have to consult with the Board of Directors and
    our membership before I would be willing to go there.
        Senator Udall. Thank you.
        I am well over time here, Mr. Chairman.
        The Chairman. That is fine. I did not have any other
    questions but I think Chairwoman Difuntorum, you are getting at
    what we are trying to do. That is to pass the BUILD Act, pass
    NAHASDA, and reauthorize the Indian Housing Program. We have
    been stuck for the last two Congresses so it is just to figure
    out how we can move forward.
        I appreciate your responses because I think what you are
    making clear and what I am trying to make clear is we are
    looking for solutions and trying to find ways to get things
    done. I would it would not be characterized as splitting the
    group in any way. That is not it.
        If we decide as a Committee to include it and we remain
    stuck, we cannot move it through the Congress. Then we are in
    the same situation we have been for the last two Congresses.
        Further, I would add it is not that the Native Hawaiians
    are just not included in BUILD, at the same time we made an
    offer to provide their funding through the appropriations
    process. I would not want that to get left out. I am a little
    concerned that those questions kind of left that out. That is
    why I think you answered it in the right way. Look, we are
    trying to find a solution that gets it accomplished.
        NAHASDA is about $650 million in reauthorization for
    housing programs. My understanding is about $2 million goes to
    Native Hawaiians. That is why we were talking about trying to
    maybe do something through appropriations so we could advance
    the ball. Simply put, the effort is not to leave anyone behind.
    The effort is trying to find a way to advance but it may take
    some creativity.
        I am open, as I said at the outset. That is the only
    concern I have with the question as put to you by the Ranking
    Member. It was kind of like this splits the BUILD. No, it is
    trying to find a creative way to get reauthorization done.
    Maybe there is another way to do it, maybe there isn't, but
    aren't we here to try to see if there is some possibilities
    that we could come up with? We are just working on trying to
    find a way to get something done. Anyway, I appreciate your
    answers.
        Yes, Chairwoman, you had a comment?
        Ms. Difuntorum. I do have a comment.
        At the beginning of the hearing, you also made comments on
    the record and several of your colleagues on the Committee have
    also commented that they were committed to working on a
    solution to see Title VIII authorized.
        I don't know what that is going to look like but I do hope
    that isn't lost in the shuffle. We would like to have Title
    VIII included. At the end of the day, people can ask me my
    opinion about it, I don't get to vote on it. I am not actually
    a legislator. I don't have a magic pen to sign things into law.
        This is the work you all are going to have to do. I was
    really encouraged by the comments and what sounded like a
    commitment from people on the Committee to try and get this
    done with Title VIII intact. I want to leave it at that.
        The Chairman. Thank you.
        Ranking Member, are there other questions you might have?
        Senator Udall. Yes. Mr. Chairman, let me first say that I
    very much appreciate your very sincere effort to reach a
    resolution. Those questions were not asked in any way to
    reflect on your effort. They were asked to try to clarify, as
    best we can, the positions of the people before us.
        As you know, Senator Schatz has objections. I very much
    appreciate your trying to work with him and we are trying to
    work, in a bipartisan way, through these issues. Unfortunately,
    when you appear before us with issues like this, I think it is
    important that we try to glean as far as possible what your
    positions are. We understand the positions the first two
    witnesses are in.
        The Chairman. I appreciate that and I think we are all
    trying to find a path forward.
        Senator Udall. Mr. Chairman, I have just a couple of
    questions on HUD-VASH but if you are really pressed, we can
    submit these for the record.
        The Chairman. No, go ahead.
        Senator Udall. This Committee agrees that we want to ensure
    that the Tribal HUD-VASH Demonstration Program is achieving
    maximum efficiency. That means that an all hands on deck effort
    from the Administration and Congress. We need to work
    collaboratively to take care of our veterans.
        Dr. Harris, could you highlight any other services the VA
    is providing for Native veterans?
        Dr. Harris. I oversee operations in the Homeless Program
    Office. I would much prefer to take that back to VA and provide
    written response if that is okay with you?
        Senator Udall. Yes, please do.
        Dr. Harris. Thank you.
        Senator Udall. Thank you very much.
        I have a follow up for the panel for our tribal witnesses
    today. How do you feel these additional VA services are working
    in Indian Country? Is there more the Department could do to
    engage with Indian Country? For example, I have heard that the
    VA's Home Loan Guarantee Program does not reach a lot of
    reservations. Do you feel that is the case?
        Dr. Harris. I can say a little bit about that. I have heard
    the same feedback, that the ideal candidate for the home
    guarantee loan, for instance, is more of a middle-class level
    Native American which is not the case, unfortunately, in too
    many cases. There is more that could be done there. I would
    defer to other panel members.
        Mr. Charlie. In response to that question, I learned about
    the Native Veteran Home Loan Program. One of the things it
    states is it has to be in trust land. In Alaska, we have very
    few or no trust lands. The question becomes how do we apply to
    the Native Home Loan Program in our region where we do not have
    trust land?
        Senator Udall. Thank you very much.
        Let me thank all the panelists today for your testimony and
    your patience. It has taken a while to get to you and we very
    much appreciate the time and effort.
        I would say again to my Chairman, it has been such a
    pleasure working with him. He is one of the most bipartisan
    Senators I know in the United States Senate. I know he is
    making an incredibly sincere effort to try to reach resolution
    on some of these contentious issues. I really look forward to
    working with him and making sure that we can get something
    done.
        Thank you very much.
        The Chairman. Thank you. Hopefully, we will get there.
        Thanks to all of the witnesses. We appreciate so much your
    being here today. I want to remind you that your full written
    testimony will made a part of the official record.
        At this point, if there are no more questions, members may
    submit follow-up questions for the record. The hearing record
    will be open for two weeks.
        Again, thanks so much for being here. We appreciate it.
        We are adjourned.
        [Whereupon, at 5:35 p.m., the Committee was adjourned.]

                                A P P E N D I X

               Prepared Statement of the American Academy of PAs
        On behalf of the more than 115,000 nationally-certified PAs
    (physician assistants) represented by the American Academy of PAs
    (AAPA), we appreciate the Senate Indian Affairs Committee's work to
    ensure high quality healthcare is available to Native Americans though
    Indian Health Services.
        AAPA appreciates efforts by the committee to improve the quality of
    care offered to American Indians and Native Alaskans at Indian Health
    Service (IHS) facilities and to ensure that IHS can recruit and retain
    needed medical providers. Currently, over 250 PAs are working to meet
    the healthcare needs of American Indians and Alaska Natives at Indian
    Health Services facilities. PAs practice medicine on healthcare teams
    with physicians and other providers. Within IHS, PAs work in emergency
    and family practice settings, as well as specialty clinics and
    programs, such as orthopedics, diabetes care, surgery, geriatric,
    pediatric, women's health, hospitalist and community health.
        AAPA respects the effort made by Senators Barrasso, Thune, and
    Chairman Hoeven to improve recruitment and retention for needed
    healthcare providers at IHS in S. 1250, the Restoring Accountability in
    the Indian Health Service Act of 2017. However, we would like to work
    with the authors and the committee to ensure this legislation reaches
    its full potential to help IHS attract and retain needed healthcare
    providers, including PAs.
        As introduced, S. 1250 seeks to improve the ability of IHS to
    recruit and retain providers by requiring the agency to establish pay
    scales where health providers are paid ``to the maximum extent
    practicable'' comparable to what such providers would make under the
    pay scales that apply to health providers at facilities operated by the
    Department of Veterans' Affairs (VA). While the VA generally takes into
    consideration wages for providers in local geographic markets, the VA
    has a flawed process in relation to PAs that does not consistently take
    into consideration local market compensation. Under the flawed
    compensation system at the VA, it is not uncommon for PAs in the VA to
    be compensated by as much as $30,000 less than other providers
    performing the exact same job. This flawed approach to compensation
    within the VA has resulted in VA facilities having difficulty
    recruiting PAs and provides PAs practicing at the VA a significant
    financial incentive to take positions with private employers. Recent
    reports by the VA Office of Inspector General consistently recognized
    the importance of PAs as part of VHA's healthcare team and identify PAs
    as one of the five critical occupations with the ``largest staffing
    shortages.'' Because of problems the flawed formula has caused the VA
    in recruiting and retaining needed providers, Senators Tester and Moran
    have introduced S. 426 that would ensure PA salaries at the VA take
    into consideration private pay rates in local markets. AAPA feels
    strongly that it is important to make sure any legislation intended to
    help IHS recruit and retain providers does not replicate inequities
    that exist at the VA.
        AAPA is committed to working to improve access to care at IHS
    facilities, and we look forward to working with the Committee on this
    critical issue.
                                     ______

           Prepared Statement of the Hawaii Congressional Delegation
        Chairman Hoeven and Vice Chairman Udall, please accept this written
    testimony in opposition to S. 1275, the Bringing Useful Initiatives for
    Indian Development (BUIILD) Act of 2017. While we have and continue to
    support reauthorizing the Native American Housing Assistance and Self-
    Determination Act (NAHASDA) programs, we strongly oppose this bill in
    its current form because it fails to include Native Hawaiian Housing
    Block Grants (NHHBG) and Section 184A Native Hawaiian Home Loan
    Guarantee programs, as set forth in Title VIII of NAHASDA.
        The housing needs faced by our Native communities are among the
    worst in our country. In recognition of the Federal Government's trust
    responsibility to Native Americans, including Alaska Natives, Congress
    passed the Native American Housing Assistance and Self-Determination
    Act in 1996. In 2000, the American Homeownership and Economic
    Opportunity Act of 2000 \1\ inserted Title VIII in NAHASDA and created
    the NHHBG and Section 184A programs to provide resources for affordable
    housing programs for Native Hawaiians, pursuant to the Hawaiian Homes
    Commission Act of 1920 (HHCA). \2\
    ---------------------------------------------------------------------------
        \1\ Public Law 106-569
        \2\ The Hawaiian Homes Commission Act was passed by Congress and
    signed into law by President Warren Harding on July 9, 1921.
    ---------------------------------------------------------------------------
        HHCA recognizes the Federal Government's ``unique trust
    responsibility to promote the welfare of the aboriginal, indigenous
    people of the State [of Hawaii].'' \3\ This law created the Hawaiian
    Home Land Trust, which includes more than 200,000 acres of land managed
    by the Department of Hawaiian Home Lands (DHHL). The purpose of the
    HHCA is to improve the lives of Native Hawaiians, who continue to be
    more economically disadvantaged and lag behind in education and health,
    compared to other Hawaii residents. The trust lands create a land base
    where beneficiaries are able to reestablish connections to their native
    lands and cultural traditions that are vital in maintaining their
    identity and foundation.
    ---------------------------------------------------------------------------
        \3\ Hawaiian Homes Commission Act of 1920,  201.5
    ---------------------------------------------------------------------------
        While many Native Hawaiian families benefit from the HHCA, there
    are a large number of low-income families who are unable to take
    advantage of these lands because obtaining and managing a property is
    not within their financial means. To put this into perspective, DHHL
    recently reported that there were more than 27,000 applicant families
    on the waitlist to reside on Hawaiian homesteads and the latest U.S.
    Census numbers indicate that approximately 16.8 percent of Native
    Hawaiians live in poverty in the State of Hawaii. \4\ The NHHBG and
    Section 184A programs are crucial in bridging the gap between low-
    income Native Hawaiian families and their ability to live on homestead
    lands.
    ---------------------------------------------------------------------------
        \4\ U.S. Census Bureau, 2015 American Community Survey 1-Year
    Estimates, Selected Population Profile in the United States, Hawaii
    http://files.hawaii.gov/dbedt/census/acs/ACS2015/ACS2015_1_Year/
    Select_Pop_Profiles/major_race_aoc.pdf
    ---------------------------------------------------------------------------
        Congress has recognized the special relationship between the U.S.
    government and Native Hawaiians, and a responsibility to continue
    promoting programs that counter these sobering figures. NAHASDA's Title
    VIII programs provide vital tools that promote safe and affordable
    housing for Native Hawaiians. Healthy, sustainable homeownership is
    also fostered through the provision of funds for direct loans, housing
    counseling, self-help housing, and home rehabilitation programs. These
    resources focus on developing strong communities that serve as
    foundations for Native Hawaiian families to improve their collective
    quality of life.
        In 2015, the U.S. House of Representatives passed legislation to
    reauthorize NAHASDA with overwhelming bipartisan support. Also in 2015,
    this committee favorably reported a Senate version to reauthorize
    NAHASDA. Both versions included improvements to allow for NAHASDA
    programs to have a greater ability to self-determine--as is stated in
    the title of the law we are discussing--how to efficiently meet local
    housing needs. To abandon this bipartisan progress and Title VIII
    entirely--as the BUIILD Act does--would be a grave mistake and
    disservice to our Native communities. This is simply not the way
    forward.
        It is incumbent upon Congress to continue to acknowledge our
    responsibility to protect and improve the lives of Native Americans,
    Alaska Natives, and Native Hawaiians, which the BUIILD Act, in its
    present form, does not do. As such, we urge members of this committee
    to oppose the BUIILD Act and to continue to work to improve on the
    progress made on NAHASDA reauthorization in the last several years.
        We look forward to working with this Committee on how we can
    continue to work toward meeting the dire housing needs of all our
    Native people.
                                     ______

      Prepared Statement of Aneva J. Yazzie, CEO, Navajo Housing Authority
        On behalf of the Navajo Housing Authority (NHA) and our NHA Board
    of Commissioners (BOC), I am grateful and appreciate the opportunity to
    provide this written statement to the United States Senate Committee on
    Indian Affairs for review of the following legislative bills: S. 1250,
    a bill to amend the Indian Health Care Improvement Act; S. 1275, the
    ``Bringing Useful Initiatives for Indian Land Development,'' (BUILD Act
    of 2017); and a bill relating to the HUD/VA Veterans Affairs Supporting
    Housing (HUD-VASH) program. It is NHA's goal to work with Congress in
    addressing our mutual interests in advancing effective policies to
    build economic and community development opportunities through
    addressing healthcare, housing and comprehensively support our Native
    Veterans.
    Background on NHA
        The Navajo Housing Authority is the Tribally Designated Housing
    Entity (TDHE) for the Navajo Nation. NHA is the largest Indian housing
    authority and is nearly the eighth largest public housing authority in
    the United States. NHA is comparable in size to the public housing
    agency for the City of Atlanta. The Navajo Nation is the largest Indian
    tribe in the United States, with a total enrollment of approximately
    320,000 tribal members, a land base of 26,897 square miles (larger than
    West Virginia) that extends into the states of Arizona, New Mexico, and
    Utah.
        Comprised of 365 employees headquartered in Window Rock, Arizona
    and 15 field offices across the reservation, NHA manages 9,200 rental
    and homeownership units including 43 administrative facilities, and
    oversees an additional 1,800 units from sub-recipients. The 15 field
    offices deliver housing services to tribal members that reside within
    110 Chapters (local regional government units) and the surrounding
    communities.
    Success of the NHA 5-Year Expenditure Plan
        In 2012, following a three-year HUD-imposed moratorium on
    development, NHA had accumulated approximately $470 million in unspent
    Indian Housing Block Grant (IHBG) funds. NHA developed and implemented
    an aggressive five-year expenditure plan to timely and responsibly
    expend a large accumulated balance.
        Over the past four years, NHA has proven that it has the sustained
    capacity to effectively and responsibly expend its allocated IHBG
    funds; over $600 million in the past four years (an average of $143
    million per year). Since the beginning of 2012, the NHA delivered
    housing services to over 10,592 households, built 538 new housing
    units, modernized 878 older housing units, funded the development of 7
    bed group homes and emergency shelters, and oversaw the acquisition and
    transition of 29 housing units for persons with disabilities. NHA is in
    its final year of the expenditure plan and is on target for a
    consecutive 5th year in meeting its spending goal by the end of Fiscal
    2017.
    S. 1250 Indian Health Care Improvement Act
        Indian Healthcare Service (IHS) programs, administered by the
    Department of Health and Human Services, are the single largest
    investment into tribal communities at $3.5 billion annually. From this
    amount, $446 million is used to fund sanitation facility
    infrastructure. As NHA and many tribal housing programs have previously
    mentioned, those sanitation funds are impeded by appropriations
    language that restricts IHS funds from being comingled with the funds
    received through the Native American Housing Assistance and Self-
    Determination Act (NAHASDA). In short, this limits a tribe's ability to
    maximize the federal investment.
        The Administration and Congress have vowed to spur growth into the
    economy by funding infrastructure, however a key challenge to providing
    housing in tribal communities is the lack of infrastructure, especially
    in rural areas. Development costs in rural areas are higher and can
    easily double the price tag or even make housing development impossible
    in many places. On Navajo, there is often no sanitation infrastructure
    and using NAHASDA funds alone for development, although authorized for
    infrastructure, significantly eats into housing funds which is
    unnecessary. Tribes should be allowed to leverage federal funding
    sources (NAHASDA and IHS sanitation funds) for developing the necessary
    sanitation infrastructure. NHA respectfully requests this Committee to
    seriously consider language that would statutorily allow the co-
    mingling of IHS sanitations funds so that the federal investment into
    infrastructure could be maximized.
    S. 1275 the ``Bringing Useful Initiatives for Indian Land
            Development,'' or BUILD Act of 2017
        The Build Act has 6 sections that re-authorizes and amends the
    Native American Housing Assistance and Self-Determination. On December
    16, 2016, the NHA BOC passed Resolution NHA-4677-2016, this resolution
    authorizes the support of key provisions for any NAHASDA
    Reauthorization bill.
        Section 2: Consolidated Environmental Review (ER), this section
    authorizes a tribe who co-mingles federal funds from different agencies
    will discharge the tribe from other applicable environmental review
    requirements of the other applicable agencies under Federal law if the
    largest source of federal funding is from HUD. NHA supports this
    provision.
        Section 3: Reauthorizes NAHASDA from 2018 through 2025. NHA
    supports this provision.
        Section 4: Extension of Leasehold interest for housing from 50
    years to 99 years. NHA takes no position on this provision.
        Section 5: Reauthorizes Training and Technical assistance from 2018
    through 2025. NHA supports this provision.
        Section 6: Reauthorizes the Indian Loan Guarantee program (commonly
    known as the 184 loan program) from 2018 through 2025, with a
    limitation on funding at $12.2 Million. NHA supports the
    reauthorization of the 184 Loan Program but does not support a
    limitation on funding.
        Section 7: Authorizing Leveraging: Allows for all grants funds
    under NAHASDA to be used for purposes of meeting matching or cost
    participation requirements under any other Federal or non-Federal
    programs. NHA supports this provision.
        NAHASDA outlined dual roles for Indian housing, to build safe homes
    and sustainable communities while spurring economic development. Under
    the IHBG, funding must first cover the continuing support of the
    remaining housing stock that was funded under the 1937 Housing Act.
    NAHASDA includes other eligible activities such as new construction,
    acquisition and rehabilitation, thus in addition to the above sections
    in the Build Act, NHA supports additional provisions in the Re-
    authorization of NAHASDA which are outlined in Resolution NHA-4677-
    2016. These additional provisions were identified to stream-line the
    administrative workload of housing authorities and to reduce the
    duplication of rules and regulations between federal agencies. Tribes
    need these provisions so that they can focus on the important task of
    building houses instead of working tirelessly to meet burdensome
    administrative rules.
    HUD/VA-Veterans Affairs Supportive Housing
    NHA Success with HUD-VASH Program
        Tribal HUD-VASH recipients are having success placing tribal
    veterans into local supportive housing but we need the program to be
    permanently authorized or else we risk leaving those homeless Native
    Veterans without affordable housing options that include critical
    supportive services.
        HUD approved 20 HUD-VASH vouchers for NHA in the amount of $268,835
    on January 6, 2016. NHA has prioritized and incorporated the 20 VASH
    vouchers for homeless Navajo Veterans and to date we have issued nine
    vouchers (four have found housing) in Arizona and New Mexico. These
    homeless Navajo Veterans were reviewed by case-managers and determined
    eligible for the program and were immediately issued a voucher. Further
    NHA took efforts a step further and instituted its own Veterans Housing
    Assistance Policy. This policy goes above and beyond Federal
    legislative authority and has helped over 120 veterans become
    homeowners and has extended $8.8 million in veteran debt forgiveness
    and assisted 17 widowers/mothers of service men and women through NHA's
    veterans housing assistance program.
    Project Coordination
        NHA partners with Veterans of the Armed Services residing on the
    Navajo Nation and are eligible to receive housing assistance services
    through the Department of Navajo Veterans Affairs (DNVA). The DNVA
    partners with Federal, state and local services, but the amount of case
    management that is needed to service our veteran population is large
    and added federal resources are need. Navajo has one case manager for
    the HUD-VASH program to handle cases that cover the entire Navajo
    reservation (Navajo extends into three states: Arizona, New Mexico and
    Utah). Moreover, the remote location of the reservation is not
    conducive to providing adequate case-management unless that case-
    management can be provided in their community as opposed to off the
    reservation. NHA believes a solution is to provide for more case-
    managers to meet the needs in the Navajo community.
    Place-based Vouchers
        The biggest problem with using the tenant based rental assistance
    vouchers on the Navajo Nation is the lack of private or non-profit
    housing for renters. Therefore, the HUD-VASH program should allow
    rental assistance vouchers to be used for housing currently included in
    the housing stock of the tribal housing program. NHA's only option for
    using our HUD-VASH rental vouchers is to use Section 8 approved
    properties off the reservation. This solution will not help veterans
    who are needing supportive services who wish to stay on the reservation
    close to their family who are helping in their recovery. Thus, creating
    a place based voucher system that stays on the reservation, where most
    tribal veterans reside is the best option to alleviate our TDHE's lack
    of public and non-profit housing.
    Conclusion
        It is the goal of NHA to help build safe sustainable homes for the
    Navajo People while strengthening the socio-economic fabric of the
    Navajo Nation. The re-authorization of NAHASDA, development of
    sanitation infrastructure and expansion of HUD-VASH coordination and
    program is critical in maintaining the growth of NHA and sustaining the
    progress of the Navajo People. We hope our testimony can assist this
    Committee in expanding each of these programs for the benefit of NHA
    and all Tribal TDHE's. Thank you for this opportunity.
                                     ______

    Prepared Statement of the United States Merit Systems Protection Board
                                     (MSPB)
        Chairman Hoeven, Vice Chairman Udall and distinguished Members of
    the United States Senate Committee on Indian Affairs (``Committee'').
    Thank you for the invitation to present a written statement on behalf
    of the United States Merit Systems Protection Board (MSPB) in
    connection with the Committee's legislative hearing to receive
    testimony on S. 1250, the ``Restoring Accountability in the Indian
    Health Service Act of 2017'' and other legislation which was held on
    June 13, 2017.
        As an initial matter, I would like to note that under statute, MSPB
    is prohibited from providing advisory opinions on any hypothetical or
    future personnel action within the executive branch of the federal
    government. 5 U.S.C.  1204(h) (``The Board shall not issue advisory
    opinions.''). Accordingly, this statement should not be construed as an
    indication of how I, any other presidentially appointed, Senate-
    confirmed Member of the Merit Systems Protection Board (``Board''), an
    MSPB administrative judge, or an administrative law judge acting on
    behalf of the MSPB would rule in any pending or future matter before
    the agency. Moreover, at this time, MSPB is not taking a policy
    position on this legislation. Accordingly, I would respectfully request
    that the Committee consider the substance of my statement to be
    technical in nature.
    The Potential Impact of S. 1250 on MSPB's Adjudicatory Function
        MSPB's views on S. 1250 derive from its statutory responsibility to
    adjudicate appeals filed by federal employees in connection with
    certain adverse employment actions. Generally, after a federal agency
    imposes an adverse personnel action upon a federal employee, such as
    removal or demotion, and the federal employee chooses to exercise his
    or her statutory right to file an appeal with MSPB, MSPB will begin the
    adjudication process. In the case of a federal employee who is removed
    from his or her position, that individual is no longer employed by the
    Federal Government, and is not receiving pay at the time he or she
    files an appeal with MSPB or at any point during the subsequent MSPB
    adjudication process.
        Once an appeal is filed, an MSPB administrative judge \1\ in one of
    MSPB's regional or field offices will first determine whether MSPB has
    jurisdiction to adjudicate the appeal. If MSPB has jurisdiction, the
    administrative judge may conduct a hearing on the merits and then issue
    an initial decision addressing the federal agency's case and the
    appellant's defenses and claims. Thereafter, either the appellant or
    the named federal agency may file a petition for review of the MSPB
    administrative judge's initial decision to the 3-Member Board. The
    Board Members constitute an administrative appellate body that reviews
    the administrative judge's decision and issues a final decision of the
    MSPB. Both the Board Members and MSPB administrative judges adjudicate
    appeals in accordance with statutory law, federal regulations,
    precedent from United States federal courts, including the Supreme
    Court of the United States and the United States Court of Appeals for
    the Federal Circuit, and MSPB precedent.
    ---------------------------------------------------------------------------
        \1\ MSPB administrative judges are federal employees under the
    General Schedule System employed by MSPB. They are not ``administrative
    law judges'' appointed under 5 U.S.C.  3105 nor federal judges.
    ---------------------------------------------------------------------------
        S. 1250 contains similar language to Section 707 of the Veterans
    Access, Choice, and Accountability Act of 2014, which was enacted into
    law and became effective in August 2014. (Public Law No. 113-146; 38
    U.S.C  713). In pertinent part, S. 1250 would allow the Secretary of
    Health and Human Services (``Secretary''), acting through the Director
    of the Service, to remove, demote, or transfer employees, including
    Senior Executive Service employees, of the Indian Health Service
    (``Service'') if the Secretary determines the performance or misconduct
    of the employee warrants such a personnel action. If the Secretary
    removes or demotes such an employee, the Secretary may:

        Remove the employee from the civil service altogether;

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

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

        With respect to the above-referenced personnel actions, S. 1250
    provides that ``the procedures under chapters 43 and 75 of title 5,
    United States Code, shall not apply.'' \2\ Instead, S. 1250 provides
    that ``before an employee may be subject to a personnel action, he or
    she must be provided with: (1) written notice of the proposed personnel
    action not less than 10 days before the personnel action is taken; and
    (2) an ``opportunity and reasonable time'' to answer orally or in
    writing.
    ---------------------------------------------------------------------------
        \2\ Under 5 U.S.C.  7513(b)(1)-(4) and (d), a federal employee
    against whom certain adverse actions are proposed is generally entitled
    to: (1) at least 30 days advance written notice stating the specific
    reasons for the federal agency's proposed action; (2) not less than 7
    days to respond to the proposed adverse action; (3) be represented by
    an attorney or other representative before the federal agency; (4) a
    written decision and the specific reasons therefor by the federal
    agency; and (5) file an appeal to MSPB under 5 U.S.C.  7701.
        Under 5 U.S.C.  4303(b)(1), a federal employee who is subject to
    removal or a reduction in grade for unacceptable performance is
    generally entitled to: 1) at least 30 days advance written notice of
    the federal agency's proposed action identifying certain information;
    2) be represented by an attorney or other representative before the
    federal agency; 3) a reasonable time to answer orally and in writing to
    the proposed adverse action; 4) a written decision by the federal
    agency specifying the instances of unacceptable performance which has
    been concurred in by an employee who is in a higher position that
    proposes the removal or reduction in grade; and 5) appeal to MSPB under
    5 U.S.C.  7701. Moreover, under 5 U.S.C.  4302(b)(5), before a
    federal agency can take a personnel action based on performance, the
    employee whose performance is in question shall be provided an
    opportunity to improve his or her unacceptable performance.
    ---------------------------------------------------------------------------
    Expedited MSPB Appeal Rights Under S. 1250
        Employees who are either removed or demoted by the Secretary may
    appeal that personnel action to MSPB ``under section 7701 of title 5.''
    Any appeal must be filed with MSPB ``not later than seven days after
    the date of the personnel action'' \3\ and the MSPB will be required to
    refer the appeal to an administrative law judge \4\ for adjudication.
    An administrative law judge would be required to issue a decision ``not
    later than 21 days after the date of the appeal,'' and that decision
    ``shall be final'' and not subject to further review, either by the
    Board or a United States federal court. In the event that an
    administrative law judge does not issue a final decision within 21
    days, the decision of the Secretary to remove or demote the employee
    becomes final and the employee has no further right to appeal.
    ---------------------------------------------------------------------------
        \3\ Generally, under current law, an appeal must be filed at MSPB
    no later than 30 days after the effective date, if any, of the action
    being appealed, or 30 days after the date of the appellant's receipt of
    the agency's decision, whichever is later. 5 C.F.R.  1201.22(b).
        \4\ MSPB does not directly employ any administrative law judges,
    but can retain the services of administrative law judges via contract.
    Thus, if S. 1250 were to become law without amendment, and MSPB was
    required to retain the services of administrative law judges to
    adjudicate appeals covered by this legislation instead of using MSPB
    administrative judges, MSPB would likely incur significant operating
    costs.
    ---------------------------------------------------------------------------
    Possible Constitutional Defects of S. 1250
        In May 2015, MSPB released a study \5\ entitled: What is Due
    Process in Federal Civil Service Employment? The report provides an
    overview of current civil service laws for adverse actions and, perhaps
    more importantly, the history and considerations behind the formation
    of those laws. It also explains why, according to the Supreme Court of
    the United States, the Constitution requires that any system which
    provides that a public employee may only be removed for specified
    causes must also include an opportunity for the employee--prior to his
    or her termination--to be made aware of the charges the employer will
    make, present a defense to those charges, and appeal the removal
    decision to an impartial adjudicator. We encourage Members of the
    Committee and their staff who have interest in these issues to read
    this report. \6\
    ---------------------------------------------------------------------------
        \5\ In addition to adjudicating appeals filed by federal employees,
    MSPB is required under statute to:
        \6\ This report can be found at: http://www.mspb.gov/netsearch/
    viewdocs.aspx?docnumber=1166935&version=1171499&application=ACROBAT
        Conduct, from time to time, special studies relating to the civil
    service and to the other merit systems in the executive branch, and
    report to the President and to Congress as to whether the public
    interest in a civil service free of prohibited personnel practices is
    being adequately protected. 5 U.S.C.  1204(a)(3).
    ---------------------------------------------------------------------------
        In the landmark decision of Cleveland Board of Education v.
    Loudermill, 470 U.S. 532 (1985) the Supreme Court held that while
    Congress (through statutes) or the president (through executive orders)
    may decide whether to grant protections to employees, they lack the
    authority to decide whether they will grant due process rights once
    those protections are granted. Stated differently, when Congress
    establishes the circumstances under which employees may be removed from
    positions (such as for misconduct or malfeasance), employees have a
    property interest in those positions. Loudermill, 470 U.S. at 538-39.
    \7\ Specifically, the Loudermill Court stated:
    ---------------------------------------------------------------------------
        \7\ The Loudermill case involved a state employee, not a federal
    employee. Nevertheless, while the Federal Government is covered by the
    Fifth Amendment and the states by the Fourteenth Amendment, the effect
    is the same. See Lachance v. Erickson, 522 U.S. 262, 266 (1998); Stone
    v. Federal Deposit Insurance Corp., 179 F.3d 1368, 1375-76 (Fed. Cir.
    1999).

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

            Id. at 541.

        The Court explained that the ``root requirement'' of the Due
    Process Clause is that ``an individual be given an opportunity for a
    hearing before he is deprived of any significant property interest,''
    and that ``this principle requires some kind of a hearing prior to the
    discharge of an employee who has a constitutionally protected property
    interest in his employment.'' Id. at 542.
        According to the Court, one reason for this due process right is
    the possibility that ``[e]ven where the facts are clear, the
    appropriateness or necessity of the discharge may not be; in such
    cases, the only meaningful opportunity to invoke the discretion of the
    decisionmaker is likely to be before the termination takes effect.''
    Id. at 542. The Court further held that ``the right to a hearing does
    not depend on a demonstration of certain success.'' Id. at 544.
        I further note that the requirements of the Constitution have
    shaped the rules under which federal agencies may take adverse actions
    against federal employees, as explained by the Supreme Court, U.S.
    Courts of Appeal, and U.S. District Courts. Accordingly, should
    Congress consider modifications to these rules, many of which have been
    in place for more than one hundred years, MSPB respectfully submits
    that the discussion be an informed one, and that all Constitutional
    requirements be considered.
        As stated above, S. 1250 provides ten days' notice to an employee
    prior to a personnel action, a ``reasonable time'' to respond, and the
    right to an expedited appeal at MSPB. Whether these rights--taken as a
    whole--satisfy constitutional due process requirements would depend on
    the various factors and the circumstances of a given appeal, and it
    would be inappropriate for me to address that issue at this point.
        Finally, and significantly, I note that a panel of judges on the
    United States Court of Appeals for the Federal Circuit--MSPB's primary
    reviewing court--recently issued a decision that casts serious doubt on
    the constitutionality of at least one provision of S. 1250. In Helman
    v. Dep't of Veterans Affairs, 856 F.3d 920, 929 (Fed. Cir. May 9,
    2017), a panel of the Federal Circuit ruled that the provision of
    Section 707 of the Veterans Access, Choice, and Accountability Act of
    2014 that allowed MSPB administrative judges to issue final decisions
    on behalf of the MSPB--without allowing review of those decisions by
    MSPB Board members--was unconstitutional. Specifically, the court found
    that this provision of Section 707 (as codified at 5 U.S.C.
    713(e)(2)) violated the Appointments Clause of Article II of the United
    States Constitution:

             Thus, we conclude that the authority to render a final
            decision, affirming or overturning the Secretary of the DVA's
            removal decision, is a significant duty that can only be
            performed by officers of the United States. Through [38 U.S.C.]
             713, Congress purports to vest this significant authority in
            [MSPB] administrative judges who are hired as employees. This
            is unconstitutional under the Appointments Clause. Accordingly,
            we declare invalid those portions of  713. See, Helman at 929
            (Fed. Cir. May 9, 2017)

        The Court also struck down the provision of Section 707 (38 U.S.C.
     713(e)(3)) that provided that the Secretary's decision became final
    in the event that an MSPB AJ was unable to issue a decision within the
    21 day period provided for in that section. Helman, 856 F.3d at 929
    n.4. We recommend that the Committee consider the Federal Circuit's
    decision in Helman before approving S. 1250 to the extent that it
    prohibits MSPB Board members from reviewing the decisions of MSPB
    administrative judges and provides that decisions shall be final in the
    event that any MSPB administrative judge does not meet any arbitrary
    deadline to decide an appeal.
    Permitting Appeals to MSPB ``Under 5 U.S.C.  7701"
        S. 1250 would permit covered employees to appeal to MSPB ``under 5
    U.S.C.  7701.'' Section 7701 of title 5, United States Code, provides
    in pertinent part that ``the decision of an agency shall be sustained.
    . .only if the agency's decision. . .is supported by a preponderance of
    the evidence.'' 5 U.S.C.  7701(c)(1)(B). The term ``preponderance of
    the evidence'' is defined as ``the degree of relevant evidence that a
    reasonable person, considering the record as a whole, would accept as
    sufficient to find that a contested fact is more likely to be true than
    untrue.'' 5 C.F.R.  1201.4(q).
        Additionally, 5 U.S.C.  7701(c)(2)(B) provides that ``an agency's
    decision may not be sustained. . .if the employee or applicant for
    employment shows that the decision was based on any prohibited
    personnel practice described in section 2302(b) [of title 5, United
    States Code].'' Among the ``prohibited personnel practices'' described
    in section 2302(b) are illegal discrimination, 5 U.S.C.
    2302(b)(1)(A)-(E), coercion of political activity or reprisal for
    refusal to engage in political activity, 5 U.S.C.  2302(b)(3), and
    reprisal for lawful ``whistleblowing,'' 5 U.S.C.  2302(b)(8). Thus, if
    such issues are raised by appellants as defenses in any appeal filed
    pursuant to the language contained in S. 1250, an administrative law
    judge acting on behalf of the MSPB will be required under law to
    consider those defenses prior to issuing a final decision.
    Restriction on the Issuance of Stays of Personnel Actions
        S. 1250 provides that the ``Merit Systems Protection Board or any
    administrative law judge may not stay any personnel action.'' While I
    take no policy position on this language, I note that it appears to be
    in direct conflict with 5 U.S.C.  1214(b)(1)(a)(i) and (ii), which
    allows the Office of Special Counsel to seek, and the MSPB to grant, a
    stay of any personnel action ``if the Special Counsel [and the MSPB]
    determines that there are reasonable grounds to believe that the
    personnel action was taken as a result of a prohibited personnel
    practice,'' including illegal retaliation for lawful whistleblowing. I
    would recommend that the Committee make clear whether it wishes to
    prohibit OSC from seeking--and the MSPB from granting, in appropriate
    circumstances--stays of personnel actions that may be the result of
    prohibited personnel practices with respect to the agency and employees
    covered by this legislation.
        This concludes my written statement. I am happy to address any
    questions for the record that Members of the Committee may have.
                                     ______

      Prepared Statement of Hon. W. Ron Allen, Chairman, Self-Governance
       Communication & Education Tribal Consortium; Tribal Chairman/CEO,
                           Jamestown S'Klallam Tribe
        On behalf of the Self-Governance Communication & Education Tribal
    Consortium (SGCETC), I am pleased to provide the following written
    testimony regarding Senate Bill 1250 (S. 1250), Restoring
    Accountability in the Indian Health Service Act of 2017. SGCETC
    appreciates the time, attention and effort this Committee and others
    have devoted to improving the quality and access to health care for all
    American Indians and Alaska Natives (AI/ANs). While we agree that
    legislation offers new opportunities for IHS, Self-Governance Tribes
    cannot support the legislation as introduced.
        Today, 352 Federally-recognized Tribes and Tribal Organizations
    exercise Self-Governance authority to operate and manage health
    programs previously managed by the Indian Health Service (IHS), while
    many more continue to evaluate their opportunities. As Tribes assume
    greater authority over the delivery of health care in their
    communities, legislation like S. 1250 is increasingly important to us
    as we seek to gain more autonomy in the management and delivery of
    health care programs in partnership with the IHS. This collaboration
    has proven successful and has improved the Indian health system that
    existed prior to the passage of the Indian Self-Determination and
    Education Assistance Act (ISDEAA).
        Over the last decade, this Committee, in partnership with Tribes,
    has passed several pieces of legislation that provided opportunities to
    modernize IHS, support self-determination, and permanently reauthorize
    the Indian Health Care Improvement Act (IHCIA). Similarly, shared
    efforts and continued partnerships will be required to successfully
    correct the health care quality challenges that IHS faces.
        We would be remiss without first reiterating that the agency is
    chronically underfunded, and receives a fixed amount of appropriations
    each year to provide health care for 2.2 million AI/AN people, a per
    capita spending level that is the lowest of any healthcare system. AI/
    AN have the right to have quality health care services, but without
    proper resources put behind these intentions, it is unlikely to be
    fully successful. We appreciate Congress expanding health programs in
    the Indian Health Care Improvement Act to increase access to health
    care services in Tribal communities, but more is needed to both
    appropriately fund these initiatives and further incorporate new and
    innovative ways to modernize IHS health delivery. Without funding to
    address the information technology gap, to treat critically diagnosed
    patients with specialized care, and improve the facilities to maintain
    accreditation and accommodate the diverse cultural health needs of
    native people, IHS will remain an outdated system that is locked in a
    ``time capsule'' and unable to achieve its mission of ``raising the
    health status of AI/AN to the highest possible level.''
        We offer the following recommendations for the Committee to
    consider and hope that additional Tribal input will improve the
    legislation to make meaningful progress toward modernization of the
    IHS.
    General Recommendations
        This legislation offers many solutions to some of IHS' leading
    challenges, including provider recruitment and retention and filling
    shortages, improving quality care and increasing Tribal engagement and
    culture in the system. While we have some specific comments below to
    provide additional insight and to identify potential unintended
    consequences of certain provisions, we also recommend that specific
    legislation be considered to advance the Federal policy that has proven
    to improve quality, increase access to care for Tribal citizens and
    reduce the federal bureaucracy--Self-Governance.
        Self-Governance is the most successful partnership between the
    Federal and Tribal governments to ever exist. S. 1250 does articulate
    protections for Tribes to assume programs, services, functions, and
    activities at any time. However, it does not encourage or create
    additional opportunities for Tribes to assume these responsibilities.
    We hope that in future legislation, the Committee will consider
    legislation to expand Self-Governance and assure Tribal rights to
    assume management of their health care.
        Additionally, Self-Governance Tribes note that the legislation does
    not authorize additional appropriations to support the new initiatives.
    We strongly believe that overlooking the funding necessary to properly
    implement the proposed programs will likely result in diminished
    returns on the Committee's efforts. In fact, even though IHCIA was
    permanently reauthorized seven years ago, more than 20 provisions
    remain unfunded and therefore unimplemented. As this legislation moves
    forward, we recommend and offer any support to Senators who can seek
    additional appropriations for IHS to improve the quality and access to
    care for all AI/ANs.
    Creating Parity between IHS and Veterans Health Administration
        Many of the programs which stand to remain unimplemented are those
    that seek to address IHS' provider shortage and vacancies. Self-
    Governance Tribes were heartened by the efforts this legislation makes
    to bring parity between the Veterans Health Administration (VHA) and
    IHS in provider compensation and personnel policy, to expand the IHS
    Loan Repayment Program, and to create demonstration projects to employ
    successful recruitment and retention strategies. However, some of the
    proposals do not recognize the challenges that exist in Indian Country.
    For instance, the housing voucher program included in Section 101 is
    limited to three years and does not acknowledge that the real challenge
    in Tribal communities is that there is a housing shortage. Recognizing
    that appropriations for IHS-constructed provider housing are far below
    need, granting IHS authority and flexibility to explore innovative
    means for addressing housing shortages would be extremely helpful. At a
    minimum, we ask that the Committee considers extending the termination
    date for this program as well as authorizing appropriations so that IHS
    and Tribes can properly support such a voucher program.
        Similar to VHA, this legislation also provides IHS additional
    flexibility to take personnel actions or to remove employees when
    necessary. Self-Governance Tribes agree that additional authority to
    manage employee performance is essential to improving quality of care
    over time. These practices also more closely mirror private industry
    standards for personnel management.
    Addressing Provider and Administrator Vacancies
        This legislation responds to long-standing Tribal requests to
    modify IHS authorities to increase qualified providers and health
    administrators through expansion of the IHS Loan Repayment Program in
    Section 104. Self-Governance Tribes support the increased flexibility
    in eligibility for the Loan Repayment Program, as it is an important
    tool for recruitment and retention. We recommend that this section be
    expanded further to provide the IHS with flexibility to repay student
    loans for shortages of providers in geographic areas with chronic
    vacancies as long as the provider agrees to serve at least 4 years in
    that location.
        Though we appreciate the efforts to better include Tribal
    leadership in important hiring decisions, we are concerned that the
    legislation may have inadvertently included too many positions for
    Tribal notification. The legislation includes the ``position of a
    manager at an Area office or Service unit'' under the Tribal
    notification requirement in Section 105(a). Self-Governance Tribes are
    concerned that this could be interpreted quite broadly and that a
    ``too'' general interpretation of this language could include an
    overwhelming number of positions at the local and area levels--creating
    significant administrative burdens for IHS Human Resources staff. This
    may lead to unintended consequences, including further delays in the
    hiring process for critical day-to-day program management and vacancy
    rate increases. The highest-level managers should have Tribal support;
    however, program level management decisions should be left to the
    Senior Executive Service (SES) positions and service unit Chief
    Executive Officers (CEOs) so as not to interfere with their autonomy,
    accountability and ability to fill vacancies at the earliest
    opportunity.
        With regard to the waiver of Indian Preference in hiring in Section
    105(b), we are unclear of the intention to allow waivers in order to
    consider former employees that have been removed from employment or
    demoted for performance or misconduct. This would seem to be at odds
    with our collective goals to provide quality health care services.
        S. 1250 offers a few solutions to improve the Service's ability to
    hire employees, including centralization of medical credentialing and
    direct hire authority. Self-Governance Tribes know all too well that an
    efficient hiring process will increase quality and access to care. We
    fully support shared credentialing throughout the IHS-operated
    facilities as proposed in Section 102, allowing IHS to efficiently
    deploy and assign providers to facilities as needed. A centralized
    medical credentialing process has been initiated by the IHS through
    Tribal Consultation under a Quality Framework, and is currently being
    implemented. We support full implementation of the Framework, and while
    IHS has created a small staff to implement the Framework by
    reallocating existing resources, implementation would be expedited and
    enhanced by appropriately funding this effort through additional
    appropriations. We further recommend that the Committee protect current
    and future Self-Governance Tribes' rights to choose to operate their
    own credentialing systems or leverage the efficiency of a centralized
    credentialing system and quality standards administered by IHS.
        Another opportunity the bill offers IHS is the Staffing
    Demonstration Project included in Section 109. Self-Governance Tribes
    know the value that demonstration projects can create in Indian
    Country. Demonstration projects often establish best practices and
    scalability of a program. However, the proposed project seems over-
    limiting in that it only includes Federally-operated sites with
    significant third-party resources. Staffing shortages are a challenge
    for all rural health care systems. Self-Governance Tribes recommend
    that access should be broad enough to include Tribes who are managing
    their health services and wish to exercise their right to participate.
    The provisions should address cases when Tribes wish to exercise their
    Self-Governance authority during the demonstration project. Self-
    Governance Tribes also recommend that an option be available to Tribal
    Health Programs to extend the liability protections for health
    professional volunteers under Section 103.
        The legislation does not address one common recommendation Tribes
    previously made to this Committee to improve recruitment and retention
    of providers. The loan repayment program has proven to be the IHS's
    best recruitment and retention tool to ensure an adequate health
    workforce to serve in the many remote IHS locations. Self-Governance
    Tribes recommend that the Committee included a provision that would
    provide IHS loan repayment program the same tax free status enjoyed by
    those who receive National Health Service Corps (NHSC) loan repayments.
    Under the IHS and NHSC programs, health care professionals provide
    needed care and services to underserved populations. However, the IHS
    uses a large portion of its resources to pay the taxes that are
    assessed on its loan recipients. Currently, the Service is spending
    29.7 percent of its Health Professions' account for taxes. Making the
    IHS loan repayments tax free would save the agency $7.21 million,
    funding an additional 232 awards. Changing the tax status of the IHS
    loans to make them tax free would enable the agency to fill two-thirds
    or more of the loan repayment requests without increasing the IHS
    Health Professions' account.
    Improving Timeliness of Care
        Self-Governance Tribes recognize that access to care can be
    partially measured by evaluating patient wait times. We appreciate the
    efforts by the proposed legislation in Section 107 to require
    measurement and accountability for patient wait times. The Improving
    Patient Care (IPC) initiative, which began in 2008, provides a good
    foundation for measuring wait times as well as other measures, and we
    would recommend the IHS implement IPC in all of its facilities.
    However, additional time may be necessary to develop the rule. One
    hundred and eighty days would likely not allow for the proper
    development of a policy and required Tribal consultation. We would
    recommend additional time to develop a new set of standards. Further we
    hope the Committee will consider requiring Consultation prior to
    implementation and that data collected be available to impacted Tribes
    on a regular basis.
    Establishing a Formal Tribal Consultation Policy
        In the Department of Health and Human Services, IHS has set the
    gold standard for government-to-government consultation. The IHS policy
    has undergone many revisions and continues to be updated as the
    relationship between Tribes and IHS changes. Tribes have been an active
    partner with the IHS in the development and subsequent changes of the
    IHS Tribal Consultation Policy. If a negotiated rule is required as
    described in Section 110, it may unnecessarily limit future Tribal
    engagement or restrict the flexibility the agency requires to serve the
    best interest of Tribes. Generally, Self-Governance Tribes agree there
    is always room to improve implementation of the IHS Tribal Consultation
    Policy, but we are unsure that development of a rule will create the
    enforcement and results the Committee is seeking.
    Fiscal Accountability
        While Self-Governance Tribes are supportive of the Committee's
    effort to ensure that valuable resources are committed to improving
    patient care, we believe this is a provision that needs additional
    consideration before passage. The current language in Section 202 is
    significantly more restrictive than current regulations and could
    inadvertently impact both the ability of the IHS to meet its
    obligations to provide care, as well as current and future Self-
    Governance opportunities.
        Specifically, narrowing the use of unobligated funds may negatively
    impact the ability of IHS and Tribes to meet accreditation standards
    and requirements in the future such as technology requirements, which
    may include additional spending categories other than those included in
    this Section. The language also does not take into account specific
    appropriations for Facilities and Contract Support Costs, which are
    limited to those appropriations accounts, and much of this funding is
    intentionally available until expended. These provisions would also
    seem to limit IHS' ability to pay funds to a Tribe under a Title I or
    Title V contract that were collected associated with a Program,
    Service, Function or Activity that is being assumed for operation by a
    Tribe. These provisions could also complicate IHS service delivery when
    there are delays in the appropriations process. Finally, the Section
    should be clarified to apply only to the IHS directly-operated program.
        With regard to the reporting requirements of Section 202, it
    appears as though the fiscal year reporting required under this section
    would also include Title I and Title V contracts and funding
    agreements. Under current law, IHS would not have the ability to obtain
    information to accurately report the requested information, because the
    fiscal data is reported by Tribes under their required audits.
        In closing, SGCETC would like to thank the Committee for the
    opportunity to submit testimony and feedback. We look forward to
    working with you to improve the quality and access to care at IHS.
                                     ______

          Prepared Statement of the Navajo Housing Authority Board of
                                 Commissioners
        Honorable Chairman Hoeven and Vice Chairman Udall, and members of
    the committee, thank you for the opportunity to provide written
    comments on a crucial legislative proposal aimed at improving the state
    of housing in Indian Country. The Navajo Housing Authority (NHA) Board
    of Commissioners, the President of the Navajo Nation, and the Navajo
    Nation Speaker recognize your commitment to Indian Country. We greatly
    appreciate your efforts to improve housing in Indian Country. We are
    grateful for the opportunity to provide this written statement to the
    United States Senate Committee on Indian Affairs for review of the
    following legislative bills: S. 1250, a bill to amend the Indian Health
    Care Improvement Act; S. 1275, the ``Bringing Useful Initiatives for
    Indian Land Development,'' (BUILD Act of 2017); and a bill relating to
    the HUD/VA Veterans Affairs Supporting Housing (HUD-VASH) program. It
    is NHA's and the Navajo Nation's goal to work with Congress in
    addressing our mutual interests in advancing effective policies to
    build economic and community development by addressing healthcare and
    housing.
    Background on NHA
        The Navajo Housing Authority is the Tribally Designated Housing
    Entity (TDHE) for the Navajo Nation. NHA is the largest Indian housing
    authority and is nearly the eighth largest public housing authority in
    the United States. NHA is comparable in size to the public housing
    agency for the City of Atlanta. The Navajo Nation is the largest Indian
    tribe in the United States, with a total enrollment of approximately
    320,000 tribal members, a land base of 26,897 square miles (larger than
    West Virginia) that extends into the states of Arizona, New Mexico, and
    Utah.
        Comprised of 365 employees headquartered in Window Rock, Arizona
    and 15 field offices across the reservation, NHA manages 9,200 rental
    and homeownership units including 43 administrative facilities, and
    oversees an additional 1,800 units from sub-recipients. The 15 field
    offices deliver housing services to tribal members that reside within
    110 Chapters (local regional government units) and the surrounding
    communities.
    S. 1250 Indian Health Care Improvement Act
        Indian Healthcare Service (IHS) programs, administered by the
    Department of Health and Human Services, are the single largest
    investment into tribal communities at $3.5 billion annually. From this
    amount, $446 million is used to fund sanitation facility
    infrastructure. As NHA and many tribal housing programs have previously
    mentioned, those sanitation funds are impeded by appropriations
    language that restricts IHS funds from being comingled with the funds
    received through the Native American Housing Assistance and Self-
    Determination Act (NAHASDA). In short, this limits a tribe's ability to
    maximize the federal investment.
        The Administration and Congress have vowed to spur growth into the
    economy by funding infrastructure, however a key challenge to providing
    housing in tribal communities is the lack of infrastructure, especially
    in rural areas. Development costs in rural areas are higher and can
    easily double the price tag or even make housing development impossible
    in many places. On Navajo, there is often no sanitation infrastructure
    and using NAHASDA funds alone for development, although authorized for
    infrastructure, significantly eats into housing funds which is
    unnecessary. Tribes should be allowed to leverage federal funding
    sources (NAHASDA and IHS sanitation funds) for developing the necessary
    sanitation infrastructure. NHA respectfully requests this Committee to
    seriously consider language that would statutorily allow the co-
    mingling of IHS sanitations funds so that the federal investment into
    infrastructure could be maximized.
    S. 1275 the ``Bringing Useful Initiatives for Indian Land
            Development,'' or BUILD Act of 2017
        NAHASDA was passed in 1996 with the Congressional intent to empower
    tribes to build homes for low-income families in Indian Country. We
    hope this intent continues in the BUILD Act, while also eliminating any
    duplicative requirements to streamline the building of homes.
        The Build Act has 6 sections that re-authorizes and amends the
    Native American Housing Assistance and Self-Determination.
        Section 2: Consolidated Environmental Review (ER), this section
    authorizes a tribe who comingles federal funds from different agencies
    will discharge the tribe from other applicable environmental review
    requirements of the other applicable agencies under Federal law if the
    largest source of federal funding is from HUD. NHA and Navajo Nation
    support this provision.
        Section 3: Reauthorizes NAHASDA from 2018 through 2025. NHA and
    Navajo Nation support this provision.
        Section 4: Extension of Leasehold interest for housing from 50
    years to 99 years. NHA takes no position on this provision.
        Section 5: Reauthorizes Training and Technical assistance from 2018
    through 2025. NHA and Navajo Nation support this provision.
        Section 6: Reauthorizes the Indian Loan Guarantee program (commonly
    known as the 184 loan program) from 2018 through 2025, with a
    limitation on funding at $12.2 Million. NHA and the Navajo Nation
    support the reauthorization of the 184 Loan Program but do not support
    a limitation on funding.
        Section 7: Authorizing Leveraging: Allows for all grants funds
    under NAHASDA to be used for purposes of meeting matching or cost
    participation requirements under any other Federal or non-Federal
    programs. NHA and the Navajo Nation support this provision.
        NAHASDA outlined dual roles for Indian housing, to build safe homes
    and sustainable communities while spurring economic development. Under
    the Indian Housing Block Grant (IHBG), funding must first cover the
    continuing support of the remaining housing stock that was funded under
    the 1937 Housing Act. NAHASDA includes other eligible activities such
    as new construction, acquisition and rehabilitation, thus in addition
    to the above sections in the Build Act, NHA supports additional
    provisions in the Re-authorization of NAHASDA. These additional
    provisions will stream-line the administrative workload of tribal
    housing entities and reduce the duplication of rules and regulations
    between federal agencies. This will help TDHE's focus on building new
    homes efficiently and effectively.
        NAHASDA expired on September 30, 2013. Since its expiration, the
    act's funds have been reauthorized on a yearly basis. This has caused
    uncertainty for Tribally Designated Housing Entities (TDHE) to meet the
    construction timelines, which furthers the delay of building any new
    homes. Reauthorizing NAHASDA through the BUILD Act will eliminate any
    uncertainty for funding housing projects in Indian Country.
    S. 1333 HUD/VA-Veterans Affairs Supportive Housing
    NHA Success with HUD-VASH Program
        Tribal HUD-VASH recipients are having success placing tribal
    veterans into local supportive housing but we need the program to be
    permanently authorized or else we risk leaving those homeless Native
    Veterans without affordable housing options that include critical
    supportive services.
        HUD approved 20 HUD-VASH vouchers for NHA in the amount of $268,835
    on January 6, 2016. NHA has prioritized and incorporated the 20 VASH
    vouchers for homeless Navajo Veterans and to date we have issued nine
    vouchers (four have found housing) in Arizona and New Mexico. These
    homeless Navajo Veterans were reviewed by case-managers and determined
    eligible for the program and were immediately issued a voucher.
    Furthermore, NHA took efforts and instituted its own Veterans Housing
    Assistance Policy. This policy goes above and beyond Federal
    legislative authority and has helped over 120 veterans become
    homeowners and has extended $8.8 million in veteran debt forgiveness
    and assisted 17 widowers/mothers of service men and women through NHA's
    veterans housing assistance program.
    Project Coordination
        NHA partners with Veterans of the Armed Services residing on the
    Navajo Nation and are eligible to receive housing assistance services
    through the Department of Navajo Veterans Affairs (DNVA). The DNVA
    partners with Federal, state and local services, but the amount of case
    management that is needed to service our veteran population is large
    and additional federal resources are needed. Navajo has one case
    manager for the HUD-VASH program to handle cases that cover the entire
    Navajo reservation (Navajo extends into three states: Arizona, New
    Mexico and Utah). Moreover, the remote location of the reservation is
    not conducive to providing adequate case-management unless that
    casemanagement can be provided in their community as opposed to off the
    reservation. NHA believes a solution is to provide for more case-
    managers to meet the needs in the Navajo community.
    Place-based Vouchers
        The biggest problem with using the tenant based rental assistance
    vouchers on the Navajo Nation is the lack of private or non-profit
    housing for renters. Therefore, the HUD-VASH program should allow
    rental assistance vouchers to be used for housing currently included in
    the housing stock of the tribal housing program. NHA's only option for
    using our HUD-VASH rental vouchers is to use Section 8 approved
    properties off the reservation. This solution will not help veterans
    who are needing supportive services who wish to stay on the reservation
    close to their family who are helping in their recovery. Thus, creating
    a place based voucher system that stays on the reservation, where most
    tribal veterans reside is the best option to alleviate our TDHE's lack
    of public and non-profit housing.
    Conclusion
        It is the goal of NHA and the Navajo Nation to help build safe
    sustainable homes for the Navajo People. The re-authorization of
    NAHASDA through the BUILD Act, the development of sanitation
    infrastructure through Restoring Accountability in the Indian Health
    Service Act, and expansion of HUDVASH coordination and program is
    critical in maintaining the growth of the Navajo Nation and sustaining
    the progress of the Navajo People. We hope our testimony can assist
    this Committee in expanding each of these programs for the benefit of
    the Navajo Nation and all Tribal TDHE's. Thank you for this
    opportunity.
                                     ______

      Joint Prepared Statement of Hon. Russell Begaye, President, Navajo
    Nation and Jonathan Hale, Chairman, Health, Education & Human Services,

                             Navajo Nation Council
        As President of the Navajo Nation and Chairman of the 23rd Navajo
    Nation Council Health, Education, and Human Services Committee, we are
    submitting the following written testimony to the Senate Committee on
    Indian Affairs (SCIA) in response to the June 13, 2017 legislative
    hearing on the Senate Bill 1250 ``Restoring Accountability in the
    Indian Health Service Act of 2017.'' We support the overall legislative
    goals of this bill to improve the quality, access, and delivery of
    health care services through the Indian Health Service (IHS). However,
    we remain concerned about several provisions, which are outlined in
    this testimony. Finally, we have concerns regarding the funding of this
    bill and support a commensurate increase in appropriations to support
    increased operations.
        The Navajo Nation is the largest land based Indian tribe in the
    United States spanning over 27,000 square miles across three states:
    Arizona, New Mexico, and Utah. We have over 300,000 enrolled tribal
    members, with nearly 180,000 members living on the Navajo Nation. The
    Navajo Nation easily comprises the largest IHS footprint in Indian
    Country. Therefore, any changes to the IHS system will have an
    overwhelmingly significant effect on our Navajo people.
        The health care system on Navajo Nation includes five Indian Health
    Service direct service units, five tribal health organizations, and the
    Navajo Department of Health. The Navajo Area Indian Health Service
    (NAIHS) is the primary health care provider that serves two federally
    recognized Indian tribes--the Navajo Nation and the San Juan Southern
    Paiute Tribe. NAIHS is responsible for providing health care services
    to nearly 246,776 users through inpatient, outpatient, purchase
    referred care for specialized services, contract providers, and an
    urban Indian health program. The NAIHS system includes five hospitals,
    six health centers, fifteen health stations and twentytwo dental
    clinics. In 2016, as a result of limited funding, the IHS per capita
    expenditure rate for patient health services was just $3,688, compared
    to $9,523 per person nationally. \1\ In order to more fully serve the
    quarter of a million individuals within the Navajo Area, IHS must be
    fully funded to appropriately deliver critical services. Therefore, any
    proposed changes should be accompanied by increased funding to fully
    implement new programs and functions, and to reduce the strain on the
    insufficiently funded IHS system.
    ---------------------------------------------------------------------------
        \1\ IHS 2016 Profile. https://www.ihs.gov/newsroom/factsheets/
    ihsprofile/
    ---------------------------------------------------------------------------
    Employee Compensation
        The Navajo Nation supports section 101 with the intent to create
    parity of employee compensation between the Veterans Administration and
    Indian Health Service. We also support the creation of a Housing
    Voucher program for critical health professionals. However, the
    proposed voucher program is limited to three years, which does not
    address the long-term shortage of adequate housing on the Navajo Nation
    and may inadvertently create a temporary workforce. In order to invest
    in long-term workforce solutions, we suggest establishing a permanent
    program to create more permanent employment opportunities to attract
    quality health care professionals into the IHS system.
    Centralized Credentialing
        We understand that IHS is piloting a similar credentialing system.
    We believe examining the results of the IHS pilot system and further
    tribal consultation will better inform all IHS stakeholders of the
    possible benefits and concerns associated with such a system. As stated
    earlier, we cannot support the creation and implementation of the
    proposed credentialing system if adequate funds are not appropriated.
    Loan Repayment Program
        The Navajo Nation supports Section 104 to increase eligibility for
    the Loan Repayment Program for health administration-related degrees,
    an important tool for the recruitment and retention of qualified health
    care professionals. Health administration-related degrees should be
    considered under the IHS Scholarship program as well. However, it is
    imperative that Congress appropriates new funding to cover these
    programs, as IHS is already severely underfunded.
    Direct Hiring Authority
        The Navajo Nation has grave concerns regarding Section 105, which
    provides the Secretary of HHS with direct hiring authority. We do not
    support waiving Indian Preference in hiring within IHS, as we believe
    there are qualified AI/AN candidates for all IHS positions, including
    Navajo tribal members.
    Employee Removal
        The Navajo Nation understands the need to refine current human
    resources practices to remove ineffective employees. However, in Helman
    v. Department of Veterans Affairs (Fed. Cir.), the proposed process has
    been deemed questionable by the United States Court of Appeals for the
    Federal Circuit. \2\ Therefore, we are opposed to this method, which
    may result in costly litigation further burdening the IHS budget
    intended for health care.
    ---------------------------------------------------------------------------
        \3\ Helman v. Department of Veterans Affairs. http://
    www.cafc.uscourts.gov/sites/default/files/opinionsorders/15-
    3086.Opinion.5-5-2017.1.PDF
    ---------------------------------------------------------------------------
    Standards to Improve Timeliness of Care
        The Navajo Nation supports Section 107, which requires IHS to
    establish standards to improve the timeliness of care in order to
    provide faster care for patients. Wait times at NAIHS facilities are
    notoriously high.
        For example, the Gallup Indian Medical Center (GIMC) provides
    dental exams three days per week. GIMC policy only allows for one
    patient per household per day to receive a dental exam. As a result,
    families are forced to make multiple trips to the facility so that
    various family members can receive critical dental services. Currently,
    GIMC only treats four dental patients per day, which has resulted in
    families arriving well before the opening hours of the facility in
    hopes of receiving care. Patients must then endure wait times greater
    than one hour. Due to the outstanding need of dental services within
    this service region, and the limited resources at GIMC, many patients
    are turned away daily, leaving them without necessary oral health
    services.
        We support the proposed data collection and establishment of
    timeliness of care standards to improve this challenge; however, we
    encourage Congress to appropriate additional funds to support this
    effort.
    Tribal Culture and History Training Programs
        We fully support the development and implementation of tribal
    culture and history training programs for all employees in a particular
    service area. Currently, Navajo employment practices mandate such
    training on the Navajo Nation. The Office of Navajo Labor Relations
    enforces Section 604 of the Navajo Preference in Employment Act, which
    mandates that:

             An employer-sponsored cross-cultural program shall be an
            essential part of the affirmative action plans required under
            the Act. Such program shall primarily focus on the education of
            non-Navajo employees, including management and supervisory
            personnel, regarding the cultural and religious traditions or
            beliefs of Navajos and their relationship to the development of
            employment policies which accommodate such traditions and
            beliefs. The cross-cultural program shall be developed and
            implemented through a process which involves the substantial
            and continuing participation of an employer's Navajo employees,
            or representative Navajo employees. \3\
    ---------------------------------------------------------------------------
        \3\ 15 N.N.C. 604(B)(11)

        Again, we encourage Congress to appropriate funding for this
    activity, which complements current requirements on the Nation.
    Staffing Demonstration Project
        The Navajo Nation understands and supports the overall goals of
    addressing workforce shortages through the development of staffing
    demonstration projects for federally managed health care facilities.
    However, the requirement for tribal contribution for construction funds
    will prevent Tribes from accessing this potential resource. Therefore,
    we believe that this requirement should not be a factor for selection.
    Additionally, we suggest that tribally operated health care facilities
    be considered for participation, such as the 2 tribally contracted and
    3 compacted facilities on the Navajo Nation. The inclusion of these
    facilities fully supports the aims of the Indian Self Determination Act
    (P.L. 93-638).
    Tribal Consultation
        Direct, meaningful Tribal consultation is a crucial part of the
    relationship between Tribal Nations and the Federal Government. In
    current practice, IHS drives the consultation efforts. While the
    proposed legislation is designed to improve consultation, we are
    concerned that a negotiated rulemaking committee may hinder or restrict
    future Tribal consultation. As proposed, potential negotiated
    rulemaking could likely result in a time-consuming and costly process.
    Alternatively, we recommend that the current IHS consultation policy be
    reexamined for improvements and be recommitted to engaging in
    meaningful consultation. Additionally, we suggest that a greater
    emphasis be placed on Tribal concerns as they arise, and this must
    result in meaningful and timely consultation.
    Proposed Reports
        The Navajo Nation supports the directive for the additional
    reporting contained within sections 302-304. To be most effective,
    reports should be developed in collaboration with Tribes. Reports
    should then be presented to affected Tribes for comment before the
    final version is officially released.
    CMS Survey
        The Navajo Nation supports the call for a CMS compliance survey.
    Again, to be most effective, the proposed survey should be developed in
    collaboration with Tribes. Reports should be presented for Tribal input
    before the final version is officially released.
    Conclusion
        In conclusion, we would like to thank the Senate Committee on
    Indian Affairs for the opportunity to submit testimony and feedback. As
    it is the goal of the Navajo Nation to ensure delivery of quality
    health care for our Navajo people, we appreciate Senators Barrasso,
    Thune, and Hoeven's efforts to improve health services within the IHS.
    It is critical that we find successful, lasting solutions to the
    current challenges facing Indian health care system, including the
    recruitment and retention of employees and unacceptable standards of
    care. We hope this testimony can assist the Committee in improving the
    quality, access, and delivery of health care services through the
    Indian Health Service (IHS). Thank you.
                                     ______

       Prepared Statement of United South and Eastern Tribes Sovereignty
                                Protection Fund
        On behalf of the United South and Eastern Tribes Sovereignty
    Protection Fund (USET SPF) we write to provide the Senate Committee on
    Indian Affairs with the following testimony for the record of its June
    13, 2017 legislative hearing on S.R. 1250, the Restoring Accountability
    to Indian Health Service Act of 2017.
        USET SPF is a non-profit, inter-tribal organization representing 26
    federally recognized Tribal Nations from Texas across to Florida and up
    to Maine. \1\ Both individually, as well as collectively through USET
    SPF, our member Tribal Nations work to improve health care services for
    American Indians. Our member Tribal Nations operate in the Nashville
    Area of the Indian Health Service, which contains 36 IHS and Tribal
    health care facilities. Our citizens receive health care services both
    directly at IHS facilities, as well as in Tribally-operated facilities
    under contracts with IHS pursuant to the Indian Self-Determination and
    Education Assistance Act (ISDEAA), P.L. 93-638.
    ---------------------------------------------------------------------------
        \1\ USET SPF member Tribal Nations include: Alabama-Coushatta Tribe
    of Texas (TX), Aroostook Band of Micmac Indians (ME), Catawba Indian
    Nation (SC), Cayuga Nation (NY), Chitimacha Tribe of Louisiana (LA),
    Coushatta Tribe of Louisiana (LA), Eastern Band of Cherokee Indians
    (NC), Houlton Band of Maliseet Indians (ME), Jena Band of Choctaw
    Indians (LA), Mashantucket Pequot Indian Tribe (CT), Mashpee Wampanoag
    Tribe (MA), Miccosukee Tribe of Indians of Florida (FL), Mississippi
    Band of Choctaw Indians (MS), Mohegan Tribe of Indians of Connecticut
    (CT), Narragansett Indian Tribe (RI), Oneida Indian Nation (NY),
    Passamaquoddy Tribe at Indian Township (ME), Passamaquoddy Tribe at
    Pleasant Point (ME), Penobscot Indian Nation (ME), Poarch Band of Creek
    Indians (AL), Saint Regis Mohawk Tribe (NY), Seminole Tribe of Florida
    (FL), Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY),
    Tunica-Biloxi Tribe of Louisiana (LA), and the Wampanoag Tribe of Gay
    Head (Aquinnah) (MA).
    ---------------------------------------------------------------------------
        While we appreciate efforts to address the healthcare disparities
    identified within the Great Plains Area of the Indian Health Service
    (IHS), we feel a broad, one-size-fits-all approach to addressing these
    problems is unwarranted. Not all IHS Areas are experiencing these same
    types of failures, and there are lessons to be learned from the best
    practices they employ. In addition, despite Tribal concerns with
    similar legislation last Congress, this bill was introduced without
    broad Tribal consultation. Any attempts to reform IHS, through
    Congressional action or otherwise, must be accomplished through
    extensive Tribal consultation. Finally, we maintain that until Congress
    fully funds the IHS, the Indian Health System will never be able to
    fully overcome its challenges and fulfill its trust obligations.
    Although USET SPF supports reforms that will improve the quality of
    service delivered by the IHS, we continue to underscore the obligation
    of Congress to meet its trust responsibility by providing full funding
    to IHS and support additional innovative legislative solutions to
    improve the Indian Health System.
    Uphold the Trust Responsibility to Tribal Nations
        The United States has a trust responsibility to Tribal Nations that
    has been reaffirmed time and time again. The most recent reaffirmation
    came though the permanent reauthorization of the Indian Health Care
    Improvement Act when, ``Congress declare[d] that it is the policy of
    this nation, in fulfillment of its special trust responsibilities and
    legal obligations to Indians to ensure the highest possible health
    status for Indians and urban Indians and to provide all resources
    necessary to effect that policy.'' This trust responsibility obligates
    the federal government to provide quality healthcare to Tribal Nations.
    Providing quality healthcare can only be accomplished when these
    programs are fully funded. We further recommend the inclusion of
    language directing the IHS to request a budget that is reflective of
    its full demonstrated financial obligation, as this is the only way to
    determine the amount of resources required to deliver comprehensive and
    quality care.
        As long as IHS remains dramatically underfunded, the root causes of
    the failures in the Great Plains and IHS will not be addressed. In FY
    2015, the IHS medical expenditure per patient was $3,136 while the
    Veteran's Administration, the only other federal provider of direct
    health care services, spent $8,760 per patient--a 36 percent
    difference. Disparities in financing for health care such as these lead
    to disparities in health outcomes. Congress must authorize full funding
    for the IHS in order to make meaningful progress on the chronic
    challenges faced by IHS. We remain hopeful that Congress will take
    necessary actions to fulfill its federal trust responsibility and
    obligation to provide quality health care to Tribal Nations, by
    providing adequate funding to the IHS.
    Authorize Advanced Appropriations
        On top of chronic underfunding, IHS and Tribal Nations face the
    problem of discretionary funding that is almost always delayed.
    Stability in program funding is a critical element in the effective
    management and delivery of health services. Since FY 1998, there has
    only been one year (FY 2006) in which appropriated funds for the IHS
    were released prior to the beginning of the new fiscal year. The FY
    2016 omnibus bill was not enacted until 79 days into the Fiscal Year,
    on December 18, 2015. Delays in funding only amplify challenges in
    providing adequate salaries and hiring of qualified professionals,
    particularly in areas with high Health Professional Shortage Areas
    where many Tribal Nations are located.
        Budgeting, recruitment, retention, provision of services, facility
    maintenance, and construction efforts all depend on annual appropriated
    funds. As Congress seeks to improve IHS' ability to attract and retain
    quality employees, as well as promote an environment conducive to
    effective health care administration and management, we urge the
    inclusion of language that would extend advance appropriations to the
    IHS.
    Clarification for Tribal Health Programs
        When it comes to Tribal Nations operating facilities pursuant to
    the Indian Self-Determination and Education Assistance Act (ISDEAA),
    P.L. 93-638, the current language is ambiguous. We recognize that many
    provisions contain a ``rule of construction'' clause that appears to be
    intended to ensure that the new obligations placed on the IHS in these
    areas would not interfere with Tribal health programs' ability to enter
    into or maintain contracts or compacts under the Indian Self-
    Determination and Education Assistance Act. We believe that such a rule
    of construction is helpful, but are concerned that the precise language
    used does not achieve its goal. Instead, these provisions should be
    revised to simply state they do not apply to Tribally-operated health
    programs. Tribal Nations should have a clear sense of which provisions
    apply to our Tribally-operated programs and which do not.
    Section-by-Section Comments
        Below, USET SPF offers section-by-section comments and concerns.
    Again, S. 1250 should not move forward without additional, thorough
    Tribal Consultation on a national basis.
    Section 101--Incentives for Recruitment and Retention
        In order to address the ongoing challenges with the recruitment and
    retention of IHS staff, the legislation would allow HHS to provide
    housing vouchers or reimburse the costs for those relocating to an area
    experiencing a high level of need for employment. Though this provision
    provides the Secretary discretion to determine whether a location is
    experiencing a high level of need, USET SPF suggests including language
    for positions that are ``difficult to fill in the absence of an
    incentive.'' This addition would allow IHS more flexibility when
    determining when to offer relocation compensation.
        USET SPF agrees that there is a need for recruitment and retention
    programs. However, the establishment of these programs should not come
    at the cost of health care services. USET SPF recommends that
    additional appropriations be authorized for the proposed recruitment
    and retention programs.
        Additionally, it is unclear why the bill includes a sunset date on
    the housing voucher program. It is unlikely that IHS staff housing
    needs will be fully addressed in only a 3-year period. USET SPF
    suggests that the sunset date be stricken.
    Section 102--Medical Credentialing System
        USET SPF has deep concerns about the centralization of any Area
    Office functions, including credentialing. Nashville Area Tribal
    Nations have consistently advocated for Area Office presence and for
    services to be administered at the Area level. Collectively, we have
    worked hard to establish the strong and high functioning Area Office we
    have today. Taking away functions from Area offices causes significant
    backlogs in services, and disrupts an established and trusted
    relationship between the Area Office and Tribal Nations. We believe
    credentialing should be kept at the Area level, utilizing established
    best practices.
    Section 103--Liability Protections for Health Professional Volunteers
            at IHS
        While USET SPF understands that providing an incentive for
    healthcare professionals to volunteer at IHS facilities by protecting
    them from liability would aid in delivering quality healthcare to
    Indian Country, we believe this provision needs further technical
    evaluation to ensure patients and healthcare providers are adequately
    protected. In addition, USET SPF recommends adding language to ensure
    similar protections are available at Tribally-operated facilities.
    Section 104--Clarification Regarding Eligibility for IHS Loan Repayment
            Program
        USET SPF encourages efforts that would expand the Indian Health
    Service Loan Repayment Program to include degrees in business
    administration, health administration, hospital administration, or
    public health professions as eligible for awards. We recommend
    including language that would expand these degrees as eligible under
    the IHS Scholarship Program as well. Allowing for comprehensive
    eligibility under these programs would increase the number of AI/AN
    individuals seeking business and health administration degrees, as well
    as increase the pool of qualified health professionals within Indian
    Country.
    Section 105--Improvements in Hiring Practices
        When it comes to improvements in hiring, three provisions are
    included in S. 1250. On the first of these, Direct Hire Authority,
    language should be included that would require the Secretary to consult
    with the Tribal Nations served by the Area office where the position
    will be filled prior to any secretarial action.
        On the second provision, we appreciate the inclusion of Tribal
    Notification of individuals who have been appointed, hired, promoted,
    transferred or reassigned within IHS. However, language should also be
    included that would provide notification to Area Tribal Nations on
    removals based on performance or misconduct. This would supplement the
    effort of this legislation in increasing transparency and allow Tribal
    Nations to have greater knowledge and confidence in healthcare
    professionals providing services to their citizens.
        On Waivers of Indian Preference, USET SPF firmly believes that the
    providers best suited to care for our communities are ones that come
    from the communities themselves. Therefore, we cannot support the
    inclusion of this provision, which would set a dangerous precedent
    throughout other federal agencies that serve Tribal communities. The
    aims of this provision can be achieved by modifying hiring practices
    within the current legal framework. There is room for improvements in
    hiring practices to ensure that positions are being filled in a timely
    manner with qualified candidates. We recommend directing the Secretary
    to update and streamline Indian preference hiring practices to ensure
    that qualified non-Indian applicants will be considered in cases where
    no qualified Indian applicants are available, at the sole discretion of
    the Tribal Nations served.
    Section 106--Removal or Demotion of IHS Employees Based on
            Performance or Misconduct
        While USET SPF understands the purposes of including language that
    would expand the Secretary's authority to remove or demote IHS
    employees based on performance or misconduct, we believe Tribal
    governments must also be notified when IHS employees within their
    Service Area become subject to a personnel action such as removal,
    transfer or demotion. In under Sec. 606 (d) ``Notice to Congress'', we
    recommend including ``Tribal Governments located in the affected
    service area'' to the list of entities the Secretary would be required
    to provide notification to 30 days after the Secretary takes a
    personnel action on an IHS employee.
    Section 107--Standards to Improve Timeliness of Care
        It is imperative that any timeliness of care standards are
    developed in consultation with Tribal Nations. We note that IHS is
    currently implementing a timeliness standard in accordance with its
    Improving Patient Care (IPC) Initiatives. We urge consultation with the
    170 IHS and Tribally-operated sites that have chosen to participate in
    the IPC Initiative, as well as aligning with these standards with IPC
    to ensure that the standards and reporting are not overly burdensome
    for Tribal health programs.
        In addition, we request that any data collected under the provision
    be provided to Tribal Nations as well as the Secretary.
    Section 108--Tribal Culture and History
        We support the inclusion of Section 108 that would require annual
    and mandatory cultural competency trainings for IHS employees,
    including contractors. However, because each Tribal Nation is unique,
    language should be included that would require IHS to compile these
    trainings through consultation with the Tribal Nations they serve, on a
    regional basis.
    Section 110--Rule Establishing Tribal Consultation Policy
        While IHS is currently operating under an existing Tribal
    Consultation Policy, it may be appropriate for Tribal Nations to
    reexamine and reevaluate its efficacy. Tribal consultation is a
    cornerstone of the relationship between federally recognized Tribal
    Nations and the federal government. We do, however, have concerns about
    the functionality of a negotiated rulemaking and its potential to
    divert attention and resources away from patient care. USET SPF
    encourages the use of a Tribal/Federal workgroup to examine, evaluate
    and update the existing policy and approve through the Public Comment
    procedures versus official negotiated rulemaking.
    Section 202--Fiscal Accountability
        USET SPF has concerns with this section and its effect on base
    funding. This section requires further technical evaluation and
    explanation, including from IHS, in order to assess its true impact.
    Section 302-304--Reports by the Secretary of HHS, Comptroller General,
            Inspector General
        USET SPF recommends including language that would require greater
    collaboration and consultation with Tribal Nations. We feel the reports
    laid out in this section should be conducted in collaboration with
    Tribal Nations and provided to those Tribal Nations for consultation
    prior to their release to Congress or the public.
    Section 305--Transparency in CMS Surveys
        As above, USET SPF recommends adding language that would require
    collaboration and consultation with Tribal Nations during the
    formulation of these compliance surveys. We also believe the results of
    these surveys should be provided to Tribal Nations prior to their
    public release.
    Conclusion
        USET SPF acknowledges the efforts of the Committee and others
    within Congress in seeking to address the long-standing challenges
    within IHS. However, we believes that S.1250 fails to recognize the
    deep disparities in funding faced by IHS and how these disparities
    contribute to failures at the Area level. We maintain that until
    Congress fully funds the IHS, the Indian Health System will never be
    able to fully overcome its challenges and fulfill its trust
    obligations. Finally, a number of provisions within S. 1250 seem to be
    responding to Area-specific concerns. While we stand with our brothers
    and sisters who are experiencing these failures, we ask that the
    Committee strongly consider the national (rather than regional)
    implications of S. 1250, and work with Tribal Nations to ensure its
    impact is positive in all IHS Areas. We thank the Committee for the
    opportunity to provide comments on this bill and look forward to
    further consultation on S. 1250, as well as an ongoing dialogue to
    address the complex challenges of health care delivery in Indian
    Country.
                                     ______

          Prepared Statement of the Department of Hawaiian Home Lands
        Chairman Hoeven, Vice-Chairman Udall, Senator Schatz and Members of
    the Senate Committee on Indian Affairs, we thank you for the
    opportunity to submit written testimony for the Committee's June 13th,
    2017 hearing on S. 1275.
        We want to express our deep appreciation to Chairman Hoeven and the
    members of this Committee for your continuing leadership in seeking to
    address the housing needs of Native American communities.
        Your efforts are a vital part of a long history of congressional
    initiatives--beginning in 1920, when the United States Congress
    recognized the dire circumstances in which native Hawaiians were living
    and enacted legislation to authorize the designation of approximately
    203,500 acres of some of the worst available lands in the Hawaiian
    Islands for homesteading. These lands were intended to provide
    permanent, safe and secure home lands for the indigenous people of what
    was later to become the 50th state of America's union of states.
        The Hawaiian Homes Commission Act of 1920 did not, however, provide
    for an appropriation of funds to develop those designated lands, and
    from that time to the present day, the Hawaiian Homes Commission and
    the Department of Hawaiian Home Lands have struggled mightily to secure
    the financial resources needed to clear forested lands and difficult
    terrain for the development of housing; to assure that roads, clean
    water resources and sources of power, including access to coal-produced
    power as well as solar- and wind-produced energy, can be supplied to
    those housing areas; and to provide for the rehabilitation of the
    native peoples of these islands while celebrating their traditional
    knowledge, language and culture.
        Title VIII of the Native American Housing and Self Determination
    Act (NAHASDA) was the response of the Congress to address the critical
    housing needs of Native Hawaiians. Title VIII moneys have provided
    opportunities for many families over the years:

        The single father of four who lost his job and could not
            qualify for a conventional loan to convert his rental to home
            ownership. With the help of Title VIII funds paying for case
            management services and homeowner financing, a year later he is
            employed and providing for his four children as a homeowner

        The autistic young man living in rural Molokai that now
            owns his own home using NAHASDA mortgage financing and a
            Section 8 home ownership voucher. In 15 years the home will be
            his, permanently affordable.

        The elderly grandmother in Maui on a fixed income who
            received a ready-to-build lot with roads, water, electrical,
            (etc.) financed by NAHASDA. Her son and grandsons, all employed
            in the construction industry, plan to help build the home.

        Today, while significant progress has been made in carrying out the
    Congress' 1920 statutory directive, challenges remain and the goals of
    1920 Act have yet to be fully realized, as documented by the recently-
    released 2017 report of the U.S. Department of Housing and Urban
    Development (HUD) on housing needs in Native America.
        According to the May 2017 Housing Needs of Native Hawaiians: A
    Report From the Assessment of American Indian, Alaska Native, and
    Native Hawaiian Housing Needs HUD study (the study) , Native Hawaiians
    comprise approximately 10 percent of the Native American population of
    the United States. Of this number, approximately 27,000 Native Hawaiian
    households are on DHHL's waitlists.
        While Native Hawaiians living in Hawaii continue to have lower
    incomes, need higher rates of assistance, and experience higher poverty
    rates than other residents of Hawaii, it is not because they are not
    working. In fact, Native Hawaiians participate in the civilian labor
    force (either working or looking for work) at higher rates than do
    other residents of Hawaii, however, the jobs that are available are low
    wage service industry jobs that do not pay enough to keep up with the
    sky-high cost of living in Hawaii.
        The study highlights that within the Native Hawaiian population,
    the Native Hawaiian households on DHHL's waiting list (DHHL applicant
    households) are more economically disadvantaged than are (1) Native
    Hawaiian households overall, (2) residents of Hawaii households, and
    (3) Native Hawaiian households already located on the home lands (DHHL
    lessees). Compared to those groups, DHHL applicant households also
    experience substantially higher rates of overcrowding and significantly
    higher rates of substandard housing.
        Specifically:

        DHHL applicant households have the lowest median income of
            the four groups: $48,000 compared with more than $60,000 for
            the three comparison groups;

        One in five of DHHL applicant households receive public
            cash assistance compared to 7 percent of Native Hawaiians and
            DHHL lessees and 3 percent for residents of Hawaii;

        Nearly 40 percent of DHHL applicant households are
            overcrowded compared to 15 percent of Native Hawaiian
            households and 8 percent of resident of Hawaii households; and

        10 percent of DHHL applicant households lack complete
            plumbing compared with one percent for all other comparison
            groups.

        The study identifies one key area affecting all resident households
    living in Hawaii: housing affordability.
        Cost burden rates for residents of the State of Hawaii of 40
    percent surpass the national rate of 36 percent. Again, Native Hawaiian
    residents experience a higher rate than the state as a whole with
    Native Hawaiian rates at 42 percent. Consistent with the earlier
    trends, DHHL applicant household rates are the worst off--experiencing
    cost burden rates of 46 percent.
        However, for residents of the home lands (DHHL lessees), the cost
    burden is very different. DHHL lessees experience a substantially lower
    rate of cost burden (21 percent) in the Hawaiian home lands communities
    that were sampled. This is due in part to the financial benefits of
    living on the home lands, including substantially-reduced housing cost
    burdens.
        For a family and a community, lower housing costs and a permanent
    home eases the pressures on parents to seek and hold multiple jobs to
    support their families, provides the opportunity for new households to
    form, and enhances the well-being of an entire native people.
        NAHASDA funding has enabled DHHL to address and target those Native
    Hawaiian households most in-need: those waiting to reside on the home
    lands. During the fiscal year ending June 30, 2016, 150 families
    participated in homebuyer and financial literacy education workshops
    and received case management services to help prepare them for
    homeownership as roads, water, drainage, electrical, and other
    infrastructure investments were being made to the home lands with
    NAHASDA resources to prepare housing lots for building.
        During the fiscal year ending June 30, 2017, 98 ready-to-build lots
    were awarded to families on Oahu, Maui, and Kauai. Working with
    selfhelp providers, contractors selected by the families, their own
    family and friends, and home-builders certified by DHHL, these families
    are now building their own homes that address their needs at a level
    they can afford. Another 211 lots are ready to be awarded in fiscal
    year 2018, available to families now because of NAHASDA.
        With NAHASDA monies, DHHL has had the financial ability to address
    those usually left behind. In Hoolimalima, a rental project on the home
    lands that converted to homeownership in the state fiscal year ending
    June 30, 2017, nearly 50 percent of the families were able to
    successfully purchase their homes because of financing offered by DHHL
    using NAHASDA resources. Without NAHASDA, the dream of homeownership
    may never have become a reality for these families.
        Over the years, we have come to know much more about the similar
    challenges that our brothers and sisters in Indian country face--our
    lands are also held in trust--making it difficult to secure loan
    guarantees and mortgage financing in the absence of Federal incentives
    that recognize and seek to address the unique circumstances of trust
    lands.
        We also share with our relatives and friends in the Alaska Native
    community the barriers of the distance of our lands from urban areas,
    creating extremely high construction costs for housing.
        For Native Hawaiians, perhaps most heart-breaking, is to see their
    beloved Hawaii Nei be priced out of their reach as land prices and
    construction expenses soar and new housing is built not for residents
    but for off-shore investors seeking a vacation home or a luxury
    residence. The Hawaiian home lands may be the most important, if not
    only, opportunity for Native Hawaiian families to stay in Hawaii in a
    permanently affordable home on land that will never be sold.
        We endeavor to address the housing needs of a hard-working Native
    population whose families often have incomes below the poverty level;
    who are forced to live in overcrowded conditions simply because the
    housing costs off the home lands are too-expensive; who must work two
    or more jobs just to pay for basic expenses: food, transportation,
    shelter, and utilities. Through financial literacy programs, self-help
    housing projects, and by providing a greater range of housing options
    we are seeking to reduce the burden of housing costs, as well as
    reducing overcrowded households and homelessness for working Native
    Hawaiian families by placing an increasing number of families on the
    home lands.
        We recognize that the resources needed to achieve this goal are
    substantial. For the state fiscal year 2018, DHHL requested over $148
    million from the Hawaii state legislature to address development costs
    associated with the development of new lots and the necessary capital
    for loans for just one fiscal year. Of the requested amount, the State
    provided $34 million or 23 percent of the amount requested. The $2
    million in NAHASDA funds appropriated by the Congress represents a
    little over 1 percent of the amount needed. Clearly, we recognize that
    public resources alone cannot meet the need.
        Accordingly, we have reached out to partners in the private and
    commercial markets who have assisted us in the means of leveraging our
    resources to attract lenders and developers who understand that with
    the development of homes and communities, comes the potential for
    greater economic development for all--as neighborhoods, community
    centers, schools, health care facilities, police and fire protection
    services, grocery supplies, service industries and stores locate in
    newly-developed areas on, near and around housing developments on the
    home lands.
        Housing programs under the authority of Title VIII of NAHASDA,
    including the Native Hawaiian Housing Block Grant, and the section
    184(A) Native Hawaiian Home Loan Guarantee programs, have made the
    dream of home-ownership possible for thousands of native Hawaiians who,
    for generations, have long thought that access to decent, affordable
    housing would never be part of their future.
        We well understand that today, there are those who harbor
    constitutional concerns about the provision of housing to America's
    native people. We believe that those concerns have been answered by the
    Congress in its enactment of over 160 laws, signed by the President of
    the United States, and designed to address the conditions of Native
    Hawaiians, as well as the enactment of hundreds of Federal laws
    addressing conditions in Indian country and Alaska Native communities.
        Like other Native Americans, we seek only to improve the lives of
    our people--loyal Native Americans who have served our country in
    defense of our nation in proportionally greater numbers--we are
    veterans and families of veterans, and we are citizens of the United
    States. Like many Americans, our people simply want to be able to live
    in the land of their forefathers, and provide a good life for their
    children and grandchildren.
        We firmly believe that if we work together, we can together forge a
    legislative path forward which will address the housing needs of all
    Native Americans--always keeping in the forefront of our minds the
    knowledge that throughout its history, our great nation has endeavored
    to assure the highest quality of life for all of its people, including
    America's first indigenous citizens.
                                     ______

     Prepared Statement of Mike Hodson, Chairman, Board of Commissioners,
                          Homestead Housing Authority
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                     ______

           Prepared Statement of the Office of Hawaiian Affairs (OHA)
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                     ______

        Prepared Statement of Robin Puanani Danner, Chairman, Sovereign
              Councils of the Hawaiian Homeland Assembly (SCHHA)
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                     ______

      Prepared Statement of Hon. Troy ``Scott'' Weston, President, Oglala
                                  Sioux Tribe
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                     ______

    Prepared Statement of Hon. Brian Cladoosby, Chairman, Swinomish Indian
                                Tribal Community
        On behalf of the Swinomish Indian Tribal Community (``Tribe''),
    thank you for convening the June 13, 2017, hearing on S.1250, the
    Restoring Accountability in the Indian Health Service Act. The
    legislation would amend the Indian Health Care Improvement Act in
    several ways and would increase transparency and accountability at the
    Indian Health Service (IHS), streamline the hiring of medical staff,
    provide incentives for doctors and nurses to stay on the job, and
    protect whistle-blowers who report violations of health and safety
    rules. Of course, all of these are laudable goals designed to address
    the many disparities in medical and dental health in Indian Country.
        During the hearing, one of the non-tribal witnesses provided
    testimony on Section 102 of the legislation. That section would
    standardize and streamline credentialing at IHS facilities. The Tribe
    would like to provide additional context to ensure that the Committee
    understands that while streamlining credentialing is important,
    volunteers are not a long term solution to health care needs in Indian
    country.
        The Swinomish Tribe and I have a particular passion for improving
    oral health and oral health care in Indian Country. Oral disease is the
    most widespread chronic disease, despite being highly preventable and
    manageable. Oral health is essential to overall health and well-being
    at every stage of life. Like any other infection or disease, oral
    disease must be managed. What is needed to best do this is a workforce
    of skilled and culturally-competent oral health providers who have a
    long-term and consistent presence in tribal communities.
        Dental professionals have recognized the unmet need for oral health
    providers in Indian Country, and have proposed volunteer or other short
    term providers as a solution. We appreciate the commitment of
    volunteers in Indian Country. But this is not an effective way to
    manage any infection or disease, and it has not been successful in
    tribal communities. Instead of looking to volunteers providing surgical
    or other short-term solutions, tribes want to replicate long-term
    strategies that follow a more medical model for oral disease management
    and utilize more members of the dental team.
        In short, we need to think about oral disease and health care
    differently, and that is just what we have done at Swinomish. We looked
    north to Alaska, where for ten years Dental Health Aide Therapists have
    been an integral party of the dental team, providing long-term,
    consistent and culturally-competent care to remote Alaska Native
    populations. The Swinomish Tribe established its own program for
    integrating Dental Therapists into our Dental Clinic team, where all
    dental providers are licensed and regulated under Swinomish Tribal law.
    The State of Washington recently passed legislation explicitly
    recognizing as practitioners Dental Health Aide Therapists who are
    licensed under Tribal law and practicing in tribal communities.
        For more than a year the Dental Therapist at our Swinomish Dental
    Clinic has been successfully working as a member of our oral health
    team. Just like the mid-level providers in our medical clinic,
    expanding the dental team with Dental Health Aide Therapists and more
    efficiently utilizing all members of the dental team has shown strong
    results in Alaska and here at Swinomish for improving oral health.
        Swinomish takes an evidence-based approach to health care.
    Researchers from the University of Washington presented a paper at the
    National Oral Health Conference this year that shows that over a 10
    year period, children and adults living in villages in Alaska with
    Dental Health Aide Therapists had fewer extractions and more access to
    preventive care than villages without Dental Health Aide Therapists.
    There has been a nearly 300 percent decrease in extractions of the
    first four front teeth for children under age three in villages with
    Dental Health Aide Therapists. That is nearly 300 percent more happy
    and healthy smiles--and that is real progress.
        This demonstrated success is the result of consistent, high
    quality, community based oral health care provided by culturally
    competent staff. It was just this success that prompted the Swinomish
    Tribe to license and hire Dental Therapists as part of its team.
        We urge the Committee in its work on this important legislation to
    be cognizant of the need to provide sustained health care for Indian
    country, including oral health. Volunteers are welcome and
    standardizing credentialing will make it more efficient to deploy them.
    Volunteers, however, will never be a long term solution to Indian
    country's unmet health care needs.
                                     ______

                 Prepared Statement of Gundersen Health System
        On behalf of Gundersen Health System we are writing to provide
    testimony in response to the committee hearing held June 13th to
    express support for Senate Bill 1250, (and companion bill H.R. 2662),
    the Restoring Accountability in the Indian Health Service Act.
    Specifically, we are supportive of Section 102, relating to medical
    credentialing systems, and Section 103 applying liability protections
    for professional volunteers.
        Gundersen Health System is an integrated health system located in
    nineteen counties throughout western Wisconsin, southeastern Minnesota
    and northeastern Iowa. Our system includes a primary hospital in La
    Crosse, four critical access hospitals and over 50 clinics throughout
    the region. With over 7,000 employees, we are the largest employer in
    the area. As a Healthgrades Top 50 hospital in overall care, many
    clinical specialty services, and patient experience, we are committed
    to supporting public policy that helps to enrich every life through
    improved community health, outstanding experience of care, and
    decreased cost burden.
        Gundersen Health System is firmly committed to providing services
    to improve the health and wellbeing of communities both near and far.
    Gundersen is proud to have established the Global Partners program that
    has provided needed healthcare services to critical areas both in U.S.
    and throughout the world. Since 2008 Gundersen Health System has
    collaborated with the Pine Ridge Service Unit of the Indian Health
    Service in South Dakota to provide healthcare services to residents on
    the reservation. Throughout this partnership, Gundersen Global Partners
    has continuously sent volunteer physicians, nurses, and staff for week-
    long periods at IHS clinics on the reservation, providing clinical,
    diagnostic, and even surgical services. The volunteers at Gundersen
    have logged thousands of hours of complimentary services for members of
    the Oglala Sioux Tribe, and is proud to continue in this partnership.
        However, administrative barriers have prevented teams from
    volunteering on a consistent basis. Procedures for credentialing of
    healthcare providers for the Indian Health Service have become
    challenging to meeting the needs of individuals and families at Pine
    Ridge. We are very pleased Section 102 establishes a uniform process
    for medical credentialing, including the consultation with existing
    services that would meet the guidelines of the Indian Health Services,
    and efficiently credential volunteer professionals. Removing
    unnecessary duplication, especially for volunteer healthcare providers
    and nurses would provide much needed relief and improve our existing
    partnership.
        In addition, we are supportive of liability protections provided in
    Section 103 of the legislation. We appreciate this provision that
    recognizes the volunteer efforts of our providers by deeming them
    public health service professionals while serving Indian Health Service
    individuals and families.
        On behalf of Gundersen Health System, and our Global Partners
    Program, we greatly appreciate the opportunity to provide comments on
    S. 1250, Restoring Accountability in the Indian Health Service Act.
    This bill would help address administrative barriers and improve our
    ability to provide services for those in need. We thank the Committee
    for holding this hearing and ask the Committee to advance the
    legislation forward.
        Please feel free to contact us with any questions or if you would
    like to learn more about Global Partners Program and partnership with
    the Pine Ridge Reservation.
                                     ______

         Response to Written Questions Submitted by Hon. Jon Tester to
                                Dr. Keith Harris
        Question 1. The Blackfeet reservation is approximately 180 miles
    one way from the nearest VA facility. How is the VA ensuring homeless
    veterans of the Blackfeet reservation or any extremely rural tribe are
    receiving the required direct services under the program?
        Answer. The Department of Veterans Affairs (VA) is ensuring that
    Veterans enrolled in the Tribal Department of Housing and Urban
    Development-VA Supportive Housing (HUD-VASH) program are receiving the
    required direct services under the program. VA case managers are
    located in or near communities served by the tribe. Case managers
    coordinate and provide VA care, including psychosocial services,
    including mental health and substance use disorder care, and also
    connect Veterans to needed services that are available locally. VA also
    has technology capabilities enabling case managers to provide services
    remotely, augmenting the face to face services described above.
        VA case managers are also working collaboratively to ensure that
    the supportive services and resources are available to Veterans. Most
    HUD-VASH programs have sought licensed clinical social workers, who
    provide a wide range of clinical services directly to the Veteran, from
    skill building to substance use disorder treatment to psychotherapy, if
    needed and appropriate. On or near many reservations, VA has community-
    based outpatient clinics (CBOC) that can provide primary care, mental
    health, and substance use disorder assistance. VA also connects
    Veterans to local service providers for assistance that VA cannot
    provide, such as assistance with employment, food or other support. The
    Indian Health Service (IHS) within the Department of Health and Human
    Services, or a tribally operated health program, may also offer primary
    care and specialty services that can be provided locally. In
    circumstances in which VA medical center specialty care is needed, the
    VA case manager can assist in securing transportation for associated
    appointments. VA case managers also have connections with groups such
    as the Elks Club, Military Outreach USA, or Home Depot, who can provide
    furniture and other household items.
        Specific to the Blackfeet Nation, VA has a temporary case manager
    in place until a permanent case manager is hired. The case manager
    travels to the Blackfeet Nation monthly and is available to travel more
    frequently as needed. The current case manager ensures that Veterans
    are connected with the CBOC in Cut Bank, Montana, which provides
    primary care, mental health, and substance use disorders services. The
    case manager also ensures the Veterans are connected with the local IHS
    facility. Additionally, ``Manpower,'' a local community center,is
    located nearby and offers a range of co-located social services,
    including employment services. The Manpower community center also
    provides an opportunity for the case manager to educate key
    stakeholders on VA services, how to coordinate referrals, and promote
    service utilization between VA and the service providers.

        Question 2. How does the VA identify or locate eligible veterans in
    areas with vast geographical challenges such as the Blackfeet Tribe of
    Montana, who are one of the 10 largest tribes in the United States, and
    sit on a reservation of approximately one-and-a-half million acres in
    the remote northwestern part of Montana?
        Answer. VA has found success in identifying or locating eligible
    Veterans by ensuring that the tribal government is part of the
    solution. The tribal government and the tribal designated housing
    entity (TDHE), along with the case manager, are collaboratively working
    on recruitment for eligible Veteran participants. The tribe has a
    central role in referring Veterans, as they are most familiar with
    which Veteran members are homeless or at-risk of homelessness. As one
    example, to enhance the identification of eligible Veterans, the VA
    Portland Health Care System (HCS) Director and the VA Office of Tribal
    Government Relations Specialist met with the Warm Springs tribal
    government, and developed a collaborative approach that has resulted in
    a significant increase in referrals.
        VA case managers are working with the VA Public Relations staff and
    tribes to engage the tribes and other local media (such as: https://
    cheyennearapahotribal.tribune.wordpress.com/2017/05/11/a-veterans-
    guide-to-the-hud-vash-tribal-program-oklahoma-city-ok-va-health-care-
    system/ or http://www.kfyrtv.com/content/news/Iraq-veteran-receives-
    new-home-thanks-to-HUD-VA-housing-grant-387033601.html) in marketing
    the program. The tribal government and TDHEs also directly refer
    Veterans to the VA case manager.
        VA case managers participate in various events hosted by the tribe
    and/or Tribal Veterans Service Officer. VA holds Homeless Veteran Stand
    Downs in tribal communities to meet and speak with Veterans who are
    homeless or at risk of homelessness.
        The HUD-VASH program office holds calls with the Tribal HUD-VASH
    case managers twice each month, at which innovative practices and
    successful engagement strategies are shared. As part of the joint
    training led by HUD and VA with the tribes and VA case managers, there
    have been modules focused on marketing and engagement strategies.
    Tribal entities and case managers worked together in these sessions to
    develop outreach and marketing strategies.

        Question 3. What has VA done to address these specific challenges
    since you wrote me that response letter?
        Answer. VA has been working on the noted challenges including:

        recruiting qualified applicants who are able to work
            independently and have the required clinical skills

        lack of available housing for case managers working on or
            near the reservations

        lack of available office space for case managers

        safety and work related challenges

        transportation challenges

        locating eligible Veterans

        educating TDHEs on the implementation of the principles of
            Housing First, the required model of care for Tribal HUD-VASH

        concerns expressed by tribes regarding program longevity

        In March, there were seven locations that did not have a VA case
    manager hired. Today, there are five locations, but of those, two have
    case managers expected to begin in August, and one is a recent vacancy
    after the case manager accepted another position. Additionally, the VA
    Montana Health Care System (HCS) has a temporary case manager assigned
    until a permanent case manager is hired.
        At this time, there are only two positions that remain difficult to
    fill, Blackfeet Nation in Montana and the Association of Village
    Council Presidents (AVCP) in Alaska. They both were approved for fiscal
    incentives, such as retention and relocation expenses. These positions
    have ongoing open announcements posted on USA Jobs. The case manager
    position for the Blackfeet Nation had two applicants, who interviewed
    on July 18, 2017, and a provisional offer was recently made to one of
    the candidates. While there is no housing available in Browning, case
    managers may live in Cut Bank or potentially in smaller communities or
    farmland areas close to the tribe. The AVCP position has several
    applicants and interviewing will be completed during the week of August
    14, 2017. VA medical centers may elect to expand the range of
    disciplines to include Licensed Marriage and Family Therapists,
    Licensed Professional Counselors, Registered Nurses, Licensed Mental
    Health Counselors, and Licensed Master Social Workers in addition to
    the standard Licensed Clinical Social Workers, particularly in those
    remote or frontier locations where other services may be more limited.
        VA facilities have been working to ensure the implementation of
    Tribal HUD-VASH. Office space continues to be a challenge, but VA case
    managers are teleworking as needed. Additionally, they meet with
    Veterans in community locations and at the TDHE. Some case managers are
    working in space provided by the tribe. Case managers may travel to VA
    CBOC locations for meetings, for Veteran assistance, and to ensure
    Veterans' documentation is submitted electronically. Black Hills VA HCS
    purchased cell phone boosters for their staff to ensure cell coverage
    throughout the reservation, and they also obtained four-wheel drive
    vehicles to account for terrain and weather. This information has been
    shared with other sites. VA is actively collaborating with tribes and
    tribal Veteran Service Organizations on outreach, the referral process,
    and marketing strategies to ensure that tribal members are aware of and
    informed about the Tribal HUD-VASH program. Notably, twenty tribes are
    now housing Veterans and two tribes have Veterans in case management
    who are actively seeking housing. While the limited stock of viable
    rental housing continues to be a concern; tribes are demonstrating
    creativity and flexibility to ensure that housing is available for the
    program. For example, tribes are housing Veterans in communities within
    their service area but off of the reservation, are electing to forgo
    funding for currently unoccupied Formula Current Assisted Stock (FCAS)
    under the Indian Housing Block Grant (IHBG) program, so that the Tribal
    HUD-VASH assistance can be used on that housing unit instead , and
    developing housing with tax credit programs. Tribes have also
    investigated potentially using Federal Emergency Management Agency
    trailers. The recent renewal funding provided by Congress in the budget
    for fiscal year 2017 demonstrates Federal commitment to the program,
    supporting tribes' continuing investment in the Tribal HUD-VASH
    program.

        Question 4. Why has it generally been so difficult to hire case
    managers to provide wrap-around services to homeless Native American
    veterans that are receiving Tribal HUD-VASH vouchers?
        Answer. Case manager recruitment has been challenging in some
    locations, primarily due to the rural/frontier location of the tribe,
    affordable housing challenges for some staff considering a move to a
    location (such as in South Dakota with the Bakken oil and gas field),
    and in a few cases, tribal governance changes such as with Leech Lake,
    which elected a new tribal government; VA was asked by the tribe's
    interim government to stand down hiring until the new government
    determined their interest in program participation. Delays in the
    hiring process have also been a contributing factor.
        The two positions that have been particularly challenging to fill
    are with the Alaska VA HCS associated with the AVCP TDHE, and the VA
    Montana HCS associated with the Blackfeet Nation. VA approved financial
    incentives to facilitate recruitment and retention, including fiscal
    relocation support for case managers for AVCP with the Alaska VA HCS
    and Blackfeet Nation with the VA Montana HCS. The VA medical centers
    also have options for broadening the pool of potential applicants. The
    Alaska VA HCS has opened recruitment to Licensed Marriage and Family
    Therapists and Licensed Master Social Workers, in addition to Licensed
    Clinical Social Workers. At this time, the Montana VA HCS has
    tentatively offered a position to a candidate, and the Alaska VA HCS is
    conducting interviews with applicants.
        As indicated earlier, VA has expanded the pool of clinical
    professions for case manager positions to help recruit qualified
    candidates. This expansion considers the degree of independent practice
    expected of the case manager. VA expects the clinical case manager to
    be able to provide clinically sound mental health and substance use
    services directly to Veterans, particularly when there are regional
    challenges to obtaining those services elsewhere. Case managers in this
    program treat Veterans with high mental health and substance use
    acuity. VA medical centers are responsible for ensuring that the scope
    of practice for each employee is appropriate for the population being
    served, which may require a particular education level, a specific
    number of years of experience, and/or a clinical license.

        Question 5. What are the other challenges that you have seen in
    implementing the Tribal HUD-VASH program, particularly to the extremely
    rural tribes such as the Blackfeet Tribe of Montana? What would you do
    to fix them?
        Answer. The greatest challenge VA has experienced with implementing
    the Tribal HUD-VASH program is the limited amount of housing stock. In
    Montana, more Veterans could be admitted to the Blackfeet Nation's
    Tribal HUD-VASH program, but the case manager is waiting for housing to
    be built and pass the housing quality standards inspections that must
    be completed before the units can be available. Some tribes are
    developing or rehabilitating housing, which similarly creates delay in
    placement.
        Zuni, Hopi, Tohono O'odham, Spokane, Osage and others allow Tribal
    HUD-VASH Veterans to live outside of the reservation due to the
    shortage of housing stock in their tribal communities. While the Tribal
    HUD-VASH program was specifically designed to serve American Indian and
    Alaska Native Veterans in their tribal communities, those sites that
    have been able to most expeditiously implement the program are those
    utilizing housing off of the reservation. The exception isYakama, which
    repurposed existing housing units from a different, previously
    terminated project. Tribes also report that the primary barrier is a
    lack of appropriately sized, decent, sanitary housing stock.
        Some tribes have had difficulty locating Veterans appropriate for
    the program. In response, a number of tribes have opened their tribal
    preference to allow any Native American Veteran who is a member of any
    tribe, living in their tribal area, to utilize the program; which has
    enhanced utilization of their grant resources.
        In areas where the tribe is fully committed to the program and a VA
    case manager is on staff, referrals have been steady and Veterans are
    being housed and are receiving services. Extensive marketing activities
    to recruit additional Veterans are also in place in these areas. There
    are Tribal HUD-VASH locations that have sufficient Veterans to
    completely utilize their grant: Oneida of Wisconsin, Cook Inlet, and
    Tohono O'odham. Additionally, Navajo, Zuni, Osage, Muscogee (Creek),
    Rosebud Sioux, and Lumbee are more than half-way to filling the units
    their grants support. Please see Attachment 1 for additional
    information.

        Question 6. How will you ensure that tribes and tribal entities are
    properly consulted about the implementation of the program? What will
    that consultation look like?
        Answer. VA and TDHEs have identified points of contact (POC) that
    meet and collaboratively discuss the program. VA case managers are
    encouraged to collaborate extensively with the tribes and TDHEs that
    they support. In some locations, the tribe has provided space for the
    case manager to work, which facilitates communication and relationship
    building, while demonstrating the partnership involved with program
    implementation.
        During initial implementation of the program, VA POCs interacted
    extensively with the tribe in program execution. There was an initial
    meeting to discuss implementation and the tribes were engaged in case
    manager recruitment. Specifically, tribes were consulted about ways to
    obtain a case manager. VA offered to develop a contract for case
    management or allow the tribe to request VA obtain a full time VA
    employee as the case manager. VA contracted with one tribe for case
    management. Some tribes were actively engaged in the hiring process and
    participated in the selection of the VA case manager. VA is committed
    to ensuring eligible tribal members or Native American candidates are
    selected, where possible, to further support collaboration and
    consultation. Currently, seven of the twenty case managers VA has hired
    have Native American ancestry, and of those, four are members of the
    tribe with whom they collaborate. One of the case managers that we
    expect to start work in August 2017 is also Native American and, while
    not a member of that tribe, is a descendant of the tribe.
        The earlier question regarding how the case managers are able to
    recruit eligible Veterans provides an example of consultative
    conversations with the tribes. VA worked with HUD to provide technical
    assistance and training for both the case managers and TDHEs,
    connecting them as a team to work on implementation. VA needs the
    tribal government and TDHE to not only help the case managers with
    marketing and referrals, but to also provide their wisdom and
    experience to help locate and engage Veterans through other local
    resources. VA continually looks for ways to engage, collaborate and
    consult with tribes on the program.

        Question 7. How does VA currently work with IHS? Can inter-agency
    collaboration over Tribal HUD-VASH be easily worked into existing
    agreements?
        Answer. VA currently collaborates with IHS in several regards, one
    of which is the 2010 Memorandum of Understanding between VA and IHS and
    pursuant to the VHA-IHS Reimbursement Agreement, under which VHA
    reimburses IHS for direct care services provided to eligible American
    Indian/Alaska Native Veterans at IHS facilities. Expanding our
    relationship with IHS would be beneficial to the Tribal HUD-VASH
    program and the Veterans and tribes that it serves. VA has an excellent
    working relationship with HUD and is confident that collaboration
    involving VA, IHS, and HUD would be beneficial and provide an
    opportunity for VA and IHS to assess the scope, capacity, and ability
    to collaborate at the specific Tribal HUD-VASH locations. VA recommends
    that IHS be consulted to determine the ability to collaborate regarding
    Tribal HUD-VASH within existing agreements.

        Question 8. Once this bill requires them to help support Tribal
    HUD-VASH, how do you envision VA working with IHS to better provide
    supportive services to Native American veterans receiving Section 8
    vouchers?
        Answer. As IHS has existing relationships with tribes, VA is
    confident that there is excellent potential for IHS and VA to
    collaborate. IHS has significant knowledge and experience understanding
    the cultural differences of each tribe, and would be a meaningful,
    collaborative partner for this program. VA had discussions with IHS
    that preceded the administration change that did not yield final
    conclusions. We believe that new discussions, with current leadership
    in both agencies, about how VA and IHS can collaborate and identify
    ways to work together in serving Veterans in Tribal HUD-VASH are
    needed. As appropriate, HUD should also be a part of these discussions.
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                     ______

         Response to Written Questions Submitted by Hon. Jon Tester to
                                Heidi Frechette
        Question 1. The Blackfeet reservation is approximately 180 miles
    one way from the nearest VA facility. How is the VA ensuring homeless
    veterans of the Blackfeet reservation or any extremely rural tribe, are
    receiving the required direct services under the program?
        Answer. This question is best answered by VA. HUD has forwarded
    this question to VA and VA will respond under separate cover.

        Question 2. What are the other challenges (aside from long distance
    to the nearest VA facility) that you have seen in implementing the
    Tribal HUD-VASH program, particularly to the extremely rural tribes
    such as the Blackfeet Tribe of Montana? What would you do to fix them?
        Answer. The Tribal HUD-VASH pilot program was created to provide
    access to the HUD-VASH benefit for veterans who are Native American and
    homeless or at-risk of homelessness and living in or near Indian
    Country. When the Tribal HUD-VASH pilot program was designed and
    implemented, HUD essentially created a new program, administered by
    Indian Housing Block Grant recipients and operating primarily in a
    rural setting. This was accomplished by working closely with the tribes
    and VA to address challenges unique to rural and remote tribal
    communities. The two main challenges HUD and tribes have encountered in
    implementing and administering the pilot program are the lack of
    housing stock, and the length of time it can take to identify eligible
    veterans.
    Lack of Housing Stock
        One of the main challenges with implementing HUD-VASH in Indian
    Country is the lack of available housing stock in the tribal
    communities. Many Tribal HUD-VASH grantees house veterans in the
    community or in nearby locations; however, other Tribal HUD-VASH
    grantee tribes simply do not have available housing stock, or have
    veterans who do not want to move outside of their community to receive
    housing.
        When the Tribal HUD-VASH pilot program was being considered, it was
    contemplated that where there was not adequate housing stock, tribes
    would leverage funding for new units. However, only a handful of tribes
    are adding new units with their Tribal HUD-VASH funding. One reason for
    tribes' reluctance to develop new units is that the program was
    established as a pilot program. Tribes are concerned that if they
    leverage HUD-VASH funding for new units, and then the program is
    discontinued, they would not be able to support the new units.
        As tribes face housing shortages, HUD has encouraged tribes to
    leverage the HUD-VASH rental subsidy to buy, rehab, or construct new
    units. HUD continues to disseminate best practices, troubleshoot
    impediments to progress, and provide training and technical assistance
    on bi-weekly calls, webinars, and as-needed to specific tribes in close
    coordination with HUD's partners at the Department of Veterans Affairs.
        Tribes are also working with each other to house veterans, and are
    seeking opportunities to house veterans in nearby communities.
    Identifying Eligible Veterans
        HUD has found that in some communities, identifying homeless
    veterans is taking longer than expected. Tribal communities are
    typically ineligible for many of HUD's homeless programs, are outside
    the homeless continuum of care operating areas, and often do not have
    homeless shelters, all of which can be a source for identifying
    veterans experiencing homelessness. Homelessness is typically less
    visible in tribal communities. Veterans experiencing homelessness live
    mainly with family or extended family in overcrowded housing, or
    ``couch surf'' among friends and relatives. Therefore, it can be
    difficult to locate and identify veterans who are homeless or at-risk
    of homelessness. Further, it takes time for the VA case manager to
    become known in the community, which is especially important since he
    or she will be going into people's homes to locate and work with
    eligible veterans.
        HUD is working closely with tribes and VA to build a network of
    partners to assist in identifying veterans eligible for the HUD-VASH
    program, including working with tribal Veterans Departments, and
    encouraging known tribal veterans to help identify and recruit their
    fellow veterans who may be eligible. Potential beneficiaries may be
    more likely to seek out the program if a fellow tribal veteran serves
    as an intermediary between them and the VA case manager. HUD continues
    to share best practices with tribes on effective marketing and
    recruitment methods that other tribes have found successful. And
    finally, HUD and VA continue to find ways to engage the Indian Health
    Service to help identify Native veterans, because the IHS serves this
    population at its facilities in Indian Country.

        Question 3. How will you ensure that tribes and tribal entities are
    properly consulted about the implementation of the program? What will
    that consultation look like?
        The demonstration program was designed based on comments received
    from tribes in both regional and national consultation sessions, and
    through an open public comment period. HUD has a website dedicated to
    the program, has provided a series of trainings, has sent ``Dear Tribal
    Leader'' letters to tribes with program information and to solicit
    feedback, and has issued program guidance and a list of ``Frequently
    Asked Questions'' that are responsive to tribal input to keep tribes
    abreast of the program and to solicit additional input.
        Currently, HUD staff directly coordinates with Tribal HUD-VASH
    points of contact (both the tribal contacts and the VA case managers)
    on no less than a bi-weekly basis. Tribes and TDHEs participated in
    HUD's and VA's face-to-face regional technical assistance trainings,
    which were open to questions and discussion amongst the participants,
    trainers and HUD and VA subject matter experts. HUD's Area Offices of
    Native American Programs communicate this feedback to HUD Headquarters
    through written reports and meetings. HUD carefully considers this
    input from tribes and has adjusted its trainings, program guidance and
    implementation strategy based on tribal comments.
        HUD will continue with its existing level of tribal consultation by
    keeping tribes abreast of program changes, having a robust webpage with
    recorded trainings, and actively soliciting feedback from tribes on
    ways to improve and refine the program.

                                      [all]