[Senate Hearing 115-89]
[From the U.S. Government Publishing Office]
S. Hrg. 115-89
S. 1250, S. 1275, AND S. 1333
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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
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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
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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
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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\
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\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.
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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
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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.
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\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.
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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.
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\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.
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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.
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\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.
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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\
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\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).
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In the landmark decision of Cleveland Board of Education v.
Loudermill, 470 U.S. 532 (1985) the Supreme Court held that while
Congress (through statutes) or the president (through executive orders)
may decide whether to grant protections to employees, they lack the
authority to decide whether they will grant due process rights once
those protections are granted. Stated differently, when Congress
establishes the circumstances under which employees may be removed from
positions (such as for misconduct or malfeasance), employees have a
property interest in those positions. Loudermill, 470 U.S. at 538-39.
\7\ Specifically, the Loudermill Court stated:
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\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.
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\1\ IHS 2016 Profile. https://www.ihs.gov/newsroom/factsheets/
ihsprofile/
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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.
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\3\ Helman v. Department of Veterans Affairs. http://
www.cafc.uscourts.gov/sites/default/files/opinionsorders/15-
3086.Opinion.5-5-2017.1.PDF
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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\
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\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.
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\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).
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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]
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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.
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