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


                                                        S. Hrg. 115-89

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

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

                                HEARING

                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 13, 2017

                               __________

         Printed for the use of the Committee on Indian Affairs
         
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT] 



                   U.S. GOVERNMENT PUBLISHING OFFICE                    
27-650 PDF                  WASHINGTON : 2017                     
          
----------------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office, 
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, 
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free). 
E-mail, [email protected]. 

               


                      COMMITTEE ON INDIAN AFFAIRS

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

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

                               Witnesses

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

                                Appendix

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

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

                              ----------                              


                         TUESDAY, JUNE 13, 2017


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Mr. Buchanan. Good afternoon, Chairman Hoeven, Vice 
Chairman Udall, and members of the Committee.
    I am Chris Buchanan, an enrolled member of the Seminole 
Nation of Oklahoma. I am the Acting Director of the Indian 
Health Service. I am pleased to be here and have the 
opportunity to testify before the Senate Committee on Indian 
Affairs on S. 1250, the Restoring Accountability in the Indian 
Health Service Act of 2017.
    The mission of IHS, in partnership with American Indians 
and Alaska Natives, is to raise the physical, mental, social 
and spiritual health of American Indians and Alaska Natives to 
the highest level. Providing quality health care is our highest 
priority. We share the urgency of addressing longstanding, 
systemic problems that hamper our ability to fully carryout the 
IHS mission.
    In November 2016, we launched our Quality Framework and 
Implementation Plan to strengthen the quality of care that IHS 
delivers to patients we serve. Since November 2016, IHS has 
made substantial progress in implementing the Quality Framework 
and addressing many of the challenges you have identified in 
your proposed legislation.
    The Quality Framework guides how we develop, implement and 
sustain an effective quality program that improves patient 
experiences and outcomes. We are doing this by strengthening 
the organizational capacity and ensuring the delivery of 
reliable, high quality health care at IHS direct service 
facilities.
    The new IHS credentialing system will streamline 
credentialing and facilitate the hiring of qualified 
practitioners, as well as privileging and performance 
evaluation of IHS practitioners. It will allow the local and 
area offices to perform these functions in alignment with the 
Centers for Medicare and Medicaid Services' conditions of 
participation and accreditation standards for governance of 
hospitals and ambulatory care facilities.
    We will pilot in four IHS areas in July 2017 and implement 
it across the remaining IHS areas by the end of 2017.
    Ensuring timely access to care requires that we develop 
standards for wait times for appointments, as well as for time 
spent in the provider's offices and that we benchmark against 
clear standards.
    Agency-wide standards for wait times are also in 
development to ensure accountability at the highest level. To 
improve transparency and access to quality of care, IHS is 
implementing a performance accountability dashboard. This 
includes reporting on patient wait times, pilot testing of 
dashboards and associated data collection is targeted for this 
summer.
    Strengthening governance and leadership at all levels of 
IHS is essential to ensure quality health care. IHS now 
requires a standardized governance process and use of a 
standard governing board agenda across all IHS areas with 
federally-operated facilities.
    The first leadership training class to prepare selected 
individuals to serve in leadership positions at the service 
unit area and headquarters levels was launched on June 6 with 
34 participants.
    IHS faces significant recruitment challenges due to remote, 
rural locations of our health care facilities and area offices. 
IHS is implementing various strategies to increase recruitment 
and retention. Global recruitment is one strategy we have 
implemented for a streamlined approach to filling critical 
provider vacancies at multiple locations.
    Applicants only need to apply at a single vacancy 
announcement and can be considered for multiple positions 
throughout the Country. Recruiting for critical positions by 
using a single announcement to recruit for multiple positions 
is showing promise. Now, IHS has priority access to new 
commissioned Corps applicants. This allows IHS to make first 
contact with these applicants in an effort to recruit and fill 
health professional vacancies throughout IHS.
    Also, IHS facilities can use the National Health Services 
Corps' scholarship and loan repayment incentive to recruit and 
retain primary care providers. As of April 2017, 472 NHSC 
recipients are currently part of our workforce serving in IHS, 
tribal and urban facilities.
    These actions demonstrate that IHS is taking its challenges 
seriously and is continuing to take assertive and proactive 
steps to address them. IHS is prepared to provide technical 
assistance on specific authorities proposed in S. 1250.
    Despite all of the challenges, I am firmly committed to 
improving quality, safety and access to health care for 
American Indians and Alaska Natives in collaboration with HHS, 
our partners across Indian Country and Congress. We look 
forward to working with the Committee on this legislation as it 
moves through the legislative process.
    I am happy to answer any questions the Committee may have. 
Thank you.
    [The prepared statement of Mr. Buchanan follows:]

  Prepared Statement of Rear Admiral Chris Buchanan, Acting Director, 
  Indian Health Service, U.S. Department of Health and Human Services
    Mr. Chairman and Members of the Committee:
    Good afternoon, Chairman Hoeven, Vice-Chairman Udall, and Members 
of the Committee. I am Chris Buchanan, an enrolled member of the 
Seminole Nation of Oklahoma and Acting Director of the Indian Health 
Service (IHS). I am pleased to have the opportunity to testify before 
the Senate Committee on Indian Affairs on S. 1250, the Restoring 
Accountability in the Indian Health Service Act of 2017. I would like 
to thank you, Chairman Hoeven, Vice-Chairman Udall, and Members of the 
Committee for elevating the importance of delivering quality care 
through the IHS.
    IHS plays a unique role in the Department of Health and Human 
Services (HHS) because it was established to carry out the 
responsibilities, authorities, and functions of the United States to 
provide healthcare services to American Indians and Alaska Natives. The 
mission of IHS, in partnership with American Indian and Alaska Native 
people, is to raise the physical, mental, social, and spiritual health 
of American Indians and Alaska Natives to the highest level. IHS 
provides comprehensive healthcare delivery to approximately 2.2 million 
American Indians and Alaska Natives through 26 hospitals, 59 health 
centers, 32 health stations, and nine school health centers. Tribes 
also provide healthcare access through an additional 19 hospitals, 284 
health centers, 163 Alaska Village Clinics, 79 health stations, and 
eight school health centers.
    Providing quality healthcare is our highest priority. We share the 
urgency of addressing longstanding systemic problems that hamper our 
ability to fully carry out the IHS mission. In November 2016, we 
launched our 2016-2017 Quality Framework and Implementation Plan to 
strengthen the quality of care that IHS delivers to the patients we 
serve. Implementation of the Quality Framework is intended to 
strengthen organizational capacity to improve quality of care, improve 
our ability to meet and maintain accreditation for IHS direct service 
facilities, align service delivery processes to improve the patient 
experience, ensure patient safety, and improve processes and strengthen 
communications for early identification of risks. The Quality Framework 
will be reviewed and updated at least annually in partnership with 
Tribes.
    The HHS Executive Council on Quality Care (the Council), which was 
stood up in November 2016, provides support to IHS by identifying and 
facilitating collaborative, action-oriented approaches from across the 
Department to address issues that affect the quality of healthcare 
provided to American Indians and Alaska Natives we serve. The Council 
includes leadership from 12 HHS Staff and Operating Divisions. The 
Council's mission is to support IHS' efforts to develop, enact, and 
sustain an effective quality program--to improve quality and patient 
safety in the hospitals and clinics that IHS administers. This may 
include providing technical assistance to bolster quality and safety, 
identifying solutions to address workforce recruitment and retention 
challenges, seeking creative solutions to infrastructure needs, and 
enhancing stakeholder engagement. The Council partners with HHS 
leadership and staff in policy implementation.
    Since November, 2016, IHS has made substantial progress in 
implementing the Quality Framework and in addressing many of the 
challenges you have identified in your proposed legislation.
Strengthening Organizational Capacity
    The Quality Framework guides how we develop, implement, and sustain 
an effective quality program that improves patient experience and 
outcomes. We are doing this by strengthening our organizational 
capacity, and ensuring the delivery of reliable, high quality 
healthcare at IHS direct service facilities.
    We recently awarded a contract for credentialing software that will 
provide enhanced capabilities and standardize the credentialing process 
across IHS. The new system will streamline credentialing and facilitate 
the hiring of qualified practitioners as well as, privileging and 
performance evaluations of IHS practitioners. This will help ensure the 
quality and safety of care delivered in IHS Federal Government 
hospitals and health centers. We are on course with the implementation 
of this medical credentialing system. We expect to test it in four IHS 
Areas in July 2017, and plan to implement it across the remaining IHS 
Areas by the end of 2017. Our agency credentialing policy is in the 
process of being updated.
    Ensuring timely access to care requires that we develop standards 
for waiting times for appointments, as well as for the time spent in 
the provider's office, and that we benchmark against clear standards. 
IHS Service Units currently collect patient wait time data to track the 
patient care experience as part of the Improving Patient Care program. 
Agency-wide standards for wait times are also in development. To ensure 
accountability at the highest level, and to improve transparency about 
access to and quality of care, IHS is implementing a performance 
accountability dashboard. This includes reporting on patient wait 
times. Pilot testing of the dashboard and associated data collection is 
targeted for this summer.
    Strengthening governance and leadership at all levels of the IHS 
system is essential to assuring quality healthcare. IHS now requires a 
standardized governance process and use of a standard governing board 
agenda across all IHS Areas with federally-operated facilities. The 
first leadership training class to prepare selected individuals to 
serve in leadership positions at the Service unit, Area, and 
Headquarters levels was launched June 6th with 34 participants. In 
addition, IHS has begun implementing a leadership coaching and 
mentoring program in the Great Plains Area as new leaders are 
recruited.
Workforce Strategies
    IHS faces significant recruitment challenges due to the remote, 
rural location of our healthcare facilities and Area offices. To make a 
career in IHS more attractive to modern healthcare practitioners, IHS 
is implementing various strategies to increase recruitment and 
retention. Global recruitment is one strategy we have implemented that 
allows for a streamlined approach to filling critical provider 
vacancies at multiple locations. Applicants only need to apply to a 
single vacancy announcement and can be considered for multiple 
positions throughout the country. Recruiting for critical positions by 
using a single announcement to recruit for multiple positions is 
showing promise.
    IHS continues the successful partnership with the Office of the 
Surgeon General to increase the recruitment and retention of 
Commissioned Corps officers, and most recently the IHS has been given 
priority access to new Commissioned Corps applicants. This allows IHS 
to make the first contact with these applicants in an effort to recruit 
them to fill health professional vacancies throughout IHS. This new 
effort began in May, and we can provide periodic updates on this 
effort. IHS also continues to partner with the National Health Service 
Corps (NHSC). Use of NHSC allows IHS facilities to recruit and retain 
primary care providers by using NHSC scholarship and loan repayment 
incentives. As of April 2017, 472 NHSC recipients are currently part of 
our workforce serving in IHS, tribal and urban facilities.
    These actions demonstrate that IHS is taking its challenges 
seriously, and is continuing to take assertive and proactive steps to 
address them.
S. 1250
    S. 1250 proposes specific authorities to aid us in elevating the 
health of American Indians and Alaska Natives to the highest level. IHS 
is prepared to provide the Committee technical assistance on the 
legislation and I would like to provide additional technical comments 
on various sections of the bill.
    Section 101 would address the need for IHS to offer more flexible 
and competitive benefits to recruit employees by establishing a 
comparable pay system as allowed under Chapter 74 of Title 38. IHS 
appreciates the authority we already have to use the pay flexibilities 
under Chapter 74 of Title 38. We are working with OPM, OMB, and other 
affected agencies to explore ways to enhance utilization of our current 
pay authorities to enhance our ability to recruit and retain high 
quality staff.
    Section 102 requires a Service-wide centralized credentialing 
system to credential licensed health professionals who seek to provide 
healthcare services at any Service facility. IHS supports the use of a 
standard system for credentialing. We are implementing a national 
system for credentialing as well as privileging and evaluating 
performance of IHS practitioners. Our new system will allow the local 
and/or Area offices to perform these functions in alignment with the 
Centers for Medicare & Medicaid Services (CMS) Conditions of 
Participation and external accreditation standards for governance of 
hospitals and ambulatory care facilities.
    Section 104 would make certain healthcare management or healthcare 
executive positions eligible professions for loan repayment awards, in 
exchange for non-clinical service obligations. Management expertise is 
very important in a health system as large as IHS.
    Section 106 addresses IHS authority to remove or demote employees. 
IHS has existing authorities to implement adverse employment actions.
    Section 107 requires IHS to develop and implement standards to 
measure the timeliness of care at direct-service IHS facilities. As 
described above, IHS is in the process of establishing agency-wide 
standards for wait times to each federally-operated service unit. A 
process for uniform data collection and reporting is also being 
established.
    Section 108 adds specific requirements for implementation of annual 
mandatory cultural competency training programs for IHS employees, and 
other contracted employees engaged in direct patient care. Cultural 
competency in the IHS workforce is essential to the provision of 
quality care and is a requirement under the accreditation standards for 
hospitals. I have recently issued direction for all IHS employees to 
complete training, which will become an annual requirement.
    Section 110 requires IHS to establish a tribal consultation policy. 
The specific provision is unnecessary as IHS already has a tribal 
consultation policy in place. The requirements for consultation are 
contained in statutes and various Presidential Executive orders 
including: the Indian Self-Determination and Education Assistance Act, 
Indian Health Care Improvement Act, Presidential Memoranda in 1994 and 
2004, and Executive Orders in 1998 and 2000. It is the policy of HHS 
and IHS that consultation with American Indian and Alaska Native Tribes 
will occur to the extent practicable and permitted by law before any 
action is taken that will significantly affect Indian Tribes. IHS is 
committed to regular and meaningful tribal consultation and 
collaboration as an essential element for a sound and productive 
relationship with Tribes.
    Despite all of the challenges, I am firmly committed to improving 
quality, safety, and access to healthcare for American Indians and 
Alaska Natives, in collaboration with HHS, our partners across Indian 
Country, and Congress. I appreciate all your efforts in helping us 
provide the best possible healthcare services to the people we serve to 
ensure a healthier future for all American Indians and Alaska Natives.
    We look forward to working with the Committee on this legislation 
as it moves through the legislative process. Thank you for your 
commitment to improving quality, safety, and access to healthcare for 
American Indians and Alaska Natives. I am happy to answer any questions 
the Committee may have.

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

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

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

  Prepared Statement of Hon. Victoria Kitcheyan, Treasurer, Winnebago 
                    Tribe of Nebraska Tribal Council
    Good afternoon Mr. Chairman and Members of the Committee:
    Thank you for holding this hearing on this very important piece of 
legislation. My name is Victoria Kitcheyan. I am a member of the 
Winnebago Tribe of Nebraska and I currently serve as Treasurer of the 
Winnebago Tribal Council. I also serve as the Great Plains Area 
Representative of the National Indian Health Board and will offer 
national-level comments on behalf of NIHB as well. The National Indian 
Health Board serves all 567 federally-recognized Tribal nations when it 
comes to health. This means we serve both tribes who receive care 
directly from the Indian Health Service and those who operate their 
health systems through self-governance compacts and contracts.
    The Federal Government has a duty, agreed to long ago and 
reaffirmed many times by all three branches of government, to provide 
healthcare to Tribes and their members throughout the country. Yet, the 
federal government has never lived up to that trust responsibility to 
provide adequate health services to our nation's indigenous peoples. 
Historical trauma, poverty, lack of access to healthy foods, loss of 
culture and many other social, economic and environmental determinants 
of health as well as lack of a developed public health infrastructure 
in Indian Country all contribute to the poor state of American Indian 
and Alaska Native (AI/AN) health. AI/ANs suffer some of the worst 
health disparities of all Americans. We live 4.5 years less than other 
Americans. In some states, life expectancy is 20 years less, and in 
some counties, the disparity is even more severe. With these 
statistics, it is unconscionable that some IHS-operated facilities 
continue to deliver a poor quality of care to our people.
    The Winnebago Tribe and national Tribal advocates support the 
efforts of Congress to address the ongoing challenges for health 
delivery at the IHS-operated facilities. We appreciate the commitment 
of the Senate Committee on Indian Affairs to find real change. 
Legislative efforts to address these issues should be conducted in 
tandem with increased oversight and scrutiny over the administration of 
the delivery of care at service units operated by the Indian Health 
Service. The legal current framework for IHS provides much of the 
necessary guidelines for the operation of the agency.
    While we appreciate the speed at which the Senate is considering 
the legislation given the critical situation going on in the Great 
Plains region, we need to make sure we get this right. It is true, our 
people need help. Some of the quality of care issues found at my Tribe 
and elsewhere in the Great Plains region cannot go on any longer. 
However, it is also important that these changes are accompanied by 
input from tribes across the country to ensure the best possible 
outcome and product. We think legislation is needed and would have 
appreciated an opportunity for the Winnebago Tribe and other tribes 
across the county to review any draft legislative language before S. 
1250 was introduced. NIHB is ready and willing to lead a legislative 
consultation on this bill and we intend to do so in throughout the 
coming weeks and months. This step must happen first before anything 
can be enacted.
Winnebago IHS Hospital
    For those of you that may not know, the Winnebago Tribe is located 
in rural northeast Nebraska. The Tribe is served by a thirteen (13) bed 
Indian Health Service operated hospital, clinic and emergency room 
located on our Reservation. This hospital provides services to members 
of the Winnebago, Omaha, Ponca and Santee Sioux Tribes. It also 
provides services to a number of people from other tribes who reside in 
the area. Collectively, the hospital has a service population of 
approximately 10,000 people.
    As I have shared in previous testimony before this Committee, since 
at least 2007 the Winnebago IHS Hospital has been operating with 
demonstrated deficiencies which should not exist at any hospital in the 
United States. The Centers for Medicare and Medicaid Services (CMS) 
deficiencies were so numerous and so life-threatening that in July 2015 
the IHS Hospital in Winnebago became what still is, to the best of our 
knowledge, the only federally operated hospital ever to lose its CMS 
certification. Other IHS facilities in the Great Plains Region have 
been experiencing similar quality of care issues throughout this time 
and are also under threat of decertification by CMS.
    Nearly two years have passed since the Winnebago Hospital lost its 
certification and IHS has yet to submit the application to CMS for 
recertification. Initially, the target date to apply for 
recertification was scheduled for October 2015. Since then, the date 
for submitting the application has been repeatedly delayed. It is an 
extremely frustrating situation and it is unacceptable that such a bad 
situation should take so long to correct. While the staff at the 
facility have been working hard to prepare for recertification and 
corrective action plans have been implemented, including multiple mock 
surveys, staff training and necessary policy changes, the fact remains 
that the facility continues to lack critical resources necessary to 
move forward.
    Senior officials at IHS have said that recertification at Winnebago 
is a top priority, but for some reason the practical resources to 
achieve this have not reached the ground level. The inability to 
generate necessary revenue from all third party sources has caused 
serious budget issues. The financial constraints in addition to 
staffing challenges have kept the facility in a dire situation. The 
Hospital Governing Body finally decided last month that the Hospital 
was ready for recertification. However, the application has not been 
submitted due to key staff vacancies including the CEO, Director of 
Nursing and Lab Supervisor. The fact that these vital positions are 
vacant is a huge indicator that the hospital is not adequately staffed 
to be ready for CMS review.
    Many of the situations that led to the Hospital losing its 
certification in the first place have also played a role in the delay 
to submit the application for recertification. For example, the Great 
Plains Region has operated under an Acting Regional Director for nearly 
one and a half years. At Winnebago, the hospital also operated with a 
series of Acting CEO's until a permanent hire was made approximately 6 
months ago. Both the Omaha and Winnebago Tribes have been very pleased 
with the progress he has made at the facility. Unfortunately, due to 
personal reasons, he is now resigning as the CEO and the position will 
be vacant once again later this month.
    These important leadership roles need to be filled by permanent, 
qualified and dedicated employees who have a vested interest making 
improvements. There have been instances where the IHS has continued to 
hire key personnel without any input from the Tribe and/or ``recycled'' 
employees who were found to be unacceptable at other IHS hospitals in 
the Great Plains Region. A multi-million dollar staffing contract was 
awarded to a company previously used by IHS that had placed 
unsatisfactory employees in many of the Great Plains IHS hospitals. 
Finally, the federal hiring freeze implemented earlier this year caused 
great delays in filling critical positions. While waivers were 
eventually obtained for many positions, it is our understanding that 
some positions necessary for CMS certification remain under a freeze 
status. The hiring freeze is detrimental to the needs of our tribal 
members and others who rely on IHS for their healthcare.
    Many missteps could have been avoided by getting input from the 
Tribes and actually acting on that input. The Governing Body for the 
Winnebago Hospital was basically non-functional around the time of the 
loss of the CMS Certification. Although the Governing Body appears to 
be meeting more often, the tribal representatives have since lost their 
seats on the Governing Body since IHS deemed that the non-IHS members 
(Tribal Council representatives from the Winnebago Tribe and the Omaha 
Tribe) have no oversight over IHS and therefore should not be on the 
Board. This is ridiculous and counter-intuitive. Perhaps Tribal Council 
members have no ``authority'' over IHS, but they know their own 
communities and are more likely to have an interest in holding 
management accountable if their actions are not conducive to patient 
care or a well operated medical facility. We have already learned that 
IHS officials in the Great Plains region were not using their authority 
to police each other, which was another reason that led to the 
decertification in the first place.
    Although some IHS regions around the country seem to function 
better than others, the Great Plains Region has been problematic for 
years, despite several reports conducted by Congress and U.S. 
Government agencies. Many provisions contained within this proposed 
legislation are designed to correct some of the issues that plague the 
Winnebago Hospital and other IHS Hospitals within the region. I will 
now provide more specific comments on S. 1250 and how certain 
provisions will help the situation in Winnebago or how it might be 
amended to meet our specific needs.
Comments on S. 1250
    First, we have some general areas of concern regarding the proposed 
legislation that we would like to stress. There are provisions in the 
bill that address new programs and functions for the IHS, which will be 
beneficial if they are actually funded. We want to make sure the 
legislation does not put forward programs that become in essence 
unfunded mandates. We urge this Committee to work with Appropriations 
to ensure that these provisions are funded so they do not end up just 
being lip service to tribal communities. The Indian Health Care 
Improvement Act was permanently enacted in 2010 and contained many 
provisions designed to modernize the provision of care, such as the 
development of new health care delivery demonstration projects and 
expansion the types of health professionals available within the Indian 
health system. Yet those provisions remained unimplemented due to lack 
of adequate funding. We do not want to see the same type of thing 
happen with this legislation. Congress cannot continue to starve the 
Indian health system and expect major change.
    The Winnebago Tribe is working its way toward self-governance, a 
status many other tribes throughout the country already have. In fact, 
about 60 percent of the IHS budget is delivered directly to the tribes 
through contracts and compacts. The proposed legislation does not do an 
adequate job of stating which provisions of the legislation pertain to 
self-governance tribes and which do not. The legislation provides a 
``Savings Clause'' that appears to ensure that the legislation does not 
interfere with tribal contracting or compacting. Yet the provision at 
607(e) of the proposed legislation is not clear on what provision or 
provisions that Savings Clause language pertains. Since we hope to be a 
self-governance tribe in the reasonably near future we would certainly 
appreciate some clarity regarding the application of this provision. 
The Winnebago Tribe and NIHB are happy to work with you on the drafting 
of that provision.
    The Winnebago Tribe and NIHB support the intent to make a 
streamlined system for licensed health care professional credentialing 
procedures, including volunteers, as outlined in Section 102. However, 
we note that these provisions should not be considered a substitute or 
final step for increasing available providers to the IHS and tribes 
throughout the country. For example, NIHB and the tribes fully support 
the expansion of the dental therapy model, which was first brought to 
the United States by tribes in Alaska in 2004. It is a highly effective 
way to provide reliable, safe, and quality dental care providers to 
underserved areas. We urge the Committee to consider models such as 
these to address the chronic staffing shortages in the Indian health 
system.
    Section 105 addresses Improvement in Hiring Practices. While we 
certainly agree that hiring practices need drastic improvement we are 
not completely comfortable with the language in the proposed 
legislation. First, this provision indicates that the Secretary has 
direct hire authority, which in and of itself is not a bad idea. 
However, the Winnebago Tribe and NIHB want to make sure that Tribal 
Preference is not ignored in the direct hire authority. This provision 
of the proposed legislation goes on to note that the Secretary shall 
notify each tribe in the service area prior to the direct hire taking 
place. While notice is appreciated, it would be useful if tribes could 
file objections to any hire, especially if the new hire is somebody who 
has been recycled through the system previously and has not performed 
well with other tribes in the Region, which has been a common practice 
at IHS. Lastly, this provision provides that the Secretary may seek 
waivers to Indian preference from each Indian tribe concerned if 
certain criteria are met. We understand that when there are no 
qualified ``Indian'' candidates or the Indian candidates have not 
performed well in the past, it may be appropriate to hire a non-Indian 
candidate. However, Tribes are concerned about diminishing Indian 
preference in the hiring process. This path should only be used in the 
most extreme circumstances and should be initiated by the Tribe(s) 
served by the facility in question.
    We are pleased to see a provision addressing the Timeliness of Care 
in Section 107. We believe that timeliness of care has been an issue at 
the Winnebago Hospital and that additional standards to improve the 
reporting and tracking of timeliness are necessary. It should be noted 
that underfunding also contributes to the inadequate and timely care. 
There is currently a system in place that, if implemented, correctly 
tracks these important care initiatives. However, if a region does 
nothing to implement the current system or inadequate staffing impedes 
the ability to track these initiatives, then it becomes a major 
problem. We feel that additional Congressional oversight over this 
particular area may be necessary. Section 107 also states that 
regulations and standards to measure the timeliness of the provisions 
of health care services must be done within 180 days of the enactment 
of this legislation. We are concerned that 180 days may not be enough 
time to develop the regulations and standards if proper consultation 
with the tribes is used to develop said regulations and standards. 
Lastly, we request that any data gathered regarding the timeliness of 
care be provided to the tribes as well as the Secretary.
    The Winnebago Tribe finds Section 108 regarding training programs 
in tribal culture and history to be of utmost importance. Meaningful 
cultural training can do nothing but help IHS employees as they learn 
the history and culture of the people they are serving on a daily 
basis. We think this training should be mandatory and it should include 
all IHS employees from headquarters to all staff at the service unit 
facilities, who have daily interaction with Native American people. It 
would be even more useful if the training involved and was tailored 
specifically for the tribes in the service area.
    Section 110 establishes rules regarding a tribal consultation 
policy. We are in complete agreement that a consultation policy should 
exist and that Tribes should have input into the way services are 
provided to tribal communities. However, it is imperative that the 
consultation policy developed under this section mandate to IHS staff 
that consultation shall be more than simple lip service or a listening 
session with the tribes. It should be viewed as a true partnership and 
collaborative effort. Tribal input is key to IHS in providing high 
quality services and must be taken seriously. The issues with the 
Winnebago Hospital would have never have risen to the level that 
existed if there was true consultation and collaboration at every step 
in this process and they never would have received the attention it has 
if it were not for Tribal action.
    Fiscal accountability is never a bad thing as laid out in Section 
202, but the provision in subsection (b) that addresses the 
prioritization of patient care is somewhat troubling in its 
specificity. This section explains that IHS should only use certain 
dollars for patient care directly and limits their use to essential 
medical equipment; purchased/referred care; and staffing. While we 
certainly appreciate the need for more scrutiny, we worry that the 
criteria may end up being too constraining on the programs. IHS should 
consult with the Tribes in their service area before they make 
decisions on what can be done with the funds pertaining to this 
section. With consultation, the money can go to the most needed 
programs in a particular service areas.
    Most of Title III of the proposed legislation deals with a variety 
of reports. The one report that drew our attention was the Inspector 
General reports on patient care in Section 304. We definitely agree 
that reports on the quality of care and patient harm at IHS are 
necessary. However, we want to draw attention to the fact that many 
tribal members end up receiving their care outside of the IHS system 
through the purchased and referred care program. For example, in South 
Dakota, approximately 70 percent of care referred outside of IHS 
facilities. It would be useful to also have information on quality of 
care once a patient has left the IHS facility and is care for in an 
outside facility. We suggest that another subsection be added to 
Section 304 in order to address this issue.
    Overall, we think this proposed legislation is necessary and once 
again thank the Committee for its genuine interest in trying to 
alleviate problems within IHS. It is clear that management, 
recruitment, accountability and transparency are all still issues that 
need to be addressed, most of which are covered in the proposed 
legislation. Nearly two years has passed since the CMS certification 
was terminated at the Winnebago Hospital and our CEO, Director of 
Nursing and Lab Director positions are once again vacant. As we have 
stated at prior hearings, real change and the rebuilding of the 
hospital cannot happen without permanent qualified personnel and the 
funding necessary to carry out the mission.
    Mr. Chairman, the Winnebago Tribe supports the passage of this 
legislation once the issues listed above are addressed and after 
thorough comment and review by Indian Country. As I stated last year at 
a hearing and this bears repeating, while everything in this bill is 
needed, legislation alone will not solve our problem. Proper training 
of hospital staff costs money, new equipment costs money, and 
recruitment under these circumstances is also going to cost money. We 
would consider the passage of this legislation an initial solid first 
step and implore you not to abandon us after this bill is passed. 
Correcting this situation is going to require a continuous team effort, 
additional resources, and consistent Congressional oversight of IHS 
activity.
    Thank you again for allowing me to testify, I will be happy to 
answer any questions you may have.

    The Chairman. Thank you.
    Dr. Crowley.

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

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

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

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

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

         The system provides the following features:

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

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

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

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

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

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

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

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

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

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

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

    Every individual will have access to the benefits of water 
        fluoridation

    Every pregnant woman will have a healthy mouth

    Every child will start kindergarten cavity free

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

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

Objectives to Achieve Practical Goals

    Establish collaboration between dental and medical services

    Build grassroots support for oral health throughout tribal 
        leadership

    Build a collaborative relationship with organized dentistry

    Establish/enhance strong, sustainable community oral health 
        prevention programs

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

    Build relationships with dental industry and research 
        entities

    Promote health literacy for sustainable results of health 
        improvement actions

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

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

Action Steps
Building Capacity

    Work with Tribal Community Health Representatives to become 
        CDHCs

    Recruit students for dental school careers

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

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

    Promote interdisciplinary approach to improve Native 
        American health care:

      Establish a dental home by age 1

      Provide mouthguards for athletes

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

Building Infrastructure

    Establish reliable data and surveillance to support health 
        improvement efforts

    Coordinate research efforts building upon relevant 
        historical data and medical surveys

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

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

Building Community

    Incorporate CDHCs into existing CHR programs

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

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

    Raise awareness of oral health value through events for 
        tribal populations

Building Partnerships

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

    Participate in Local and State Oral Health Coalition 
        meetings

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

    Senator Murkowski. Dr. Harris.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

                            A P P E N D I X

           Prepared Statement of the American Academy of PAs
    On behalf of the more than 115,000 nationally-certified PAs 
(physician assistants) represented by the American Academy of PAs 
(AAPA), we appreciate the Senate Indian Affairs Committee's work to 
ensure high quality healthcare is available to Native Americans though 
Indian Health Services.
    AAPA appreciates efforts by the committee to improve the quality of 
care offered to American Indians and Native Alaskans at Indian Health 
Service (IHS) facilities and to ensure that IHS can recruit and retain 
needed medical providers. Currently, over 250 PAs are working to meet 
the healthcare needs of American Indians and Alaska Natives at Indian 
Health Services facilities. PAs practice medicine on healthcare teams 
with physicians and other providers. Within IHS, PAs work in emergency 
and family practice settings, as well as specialty clinics and 
programs, such as orthopedics, diabetes care, surgery, geriatric, 
pediatric, women's health, hospitalist and community health.
    AAPA respects the effort made by Senators Barrasso, Thune, and 
Chairman Hoeven to improve recruitment and retention for needed 
healthcare providers at IHS in S. 1250, the Restoring Accountability in 
the Indian Health Service Act of 2017. However, we would like to work 
with the authors and the committee to ensure this legislation reaches 
its full potential to help IHS attract and retain needed healthcare 
providers, including PAs.
    As introduced, S. 1250 seeks to improve the ability of IHS to 
recruit and retain providers by requiring the agency to establish pay 
scales where health providers are paid ``to the maximum extent 
practicable'' comparable to what such providers would make under the 
pay scales that apply to health providers at facilities operated by the 
Department of Veterans' Affairs (VA). While the VA generally takes into 
consideration wages for providers in local geographic markets, the VA 
has a flawed process in relation to PAs that does not consistently take 
into consideration local market compensation. Under the flawed 
compensation system at the VA, it is not uncommon for PAs in the VA to 
be compensated by as much as $30,000 less than other providers 
performing the exact same job. This flawed approach to compensation 
within the VA has resulted in VA facilities having difficulty 
recruiting PAs and provides PAs practicing at the VA a significant 
financial incentive to take positions with private employers. Recent 
reports by the VA Office of Inspector General consistently recognized 
the importance of PAs as part of VHA's healthcare team and identify PAs 
as one of the five critical occupations with the ``largest staffing 
shortages.'' Because of problems the flawed formula has caused the VA 
in recruiting and retaining needed providers, Senators Tester and Moran 
have introduced S. 426 that would ensure PA salaries at the VA take 
into consideration private pay rates in local markets. AAPA feels 
strongly that it is important to make sure any legislation intended to 
help IHS recruit and retain providers does not replicate inequities 
that exist at the VA.
    AAPA is committed to working to improve access to care at IHS 
facilities, and we look forward to working with the Committee on this 
critical issue.
                                 ______
                                 
       Prepared Statement of the Hawaii Congressional Delegation
    Chairman Hoeven and Vice Chairman Udall, please accept this written 
testimony in opposition to S. 1275, the Bringing Useful Initiatives for 
Indian Development (BUIILD) Act of 2017. While we have and continue to 
support reauthorizing the Native American Housing Assistance and Self-
Determination Act (NAHASDA) programs, we strongly oppose this bill in 
its current form because it fails to include Native Hawaiian Housing 
Block Grants (NHHBG) and Section 184A Native Hawaiian Home Loan 
Guarantee programs, as set forth in Title VIII of NAHASDA.
    The housing needs faced by our Native communities are among the 
worst in our country. In recognition of the Federal Government's trust 
responsibility to Native Americans, including Alaska Natives, Congress 
passed the Native American Housing Assistance and Self-Determination 
Act in 1996. In 2000, the American Homeownership and Economic 
Opportunity Act of 2000 \1\ inserted Title VIII in NAHASDA and created 
the NHHBG and Section 184A programs to provide resources for affordable 
housing programs for Native Hawaiians, pursuant to the Hawaiian Homes 
Commission Act of 1920 (HHCA). \2\
---------------------------------------------------------------------------
    \1\ Public Law 106-569
    \2\ The Hawaiian Homes Commission Act was passed by Congress and 
signed into law by President Warren Harding on July 9, 1921.
---------------------------------------------------------------------------
    HHCA recognizes the Federal Government's ``unique trust 
responsibility to promote the welfare of the aboriginal, indigenous 
people of the State [of Hawaii].'' \3\ This law created the Hawaiian 
Home Land Trust, which includes more than 200,000 acres of land managed 
by the Department of Hawaiian Home Lands (DHHL). The purpose of the 
HHCA is to improve the lives of Native Hawaiians, who continue to be 
more economically disadvantaged and lag behind in education and health, 
compared to other Hawaii residents. The trust lands create a land base 
where beneficiaries are able to reestablish connections to their native 
lands and cultural traditions that are vital in maintaining their 
identity and foundation.
---------------------------------------------------------------------------
    \3\ Hawaiian Homes Commission Act of 1920,  201.5
---------------------------------------------------------------------------
    While many Native Hawaiian families benefit from the HHCA, there 
are a large number of low-income families who are unable to take 
advantage of these lands because obtaining and managing a property is 
not within their financial means. To put this into perspective, DHHL 
recently reported that there were more than 27,000 applicant families 
on the waitlist to reside on Hawaiian homesteads and the latest U.S. 
Census numbers indicate that approximately 16.8 percent of Native 
Hawaiians live in poverty in the State of Hawaii. \4\ The NHHBG and 
Section 184A programs are crucial in bridging the gap between low-
income Native Hawaiian families and their ability to live on homestead 
lands.
---------------------------------------------------------------------------
    \4\ U.S. Census Bureau, 2015 American Community Survey 1-Year 
Estimates, Selected Population Profile in the United States, Hawaii 
http://files.hawaii.gov/dbedt/census/acs/ACS2015/ACS2015_1_Year/
Select_Pop_Profiles/major_race_aoc.pdf
---------------------------------------------------------------------------
    Congress has recognized the special relationship between the U.S. 
government and Native Hawaiians, and a responsibility to continue 
promoting programs that counter these sobering figures. NAHASDA's Title 
VIII programs provide vital tools that promote safe and affordable 
housing for Native Hawaiians. Healthy, sustainable homeownership is 
also fostered through the provision of funds for direct loans, housing 
counseling, self-help housing, and home rehabilitation programs. These 
resources focus on developing strong communities that serve as 
foundations for Native Hawaiian families to improve their collective 
quality of life.
    In 2015, the U.S. House of Representatives passed legislation to 
reauthorize NAHASDA with overwhelming bipartisan support. Also in 2015, 
this committee favorably reported a Senate version to reauthorize 
NAHASDA. Both versions included improvements to allow for NAHASDA 
programs to have a greater ability to self-determine--as is stated in 
the title of the law we are discussing--how to efficiently meet local 
housing needs. To abandon this bipartisan progress and Title VIII 
entirely--as the BUIILD Act does--would be a grave mistake and 
disservice to our Native communities. This is simply not the way 
forward.
    It is incumbent upon Congress to continue to acknowledge our 
responsibility to protect and improve the lives of Native Americans, 
Alaska Natives, and Native Hawaiians, which the BUIILD Act, in its 
present form, does not do. As such, we urge members of this committee 
to oppose the BUIILD Act and to continue to work to improve on the 
progress made on NAHASDA reauthorization in the last several years.
    We look forward to working with this Committee on how we can 
continue to work toward meeting the dire housing needs of all our 
Native people.
                                 ______
                                 
  Prepared Statement of Aneva J. Yazzie, CEO, Navajo Housing Authority
    On behalf of the Navajo Housing Authority (NHA) and our NHA Board 
of Commissioners (BOC), I am grateful and appreciate the opportunity to 
provide this written statement to the United States Senate Committee on 
Indian Affairs for review of the following legislative bills: S. 1250, 
a bill to amend the Indian Health Care Improvement Act; S. 1275, the 
``Bringing Useful Initiatives for Indian Land Development,'' (BUILD Act 
of 2017); and a bill relating to the HUD/VA Veterans Affairs Supporting 
Housing (HUD-VASH) program. It is NHA's goal to work with Congress in 
addressing our mutual interests in advancing effective policies to 
build economic and community development opportunities through 
addressing healthcare, housing and comprehensively support our Native 
Veterans.
Background on NHA
    The Navajo Housing Authority is the Tribally Designated Housing 
Entity (TDHE) for the Navajo Nation. NHA is the largest Indian housing 
authority and is nearly the eighth largest public housing authority in 
the United States. NHA is comparable in size to the public housing 
agency for the City of Atlanta. The Navajo Nation is the largest Indian 
tribe in the United States, with a total enrollment of approximately 
320,000 tribal members, a land base of 26,897 square miles (larger than 
West Virginia) that extends into the states of Arizona, New Mexico, and 
Utah.
    Comprised of 365 employees headquartered in Window Rock, Arizona 
and 15 field offices across the reservation, NHA manages 9,200 rental 
and homeownership units including 43 administrative facilities, and 
oversees an additional 1,800 units from sub-recipients. The 15 field 
offices deliver housing services to tribal members that reside within 
110 Chapters (local regional government units) and the surrounding 
communities.
Success of the NHA 5-Year Expenditure Plan
    In 2012, following a three-year HUD-imposed moratorium on 
development, NHA had accumulated approximately $470 million in unspent 
Indian Housing Block Grant (IHBG) funds. NHA developed and implemented 
an aggressive five-year expenditure plan to timely and responsibly 
expend a large accumulated balance.
    Over the past four years, NHA has proven that it has the sustained 
capacity to effectively and responsibly expend its allocated IHBG 
funds; over $600 million in the past four years (an average of $143 
million per year). Since the beginning of 2012, the NHA delivered 
housing services to over 10,592 households, built 538 new housing 
units, modernized 878 older housing units, funded the development of 7 
bed group homes and emergency shelters, and oversaw the acquisition and 
transition of 29 housing units for persons with disabilities. NHA is in 
its final year of the expenditure plan and is on target for a 
consecutive 5th year in meeting its spending goal by the end of Fiscal 
2017.
S. 1250 Indian Health Care Improvement Act
    Indian Healthcare Service (IHS) programs, administered by the 
Department of Health and Human Services, are the single largest 
investment into tribal communities at $3.5 billion annually. From this 
amount, $446 million is used to fund sanitation facility 
infrastructure. As NHA and many tribal housing programs have previously 
mentioned, those sanitation funds are impeded by appropriations 
language that restricts IHS funds from being comingled with the funds 
received through the Native American Housing Assistance and Self-
Determination Act (NAHASDA). In short, this limits a tribe's ability to 
maximize the federal investment.
    The Administration and Congress have vowed to spur growth into the 
economy by funding infrastructure, however a key challenge to providing 
housing in tribal communities is the lack of infrastructure, especially 
in rural areas. Development costs in rural areas are higher and can 
easily double the price tag or even make housing development impossible 
in many places. On Navajo, there is often no sanitation infrastructure 
and using NAHASDA funds alone for development, although authorized for 
infrastructure, significantly eats into housing funds which is 
unnecessary. Tribes should be allowed to leverage federal funding 
sources (NAHASDA and IHS sanitation funds) for developing the necessary 
sanitation infrastructure. NHA respectfully requests this Committee to 
seriously consider language that would statutorily allow the co-
mingling of IHS sanitations funds so that the federal investment into 
infrastructure could be maximized.
S. 1275 the ``Bringing Useful Initiatives for Indian Land 
        Development,'' or BUILD Act of 2017
    The Build Act has 6 sections that re-authorizes and amends the 
Native American Housing Assistance and Self-Determination. On December 
16, 2016, the NHA BOC passed Resolution NHA-4677-2016, this resolution 
authorizes the support of key provisions for any NAHASDA 
Reauthorization bill.
    Section 2: Consolidated Environmental Review (ER), this section 
authorizes a tribe who co-mingles federal funds from different agencies 
will discharge the tribe from other applicable environmental review 
requirements of the other applicable agencies under Federal law if the 
largest source of federal funding is from HUD. NHA supports this 
provision.
    Section 3: Reauthorizes NAHASDA from 2018 through 2025. NHA 
supports this provision.
    Section 4: Extension of Leasehold interest for housing from 50 
years to 99 years. NHA takes no position on this provision.
    Section 5: Reauthorizes Training and Technical assistance from 2018 
through 2025. NHA supports this provision.
    Section 6: Reauthorizes the Indian Loan Guarantee program (commonly 
known as the 184 loan program) from 2018 through 2025, with a 
limitation on funding at $12.2 Million. NHA supports the 
reauthorization of the 184 Loan Program but does not support a 
limitation on funding.
    Section 7: Authorizing Leveraging: Allows for all grants funds 
under NAHASDA to be used for purposes of meeting matching or cost 
participation requirements under any other Federal or non-Federal 
programs. NHA supports this provision.
    NAHASDA outlined dual roles for Indian housing, to build safe homes 
and sustainable communities while spurring economic development. Under 
the IHBG, funding must first cover the continuing support of the 
remaining housing stock that was funded under the 1937 Housing Act. 
NAHASDA includes other eligible activities such as new construction, 
acquisition and rehabilitation, thus in addition to the above sections 
in the Build Act, NHA supports additional provisions in the Re-
authorization of NAHASDA which are outlined in Resolution NHA-4677-
2016. These additional provisions were identified to stream-line the 
administrative workload of housing authorities and to reduce the 
duplication of rules and regulations between federal agencies. Tribes 
need these provisions so that they can focus on the important task of 
building houses instead of working tirelessly to meet burdensome 
administrative rules.
HUD/VA-Veterans Affairs Supportive Housing
NHA Success with HUD-VASH Program
    Tribal HUD-VASH recipients are having success placing tribal 
veterans into local supportive housing but we need the program to be 
permanently authorized or else we risk leaving those homeless Native 
Veterans without affordable housing options that include critical 
supportive services.
    HUD approved 20 HUD-VASH vouchers for NHA in the amount of $268,835 
on January 6, 2016. NHA has prioritized and incorporated the 20 VASH 
vouchers for homeless Navajo Veterans and to date we have issued nine 
vouchers (four have found housing) in Arizona and New Mexico. These 
homeless Navajo Veterans were reviewed by case-managers and determined 
eligible for the program and were immediately issued a voucher. Further 
NHA took efforts a step further and instituted its own Veterans Housing 
Assistance Policy. This policy goes above and beyond Federal 
legislative authority and has helped over 120 veterans become 
homeowners and has extended $8.8 million in veteran debt forgiveness 
and assisted 17 widowers/mothers of service men and women through NHA's 
veterans housing assistance program.
Project Coordination
    NHA partners with Veterans of the Armed Services residing on the 
Navajo Nation and are eligible to receive housing assistance services 
through the Department of Navajo Veterans Affairs (DNVA). The DNVA 
partners with Federal, state and local services, but the amount of case 
management that is needed to service our veteran population is large 
and added federal resources are need. Navajo has one case manager for 
the HUD-VASH program to handle cases that cover the entire Navajo 
reservation (Navajo extends into three states: Arizona, New Mexico and 
Utah). Moreover, the remote location of the reservation is not 
conducive to providing adequate case-management unless that case-
management can be provided in their community as opposed to off the 
reservation. NHA believes a solution is to provide for more case-
managers to meet the needs in the Navajo community.
Place-based Vouchers
    The biggest problem with using the tenant based rental assistance 
vouchers on the Navajo Nation is the lack of private or non-profit 
housing for renters. Therefore, the HUD-VASH program should allow 
rental assistance vouchers to be used for housing currently included in 
the housing stock of the tribal housing program. NHA's only option for 
using our HUD-VASH rental vouchers is to use Section 8 approved 
properties off the reservation. This solution will not help veterans 
who are needing supportive services who wish to stay on the reservation 
close to their family who are helping in their recovery. Thus, creating 
a place based voucher system that stays on the reservation, where most 
tribal veterans reside is the best option to alleviate our TDHE's lack 
of public and non-profit housing.
Conclusion
    It is the goal of NHA to help build safe sustainable homes for the 
Navajo People while strengthening the socio-economic fabric of the 
Navajo Nation. The re-authorization of NAHASDA, development of 
sanitation infrastructure and expansion of HUD-VASH coordination and 
program is critical in maintaining the growth of NHA and sustaining the 
progress of the Navajo People. We hope our testimony can assist this 
Committee in expanding each of these programs for the benefit of NHA 
and all Tribal TDHE's. Thank you for this opportunity.
                                 ______
                                 
Prepared Statement of the United States Merit Systems Protection Board 
                                 (MSPB)
    Chairman Hoeven, Vice Chairman Udall and distinguished Members of 
the United States Senate Committee on Indian Affairs (``Committee''). 
Thank you for the invitation to present a written statement on behalf 
of the United States Merit Systems Protection Board (MSPB) in 
connection with the Committee's legislative hearing to receive 
testimony on S. 1250, the ``Restoring Accountability in the Indian 
Health Service Act of 2017'' and other legislation which was held on 
June 13, 2017.
    As an initial matter, I would like to note that under statute, MSPB 
is prohibited from providing advisory opinions on any hypothetical or 
future personnel action within the executive branch of the federal 
government. 5 U.S.C.  1204(h) (``The Board shall not issue advisory 
opinions.''). Accordingly, this statement should not be construed as an 
indication of how I, any other presidentially appointed, Senate-
confirmed Member of the Merit Systems Protection Board (``Board''), an 
MSPB administrative judge, or an administrative law judge acting on 
behalf of the MSPB would rule in any pending or future matter before 
the agency. Moreover, at this time, MSPB is not taking a policy 
position on this legislation. Accordingly, I would respectfully request 
that the Committee consider the substance of my statement to be 
technical in nature.
The Potential Impact of S. 1250 on MSPB's Adjudicatory Function
    MSPB's views on S. 1250 derive from its statutory responsibility to 
adjudicate appeals filed by federal employees in connection with 
certain adverse employment actions. Generally, after a federal agency 
imposes an adverse personnel action upon a federal employee, such as 
removal or demotion, and the federal employee chooses to exercise his 
or her statutory right to file an appeal with MSPB, MSPB will begin the 
adjudication process. In the case of a federal employee who is removed 
from his or her position, that individual is no longer employed by the 
Federal Government, and is not receiving pay at the time he or she 
files an appeal with MSPB or at any point during the subsequent MSPB 
adjudication process.
    Once an appeal is filed, an MSPB administrative judge \1\ in one of 
MSPB's regional or field offices will first determine whether MSPB has 
jurisdiction to adjudicate the appeal. If MSPB has jurisdiction, the 
administrative judge may conduct a hearing on the merits and then issue 
an initial decision addressing the federal agency's case and the 
appellant's defenses and claims. Thereafter, either the appellant or 
the named federal agency may file a petition for review of the MSPB 
administrative judge's initial decision to the 3-Member Board. The 
Board Members constitute an administrative appellate body that reviews 
the administrative judge's decision and issues a final decision of the 
MSPB. Both the Board Members and MSPB administrative judges adjudicate 
appeals in accordance with statutory law, federal regulations, 
precedent from United States federal courts, including the Supreme 
Court of the United States and the United States Court of Appeals for 
the Federal Circuit, and MSPB precedent.
---------------------------------------------------------------------------
    \1\ MSPB administrative judges are federal employees under the 
General Schedule System employed by MSPB. They are not ``administrative 
law judges'' appointed under 5 U.S.C.  3105 nor federal judges.
---------------------------------------------------------------------------
    S. 1250 contains similar language to Section 707 of the Veterans 
Access, Choice, and Accountability Act of 2014, which was enacted into 
law and became effective in August 2014. (Public Law No. 113-146; 38 
U.S.C  713). In pertinent part, S. 1250 would allow the Secretary of 
Health and Human Services (``Secretary''), acting through the Director 
of the Service, to remove, demote, or transfer employees, including 
Senior Executive Service employees, of the Indian Health Service 
(``Service'') if the Secretary determines the performance or misconduct 
of the employee warrants such a personnel action. If the Secretary 
removes or demotes such an employee, the Secretary may:

    Remove the employee from the civil service altogether;

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

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

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

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

        Id. at 541.

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

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

    The Court also struck down the provision of Section 707 (38 U.S.C. 
 713(e)(3)) that provided that the Secretary's decision became final 
in the event that an MSPB AJ was unable to issue a decision within the 
21 day period provided for in that section. Helman, 856 F.3d at 929 
n.4. We recommend that the Committee consider the Federal Circuit's 
decision in Helman before approving S. 1250 to the extent that it 
prohibits MSPB Board members from reviewing the decisions of MSPB 
administrative judges and provides that decisions shall be final in the 
event that any MSPB administrative judge does not meet any arbitrary 
deadline to decide an appeal.
Permitting Appeals to MSPB ``Under 5 U.S.C.  7701"
    S. 1250 would permit covered employees to appeal to MSPB ``under 5 
U.S.C.  7701.'' Section 7701 of title 5, United States Code, provides 
in pertinent part that ``the decision of an agency shall be sustained. 
. .only if the agency's decision. . .is supported by a preponderance of 
the evidence.'' 5 U.S.C.  7701(c)(1)(B). The term ``preponderance of 
the evidence'' is defined as ``the degree of relevant evidence that a 
reasonable person, considering the record as a whole, would accept as 
sufficient to find that a contested fact is more likely to be true than 
untrue.'' 5 C.F.R.  1201.4(q).
    Additionally, 5 U.S.C.  7701(c)(2)(B) provides that ``an agency's 
decision may not be sustained. . .if the employee or applicant for 
employment shows that the decision was based on any prohibited 
personnel practice described in section 2302(b) [of title 5, United 
States Code].'' Among the ``prohibited personnel practices'' described 
in section 2302(b) are illegal discrimination, 5 U.S.C.  
2302(b)(1)(A)-(E), coercion of political activity or reprisal for 
refusal to engage in political activity, 5 U.S.C.  2302(b)(3), and 
reprisal for lawful ``whistleblowing,'' 5 U.S.C.  2302(b)(8). Thus, if 
such issues are raised by appellants as defenses in any appeal filed 
pursuant to the language contained in S. 1250, an administrative law 
judge acting on behalf of the MSPB will be required under law to 
consider those defenses prior to issuing a final decision.
Restriction on the Issuance of Stays of Personnel Actions
    S. 1250 provides that the ``Merit Systems Protection Board or any 
administrative law judge may not stay any personnel action.'' While I 
take no policy position on this language, I note that it appears to be 
in direct conflict with 5 U.S.C.  1214(b)(1)(a)(i) and (ii), which 
allows the Office of Special Counsel to seek, and the MSPB to grant, a 
stay of any personnel action ``if the Special Counsel [and the MSPB] 
determines that there are reasonable grounds to believe that the 
personnel action was taken as a result of a prohibited personnel 
practice,'' including illegal retaliation for lawful whistleblowing. I 
would recommend that the Committee make clear whether it wishes to 
prohibit OSC from seeking--and the MSPB from granting, in appropriate 
circumstances--stays of personnel actions that may be the result of 
prohibited personnel practices with respect to the agency and employees 
covered by this legislation.
    This concludes my written statement. I am happy to address any 
questions for the record that Members of the Committee may have.
                                 ______
                                 
  Prepared Statement of Hon. W. Ron Allen, Chairman, Self-Governance 
   Communication & Education Tribal Consortium; Tribal Chairman/CEO, 
                       Jamestown S'Klallam Tribe
    On behalf of the Self-Governance Communication & Education Tribal 
Consortium (SGCETC), I am pleased to provide the following written 
testimony regarding Senate Bill 1250 (S. 1250), Restoring 
Accountability in the Indian Health Service Act of 2017. SGCETC 
appreciates the time, attention and effort this Committee and others 
have devoted to improving the quality and access to health care for all 
American Indians and Alaska Natives (AI/ANs). While we agree that 
legislation offers new opportunities for IHS, Self-Governance Tribes 
cannot support the legislation as introduced.
    Today, 352 Federally-recognized Tribes and Tribal Organizations 
exercise Self-Governance authority to operate and manage health 
programs previously managed by the Indian Health Service (IHS), while 
many more continue to evaluate their opportunities. As Tribes assume 
greater authority over the delivery of health care in their 
communities, legislation like S. 1250 is increasingly important to us 
as we seek to gain more autonomy in the management and delivery of 
health care programs in partnership with the IHS. This collaboration 
has proven successful and has improved the Indian health system that 
existed prior to the passage of the Indian Self-Determination and 
Education Assistance Act (ISDEAA).
    Over the last decade, this Committee, in partnership with Tribes, 
has passed several pieces of legislation that provided opportunities to 
modernize IHS, support self-determination, and permanently reauthorize 
the Indian Health Care Improvement Act (IHCIA). Similarly, shared 
efforts and continued partnerships will be required to successfully 
correct the health care quality challenges that IHS faces.
    We would be remiss without first reiterating that the agency is 
chronically underfunded, and receives a fixed amount of appropriations 
each year to provide health care for 2.2 million AI/AN people, a per 
capita spending level that is the lowest of any healthcare system. AI/
AN have the right to have quality health care services, but without 
proper resources put behind these intentions, it is unlikely to be 
fully successful. We appreciate Congress expanding health programs in 
the Indian Health Care Improvement Act to increase access to health 
care services in Tribal communities, but more is needed to both 
appropriately fund these initiatives and further incorporate new and 
innovative ways to modernize IHS health delivery. Without funding to 
address the information technology gap, to treat critically diagnosed 
patients with specialized care, and improve the facilities to maintain 
accreditation and accommodate the diverse cultural health needs of 
native people, IHS will remain an outdated system that is locked in a 
``time capsule'' and unable to achieve its mission of ``raising the 
health status of AI/AN to the highest possible level.''
    We offer the following recommendations for the Committee to 
consider and hope that additional Tribal input will improve the 
legislation to make meaningful progress toward modernization of the 
IHS.
General Recommendations
    This legislation offers many solutions to some of IHS' leading 
challenges, including provider recruitment and retention and filling 
shortages, improving quality care and increasing Tribal engagement and 
culture in the system. While we have some specific comments below to 
provide additional insight and to identify potential unintended 
consequences of certain provisions, we also recommend that specific 
legislation be considered to advance the Federal policy that has proven 
to improve quality, increase access to care for Tribal citizens and 
reduce the federal bureaucracy--Self-Governance.
    Self-Governance is the most successful partnership between the 
Federal and Tribal governments to ever exist. S. 1250 does articulate 
protections for Tribes to assume programs, services, functions, and 
activities at any time. However, it does not encourage or create 
additional opportunities for Tribes to assume these responsibilities. 
We hope that in future legislation, the Committee will consider 
legislation to expand Self-Governance and assure Tribal rights to 
assume management of their health care.
    Additionally, Self-Governance Tribes note that the legislation does 
not authorize additional appropriations to support the new initiatives. 
We strongly believe that overlooking the funding necessary to properly 
implement the proposed programs will likely result in diminished 
returns on the Committee's efforts. In fact, even though IHCIA was 
permanently reauthorized seven years ago, more than 20 provisions 
remain unfunded and therefore unimplemented. As this legislation moves 
forward, we recommend and offer any support to Senators who can seek 
additional appropriations for IHS to improve the quality and access to 
care for all AI/ANs.
Creating Parity between IHS and Veterans Health Administration
    Many of the programs which stand to remain unimplemented are those 
that seek to address IHS' provider shortage and vacancies. Self-
Governance Tribes were heartened by the efforts this legislation makes 
to bring parity between the Veterans Health Administration (VHA) and 
IHS in provider compensation and personnel policy, to expand the IHS 
Loan Repayment Program, and to create demonstration projects to employ 
successful recruitment and retention strategies. However, some of the 
proposals do not recognize the challenges that exist in Indian Country. 
For instance, the housing voucher program included in Section 101 is 
limited to three years and does not acknowledge that the real challenge 
in Tribal communities is that there is a housing shortage. Recognizing 
that appropriations for IHS-constructed provider housing are far below 
need, granting IHS authority and flexibility to explore innovative 
means for addressing housing shortages would be extremely helpful. At a 
minimum, we ask that the Committee considers extending the termination 
date for this program as well as authorizing appropriations so that IHS 
and Tribes can properly support such a voucher program.
    Similar to VHA, this legislation also provides IHS additional 
flexibility to take personnel actions or to remove employees when 
necessary. Self-Governance Tribes agree that additional authority to 
manage employee performance is essential to improving quality of care 
over time. These practices also more closely mirror private industry 
standards for personnel management.
Addressing Provider and Administrator Vacancies
    This legislation responds to long-standing Tribal requests to 
modify IHS authorities to increase qualified providers and health 
administrators through expansion of the IHS Loan Repayment Program in 
Section 104. Self-Governance Tribes support the increased flexibility 
in eligibility for the Loan Repayment Program, as it is an important 
tool for recruitment and retention. We recommend that this section be 
expanded further to provide the IHS with flexibility to repay student 
loans for shortages of providers in geographic areas with chronic 
vacancies as long as the provider agrees to serve at least 4 years in 
that location.
    Though we appreciate the efforts to better include Tribal 
leadership in important hiring decisions, we are concerned that the 
legislation may have inadvertently included too many positions for 
Tribal notification. The legislation includes the ``position of a 
manager at an Area office or Service unit'' under the Tribal 
notification requirement in Section 105(a). Self-Governance Tribes are 
concerned that this could be interpreted quite broadly and that a 
``too'' general interpretation of this language could include an 
overwhelming number of positions at the local and area levels--creating 
significant administrative burdens for IHS Human Resources staff. This 
may lead to unintended consequences, including further delays in the 
hiring process for critical day-to-day program management and vacancy 
rate increases. The highest-level managers should have Tribal support; 
however, program level management decisions should be left to the 
Senior Executive Service (SES) positions and service unit Chief 
Executive Officers (CEOs) so as not to interfere with their autonomy, 
accountability and ability to fill vacancies at the earliest 
opportunity.
    With regard to the waiver of Indian Preference in hiring in Section 
105(b), we are unclear of the intention to allow waivers in order to 
consider former employees that have been removed from employment or 
demoted for performance or misconduct. This would seem to be at odds 
with our collective goals to provide quality health care services.
    S. 1250 offers a few solutions to improve the Service's ability to 
hire employees, including centralization of medical credentialing and 
direct hire authority. Self-Governance Tribes know all too well that an 
efficient hiring process will increase quality and access to care. We 
fully support shared credentialing throughout the IHS-operated 
facilities as proposed in Section 102, allowing IHS to efficiently 
deploy and assign providers to facilities as needed. A centralized 
medical credentialing process has been initiated by the IHS through 
Tribal Consultation under a Quality Framework, and is currently being 
implemented. We support full implementation of the Framework, and while 
IHS has created a small staff to implement the Framework by 
reallocating existing resources, implementation would be expedited and 
enhanced by appropriately funding this effort through additional 
appropriations. We further recommend that the Committee protect current 
and future Self-Governance Tribes' rights to choose to operate their 
own credentialing systems or leverage the efficiency of a centralized 
credentialing system and quality standards administered by IHS.
    Another opportunity the bill offers IHS is the Staffing 
Demonstration Project included in Section 109. Self-Governance Tribes 
know the value that demonstration projects can create in Indian 
Country. Demonstration projects often establish best practices and 
scalability of a program. However, the proposed project seems over-
limiting in that it only includes Federally-operated sites with 
significant third-party resources. Staffing shortages are a challenge 
for all rural health care systems. Self-Governance Tribes recommend 
that access should be broad enough to include Tribes who are managing 
their health services and wish to exercise their right to participate. 
The provisions should address cases when Tribes wish to exercise their 
Self-Governance authority during the demonstration project. Self-
Governance Tribes also recommend that an option be available to Tribal 
Health Programs to extend the liability protections for health 
professional volunteers under Section 103.
    The legislation does not address one common recommendation Tribes 
previously made to this Committee to improve recruitment and retention 
of providers. The loan repayment program has proven to be the IHS's 
best recruitment and retention tool to ensure an adequate health 
workforce to serve in the many remote IHS locations. Self-Governance 
Tribes recommend that the Committee included a provision that would 
provide IHS loan repayment program the same tax free status enjoyed by 
those who receive National Health Service Corps (NHSC) loan repayments. 
Under the IHS and NHSC programs, health care professionals provide 
needed care and services to underserved populations. However, the IHS 
uses a large portion of its resources to pay the taxes that are 
assessed on its loan recipients. Currently, the Service is spending 
29.7 percent of its Health Professions' account for taxes. Making the 
IHS loan repayments tax free would save the agency $7.21 million, 
funding an additional 232 awards. Changing the tax status of the IHS 
loans to make them tax free would enable the agency to fill two-thirds 
or more of the loan repayment requests without increasing the IHS 
Health Professions' account.
Improving Timeliness of Care
    Self-Governance Tribes recognize that access to care can be 
partially measured by evaluating patient wait times. We appreciate the 
efforts by the proposed legislation in Section 107 to require 
measurement and accountability for patient wait times. The Improving 
Patient Care (IPC) initiative, which began in 2008, provides a good 
foundation for measuring wait times as well as other measures, and we 
would recommend the IHS implement IPC in all of its facilities. 
However, additional time may be necessary to develop the rule. One 
hundred and eighty days would likely not allow for the proper 
development of a policy and required Tribal consultation. We would 
recommend additional time to develop a new set of standards. Further we 
hope the Committee will consider requiring Consultation prior to 
implementation and that data collected be available to impacted Tribes 
on a regular basis.
Establishing a Formal Tribal Consultation Policy
    In the Department of Health and Human Services, IHS has set the 
gold standard for government-to-government consultation. The IHS policy 
has undergone many revisions and continues to be updated as the 
relationship between Tribes and IHS changes. Tribes have been an active 
partner with the IHS in the development and subsequent changes of the 
IHS Tribal Consultation Policy. If a negotiated rule is required as 
described in Section 110, it may unnecessarily limit future Tribal 
engagement or restrict the flexibility the agency requires to serve the 
best interest of Tribes. Generally, Self-Governance Tribes agree there 
is always room to improve implementation of the IHS Tribal Consultation 
Policy, but we are unsure that development of a rule will create the 
enforcement and results the Committee is seeking.
Fiscal Accountability
    While Self-Governance Tribes are supportive of the Committee's 
effort to ensure that valuable resources are committed to improving 
patient care, we believe this is a provision that needs additional 
consideration before passage. The current language in Section 202 is 
significantly more restrictive than current regulations and could 
inadvertently impact both the ability of the IHS to meet its 
obligations to provide care, as well as current and future Self-
Governance opportunities.
    Specifically, narrowing the use of unobligated funds may negatively 
impact the ability of IHS and Tribes to meet accreditation standards 
and requirements in the future such as technology requirements, which 
may include additional spending categories other than those included in 
this Section. The language also does not take into account specific 
appropriations for Facilities and Contract Support Costs, which are 
limited to those appropriations accounts, and much of this funding is 
intentionally available until expended. These provisions would also 
seem to limit IHS' ability to pay funds to a Tribe under a Title I or 
Title V contract that were collected associated with a Program, 
Service, Function or Activity that is being assumed for operation by a 
Tribe. These provisions could also complicate IHS service delivery when 
there are delays in the appropriations process. Finally, the Section 
should be clarified to apply only to the IHS directly-operated program.
    With regard to the reporting requirements of Section 202, it 
appears as though the fiscal year reporting required under this section 
would also include Title I and Title V contracts and funding 
agreements. Under current law, IHS would not have the ability to obtain 
information to accurately report the requested information, because the 
fiscal data is reported by Tribes under their required audits.
    In closing, SGCETC would like to thank the Committee for the 
opportunity to submit testimony and feedback. We look forward to 
working with you to improve the quality and access to care at IHS.
                                 ______
                                 
      Prepared Statement of the Navajo Housing Authority Board of 
                             Commissioners
    Honorable Chairman Hoeven and Vice Chairman Udall, and members of 
the committee, thank you for the opportunity to provide written 
comments on a crucial legislative proposal aimed at improving the state 
of housing in Indian Country. The Navajo Housing Authority (NHA) Board 
of Commissioners, the President of the Navajo Nation, and the Navajo 
Nation Speaker recognize your commitment to Indian Country. We greatly 
appreciate your efforts to improve housing in Indian Country. We are 
grateful for the opportunity to provide this written statement to the 
United States Senate Committee on Indian Affairs for review of the 
following legislative bills: S. 1250, a bill to amend the Indian Health 
Care Improvement Act; S. 1275, the ``Bringing Useful Initiatives for 
Indian Land Development,'' (BUILD Act of 2017); and a bill relating to 
the HUD/VA Veterans Affairs Supporting Housing (HUD-VASH) program. It 
is NHA's and the Navajo Nation's goal to work with Congress in 
addressing our mutual interests in advancing effective policies to 
build economic and community development by addressing healthcare and 
housing.
Background on NHA
    The Navajo Housing Authority is the Tribally Designated Housing 
Entity (TDHE) for the Navajo Nation. NHA is the largest Indian housing 
authority and is nearly the eighth largest public housing authority in 
the United States. NHA is comparable in size to the public housing 
agency for the City of Atlanta. The Navajo Nation is the largest Indian 
tribe in the United States, with a total enrollment of approximately 
320,000 tribal members, a land base of 26,897 square miles (larger than 
West Virginia) that extends into the states of Arizona, New Mexico, and 
Utah.
    Comprised of 365 employees headquartered in Window Rock, Arizona 
and 15 field offices across the reservation, NHA manages 9,200 rental 
and homeownership units including 43 administrative facilities, and 
oversees an additional 1,800 units from sub-recipients. The 15 field 
offices deliver housing services to tribal members that reside within 
110 Chapters (local regional government units) and the surrounding 
communities.
S. 1250 Indian Health Care Improvement Act
    Indian Healthcare Service (IHS) programs, administered by the 
Department of Health and Human Services, are the single largest 
investment into tribal communities at $3.5 billion annually. From this 
amount, $446 million is used to fund sanitation facility 
infrastructure. As NHA and many tribal housing programs have previously 
mentioned, those sanitation funds are impeded by appropriations 
language that restricts IHS funds from being comingled with the funds 
received through the Native American Housing Assistance and Self-
Determination Act (NAHASDA). In short, this limits a tribe's ability to 
maximize the federal investment.
    The Administration and Congress have vowed to spur growth into the 
economy by funding infrastructure, however a key challenge to providing 
housing in tribal communities is the lack of infrastructure, especially 
in rural areas. Development costs in rural areas are higher and can 
easily double the price tag or even make housing development impossible 
in many places. On Navajo, there is often no sanitation infrastructure 
and using NAHASDA funds alone for development, although authorized for 
infrastructure, significantly eats into housing funds which is 
unnecessary. Tribes should be allowed to leverage federal funding 
sources (NAHASDA and IHS sanitation funds) for developing the necessary 
sanitation infrastructure. NHA respectfully requests this Committee to 
seriously consider language that would statutorily allow the co-
mingling of IHS sanitations funds so that the federal investment into 
infrastructure could be maximized.
S. 1275 the ``Bringing Useful Initiatives for Indian Land 
        Development,'' or BUILD Act of 2017
    NAHASDA was passed in 1996 with the Congressional intent to empower 
tribes to build homes for low-income families in Indian Country. We 
hope this intent continues in the BUILD Act, while also eliminating any 
duplicative requirements to streamline the building of homes.
    The Build Act has 6 sections that re-authorizes and amends the 
Native American Housing Assistance and Self-Determination.
    Section 2: Consolidated Environmental Review (ER), this section 
authorizes a tribe who comingles federal funds from different agencies 
will discharge the tribe from other applicable environmental review 
requirements of the other applicable agencies under Federal law if the 
largest source of federal funding is from HUD. NHA and Navajo Nation 
support this provision.
    Section 3: Reauthorizes NAHASDA from 2018 through 2025. NHA and 
Navajo Nation support this provision.
    Section 4: Extension of Leasehold interest for housing from 50 
years to 99 years. NHA takes no position on this provision.
    Section 5: Reauthorizes Training and Technical assistance from 2018 
through 2025. NHA and Navajo Nation support this provision.
    Section 6: Reauthorizes the Indian Loan Guarantee program (commonly 
known as the 184 loan program) from 2018 through 2025, with a 
limitation on funding at $12.2 Million. NHA and the Navajo Nation 
support the reauthorization of the 184 Loan Program but do not support 
a limitation on funding.
    Section 7: Authorizing Leveraging: Allows for all grants funds 
under NAHASDA to be used for purposes of meeting matching or cost 
participation requirements under any other Federal or non-Federal 
programs. NHA and the Navajo Nation support this provision.
    NAHASDA outlined dual roles for Indian housing, to build safe homes 
and sustainable communities while spurring economic development. Under 
the Indian Housing Block Grant (IHBG), funding must first cover the 
continuing support of the remaining housing stock that was funded under 
the 1937 Housing Act. NAHASDA includes other eligible activities such 
as new construction, acquisition and rehabilitation, thus in addition 
to the above sections in the Build Act, NHA supports additional 
provisions in the Re-authorization of NAHASDA. These additional 
provisions will stream-line the administrative workload of tribal 
housing entities and reduce the duplication of rules and regulations 
between federal agencies. This will help TDHE's focus on building new 
homes efficiently and effectively.
    NAHASDA expired on September 30, 2013. Since its expiration, the 
act's funds have been reauthorized on a yearly basis. This has caused 
uncertainty for Tribally Designated Housing Entities (TDHE) to meet the 
construction timelines, which furthers the delay of building any new 
homes. Reauthorizing NAHASDA through the BUILD Act will eliminate any 
uncertainty for funding housing projects in Indian Country.
S. 1333 HUD/VA-Veterans Affairs Supportive Housing
NHA Success with HUD-VASH Program
    Tribal HUD-VASH recipients are having success placing tribal 
veterans into local supportive housing but we need the program to be 
permanently authorized or else we risk leaving those homeless Native 
Veterans without affordable housing options that include critical 
supportive services.
    HUD approved 20 HUD-VASH vouchers for NHA in the amount of $268,835 
on January 6, 2016. NHA has prioritized and incorporated the 20 VASH 
vouchers for homeless Navajo Veterans and to date we have issued nine 
vouchers (four have found housing) in Arizona and New Mexico. These 
homeless Navajo Veterans were reviewed by case-managers and determined 
eligible for the program and were immediately issued a voucher. 
Furthermore, NHA took efforts and instituted its own Veterans Housing 
Assistance Policy. This policy goes above and beyond Federal 
legislative authority and has helped over 120 veterans become 
homeowners and has extended $8.8 million in veteran debt forgiveness 
and assisted 17 widowers/mothers of service men and women through NHA's 
veterans housing assistance program.
Project Coordination
    NHA partners with Veterans of the Armed Services residing on the 
Navajo Nation and are eligible to receive housing assistance services 
through the Department of Navajo Veterans Affairs (DNVA). The DNVA 
partners with Federal, state and local services, but the amount of case 
management that is needed to service our veteran population is large 
and additional federal resources are needed. Navajo has one case 
manager for the HUD-VASH program to handle cases that cover the entire 
Navajo reservation (Navajo extends into three states: Arizona, New 
Mexico and Utah). Moreover, the remote location of the reservation is 
not conducive to providing adequate case-management unless that 
casemanagement can be provided in their community as opposed to off the 
reservation. NHA believes a solution is to provide for more case-
managers to meet the needs in the Navajo community.
Place-based Vouchers
    The biggest problem with using the tenant based rental assistance 
vouchers on the Navajo Nation is the lack of private or non-profit 
housing for renters. Therefore, the HUD-VASH program should allow 
rental assistance vouchers to be used for housing currently included in 
the housing stock of the tribal housing program. NHA's only option for 
using our HUD-VASH rental vouchers is to use Section 8 approved 
properties off the reservation. This solution will not help veterans 
who are needing supportive services who wish to stay on the reservation 
close to their family who are helping in their recovery. Thus, creating 
a place based voucher system that stays on the reservation, where most 
tribal veterans reside is the best option to alleviate our TDHE's lack 
of public and non-profit housing.
Conclusion
    It is the goal of NHA and the Navajo Nation to help build safe 
sustainable homes for the Navajo People. The re-authorization of 
NAHASDA through the BUILD Act, the development of sanitation 
infrastructure through Restoring Accountability in the Indian Health 
Service Act, and expansion of HUDVASH coordination and program is 
critical in maintaining the growth of the Navajo Nation and sustaining 
the progress of the Navajo People. We hope our testimony can assist 
this Committee in expanding each of these programs for the benefit of 
the Navajo Nation and all Tribal TDHE's. Thank you for this 
opportunity.
                                 ______
                                 
  Joint Prepared Statement of Hon. Russell Begaye, President, Navajo 
Nation and Jonathan Hale, Chairman, Health, Education & Human Services, 

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

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

    Again, we encourage Congress to appropriate funding for this 
activity, which complements current requirements on the Nation.
Staffing Demonstration Project
    The Navajo Nation understands and supports the overall goals of 
addressing workforce shortages through the development of staffing 
demonstration projects for federally managed health care facilities. 
However, the requirement for tribal contribution for construction funds 
will prevent Tribes from accessing this potential resource. Therefore, 
we believe that this requirement should not be a factor for selection. 
Additionally, we suggest that tribally operated health care facilities 
be considered for participation, such as the 2 tribally contracted and 
3 compacted facilities on the Navajo Nation. The inclusion of these 
facilities fully supports the aims of the Indian Self Determination Act 
(P.L. 93-638).
Tribal Consultation
    Direct, meaningful Tribal consultation is a crucial part of the 
relationship between Tribal Nations and the Federal Government. In 
current practice, IHS drives the consultation efforts. While the 
proposed legislation is designed to improve consultation, we are 
concerned that a negotiated rulemaking committee may hinder or restrict 
future Tribal consultation. As proposed, potential negotiated 
rulemaking could likely result in a time-consuming and costly process. 
Alternatively, we recommend that the current IHS consultation policy be 
reexamined for improvements and be recommitted to engaging in 
meaningful consultation. Additionally, we suggest that a greater 
emphasis be placed on Tribal concerns as they arise, and this must 
result in meaningful and timely consultation.
Proposed Reports
    The Navajo Nation supports the directive for the additional 
reporting contained within sections 302-304. To be most effective, 
reports should be developed in collaboration with Tribes. Reports 
should then be presented to affected Tribes for comment before the 
final version is officially released.
CMS Survey
    The Navajo Nation supports the call for a CMS compliance survey. 
Again, to be most effective, the proposed survey should be developed in 
collaboration with Tribes. Reports should be presented for Tribal input 
before the final version is officially released.
Conclusion
    In conclusion, we would like to thank the Senate Committee on 
Indian Affairs for the opportunity to submit testimony and feedback. As 
it is the goal of the Navajo Nation to ensure delivery of quality 
health care for our Navajo people, we appreciate Senators Barrasso, 
Thune, and Hoeven's efforts to improve health services within the IHS. 
It is critical that we find successful, lasting solutions to the 
current challenges facing Indian health care system, including the 
recruitment and retention of employees and unacceptable standards of 
care. We hope this testimony can assist the Committee in improving the 
quality, access, and delivery of health care services through the 
Indian Health Service (IHS). Thank you.
                                 ______
                                 
   Prepared Statement of United South and Eastern Tribes Sovereignty 
                            Protection Fund
    On behalf of the United South and Eastern Tribes Sovereignty 
Protection Fund (USET SPF) we write to provide the Senate Committee on 
Indian Affairs with the following testimony for the record of its June 
13, 2017 legislative hearing on S.R. 1250, the Restoring Accountability 
to Indian Health Service Act of 2017.
    USET SPF is a non-profit, inter-tribal organization representing 26 
federally recognized Tribal Nations from Texas across to Florida and up 
to Maine. \1\ Both individually, as well as collectively through USET 
SPF, our member Tribal Nations work to improve health care services for 
American Indians. Our member Tribal Nations operate in the Nashville 
Area of the Indian Health Service, which contains 36 IHS and Tribal 
health care facilities. Our citizens receive health care services both 
directly at IHS facilities, as well as in Tribally-operated facilities 
under contracts with IHS pursuant to the Indian Self-Determination and 
Education Assistance Act (ISDEAA), P.L. 93-638.
---------------------------------------------------------------------------
    \1\ USET SPF member Tribal Nations include: Alabama-Coushatta Tribe 
of Texas (TX), Aroostook Band of Micmac Indians (ME), Catawba Indian 
Nation (SC), Cayuga Nation (NY), Chitimacha Tribe of Louisiana (LA), 
Coushatta Tribe of Louisiana (LA), Eastern Band of Cherokee Indians 
(NC), Houlton Band of Maliseet Indians (ME), Jena Band of Choctaw 
Indians (LA), Mashantucket Pequot Indian Tribe (CT), Mashpee Wampanoag 
Tribe (MA), Miccosukee Tribe of Indians of Florida (FL), Mississippi 
Band of Choctaw Indians (MS), Mohegan Tribe of Indians of Connecticut 
(CT), Narragansett Indian Tribe (RI), Oneida Indian Nation (NY), 
Passamaquoddy Tribe at Indian Township (ME), Passamaquoddy Tribe at 
Pleasant Point (ME), Penobscot Indian Nation (ME), Poarch Band of Creek 
Indians (AL), Saint Regis Mohawk Tribe (NY), Seminole Tribe of Florida 
(FL), Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY), 
Tunica-Biloxi Tribe of Louisiana (LA), and the Wampanoag Tribe of Gay 
Head (Aquinnah) (MA).
---------------------------------------------------------------------------
    While we appreciate efforts to address the healthcare disparities 
identified within the Great Plains Area of the Indian Health Service 
(IHS), we feel a broad, one-size-fits-all approach to addressing these 
problems is unwarranted. Not all IHS Areas are experiencing these same 
types of failures, and there are lessons to be learned from the best 
practices they employ. In addition, despite Tribal concerns with 
similar legislation last Congress, this bill was introduced without 
broad Tribal consultation. Any attempts to reform IHS, through 
Congressional action or otherwise, must be accomplished through 
extensive Tribal consultation. Finally, we maintain that until Congress 
fully funds the IHS, the Indian Health System will never be able to 
fully overcome its challenges and fulfill its trust obligations. 
Although USET SPF supports reforms that will improve the quality of 
service delivered by the IHS, we continue to underscore the obligation 
of Congress to meet its trust responsibility by providing full funding 
to IHS and support additional innovative legislative solutions to 
improve the Indian Health System.
Uphold the Trust Responsibility to Tribal Nations
    The United States has a trust responsibility to Tribal Nations that 
has been reaffirmed time and time again. The most recent reaffirmation 
came though the permanent reauthorization of the Indian Health Care 
Improvement Act when, ``Congress declare[d] that it is the policy of 
this nation, in fulfillment of its special trust responsibilities and 
legal obligations to Indians to ensure the highest possible health 
status for Indians and urban Indians and to provide all resources 
necessary to effect that policy.'' This trust responsibility obligates 
the federal government to provide quality healthcare to Tribal Nations. 
Providing quality healthcare can only be accomplished when these 
programs are fully funded. We further recommend the inclusion of 
language directing the IHS to request a budget that is reflective of 
its full demonstrated financial obligation, as this is the only way to 
determine the amount of resources required to deliver comprehensive and 
quality care.
    As long as IHS remains dramatically underfunded, the root causes of 
the failures in the Great Plains and IHS will not be addressed. In FY 
2015, the IHS medical expenditure per patient was $3,136 while the 
Veteran's Administration, the only other federal provider of direct 
health care services, spent $8,760 per patient--a 36 percent 
difference. Disparities in financing for health care such as these lead 
to disparities in health outcomes. Congress must authorize full funding 
for the IHS in order to make meaningful progress on the chronic 
challenges faced by IHS. We remain hopeful that Congress will take 
necessary actions to fulfill its federal trust responsibility and 
obligation to provide quality health care to Tribal Nations, by 
providing adequate funding to the IHS.
Authorize Advanced Appropriations
    On top of chronic underfunding, IHS and Tribal Nations face the 
problem of discretionary funding that is almost always delayed. 
Stability in program funding is a critical element in the effective 
management and delivery of health services. Since FY 1998, there has 
only been one year (FY 2006) in which appropriated funds for the IHS 
were released prior to the beginning of the new fiscal year. The FY 
2016 omnibus bill was not enacted until 79 days into the Fiscal Year, 
on December 18, 2015. Delays in funding only amplify challenges in 
providing adequate salaries and hiring of qualified professionals, 
particularly in areas with high Health Professional Shortage Areas 
where many Tribal Nations are located.
    Budgeting, recruitment, retention, provision of services, facility 
maintenance, and construction efforts all depend on annual appropriated 
funds. As Congress seeks to improve IHS' ability to attract and retain 
quality employees, as well as promote an environment conducive to 
effective health care administration and management, we urge the 
inclusion of language that would extend advance appropriations to the 
IHS.
Clarification for Tribal Health Programs
    When it comes to Tribal Nations operating facilities pursuant to 
the Indian Self-Determination and Education Assistance Act (ISDEAA), 
P.L. 93-638, the current language is ambiguous. We recognize that many 
provisions contain a ``rule of construction'' clause that appears to be 
intended to ensure that the new obligations placed on the IHS in these 
areas would not interfere with Tribal health programs' ability to enter 
into or maintain contracts or compacts under the Indian Self-
Determination and Education Assistance Act. We believe that such a rule 
of construction is helpful, but are concerned that the precise language 
used does not achieve its goal. Instead, these provisions should be 
revised to simply state they do not apply to Tribally-operated health 
programs. Tribal Nations should have a clear sense of which provisions 
apply to our Tribally-operated programs and which do not.
Section-by-Section Comments
    Below, USET SPF offers section-by-section comments and concerns. 
Again, S. 1250 should not move forward without additional, thorough 
Tribal Consultation on a national basis.
Section 101--Incentives for Recruitment and Retention
    In order to address the ongoing challenges with the recruitment and 
retention of IHS staff, the legislation would allow HHS to provide 
housing vouchers or reimburse the costs for those relocating to an area 
experiencing a high level of need for employment. Though this provision 
provides the Secretary discretion to determine whether a location is 
experiencing a high level of need, USET SPF suggests including language 
for positions that are ``difficult to fill in the absence of an 
incentive.'' This addition would allow IHS more flexibility when 
determining when to offer relocation compensation.
    USET SPF agrees that there is a need for recruitment and retention 
programs. However, the establishment of these programs should not come 
at the cost of health care services. USET SPF recommends that 
additional appropriations be authorized for the proposed recruitment 
and retention programs.
    Additionally, it is unclear why the bill includes a sunset date on 
the housing voucher program. It is unlikely that IHS staff housing 
needs will be fully addressed in only a 3-year period. USET SPF 
suggests that the sunset date be stricken.
Section 102--Medical Credentialing System
    USET SPF has deep concerns about the centralization of any Area 
Office functions, including credentialing. Nashville Area Tribal 
Nations have consistently advocated for Area Office presence and for 
services to be administered at the Area level. Collectively, we have 
worked hard to establish the strong and high functioning Area Office we 
have today. Taking away functions from Area offices causes significant 
backlogs in services, and disrupts an established and trusted 
relationship between the Area Office and Tribal Nations. We believe 
credentialing should be kept at the Area level, utilizing established 
best practices.
Section 103--Liability Protections for Health Professional Volunteers 
        at IHS
    While USET SPF understands that providing an incentive for 
healthcare professionals to volunteer at IHS facilities by protecting 
them from liability would aid in delivering quality healthcare to 
Indian Country, we believe this provision needs further technical 
evaluation to ensure patients and healthcare providers are adequately 
protected. In addition, USET SPF recommends adding language to ensure 
similar protections are available at Tribally-operated facilities.
Section 104--Clarification Regarding Eligibility for IHS Loan Repayment 
        Program
    USET SPF encourages efforts that would expand the Indian Health 
Service Loan Repayment Program to include degrees in business 
administration, health administration, hospital administration, or 
public health professions as eligible for awards. We recommend 
including language that would expand these degrees as eligible under 
the IHS Scholarship Program as well. Allowing for comprehensive 
eligibility under these programs would increase the number of AI/AN 
individuals seeking business and health administration degrees, as well 
as increase the pool of qualified health professionals within Indian 
Country.
Section 105--Improvements in Hiring Practices
    When it comes to improvements in hiring, three provisions are 
included in S. 1250. On the first of these, Direct Hire Authority, 
language should be included that would require the Secretary to consult 
with the Tribal Nations served by the Area office where the position 
will be filled prior to any secretarial action.
    On the second provision, we appreciate the inclusion of Tribal 
Notification of individuals who have been appointed, hired, promoted, 
transferred or reassigned within IHS. However, language should also be 
included that would provide notification to Area Tribal Nations on 
removals based on performance or misconduct. This would supplement the 
effort of this legislation in increasing transparency and allow Tribal 
Nations to have greater knowledge and confidence in healthcare 
professionals providing services to their citizens.
    On Waivers of Indian Preference, USET SPF firmly believes that the 
providers best suited to care for our communities are ones that come 
from the communities themselves. Therefore, we cannot support the 
inclusion of this provision, which would set a dangerous precedent 
throughout other federal agencies that serve Tribal communities. The 
aims of this provision can be achieved by modifying hiring practices 
within the current legal framework. There is room for improvements in 
hiring practices to ensure that positions are being filled in a timely 
manner with qualified candidates. We recommend directing the Secretary 
to update and streamline Indian preference hiring practices to ensure 
that qualified non-Indian applicants will be considered in cases where 
no qualified Indian applicants are available, at the sole discretion of 
the Tribal Nations served.
Section 106--Removal or Demotion of IHS Employees Based on 
        Performance or Misconduct
    While USET SPF understands the purposes of including language that 
would expand the Secretary's authority to remove or demote IHS 
employees based on performance or misconduct, we believe Tribal 
governments must also be notified when IHS employees within their 
Service Area become subject to a personnel action such as removal, 
transfer or demotion. In under Sec. 606 (d) ``Notice to Congress'', we 
recommend including ``Tribal Governments located in the affected 
service area'' to the list of entities the Secretary would be required 
to provide notification to 30 days after the Secretary takes a 
personnel action on an IHS employee.
Section 107--Standards to Improve Timeliness of Care
    It is imperative that any timeliness of care standards are 
developed in consultation with Tribal Nations. We note that IHS is 
currently implementing a timeliness standard in accordance with its 
Improving Patient Care (IPC) Initiatives. We urge consultation with the 
170 IHS and Tribally-operated sites that have chosen to participate in 
the IPC Initiative, as well as aligning with these standards with IPC 
to ensure that the standards and reporting are not overly burdensome 
for Tribal health programs.
    In addition, we request that any data collected under the provision 
be provided to Tribal Nations as well as the Secretary.
Section 108--Tribal Culture and History
    We support the inclusion of Section 108 that would require annual 
and mandatory cultural competency trainings for IHS employees, 
including contractors. However, because each Tribal Nation is unique, 
language should be included that would require IHS to compile these 
trainings through consultation with the Tribal Nations they serve, on a 
regional basis.
Section 110--Rule Establishing Tribal Consultation Policy
    While IHS is currently operating under an existing Tribal 
Consultation Policy, it may be appropriate for Tribal Nations to 
reexamine and reevaluate its efficacy. Tribal consultation is a 
cornerstone of the relationship between federally recognized Tribal 
Nations and the federal government. We do, however, have concerns about 
the functionality of a negotiated rulemaking and its potential to 
divert attention and resources away from patient care. USET SPF 
encourages the use of a Tribal/Federal workgroup to examine, evaluate 
and update the existing policy and approve through the Public Comment 
procedures versus official negotiated rulemaking.
Section 202--Fiscal Accountability
    USET SPF has concerns with this section and its effect on base 
funding. This section requires further technical evaluation and 
explanation, including from IHS, in order to assess its true impact.
Section 302-304--Reports by the Secretary of HHS, Comptroller General, 
        Inspector General
    USET SPF recommends including language that would require greater 
collaboration and consultation with Tribal Nations. We feel the reports 
laid out in this section should be conducted in collaboration with 
Tribal Nations and provided to those Tribal Nations for consultation 
prior to their release to Congress or the public.
Section 305--Transparency in CMS Surveys
    As above, USET SPF recommends adding language that would require 
collaboration and consultation with Tribal Nations during the 
formulation of these compliance surveys. We also believe the results of 
these surveys should be provided to Tribal Nations prior to their 
public release.
Conclusion
    USET SPF acknowledges the efforts of the Committee and others 
within Congress in seeking to address the long-standing challenges 
within IHS. However, we believes that S.1250 fails to recognize the 
deep disparities in funding faced by IHS and how these disparities 
contribute to failures at the Area level. We maintain that until 
Congress fully funds the IHS, the Indian Health System will never be 
able to fully overcome its challenges and fulfill its trust 
obligations. Finally, a number of provisions within S. 1250 seem to be 
responding to Area-specific concerns. While we stand with our brothers 
and sisters who are experiencing these failures, we ask that the 
Committee strongly consider the national (rather than regional) 
implications of S. 1250, and work with Tribal Nations to ensure its 
impact is positive in all IHS Areas. We thank the Committee for the 
opportunity to provide comments on this bill and look forward to 
further consultation on S. 1250, as well as an ongoing dialogue to 
address the complex challenges of health care delivery in Indian 
Country.
                                 ______
                                 
      Prepared Statement of the Department of Hawaiian Home Lands
    Chairman Hoeven, Vice-Chairman Udall, Senator Schatz and Members of 
the Senate Committee on Indian Affairs, we thank you for the 
opportunity to submit written testimony for the Committee's June 13th, 
2017 hearing on S. 1275.
    We want to express our deep appreciation to Chairman Hoeven and the 
members of this Committee for your continuing leadership in seeking to 
address the housing needs of Native American communities.
    Your efforts are a vital part of a long history of congressional 
initiatives--beginning in 1920, when the United States Congress 
recognized the dire circumstances in which native Hawaiians were living 
and enacted legislation to authorize the designation of approximately 
203,500 acres of some of the worst available lands in the Hawaiian 
Islands for homesteading. These lands were intended to provide 
permanent, safe and secure home lands for the indigenous people of what 
was later to become the 50th state of America's union of states.
    The Hawaiian Homes Commission Act of 1920 did not, however, provide 
for an appropriation of funds to develop those designated lands, and 
from that time to the present day, the Hawaiian Homes Commission and 
the Department of Hawaiian Home Lands have struggled mightily to secure 
the financial resources needed to clear forested lands and difficult 
terrain for the development of housing; to assure that roads, clean 
water resources and sources of power, including access to coal-produced 
power as well as solar- and wind-produced energy, can be supplied to 
those housing areas; and to provide for the rehabilitation of the 
native peoples of these islands while celebrating their traditional 
knowledge, language and culture.
    Title VIII of the Native American Housing and Self Determination 
Act (NAHASDA) was the response of the Congress to address the critical 
housing needs of Native Hawaiians. Title VIII moneys have provided 
opportunities for many families over the years:

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

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

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

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

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

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

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

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

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

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

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

                                 ______
                                 
  Prepared Statement of Hon. Troy ``Scott'' Weston, President, Oglala 
                              Sioux Tribe
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                 ______
                                 
Prepared Statement of Hon. Brian Cladoosby, Chairman, Swinomish Indian 
                            Tribal Community
    On behalf of the Swinomish Indian Tribal Community (``Tribe''), 
thank you for convening the June 13, 2017, hearing on S.1250, the 
Restoring Accountability in the Indian Health Service Act. The 
legislation would amend the Indian Health Care Improvement Act in 
several ways and would increase transparency and accountability at the 
Indian Health Service (IHS), streamline the hiring of medical staff, 
provide incentives for doctors and nurses to stay on the job, and 
protect whistle-blowers who report violations of health and safety 
rules. Of course, all of these are laudable goals designed to address 
the many disparities in medical and dental health in Indian Country.
    During the hearing, one of the non-tribal witnesses provided 
testimony on Section 102 of the legislation. That section would 
standardize and streamline credentialing at IHS facilities. The Tribe 
would like to provide additional context to ensure that the Committee 
understands that while streamlining credentialing is important, 
volunteers are not a long term solution to health care needs in Indian 
country.
    The Swinomish Tribe and I have a particular passion for improving 
oral health and oral health care in Indian Country. Oral disease is the 
most widespread chronic disease, despite being highly preventable and 
manageable. Oral health is essential to overall health and well-being 
at every stage of life. Like any other infection or disease, oral 
disease must be managed. What is needed to best do this is a workforce 
of skilled and culturally-competent oral health providers who have a 
long-term and consistent presence in tribal communities.
    Dental professionals have recognized the unmet need for oral health 
providers in Indian Country, and have proposed volunteer or other short 
term providers as a solution. We appreciate the commitment of 
volunteers in Indian Country. But this is not an effective way to 
manage any infection or disease, and it has not been successful in 
tribal communities. Instead of looking to volunteers providing surgical 
or other short-term solutions, tribes want to replicate long-term 
strategies that follow a more medical model for oral disease management 
and utilize more members of the dental team.
    In short, we need to think about oral disease and health care 
differently, and that is just what we have done at Swinomish. We looked 
north to Alaska, where for ten years Dental Health Aide Therapists have 
been an integral party of the dental team, providing long-term, 
consistent and culturally-competent care to remote Alaska Native 
populations. The Swinomish Tribe established its own program for 
integrating Dental Therapists into our Dental Clinic team, where all 
dental providers are licensed and regulated under Swinomish Tribal law. 
The State of Washington recently passed legislation explicitly 
recognizing as practitioners Dental Health Aide Therapists who are 
licensed under Tribal law and practicing in tribal communities.
    For more than a year the Dental Therapist at our Swinomish Dental 
Clinic has been successfully working as a member of our oral health 
team. Just like the mid-level providers in our medical clinic, 
expanding the dental team with Dental Health Aide Therapists and more 
efficiently utilizing all members of the dental team has shown strong 
results in Alaska and here at Swinomish for improving oral health.
    Swinomish takes an evidence-based approach to health care. 
Researchers from the University of Washington presented a paper at the 
National Oral Health Conference this year that shows that over a 10 
year period, children and adults living in villages in Alaska with 
Dental Health Aide Therapists had fewer extractions and more access to 
preventive care than villages without Dental Health Aide Therapists. 
There has been a nearly 300 percent decrease in extractions of the 
first four front teeth for children under age three in villages with 
Dental Health Aide Therapists. That is nearly 300 percent more happy 
and healthy smiles--and that is real progress.
    This demonstrated success is the result of consistent, high 
quality, community based oral health care provided by culturally 
competent staff. It was just this success that prompted the Swinomish 
Tribe to license and hire Dental Therapists as part of its team.
    We urge the Committee in its work on this important legislation to 
be cognizant of the need to provide sustained health care for Indian 
country, including oral health. Volunteers are welcome and 
standardizing credentialing will make it more efficient to deploy them. 
Volunteers, however, will never be a long term solution to Indian 
country's unmet health care needs.
                                 ______
                                 
             Prepared Statement of Gundersen Health System
    On behalf of Gundersen Health System we are writing to provide 
testimony in response to the committee hearing held June 13th to 
express support for Senate Bill 1250, (and companion bill H.R. 2662), 
the Restoring Accountability in the Indian Health Service Act. 
Specifically, we are supportive of Section 102, relating to medical 
credentialing systems, and Section 103 applying liability protections 
for professional volunteers.
    Gundersen Health System is an integrated health system located in 
nineteen counties throughout western Wisconsin, southeastern Minnesota 
and northeastern Iowa. Our system includes a primary hospital in La 
Crosse, four critical access hospitals and over 50 clinics throughout 
the region. With over 7,000 employees, we are the largest employer in 
the area. As a Healthgrades Top 50 hospital in overall care, many 
clinical specialty services, and patient experience, we are committed 
to supporting public policy that helps to enrich every life through 
improved community health, outstanding experience of care, and 
decreased cost burden.
    Gundersen Health System is firmly committed to providing services 
to improve the health and wellbeing of communities both near and far. 
Gundersen is proud to have established the Global Partners program that 
has provided needed healthcare services to critical areas both in U.S. 
and throughout the world. Since 2008 Gundersen Health System has 
collaborated with the Pine Ridge Service Unit of the Indian Health 
Service in South Dakota to provide healthcare services to residents on 
the reservation. Throughout this partnership, Gundersen Global Partners 
has continuously sent volunteer physicians, nurses, and staff for week-
long periods at IHS clinics on the reservation, providing clinical, 
diagnostic, and even surgical services. The volunteers at Gundersen 
have logged thousands of hours of complimentary services for members of 
the Oglala Sioux Tribe, and is proud to continue in this partnership.
    However, administrative barriers have prevented teams from 
volunteering on a consistent basis. Procedures for credentialing of 
healthcare providers for the Indian Health Service have become 
challenging to meeting the needs of individuals and families at Pine 
Ridge. We are very pleased Section 102 establishes a uniform process 
for medical credentialing, including the consultation with existing 
services that would meet the guidelines of the Indian Health Services, 
and efficiently credential volunteer professionals. Removing 
unnecessary duplication, especially for volunteer healthcare providers 
and nurses would provide much needed relief and improve our existing 
partnership.
    In addition, we are supportive of liability protections provided in 
Section 103 of the legislation. We appreciate this provision that 
recognizes the volunteer efforts of our providers by deeming them 
public health service professionals while serving Indian Health Service 
individuals and families.
    On behalf of Gundersen Health System, and our Global Partners 
Program, we greatly appreciate the opportunity to provide comments on 
S. 1250, Restoring Accountability in the Indian Health Service Act. 
This bill would help address administrative barriers and improve our 
ability to provide services for those in need. We thank the Committee 
for holding this hearing and ask the Committee to advance the 
legislation forward.
    Please feel free to contact us with any questions or if you would 
like to learn more about Global Partners Program and partnership with 
the Pine Ridge Reservation.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Jon Tester to 
                            Dr. Keith Harris
    Question 1. The Blackfeet reservation is approximately 180 miles 
one way from the nearest VA facility. How is the VA ensuring homeless 
veterans of the Blackfeet reservation or any extremely rural tribe are 
receiving the required direct services under the program?
    Answer. The Department of Veterans Affairs (VA) is ensuring that 
Veterans enrolled in the Tribal Department of Housing and Urban 
Development-VA Supportive Housing (HUD-VASH) program are receiving the 
required direct services under the program. VA case managers are 
located in or near communities served by the tribe. Case managers 
coordinate and provide VA care, including psychosocial services, 
including mental health and substance use disorder care, and also 
connect Veterans to needed services that are available locally. VA also 
has technology capabilities enabling case managers to provide services 
remotely, augmenting the face to face services described above.
    VA case managers are also working collaboratively to ensure that 
the supportive services and resources are available to Veterans. Most 
HUD-VASH programs have sought licensed clinical social workers, who 
provide a wide range of clinical services directly to the Veteran, from 
skill building to substance use disorder treatment to psychotherapy, if 
needed and appropriate. On or near many reservations, VA has community-
based outpatient clinics (CBOC) that can provide primary care, mental 
health, and substance use disorder assistance. VA also connects 
Veterans to local service providers for assistance that VA cannot 
provide, such as assistance with employment, food or other support. The 
Indian Health Service (IHS) within the Department of Health and Human 
Services, or a tribally operated health program, may also offer primary 
care and specialty services that can be provided locally. In 
circumstances in which VA medical center specialty care is needed, the 
VA case manager can assist in securing transportation for associated 
appointments. VA case managers also have connections with groups such 
as the Elks Club, Military Outreach USA, or Home Depot, who can provide 
furniture and other household items.
    Specific to the Blackfeet Nation, VA has a temporary case manager 
in place until a permanent case manager is hired. The case manager 
travels to the Blackfeet Nation monthly and is available to travel more 
frequently as needed. The current case manager ensures that Veterans 
are connected with the CBOC in Cut Bank, Montana, which provides 
primary care, mental health, and substance use disorders services. The 
case manager also ensures the Veterans are connected with the local IHS 
facility. Additionally, ``Manpower,'' a local community center,is 
located nearby and offers a range of co-located social services, 
including employment services. The Manpower community center also 
provides an opportunity for the case manager to educate key 
stakeholders on VA services, how to coordinate referrals, and promote 
service utilization between VA and the service providers.

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

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

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

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

    lack of available office space for case managers

    safety and work related challenges

    transportation challenges

    locating eligible Veterans

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

    concerns expressed by tribes regarding program longevity

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

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

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

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

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

    Question 8. Once this bill requires them to help support Tribal 
HUD-VASH, how do you envision VA working with IHS to better provide 
supportive services to Native American veterans receiving Section 8 
vouchers?
    Answer. As IHS has existing relationships with tribes, VA is 
confident that there is excellent potential for IHS and VA to 
collaborate. IHS has significant knowledge and experience understanding 
the cultural differences of each tribe, and would be a meaningful, 
collaborative partner for this program. VA had discussions with IHS 
that preceded the administration change that did not yield final 
conclusions. We believe that new discussions, with current leadership 
in both agencies, about how VA and IHS can collaborate and identify 
ways to work together in serving Veterans in Tribal HUD-VASH are 
needed. As appropriate, HUD should also be a part of these discussions.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Jon Tester to 
                            Heidi Frechette
    Question 1. The Blackfeet reservation is approximately 180 miles 
one way from the nearest VA facility. How is the VA ensuring homeless 
veterans of the Blackfeet reservation or any extremely rural tribe, are 
receiving the required direct services under the program?
    Answer. This question is best answered by VA. HUD has forwarded 
this question to VA and VA will respond under separate cover.

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

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

                                  [all]