    [Senate Hearing 115-235]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 115-235

      HIGH RISK INDIAN PROGRAMS: PROGRESS AND EFFORTS IN ADDRESSING GAO'S
                                RECOMMENDATIONS

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

                                    HEARING

                                   before the

                          COMMITTEE ON INDIAN AFFAIRS
                              UNITED STATES SENATE

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                               SEPTEMBER 13, 2017

                                   __________

             Printed for the use of the Committee on Indian Affairs

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                      ______

                             U.S. GOVERNMENT PUBLISHING OFFICE

    30-089 PDF                     WASHINGTON : 2018

                          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 September 13, 2017...............................     1
    Statement of Senator Cortez Masto................................    69
    Statement of Senator Franken.....................................    67
    Statement of Senator Hoeven......................................     1
    Statement of Senator Udall.......................................     2

                                   Witnesses

    Black, Michael S., Acting Assistant Secretary, Indian Affairs,
      U.S. Department of the Interior................................    46
        Prepared statement...........................................    47
    Dearman, Tony, Director, Bureau of Indian Education, U.S.
      Department of the Interior.....................................    56
        Prepared statement...........................................    58
    Emrey-Arras, Melissa, Director, Education, Workforce, and Income
      Security Issues, U.S. Government Accountability Office.........     4
        Prepared statement...........................................     6
    Weahkee, Rear Admiral Michael D., Acting Director, Indian Health
      Service, U.S. Department of Health and Human Services..........    51
        Prepared statement...........................................    53

                                    Appendix

    Floyd, Hon, James R., Principal Chief, Muscogee (Creek) Nation,
      prepared statement.............................................    79
    Response to written questions submitted by Hon. Steve Daines to
      Melissa Emrey-Arras............................................    80
    Response to written questions submitted by Hon. John McCain to
      RADM Michael D. Weahkee........................................    88
    Response to written questions submitted by Hon. Tom Udall to:
        Michael S. Black.............................................    84
        Tony Dearman.................................................    81
        RADM Michael D. Weahkee......................................    86

      HIGH RISK INDIAN PROGRAMS: PROGRESS AND EFFORTS IN ADDRESSING GAO'S
                                RECOMMENDATIONS

                                  ----------

                         WEDNESDAY, SEPTEMBER 13, 2017

                                           U.S. Senate,
                                   Committee on Indian Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 2:59 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. Today, the Committee is holding an important
    hearing on follow up to our May 17, 2017 hearing on the
    Government Accountability Office, GAO, and their High Risk
    List, which included for the first time, three Indian programs.
        In this hearing, we will examine the progress of the Bureau
    of Indian Affairs, the Bureau of Indian Education, and the
    Indian Health Service in addressing the GAO's open
    recommendations for these agencies programs. We want all of
    these programs to be successful.
        I want to thank the GAO for bringing forward their
    recommendations and the numerous challenges facing these
    Federal Indian programs, not just identifying the problem but
    also providing recommendations.
        We want to work with the agencies in finding a path forward
    on these issues. Any further guidance from the GAO is welcome.
    That is why we appreciate having you here today. I also want to
    thank the witnesses for getting their testimony in on time.
        On February 15, 2017, the GAO issued its biannual High Risk
    List, which included Indian energy, Indian education, and
    Indian health care. These programs were considered high risk
    because they were vulnerable to fraud, waste, abuse and
    mismanagement.
        These programs are vitally important to Native Americans.
    They affect the safety of school buildings and facilities, the
    quality of health care, education, and the advancement of
    Indian energy development projects.
        These high risk programs put the health and safety of
    Native Americans at risk. By implementing the GAO
    recommendations, the risks identified should be diminished.
    Likewise, the affected agencies can be strengthened in
    delivering programs and services to Native Americans.
        According to the GAO, there are 23 open recommendations for
    Indian education, 14 open recommendations for Indian health and
    13 open recommendations for Indian energy. The GAO stated in
    its previous testimony that it uses five criteria to determine
    if a program should be removed from the High Risk List.
        To be removed from this list, the agency must demonstrate
    leadership commitment, agency capacity and resources, an action
    plan, monitoring and, of course, progress.
        We will continue to closely monitor the progress and
    commitment of these agencies as they work with the GAO in
    efficiently closing out the open recommendations. I also expect
    any future recommendations by the GAO will be taken seriously
    and implemented by the agencies.
        I know there is still more work to be done by the agencies;
    however, I am encouraged by recent updates by the GAO that
    these agencies are making progress in satisfying the open
    recommendations, especially at BIE and IHS.
        I am still concerned that there are open recommendations
    and also am concerned about progress in regard to Indian
    energy.
        Again, I welcome our witnesses today and look forward to
    hearing what progress we have made and also how we can make
    more progress. Rest assured, this will not be the last hearing
    on this subject.
        With that, I will turn to Vice Chairman Udall.

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

        Senator Udall. Thank you, Chairman Hoeven.
        Here at the beginning, I would like to recognize now the
    Navajo Nation Council delegate, Walter Phelps from Arizona, who
    is attending this hearing today.
        This hearing starts where we left off after our first
    hearing on the GAO High Risk Report in May. Thank you for
    calling GAO, the BIE and the IHS back here so the agencies can
    update the Committee on their progress towards addressing GAO's
    open recommendations so that we can examine how and whether
    they have been adequately focusing resources and expertise to
    improve their Indian programs.
        Before I get into discussing the high risk designation, I
    want to share a bit of information. The Santa Fe Indian School
    has a graduation rate of 96 percent; 88 percent of their
    students go on to attend a post secondary institution.
        At the Kiawah Public Health Corporation, a longer 30-minute
    visit standard is making visits meaningful for patients and
    providers. In the Albuquerque service area, providers are
    tracking patient wait times electronically and deploying
    customer satisfaction surveys to ensure they are meeting the
    needs of their patients.
        A team of pre-engineering students at the Southwestern
    Indian Polytechnic Institute recently competed against 20
    colleges from across the Country winning a national NASA
    robotics competition.
        These success stories show the persistence and tenacity of
    tribal communities. They underscore the need for better sharing
    of best practices within Federal Indian programs and most of
    all, they should remind this Committee that tribal communities
    can and do succeed despite the agency level administrative
    shortcomings they face.
        I would ask my colleagues here today to imagine how much
    more could be accomplished if their Federal partners were
    offering them needed support instead of getting in their way.
    For years, GAO's work has provided evidence of something many
    tribal communities have long reported, that bureaucratic
    barriers at agencies like the BIA, the BIE and the IHS reduce
    the effectiveness of Indian programs across the Federal
    Government.
        BIE schools have reported that agency hiring directives
    continue to prevent them from filling key staff positions. IHS
    facilities in the Great Plains are still in CMS certification
    limbo as Native patients face uncertainty.
        The lack of necessary modern IT infrastructure affects
    everything from education to energy, grinding some tribal
    communities to a bureaucratically-induced halt. Unfortunately,
    these agencies have not taken a proactive approach to
    responding to tribal concerns. This high risk designation
    proves they were not committing themselves to resolving GAO's
    findings.
        I read the GAO's testimony today and was pleased to learn
    that BIA, BIE and IHS programs have benefited from the
    additional scrutiny put on them since they have been labeled
    high risk. It appears progress can only be made when Congress
    keeps the pressure on. Mr. Chairman, I appreciate you doing
    that. That is why I appreciate the Chairman's follow through on
    this topic.
        The members of this Committee must do all we can to address
    the Federal Government's shortcomings to improve its
    accountability and administration of Indian programs. I am
    looking forward to hearing what progress has been made to
    address GAO's recommendations. I thank the Federal witnesses
    for being here today.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Vice Chairman Udall.
        Are there other opening statements?
        [No audible response.]
        The Chairman. Then we will turn to our witnesses.
        Our witnesses today are: Ms. Melissa Emrey-Arras, Director,
    U.S. Government Accountability Office, Washington, D.C.; Mr.
    Michael S. Black, Acting Assistant Secretary, Indian Affairs,
    U.S. Department of the Interior; Rear Admiral Michael D.
    Weahkee, Acting Director, Indian Health Service, U.S.
    Department of Health and Human Services, Rockville, Maryland;
    and Mr. Tony Dearman, Director, Bureau of Indian Education,
    U.S. Department of the Interior.
        Ms. Emrey-Arras. we will turn to you.

              STATEMENT OF MELISSA EMREY-ARRAS, DIRECTOR,
        EDUCATION, WORKFORCE, AND INCOME SECURITY ISSUES, U.S.
                   GOVERNMENT ACCOUNTABILITY OFFICE;
             ACCOMPANIED BY FRANK RUSCO, DIRECTOR, NATURAL
       RESOURCES AND ENVIRONMENT TEAM; AND KATHY KING, DIRECTOR,
                              HEALTH CARE

        Ms. Emrey-Arras. Thank you for inviting me here today to
    discuss a new area we added to our High Risk List this year:
    improving Federal management of programs that serve tribes and
    their members. We added this area to our High Risk List this
    past February in response to serious problems in Federal
    management and oversight of Indian education, energy resources
    and health care programs which were highlighted in several
    prior reports.
        Overall, our High Risk Program has served to identify and
    help resolve serious weaknesses in areas involving substantial
    resources and providing critical services to the public. Today,
    I will focus on Interior and HHS's efforts to address our
    recommendations.
        In our High Risk Report, we cited nearly 40 recommendations
    that were not implemented. Since then we have made an
    additional 12 recommendations in two new reports on BIE school
    safety and construction, published in May of this year. While
    Interior and HHS have taken some steps to address these
    recommendations, only one has been fully implemented.
        We are happy to report that we just closed a recommendation
    we made to HHS to develop specific agency-wide standards for
    patient wait times. HHS developed these standards and published
    them on the IHS Indian Health Manual website just last month.
    This recommendation is now closed as fully implemented. The
    other recommendations, however, remain open.
        In some cases, the agencies have made plans or taken
    preliminary steps to address the recommendations, but have not
    fully implemented them. For example, in the area of Indian
    education, we recommended in 2014 that Interior develop
    procedures to oversee school spending for major programs. In
    May, the BIE director noted that the agency planned to complete
    this recommendation by the middle of 2019. Last month,
    officials reported to us that they had drafted procedures but
    further review and revision were needed before the procedures
    could be finalized and implemented.
        Also, in some cases, the agencies have yet to provide us
    supporting documentation that they have fully implemented our
    recommendations. Such documentation is needed for us to verify
    that the agency actions have occurred.
        For example, in the area of Indian energy, we recommended
    that BIA take steps to complete its GIS mapping module in its
    database to identify who owns and uses resources. On August 31,
    BIA officials told us that they had added this mapping
    capability to the database but the officials did not provide us
    with the supporting documentation to enable us to determine if
    the GIS capability addresses our recommendation. We are now
    working with BIA to obtain this needed documentation to
    determine if this function will comply with our recommendation.
        In other cases, however, an agency may not have taken any
    action on our recommendations. For example, in the area of
    Indian health care, IHS had agreed with two of our
    recommendations to make the allocation of Purchased/Referred
    Care (PRC) funds more equitable but has not yet taken action to
    implement them.
        Our experience has shown that among the key elements needed
    to make progress in high risk areas is top level attention by
    the Administration and agency leaders. As the Chairman
    mentioned, we have five key elements we look at to decide
    whether or not an area should be removed from our High Risk
    List. These are: leadership commitment; capacity, which is
    having the people and resources to resolve the risk; having a
    corrective action plan; monitoring; and demonstrating progress.
        If the agencies can demonstrate significant improvement in
    these areas, they can be taken off the High Risk List.
    Likewise, individual issues can be removed if sufficient
    progress is made. For example, if sufficient progress is made
    in Federal management of Indian energy programs, Indian energy
    issues can be removed from the list, even if Indian education
    and health care issues remain on the list.
        We plan to continue monitoring the agencies' efforts to
    address the approximately 50 recommendations that remain open.
    We look forward to continuing our work with this Committee in
    overseeing Interior and HHS to improve services to tribes and
    their members.
        My colleagues and I would be happy to answer any questions
    you may have.
        [The prepared statement of Ms. Emrey-Arras follows:]

        Prepared Statement of Melissa Emrey-Arras, Director, Education,
     Workforce, and Income Security Issues, U.S. Government Accountability
                                     Office

     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        The Chairman. Thank you.
        Next is Acting Assistant Secretary Black.

            STATEMENT OF MICHAEL S. BLACK, ACTING ASSISTANT
           SECRETARY, INDIAN AFFAIRS, U.S. DEPARTMENT OF THE
                                INTERIOR

        Mr. Black. Good afternoon, Chairman Hoeven, Vice Chairman,
    and members of the Committee.
        Thank you for the opportunity to come back and present an
    update on behalf of the Department of Interior regarding Indian
    Affairs' role in the development of Indian energy and our
    continued commitment to address the high risk designation in
    the Government Accountability Office High Risk Report.
        As we stated in my testimony in May, the Department agreed
    with GAO's recommendations and we continue to address the
    recommendations in order to help foster energy independence
    among tribes who are developing their resources.
        As the High Risk Report notes, GAO made 14 recommendations
    to the Bureau of Indian Affairs via three reports. I am happy
    to note that we have made some progress on a number of those
    recommendations and plan to submit closure packages for those
    recommendations in the near future.
        I acknowledge that we have a significant amount of work to
    do. My testimony today will update the Committee on our
    progress towards implementation of the various recommendations.
        GAO recommended the development and implementation of a GIS
    mapping module that could be included in our Trust Asset
    Accounting Management System or TAAMS. In response, we have
    developed a GIS Map Viewer to work along with our TAAMS system.
        The Viewer was successfully tested and deployed on August
    31, 2017. A closure package for this recommendation has been
    signed and is in the process of being submitted for
    consideration of closure.
        In addition, we will be providing a demonstration of that
    system to GAO tomorrow in order to better demonstrate the
    capabilities of the system.
        GAO has also recommended that we provide additional
    guidance related to the Tribal Energy Resource or TERA
    Agreements. As a result, the Office of Indian Energy and
    Economic Development has reviewed the tribal comments it has
    received and found that the inherently Federal functions is one
    of the number one issues that tribes have identified in need of
    clarity.
        In consultation with Department's Office of Solicitor, it
    was determined that the term can only truly be defined on a
    case-by-case basis when tribes have made a request to take over
    a specific Federal program, function, service or activity.
        In order to provide additional guidance, IEED, our Indian
    Energy and Economic Development Office, has placed on its
    website additional guidance related to TERA for those tribes
    interested in assuming energy-related functions.
        In addition, I have talked to my staff in the Indian Energy
    and Economic Development Program about the possibility of
    developing a primer or some type of guidance on conducting
    additional training opportunities for tribes interested in
    pursuing TERA.
        In order to respond to the GAO's recommendation to include
    other Federal agencies in the activities of the Indian Energy
    and Economic Development Program or IESC Service Center, we
    have been working to implement memoranda of understanding or
    MOUs with the appropriate department bureaus and other Federal
    agencies involved in development of Indian energy and mineral
    resources and to define roles and responsibilities regarding
    the development of those resources on trust lands.
        MOUs are being developed with Fish and Wildlife, the
    Environmental Protection Agency and the Army Corps of
    Engineers. In addition, not too long ago, we signed a MOU
    between the Division of Energy and Mineral Development and the
    Department of Energy. Included in that, we are trying to look
    at the Indian Energy Service Center as becoming a participatory
    party to that MOU.
        IESC has prepared an addendum to the MOU with IEED and DOE
    in order to finalize the agreement. The addendum is currently
    the review process. We do need to make sure the MOU clearly
    identifies the roles of the different offices in relation to
    executing the Indian Energy Program.
        GAO has also identified the need to establish a documented
    process for seeking input from key stakeholders. In response,
    the IESC has developed a process including intake forms that
    allow key agencies to provide input and requests for service
    received on behalf of tribes and other agencies.
        This information will allow the service center to
    prioritize work tasks based on a standard set of criteria
    contained in the IESC referral priority assessment. The
    priority assessment considers the potential work items'
    relative benefit to expediting an Indian energy project. The
    IESC began utilizing intake forms in August to obtain input
    regularly from stakeholders.
        In addition, the BIA is continuing the process of
    identifying and implementing the workforce plan regarding
    positions associated with the development of Indian energy and
    minerals.
        As I testified in May before the Committee, the IESC will
    collect data directly from BIA, BLM, ONRR and OST employees in
    an effort to identify workload and necessary technical
    competencies.
        The IEMSC will work with the partner bureaus to assess
    skills and competencies needed for energy and mineral workforce
    standards as well as identifying any existing gaps that may
    exist out there. An initial survey was distributed in August
    2017 to key employees across the bureaus to identify workload
    and necessary technical competencies. The results are currently
    being analyzed. The BIA is on target and expects to complete
    this recommendation by the end of 2017.
        Thank you for the opportunity to present an update on our
    progress. I look forward to answering any questions.
        Thank you.
        [The prepared statement of Mr. Black follows:]

      Prepared Statement of Michael S. Black, Acting Assistant Secretary,
                Indian Affairs, U.S. Department of the Interior
        Chairman Hoeven, Vice Chairman Udall, and Members of the Committee,
    my name is Michael Black and I am the Acting Assistant Secretary for
    Indian Affairs at the Department of the Interior. Thank you for the
    opportunity to come back and present an update on behalf of the
    Department of the Interior (Department or DOI) regarding Indian
    Affairs' role in the development of Indian energy and our continued
    commitment to address the high risk designation in the Government
    Accountability Office (GAO) High Risk Report (GAO-17-317 High Risk
    Series).
        As we stated in our testimony in May, the Department agreed with
    GAO's recommendations and we continue to address the recommendations by
    implementing widespread reform to help foster energy independence among
    Tribes who are interested in developing their resources.
        As the High Risk report notes, GAO made fourteen recommendations to
    the Bureau of Indian Affairs (BIA), via three reports. I am happy to
    note that we've made progress on a number of the recommendations and
    plan to submit closure packages for those recommendations in the near
    future.
        As the former Director of BIA and current Acting Assistant
    Secretary, I know these issues well and acknowledge that we have a
    significant amount of work to do. My testimony today will update the
    Committee on our progress towards implementation of the various GAO
    recommendations.
    GAO 15-502
        Recommendation 1: To ensure it can verify ownership in a timely
    manner and identify resources available for development, BIA should
    take steps to complete its GIS mapping module in TAAMS.

        Previously, Indian Affairs testified that the Trust Asset and
    Accounting Management System (TAAMS) was not designed as a geospatial
    mapping system, but is simply a system to reflect legal descriptions as
    they appear on documents recorded as required by federal law.
        In our previous testimony we also stated that the BIA would not be
    building out the GIS mapping module in TAAMS. Rather, the BIA would
    utilize commercially available, off-the-shelf mapping technology to
    integrate data viewing and map creation capabilities into TAAMS at the
    desktop. The GIS Map Viewer is based upon verified legal land
    descriptions and ownership data available in TAAMS with base reference
    data for mapping.
        We are pleased to announce that the Indian Affairs Information
    Technology Change Advisory Board and Architectural Review Committee
    granted the Authority to Operate the GIS Map Viewer and that the GIS
    Map Viewer has been deployed, as of August 31, 2017. The GAO closure
    package is currently being prepared.

        Recommendation 2: To ensure it can verify ownership in a timely
    manner and identify resources available for development, BIA should
    work with BLM to identify cadastral survey needs.

        The BIA and the BLM, in a coordinated and focused effort, prepared
    a Reimbursable Service Agreement between the two agencies to identify
    and deliver the much needed survey-related products and services. We
    are continuing to evaluate the cadastral survey inventories and our
    FY17 survey requests have been approved for funding and completion by
    BLM.
        An example of our progress is the Nevada Native Nations Land Act of
    2016, passed by Congress last year, which transferred 71,137 acres of
    BLM and Forest Service lands to six different tribes; these lands are
    being surveyed now by BLM to establish tribal trust land descriptions
    and boundaries.

        Recommendation 3: To improve the efficiency and transparency of its
    review process, BIA should develop a documented process to track its
    review and response times.

        We previously stated that the BIA was in the process of evaluating
    and reviewing the current realty review and approval process and
    information stored in TAAMS in order to improve efficiencies and
    timeliness in processing workloads. BIA subject matter experts have
    been developing requirements for tracking proposed mineral documents
    within TAAMS. Due to the fact that modifications to data systems must
    be reviewed by multiple entities within the Department, a request for
    an extension of time has been requested until the end of FY18. The BIA
    is waiting to hear whether this extension has been granted.

        Recommendation 4: To improve the efficiency and transparency of its
    review process, BIA should enhance data collection efforts to ensure it
    has data needed to track its review and response times.

        The Indian Energy Service Center has been working closely with BIA,
    ONRR, and BLM IT personnel to navigate system and software access
    challenges. Currently, access testing is ongoing but preliminary
    results indicate the IESC experiences significant efficiency gains as
    the office gains access to systems and software. For example, IESC ONRR
    staff has access to the BIA TAAMS system allowing for greater
    efficiency and transparency for each of the offices in the processing
    of Indian oil and gas projects.

        Recommendation 5: Provide additional energy development-specific
    guidance on provisions of Tribal Energy Resource Agreement (TERA)
    regulations that tribes have identified to Interior as unclear.

        After the previous hearing, the Office of Indian Energy and
    Economic Development (IEED) reviewed Tribal comments regarding the
    term, ``inherently federal functions.'' We noticed that the term
    ``inherently federal functions'' is the only provision of the TERA
    regulations that Tribes have described to IEED as unclear. IEED
    consulted with the Department's Office of the Solicitor (SOL), which
    determined that this term can only be defined on a case-by-case basis
    when tribes have made a request to take over a specific federal
    program, function, service and activity (PFSAs). On August 31, 2017,
    IEED placed on its web site guidance to tribes with an approved TERA or
    which seek to assume energy-related administrative functions under
    Public Law 93-638. The GAO closure package is currently being prepared.
    GAO 16-553
        Recommendation 6: Establish required timeframes for the review and
    approval of Indian Communitization Agreements (CAs) to ensure a more
    timely CA process.

        The Department is continuing its work to ensure CA processes are
    timely. A National Policy Memorandum (Memorandum) was issued that
    establishes a tracking mechanism to monitor the existing timeframes for
    review and approval of Indian CAs. This tracking mechanism will provide
    the data which will be used to establish standard and reasonable
    timeframes for CA review and approval. The timeframes will also be
    incorporated into the BIA Fluid Mineral Estate Procedural Handbook and
    the Onshore Energy and Mineral Lease Management Interagency Standard
    Operating Procedures as updates to this document occur. On April 27,
    2017, the Department received notice than an extension was granted by
    OIEA to extend the target date to the end of FY18.

        Recommendation 7: Develop a systematic mechanism for tracking
    Indian CAs through the review and approval process to determine, among
    other things, whether the revised CA process meets newly established
    timeframes.

        The BIA is still developing a systematic mechanism to track Indian
    CAs through the review and approval process. Until TAAMS can be
    modified to incorporate the key identifiers and data fields, the BIA is
    utilizing a centralized tracking spreadsheet on the Google platform.
    BIA leads the development and deployment of this tracking spreadsheet
    in consultation and coordination with BLM. We received an extension
    from GAO to complete this recommendation by the end of FY18 and are on
    track to meet our target.

        Recommendation 8: Assess whether the revised CA process is
    achieving its objective to improve the timeliness of the review and
    approval of Indian CAs, and if not, make changes as appropriate.

        BIA and BLM will continue to use the tracking spreadsheet mentioned
    above, and, upon completion, the enhanced TAAMS capabilities, to
    monitor and assess the results of the efforts to streamline the Indian
    CA review and approval process. The bureaus will continue to coordinate
    to establish a process for review of the collected data, which will
    assist in identifying and implementing any necessary process
    modifications.
    GAO 17-43
        Recommendation 9: Include the other regulatory agencies in the
    Service Center, such as Fish and Wildlife Services, the Environmental
    Protection Agency, and the Army Corps of Engineers, so that the Service
    Center can act as a single point of contact or a lead agency to
    coordinate and navigate the regulatory process.

        The Indian Energy Service Center (IESC) is working to implement
    Memoranda of Understanding (MOU) with the appropriate Department
    bureaus and other Federal agencies involved in the development of
    Indian energy and mineral resources and to define roles and
    responsibilities regarding the development of those resources on trust
    lands. MOUs are being developed with the Fish and Wildlife Service
    (FWS), Environmental Protection Agency (EPA), Army Corps of Engineers
    (Corps), as well as IEED and Department of Energy (DOE).
        The BIA/IESC, through the Indian Energy Minerals Steering Committee
    (IEMSC), has also established Federal Partners Groups, where needed,
    which include: BIA, BLM, Office of Natural Resource Revenue (ONRR),
    Corps, FWS, and EPA. These groups provide field knowledge on energy and
    mineral issues and serve to facilitate and focus the single point of
    contact desired by the respective parties regarding the processing of
    energy development for each region.
        Currently, Federal Partner Groups are being established for the
    Navajo Region, the Southwest Region, and the Rocky Mountain Region.
    Federal Partner Groups for the Great Plains Region, the Eastern
    Oklahoma/Southern Plains Regions, and the Western Region are currently
    meeting on a regular basis.

        Recommendation 10: Direct the Bureau of Indian Affairs to establish
    formal agreements with IEED and DOE that identify, at a minimum, the
    advisory or support role of each office.

        BIA recognizes that in addition to the identification of potential
    energy resources, there must be organized coordination between agencies
    to fully develop and/or protect Indian energy and mineral resources.
        In an effort to improve communication between the two offices, an
    MOU was recently signed between IEED and DOE outlining a partnership
    going forward. The IESC reviewed this MOU with the intent of also
    entering into the existing agreement. The IESC prepared an addendum to
    the MOU with IEED and DOE to finalize the agreement. The addendum is
    currently in the surname process.

        Recommendation 11: Direct Bureau of Indian Affairs to establish a
    documented process for seeking and obtaining input from key
    stakeholders, such as BIA employees, on the Service Center activities.

        The IESC developed a process that allows key agencies to provide
    input and requests for service received on behalf of tribes from the
    IESC. The process includes guidance on the prioritization of task
    orders. The Executive Management Group of the IESC, is comprised of the
    directors of the BIA, BLM, ONRR, and Office of the Special Trustee for
    American Indians (OST), are engaged in this effort. The IESC began
    utilizing the intake forms in August, to obtain input regularly from
    stakeholders, and currently has no data to report.

        Recommendation 12: Direct the Bureau of Indian Affairs to document
    the rationale for key decisions related to the establishment of the
    Service Center, such as alternatives and tribal requests that were
    considered.

        The development of the IESC was the result of a concept paper
    produced by a multi-agency team formed by the IEMSC. The multi-agency
    team held a tribal listening session, received written comments, and
    conducted conference calls in an effort to gather input from relevant
    stakeholders. The final version of the concept paper also included an
    organization chart which set forth the IESC chain-of-command. The IEMSC
    accepted and approved the concept paper as presented by the multi-
    agency team. At this point, the BIA believes this recommendation is
    complete and the GAO closure package is currently being prepared

        Recommendation 13: Direct the Bureau of Indian Affairs to
    incorporate effective workforce planning standards by assessing
    critical skills and competencies needed to fulfill BIA's
    responsibilities related to energy development and by identifying
    potential gaps.

        The BIA is continuing the process of identifying and implementing a
    workforce plan regarding positions associated with the development of
    Indian energy and minerals. As we testified in May before the
    Committee, the IESC will collect data directly from BIA, BLM, ONRR, and
    OST employees in an effort to identify workload and necessary technical
    competencies. Then, the IESC will work with partner bureaus to assess
    skills and competencies needed for energy and mineral workforce
    standards. The initial survey was distributed in August 2017 to key
    employees across BLM, ONRR, OST and BIA; results are being analyzed.
    The BIA is on target and expects to complete this recommendation by the
    end of 2017.

        Recommendation 14: Direct the Bureau of Indian Affairs to establish
    a documented process for assessing BIA's workforce composition at
    agency offices taking into account BIA's mission, goals, and tribal
    priorities.

        The BIA is assessing the BIA Indian energy and mineral workforce
    composition using the same process as described in Recommendation 13.
    This includes collecting data directly from BIA, BLM, ONRR, and OST
    employees. The BIA is on target to complete this assessment by December
    31, 2017.
    Conclusion
        Thank you for the opportunity to present an update on our progress
    in addressing the GAO recommendations from past reports and the GAO
    High Risk Report (GAO-17-317 High Risk Series). I would be glad to
    answer any questions the Committee may have.

        The Chairman. Thank you, Assistant Secretary Black.
        I will now turn to Rear Admiral Michael Weahkee.

             STATEMENT OF REAR ADMIRAL MICHAEL D. WEAHKEE,
             ACTING DIRECTOR, INDIAN HEALTH SERVICE, U.S.
                DEPARTMENT OF HEALTH AND HUMAN SERVICES

        Mr. Weahkee. Good afternoon, Chairman Hoeven, Vice Chairman
    Udall and members of the Committee.
        I am pleased to provide testimony before the Committee
    today and would like to thank you for elevating the importance
    of delivering quality health care throughout the IHS. The IHS
    is committed to overcoming the longstanding, systemic problems
    hindering our efforts to provide quality health care for
    American Indians and Alaska Natives.
        I am proud to report that our concerted efforts are
    producing results. As of September 1, the Rosebud Indian Health
    Service Hospital is no longer under a Systems Improvement
    Agreement. We are striving to achieve a similar result for the
    Pine Ridge and Omaha Winnebago hospitals.
        Also in August, I signed the Official Patient Wait Times
    Policy and GAO has agreed to close that recommendation.
        The GAO identified a number of challenges facing the IHS in
    administering our health care programs. To overcome these
    challenges, we developed a Quality Framework and have worked
    diligently to refine and operationalize it.
        In less than a year, we have updated governing board
    bylaws, acquired a credentialing software system, developed a
    standard patient experience of care survey, developed patient
    wait time standards, and developed a performance accountability
    dashboard.
        We are on course to address the four key GAO
    recommendations on improvement of agency oversight of quality
    health care. In December 2016, IHS developed contingency and
    succession plans for the replacement of key personnel,
    including our area director positions. These succession plans
    are currently being updated and will be updated on a semi-
    annual basis. We will provide GAO with the copy they need as
    evidence of completion. We have requested closure of this
    recommendation.
        The second and third recommendations I would like to
    address concern patient wait times for appointments. The
    official patient wait times policy is now in effect. This
    policy finalizes the interim standards initially established in
    July of this year.
        The fourth quality-related recommendation is the agency-
    wide oversight of quality. We developed a performance
    accountability dashboard and acquired a practitioner
    credentialing software system. Dashboard metrics will allow
    oversight and management of compliance with policy and
    regulatory requirements that ensure quality and safety of care.
    The system-wide dashboard will be in full operation in the fall
    of 2017.
        The national provider credentialing and privileging system
    standardizes and streamlines the credentialing process across
    the IHS. We are implementing it in four IHS areas with plans to
    expand it to the rest of the agency by the end of 2017.
        I am also happy to report that the agency has made progress
    in addressing the ten key GAO recommendations on the
    improvement of our Purchased and Referred Care Program. To
    address the first of these three recommendations, IHS modified
    the data system that tracks PRC referrals and emergency self
    referrals. We will report baseline data for calendar year 2017.
        IHS is also researching industry standards and will develop
    separate payment timeframe targets for these two referral
    types. We will request closure of this recommendation when that
    work is completed.
        GAO's second recommendation was for PRC funds to be used to
    pay for program staff. Historically, IHS' internal policy was
    to use PRC funds solely for the purchase of health care
    services. Any change in the current use of PRC should be
    balanced with the continuing need to assure access to services
    we cannot provide in our facilities.
        In response to the third recommendation, we provide
    patients with current information regarding opportunities for
    new coverage options. While we agree with the premise of the
    GAO's recommendation, we have reservations about the specifics
    and would like to discuss this further with the GAO. The agency
    has requested closure of these two recommendations.
        The recommendation to cap payment rates has been
    implemented. Since capping PRC payment rates for non-hospital
    services, the IHS and participating tribes have realized a
    savings of more than $178 million so far in this calendar year.
    The additional savings realized enabled IHS and tribes to
    increase access to more health care services.
        IHS also developed an online PRC rate provider tracking
    tool to monitor patient access to care. We look forward to
    demonstrating that tool for the GAO. IHS has requested closure
    of this recommendation.
        I would like to address GAO's three recommendations on the
    allocation of PRC program resources by describing the Federal-
    tribal administration of PRC funds. Approximately 60 percent of
    the PRC funds are distributed through Indian Self-Determination
    awards and are protected from unilateral reductions or
    reallocation by the agency.
        Any future changes in the PRC allocation methods, such as
    the two recommended by the GAO, will require tribal
    consultation. IHS has requested closure of these
    recommendations.
        We are also taking steps to address the third
    recommendation related to development of written PRC allocation
    policies and procedures. To assure transparency, IHS routinely
    directs area directors through official PRC allocation of funds
    distribution memos.
        These memos are official policy guidance and become part of
    the PRC policy chapter of the Indian Health Manual. The revised
    chapter is currently under final agency review. The agency has
    requested closure of this recommendation.
        We continue to address the remaining recommendations not
    discussed above: one related to the enrollment processes
    improvement and two focused on oversight for estimating need.
    Closure of these recommendations will be requested when we
    complete the steps necessary to document the changes and
    improvements we have made since 2011.
        I am very proud of the dedication and commitment of our IHS
    staff, at all levels of the agency, who have accomplished these
    objectives in the past year. I want to thank you again for your
    commitment to improving quality, safety and access to health
    care for American Indians and Alaska Natives.
        I am happy to answer any questions the Committee may have.
    Thank you, sir.
        [The prepared statement of Admiral Weahkee follows:]

    Prepared Statement of Rear Admiral Michael D. Weahkee, Acting Director,
      Indian Health Service, U.S. Department of Health and Human Services
        Chairman and Members of the Committee:
        Good afternoon, Chairman Hoeven, Vice-Chairman Udall, and Members
    of the Committee. I am RADM Michael D. Weahkee, Acting Director of the
    Indian Health Service (IHS). I am pleased to provide testimony before
    the Senate Committee on Indian Affairs on ``High Risk Indian Programs:
    Progress and Efforts in Addressing GAO's Recommendations''. 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.
        I am an enrolled member of the Zuni Tribe. Most recently, I served
    as the Chief Executive Officer (CEO) of the Phoenix Indian Medical
    Center, leading the largest federally-operated IHS hospital in the
    nation. I have previously served at IHS headquarters in a variety of
    posts. Before that, I served in leadership roles on behalf of the
    California Rural Indian Health Board. I am honored to be a veteran of
    the United States Air Force, where I served as a Public Health
    Specialist. I am also proud of the fact that I was born at the IHS
    hospital in Shiprock, New Mexico, and grew up as an active user of the
    IHS health care system. Essentially, Indian health care and public
    health have been my lifelong pursuits and are my passion.
        IHS is a distinctive agency in the Department of Health and Human
    Services (HHS), established to carry out the responsibilities,
    authorities, and functions of the United States to provide health care
    services to American Indians and Alaska Natives. It is the only HHS
    agency whose primary function is direct delivery of health care. 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. The IHS
    system consists of 12 Area offices, which oversee 170 Service Units
    that provide care at the local level. Health services are provided
    through facilities managed by IHS, by Tribes and tribal organizations
    under authorities of the Indian Self-Determination and Education
    Assistance Act (ISDEAA), and through contracts and grants awarded to
    urban Indian organizations authorized by the Indian Health Care
    Improvement Act.
        IHS is steadfastly committed to overcoming the longstanding
    systemic problems that have hindered our efforts to provide quality
    health care to American Indians and Alaska Natives, and I am proud to
    report that our concerted efforts are producing results. As of
    September 1, the Rosebud IHS Hospital is no longer under a Centers for
    Medicare & Medicaid Services (CMS) Systems Improvement Agreement. CMS
    determined that the hospital had substantially met all of the Medicare
    Conditions of Participation. We are striving to achieve a similar
    result for Pine Ridge and Omaha Winnebago IHS Hospitals.
        IHS is also committed to doing all that is necessary to be removed
    from GAO's High Risk list. The GAO's High Risk Report cited 14
    recommendations that focus on IHS, derived from seven reports issued
    over a period of six years (2011 to 2017). Although all 14
    recommendations remain open at this time, we have made substantial
    progress and are continuing to press forward. In July, IHS provided an
    update to GAO and requested closure of seven recommendations. GAO
    requested additional documentation concerning those requests that we
    are currently providing, and we will continue to submit additional
    responses to address the remaining GAO recommendations. I will describe
    the actions we are taking to address the recommendations and strengthen
    the IHS' ability to ensure quality health care.
    Ensuring Quality Care
        GAO identified a number of challenges facing IHS in administering
    Indian health care programs that have hindered our ability to ensure
    quality of care to Indian communities. To overcome these challenges,
    IHS developed a Quality Framework--a plan to develop, implement and
    sustain quality-focused compliance programs at all of our hospitals and
    clinics. The Framework incorporates quality standards from national
    experts, including best practices and expertise from across the IHS
    system of care. Core elements of the Framework focus on strengthening
    our organizational capacity to improve quality of care and systems,
    meeting and maintaining accreditation for IHS Direct Service
    Facilities, aligning our service delivery processes to improve patient
    experience, ensuring patient safety, and improving transparency and
    communication about patient safety and quality to IHS stakeholders.
        IHS has worked diligently to refine and operationalize the Quality
    Framework. In less than a year, we have updated Governing Board Bylaws,
    acquired a credentialing software system, developed a standard patient
    experience of care survey and an implementation strategy using
    electronic tablets, developed patient wait time standards for the
    primary care setting, developed a quality assurance accountability
    dashboard (the data reporting tool is currently undergoing functional
    testing), and are nearing award of a master contract for accreditation
    of hospitals. The Deputy Director for Quality Health Care provides
    senior leadership oversight of critical quality improvement strategies
    related to accreditation/certification, patient safety, and quality
    care.
        IHS has made remarkable progress and will continue to pursue
    implementation of the Quality Framework at all levels of IHS and in
    partnership with Tribal/Urban Indian organization partners as a key
    priority. Our leadership team is focused on ensuring quality in all
    that we do as an agency, and I expect this perspective and commitment
    will continue to produce results.
        We are strengthening the agency's use of standards by developing
    new policies that define the standards and implementing system level
    reporting and oversight through Agency-wide improvements. We are on
    course to address the four key GAO recommendations on improvement of
    agency oversight of quality of care, and requested closure of one of
    these four recommendations in July.
        The first recommendation I would like to address concerns
    succession planning for key leadership personnel. In December 2016, IHS
    developed contingency and succession plans, including skills gap
    analyses and appropriate developmental programs for the replacement of
    key personnel, including Area Directors. The December 2016 succession
    plans are currently being updated and will continue to be updated on a
    semi-annual basis. In addition to the contingency and succession plans,
    IHS has developed leadership training academies for senior leaders. For
    example, the IHS Leadership Training program is designed to prepare
    selected IHS individuals to serve in leadership positions at the
    Service Unit, Area, and Headquarters levels. In addition, staff
    rotations through IHS Headquarters provide additional training for
    senior level positions, and a mentoring initiative for those who have
    recently been promoted to key leadership positions has been
    implemented. We have requested closure of this recommendation.
        The second and third recommendations I would like to address
    concern patient wait times for appointments. Wait times are an
    important measure of the patient experience and IHS federally-operated
    service units have been collecting and tracking this data to improve
    patient services. On August 25, I signed the official Patient Wait
    Times policy formalizing the IHS wait times standards for outpatient
    primary care visits in direct care IHS facilities. This policy
    finalizes the interim standards initially established in July of this
    year. Under these new standards, the mean wait time for a primary care
    appointment will be 28 days or less and for urgent appointments it will
    be 48 hours or less. These mean appointment wait times are the core
    measures that will be collected in all primary care settings. The data
    collected across IHS' direct service sites will be used to continually
    improve patient wait times. In order to implement the agency-wide
    standards by December 31, 2017, the IHS Chief Medical Officer
    communicated the Patient Wait Time policy Circular to Area clinical
    leadership on September 1, 2017. As part of its implementation, IHS
    will monitor the outcome data and ensure corrective actions are taken
    if standards are not met.
        The fourth quality-related recommendation I will address is the
    Agency-wide oversight of quality. IHS has developed a performance
    accountability dashboard and acquired a practitioner credentialing
    software system. The accountability dashboard incorporates the five
    dimensions of health: patient safety, care effectiveness, patient-
    centeredness, timeliness, and care efficiency. Dashboard metrics will
    allow oversight and management of compliance with policy and regulatory
    requirements that ensure quality and safety of care. The measure
    definitions are complete, the data collection tool is in testing, and
    the dashboard for visualization is under development. The IHS will have
    the system-wide dashboard of performance accountability metrics in
    operation in the fall 2017. The dashboard is a powerful tool that will
    enable Headquarters and Area Offices to have real-time visibility
    across the IHS system. This will facilitate implementation and
    monitoring of quality measures throughout the system over time.
        We are making other system-wide changes to ensure that quality
    improvements made by the federally-operated facilities are supported
    and sustained over time. IHS is modernizing the way provider
    credentialing and privileging, and facility accreditation preparedness
    is carried out within the federally-operated hospitals and clinics.
    Also, we strengthened the governance and oversight of the hospitals by
    implementing standard Hospital Governing Board requirements.
        To facilitate the hiring of qualified providers and ensure patient
    safety, the IHS is implementing a national provider credentialing and
    privileging system. The system is being implemented first in four IHS
    Areas and then will be expanded to the remaining IHS Areas by the end
    of 2017. The national credentialing system standardizes and streamlines
    the credentialing process across the IHS. Privileging and performance
    evaluations of IHS practitioners will be key aspects tracked in the new
    system that help address quality and patient safety. The IHS
    credentialing and privileging policy is being updated to support the
    new system.
        Additionally, IHS expects to award a contract to a single
    accrediting organization for IHS hospitals later this month. IHS' use
    of one accreditation body will support the Agency-wide approach to
    quality improvement in the IHS facilities to help maintain
    accreditation. IHS' existing partnership with CMS further supports best
    health care practices and other organizational improvements for IHS
    federally-operated hospitals that participate in the Medicare program.
        Lastly, since January 2017, IHS Hospital Governing Board (GB)
    Bylaws for inpatient acute care hospitals have been standardized across
    the Agency. We set minimum standards IHS-wide, while maintaining
    flexibility for the Areas and Service Units to accommodate needs
    specific to their locations and service populations. GB bylaws now
    specify minimum meeting frequency, agenda topics, and membership. Area
    Directors were instructed to immediately incorporate these changes into
    GB Bylaws for each hospital, communicate these new requirements to
    their Service Units and verify completion of these changes to IHS
    Headquarters (which was accomplished by February 2017).
    Purchased/Referred Care Improvements
        I can report that the agency has made progress in addressing the 10
    key GAO recommendations on improvement of the Purchased/Referred Care
    (PRC) program. The IHS is improving and increasing access to care for
    our beneficiaries through outreach, education and enrollment
    activities, and requested closure of six recommendations in July. We
    are working to provide GAO with additional documentation of our
    progress.
        The first GAO recommendations on the PRC program that I can report
    progress on address opportunities for improving the administration of
    the program. IHS places a high priority on timely processing of
    purchase orders, private provider claims, and payments for those
    services that cannot be provided by our facilities directly. Improving
    the data reporting and measurement system is essential to assuring that
    PRC programs are efficient. To that end and to address the first of the
    three recommendations, IHS modified the data system that tracks PRC
    referrals and emergency self-referrals and expects to begin baseline
    reporting for calendar year (CY) 2017 that will be available in CY
    2018. IHS is currently researching industry standards and expects to
    have separate payment timeframe targets for these two referral types.
    We will request closure of this recommendation when the work is
    completed on all the items. GAO's second recommendation was for PRC
    funds to be used to pay for program staff. Historically, IHS' internal
    policy was to use PRC funds solely for the purchase of health care
    services. Any change in the current use of PRC should be balanced with
    the continuing need to assure access to services we cannot provide in
    our facilities. As for the third recommendation, we provide patients
    with current information regarding opportunities for new coverage
    options and ability to access care without obtaining a PRC referral.
    The Agency has requested closure of these two recommendations.
        I can report that the recommendation to cap payment rates for non-
    hospital services has been addressed. IHS issued a final rule with
    comment, which amended the IHS regulations at 42 CFR part 136 to add a
    new Subpart I. The new Subpart I applies Medicare payment methodologies
    to physician and other non-hospital services or items purchased through
    the PRC program. The additional savings realized enables IHS and Tribal
    providers to increase access to more health care services. After
    capping PRC payment rates for non-hospital services, IHS and Tribes
    that use the IHS fiscal intermediary for the processing of PRC claims
    have realized a savings of more than $178 million so far this calendar
    year. All IHS PRC programs participate in the PRC payment rates; Tribes
    are not required to participate, but may opt in. To date, six Tribes
    have opted in to participate. IHS also developed an online PRC Rates
    Provider Tracking tool to monitor the access to physician and other
    non-hospital care. This tool enables PRC programs to document providers
    that refuse to contract for their most favored customer rate or accept
    the PRC rates. IHS provided training on use of the tool to the Area PRC
    officers at a face-to-face meeting in December 2016. The tool went live
    in January 2017. IHS has requested closure of this recommendation.
        I would like to address GAO's three recommendations on the
    allocation of PRC program resources by describing the federal-tribal
    administration of PRC funds and its implications for our response to
    the first and second recommendations. Approximately sixty percent of
    the PRC funds are distributed through Indian Self-Determination awards
    and are protected from unilateral reductions or reallocation by the
    agency, absent one of the circumstances set forth in 25 U.S.C.
    5325(b)(2) or 25 U.S.C.  5388(d)(1)(C)(ii). IHS partners with tribal
    leaders in making PRC fund allocation decisions. Any future changes in
    PRC allocation methods, such as the two recommended by GAO, will
    undergo tribal consultation. The tribal-federal workgroup on improving
    PRC met in June of this year and recommended not changing the fund
    allocation methodology at a time when there is uncertainty in the
    future of federal health care financing and policy. IHS has requested
    closure of these two recommendations.
        I would also like to report on actions we are taking to address the
    third recommendation related to the development of written PRC
    allocation policies and procedures. To assure transparency, IHS
    distributed guidance on PRC allocation of funds to Area Directors and
    PRC officers in CY 2016. IHS routinely directs Area Directors through
    official PRC allocation-of-funds distribution memos. These memos are
    official procedural documents that become a part of the PRC policy
    chapter of the Indian Health Manual. The chapter is under final agency
    review. The Agency has requested closure of this recommendation.
        We continue our work addressing the remaining recommendations not
    discussed above: one addressing improvement in the enrollment processes
    and two focused on oversight for estimating need. We expect to request
    closure for these three open recommendations when we complete all the
    steps necessary to document the changes and improvements the Agency has
    adopted since 2011.
        IHS is committed to addressing all risks impacting our ability to
    carry out our Agency mission. We have incorporated the GAO's High Risk
    Report recommendations into the IHS risk management work plan for 2017.
    IHS has entrusted leadership at all levels of the organization to
    identify current controls and will review their effectiveness in our
    annual internal management assessments. Where controls are deemed
    insufficient, actions to strengthen them will be taken. This special
    focus on identifying and mapping internal controls will help to inform
    strategic planning and identify appropriate areas for resource
    allocation.
        I am very proud of the dedication and commitment of IHS staff at
    all levels of the agency who have accomplished these objectives in the
    past year. And I think you will agree with me that these actions
    demonstrate that IHS is taking its challenges seriously, and is
    continuing to take assertive and proactive steps to address them. Thank
    you for your commitment to improving quality, safety, and access to
    health care for American Indians and Alaska Natives. I will be happy to
    answer any questions the Committee may have.

        The Chairman. Thank you, Admiral.
        Mr. Dearman.

         STATEMENT OF TONY DEARMAN, DIRECTOR, BUREAU OF INDIAN
               EDUCATION, U.S. DEPARTMENT OF THE INTERIOR

        Mr. Dearman. Good afternoon, Chairman Hoeven and members of
    the Committee.
        Thank you for the invitation to appear again on behalf of
    the Bureau of Indian Education in regard to our recent work
    addressing BIE's High Risk designation.
        As highlighted in the GAO reports, much work remains, but I
    am glad to report progress since the last time we met. Since
    the last hearing, we continue to prioritize the GAO
    recommendations and view their reports as a constructive tool
    to improve the agency and help the students we are committed to
    serve.
        In three separate reports dating back to 2013, GAO provided
    13 recommendations to improve the management of BIE schools.
    Currently, 11 of the GAO's recommendations remain open but
    progress is being made on these outstanding recommendations.
        GAO issued three additional reports in May of 2017 since
    the last Committee hearing. The three additional GAO reports
    include several new recommendations, ten of which directly
    involve the BIE while the others require coordination with
    other bureaus within Indian Affairs.
        As director, I am working with our senior leadership team
    within BIE, as well as with Indian Affairs, the Secretary's
    office, and our colleagues at the GAO to ensure that BIE
    comprehensively addresses each outstanding recommendation.
        We appreciate the assistance and collaboration offered by
    GAO. In recent months, the BIE, through the support of the
    department, has increased its direct communication with GAO,
    which has enhanced BIE's ability to more effectively address
    outstanding recommendations.
        Through in-person meetings and follow-up teleconferences,
    GAO has provided BIE comments and suggestions for closing the
    outstanding recommendations.
        Regarding GAO-13-774, BIE has completed implementation of
    recommendations two and three, which includes development of a
    communications strategy and increased collaboration with the
    Department of Education.
        Recommendation five, revision of a strategic workforce
    plan, was previously considered closed by the department, but
    not GAO. After a thorough review of the recommendation five
    closure package with GAO, BIE and the department have chosen to
    list the recommendation as open and are working to submit a new
    closure package.
        Further, BIE is currently working to implement
    recommendations one, four, and five, which are to develop
    documented decision-making procedures, a strategic plan, and a
    comprehensive workforce plan. BIE plans to fully implement the
    remaining recommendations contained in GAO-13-774 by 2018.
        Regarding GAO-15-121, BIE continues to implement GAO's four
    recommendations and complete its work with respect to
    recommendations one and two no later than the close of 2018 and
    recommendations three and four by the middle of 2019.
        Regarding GAO-16-313 and GAO-17-421, Indian Affairs has
    formed an interagency workgroup to address all safety-related
    GAO recommendations. The workgroup consists of staff from BIE,
    BIA, and pertinent partners across Indian Affairs. The group's
    first meeting was held on May 31 through June 1, 2017, with a
    second meeting held on August 15-16, 2017.
        Working with BIA, BIE is currently crafting and
    implementing comprehensive safety inspection policies and
    procedures to ensure that high quality inspections and reports
    are carried out.
        Regarding GAO-17-423, not all recommendations are directly
    under BIE's purview. However, BIE tentatively concurs with
    recommendation seven and is examining the feasibility and cost
    of implementation.
        With regard to Recommendation 8, BIE non-concurs with GAO
    regarding this recommendation. While altering the
    transportation formula could be beneficial, it would require a
    formally-negotiated rulemaking. To consider such rulemaking,
    BIE would need to have support of its tribal partners.
        Regarding GAO-17-447, BIE is working cooperatively with
    partners across Indian Affairs to address GAO's
    recommendations. As this is a new report, these items are not
    outstanding but will nonetheless be addressed as expeditiously
    as possible.
        Members of the Committee, thank you for the opportunity to
    present testimony today and provide the Committee an update
    regarding our GAO work. BIE is excited about our recent
    progress and remains committed to sustained improvement. The
    BIE looks forward to working with you and appreciates your time
    and attention in this important matter.
        I would be honored to answer any questions you may have.
        [The prepared statement of Mr. Dearman follows:]

        Prepared Statement of Tony Dearman, Director, Bureau of Indian
                   Education, U.S. Department of the Interior
        Good afternoon Chairman Hoeven, Vice Chairman Udall, and Members of
    the Committee. Thank you for the invitation to appear again on behalf
    of the Bureau of Indian Education (BIE) to discuss our ongoing work to
    address the high risk designation from the Government Accountability
    Office (GAO) in the High Risk Report (GAO-17-317 High Risk Series).
        As highlighted in the GAO reports, much work remains, but I am glad
    to update this Committee on progress made since I last testified in
    May. A priority as BIE Director includes addressing the GAO
    recommendations and the issues highlighted head on. As I previously
    testified, the BIE team views the GAO's reports as a constructive tool
    to improve our agency and help the students we are committed to serve.
    As such, I will update you on headway made in the following areas:

            1. GAO High Risk Status for BIE
            2. GAO Recommendations
            3. GAO Recommendations Status & BIE Next Steps

    GAO High Risk Status for BIE
        In February, the GAO released its High Risk Report (GAO-17-317 High
    Risk Series) designating BIE as a high risk agency. The GAO highlighted
    the following persistent weaknesses noted in previous reports that
    inhibit the agency from efficiently executing its mission to serve
    Indian students:

        Indian Affairs' (IA) oversight of school safety and
            construction, as well as how BIE monitors the way schools use
            Interior funds;

        The impact of limited workforce planning in several key
            areas related to BIE schools;

        The effects of aging BIE school facilities and equipment
            and how such facilities contribute to degraded and unsafe
            conditions for students and staff; and

        How the lack of internal controls and other weaknesses
            hinder IA's ability to collect complete and accurate
            information on the physical conditions of BIE schools.

        In three separate reports dating back to 2013, the GAO provided
    thirteen recommendations to improve IA's management of BIE schools.
    Currently, eleven of GAO's recommendations remain open. However,
    progress is being made to address BIE's outstanding recommendations.
    GAO issued three additional reports in May 2017 since the last
    Committee hearing on this subject. These new GAO reports include
    several new recommendations, ten of which would require a response
    solely from BIE. BIE tentatively concurred with one of the ten new
    recommendations and disagreed with one other new recommendation. The
    remaining recommendations, due to agency authority, are directed to
    other entities within IA, or a combination of agencies within IA.
        As Director, I am committed to addressing these outstanding items.
    To that end, I am working with our senior leadership team within BIE as
    well as with the Bureau of Indian Affairs (BIA), the Office of the
    Assistant Secretary for Indian Affairs, the Secretary's Office, and our
    colleagues at GAO to ensure BIE comprehensively addresses each
    outstanding recommendation as expeditiously and effectively as
    possible. We are appreciative of the assistance and collaboration
    offered by GAO. In recent months, the BIE, through the support of the
    Department, has increased its direct communication with GAO, which has
    enhanced BIE's ability to efficiently address outstanding
    recommendations. Through in-person meetings and follow-up
    teleconferences, GAO has provided BIE comments and suggestions for
    closing recommendations in a timely manner.
        GAO recommendations are a roadmap for BIE to establish and maintain
    comprehensive internal policies and procedures that support service
    delivery, ensure accountability, and provide organizational stability.
    We look forward to continuing our work with GAO and this Committee.
    GAO Recommendations: Status and BIE Next Steps
        In the past few years, BIE planned, consulted on, designed, and
    implemented a complex, multifaceted, bureau-wide reorganization. In
    February 2016, the Department of the Interior directed BIE to move
    forward with Phase I of its reorganization, with the agency committing
    considerable time, energy, and resources to carry out the directive.
    Simultaneously, considerable turnover within BIE senior leadership
    reduced capacity and focused BIE's attention on day-to-day services
    rather than addressing critical, long-term organizational improvement
    strategies highlighted in the GAO reports. BIE has now prioritized
    resources and critical personnel to refocus efforts to address the
    longstanding issues outlined in GAO reports that will ultimately
    improve our ability to serve Indian students.
        In November 2016, the BIE filled several key positions that have
    been tasked with serving on an internal working group focused on
    evaluating all outstanding GAO recommendations as well as BIE's past
    GAO closure submissions. The team completed its analysis in early 2017
    and reported its findings and recommendations to BIE leadership in mid-
    March. Based on the information received, BIE leadership is not
    satisfied with the quality and timeliness of the work to date, and
    recognizes the shortcomings and need for each GAO recommendation to be
    reexamined and addressed. BIE is currently working to complete the
    actions recommended in each of these three GAO reports.
                        outstanding gao recommendations
        GAO-13-774--INDIAN AFFAIRS: Better Management and Accountability
    Needed to Improve Indian Education (September, 2013).

        GAO made five recommendations:

            I.) Develop and implement decisionmaking procedures which are
            documented in management directives, administrative policies,
            or operating manuals;

            II.) Develop a communication strategy;

            III.) Appoint permanent members to the BIE-Education committee
            and meet on a quarterly basis;

            IV.) Draft and implement a strategic plan with stakeholder
            input; and

            V.) Revise the BIE strategic workforce plan.

        BIE has completed implementation of recommendations two and three,
    which includes development of a communications strategy and increased
    collaboration with the Department of Education (ED) through several
    mechanisms, including a BIE-ED Committee that meets every other week
    (rather than just quarterly). Recommendation five, revision of a
    strategic workforce plan, was previously considered closed by the
    Department, but not GAO. After reviewing the previous work submitted by
    BIE regarding recommendation five, and after closely collaborating with
    GAO regarding the work product, BIE and the Department relisted the
    recommendation as open and will continue to work collaboratively with
    GAO until fully implemented. Additionally, BIE will assess the
    effectiveness of its implementation of GAO's closed recommendations in
    an effort to continually improve BIE's operations. BIE is currently
    working to implement recommendations one, four, and five, which are to
    develop documented decisionmaking procedures, a strategic plan, and a
    comprehensive workforce plan. BIE plans to fully implement the
    remaining recommendations contained in GAO-13-774 by 2018.
        Recommendation I--In June 2017, the BIE workgroup convened staff
    from across the Bureau for a two-day workshop. During the workshop, the
    workgroup solicited inter-departmental input regarding a formal
    strategic decisionmaking policy. A draft strategic decisionmaking
    procedure was produced by the workgroup shortly thereafter. On July 14,
    2017, the BIE workgroup provided a copy of the draft strategic
    decisionmaking procedure to all BIE senior leaders for a one-week
    review and input period. Following the one week review, the workgroup
    incorporated all feedback and submitted the draft procedure to the IA's
    Office of Regulatory Affairs and Collaborative Action (RACA) on July
    28, 2017.
        RACA is the office responsible for reviewing, and ultimately
    publishing, the document in the Indian Affairs Manual (IAM), which is a
    reference for all agencies and offices within IA. On August 18, 2017,
    RACA provided BIE edits and input for review. On August 21, 2017, BIE
    completed its review of RACA's feedback and resubmitted the draft
    decisionmaking procedure for publication into the IAM. BIE is awaiting
    final publication of the strategic decisionmaking procedure by RACA.
    Upon final publication, BIE will schedule a training event for all
    appropriate personnel regarding the use of the newly drafted strategic
    decisionmaking policy as well as work to provide a closure package to
    GAO.
        Recommendation IV--BIE, working cooperatively with leadership
    within IA and pertinent stakeholders, has reviewed the strategic plan
    submitted to GAO in September 2016 and has determined the quality of
    work as unsatisfactory, both for the purposes of closing recommendation
    four and for working as a functional tool intended to guide the
    organization in achieving its mission. At the close of this review, BIE
    immediately began the process of planning and drafting a revised
    strategic plan.
        On March 8, 2017, BIE conducted a senior leader strategic planning
    exercise. On April 11, 2017 BIE held a follow-up strategic planning
    session, convening local, regional, and central office personnel to
    determine paths forward. By the end of April 2017, BIE began revising
    its mission and vision statement and identified draft goals. On June
    14, 2017 and July 18--20, 2017, BIE held additional strategic planning
    sessions to identify strategies aligned to goals and established a
    communications plan for sharing the draft plan with internal and
    external stakeholders to solicit feedback as well as developing a
    timeframe for formal consultation with Indian tribes. In addition, BIE
    identified dates for additional organization-wide planning meetings on
    August 29-30, 2017 and September 26-28, 2017.
        To ensure that the strategic planning process is effective and
    results in a high quality and useful work product, the BIE has
    partnered with external subject matter expert organizations, such as
    the Council of Chief State School Officers (CCSSO), the South Central
    Comprehensive Center (SC3), and the Building State Capacity and
    Productivity Center (BSCPC). These organizations have provided BIE with
    technical expertise and shared best practices in developing an
    effective, long-term strategic plan as well as creating a functional
    action plan for implementing a measurement system to track progress
    once the strategic plan is implemented.
        GAO-15-121--INDIAN AFFAIRS: Bureau of Indian Education Needs to
    Improve Oversight of School Spending (November, 2014).

        GAO made four recommendations:

            I.) Develop a comprehensive workforce plan;

            II.) Implement an information sharing procedure;

            III.) Draft a written procedure for making major program
            expenditures; and

            IV.) Create a risk-based approach in managing BIE school
            expenditures.

        BIE is continuing its work to implement GAO's four recommendations
    contained in GAO-15-121. To that end, the BIE plans to complete its
    work with respect to recommendations one and two no later than the
    close of 2018 and recommendations three and four by the middle of 2019.
        Recommendation I--During the early stages of the current BIE
    reform, IA contracted a workforce study. However, following BIE's
    meetings with GAO on June 17, 2017 and August 16, 2017, GAO provided
    clarification regarding work product expectations identifying skills
    gap, prioritization of vacancies, and the need for plans contingent on
    varying outcomes, such as available funding and hiring constraints. BIE
    plans to revisit the work done by IA in the prior study and reexamine
    its workforce planning efforts in light of GAO's feedback.
        Recommendation II--BIE staff is working to ensure that necessary
    financial oversight information is shared across the agency. In the
    short term, BIE has developed a share point system and ensured all key
    staff members, such as those involved with calculating the 2017-2018
    school risk matrix, have access to audit reports. Additionally, BIE now
    has access to the IA Division of Internal Evaluation and Assessment
    (DIEA) Audit Report Tracking Tool (ARTT) system that provides a real-
    time status of Audit report findings, recommendations and questioned
    costs.
        In June 2017, the BIE working group convened staff from across the
    BIE for a two-day workshop to develop a permanent, comprehensive,
    interdepartmental policy and procedure for sharing information across
    the Bureau. In addition, BIE is currently working with its Information
    Technology support staff to examine the feasibility of implementing an
    electronic tool that would provide all internal divisions within BIE
    fiscal monitoring access to upload and share documents and information.
        Recommendation III--As part of its work, BIE leadership has given
    all staff with fiscal monitoring responsibilities the directive that
    all school monitoring events will be made in a single, coordinated
    manner. This will ensure that staff from the Division of Performance
    and Accountability, School Operations, Education Resource Center, and
    Associate Deputy Director offices will conduct single, coordinated
    visits to all schools identified as high risk through the utilization
    of the BIE High-Risk Matrix.
        In addition, the BIE workgroup convened a two-day workshop in June
    2017 concentrated solely on addressing all outstanding recommendations
    related to BIE's fiscal monitoring activities. During the workshop, the
    workgroup solicited inter-departmental input regarding a uniform,
    comprehensive, interdepartmental fiscal monitoring policy and
    procedure. A draft fiscal monitoring policy and procedure is in draft
    form but still requires further input and editing, which will be
    completed in the coming months. Following the workgroup's final
    drafting efforts, BIE plans to submit the fiscal monitoring policy and
    procedure to all BIE senior leaders for a review and input period,
    after which BIE will submit the proposed policy and procedure to RACA
    for review and publishing into the IAM.
        Finally, on August 14, 2017, the BIE received Departmental approval
    to advertise and fill three key fiscal monitoring related positions.
    These positions are newly established under the reform and were
    specifically designed to provide BIE with increased human capital
    needed to effectively conduct fiscal monitoring. These positions
    include a Program Manager for Budget and Finance and two auditor
    positions.
        Recommendation IV--In June 2017, members of the BIE working group
    met to begin drafting a comprehensive risk-based monitoring methodology
    to ensure compliance with the Fraud Reduction and Data Analytics Act of
    2015 (Public Law 114-186). During the workshop, the workgroup solicited
    inter-departmental input regarding a comprehensive risk assessment
    methodology. The workgroup has completed its work implementing the
    2017-2018 risk assessment based on the comprehensive methodology.
        The workgroup is also drafting a risk assessment policy and
    procedure to ensure the methodology is used annually in a standardized
    and uniform manner. However, the policy and procedure requires further
    input and editing, which will take place in coming months. Following
    the workgroup's final drafting efforts, BIE plans to submit the risk
    assessment policy and procedure to all BIE senior leaders for a review
    and input period, after which BIE will submit the proposed policy and
    procedure to RACA for review and publishing into the IAM.
        GAO-16-313--INDIAN AFFAIRS: Key Actions Needed to Ensure Safety and
    Health at Indian School Facilities (March, 2016)

        GAO made recommendations:

            I.) Ensure that all BIE schools are inspected as well as
            implement a plan to mitigate challenges;

            II.) Prioritize inspections at schools where facility
            conditions may pose a greater risk to students;

            III.) Develop a plan to build schools' capacity to promptly
            address safety and health problems with facilities and improve
            the expertise of facility staff to maintain and repair school
            buildings; and

            IV.) Consistently monitor whether schools have established
            required safety committees.

        BIE is working to implement GAO's four recommendations contained in
    GAO-16-313.
        Recommendations I and II--BIE has worked with the Bureau of Indian
    Affairs (BIA) to address the first recommendation by implementing a
    Safe School Audit. BIA completed safety inspections at all BIE-funded
    schools for the first time in 2016. BIE and BIA are currently on time
    in completing all school inspections in 2017 as well. However, BIE
    understands the need to ensure focus on completion does not detract
    from the quality of inspections. To that end, BIA has formed an inter-
    agency workgroup to address all safety-related GAO recommendations. The
    workgroup consists of staff from across IA, including the BIE, BIA,
    DIEA, the Deputy Assistant Secretary--Management (DAS-M), and Division
    of Facilities Management and Construction (DFMC). The workgroup's first
    meeting was held on May 31 through June 1, 2017, with a follow-up
    meeting held August 15-16, 2017.
        As a contingency plan, the workgroup has also drafted an inspection
    mitigation and prioritization plan based on risk should it be unable to
    complete 100 percent of inspections in future years. BIE plans to
    submit its mitigation and prioritization plan to its IA partners for
    review and input no later than September 2017.
        Recommendations III and IV--BIE is conducting ongoing staff and
    administrator training and is working with BIA to provide long-term
    support of school safety committees through school inspections. We
    recognize that reporting for such activities is inadequate, so BIE is
    working with BIA to provide oversight of such inspections. The
    agencies, through the workgroup members described in GAO 16-313
    Recommendations I and II, are working to produce formal policies and
    procedures to address shortcomings through a recently formed inter-
    agency workgroup that met throughout the summer coordinate activities
    to ensure such committees are formed and trained in a timely and
    consistent manner.
                            2017 gao recommendations
        GAO-17-421--INDIAN AFFAIRS: Further Actions Needed to Improve
    Oversight and Accountability for School Safety Inspections (May, 2017)

        GAO made six recommendations, five of which apply to BIE in
    conjunction with IA and BIA:

            I.) Develop and take corrective actions to address BIA safety
            program weaknesses identified in prior Interior evaluations;

            II.) Develop and implement a plan to assess employees' safety
            training needs and monitor compliance with IA's safety training
            requirements;

            III.) Ensure employee performance standards on inspections are
            consistently incorporated into the appraisal plans of all
            personnel with safety program responsibilities;

            IV.) Develop performance and quality standards and establish a
            process for routinely monitoring the quality of inspection
            reports;

            V.) Develop a system which routinely monitors and require
            inspectors to submit completed safety reports to schools within
            a 30-day timeframe; and

            VI.) Use timelines information to assess employee performance
            for personnel with safety program responsibilities.

        IA has formed an inter-agency workgroup to address all safety
    related GAO recommendations. The workgroup consists of staff from BIE,
    BIA, IA, DIEA, and DFMC. The group's first meeting was held on May 31
    through June 1, 2017, with a second follow-up meeting held on August
    15-16, 2017. Working with BIA, BIE is currently crafting and
    implementing comprehensive safety inspection policies and procedure to
    ensure that inspections and reports are carried out in a timely manner
    and are of sufficient quality.
        GAO-17-423--INDIAN AFFAIRS: Better Data Could Improve Road
    Management and Inform Indian Student Attendance Strategies (May, 2017)

        GAO made eight recommendations, two of which apply to BIE:

            VII.) Provide guidance to BIE schools to collect data on
            student absences related to road and weather conditions; and

            VIII.) Review the BIE Transportation Formula and determine,
            with BIA and tribal stakeholders, what adjustments are needed
            to better reflect transportation costs for schools.

        Recommendation VII--BIE tentatively concurs with this
    recommendation and is currently examining feasibility and costs of
    tracking absences due to road conditions, among other important data
    points, within its Native American Student Information System (NASIS)
    system.

        Recommendation VIII--BIE non-concurs with GAO regarding this
    recommendation. While this could be beneficial, altering the
    transportation formula would require formal negotiated rulemaking. The
    BIE would only consider undergoing such rulemaking with the support of
    its tribal partners. To date, BIE has not received any such
    communication.
        GAO 17-447--INDIAN AFFAIRS: Actions Needed to Better Manage Indian
    School Construction Projects (May, 2017)

        GAO made six recommendations, two of which apply to BIE:

            V.) Improve oversight and technical assistance to tribal
            organizations to enhance tribal capacity to manage major
            constructions projects; and

            VI.) Develop and implement guidance for maintaining complete
            contract and grant files for all BIE school construction
            projects.

        Recommendation V--BIE will work cooperatively with IA Office of
    Facilities, Property and Safety Management (OFPSM) and DFMC to draft an
    engagement plan and high risk project tracking system on time to GAO.
    As this is a new report, these items are not outstanding but will be
    addressed as expeditiously as possible.

        Recommendation VI--BIE will work cooperatively with OFPSM and DFMC
    to draft guidance regarding how official contract and grant files are
    required to be held by the contracting officer or awarding official and
    any requirements for retention and location of such files. BIE will
    coordinate activities to ensure on time delivery to GAO. As this is a
    new report, these items are not outstanding but will be addressed as
    expeditiously as possible.
    Conclusion
        Chairman Hoeven, Vice Chairman Udall, and Members of the Committee,
    thank you for the opportunity to present testimony today and provide
    the Committee an update regarding our work with GAO. BIE is excited
    about our recent progress and remains committed to addressing all of
    GAO's recommendations in order to achieve sustained improvement. The
    BIE looks forward to working with you and our partners as we address
    the recommendations. Thank you for your time, and I would be honored to
    answer any questions you may have.

        The Chairman. Thank you, Mr. Dearman.
        We will start with five-minute rounds of questioning.
        I would like to direct my opening question to Ms. Emrey-
    Arras. According to GAO, there are 23 open recommendations for
    Indian education; 14 open recommendations for Indian health;
    and 13 open for Indian energy.
        Talk to me about how we make progress to close out all of
    those. What is the best way in terms of oversight and follow up
    to make sure these are tracked and closed out in a way that
    both you and the agency come to agreement that it is resolved
    or we are back here talking about it?
        Ms. Emrey-Arras. I think within the education area, we have
    been doing a lot of additional communication. As Director
    Dearman noted, we have done a lot more in-person meetings, and
    a lot of additional phone meetings to provide suggestions on
    how to implement recommendations and provide direct and
    immediate feedback on their ideas.
        I think that kind of interaction is very constructive in
    terms of moving towards implementation. I do think within the
    education area, there has been a lot of movement since we put
    them on the High Risk List and since we last testified. Plans
    have been put in place for all the education recommendations
    and steps are being laid out to accomplish implementation.
        At this point, we are not able to close any of those, but
    we would like to see continued progress in those areas.
        The Chairman. What is a realistic timeframe for getting
    them closed and being back here reporting, not that we would
    have them all closed but a realistic timeline to do a follow up
    on progress?
        Ms. Emrey-Arras. I think another six months. I think that
    would be an excellent time to see where we stand. Certainly,
    there are recommendations across these three areas of energy,
    education and health care that are more intensive, that
    require, for example, more collaboration and consultation and
    the like.
        On the other hand, there are some low hanging fruit
    recommendations shall we say, some easy fixes that could be put
    in place for some of them. For example, I think we would say
    that it should not take four and a half years to develop
    procedures to oversee school spending. We know right now there
    are, in fact, draft procedures they mentioned they have.
        Instead of waiting until the middle of 2019 to finalize and
    implement those, our hope would be within the next six months,
    if possible, those could be rolled out so we would have more
    oversight of school spending.
        The Chairman. Are there provisions in regard to any of
    these recommendations where you hit impasse?
        Ms. Emrey-Arras. I would not say within the education area.
    Let me defer to my other colleagues in energy and health care
    and see on their ends.
        Ms. King. Senator, I am Kathleen King from the healthcare
    team. Thank you for having us here.
        I would say in the health care arena, we have some
    disagreements with the agency over the PRC program. In 2012, we
    actually made a matter to Congress in terms of directing IHS to
    develop a new formula for the PRC program because we found
    there was a great disparity in spending per capita ranging from
    a low of $300 to a high of $800.
        We knew at that time the agency would not agree with that
    so we made that a matter for Congress.
        We also made some recommendations to the agency at that
    time about how they count PRC users and how they calculate the
    availability of hospital services. That was in 2012. At that
    time, the agency agreed with us. Most recently, the agency has
    said that is a matter for tribal consultation and indicated
    today the Tribal Consultation Group had said they are not in
    favor of any changes at this time.
        The Chairman. Are there other areas of disagreement within
    IHS and with the GAO recommendations?
        Ms. King. I think the only other outstanding disagreement
    has to do with their use of PRC funds for staff. In our view,
    we thought there is such a shortage of staff to process
    enrollments and help people figure out whether they are
    eligible for Medicaid or other things that some of the PRC
    funds should be allocated for that purpose. The agency
    disagreed with that.
        The Chairman. Anything else in regard to IHS?
        Ms. King. One more thing and this is not really a
    recommendation but we would be interested in seeing what the
    agency's third-party reimbursements have been over the last
    several years after the implementation of the Affordable Care
    Act. That is not work we have conducted or have underway.
        The Chairman. Thank you.
        In regard to energy?
        Mr. Rusco. Thank you. I am Frank Rusco.
        I would not characterize it exactly as an impasse but more
    of we are not exactly on the same page in one particular area.
    That would be in oversight and monitoring practices at the
    Bureau agency level.
        BIA has been working on documents to set standards and also
    to identify problems. What we have not seen yet is plans to
    roll out those and get those plans and guidance to the agency
    level and then to follow up with monitoring and measurement.
    Until we see that, it will not happen on the ground.
        I could give you some more specifics but I think it is
    better that we work directly with BIA and talk with them to try
    to sort out that sort of disconnect.
        The Chairman. Is there disagreement or has it just not been
    figured out?
        Mr. Rusco. I am not sure, because we have not had the
    conversation, whether it is something that they're missing
    about what we expect but what we see them doing is not clearly
    what we want them to do. I think we are going to have a round
    of conversation shortly about that.
        The Chairman. We will ask that question as well.
        Thank you.
        Mr. Rusco. Thank you.
        The Chairman. Now I will turn to the Vice Chairman.
        Senator Udall. Thank you, Chairman Hoeven.
        I very much appreciate Senator Franken pitch hitting. He is
    always very good at that.
        I would like to talk about the efforts to reduce BIA's
    workforce. We have heard news reports about personnel moves
    affecting dozens of high level SES employees and yet the
    Administration left Congress in the dark about Interior's
    plans.
        The proposed personnel moves are uprooting employees who
    have formed deep and lasting relationships with the surrounding
    communities, including individuals with the Office of the
    Assistant Secretary for Indian Affairs and the Bureau of Indian
    Affairs.
        The GAO noted repeatedly in its High Risk Reports that an
    under staffed and ill equipped workforce is already an issue
    that hinders Indian energy development. For Mike Black, I am
    concerned that Interior's personnel moves will only exacerbate
    the issues identified by the GAO.
        I sent two letters to the Department of the Interior about
    these recent personnel moves, one on July 11 and another on
    August 21, neither of which has received a response.
        Can you commit to me today I will have a response to all of
    my questions and my colleagues' questions by this Friday,
    September 15?
        Mr. Black. I will certainly take back that message to the
    Administration that you are requesting that.
        Senator Udall. Thank you.
        I know these letters were above your pay grade but just
    want you to take back to Secretary Zinke, the Deputy Secretary
    and others that he committed to answering these both talking to
    me privately and publicly. We expect answers when all of us put
    in letters of this nature.
        One issue the GAO High Risk Report highlights is the lack
    of interagency coordination for Indian programs. That certainly
    is no surprise to this Committee. One school in my home State
    of New Mexico, the Dz School on the Navajo Nation has recently
    suffered from this lack of coordination.
        Because of some unforeseen issues with the campus sewage
    system and the location of the school's gym, their school
    camp's replacement has stalled. BIE, BIA, DOI leadership and
    IHS all need to come to the table before these issues will be
    resolved.
        Mr. Dearman, you were at a meeting my staff had at the Dz
    School recently so I know you heard about these unique issues
    firsthand. Has your office made any progress on these issues
    since that meeting last month?
        Mr. Dearman. Yes, Senator, we have. We actually reached out
    to the Division of Facilities Management and Construction and
    started talking about the issues raise during our school visit.
        You are exactly right. We have to have other departments of
    Indian Affairs at the table. BIA and BIE, including the tribe,
    will need to be at the table to discuss the issues that were
    brought up.
        Senator Udall. Also, the Indian Health Service. I want to
    ask Admiral Weahkee, was your office aware that the IHS clinic
    near the school uses the school's sewage system?
        Mr. Weahkee. Sir, the issue just came to our attention at
    the national level recently but our engineers and sanitarians
    in the Navajo area have been working closely with Indian
    education in Dz. Yes, sir, we do have folks addressing the
    issue there.
        Senator Udall. Can I get your commitment that you will have
    your team work with Mr. Dearman and the Navajo Nation and the
    Dz school board to get this sewage issue resolved in a timely
    manner?
        Mr. Weahkee. Yes, sir.
        Senator Udall. Mr. Black, was your office aware of the Dz
    gym sitting on BIA-held land?
        Mr. Black. Yes, sir. Mr. Dearman made me aware of that
    issue as well.
        Senator Udall. Can I get your commitment to see if the
    Bureau can resolve this issue internally to follow up with my
    staff and the school if congressional action is needed?
        Mr. Black. Yes, sir, certainly.
        Senator Udall. For the panel as a whole, the Dz School
    example illustrates this larger coordination issue perfectly.
    How will each of your offices do a better job of interagency
    coordination moving forward? Why don't we start with you, Mr.
    Black?
        Mr. Black. I think quite honestly, sir, that is something
    we all have to address between all the different bureaus and
    agencies, especially when we are dealing with
    multijurisdictional issues such as this.
        Coming from the region, I have had some experience where we
    have to make sure and sometimes just incorporating regular
    meetings between Indian Health Service, BIA and BIE, it really
    starts at the local level and works its way up versus top down.
    We need to get that message out to our staff.
        Senator Udall. Admiral Weahkee?
        Mr. Weahkee. Yes, sir, I would reiterate the structural
    issues of covering vast geography. We do have great leaders on
    the ground to elevate issues to their area leadership. We need
    to be more transparent and communicative with those area
    directors on issues such as these that cross barriers and
    boundaries.
        Senator Udall. Thank you.
        Mr. Dearman, briefly.
        Mr. Dearman. Vice Chairman, not only the Senate Committee
    on Indian Affairs is holding us accountable, so is Secretary
    Zinke. We are working with all the departments within Indian
    Affairs that have their hand in our schools, meaning BIA, DASM,
    Deputy Assistant Secretary of Management, and IHS to help take
    care of our kids.
        We have really collaborated with agencies that have a hand
    in running our schools. We have gotten a lot of support from
    the Administration and the departments I have been working with
    to make sure our kids and schools are taken care of.
        Senator Udall. Thank you.
        Thank you, Mr. Chairman.
        The Chairman. I would now like to turn to our other Vice
    Chairman, Senator Al Franken.

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

        Senator Franken. We might as well just have three, Senator
    Cortez Masto as well.
        I just have a question concerning the extent to which Mike
    Black and Secretary Zinke have gotten involved with this GAO
    report and how hands-on they are in addressing this issue. Does
    anyone have any comment on that? Ms. Emrey-Arras?
        Ms. Emrey-Arras. I would say that Mr. Black has certainly
    been involved in our meetings. I would defer to the agency
    officials regarding the Secretary's involvement.
        Mr. Black. Since long before I became the Acting Assistant
    Secretary, I have been involved in a lot of these efforts
    related to the GAO on the energy side of it. Since becoming
    Acting Assistant Secretary, I have had regular interaction with
    Tony to make sure I have updates to find out where they are in
    the process, what they are doing, and making sure they are
    getting the support they need from my office.
        The Administration and the Secretary's office on down has
    been very supportive of all of the activities we are doing and
    encouraging us. Indian energy and education are two of the
    Secretary's priorities and things he wants us to carry forward.
    We are getting the full support of his office as well.
        Senator Franken. His office. Do you see him much?
        Mr. Black. I don't interact that often with the Secretary
    himself, but he has been busy trying to catch up on a lot of
    things, the first part of the transition, but he is aware of
    the issues going on. We are making sure he is being updated as
    well.
        Senator Franken. I want to talk about a crisis that is
    going on not just in Indian Country but especially in Indian
    Country, something that has been declared a crisis by the
    Administration. That is the opioid epidemic.
        Indian reservations are the front lines. In my State,
    Indian babies are now over ten times more likely to be
    diagnosed with Neonatal Abstinence Syndrome or opioid
    withdrawal symptoms than other babies in our State's Medicaid
    program. Earlier this year on the Red Lake Reservation from
    February to July, nearly three dozen people overdosed,
    including ten overdoses in July alone.
        At one point the crisis was so bad, the local hospital ran
    out of narcan which blocks the effects of opioids and helps
    reverse an overdose.
        I met with a number of tribal leaders. It was clear from
    these meetings that we need a multi-pronged approach to address
    the opioid crisis in Indian Country. We need more research,
    lower prescribing rates, greater resources for prevention, and
    better access to treatment.
        We also need to consider integrating traditional
    ceremonies, culturally sensitive recovery and those kinds of
    activities into evidence-based treatment and recovery programs.
    The White Earth Reservation in the northwest part of my State
    has a successful MOMS Program.
        Again, the President's Commission on Combating Drug
    Addiction and the opioid crisis has declared this a crisis. Led
    by Chris Christie from New Jersey, they recently posted the
    interim report of recommendations to address the opioid crisis.
        The primary recommendation was to declare the opioid
    epidemic a national emergency in order to permit the use of
    Federal disaster funds in fighting outbreak, to encourage swift
    action by Federal agencies to address the crisis and to raise
    public awareness and prompt congressional action.
        While the Administration is evaluating the legal
    implications of such a declaration, the Commission is working
    on a final report which is expected in October. Several tribes
    in Minnesota have also issued similar public emergencies.
        Admiral Weahkee, what recommendations did you make to Chris
    Christie and the Commission on how to address the opioid
    epidemic in Indian Country?
        Mr. Weahkee. Thank you, Senator Franken, for bringing up
    this issue of the opioid epidemic. We know it is a national
    issue. It definitely has had a dramatic impact in Indian
    Country.
        I believe that some of the efforts that have been made
    across our agencies to ensure the availability of naloxone are
    a great start within the IHS. We have also been training our
    providers ensuring that they are properly certified for
    medication assisted treatments. You already mentioned the
    culturally appropriate and community specific modalities.
        I believe tribes need to be at the table in helping to
    define what is going to work best for their communities. I
    think number one is bringing the tribes to the table to be
    engaged in the conversation.
        Senator Franken. Bringing the tribe to the table?
        Mr. Weahkee. Yes, sir.
        Senator Franken. I know my time has run out. I just feel
    this is such a crisis that we are seeing, such devastation. I
    just would like to see resources. I think that is why you
    declare an emergency, you can use resources to get people
    treatment and medication therapy, and get them some proper
    medication to substitute that does not cause you to get high.
        It just feels like an all hands on deck emergency all over
    the Country but especially in Indian Country, especially in
    Minnesota. I think we need to understand this is something that
    can be treated and needs to be treated.
        I would urge you especially to be in contact or Indian
    Health to be in contact with the Commission. Okay?
        Mr. Weahkee. Thank you, sir.
        Senator Franken. Thank you.
        The Chairman. Vice Chairman Cortez Masto.

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

        Senator Cortez Masto. Thank you, Mr. Chairman.
        Let me follow up on that conversation, Admiral, because we
    all know opioids are a crisis across the Country. I want to
    understand. You are not just now bringing tribes to the table;
    this is a conversation we have already been having with these
    tribes, is that correct?
        Mr. Weahkee. Yes, ma'am. My response was in regard to what
    would I tell Governor Chris Christie. Tribes have definitely
    been heavily engaged with us in developing programs that work
    for their communities.
        Another example of something we have done within our agency
    is the development of what we call the HOPE Committee which
    focuses on heroin, opioids and pain efforts. Getting tribes
    involved in conversations about what is going to work,
    culturally what is going to work within their communities,
    looking at the available resources and filling in those gaps is
    imperative.
        Senator Cortez Masto. Thank you.
        First of all, let me say thank you for what you have done
    to implement some of the recommendations. I know one of the
    recommendations you looked at was to address the patient wait
    time and having a tracking system in place.
        Something has come to my attention, and I just want to
    verify this. The medical records system that IHS uses was
    developed by Veterans Affairs but the VA is going to
    discontinue support of this system within the next few years.
    Your new patient wait time tracking program is attached to that
    system.
        Is that true and what do you intend to do if the VA is no
    longer supporting your RPMS system?
        Mr. Weahkee. Thank you for the question.
        First, the VA has announced they are moving away from their
    VISTA Electronic Health Record. We have historically relied on
    the VA for programming support of our own Resource and Patient
    Management System, RPMS.
        Fortunately, in this case, with regard to the tool that we
    developed for patient wait times, we developed that separate
    from the EHR and in a way that it can be used with any
    electronic health record, business intelligence software that
    is not necessarily a part of RPMS, so they are separate
    systems.
        Senator Cortez Masto. It is not going to have an impact at
    all on your patient tracking?
        Mr. Weahkee. It will have an impact on patient tracking but
    in regard to how we are going to monitor it with our new
    tracking tool, no.
        Senator Cortez Masto. Is VA discontinuing support of the
    system going to impact you in any way whatsoever?
        Mr. Weahkee. The discontinuation of their program support
    will definitely have an impact on the Indian Health Service. We
    have initiated robust conversations not only with the VA but we
    have held tribal listening sessions, initiated conversations
    with DOD, the Coast Guard, all of which are going through or
    have gone through similar conversions.
        We are at a point where we are information gathering to
    really assess what our options will be moving forward.
        Senator Cortez Masto. Then putting a plan together to come
    up with any gap to address the changes that need to take place
    and any resources that need to be associated with it?
        Mr. Weahkee. Yes, ma'am.
        Senator Cortez Masto. Is that going to happen this budget
    cycle if you need resources?
        Mr. Weahkee. We have initiated conversations internally. As
    you mentioned, the VA's plan is to transition off over several
    years. We know at least in the next several budget cycles. We
    are more in an information gathering and planning phase. When
    we start to need the resources to purchase consultants or
    hardware, those asks will come should we make the decision to
    convert the EHR.
        Senator Cortez Masto. Thank you.
        First of all, thank you gentlemen for being here as well as
    GAO. It is very, very important and we appreciate you coming
    back here and talking about the changes and recommendations
    that are necessary.
        Mr. Dearman, we talked in the past, the last time you were
    here. One of the things we talked about was the school
    accountability data and the lack of up-to-date information that
    was necessary on the websites.
        Correct me if I am wrong, did I hear that you are any
    closer to having real time data or up-to-date data that is
    available?
        Mr. Dearman. We are getting closer, Senator, to gathering
    that data and having that where we can actually start
    distributing that data. We are not quite there yet.
        Senator Cortez Masto. What is the timeframe, you think, for
    that?
        Mr. Dearman. I can get back to you on the timeframe. We are
    working collaboratively with the Department of Education on
    this task. I can get back to you with the timeframe.
        Senator Cortez Masto. That would be very helpful.
        You have a lot on your plate. The other question I have is,
    is it a resource issue or a staffing issue to help address some
    of these changes that are going to be necessary?
        Mr. Dearman. It is just the lack of gathering and
    collecting data over the past three years. We are playing catch
    up to catch up with all the data we haven't collected. That is
    the reason we are behind.
        Senator Cortez Masto. With the Chairman's indulgence,
    because I know my time is up, we heard from GAO some of their
    concerns that there may be some impasse still. I did not hear
    your response to that, the concerns they brought up. Do you
    have any response to that?
        Mr. Black. Let me go ahead, Senator, if you don't mind.
        Especially like for BIA on the energy stuff, it wasn't
    necessarily an impasse. I think we need to do a better job of
    communicating and working directly with the GAO folks on our
    BIA energy. Similar to what our BIE folks have been doing with
    school education, they have been working closely with them. We
    just need to do a better job.
        It is not that we are not taking proactive steps. We need
    to make sure we are communicating better with GAO.
        Senator Cortez Masto. Thank you.
        Anything else to add?
        Mr. Weahkee. Yes, ma'am. With regard to the Indian Health
    Service items specific to our Purchase and Referred Care
    Program, I agree also that robust discussion with Ms. King and
    her team is going to be needed to come up with a final
    determination.
        Our tribes, in consultation, have told us some of the items
    they are absolutely opposed to. Bringing all partners together
    and doing what is best for our patients and the communities is
    key. When it comes down to it, that is what we are here for. We
    need to make those decisions in a patient-centered manner.
        Senator Cortez Masto. Thank you.
        Thank you, Mr. Chairman, for letting me go over my time. I
    appreciate it.
        The Chairman. Absolutely, Senator.
        Admiral, let us go to you and talk about the PRC Program.
    The question I had for Ms. Emrey-Arras was where is there some
    disagreement in resolving the outstanding recommendations? We
    will meet again in six months just like we are today and we
    want to see what we are down to. We are going to just work
    through these.
        That is why I was asking where there is disagreement. It
    sounds like there is some disagreement on the PRC Program.
    Would you address that for me?
        Mr. Weahkee. Yes, sir.
        I will start with the first one being the allocation
    methodology.
        The Chairman. The second was shifting money to staffing.
        Mr. Weahkee. Yes, sir.
        With the allocation methodology, we currently use, as part
    of our formula, the number of active users of our facilities.
    The GAO has asked us to look at using the historical number or
    the actual number of PRC users which is a subset of the active
    user count.
        By doing that, we actually will run into some problems
    because the use of the PRC Program changes from year to year.
        They also asked that we develop a defined benefits package.
    Without this funding coming through a mandatory source, it is
    difficult to define the minimum package.
        I believe a third recommendation that was made was that we
    give all of our PRC-eligible patients a card to identify that
    they are eligible for PRC. That is also a problem because
    something as simple as a member moving off reservation out of
    the CHSDA would no longer make them eligible for the PRC.
        These are just some examples of the more robust
    conversations I think we need to have with the GAO around some
    of those issues.
        With regard to the use of PRC funding for staff or other
    administration of the program, I think we are open to having
    more conversation in that regard. I think there is variation
    across our agency and that we should be giving our sites more
    tools than further restricting their choice and ability to
    manage the program in the way they see fit. I think there is
    more to be said in that regard.
        The Chairman. That would make sense in two respects, both
    because I want you to work with GAO because we are going to
    meet again in six months and I want to encourage you to work
    together so that when we come back it is something that we have
    agreement on. Also, it is going to relate to another question I
    will ask here in a minute.
        The other area was on energy for you, Mike. The question
    that came up was oversight monitoring but basically getting
    guidance, measurement and standards down to the offices and
    some kind of follow up for making sure they meet them. Do you
    follow me?
        We are getting stories, for example, that in Colorado if
    you want to site a well or something like that, it is taking
    three months off the reservation but 31 months on the
    reservation for energy development. That is one example. I
    think it goes to what you talked about and why it needs to be
    addressed.
        Mr. Black. Certainly, sir. I think we are trying to take
    those steps to get there. Part of that is being able to collect
    the data and have the necessary information to number one,
    confirm those types of reports. I cannot really confirm that it
    takes 31 months on the reservation versus three months off. We
    need to be able to collect that data and in the entire process,
    be able to verify that.
        The Chairman. Mr. Secretary, it is. I am hearing from
    tribal chairmen and others that it is. What I am more concerned
    about is that you are getting standards down. I get that you
    are working to put that in place, but also, in the meantime,
    people are waiting to execute that lease. That is a lot of
    opportunity cost for the tribe.
        How can you address that more expeditiously both interim
    and on a permanent basis is what I am getting at.
        Mr. Black. In the process of trying to collect data, I hope
    you did not get me wrong, it is not like we are trying to stop
    everything else to get data so that we can move forward. We are
    trying to continue with that process utilizing the Indian
    Energy Service Center and the other resources that we have
    available to us to be able to address APDs, leases and right-
    of-ways at all of our different offices.
        We are using our Division of Energy and Mineral
    Developments and some of their programs to provide some
    assistance. We are using our regional offices to supplement and
    help the agency offices to get activities done.
        We are identifying through the process I mentioned a bit
    earlier through different intakes from the field as far as what
    is the work out there that needs to be done, what resources do
    we need to put out there to make this happen.
        The Chairman. I would encourage you to get input from the
    field, talk to the States too. Maybe they can give you some
    resources to help leverage your efforts but you really have to
    look both in terms of the solution you want to put in place but
    some interim steps to help this along while you are doing that.
        Mr. Black. I totally agree, sir.
        The Chairman. Okay. For the BIE staffing, clearly staffing
    is a problem, Mr. Dearman. What are you doing to address the
    staffing issue? I know it is not easy but it is clearly really
    important.
        Mr. Dearman. Mr. Chairman, we have received 77 waivers as
    was mentioned in our written testimony. Currently, at the
    school level, we have 90 teacher vacancies and 871 positions
    filled.
        One of the things we have done is we had to address the
    immediate problem right now with losing our teachers. In
    talking to our schools, one problem causing us to lose our
    teachers was because it took so long to go through the
    application process.
        One of the things our HR was having to do because of our
    process was having to go through every class that a teacher
    candidate had in their college transcripts. Just recently we
    put in place that BIE will recognize State certification of the
    States our schools reside in. Therefore, when we get a teacher
    application, if that certification is attached, there will not
    be two weeks of going through transcripts.
        We are really trying to address the immediate problem of
    why we are losing our teachers. That is what we are doing at
    that level.
        We are currently in the process of advertising the 77
    waivers that we have received and moving forward with filling
    the positions.
        The Chairman. That is maybe one of the best answers we have
    heard today. That is exactly what you should be doing, working
    with the State, leveraging your resources, if they have those
    approvals and you can rely on them, that helps you get people
    faster. That is a great example. It doesn't cost you more money
    but enables you to get the job done more expeditiously.
        I appreciate that. That is the kind of solutions we are
    looking for because we are always in a resource-constrained
    environment. Any leveraging like that you can do, I commend you
    on that solution.
        Admiral Weahkee, yesterday morning, we heard from tribal
    leaders from Arizona. The White House had a lot of the tribal
    chairmen in and we met with them. Dr. Price, the Secretary of
    HHS, met with them.
        Specifically, we heard leaders from the Gila River Indian
    Community and the Quechan Tribe that IHS is in the process of
    constructing two IHS health care facilities. There are others
    going on too. For example, in my home State of North Dakota,
    three affiliated tribes and Chairman Fox is also working on a
    facility.
        The staffing is the concern. The tribe is building
    facilities but they need IHS either staffing or funding, if
    they go through the 638 Program. I want to make sure you are
    asking for those funds through the budgeting process and you
    are doing everything you can.
        Again, this is a leveraging effort between the tribe
    building the facility and the Federal Government providing the
    staffing or the funding for 638 staffing. Can you address that?
    How do we make sure that happens that as they build these
    facilities, they have the staff there because this is progress
    in providing quality health care on the reservation? That is
    what we are after.
        Mr. Weahkee. Yes, sir. Thank you for the question.
        We have a series of six to seven different facilities. Some
    of them are brand new facilities; some of them are replacement
    facilities; and some are joint venture projects where we
    partnered with the tribes. They provided the funding for the
    construction and we have agreed to provide the staffing and
    operations support.
        In the case of Gila River, which will be opening the Red
    Tail Hawk or what we refer to also as the Southeast Ambulatory
    Care Center and the Quechan Tribe in Fort Yuma, this is one of
    those situations where the first to complete the facility, we
    fund the facilities as they are completed using the date of
    occupancy as the key date. The tribes are working hard to get
    their facilities built ahead of time.
        In the most recent budget cycle, we had to make a tough
    decision about what could be funded. The decisions were to
    allocate the funds or ask for the funds for those positions or
    those sites that were going to be opened first. We know these
    two facilities will be coming online in 2018.
        We are appreciative of the recent markups that we have seen
    in the budgeting process. We really appreciate that.
        The Chairman. I would really emphasize again, given the
    leverage and joint nature of these programs, that we do
    everything we can to fund them. I will work on that from the
    appropriations side with you but we need to make sure they are
    funded.
        Mr. Weahkee. Thank you, sir.
        I am also meeting with Representative O'Halleran from
    Arizona later this week on the same topic.
        The Chairman. I believe that needs to be a part of the
    request and that we need to do everything we can to make sure
    it is appropriated funding for these facilities. I think it has
    to be a priority.
        Mr. Weahkee. Absolutely, expansion and access to care for
    all of these new facilities.
        The Chairman. When the tribes take the initiative to build
    the facility and pay for it, we just have to find a way to fund
    it, particularly for something like health care on the
    reservation. It is a huge priority.
        I will wrap up there. Again, I appreciate the progress that
    you have made. As I say, we will be doing this again in six
    months.
        I will now turn to the Vice Chairman.
        Senator Udall. Thank you, Mr. Chairman.
        BIE has only existed as a standalone bureau since 2006. It
    was previously a part of BIA and that legacy can still be seen
    in the way the many administrative tasks are divided between
    the two agencies. In fact, many of GAO's recommendations to
    improve Indian education will require BIA to work hand in hand
    with BIE.
        Yet, Mr. Black, I noticed your testimony here today and in
    May only focused on Indian energy. How engaged has BIA
    leadership been with the review of GAO's Indian education
    recommendations?
        Mr. Black. I think Mr. Dearman can confirm for me or with
    me that the Bureau of Indian Affairs has been engaged and
    working with them in those areas where we do have cross
    responsibilities and safety is a good example.
        We are working very closely with our Bureau of Indian
    Education and the BIA safety individuals to ensure that we are
    having regular meetings and developing the necessary standards
    and policies to be able to address the safety inspections. That
    is just one example.
        Then in the area of facility management, we are working
    with the Deputy Assistant Secretary for Management's office as
    well and our facility management operations, working real close
    with Tony and his staff to make sure we are addressing their
    needs as well.
        Senator Udall. Mr. Dearman, do you believe that BIA has
    taken the issue surrounding Indian education outlined in the
    High Risk Report seriously or could they be doing more?
        Mr. Dearman. Vice Chairman, yes, I do believe they are
    taking it seriously. They have been at the table with us at all
    of our meetings and have been actively engaged in improving our
    system based on GAO's recommendations.
        Mr. Black touched on a lot of different areas but even in
    the contract area, the contract area for purchasing books and
    things like that, we have to work with BIA as well. BIA has
    really been involved.
        Senator Udall. The same question to Ms. Emrey-Arras, do you
    believe BIA has taken the issues surrounding Indian education
    outlined in the High Risk Report seriously or could they be
    doing more?
        Ms. Emrey-Arras. Yes, we do, and we think that their focus
    on school safety is particularly important given the health
    hazards we have identified in schools in the past. We think
    that continued collaboration is essential to resolving those
    recommendations and ensuring safe schools for these children.
        Senator Udall. One coordination issue between BIE, BIA and
    DOI I have heard about recently relates to SIPI, one of the two
    federally-operated tribal colleges that happens to be located
    in my home State of New Mexico.
        They have faced many issues getting timely BIA and DOI
    signoff on contract procurement and staff hiring approvals. Now
    I have learned these delays could cost the school its
    accreditation and potential grant funding.
        Mr. Black, was your office aware of these delays and how do
    they impact the SIPI school community?
        Mr. Black. Mr. Dearman has made me aware that there have
    been some issues at SIPI that we have been trying to address,
    working, again, between BIA and the department, particularly on
    the hiring situation. We have had approval to do the hiring at
    SIPI and that is currently in the recruitment process.
        Anything further related to that, I would have to pass off
    to Tony.
        Senator Udall. What can be done on your end to resolve
    these pending approvals in a timely manner? What can your
    office do to make sure these types of delays do not happen
    again?
        Mr. Black. Part of that is I can always go back to
    communication, Senator, to make sure we have the proper
    protocols in place to make sure we are communicating these
    issues and the right people are getting the right information.
        Senator Udall. Mike, as you know, tribal energy sovereignty
    is a goal that we need to strive for. Consider these numbers.
    While reservations account for 2 percent of the Nation's land
    mass, they hold 5 percent of the Nation's potential renewable
    energy resources.
        The Department of Energy estimates that wind power from
    tribal lands could satisfy 32 percent of the total U.S.
    electricity demand.
        GAO issues a number of reports on this topic over the
    years, yet the same problems continue to arise, BIA's failure
    to coordinate, inadequate workforce numbers and training, and
    outdated technology.
        We heard from GAO that BIA is addressing its
    recommendations but only for conventional energy production.
    Why is that and what is BIA doing to assist tribes with the
    development of renewable energy?
        Mr. Black. The impetus of some of the reports has been more
    on the conventional but we are not ignoring the renewable
    energy or the wind side as well. As more and more tribes become
    interested in bringing those things to our attention and our
    table, we are working with them closely.
        The HEARTH Act is a good example that allows tribes to
    utilize some of the leasing tools in order for the development
    of renewable resources. We are working to make sure that our
    staff is aware. That is going to become another function of the
    Indian Energy Service Center. As more and more of the renewable
    energy programs become active, we will be utilizing the service
    center to provide training, resources and applicability.
        Senator Udall. Good. I hope you keep pushing on both sides
    there.
        Mr. Chairman, I have one more question.
        Admiral Weahkee, last month, you issued Circular 17-11 to
    set national patient appointment wait time standards for IHS
    facilities. These standards focus on how long it takes to
    secure an appointment but I did not see any reference to wait
    times or how long it takes a patient to be seen once they
    arrive at an IHS facility.
        I know several service units within the IHS Albuquerque
    service area already have patient wait time tracking systems in
    place. In fact, I believe many service units report patients
    being able to complete their full appointment from the sign-in
    to the doctor's visit to pharmacy pickup in under an hour.
        Melissa, has the GAO evaluated these efforts to address
    patient wait times? If so, does GAO believe they will resolve
    the issues uncovered in the 2016 report?
        Ms. Emrey-Arras. I will defer to my colleague, the Director
    in the health care area, Kathy King.
        Senator Udall. Thank you, Kathy.
        Ms. King. We have not had a chance to evaluate them yet
    since they just went into effect. It would take some time for
    us to see how they are implemented. Then we would have a chance
    to evaluate.
        Senator Udall. Okay. Focusing now on Admiral Weahkee, how
    will the new standards in Circular 17-11 and the new wait times
    tracking software related to it interact with local service
    units who already have metrics in place?
        Mr. Weahkee. We see these metrics as trigger points for
    those sites that already have systems in place and may even
    have better metrics than those that have been identified as the
    benchmarks. We definitely do not want to impact negatively on
    those benchmarks.
        We also see these as preliminary metrics. As you have
    identified, through the emergency department or other primary
    care visits there are other parameters that we should be
    measuring like dental visits and behavioral health visits.
        In terms of how it impacts those sites that are already
    using a system, there will be no impact but if they go beyond
    that 28 day or 48 hour trigger, they will be getting questions
    about what is going on and what help they need to make sure we
    are meeting those thresholds.
        Senator Udall. Good. This potential disconnect between
    service units, service areas and national IHS efforts on the
    issue of patient wait times is not unique. GAO identified
    inconsistent policies between levels of IHS leadership as an
    overarching issue with the service.
        Admiral Weahkee, what is IHS doing to make sure that
    innovations and best practices at the local level, particularly
    in tribally-operated facilities, are shared with the larger
    system and not stifled?
        Mr. Weahkee. Thank you for the question, Senator.
        One of the tools we are using is what we call our improving
    patient care collaborative, an opportunity for sites to share
    in an email format what is going well. Somebody may ask for a
    policy on a given topic and get that response from another
    site.
        I definitely agree that sometimes the best innovation and
    more often than not, the innovation happens at the front lines
    by the staff doing the work. In that regard, the IPC
    collaborative is one good example of that information being
    shared across the system.
        The other thing we are doing is reaching out to our tribal
    partners and hearing what they have. We made a recent visit to
    Alaska to look at the Nuka Institute. We will be making a visit
    out to Oklahoma next week and have the opportunity to hear from
    Cherokee Nation about some of the innovative work they are
    doing in program planning around recruitment and retention and
    developing their own home grown training programs for medical
    providers.
        We are really excited about some of the innovation that is
    coming out of our Indian partners.
        Senator Udall. Thank you. That is very encouraging.
        As I sum up, Mr. Chairman, let me say I fully support your
    effort to have the parties, the agencies and agency heads
    return here in six months to see how they have done on the
    recommendations and see which things we are closing out and
    what kind of progress we are making.
        Thank you very much, Mr. Chairman.
        The Chairman. Thank you, Vice Chairman Udall.
        Again, thank you to our witnesses for being here today. We
    will have you back in six months and again review the progress
    on all of these important issues. I do appreciate the work that
    has been done while recognizing there is a lot more to do and
    that it is very important for Indian Country. Thanks to all of
    you.
        For members of the Committee, if they have additional
    questions, they can submit them for the record over the next
    two weeks.
        Again, thank you. With that, this hearing is adjourned.
        [Whereupon, at 4:18 p.m., the Committee was adjourned.]

                                A P P E N D I X

     Prepared Statement of Hon, James R. Floyd, Principal Chief, Muscogee
                                 (Creek) Nation
        The Muscogee (Creek) Nation is the fourth largest tribe in the
    United States with more than 85,000 citizens across the United States
    and has jurisdiction over more than eight counties. Under the Indian
    Self-Determination and Education Assistance Act (ISDEAA), the Nation
    has assumed authority to provide health care, social and realty
    services, public safety, natural resources management, infrastructure
    development and repair and economic development. Additionally, MCN
    operates the Eufaula Dormitory, a peripheral dormitory, through a
    Bureau of Indian Affairs (BIA) grant. As such, the Nation was very
    concerned when the Government Accountability Office (GAO) included the
    BIA, Bureau of Indian Education (BIE), and Indian Health Service (IHS)
    programs in their 2017 High Risk Report.
        On behalf of the Nation, I write to express my appreciation for the
    oversight that Senators and the Senate Committee on Indian Affairs have
    provided while seeking solutions and closure of the GAO
    recommendations. The Committee's partnership and persistence is
    critical while the three agencies work to correct concerns highlighted
    by Senators and tribes. I have also provided a few comments on the
    updates provided during the September 13th oversight hearing that are
    of interest to MCN.

        The Trust Asset and Accounting Management System (TAAMS) does not
    include functions necessary to adequately track and record issues
    related to restricted land.

        MCN utilizes the TAAMS to preform various realty functions,
    including land title and record services. T AAMS has been instrumental
    in improving record keeping and modernizing realty functions and the
    GAO recommendations would continue to increase the helpfulness of the
    system overall. However, when the BIA initially developed TAAMS it did
    not include functions to adequately document restricted land ownership
    and the unique situations which rise from restricted land status. As a
    result, MCN's Realty Office utilizes electronic and hard copy record
    keeping practices in order to properly track ownership, leases and
    other land use agreements on behalf of the Nation's restricted land
    owners. MCN would recommend that the Committee continue to monitor the
    BIA's progress in expanding the functionality of the TAAMS.

        Tribes consistently provide feedback to IHS regarding the
    Purchased/Referred Care (PRC) Funding Allocation Methodology.

        Along with many other tribes and tribal organizations, MCN provides
    regular feedback regarding the PRC program implementation and funding
    allocation methodology. In fact, shortly after the passage of the
    Patient Protection and Affordable Care Act (ACA), tribes weighed
    whether the PRC allocation should be updated to reflect new factors
    that changed as a result of health care reform. However, tribal
    leadership did not believe the impact of the legislation would be
    measurable in Indian Country for quite some time. Since those initial
    discussions, tribes have regularly reviewed the allocation methodology
    and data regarding implementation of the law across the country. Rear
    Admiral Weahkee was correct in his statement that, nationally, there is
    tribal consensus that the methodology should not be changed. As such,
    MCN was startled when GAO claimed that IHS had not worked cooperatively
    toward implementing their PRC recommendations.
        Though the system is imperfect, the failure is not entirely IHS's
    to bear. Failure to adequately fund the Indian health system has
    resulted in the need to ration care that cannot be provided by Indian,
    tribal or urban health programs. PRC is the funding methodology and
    medical priority system that IHS utilizes to ration that care. Tribes
    have worked collaboratively with IHS to develop this methodology using
    several data points. The current-methodology includes data and a system
    of weighting data that consider the care available to Indians across
    all IHS areas. GAO's scope of work and recommendations, though
    thoughtful, do not apply the same level of expertise tribes have
    developed regarding the allocation of the entire IHS budget.
    Additionally, the GAO's recommendations do not accurately capture or
    consider the various other streams of funding that are distributed
    using other data points. MCN would be happy to provide additional
    information and insight regarding the methodology development and
    agrees with the national consensus that the PRC methodology does not
    have to be altered at this point in time.
        The Nation remains committed to providing the best possible
    services under its ISDEAA agreements and looks forward to working with
    the Committee members, Administration leadership, and others to
    implement solutions that improve access to and quality of those
    services. I appreciate the opportunity to provide the comments above
    and your continued efforts to oversee the trust responsibility
    relationship.
                                     ______

        Response to Written Questions Submitted by Hon. Steve Daines to
                              Melissa Emrey-Arras
        Question 1. Ms. Emery-Arras, exactly how many recommendations to
    the Indian Health Service were open when the Government Accountability
    Office added the agency to the high risk list?
        Answer. When we issued our 2017 High Risk report, there were 13
    recommendations to HHS that were unimplemented.

        Question 2. And how many have been fully implemented?
        Answer. Since our 2017 High Risk report was issued, IHS has
    implemented three of these recommendations.

       In response to a recommendation in GAO-13-272, to monitor
            the Purchased/Referred Care (PRC) program access to physician
            and other nonhospital care, and to assess how the PRC payment
            rates may impede the availability of care, IHS developed an
            online PRC Rates Provider Tracking tool. The use of this tool
            enables PRC programs to document providers that refuse to
            contract for their most favored customer rate or accept the
            PRC. On October 3, 2017 IHS officials met in-person with GAO
            and provided a demonstration of the PRC Rates Provider Tracking
            Tool.

       In response to a recommendation in GAO-16-333, IHS developed
            specific standards for patient wait times and published them to
            the IHS Indian Health Manual website in August 2017.

       In response to a recommendation in GAO-17-181, in December
            2016, the former IHS Principal Deputy Director, issued a
            directive for all HQ and Area Offices to develop succession and
            contingency plans to identify potential leaders or senior
            managers to fill critical positions in the short- or the long-
            term, and identify individuals available immediately for
            unexpected absences or departures. The IHS Office of Human
            Resources issued guidance, instructions, and a template for
            identifying key leadership positions in the HQ Offices, Area
            Offices, and Service Units. The instructions also included a
            requirement to conduct a skills-gap analysis to assess any
            identified employee's current competencies against those needed
            for the target leadership position.

        Question 3. And how long has it been since the earliest of these
    recommendations were made to IHS?
        Answer. In our February 2017 High Risk report, we cited 2
    recommendations from a fiscal year 2011 report on the accuracy of data
    used for estimating PRC needs, with which HHS agreed. These
    recommendations remain unimplemented.

        Question 4. Would you say that period of time is enough to have
    implemented these recommendations?
        Answer. GAO tracks and publicly reports annually on the percentage
    of recommendations made 4 years ago that have since been implemented.
    We use a 4-year reporting window because it generally takes 4 full
    years to implement some of our recommendations. In fiscal year 2015, we
    reported that 79 percent of recommendations made in fiscal year 2011
    had been implemented. We believe the recommendations that we have made
    to IHS could have been implemented within this timeframe and we will
    continue to monitor IHS's efforts to implement our recommendations in a
    timely manner.

        Question 5. I understand that responsiveness to GAO from IHS on the
    status of the recommendations has been an issue. Could you describe
    what those challenges have been?
        Answer. While IHS's responsiveness to our recommendations has been
    an issue in the past, since we added the agency to our High Risk list,
    agency officials have become more responsive. For example, in October
    2017, GAO and IHS officials met in person to discuss all unimplemented
    recommendations to determine possible implementation solutions. After
    this meeting, we were able to close one recommendation as implemented.
    In addition, we have received several e-mails in the past few months
    providing information documenting steps that IHS officials have taken
    to implement our recommendations. We hope to continue this
    collaborative relationship as the agency moves forward with
    implementing other recommendations.

        Question 6. I also understand that in multiple instances, when IHS
    stated that they've implemented various recommendations, the
    documentation has been subpar. Can you provide a couple examples of
    when that evidence was insufficient?
        Answer. In the past, IHS officials have requested that we close
    recommendations as implemented but provided no evidence. For example,
    IHS officials informed us that the agency developed a requirement for
    contingency and succession planning for key leadership positions at
    headquarters and area offices, but did not provide documentation of
    their efforts.
        In addition, officials have sometimes provided documentation of
    their efforts to implement recommendations, but the documentation was
    insufficient to determine what steps had been taken. For example, when
    attempting to document the development and use of the PRC Rates
    Provider Tracking tool, officials provided a link to a secure area of
    the IHS website that was not available to GAO staff. When informed of
    this, IHS officials sent a screenshot of the webpage that showed the
    button for the tool in the lower left hand corner of the site. This was
    not sufficient to determine what the agency had done to implement the
    recommendations.
        However, IHS officials have since sent sufficient documentation of
    their contingency and succession planning efforts, as well as the PRC
    Rates Provider Tracking tool. The inperson meeting in October was
    particularly helpful and allowed us to explain the level of
    documentation that we need in order to consider a recommendation
    implemented. During this meeting, IHS staff demonstrated the tracking
    tool, and showed us a user guide, the data entry page, and an example
    of a provider refusals report.

        Question 7. I understand there was one instance in particular--and
    it's particularly mindboggling--where IHS actually sent a screenshot of
    a corner of a website as documentation of their having implemented the
    recommendation. Could you share what happened there?
        Answer. See answer to question 6 above.
                                     ______

         Response to Written Questions Submitted by Hon. Tom Udall to
                                  Tony Dearman
    BIE Student Outcomes Data
        Question 1. The most recent school and Bureau accountability data
    provided on the BIE website
        dates to SY2012-2013. The Committee is unaware of any other
    locations where the Bureau might have published accountability data for
    the three school years completed sinceSY2012-2013 concluded and
    required under Section 1111 of the Elementary and Secondary Education
    Act through August 1, 2016.
        Please provide a copy of all statutorily required school
    accountability data for SY2013-2014, SY2014-2015, and SY2015-2016. If
    this information is not currently available, please provide a firm
    timeline of when such information can be made available to the Chairman
    and the Vice Chairman.
        Answer. Available data has been reported to the U.S. Department of
    Education's (ED) EDFacts data collection system. The Bureau is working
    to update and post additional, required public reporting on school
    accountability. However, most information has not yet been aggregated
    and remains partially incomplete. Recently, leadership has refocused
    attention to increasing data-driven decisionmaking across the Bureau
    through improved data collection. As of 2018, the Bureau has hired an
    Accountability and Assessment Supervisor as well as several Education
    Research Analysts and has filled six Native American School Information
    Specialists (NASIS) positions. These personnel are specifically focused
    on data by expanding technical assistance to schools as well as
    improving the Bureau's collection and use of key data metrics critical
    to supporting the needs of students attending BIE-funded schools.

        Question 2. Title I of the Every Student Succeeds Act (ESSA)
    requires states to design and implement an accountability system to
    measure school quality and performance in consultation with a variety
    of stakeholders. The Department of Education (ED) indicates on its
    website that BIE, acting in its capacity as the State Education Agency
    (SEA) for BIE-funded schools, provided notice of intent to submit its
    state accountability plan to ED on September 18, 2017. Yet, as on the
    date of this hearing, the BIE's webpage on the Bureau's ESSA State Plan
    is completely blank.
        What is the status of the BIE state plan? Please provide a summary
    of any BIE's coordination between BIE and ED on this issue and a
    description of all relevant consultations undertaken by BIE to date on
    development of a state accountability plan.
        Answer. To meet its obligations under the Elementary and Secondary
    Education Act of 1966, as amended by the Every Student Succeeds Act
    (ESEA) and develop a State Plan, the BIE will amend its existing
    standards, assessments, and accountability regulations through
    Negotiated Rulemaking (NRM); and solicit stakeholder and tribal input
    through consultation regarding the BIE State Plan. At a December 8,
    2016 meeting between BIE and ED, Education officials expressed a view
    that the State Plan under ESEA was optional for the BIB. BIE Director
    Dearman announced the BIB would move forward with developing a State
    Plan, as approved through rulemaking, as a means to facilitate a
    transition to ESEA and ensure the development of a coherent federal
    education system across the twenty-three (23) states in which BIE
    facilities operate. The BIE notified ED via email on January 7, 2017
    that it would submit a State Plan.
        To meet its ESEA obligations and develop a State Plan, the BIE
    will: (1) amend its existing standards, assessments, and accountability
    regulations through Negotiated Rulemaking (NRM), and (2) solicit
    stakeholder and tribal input through consultation regarding the BEE
    State Plan. On November 9, 2015, the BIE published a notice of intent
    (80 FR 69161) requesting comments and nominations for tribal
    representatives for the NRM. Upon transition between Administrations,
    the initial formulation of the NRM was postponed in order to provide
    incoming Department staff adequate time to review prior work. As of
    August 2017, the BIE was provided clearance to move forward with re-
    initiating the Committee and working and consulting with stakeholders
    to determine membership and subsequent steps.
        The negotiated rulemaking committee was re-advertised in Federal
    Register notice (82 FR 43199) soliciting nominations on September 14,
    2017, with a deadline for submission of nominations by October 16,
    2017. The nominations received were reviewed by Department and BIE
    officials and selected members will be announced through a notice in
    the Federal Register, which will be available for public review and
    comment. After such time, a subsequent Federal Register Notice will
    announce the final NRM members and initial meeting dates.
        Ultimately, the NRM will recommend revisions to existing
    regulations (25 CFR Part 30), replace the No Child Left Behind Act
    (NCLB) Adequate Yearly Progress regulatory language, and implement the
    Secretary's statutory responsibility to define the standards,
    assessments, and accountability system, consistent with the ESEA The
    BIE and ED consult and work together on a range of Indian education
    related issues, through the departments' interagency work group that
    meets bi-weekly and through direct communication.

        Question 2a. Please provide an overview of BIE,'s efforts to comply
    with ESSA as a whole and outline how the Bureau has worked with ED to
    ensure full compliance moving forward.
        Answer. To meet its obligations, the BIE will: (1) amend its
    existing standards, assessments, and accountability regulations through
    negotiated rulemaking, and (2) solicit stakeholder and tribal input
    through consultation regarding the BIE State Plan. The BEE has elected
    to adopt a State Plan that will work to improve the BLE's support of
    Bureau-funded schools. Through tribal consultation and solicitation of
    stakeholder feedback, the BIE will ensure ESEA requirements are met.
        Ultimately, the BIE will carry out its obligations under the ESEA
    through rules and regulations determined under the NRM, which will
    recommend revisions to the existing regulations (25 CFR Part 30) to
    replace the NCLB Adequate Yearly Progress regulatory language and
    implement the Secretary's statutory responsibility to define the
    standards, assessments, and accountability system, consistent with the
    ESEA.

        Question 3. The Navajo Nation reports to my Office that the BIE is
    currently not efficiently transferring student data required under a
    signed memorandum of understanding between the Tribe and the Bureau. Is
    BIE working with the Navajo Nation to ensure the spirit and letter of
    the MOU are followed?
        Answer. BIE has and continues to work with the Navajo Nation tribal
    government as well as Department of Dine Education (DODE) on an ongoing
    basis as the tribe and its education agency work to clarify their
    preference for outreach with the BIE,. For instance, BIE Associate
    Deputy Director (ADD) of Navajo Schools has worked to share Partnership
    for Assessment of Readiness for College and Careers (PARCC) data for SY
    2014-2015 (NM only Navajo schools), 2015-2016 and 2016-2017. The Navajo
    ADD offices have continued to support the Navajo Nation with ongoing
    NASIS data training with meetings held as recently as October 2017. The
    Navajo Nation is now in the process of amending their Data Agreement to
    include Personally Identifiable Information (PII) assurance
    documentation, which was shared with the President of the Navajo Nation
    at the NIEA convention held in early October 2017.

        Question 3a. How is BIE ensuring that tribes with members enrolled
    in BIE-funded schools have timely access to information necessary to
    track student outcomes?
        Answer. The BIE is provided with short-cycle assessment data by
    Northwest Evaluation Association (NWEA) after each testing window which
    informs instructional practices and student outcomes. Such data are
    accessible at school sites by instructors and school leadership. The
    test results are normally sent to each school site by the vendor,
    Measured Progress/Smarter Balance, in late June.
        In regards to summative data, the BIE has access to state
    assessment data through schools that receive such information directly;
    the BIE does not have direct access to all state assessment data and
    often must request the data from individual schools. Although BIE has
    Memoranda of Agreement in place for sharing state assessment data for
    many schools this is not the case for all states in which the BIF.,
    operates. As noted in a previous response, the BIE is currently in the
    process of establishing a Negotiated Rulemaking Committee that will,
    among other things, determine if the BIE should establish its own
    unique accountability system under the ESEA, which could improve the
    BIE's data disaggregation and dissemination capabilities through a
    uniform system, or continue to operate and serve schools based on the
    23 states in which the schools are located.

        Question 3b. What mechanisms within BIE are in place to lift tribal
    accountability to the level of the federally-mandated accountability
    plans referenced in question (2) above?
        Answer. Indian Tribes may seek waivers from the BIE's standards,
    assessment and accountability system requirements, under ESEA section
    8204(c). BIE continues to partner with ED to facilitate such waiver
    requests and provide technical assistance and support to ensure
    successful transition of such authority to a Tribe. As of 2018, the
    Navajo Nation and Miccosukee Tribe have waivers approved by the two
    agencies, which supports local control of education and provides Tribes
    the flexibility to better meet their local needs. For example, Navajo
    Nation's agreement includes an alternative system of accountability for
    schools that allows BIE-funded schools that serve the Tribe but are
    located in three different states to operate under a uniform system.
    Currently, BIE Education Resource Center staff provides ongoing
    technical assistance to tribes with such waivers.

        Question 3c. Does BIE have any other student outcome related data
    (for example--graduation rate trends, or absenteeism trends in BIE
    schools) that it can share? If so, please provide it here or provide a
    firm timeline of when such information can be made available to the
    Chairman and the Vice Chairman.
        Answer. The Bureau is working to bring recent data sets up to date.
    Currently, an analysis of longitudinal data trends is unavailable until
    such data strands are collected and verified. However, the Bureau has
    enclosed the following 2015 Bureau of Indian Education Report on
    Student Achievement and Growth from the Northwest Evaluation
    Association for the Committee's review. Its results suggest that BIE
    students have shown some improvements over time in achievement and
    growth rates, most notably in mathematics and for students attending
    earlier grade levels. However, gaps persist and BIE remains committed
    to improving service delivery that will help narrow the gap for
    students attending Bureau-funded schools.
    IT Infrastructure Challenges
        Question 4. One issue BIE school-level leadership has repeatedly
    raised involves challenges meeting the Bureau's data reporting
    requests. For example, the administration team at Southwestern Indian
    Polytechnic Institute (SIPI) never received the credentials they needed
    to access BIE reporting software. Several folks from the school reached
    out to regional BIE and BIA staff--who are located in an office right
    down the road in Albuquerque--but they never received a response. Can
    you commit to working with SIPI to resolve this systems access issue?
        Answer. Yes.

        Question 4a. How is your office working to make sure BIE schools
    have sufficient technical assistance to fully utilize reporting
    software like Maximo?
        Answer. BIE has offered technical assistance and training
    opportunities to BIE schools regarding the use of the Maximo system via
    five four-day sessions held in Albuquerque, NM as well as across the
    country at regional training.

        Question 4b. How is your office working to make sure data reporting
    requirements aren't duplicative or unnecessarily burdensome for tribes
    and schools staff?
        Answer. BIE leadership does not want such reporting requirements to
    impede school-level functions or create unnecessary burdens on local
    staff. As such, BIB leadership is working to ensure compliance and
    technical assistance teams visit schools in a coordinated manner to
    increase efficiency in compliance monitoring while decreasing the
    number of site visits held each year.

        Question 5. GAO has found that BIE's student attendance system had
    no way to note that an absence was caused by transportation issues. BIE
    is working to update the data system related to this issue; but this is
    just one small piece of a larger data and IT issue facing BIE. When
    will the transportation-related absentee tracking issue identified by
    GAO in May be fully implemented?
        Answer. BIE tentatively agreed to GA0-17-423: Tribal Transportation
    recommendation 7. The BIE is currently exploring the addition of a
    field within NASIS to capture whether an individual student's absence
    is due to inclement weather or road conditions. The BIE will consult
    with the NASIS vendor to discuss the feasibility and cost involved for
    this additional requirement and consider implementation of
    recommendation 7 based on this information and available resources.

        Question 5a. Please list and explain other data and IT issues that
    BIE is currently working to improve.
        Answer. The BIE has formed a bureau-wide working group to improve
    its data collection, management, and reporting. The working group was
    formed in early 2017 and was initially tasked with bringing outdated
    EdFacts data up-to-date. The working group is now performing a bureau-
    wide data audit and is in the early stages of creating policies and
    procedures designed to improve the Bureau's collection, management, and
    reporting of data.
                                     ______

         Response to Written Questions Submitted by Hon. Tom Udall to
                                Michael S. Black
    Inter-Agency Coordination: Impact of Zinke Reorganization on the Indian
            Energy Service Center
        Question 1. The GAO reported that the BIA continues to fail in
    coordinating with other agencies that play a role in the development of
    Indian energy, like Fish and Wildlife Service, the Army Corps of
    Engineers, and the Environmental Protection Agency. As a result, the
    Service Center does not serve as the central point of collaboration/
    coordination as originally envisioned. Potentially compounding matters,
    Secretary Zinke floated a proposal at a House Appropriations hearing to
    reorganize the Department into a system modeled on the military's joint
    command model that would shift employees from D.C. and regional
    headquarters offices to field locations. There are concerns that
    Secretary Zinke's proposed reorganization of Interior's sub-agencies
    will further complicate or delay attempts to better coordinate within
    Interior the permitting and approval of Indian energy projects. In
    addition, tribes have reported that Interior's consultation with them
    on these moves is limited, if it happens at all. How will the proposed
    reorganization of the Department of the Interior affect ongoing efforts
    to make sure agencies are coordinating with the Service Center?
        Answer. The Indian Energy Service Center (IESC) is a multi-agency
    office comprising Bureau of Indian Affairs (BIA), the Office of Natural
    Resource Revenue (ONRR), and the Bureau of Land Management (BLM) staff
    components that provide support of Indian energy development on Indian
    lands. The Department will continue efforts to improve coordination
    among bureaus in support of tribal management of energy resources.

        Question 1a. The Indian Energy Service Center was a result of
    robust collaboration between Interior and tribes. To the extent the
    proposed reorganization impacts the Service Center, will the BIA
    consult with tribes to limit adverse impacts to coordination?
        Answer. The Department does not anticipate any adverse impacts to
    coordination and services resulting from the proposed reorganization.
    The BIA has initiated discussions with Indian Country and will continue
    with formal tribal consultations regarding any proposed adjustments to
    the regional field organizations serving the BIA and BIE.
    IT Infrastructure: Energy Lease Review and Response
        Question 2. In its 2015 report, GAO found that BIA did not have a
    clear system for or the data needed to track its review and response
    times for the approval of leases, rights-of-way, and appraisals for
    energy development on Indian lands. The BIA must be able to track its
    review and response times to ensure the approval process is efficient,
    transparent, and meets the needs of tribes that seek to utilize their
    natural resources.
        It is absolutely essential that the process for tracking review and
    response times is comprehensive. Can you confirm that the process will
    include all documents that need to be approved before and after
    resource development can occur?
        Answer. We have made progress on this issue, and tracking some data
    from leases, rights-of-way, and mineral-related agreements
    (Communitization agreements and Unit agreements) is in place for BIA.
    This remains an ongoing process.
    IT Infrastructure: GIS Mapping of Indian Energy
        Question 3. GAO identified issues with outdated and deteriorating
    equipment, technology, and infrastructure at BIA, which has led to the
    inefficient management of Indian energy resources. One recurring
    problem for the BIA, and one that has existed for years, is inadequate
    information about ownership over surface and mineral rights. The BIA
    has stated its intent to develop a national dataset of all Indian land
    tracts and boundaries, but has not provided a timeline-or even what
    resources are necessary-to complete this survey. GAO found, for
    example, that some tribes couldn't pursue development opportunities
    because BIA did not have an inventory of the tribe's energy assets
    available. GAO recommended that Interior incorporate mapping technology
    that would greatly increase the agency's efficiency. Can you describe
    how Interior has updated its mapping technology?
        Answer. In response to the Government Accountability Office's May
    2017 Report, BIA has taken steps to integrate geographic information
    system (GIS) technology into the Trust Asset and Accounting Management
    System (TAAMS).
        Version 1.0 of TAAMS ``Map Viewer'' was placed into production and
    is currently available for use as of August 31, 2017. A demonstration
    of the capabilities of the Map Viewer was performed on September 14,
    2017, for GAO program auditors. On September 13, 2017, the Assistant
    Secretary reported to the Senate Committee on Indian Affairs on this
    accomplishment and submission of the closure package to the GAO on this
    recommendation.
        Program level staff and tribes are now able to view and print maps
    from TAAMS that can be shared with landowners and enable managers to
    make informed decisions regarding energy resources in a timely manner.
        The Map Viewer, in conjunction with the TAAMS ownership and
    encumbrance reports, provide program level managers with the
    information regarding title and restrictions for making timely energy
    resource decisions. There are 193,487 Indian land tracts that are
    viewable through the Map Viewer and 21,280 tracts which must be
    converted into a spatial representation as resources permit. Please
    refer to the table below for statistics by Region.

    ------------------------------------------------------------------------
                                                            Tracts Remaining
                                                              that Require
                                        Tracts Visable in       Spatial
                BIA Region               TAAMS Viewer  8/   Conversion to be
                                             30/2017       visable in Viewer
                                                               8/30/21017
    ------------------------------------------------------------------------
    Eastern (LAC 0-99)                                141                200
    Northwest (LAC 100-199)                        26,410              5,577
    Rocky Mountain (LAC 200-299)                   46.804              3,951
    Great Plains (LAC 300-399)                     61.063              2,437
    Midwest (LAC 400-499)                           7,844              3,111
    Pacific (LAC 500-599)                           2,878                844
    Western (LAC 600-699)                          12.664                859
    Southwest/Navajo (LAC 700-799)                  7.228              1,330
    Southern Plains (LAC 800-899)                   9,818                862
    Eastern Oklahoma/Alaska (LAC 900-              18.637              2,109
     999)
    ------------------------------------------------------------------------
        Totals                                    193,487             21,280
    ------------------------------------------------------------------------

        Additionally, new land area boundary representations (Reservation,
    Rancheria, Public Domain Allotment, etc.) are under development and are
    made viewable in the Map viewer as they are completed. Nationally,
    boundary data for the current 333 federally recognized tribal land
    areas, referenced in the following table, are expected to be completed
    by Spring of FY18.

    ------------------------------------------------------------------------
                                                           Total Land Area
                          Region                        Boundaries by Region
    ------------------------------------------------------------------------
    Rocky Mountain                                                         7
    Midwest                                                               37
    Northwest                                                             45
    Great Plains                                                          16
    Pacific                                                              105
    Eastern                                                               30
    Eastern Oklahoma                                                       2
    Southern Plains                                                        6
    Southwest                                                             26
    Western                                                               56
    Navajo                                                                 3
    ------------------------------------------------------------------------
        Total                                                            333
    ------------------------------------------------------------------------

        The procedure for developing the data is described in the Indian
    Land Tract and Land Area Boundary Mapping Training Guide. The BIA plans
    to continue to advance the Map Viewer to include other nationally
    stewarded and standardized geospatial datasets to support energy
    development.

        Question 3a. How do initiatives like updating IT infrastructure and
    creating new planning processes impact the resources you have available
    for providing services to tribes?
        Answer. Initiatives for updating IT infrastructure are important
    and required to address limited and aged IT network infrastructure,
    which impact the BIA resources for providing timely services to tribes.
    TAAMS services, for example, are often delayed due to high usage,
    limited data line capacity, remote locations and restricted access.
    Further, planning processes such as developing national geospatial
    databases with rigorous standards are needed but are resource intensive
    and require expertise in GIS.
                                     ______

         Response to Written Questions Submitted by Hon. Tom Udall to
                              RADM Michael Weahkee
    Inter-Agency Coordination
        Question 1. In 2015, the Centers for Medicare & Medicaid Services
    (CMS) withdrew its accreditation of the Omaha-Winnebago IHS Hospital in
    Nebraska. At the GAO High Risk hearing in June, IHS Deputy Director
    Buchanan testified that the hospital would be reaccredited within a
    matter of months. The loss of CMS certification is both a safety
    concern and a funding issue. What is the current CMS accreditation
    status of the Omaha-Winnebago IHS Hospital?
        Answer. One of the Indian Health Service (IHS) priorities is to
    bring the Omaha-Winnebago Hospital (OWH) into full compliance with the
    Centers for Medicare & Medicaid Services (CMS) standards. The hospital
    is not currently CMS-certified. Filling critical hospital leadership
    positions is essential to achieving and sustaining CMS accreditation.
    We hired a Clinical Director, Chief Nurse Officer, and Quality Manager
    for OWH in recent months. We want to ensure the OWH is fully prepared
    before requesting CMS return for a re-survey, and we continue to assess
    progress on an on-going basis.

        Question 1a. Are you working with CMS to address the cited
    deficiencies?
        Answer. The IHS Omaha-Winnebago Hospital continues to work
    diligently on quality improvement and patient safety, supported by
    technical assistance from Joint Commission Resources, to address
    quality improvement and patient safety requirements of CMS. The OWH
    will be going through a Joint Commission Resources unannounced survey
    in the coming weeks. Once successfully completed and OWH is determined
    to be fully prepared for a CMS survey, a re-certification application
    will be submitted.
    Inter-Agency Coordination
        Question 2. During a series of site visits over the last year, the
    Albuquerque IHS Service Area reported to my staff that all Albuquerque-
    area Service Units are deploying patient satisfaction surveys. Are
    other IHS Service Areas currently utilizing the same or similar patient
    satisfaction surveys?
        Answer. The Quality Framework Steering Committee established the
    Patient Experience of Care Survey working group to develop a
    standardized patient experience survey for IHS. In their pre-
    development phase of work, the working group surveyed IHS facilities on
    the use of Improving Patient Care (IPC) survey instruments. Fifty
    percent (50 percent) of 34 responding facilities reported use of the
    IPC survey. The remaining respondents indicated use of Agency for
    Healthcare Research & Quality Consumer Assessment of Healthcare
    Providers & Systems (AHRQ CAHPS), Net Promoter, and Care and Health
    Outcomes (ECHO). A pilot of implementing the new Patient Experience
    Survey using electronic tablets was completed at four facilities in
    four IHS Areas in June 2017 and achieved excellent results for patient
    acceptability, usability, immediate access to survey results (locally
    actionable data), and staff workload (collecting and analyzing
    results). While IHS implements the new Patient Experience of Care
    Survey tool more broadly throughout the system, IHS continues to
    support Service Units' use of the IHS IPC Patient Satisfaction Survey
    tool to monitor patient perceptions of care.

        Question 2a. What is IHS doing to share and implement best
    practices, e.g., patient experience surveys, between Areas?
        Answer. The IHS shares information with participating Service Units
    via the IPC Program Portal and the Quality Framework Steering Committee
    hosts monthly webinars with all Area and Service Unit Quality Managers.
    In partnership with CMS, all IHS hospitals also participate in the
    Partnership to Advance Tribal Health (PATH), a single Quality
    Improvement Network (QIN)-Quality Improvement Organization (QIO) entity
    dedicated to improving quality of care by implementing best practices
    and identifying opportunities for operational improvement across IHS
    hospitals.

        Question 2b. Are you aware of any agencies (HRSA, HHS) that have
    expertise in developing key processes and policies aimed at improving
    patient experience? Are you working with those agencies to further
    develop IHS policies?
        Answer. IHS consulted with the SouthCentral Foundation (tribal
    health program) and the Agency for Healthcare Research and Quality
    (AHRQ), Office of the National Coordinator (ONC), Office of the
    Assistant Secretary for Health (OASH), Health Resources and Services
    Administration (HRSA), National Institutes of Health (NIH), and the
    Assistant Secretary for Planning and Evaluation (ASPE) to develop its
    standardized patient experience survey. IHS is aware of the HRSA Health
    Center Patient Survey (HCPS) and is also consulting with the Veterans
    Health Administration Patient Experience Office on strategies to
    optimize survey use.
    IT and Data Infrastructure:
        Question 3. IHS uses a medical records system originally developed
    by the Veterans Affairs Department called the Resource and Patient
    Management System (``RPMS''). The VA will discontinue support of this
    system within the next few years, and tribes are concerned the IHS will
    have no structure or resources in place to implement or purchase a new
    system. It does not appear that IHS has a replacement plan to address
    this issue. What is IHS's plan to replace RPMS and will the Service
    need any additional budgetary resources to implement it?
        Answer. The IHS is undertaking a thorough and comprehensive
    analysis of alternatives that includes federal, tribal, and urban
    stakeholder input to consider all options for our Electronic Health
    Record (EHR) strategy. While commercial EHR solutions offer out-of-the-
    box capabilities, the Department of Veterans Affairs (VA) and IHS
    systems are designed specifically to meet the unique needs of the
    agencies through customized medical applications, which can be more
    complex with a greater focus on longitudinal care over time than
    commercial EHR systems.
        As part of our engagement with tribal programs, the Muscogee-Creek
    Nation provided an in-depth briefing demonstrating implementation of
    their two commercial EHR systems. The Cherokee Nation briefed the IHS
    Chief Medical Officer on their commercial EHR system and we have been
    engaged in dialogue with tribal health programs from Alaska on this
    issue. We have been engaged with other tribal health programs or tribal
    health committees as well.
        Under the current arrangement, the IHS was able to adapt the VA
    software for use in our EHR system without having to expend funds on
    the development. The loss of the VA as a source of software code will
    likely have a budgetary impact on the IHS as we plan for the future.

        Question 3a. Could you please provide an outline of this plan and
    an estimate of IHS's IT needs over the next several years?
        Answer. The timing for IHS must remain largely in synchronization
    with the plans and the timeline of the VA. The VA's plans and timelines
    are still under development, but early indications point to a 7-8 year
    project timeline. With that in mind, the VA will need to continue its
    support for VistA for years, which means that the IHS will continue to
    have support for RPMS for years. The VA will still be releasing new
    patches for a while, but it will begin shifting away from new
    development to add functionality and start focusing narrowly on patches
    that address patient safety, and get the system ready for data sharing
    and archive.
        The IHS is currently developing a timeline that recognizes the end
    of support for the current EHR system and considers potential
    replacement. We estimate that a replacement would be a multi-year
    project. During the first year, the IHS would be heavily involved with
    exploration, comparison, and decisional activities. The second year
    would entail acquisition activities. Additional years would focus on
    rolling implementation at clinics and hospitals. The funding required
    will be determined in large part by the EHR system(s) chosen.

        Question 4. IHS also recently announced a new patient wait-time
    tracking addition to RPMS. They believe this expansion of RPMS will
    address one of GAO's unresolved recommendations from 2016. However, IHS
    told staff this new ``fix'' to track patient wait times might become
    obsolete as soon as the RPMS system goes out of use. How will the
    eventual replacement of RPMS impact the ability of IHS headquarters to
    monitor patient wait-times?
        Answer. IHS has focused on the use of business intelligence (BI)
    software to work alongside the Resource and Patient Management System
    Electronic Health Record (RPMS EHR) in order to systematically measure
    and track wait times. Business intelligence software can be utilized
    with any EHR. Any EHR transition would require updates in the linkages
    between the BI software and the EHR. IHS will include wait times
    metrics as a requirement for health information systems.

        Question 5. Several Service Units within the IHS-Albuquerque
    Service Area utilize a patient appointment program known as CQueque to
    electronically monitor patient wait times once an individual arrives
    for their appointment. These Units report to my staff that this program
    helps them self-audit staff performance and departmental progress
    towards patient experience goals.
        Do any Service Units or Areas outside of Albuquerque utilize
    similar ``sign-in'' software to track the efficiency of patient flows
    within IHS facilities or between difference departments within one
    facility?
        Answer. Yes. Efficiency and patient flow are important metrics in
    the Improving Patient Care (IPC) program. RPMS includes the ability to
    track appointment check-in, and data from RPMS can be utilized with or
    without business intelligence software to augment the measuring and
    tracking capabilities. Not all patient flow data is captured in the
    EHR, so IHS facilities use data both from within and external to the
    EHR to track efficiency and patient flow.

        Question 5a. Is IHS exploring a way to include tracking of similar
    wait-time information in its efforts to address patient experience and
    wait time issues identified by GAO in the series of reports listed in
    the High Risk Report?
        Answer. The IHS Improving Patient Care (IPC) Program addresses
    measurement and improvement efforts to shorten cycle time (start to
    finish of an appointment). IHS continues to explore opportunities and
    options for improving its capacity to measure cycle time and other
    wait-time metrics as a component of the patient experience of care. We
    are looking to extend the use of wait time standards to other services
    we provide such as dental and behavioral health.
                                     ______

        Response to Written Questions Submitted by Hon. John McCain to
                            RADM Michael D. Weahkee
        Question. The Gila River Indian Community has contacted my office
    concerning budget shortfalls in the FY 2018 budget that could delay the
    2018 opening of the newly constructed Red Tail Hawk Health Clinic. I
    understand that the Clinic has remained on budget for many years, and
    that IHS is aware of the 2018 opening date. What is the status of the
    facility for the next fiscal year?
        Answer. The funding of national priorities reflected in the FY 2018
    President's Budget required IHS to make choices between its programs
    and investments. The Indian Health Service (IHS) currently expects the
    Red Tail Hawk Health Center to be completed during January 2018.
    However, the FY 2018 request does not currently include staffing and
    operational funds for this new clinic.

                                      [all]