[Senate Hearing 115-]
[From the U.S. Government Publishing Office]
DEPARTMENT OF THE INTERIOR, ENVIRONMENT, AND RELATED AGENCIES
APPROPRIATIONS FOR FISCAL YEAR 2018
----------
WEDNESDAY, JULY 12, 2017
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 9:36 a.m., in room SD-124, Dirksen
Senate Office Building, Hon. Lisa Murkowski (Chairman)
presiding.
Present: Senators Murkowski, Hoeven, Daines, Udall, Tester,
and Van Hollen.
INDIAN HEALTH SERVICE
STATEMENT OF REAR ADMIRAL MICHAEL WEAHKEE, ACTING
DIRECTOR
ACCOMPANIED BY:
REAR ADMIRAL CHRIS BUCHANAN, DEPUTY DIRECTOR
GARY HARTZ, DIRECTOR OF THE OFFICE OF ENVIRONMENTAL HEALTH AND
ENGINEERING
ELIZABETH FOWLER, DEPUTY DIRECTOR FOR MANAGEMENT OPERATIONS
OPENING STATEMENT OF SENATOR LISA MURKOWSKI
Senator Murkowski. Good morning. The subcommittee will come
to order.
I would like to welcome everyone this morning to the final
budget hearing. I cannot believe it is already the final.
Senator Udall. Yes.
Senator Murkowski. It seems like we just got started.
Senator Udall. We are roaring through them.
Senator Murkowski. Yes. Anyway, this is an important one
this morning for the Interior Appropriations Subcommittee.
Today, we will examine the budget request for the Indian
Health Service, IHS. I would like to thank and welcome Rear
Admiral Michael Weahkee, the new Acting Director for the Indian
Health Service, appearing before us today.
I think we all recognize that the head of IHS is a tough
job and it is also a critical one. It is certainly critical for
us in Alaska. I know for Senator Udall, it is equally important
and critical in his State, but recognizing that, again, we
appreciate the role that you play here today.
Director Weahkee is accompanied by Rear Admiral Chris
Buchanan, the Deputy Director for IHS; Gary Hartz, the Director
of the Office of Environmental Health and Engineering; and
Elizabeth Fowler, the Deputy Director for Management
Operations. So we welcome all of you.
The IHS budget request for fiscal year 2018 is $4.7 billion
for programs within this subcommittee's jurisdiction. This is a
decrease of $300 million, 6 percent below last year's enacted.
By comparison, other agencies within the Department of Health
and Human Services were reduced by an average of 18 percent. So
I think when you compare it on balance, it is important to
recognize that I think there was some effort to mitigate the
impacts on the IHS budget relative to other agencies.
I am pleased to recognize that the budget does provide full
funding for Contract Support Costs by maintaining the
indefinite appropriations language that I first included in the
fiscal year 2016 appropriations bills. I think that this has
helped provide a level of certainty for Tribes as well as
protecting other IHS programs. What we were seeing was
effectively robbing Peter to pay Paul, borrowing from other
accounts. And while it may have helped one, it was at the
expense of others, which I think we recognized was not a good
direction in how we meet the Government's legal obligations.
Now having said that, I support where we are with contract
support, and appreciating the fact that the cuts that we are
seeing within the IHS budget are not as severe as they are in
other areas, I am very, very concerned that the budget request
does not adequately meet the needs for healthcare in Indian
country. I think we recognize the disparities between health
outcomes for American Indian and Alaska Native people compared
to the population at large are staggering, just staggering.
For example, American Indians and Alaska Natives are three
times more likely to die from diabetes. The drug-related death
rate for Native Americans has increased 454 percent since 1979
to almost twice the rate for all other ethnicities. Of course,
we unfortunately talk far too often about the incidence of
suicide. The suicide rate amongst our First Peoples is roughly
twice that for the rest of the population.
So in order to improve healthcare delivery, the IHS must do
a better job at hiring, as well as retaining, an adequate
number of qualified doctors and nurses. The IHS must also do a
better job of maintaining a large facilities infrastructure
that serves 2.2 million American Indians and Alaska Natives,
and this requires significant resources. We all recognize and
appreciate that.
Currently, the vacancy rate for IHS doctors, dentists, and
physician assistants is roughly 30 percent. The backlog of
facilities maintenance at IHS hospitals is over half a billion
dollars and this according to the agency's own budget
documents. The average age of its facilities is roughly four
times that of its private sector counterparts.
And I think we recognize that additional resources are not
the only answer. So much of this comes down to the quality of
the existing workforce.
I read, and I am sure that my colleagues also read, several
of the articles that appeared in the ``Wall Street Journal''
just last week on July 7. And I have to tell you, I was
horrified. I was sickened. I was mad. There was a whole range
of emotions as I read that because this is our IHS. These are
our facilities that are supposed to care for our First People.
The stories that were detailed were shocking. There are
deplorable conditions that we see, unfortunately, at several of
our IHS facilities at the Great Plains.
In one case, a 35-year-old man stopped breathing in his
hospital room. You have nurses that are responding to the
emergency and they cannot find a crucial medical device that is
needed to prop open airways to his lungs. It is a device that
should have been stored in an emergency supply cart. It cost
them a crucial 20 minutes.
Later in the internal report, they found that that 20-
minute delay cost the patient his life. The investigation also
revealed that the responding nurses were unfamiliar with how to
use the hospital's intercom system or defibrillator.
In another case, a 45-year-old woman died 10 hours after
IHS nurses ignored a doctor's orders to stop giving the patient
a powerful cocktail of narcotics. A Federal inspection report
found that two different doctors told staff that they were
concerned that the patient was being over sedated.
One of the doctors ordered nurses to stop giving the
patient morphine and to remove a patch that dispensed fentanyl.
The patch was never removed and when the patient fell off her
bed that night, nurses gave her even more pain medicine
including a sleeping pill and oxycodone. As she fell into a
catatonic state, coughing and frothing at the mouth, nurses
failed to alert doctors. She was later found dead.
I will have both of these articles from the ``Wall Street
Journal'' from July 7, 2017 included as part of the record.
[The information follows:]
[Articles from the Wall Street Journal, Friday, July 7, 2017]
_______________________________________________________________________
FAMILIES SPEAK OUT: STORIES OF INDIAN HEALTH SERVICE PATIENTS
Regulators cite facilities of Federal health agency for Native
Americans for dangerous care, unnecessary deaths
The Indian Health Service is responsible for providing medical care
to about 2.2 million Tribal members across the U.S., but the system is
in crisis after IHS hospitals repeatedly failed inspections, shut down
services or lost access to crucial Federal funds.
The facilities, which operate in some of the poorest areas of the
country, have rendered dangerous care and caused unnecessary deaths,
according to Federal regulators, agency documents and interviews.
The families of some IHS patients who died say the agency is
responsible for their deaths. An IHS spokeswoman, Jennifer Buschick,
provided a written statement saying the agency, a unit of the
Department of Health and Human Services, declined to comment on
specific medical cases, lawsuits or regulatory findings.
Debra Free
Ten hours after nurses ignored a doctor's orders to stop giving
Debra Free a powerful cocktail of narcotics, she died of an apparent
opioid overdose at the Indian Health Service hospital in Winnebago,
Neb.
Federal hospital regulators laid the blame for her death at the
feet of the hospital's medical staff, who they said disregarded
concerns that the 45-year-old food-services worker was being over-
sedated, documents from the Centers for Medicare and Medicaid Services
show.
Ms. Free was initially admitted to the Winnebago IHS facility on
April 5, 2011, for complications from toe amputations due to her
chronic diabetes, a common condition among Native Americans that the
agency often treats.
A Federal inspection report found that on April 8, two different
doctors told staff they were concerned that Ms. Free was being
oversedated. At one point, one of the doctors ordered nurses to stop
giving Ms. Free morphine and to remove a patch that dispensed Fentanyl,
a highly potent synthetic narcotic. But that never happened, regulators
found. Instead, a nurse who was told to remove the Fentanyl patch
mistakenly thought she was meant to leave it on until it expired in 72
hours.
When Ms. Free fell off her bed that night, medical staff responded
by plying her with more pain medicine--a sleeping pill and oxycodone--
regulators said.
Ms. Free soon drifted into a catatonic state, sometimes coughing
and frothing at the mouth, the report said. But even as her condition
deteriorated, nurses never alerted doctors. Ms. Free was found dead in
her bed by hospital staff in the early morning hours of April 9.
According to Ms. Free's death certificate, the cause was cardiac
arrest.
CMS declined to comment on its report.
Ms. Free's niece, Tori Kitcheyan, a Winnebago Tribal councilor,
helps take care of Ms. Free's only daughter, Angelina, now 15. Last
year, Ms. Kitcheyan told her aunt's story before a congressional
committee. She blames the IHS for Ms. Free's death and is leading a
push for the Tribe to take over operations of the hospital from the
IHS.
Ms. Kitcheyan recalled her aunt as a passionate cook, who devoted
hours to preparing meals for family events.
``She was a constant presence in our lives. Our family has never
been the same since she died. It has been devastating,'' she said.
Charles White Pipe
Charles White Pipe, 68, a former Tribal treasurer and council
member for the Rosebud Sioux, was first diagnosed with lymph-node
cancer on April 2, 2016. But it took the Indian Health Service until
early May to approve specialized treatment at a private hospital, his
daughter said. By then, Mr. White Pipe was near death and had
complained of untreated pain for weeks.
The IHS's program for referrals is often short on funding, leaving
patients waiting, IHS records show. An agency budget document said it
rejected around 40 percent of such claims for needed treatment in 2015
because of a lack of funding.
Lisa White Pipe, Charles's daughter and a Rosebud Tribal councilor,
said that after her father was diagnosed, he attempted several times to
seek relief and treatment at the reservation's Indian hospital.
On April 21, Mr. White Pipe, unable to hold down any food, called
the Rosebud hospital to say his pain was increasing, but he was told to
wait at home for a referral to a cancer specialist, she said. A few
days later, when he called again, a medical staffer said the facility
was too crowded, his daughter said, noting that he wasn't prescribed
additional medication for his pain.
On the night of April 27, her father now barely able to walk, his
legs and feet swollen, Ms. White Pipe drove him to the Rosebud
hospital. Medical providers there informed Mr. White Pipe that his
condition was terminal, gave him more pain medication and told him to
keep waiting for his referral, his daughter said.
When Mr. White Pipe finally received a referral to a Sioux Falls,
South Dakota, cancer center, doctors there said it was too late to
determine where the cancer originated and that there was little they
could do, she recounted.
He died on May 28.
``It felt undignified how he was treated,'' Ms. White Pipe said.
``He was in pain and just pushed to the side.''
Shiree Wilson
Hours after she was discharged from the Indian Health Service
hospital in Belcourt, North Dakota, with a diagnosis of pneumonia,
Shiree Wilson, a 24-year-old new mother, collapsed on the floor of her
home and later died.
Eight days earlier, on Jan. 14, 2014, Ms. Wilson's son had been
delivered by caesarean section at the IHS hospital.
Ms. Wilson, who was diagnosed with a mild cough and high white
blood cell count in the days before she gave birth, returned to the
facility on Jan. 22, complaining that her cough had worsened.
According to a wrongful-death lawsuit filed by Ms. Wilson's mother,
Christine Fluhrer, tests conducted during that visit revealed fluid was
possibly seeping into her lungs, her white blood cell count had risen
and her heart was ``mildly enlarged.'' After diagnosing Ms. Wilson with
pneumonia, doctors sent her home with decongestants and antibiotics.
After she died, the Grand Forks County coroner found Ms. Wilson's
heart weighed 580 grams, twice the normal heart weight for someone her
age, and that she suffered from severe pulmonary congestion and edema,
according to the court filings.
The lawsuit alleges IHS medical staff failed to follow up, despite
warning signs. A doctor also noted in Ms. Wilson's chart that he was
concerned about a pulmonary embolism, the suit said. The IHS
acknowledged the basic facts of Ms. Wilson's treatment and medical
ailments, court filings show, though the agency denied any wrongdoing
in her death.
In November, the IHS settled the lawsuit for an undisclosed sum,
Ms. Fluhrer's lawyer, Reed Soderstrom, said. He declined to comment
further. Ms. Fluhrer said she didn't wish to discuss her daughter's
death.
According to an obituary, Ms. Wilson had worked at a local cafe for
many years and wanted to learn how to cook. She loved swimming at the
local pool and going to horse races. Her newborn son, Paxton, was her
only child.
Paul West
When Paul West stopped breathing in his hospital room, nurses
responding to the ``code blue'' couldn't find a crucial medical device
used to prop open airways that was supposed to be stored in their
emergency supply cart.
That problem cost the team of nurses and doctors responding to the
incident a critical 20 minutes--and Mr. West, his life--according to an
internal report by an Indian Health Service nurse and a lawsuit brought
by his family.
Mr. West, a 35-year-old porter at the local casino, was declared
dead at the Winnebago hospital on April 17, 2014.
``Delay in care for patient, and ultimately death of patient,''
said the internal report, called a Code Blue Critique, examining the
case. The report, which was reviewed by The Wall Street Journal,
concluded the hospital should ``stock the Crash Cart'' and practice
code blues--emergency situations typically demanding patient
resuscitations--at least monthly.
Regulators separately said nurses responding to the incident were
unfamiliar with how to operate equipment ranging from the hospital's
intercom system to the defibrillator.
The IHS said in a statement after this article was published online
that the Winnebago hospital ``holds monthly practice `code blues',''
reviews logs of those practice sessions quarterly and checks crash cart
inventory daily.
Some of the medical staff who participated in his care said in
emails at the time and in interviews with the Journal that the
Winnebago staff missed other chances to save Mr. West, too. Mr. West,
who was obese and had a variety of chronic illnesses, had been getting
sicker throughout the morning before he died. He had begun falling
asleep while talking, and could no longer breathe without leaning
forward, his family said in the lawsuit. U.S. lawyers denied many of
the family's allegations in a court filing, saying alleged injuries
weren't caused by negligent acts by government employees.
The death of Mr. West, who was described by Tribal members as a
gregarious personality who made lighthearted jokes, shocked the
Winnebago reservation, because of his young age and popularity. His
family declined to comment through their lawyer.
_______________________________________________________________________
``PEOPLE ARE DYING HERE'': FEDERAL HOSPITALS FAIL TRIBES
Indian Health Service facilities sanctioned for dangerous, faulty care,
leaving often-impoverished patients on remote reservations without
services required by law
(By Dan Frosch and Christopher Weaver)
Service hospital in Pine Ridge, South Dakota, a 57-year-old man was
sent home with a bronchitis diagnosis--only to die five hours later of
heart failure. When a patient at the Federal agency's Winnebago,
Nebraska, facility stopped breathing, nurses responding to the ``code
blue'' found the emergency supply cart was empty, and the man died. In
Sisseton, South Dakota, a high school prom queen was coughing up blood.
An IHS doctor gave her cough syrup and antianxiety medication; within
days she died of a blood clot in her lung.
In some of the Nation's poorest places, the government health
service charged with treating Native Americans failed to meet minimum
U.S. standards for medical facilities, turned away gravely ill patients
and caused unnecessary deaths, according to Federal regulators, agency
documents and interviews.
But that system has collapsed in the often-remote corners of Indian
Country, where patients live hours from other medical providers, often
have no insurance and depend on the Federal service. ``We've lost faith
in the IHS, but we have no alternatives to go anywhere else,'' said
Lisa White Pipe, a Tribal Council member for the Rosebud Sioux, whose
father died last year after a delay in cancer treatment that she blames
on the agency. Read more about his and other cases, and see the
regulator's reports.
The problems have come to a head in recent months after IHS
hospitals repeatedly failed inspections, shut down services or lost
access to crucial Federal funds. Such failures have prompted new calls
for broader oversight of the IHS by Congress. The Rosebud Tribe, whose
reservation stretches across a rural swath of South Dakota, is also now
suing the agency in Federal court, alleging that the IHS has failed to
fulfill its treaty responsibility to care for Tribal members.
``People are dying here as a result of the care they are not
receiving, or the care they are receiving,'' said U.S. Senator John
Barrasso, (Republican, Wyoming), who until January chaired Congress's
Indian Affairs Committee, in an interview.
The IHS, a unit of the Department of Health and Human Services,
operates a network of hospitals and clinics, much like the Veterans
Health Administration. Under U.S. treaties that date back generations,
the service is legally responsible for providing medical care to about
2.2 million Tribal members.
The latest crisis has arisen after the IHS and the Health
Department failed to address a chorus of warnings over many years about
neglect at the agency's facilities. The warnings came from lawmakers in
both parties, internal whistleblowers and the families of patients who
died. Over and over, they reported that IHS hospitals were plagued by
inadequate supplies, poor training, overwhelmed staff and critical
positions left unfilled.
The agency has lacked a permanent director since 2015. People
familiar with the matter said they expect a nominee for that post to be
announced soon.
Rear Adm. Michael D. Weahkee, the agency's current acting director,
said in a statement after this article was published online, ``IHS is
committed to improving patient safety and the quality of healthcare
across the agency. We are faced with many challenges, but that is no
excuse for substandard care.'' He said the agency is ``holding all
employees fully accountable and working to improve the systems that
recruit, retain, and support those employees to meet standards.''
Adm. Weahkee, a member of the U.S. Public Health Service
Commissioned Corps, which provides medical staff to Federal agencies,
was appointed to temporarily lead IHS in June. Back in 2010, a
commission chaired by then-Senator Byron Dorgan, (Democrat, North
Dakota), found improperly credentialed medical staff were treating
patients at some remote hospitals and employees accused of misconduct--
even crimes, including stealing drugs from hospital pharmacies--weren't
disciplined.
The agency promised changes, but the situation has only
disintegrated since, according to interviews with Tribal officials,
civil and criminal court records, and a raft of Federal inspection
reports.
Wilmer Spotted Wood hobbled into the IHS hospital in Winnebago but
was sent home without treatment despite medical staff documenting his
severe back pain--10 on a scale of 10--and ashen skin color, according
to one of those reports.
Hours later, a nurse read a test result that showed his kidneys
were shutting down. The finding would normally lead to hospitalization,
doctors say. Instead, the nurse left a phone message telling Mr.
Spotted Wood to avoid calcium products like the antacid Tums and come
back in two days, a Federal inspection report said.
One of his sisters, Betsy Spotted Wood, herself an IHS nurse who
was at the hospital that day, said ``his skin coloring was way off. You
could tell something was seriously wrong.'' Mr. Spotted Wood didn't
make it to his follow-up appointment. He died in his bed of kidney
failure on Jan. 1, 2015, the day he had planned to return to the
hospital.
An IHS spokeswoman, Jennifer Buschick, provided a statement saying
the agency wouldn't comment on specific medical cases, lawsuits or
regulatory findings. Officials at the IHS's Maryland headquarters
fielded queries from The Wall Street Journal related to the agency's
individual hospitals and clinics.
Following Mr. Spotted Wood's death, U.S. hospital regulators found
the Winnebago facility failed to meet basic standards in 11 of 30
random cases they reviewed, including his case, during a routine
inspection.
Winnebago is one of seven IHS hospitals that the regulator, the
Centers for Medicare and Medicaid Services, said had put patients in
danger since 2010--more than a quarter of the 26 hospitals the IHS
manages around the country.
The IHS and Tribal health advocates say Congress underfunds the
agency, and the Trump administration's 2018 budget proposes cutting
about $300 million, a roughly 6 percent decrease from its 2017 level.
The IHS spent $3,688 on care for the average patient in 2015,
according to an agency document. The Veterans Health Administration,
for comparison, spent an average of $11,056 on medical services for
each veteran receiving VA healthcare in 2015, that agency's records
show. The two agencies count the users of their services differently,
and their populations vary.
Obesity and diabetes on the Rosebud and Pine Ridge reservations are
more than 40 percent higher than nationwide, according to a Journal
analysis of data from the University of Wisconsin. At least 50 percent
of residents of those two reservations, as well as a third of those
served by the Winnebago hospital, earned less than the Federal poverty
line, 2015 data show.
Such factors, coupled with remoteness--Rosebud is more than 100
miles from the nearest Wal-Mart--make recruitment difficult. The IHS
said vacancy rates for medical staff at its Great Plains facilities run
as high as 37 percent. By contrast, the Massachusetts Health and
Hospital Association reported only about 6 percent of nursing jobs
vacant in 2015.
Earlier this year, a longtime Pine Ridge pediatrician was indicted
for allegedly sexually assaulting his patients. The doctor, Stanley
Patrick Weber, who resigned last spring from the agency, pleaded not
guilty. His lawyers didn't respond to a request for comment.
The top medical officer at Winnebago was indicted late last year on
allegations he defrauded Tennessee's Medicaid program before joining
the IHS, court records show. The doctor, Scott McLain, had been brought
on in a shake-up the IHS said showed commitment to high-quality care.
Dr. McLain entered a plea of not guilty and has asked a judge to
dismiss the case, his lawyer said. He said Dr. McLain had resigned from
the IHS.
In its written statement, the IHS declined to comment on the
indictments. It said the agency has revamped staff credentialing
procedures, overhauled management of many hospitals and brought in
outside contractors to fill vacancies.
The agency's seven sanctioned hospitals--in Pine Ridge, Rosebud and
Rapid City, South Dakota; Cass Lake, Minnesota; Crow Agency, Montana;
Acoma, New Mexico; and the Winnebago facility that treated Mr. Spotted
Wood--all put patients in ``immediate jeopardy'' of harm and failed to
meet hospital requirements, according to Federal regulators.
The South Dakota and Nebraska facilities have each been cited for
putting patients in danger multiple times. Since 2011, regulators
reviewing cases at those four IHS hospitals said inadequate care
contributed to at least 11 deaths, documents show.
In a second statement after this article was published online, the
IHS said it complies with widely accepted ``death review processes''
and reviews adverse events at the regional level, but doesn't report
nationwide tallies of such incidents.
The agency said, ``Any deficiency in service to patients receiving
care at any IHS facility is unacceptable and does not reflect the
organization's commitment to delivering a high quality of care to its
patients. Upon learning of these survey results IHS immediately began
instituting improvements at each hospital.''
In many cases, the hospitals haven't fixed their problems,
according to regulatory documents. In April, inspectors cited ongoing
failures at the Rosebud hospital for at least the third time in a row;
in 2015 and 2016, its emergency room was closed for 7 months. In May,
inspectors found the Pine Ridge facility had failed U.S. hospital
requirements for the second time in 5 months. The Winnebago hospital
has been barred since 2015 from billing Medicare because it failed to
meet requirements for hospitals participating in Federal programs, a
punishment given to just five general hospitals in the U.S. that year,
Federal data show.
In its initial written statement, the agency cited data showing
many non-IHS hospitals in North and South Dakota and Nebraska also
failed to meet requirements. It is less common though for regulators to
cite hospitals for putting patients in danger in connection with such
failures. Regulatory data show half of the eight facilities run by the
IHS in the three States were found to have put patients in danger from
2011 to 2015. The data show the proportion for all non-IHS general
hospitals with a patient-harm finding in those States was 7 percent.
Some of the families of patients who died unexpectedly under the
IHS's care said the toll extends beyond the hospitals that have been
sanctioned. Among them, is Wakanda Gonsalves, a high school senior and
prom queen, who went to an IHS clinic in Sisseton, South Dakota, on May
4, 2012, because she was coughing up blood. She was sent home that same
day, with cough syrup, an inhaler and antianxiety medication. Two
nights later, her parents woke to Ms. Gonsalves's screams, her mother,
Lisa, recalled. They found her convulsing in bed before she went limp.
``My husband kept doing CPR and chest compressions. Over and over,''
Lisa Gonsalves said. ``But she had no pulse.''
An autopsy showed Ms. Gonsalves suffered a blood clot in her lung.
The IHS-contracted doctor who treated her said in a court deposition he
didn't review an X-ray showing a lung abnormality, or follow up after
an irregular blood test. The staffing agency that employed the doctor
settled a lawsuit with Ms. Gonsalves's family for an undisclosed sum in
2015.
In court filings, both the doctor and the contractor denied any
wrongdoing. Lawyers for both didn't respond to requests for comment.
When confronted with regulatory failures, top IHS officials
prioritized other matters, and Health Department leadership brushed
aside warnings, records and interviews show.
After a 2010 Senate hearing on Senator Dorgan's probe outlining
serious deficiencies in care and training, then-IHS director Yvette
Roubideaux emailed agency employees, acknowledging problems and saying
fixes ``cannot happen overnight.'' She asked staff to, among other
things, ``put a story in the local newspaper about all the good things
you are doing,'' according to a 2010 email reviewed by the Journal.
In 2014, despite complaints of understaffing, Dr. Roubideaux
dispatched 21 IHS medical staffers to West Africa to aid the U.S.
response to the Ebola outbreak, over protests of Tribal health
officials.
``If the Federal Government is going to send public health
officials anywhere it should be sending them to Indian Country,'' a
Tribal health committee wrote to Dr. Roubideaux.
Dr. Roubideaux argued the outbreak was an unprecedented epidemic.
The agency statement to the Journal said the staff was needed to help
prevent a potential U.S. outbreak.
Dr. Roubideaux, a Rosebud Tribal member and Harvard-trained doctor
who left the agency in 2015, referred inquiries from the Journal to the
IHS about what she called ``longstanding'' problems.
At a meeting of regional IHS heads in 2013 called by agency
leadership, ``we were basically told, `these are your problems, you
deal with it,' '' said Anna Whiting Sorrell, who formerly ran the IHS's
Billings, Montona-based region, where a hospital was sanctioned for
dangerous care in 2014. The agency told the Journal that the IHS's
regional chief medical officers have ``primary responsibility for
clinical issues.''
One doctor, Alida Asencio, said she was ridiculed at staff meetings
after telling the Winnebago medical director about problems in 2014.
Dr. Asencio later raised a concern about a death at the hospital with
regulators, who, documents show, concluded it was avoidable. She later
complained to top agency officials that her supervisor pressured her to
take paid leave ahead of an inspection to keep her from raising further
concerns, an email viewed by the Journal shows.
The agency said its ``leadership maintains a culture where
employees are encouraged and expected to report any reasonable
suspicion of wrongdoing, misconduct, waste, or abuse, particularly when
it involves the safety and wellbeing of patients or employees.'' It
said such disclosures can ``save lives.''
Then-U.S. Senator Mark Begich, an Alaska Democrat, said he met with
former Health and Human Services Secretary Kathleen Sebelius in 2012 to
discuss IHS concerns. He said it was clear from the conversation that
implementing the Affordable Care Act ``eclipsed things.''
Ms. Sebelius said in an interview ``it's totally appropriate for
him to say, `they just didn't do enough,' '' referring to her own
department. She said she took the IHS's failures seriously and tried to
address them by seeking more funds and improving communication with
tribes. The current Health Department secretary, Tom Price, said during
his confirmation hearing in January he was committed to turning the IHS
around.
Some people who rely on the troubled hospitals said they are afraid
to seek treatment there. Among them is the family of Tonya Drapeau, a
39-year-old mother of five from the Omaha reservation, who died
suddenly in March 2016 after a visit to the Winnebago hospital. Days
later, a government doctor wrote in a letter to an IHS official that
Ms. Drapeau's treatment ``was below the standard of care.''
Her family filed a legal claim alleging negligence in February with
the Health Department, their lawyer said, the first step in filing a
lawsuit against the U.S. Government. Medical records show Ms. Drapeau
went to Winnebago because she was having trouble breathing.
The agency's records of her past care, which medical staff reviewed
that morning, showed she had diabetes and a history of respiratory
complications. A doctor didn't check her blood sugar and sent her home
later that day with antianxiety pills.
Hours later, Ms. Drapeau's teenage son found her unconscious. The
records show she died, after being airlifted to a private hospital, of
diabetic shock.
Senator Murkowski. But again, I think when we read these as
lawmakers--and certainly as one who has oversight of IHS
through this appropriations subcommittee, but as one who serves
on the Indian Affairs Committee--this is not acceptable.
I know that oftentimes they say when it is not about the
funding, it really is about the funding. But it is about the
funding. It is about the quality of the individuals. It is
about the ability to get good people in. It is about making
sure that the infrastructure is maintained. We are not doing
right by our Native peoples and this must be remedied.
Last year, we had the Acting Director of IHS, Mary Smith,
before the subcommittee and I asked what the agency was doing
to fix the serious problems in the Great Plains region at the
Pine Ridge, Rosebud, and Winnebago hospitals, all of which were
mentioned in these ``Wall Street Journal'' articles. She
indicated at the time that the agency was committed to doing,
quote, ``whatever it takes,'' to deliver quality care.
Well, here we are. I do believe that the agency is aware,
does understand, is sincere in its desire to fix these
problems, but we cannot move from year to year and continue to
see a degradation in the services.
The Winnebago hospital has not received certification from
CMS. The Rosebud Hospital and the Pine Ridge Hospital are still
operating under System Improvement Agreements with CMS. So it
is one thing to come before the subcommittee and say, ``We are
going to try to do better.'' But we have to have better
results, and I think you know that.
In the fiscal year 2017 Omnibus Appropriations, the
subcommittee provided an additional $29 million to address
problems at these facilities.
So I would hope that today we will hear how the agency is
allocating these funds, and if there was a shortage, why you
did not request further funding for the problems that we have
seen in the Great Plains region for fiscal year 2018.
I think, again, the situation is absolutely unacceptable,
intolerable, and we need to have a clear and specific plan as
to how to address it.
So I now turn to my Ranking Member for his comments, and
then we look forward to responses from the panel and questions
from us.
STATEMENT OF SENATOR TOM UDALL
Senator Udall. Thank you, so much, Madam Chair.
And I join you on your outrage on the situation in the
Great Plains region. It is a really deplorable situation, which
we hope you can assure us that we are going to get on a path,
so we can remedy this.
I want to offer a warm welcome to the new IHS Acting
Director, Rear Admiral Michael Weahkee, who hails from New
Mexico. I believe the Zuni Pueblo. I am told that you have a
lifetime experience with the IHS system starting from the very
beginning when you were born in an IHS hospital in Shiprock,
New Mexico.
I also want to welcome Rear Admiral Chris Buchanan, IHS
Deputy Director; Mr. Gary Hartz, Director, IHS Office of
Environmental Health and Engineering; and Ms. Elizabeth Fowler,
IHS Deputy Director for Management Operations. We really look
forward to hearing from you here today.
Before we get to the budget, I want to recognize the
leadership of Senator Murkowski, who has done a tremendous job
as Chair of this subcommittee, and is someone I am really proud
to work with. Senator Murkowski, and all the Members of this
subcommittee, understands the value and importance of IHS for
all Native communities. We have made real progress to secure
funding to improve healthcare in Indian country.
I am proud of the subcommittee's work that included an
increase for IHS in the most recent Omnibus. Securing a 5
percent increase for IHS for fiscal year 2017--one of the
largest increases in the entire appropriations bill--was no
small feat. But the Members of this subcommittee believe that
these investments are critical for healthy Native communities
and families.
I look forward to continuing our work together as a
subcommittee and to continued cooperation on a bipartisan
basis.
The budget proposed by the administration for fiscal year
2018 is a complete departure from the progress we have made to
rebuild the IHS budget. This proposal would not provide the
resources needed for the health and wellbeing of American
Indians and Alaska Natives. It is wholly insufficient to
effectively serve communities in dire need of healthcare
services.
Passing the President's budget would mean less money for
inpatient services, preventive healthcare programs, drug
addiction treatment, mental health programs, and specialty
care. It would mean fewer resources to recruit and retain a
qualified workforce and to address already underfunded facility
infrastructure needs.
With a proposed overall cut to the service of $300.5
million, this budget would eviscerate the gains we made in
fiscal year 2017 by instituting a 6 percent reduction, and undo
the progress we have made to restore IHS funding levels to the
pre-2013 sequestration levels.
My experiences have taught me that healthcare in Indian
country suffers from generations of underfunding. It is
disheartening to see this administration put forward a budget
that would force entire Tribal communities to fully return to a
cruel system of healthcare rationing. Life or limb is no way to
run a hospital and no way to promote healthy Native communities
and families.
The President's proposed fiscal year 2018 budget
systematically cuts the legs out from that progress. I am
concerned and I know that Tribes are as well.
I am concerned that this budget cuts $99 million from IHS
facilities despite the Service's estimated $10 billion
construction backlog.
I am concerned that it cuts funding for hospitals and
health clinic services by $64 million.
I am concerned it cuts $22 million from mental health and
substance abuse programs.
And I am concerned it cuts $6 million from loan repayment
and scholarship programs needed to fill critical vacancies at
IHS facilities.
MEDICAID
Finally, I would quickly like to address the issue of the
larger 2018 budget and the cuts it assumes to Medicaid. For
decades, Medicaid has been a crucial program for fulfillment of
the Federal Government's trust responsibilities.
It is clear to me that any potential changes to national
policy regarding Medicaid and health insurance programs--like
those contained in the Senate Republicans' Better Care
Reconciliation Act--will directly impact Tribal communities and
Native lives.
So for the record, I would like to urge the majority on all
committees to follow regular order, hold hearings, and seek
Tribal consultation on any proposal that would cut access to
critical healthcare programs.
Now is not the time to lose ground on the progress we have
made. We know that Tribal communities can thrive when they have
adequate access to healthcare. We know that Tribal health
outcomes improve when access to quality, preventative care is
expanded, like what we have seen over the past 20 years with
the Special Diabetes Program for Indians, SDPI, and like we
have seen over the past few years with Medicaid expansion and
third party billing revenue increases.
I look forward to speaking with all of you today about how
we can do more for Indian country. And I look forward to the
work of this subcommittee to secure the resources necessary to
make this happen.
Thank you, Madam Chair.
Senator Murkowski. Thank you, Senator Udall.
At this time, we will hear from Rear Admiral Michael
Weahkee, who is, again, the Acting Director for IHS.
So do I understand correctly that the others will just be
there as back up, or will you, Rear Admiral Buchanan, or Mr.
Hartz, or Ms. Fowler be addressing the subcommittee as well?
Admiral Weahkee. Yes, ma'am. I will make the primary
comments and call on my colleagues as needed.
Senator Murkowski. Great. Thank you.
Admiral Weahkee. Thank you.
Senator Murkowski. If you will proceed, thank you.
SUMMARY STATEMENT OF REAR ADMIRAL MICHAEL WEAHKEE
Admiral Weahkee. Good morning, Madam Chairman, and Members
of the subcommittee.
As mentioned, my name is Michael Weahkee, Rear Admiral in
the U.S. Public Health Service and Acting Director of the
Indian Health Service.
I am here today with three of my colleagues, Rear Admiral
Chris Buchanan, the Permanent Deputy Director with the Indian
Health Service; Elizabeth Fowler, the Deputy Director for
Management Operations; and Gary Hartz, Director of Office of
Environmental Health and Engineering.
Today, I am providing testimony on the President's fiscal
year 2018 budget request for the Indian Health Service, which
will allow us to maintain and address our agency mission to
raise the physical, mental, social, and spiritual health of
American Indians and Alaska Natives to the highest level.
Our four agency priorities of people, partnerships,
quality, and resources put our patients at the center of
everything we do. In addition, IHS is proud of the work we are
doing in aligning with our Secretary's three health priorities
on childhood obesity, mental health, and opioids.
The IHS is responsible for providing Federal healthcare
services to approximately 2.2 million American Indians and
Alaska Natives from 567 federally recognized Tribes located in
36 States across our Nation.
Health services are provided through facilities managed
directly by the Indian Health Service, by Tribes and Tribal
organizations, and through urban Indian health programs.
Our budget plays a critical role in providing a path to
fulfill our commitment to ensure a healthier future for all
American Indians and Alaska Natives.
The fiscal year 2018 President's budget proposes a total
discretionary budget authority for IHS of $4.7 billion, which
was $59 million below the fiscal year 2017 annualized
continuing resolution. The fiscal year 2017 annualized
continuing resolution was the planning base level for this
budget.
This budget reflects the administration's high priority
commitment to protecting direct Indian healthcare investments,
and reducing IHS's overall program level by only 0.9 percent in
the context of an 18 percent reduction within the overall HHS
discretionary budget.
The budget also supports self-determination by continuing
the separate, indefinite appropriation account for Contract
Support Costs.
In order to prioritize funding for direct healthcare
services for our people, the budget includes a reduction to the
funding level for facilities infrastructure projects and
management activities of $75 million below the fiscal year 2017
annualized continuing resolution.
The IHS remains committed to addressing behavioral health
challenges including high rates of alcohol and substance abuse,
mental health disorders, and suicide in our American Indian and
Alaska Native communities. The budget for these services is
maintained at the fiscal year 2016 level for a total of $288
million.
The IHS, in partnership with Tribes, uses evidence-based
practices to reduce the incidence of preventable disease and
improve the health of individuals, families, and communities
across Indian country.
Programs such as public health nursing, health education,
and community health representatives play integral roles in
delivering culturally appropriate services to American Indians
and Alaska Natives who live in rural and isolated communities.
DIABETES
The Special Diabetes Program for Indians, or SDPI, provides
grants for evidence-based diabetes treatment and prevention
services across Indian country. Diabetes health outcomes have
improved significantly in American Indian and Alaska Native
communities since the inception of the SDPI.
Within our communities, the longtime trend of increasing
rates of diabetes ended in 2011. One of the most important
improvements has been an 8 percent reduction in the average
blood sugar level of American Indian and Alaska Natives with
diagnosed diabetes between the years 1997 and 2015.
Improved blood sugar control reduces complications from
diabetes. In addition, new cases of kidney failure due to
diabetes have declined by 54 percent among American Indians and
Alaska Native adults from 1996 to 2013.
The budget request includes $20 million to support staffing
and operating costs for two joint venture construction program
projects that include the Choctaw Nation Regional Medical
Clinic in Oklahoma and the Flandreau Health Center in South
Dakota.
The IHS, through these joint venture agreements, and
partners with Tribes to provide funds for staffing, equipment,
and operating the facilities while the Tribes invest in the
design and construction costs associated with the new
facilities.
The healthcare facilities construction budget includes
funding for three facility projects including the Alamo Health
Center in New Mexico, the Rapid City Health Center in South
Dakota, and the Dilkon Alternative Rural Health Center in
Arizona.
IHS has a lot of positive information to share about the
care we are providing throughout the system. Some examples
include launching a new pilot project to integrate trauma
informed care at IHS and Tribal facilities in conjunction with
the Pediatric Integrated Care Collaborative, which is part of
the Johns Hopkins Center for Mental Health Services.
Advancing innovation and new technologies bring emergency
medicine expertise to our emergency departments in both the
Great Plains and the Billings areas, and initiating telehealth
services in the Portland and Albuquerque areas with direct
support from the University of New Mexico's Project ECHO.
Continued implementation of our improving patient care
initiative, such as the Lawton Indian Hospital in the Oklahoma
City area, has been able to reduce their emergency room's
medium length of stay from 138 minutes down to 86 minutes.
All of our IHS areas are continually engaging in training
and accreditation readiness survey activities. For example, in
our Portland area, an area survey readiness team has been
established which includes inter-facility participation by both
chief executive officers and clinic directors to learn and
share best practices.
QUALITY FRAMEWORK
Finally, we are continuing to focus our efforts to improve
quality. In November of 2016, we launched our quality framework
to strengthen the quality of care that the IHS delivers to the
patients that we serve.
Implementation of the quality framework will strengthen
organizational capacity to improve quality of care, improve our
ability to meet and maintain accreditation for our IHS direct
service facilities, align service delivery processes to improve
the patient experience, ensure patient safety, and improve
processes and strengthen communications for early
identification of risks. This framework will be reviewed and
updated as necessary in partnership with our Tribes and other
stakeholders.
Despite all the challenges, I am firmly committed to
improving quality, safety, and access to healthcare for
American Indians and Alaska Natives in collaboration with HHS,
our partners across Indian country, and in collaboration with
Congress.
I appreciate all your efforts in helping us provide the
best possible healthcare services to the people we serve to
ensure a healthier future for all American Indians and Alaska
Natives.
Thank you.
And I am happy to answer any questions that you may have.
[The statement follows:]
Prepared Statement of Rear Admiral Michael Weahkee
Mr. Chairman and Members of the subcommittee:
Good morning. I am RADM Michael Weahkee, Acting Director of the
Indian Health Service (IHS). I am pleased to provide testimony on the
President's fiscal year 2018 budget request for the IHS, which will
allow us to maintain and address our agency mission to raise the
physical, mental, social, and spiritual health of American Indians and
Alaska Natives (AI/ANs) to the highest level. Our four agency
priorities put our patients at the center of everything we do, and
these include recruiting, developing, and retaining a dedicated,
competent, caring workforce; building, strengthening and sustaining
collaborative relationships; excellence in everything we do to assure a
high-performing Indian health system; and securing and effectively
managing the assets needed to promote the IHS mission.
The IHS, an agency within the Department of Health and Human
Services (HHS), is responsible for providing Federal health services to
approximately 2.2 million AI/ANs from 567 federally recognized Tribes
in 36 States. 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 directly by the IHS, by Tribes
and Tribal organizations under authorities of the Indian Self-
Determination and Education Assistance Act (ISDEAA), through services
purchased from private providers, and through contracts and grants
awarded to urban Indian organizations authorized by the Indian Health
Care Improvement Act.
Our budget plays a critical role in providing a path to fulfill our
commitment to ensure a healthier future for all AI/AN people and to
maintain progress made to date. The fiscal year 2018 President's budget
proposed a total discretionary budget authority for IHS of $4.7
billion, which was $59 million below the fiscal year 2017 Annualized
Continuing Resolution and proposes Program Level funding of $6.1
billion, which was $56 million below the fiscal year 2017 Annualized
Continuing Resolution. The fiscal year 2017 Annualized Continuing
Resolution was the planning base level for this budget.
prioritizing health care services
The IHS provides comprehensive healthcare, including but not
limited to primary medical services, dental care, behavioral health
services, community health services, and public health services such as
environmental health and sanitation facilities, through a network of
662 hospitals, clinics, and health stations in and near Indian
reservations. The budget reflects the administration's high priority
commitment to Indian Country, protecting direct healthcare investments
and reducing IHS's overall program level by only 0.9 percent when
compared to the Annualized Continuing Resolution, in the context of an
18 percent reduction within the overall HHS discretionary budget. In
order to prioritize funding for direct healthcare services to AI/ANs
and the staffing and operating costs for newly-constructed Joint
Venture healthcare facilities scheduled to open in fiscal year 2017,
the budget includes a reduction to the funding level for facilities
infrastructure projects and management activities of $75 million below
the fiscal year 2017 Annualized Continuing Resolution. Direct
healthcare services include outpatient and inpatient care in hospitals
and clinics, behavioral health services, and dental health services.
The budget maintains the Purchased/Referred Care program funding
that is essential for ensuring access to care by our AI/AN patients at
$914 million, which is $2 million above the fiscal year 2017 Annualized
Continuing Resolution. This program provides critical healthcare
services that IHS and tribally-managed facilities are otherwise unable
to provide through contracts with hospitals and other healthcare
providers to purchase such specialized or critical care. In addition,
it supports high cost medical care for catastrophic injuries and
specialized care.
The IHS remains committed to addressing behavioral health
challenges, including high rates of alcohol and substance abuse, mental
health disorders, and suicide in AI/AN communities. The budget for
these services is maintained at the fiscal year 2016 level for a total
of $288 million, which is $1 million above the fiscal year 2017
Annualized Continuing Resolution.
Funding for preventive health services is preserved at the fiscal
year 2016 level as well for a total of $157 million, which is $1
million above the fiscal year 2017 Annualized Continuing Resolution.
The IHS, in partnership with Tribes, uses evidence-based practices at
the local level to reduce the incidence of preventable disease, and
improve the health of individuals, families, and communities across
Indian Country. Programs such as public health nursing, health
education, and community health representatives play integral roles in
delivering culturally appropriate services to AI/ANs and ensuring
access to care for homebound patients and others who live in rural and
isolated communities.
special diabetes program for indians
The Special Diabetes Program for Indians (SDPI) provides grants for
evidence-based diabetes treatment and prevention services across Indian
Country. Diabetes health outcomes have improved significantly in AI/AN
communities since the inception of the SDPI. Within our communities,
the longtime trend of increasing rates of diabetes ended in 2011. One
of the most important improvements has been an 8 percent reduction in
the average blood sugar level of AI/ANs with diagnosed diabetes between
1997 and 2015. Improved blood sugar control reduces complications from
diabetes. In addition, new cases of kidney failure due to diabetes
declined by 54 percent among AI/AN adults from 1996 to 2013.
The SDPI grant program provides funding for diabetes treatment and
prevention to 301 Indian health, Tribal, and Urban health programs.
Most recently, the SDPI was reauthorized through September 2017.
health insurance reimbursements
The budget assumes $1.2 billion in estimated health insurance
reimbursements from third party collections. The collection of health
insurance reimbursements for the provision of care to patients covered
by Medicare, Medicaid, the Veterans Health Administration, and private
insurance allows IHS and tribally-managed programs to meet
accreditation and compliance standards and expand the provision of
healthcare services by funding staff positions, purchasing new medical
equipment, and maintaining and improving buildings.
access to quality health care services through improved infrastructure
The budget proposes $20 million for staffing of newly-constructed
healthcare facilities. This funding will support staffing and operating
costs for two Joint Venture Construction Program (JVCP) projects: the
Choctaw Nation Regional Medical Clinic in Oklahoma and the Flandreau
Health Center in South Dakota. Through JVCP agreements, the IHS
partnered with the Tribes to provide funds for staffing, equipping, and
operating the facilities while the Tribes invested in the design and
construction costs associated with the new facilities. These funds will
allow the new facilities to expand the provision of healthcare in areas
where the existing capacity is overextended.
The Health Care Facilities Construction budget includes funding for
the following three facilities projects: (1) to design the Alamo Health
Center in New Mexico, (2) to complete replacement of the Rapid City
Health Center in South Dakota, and (3) to continue construction of the
Dilkon Alternative Rural Health Center in Arizona.
supporting indian self-determination
The budget supports self-determination by continuing the separate
indefinite appropriation account for contract support costs (CSC)
through fiscal year 2018. Authorized and required by the ISDEAA, CSC
funding supports certain operational costs of Tribes and Tribal
organizations administering healthcare service programs under self-
determination contracts and self-governance compacts. The budget
includes an estimate of $718 million to fully fund CSC, which is $1
million above the fiscal year 2017 Annualized Continuing Resolution.
Maintaining the flexible funding authority of an indefinite
appropriation allows the IHS to guarantee full funding of CSC, as
required by the law, while protecting services funding for direct
services Tribes.
ihs health care
IHS has a lot of positive information to share about the care we're
providing throughout the IHS system. Some examples include: launching a
new year-long pilot project at 10 locations to integrate trauma-
informed care at IHS and tribal facilities, in conjunction with the
Pediatric Integrated Care Collaborative, part of the Johns Hopkins
Center for Mental Health Services in Pediatric Primary Care; advancing
innovation and new technologies to bring emergency medicine expertise
to emergency departments in the Great Plains and Billings Areas through
a telehealth contract and initiating telehealth services in the
Portland and Albuquerque Areas to screen, diagnose, and treat chronic
hepatitis C with direct support from the University of New Mexico's
Extension for Community Healthcare Outcomes (Project ECHO) hepatitis C
program, which has resulted in screening rates of 92 percent in the
Portland target population, up from 67 percent in 2015; and continued
implementation of the Improving Patient Care initiative, such as at the
Lawton Indian Hospital in the Oklahoma City Area which has reduced
their Emergency Room's Median Length of Stay from 138 minutes in April
of 2016 to 86 minutes in June of 2017. All Areas also continually
engage in training and accreditation survey readiness activities, with
a few notable examples. The Claremore Indian Hospital embarked on an
initiative to design a better clinical skills and competency nurse
training program in fiscal year 2016. Claremore implemented the use of
the METIMan Patient Simulator, which allows local nursing staff to
have available the most advanced physiological modeling system
incorporated into their training and competency program. Claremore
hired nurse educators with experience in clinical simulations and
integrated simulation in their curriculum in multiple locations in the
hospital. Nursing staff has reporting increased satisfaction with
clinical training since the integration of clinical simulations. The
Albuquerque Area utilizes a laboratory team made up of the Area Lab
Consultant and Service Unit Lab Supervisors to stay in continuous
readiness for laboratory accreditation. As a result, the Mescalero
Indian Hospital received national recognition and received their
National Excellence Award in 2016. In the Portland Area, an Area Survey
Readiness Team has been established which includes interfacility
participation by Chief Executive Officers and Clinical Directors to
learn and share best practices. In addition, in the Bemidji Area, the
White Earth clinic achieved the highest scores possible when it
received accreditation from the Accreditation Association for
Ambulatory Health Care.
Finally, we are continuing to focus our efforts to improve quality.
The position of Deputy Director for Quality Health Care was established
as part of the senior leadership team at Headquarters to provide
specific expertise in advising me as acting IHS Director and providing
leadership and guidance to the field on all aspects of assuring quality
healthcare. In November 2016, we launched our 2016-2017 Quality
Framework and Implementation Plan to strengthen the quality of care
that the IHS delivers to the patients we serve. Implementation of the
Quality Framework will strengthen organizational capacity to improve
quality of care, improve our ability to meet and maintain accreditation
for IHS direct service facilities, align service delivery processes to
improve the patient experience, ensure patient safety, and improve
processes and strengthen communications for early identification of
risks. This framework will be reviewed and updated as needed in
partnership with Tribes.
IHS also has worked collaboratively with HHS staff and operating
divisions to identify Department-wide strategies and resources that can
be used to address issues affecting the quality of healthcare provided
to AI/ANs served by IHS facilities. Through this work IHS was able to
leverage additional staff support for patient care and technical
assistance and accomplish policy changes that helped IHS complete
salary negotiations and relocation allowances more efficiently to
improve the recruitment process. IHS continues to actively engage with
HHS in its work to update its Strategic Plan and was an eager
participant in the Reimagine HHS work which was focused on making HHS
more effective at fulfilling its mission, more focused on serving the
American people, and a better place to work. In concert with these
activities, IHS is seeking to implement innovative approaches to
delivering and improving healthcare, identifying areas where regulatory
reform can facilitate IHS' processes, and strengthening our structure
to carry out our mission more effectively and efficiently.
Despite all of the challenges, I am firmly committed to improving
quality, safety, and access to healthcare for American Indians and
Alaska Natives, in collaboration with HHS, our partners across Indian
Country, and Congress. I appreciate all your efforts in helping us
provide the best possible healthcare services to the people we serve to
ensure a healthier future for all American Indians and Alaska Natives.
Thank you and I am happy to answer any questions you may have.
Senator Murkowski. Thank you, Rear Admiral.
I know that your job is to defend this budget, but I just
have to say wow. After listening to that, I would think that we
do not have a problem within the IHS system. That we do not
have a scenario as was described in these two recent articles
from just last week with regards to the facilities,
particularly in the Great Plains.
You say that the goal here is to improve the patient
experience. Well, the experience is people are dying in these
facilities. So to suggest that all is good and that you can
have a budget that is sufficient from a facilities' perspective
or otherwise, if we take it back to the fiscal year 2016
levels, I just find quite stunning.
We need you to be the advocate for those within the IHS
system. I know that everyone within the administration has to
walk that fine line where you have a budget proposal that is
presented to you.
But I guess I would ask the question, have you read these
two articles that I referenced from the ``Wall Street Journal''
from last week?
Admiral Weahkee. Yes, ma'am. I have.
Senator Murkowski. Do you think that those reflect
accurately some of what we have seen at these facilities in the
Great Plains regions?
Admiral Weahkee. Ma'am, I had the opportunity on my second
day on the job at the request of Secretary Price, to travel to
Pine Ridge, and do a firsthand assessment of the situation, and
what the progress has been like.
Senator Murkowski. And what did you see there at Pine
Ridge?
Admiral Weahkee. I definitely saw a committed, caring
workforce who has been working hard to address the issues that
have been identified by CMS. They are making significant
improvements in their quality assurance and performance
improvements, and their oversight of the emergency departments.
They work with the area office to ensure governance is
monitoring the right things.
I took that trip also with some objective reviewers, the
Acting Surgeon General, Rear Admiral Sylvia Trent-Adams, also
accompanied me on that visit. And we provided a firsthand
account of our findings back to the Secretary, who asked that I
convey to the subcommittee his commitment to improving the
Indian Health Service.
Senator Murkowski. Do you think that you can keep that
commitment and he can keep that commitment to improving the
Indian Health Service with the funding levels that are proposed
within this budget here?
Admiral Weahkee. Well, ma'am, we see the budget as an
initial proposal, but we are open to working with you and
others to identify and help meet the needs of our American
Indian and Alaska Native people.
Senator Murkowski. Well, I want to work with you. Know that
that is sincere and I think that is so with every other Member
of this subcommittee.
But I guess I am a little bit--no, I am not a little bit--I
am really concerned with the situation that has been clearly
articulated in the fiscal year 2017 budget. We said, ``Look. We
have issues in the Great Plains with Winnebago, with Pine
Ridge, with Rosebud.'' There was specific funding that was
directed for these accreditation emergencies.
Again, it is my understanding that we still have not seen
the recertification from CMS. The Winnebago, the Rosebud, and
the Pine Ridge hospitals are still operating under this system
improvement agreement. And so, I am wondering, has that $29
million----
You have indicated that you are seeing some progress there
at Pine Ridge. But you have not come to us with a request for
additional funding to address any of these discrepancies with
fiscal year 2018.
Do you think that you can address what you need to address,
and again, given the reductions that we are seeing in this
budget for these accounts?
Admiral Weahkee. The IHS really appreciates the funding
that was provided in the 2017 budget for accreditation
emergencies. We are using those funds to support contracts,
national contracts to address credentialing, national contracts
for accreditation. We know that the challenges will persist.
Senator Murkowski. Is the $29 million that you received
last year sufficient to do what it is that we asked you to do
within that Omnibus bill?
Admiral Weahkee. IHS is committed to patient safety and the
quality of healthcare.
Senator Murkowski. Right. But is the $29 million sufficient
for you to do the job that we need you to do, and that those
who receive services there at these facilities expect and
deserve?
Admiral Weahkee. We are focusing a lot of efforts in the
three locations that you have identified: Rapid City, or I am
sorry, Pine Ridge, Rosebud, and Omaha Winnebago.
A lot of the changes that we are making to the system
overall are a result of what we have found in the improvement
work that we have really focused in those areas.
We have experts from the Oklahoma City area, from Phoenix,
from the Portland area repositioned and really working directly
with those programs to implement best practices. Not only from
other parts of the IHS, but from our Tribal programs like the
South Central Foundation, the Nuka Institute, implementing
patient-centered medical homes and care teams.
So we appreciate the resources that are dedicated to
helping us address these issues.
Senator Murkowski. Well, sir, you have not directly
answered the question whether or not we have provided you with
sufficient resources. That is what this subcommittee does as
the appropriation subcommittee for the Interior for oversight
of IHS.
We want to help you. We want to know that you have the
resources that you need because it is my assumption that the
three that I am highlighting here--Rosebud, Pine Ridge, and
Winnebago--are just the ones that make the ``Wall Street
Journal''. That there are other facilities; I know that there
are other facilities.
In Alaska, we are a different model, a different system.
And I think you know, certainly my colleagues here know that
usually I am laser focused on the situation in Alaska. But I
cannot stand down knowing that our system is failing so many of
our Native people around the country.
So we want to help you, but we need to know how we can best
facilitate that. So this conversation will continue.
I will turn to my colleague, Senator Udall.
Senator Udall. Thank you, Madam Chair.
Admiral, I want to quickly raise a process concern. It is a
longstanding practice for Members of this subcommittee of both
parties to request information from your department.
PURCHASED REFERRED CARE
Can you confirm that you will continue the longstanding
practice of responding to all questions, including written
correspondence, from both majority and minority Members of this
subcommittee as quickly as possible?
Admiral Weahkee. Yes, sir. Absolutely, we will work with
you very closely in helping fulfill it.
Senator Udall. Thank you very much.
This budget reduces funding for purchased and referred care
by over $14 million. I have heard from many Tribes, who are
rightfully very concerned, about the ability of IHS to continue
serving patients above Medical Priority Level One. They are
concerned about returning to an era of IHS healthcare
rationing.
This question is for Ms. Fowler. Do you have an estimate of
the total amount of reimbursement IHS facilities have received
due to the Medicaid expansion?
Ms. Fowler. Thank you for the question.
I do not have the specific amount that is due specifically
to Medicaid expansion, but we can provide some additional
follow up for you on that.
Senator Udall. Will you give me those numbers, please?
Ms. Fowler. To the extent that we have it available.
Senator Udall. Yes. Well, I know in previous testimony with
Admiral Buchanan, the discussion was about a significant amount
of resources coming in as a result of Medicaid expansion. And
so, I really want to have those numbers.
[The information follows:]
total amount of reimbursements ihs facilities have received due to
medicaid expansion
The Indian Health Service (IHS) reported a total of $807.6 million
in Medicaid reimbursements during fiscal year 2016. The table provided
below shows an upward trend in Medicaid collections from fiscal year
2012 to fiscal year 2016.
Note: Medicaid Collections in this chart include Tribal collection
estimates from the Centers for Medicare & Medicaid Services (CMS) and
Tribal collection estimates due to direct billing between fiscal year
2002-fiscal year 2015.
The IHS is unable to identify which patients became eligible as a
result of Medicaid expansion on or after January 1, 2014. Therefore,
the IHS cannot determine how much of the increase in Medicaid
reimbursements is directly attributable to services provided to:
--Patients in the new ``expansion'' categories;
--Patients in ``restoration'' categories (in States where enrollment
in certain eligibility categories was frozen prior to Medicaid
expansion);
--Patients who may have previously been eligible but not enrolled
prior to January 1, 2014, and,
--Previously enrolled patients.
For additional details regarding Medicaid, expenditure reports from
the CMS known as the ``CMS 64 Reports'' for fiscal year 2013-fiscal
year 2016 are enclosed. The reports include Federal reimbursement to
State Medicaid programs for services eligible for 100 percent Federal
Medical Assistance Percentages which are provided by IHS and Tribal
Health Programs operated under Public Law 93-638, the Indian Self-
Determination and Education Assistance Act. States may request
adjustments in expenditures up to 2 years after the respective quarter
of expenditures. These reports were updated as of August 7, 2017.
Senator Udall. Admiral Weahkee, do you have anything to add
there in terms of specifically the amount of money because of
the Medicaid expansion?
Admiral Weahkee. Sir, not with specificity, but my job
prior to coming into this role was as a CEO at the hospital
level.
I know that we rely very heavily on our third party
collections not only Medicaid, but Medicare, private insurance,
and V.A. reimbursements as well to help meet the needs of our
patients.
Senator Udall. Yes.
Ms. Fowler, how many IHS service units used Medicaid
expansion to provide services at Medical Priority Level 2 or
higher in fiscal year 2016?
Ms. Fowler. In 2016, 47 out of 67 Federal PRC programs were
able to fund care at Priority 2 and lower.
Senator Udall. Thank you.
If Medicaid expansion funding were eliminated, how much
additional purchased and referred care appropriations funding
would IHS need to maintain care above Medical Priority Level 1?
Ms. Fowler. That is a difficult question to answer. Again,
attributing the amount to patients who were eligible for
Medicaid as a result of Medicaid expansion is the key there.
And I do not believe that we have information data that goes to
that level of specificity, but we can certainly see what
information we do have and provide that to you and follow up.
Senator Udall. Thank you very much. Please do that for the
record.
[The information follows:]
amount of additional purchased and referred care appropriations funding
needed to maintain care above medical priority level i if medicaid
expansion funding were eliminated
The Indian Health Service (IHS) cannot reasonably determine the
additional amount of appropriated Purchased/Referred Care (PRC) funding
that might be needed to maintain or provide healthcare services beyond
Medical Priority Level I (life or limb threatening) if Medicaid
expansion were eliminated. This is because American Indian and Alaska
Native patients eligible for Medicaid do not need a PRC referral to
access care. In the case of Medicaid eligible patients, Medicaid
reimburses the private provider in full and there is no cost sharing
for the beneficiary or the PRC program. Since a referral or request for
service is not required and patients often go on their own to Medicaid
providers, the IHS is unable to track these instances when Medicaid is
the payer instead of the PRC program.
Senator Udall. As all of you know, there used to be a
saying in the Indian Health Service, ``Do not get sick after
June,'' and that is because we ran out of money in this
purchased and referred care item. And so my belief is that is
no way to run a hospital and a healthcare system.
So we need to make sure that we try to do the very best and
I think that is the same theme that Senator Murkowski has
pushed here today.
Republican proposals to repeal Medicaid expansion, along
with the ACA, would clearly have direct and dramatic impacts on
the Indian Health Service.
Admiral Weahkee, can you please answer me with a simple yes
or no to the following question? Have you, or any of your
staff, at IHS been contacted by House or Senate Republican
Leadership or the White House, requesting consultation or
technical assistance for various drafts of Trumpcare?
Admiral Weahkee. Not to my knowledge, sir. Again, this is
my third week on the job and I am not aware of any requests for
information at this point.
Senator Udall. Admiral Buchanan, would you answer that
question?
Admiral Buchanan. Not to my knowledge either.
Senator Udall. Thank you.
As mentioned in my opening, I am concerned this budget
proposal would cut more than $12 million from these line items,
that is, mental health and substance abuse. This steep cut to
an already underfunded line item would be particularly
devastating if combined with the repeal of Federal essential
health benefit requirements, like the BCRA that requires
Medicaid and insurance coverage of these critical services.
Can you tell me what mental health and substance abuse
services would be cut if this $12 million decrease were
enacted?
BEHAVIORAL HEALTH
Admiral Weahkee. I have information in terms of some of the
work that we are doing in behavioral health. We are funding
substance abuse and suicide prevention grants. We are funding
domestic violence prevention programs.
We are very close to announcing the next round of substance
abuse grantees. I believe we have it in the range of 30 of
them. Many of those successful grantees are from the State of
Alaska. We will soon be putting another solicitation out for
domestic violence. I think we have funding for an additional 20
in terms of the specifics about impacts with the changes.
I may have to defer here on this one to Ms. Fowler, if she
has any thoughts on that.
Ms. Fowler. I would just say that as Admiral Weahkee has
already indicated that we view this budget as an initial
proposal. So we would hope to work with you on adjusting the
needs particularly for our behavioral health services.
Senator Udall. Yes. Well, I do not have any doubt that if
you are cutting $12 million out of mental health and substance
abuse treatment that people are going to lose services, and we
are going to be in a worse situation.
Thank you, Madam Chair.
Senator Murkowski. Senator Van Hollen.
Senator Van Hollen. Thank you, Madam Chair.
Thank you and the Ranking Member for your leadership on
this issue as I welcome everybody.
The Indian Health Service has major facilities in the State
of Maryland, in Rockville, in the State of Maryland and I look
forward to working with all of you going forward.
I have to say I have been appalled in preparing for this
hearing and reading the articles that Senator Murkowski
referenced. What is even more appalling is that if you do a
little work, you realize that this has been a chronic issue.
Right? I mean, there have been hearings in the Congress dating
back many, many years that focused a spotlight on this issue
and yet, it does not seem to be getting any better.
With all respect, Admiral, I understand you are recently
appointed here in terms of your current capacity, but I think
you were obviously given a particular budget.
I think what this committee needs is information from all
of you, facts, so we can evaluate the impact. And so, I would
appreciate it if you would get us some information, first of
all, regarding the impact of the proposed Medicaid cuts.
As I looked at the sources of revenue for a lot of the
healthcare services provided by the Indian Health Service, you
have a number of third party payers. The largest, by far, is
Medicaid. Over 60 percent, I believe, of the payments for
services rendered.
Is that correct?
Admiral Weahkee. Yes, sir.
Senator Van Hollen. All right. So if you could please give
us an analysis of what the impact of the current proposal here
in the Senate with respect to this so-called healthcare bill,
which would cut over $770 billion from Medicaid would be, plus
the $600 billion additional cut proposed in the budget that has
been submitted by the Trump administration. That is $1.4
trillion overall. And the Indian Health Service more than most
other agencies is highly dependent on those Medicaid funds.
So can you commit to providing us with an analysis of your
assessment of what the impact of those cuts would be on your
ability to provide healthcare both in the physical health area,
but also importantly in the behavioral health area? Could you
give us that information and that analysis?
Admiral Weahkee. We will undertake that assessment and
provide you with the information. Look forward to partnering
with you.
[The information follows:]
analysis of what the impact of cuts to the budget would have on the
physical health area and the behavioral health area
The fiscal year 2018 President's budget reflects the
administration's high priority commitment to Indian Country, protecting
direct healthcare investments and reducing IHS's overall program level
by only 0.9 percent when compared to the Annualized Continuing
Resolution, in the context of an 18 percent reduction within the
overall HHS discretionary budget. Therefore, difficult decisions at the
Department and across the Federal Government were required to ensure
fiscal responsibility and long-term sustainability. The IHS remains
dedicated to the mission and will continue to prioritize funding for
direct healthcare services.
Please refer to the enclosed table that provides a comparison of
the fiscal year 2017 enacted funding level and the proposed fiscal year
2018 budget. Reductions to IHS funding levels may result in the
reduction or elimination of programs.
In addition, some aging healthcare equipment may need to be used
well beyond recommended replacement cycles in order to prioritize
funding for repair or replacement of only the most critical equipment
necessary for safe patient care. Most IHS healthcare sites supplement
their annual medical equipment funds with collections to replace
medical equipment. IHS healthcare sites with more robust collections
have the resources available to purchase medical equipment at a greater
rate. Other sites may need to pool resources over a few years.
Senator Van Hollen. I would appreciate that.
I also think it is important that in addition to those
cuts, we get an assessment, a factual assessment, of the impact
of the proposed cuts to your specific budget, the $300 million
cut. Because I know on a bipartisan basis, Members of the
Senate and the House have worked to try to address some of
those issues and provide additional resources to avoid the kind
of problems that we are seeing.
I agree with Senator Murkowski, I think the ``Wall Street
Journal'' decided to look at three particular facilities, but
my guess is if you are seeing such chronic problems at these
three, if they were to do an investigation of some of the other
sites, we would uncover some more issues.
So I know you believe in your mission. I think our mission
is to try to make sure we get the information necessary so we
can make reasonable judgments about resources. And so your
analysis, you have the information with respect to how much
received from Medicaid, and so I would very much appreciate it
if you could give us that analysis. Just the facts.
Can you do that?
Admiral Weahkee. Thank you, sir. Yes, sir.
[The information follows:]
FACTUAL ASSESSMENT OF THE IMPACT OF CUTS TO THE SPECIFIC IHS BUDGET
[Dollars in thousands]
----------------------------------------------------------------------------------------------------------------
Fiscal Year Fiscal Year
Fiscal Year 2018 2017 +/-
Program 2017 Enacted President's Fiscal Year Notes
Budget 2018
----------------------------------------------------------------------------------------------------------------
SERVICES
Hospitals & Health Clinics............ $1,935,178 $1,870,405 ($64,773) Loss of $1 million
Prescription Drug
Monitoring, $4 million
Domestic Violence
Prevention Program, $27
million Accreditation
Emergency Fund, $9
million Tribal Clinic
Leases, $21 million
Current Services; and a
reduction of $1.6
million to offset the
funding request for
Staffing New Facilities
Dental Services....................... $182,597 $179,751 ($2,846) Loss of Current Services
Mental Health......................... $94,080 $82,654 ($11,426) Loss of $6.9 million
Behavioral Health
Integration, $3.6
million Zero Suicide,
and $942,000 Current
Services
Alcohol & Substance Abuse............. $218,353 $205,593 ($12,760) Loss of $6.5 million
Generation Indigenous
(Substance Abuse and
Suicide Prevention
Program), $1.8 million
Youth Aftercare Pilots,
$2 million
Detoxification
Services, and $2.5
million Current
Services
Purchased/Referred Care............... $928,830 $914,139 ($14,691) Loss of Current Services
-------------------------------------------------------------------------
Total, Clinical Services.......... $3,359,038 $3,252,542 ($106,496)
Public Health Nursing................. $78,701 $77,498 ($1,203) Loss of Current Services
Health Education...................... $18,663 $18,313 ($350) Loss of Current Services
Community Health Representatives...... $60,325 $58,906 ($1,419) Loss of Current Services
Immunization AK....................... $2,041 $1,950 ($91) Loss of Current Services
-------------------------------------------------------------------------
Total, Preventive Health.......... $159,730 $156,667 ($3,063)
Urban Health.......................... $47,678 $44,741 ($2,937) Loss of $1.1 million
Program Increase and
$1.8 million Current
Services
Indian Health Professions............. $49,345 $43,342 ($6,003) Loss of $500,000 Program
Increase and $503,000
Current Services; and a
reduction of $5 million
to offset the funding
request for Staffing
New Facilities
Tribal Management Grants.............. $2,465 $0 ($2,465) Loss of $23,000 Current
Services and a
reduction of $2.4
million to offset the
funding request for
Staffing New Facilities
Direct Operations..................... $70,420 $72,338 $1,918
Self-Governance....................... $5,786 $4,735 ($1,051) Loss of $51,000 Current
Services and a
reduction of $1 million
to offset the funding
request for Staffing
New Facilities
-------------------------------------------------------------------------
Total, Other Services............. $175,694 $165,156 ($10,538)
-------------------------------------------------------------------------
TOTAL, SERVICES....................... $3,694,462 $3,574,365 ($120,097)
=========================================================================
CONTRACT SUPPORT COSTS
TOTAL, CONTRACT SUPPORT COSTS......... $800,000 $717,970 ($82,030) Reflects estimated CSC
need at the time the
President's budget was
submitted
=========================================================================
FACILITIES
Maintenance & Improvement............. $75,745 $60,000 ($15,745) Program reduction,
results in only 85
percent sustainment of
M&I needs
Sanitation Facilities Construction.... $101,772 $75,423 ($26,349) Program reduction,
decreases the number of
sanitation programs
that can be funded
Health Care Facilities Construction... $117,991 $100,000 ($17,991) Program reduction.
Annual funding at this
level increases the
length of time needed
to complete the
``grandfathered''
priority list of
facilities
Facilities & Environmental Health $226,950 $192,022 ($34,928) Program reduction,
Support. results in the need to
redirect funding from
other sources (e.g.,
third party
collections) to fund
FTEs
Equipment............................. $22,966 $19,511 ($3,455) Program reduction,
results in decreased
equipment distributions
and increased usage of
equipment beyond
recommended lifecycle
refresh periods
-------------------------------------------------------------------------
TOTAL, FACILITIES................. $545,424 $446,956 ($98,468)
=========================================================================
TOTAL, BUDGET AUTHORITY............... $5,039,886 $4,739,291 ($300,595)
----------------------------------------------------------------------------------------------------------------
Senator Van Hollen. Thank you.
Senator Murkowski. Senator Van Hollen, thank you for
raising that.
Admiral, I would add to Senator Van Hollen's request that
you provide us with this level of detail, but that you do it on
a very expedited basis.
As we all know, the current subject of discussion right
now, we are going to have a new discussion draft that will be
laid down supposedly on Thursday. I am not certain what it will
entail, but I have been unable to get from Health and Social
Services this break down as to how IHS is impacted by the
various proposals to cut Medicaid. Medicaid expansion is one
aspect of it.
But I am told that they cannot separate out the numbers
insofar as the various categories within Medicaid, whether it
is children, those with disabilities, or seniors. I am asking,
I think, a very fair and legitimate question.
If you do not have the numbers and the data between IHS and
Health and Social Services, how can I do a fair assessment as
to the impact of these proposals on our Alaska Native people or
our American Indians, our Native people in the country?
So I have asked for these numbers from Health and Social
Services. You now have a formal request from the subcommittee.
But we would ask that you do it on a very expedited basis
because it is imperative that we have this understanding.
Senator Tester.
Senator Tester. Thank you, Madam Chair. Could I get my time
set back?
Senator Murkowski. You have it.
Senator Tester. I just want to make sure.
Senator Murkowski. That is your introduction.
Senator Tester. Thank you very much.
Well, first of all, thank you for coming.
Rear Admiral, when I was looking at your bio, you worked at
IHS facility in Phoenix.
Is that correct?
Admiral Weahkee. Yes, sir.
Senator Tester. And then you worked in the IHS, I assume,
here in DC Clinical and Prevention Services, manager of Policy
and Internal Control Staff.
Is that correct? Anything else you would like to add to
that resume that is particularly pertinent here?
Admiral Weahkee. I think important to my upbringing, if you
will, is 6 years spent with the California Tribes getting a
perspective on the other side.
Senator Tester. So I do not think any of the things that
have been brought up here today by the Chairman, or Ranking
Member, or Senator Van Hollen should be a surprise to you. You
probably have lived it. We have not.
And so when we talk about inadequate facilities, or not
having enough staff, or dealing with behavioral health, this is
not new to you. Right?
Admiral Weahkee. Our agency has many challenges.
Senator Tester. I am talking about you personally. It is
not new to you.
Admiral Weahkee. I have made a career serving my people.
Yes, sir.
Senator Tester. Were you told not to answer any questions
here, by the way?
Admiral Weahkee. No, no.
Senator Tester. Okay. Because I think it is absolutely
unbelievable that you cannot separate how much money that
Medicaid has helped you with third party billing.
I mean, to the point where I think we should almost demand
an audit because that is not how things work and you should
have those numbers at the tip of your tongue, to be honest with
you. If we are going to make policy here, we have to figure out
what the impacts of that policy are going to be. And, by the
way, it is your agency that deals with Indian health, nothing
else. And so, we have to have it.
I do not mean to lecture to you, but have you had a chance
to do an assessment on what the needs are during your 3 weeks
at IHS?
Admiral Weahkee. I have been able to leverage a lot of work
that has been done prior.
Senator Tester. What would you say is the number one need
is in IHS right now?
Admiral Weahkee. Absolutely, it is shoring up our
longstanding vacancies in some key leadership positions.
Senator Tester. So it is people.
Admiral Weahkee. People. Yes, sir.
Senator Tester. What does this budget do to your ability to
hire staff?
Admiral Weahkee. We have a lot of efforts underway.
Senator Tester. Is there an increase in dollars for hiring
staff or a decrease?
Admiral Weahkee. We prioritized maintaining direct care
services.
Senator Tester. As far as total dollars go, is there an
increase in dollars for hiring staff or a decrease?
Admiral Weahkee. Our priority has been on ensuring that we
can continue direct care services.
Senator Tester. That is not my question. You said it is the
number one issue facing. I agree with you, by the way.
So does the budget, does it increase the number of dollars
for hiring people or is it a decrease? I would assume you would
know that.
Admiral Weahkee. Well, sir, we had to make a lot of tough
decisions.
Senator Tester. Okay. So it is a decrease. Is that what you
are saying?
Admiral Weahkee. No, sir. I did not say that.
Senator Tester. So is it? Come on, man. I mean, just answer
the question. I will back you if the administration comes after
you, but is it an increase or a decrease?
Admiral Weahkee. We really prioritize----
Senator Tester. No, no, no, no. Come on.
Admiral Weahkee [continuing]. Our direct services.
Senator Tester. Really? I mean, I am on your side. Okay? I
am a former Chairman of Indian Affairs Committee, former
Ranking Member. I have been on this subcommittee now for 8
years. Just tell me if it is an increase or a decrease. It is
that simple.
Admiral Weahkee. Well, sir, looking at our line items, our
priority has been to ensure that we can continue to provide
direct healthcare services, and those funds had been
prioritized and maintained at the levels that we can ensure
that we do not have to decrease the level of service.
Senator Tester. And that is your answer.
Admiral Weahkee. That is my answer. Yes, sir.
Senator Tester. Wow. I am not even going to go into
facilities. I am not going to go into what is going on with
mental health. I am not going to go into what is going on with
the problem with drugs.
I will tell you that with the previous IHS staff, I
remember giving a speech similar to what the Chairman did, and
that is if you guys do not advocate for a budget, how are we
supposed to fix it?
I have never had in 10 years on this subcommittee, I have
never had somebody come up here and when I asked them a direct
question, they do not answer it.
I asked you a direct question on whether this budget was up
or down, and you would not answer. You refused to answer it.
That is totally unacceptable. I did not come in here with my
hair on fire, but I am leaving here with it.
I am going to tell you something. Indian Health Service is
in a crisis and if you have served in Indian Health Service for
10 years, and you have answered the questions in Indian Health
Service like you have here today, it is no wonder that it is in
crisis.
I cannot believe what has transpired in this hearing today.
All I want is some answers. That is it. And if we cannot get
answers from Indian Health, where do we go to get those
answers? I do not expect you to answer that either.
This is an unbelievable hearing. I just have to tell you. I
have not had one like this in my tenure in here. When I ask a
question, I want an answer. It is unbelievable.
Senator Murkowski. Thank you, Senator. I think all of us
share the frustration.
Senator Hoeven.
Senator Hoeven. Thank you, Madam Chairman.
Admiral, pronounce your last name for me, please.
Admiral Weahkee. It is Weahkee.
Senator Hoeven. Weahkee.
GAO
Earlier this year, the GAO released a report on Government
agencies that were at high risk for financial waste, fraud, and
abuse. IHS was listed as one of them. As part of the report,
GAO made recommendations for IHS to address these shortcomings.
On June 13, the Deputy Acting Director, Admiral Chris
Buchanan, who is also here today, came before the Indian
Affairs Committee and committed IHS to implementing the
recommendations in a timely manner from that GAO report.
Can you share with the subcommittee what recommendations
from GAO have been implemented and do you have a timeline when
outstanding recommendations will be put in place? And that is
both for you and for Admiral Buchanan.
Admiral Weahkee. Thank you, Senator Hoeven.
I will take the good news first, which is we are happy to
identify that just last week, we have submitted recommendations
to close four of those outstanding GAO reports.
And I would like to ask Admiral Buchanan to talk a little
bit more with some specificity about those GAO reports.
Admiral Buchanan. Thank you and appreciate the opportunity
to respond.
As Admiral Weahkee had mentioned, four of the nine reports
have been submitted for closure. Of those, there are about
roughly 14 specific recommendations. Of those, seven we are
recommending closure. Where we have implemented one, we did not
agree with the recommendation and the other eight, I believe,
are in the process of closure.
So with the anticipated timeline, by the end of this year,
I believe, there is opportunity to close out those other opened
recommendations.
Senator Hoeven. So one more time, take me through how many
have been closed out and how many are still in process?
Admiral Buchanan. Okay. Seven have been recommended for
closure to GAO. One is not, we did not agree with GAO
recommendations. And the other eight, I believe, are still in
process.
Senator Hoeven. Okay. And your timeline on those is by the
end of this year?
Admiral Buchanan. Anticipated by the end of this year.
Right.
Senator Hoeven. And as we discussed at our last Indian
Affairs Committee hearing where you were present, I am going to
ask you to appear for the committee again.
We had looked at possibly doing it in July. Based on the
schedule now, we may do it in early August or the first part of
September. And then we are going to want a detailed report on
the closed items and then also on the pending items.
Admiral Buchanan. Definitely.
Senator Hoeven. Okay. And we will ask you to appear.
IHS CREDENTIALING SYSTEM
One of the challenges I have learned, regarding IHS
personnel, is the credentialing system the agency employs.
While it is necessary to ensure that IHS healthcare providers
have the proper qualifications, the credentialing process has
been reported as cumbersome and deters qualified healthcare
professionals, who are in good standing with their States'
medical boards, from offering their services in Indian country.
We want to get more health services out in Indian country, so
this is a problem.
Has IHS taken actions to streamline the credentialing
process? And if not, what are you doing and what can you do to
get more healthcare providers, as well as volunteers, to come
out in some of these underserved areas in Indian country?
Again, Admiral Weahkee, I will start with you, and then ask
for Admiral Buchanan to respond as well.
Admiral Weahkee. Thank you, sir. I appreciate the question.
The credentialing issue has been undertaken as part of our
quality framework and we have launched a national system to
credential healthcare providers across all of IHS,
standardizing and increasing process efficiency to shorten the
time that it takes to get providers in, and to help ensure that
problem providers are not credentialed anywhere else in the
IHS.
We have recently contracted with a software company to
purchase a system for the entire agency. We have taken a phased
implementation. We have started with four pilot sites to work
out the bugs, and we anticipate to have that new credentialing
system completely implemented agency-wide by the end of the
year.
I will turn to Admiral Buchanan, if he has anything else to
add.
Admiral Buchanan. Yes, just the quality framework is at the
forefront of everything that we have been doing related to
organizational capacity, recruitment and retention activities.
We have been actively involved in several of those,
including global recruitment activities. We have some programs
that we are working on. We are working with some postgraduate
training activities to increase our access. We are showing, as
I mentioned, the global recruitment, a lot of promise in being
able to put out one announcement and have multiple applications
from across the country.
Another activity that we have been doing is with the
Commissioned Corps related to what I have been calling, or what
the agency has been calling, we have been talking about is
first dibs. Meaning that people interested in applying to the
Commissioned Corps are given priority to Great Plains,
Billings, and Navajo.
So those are just a couple of additional items that I would
like to add.
Senator Hoeven. Well, again, I want to emphasize the
importance because of our need to get qualified healthcare
professionals out in Indian country. As well as to take
advantage of volunteers, for example, in dentistry and other
areas; to get healthcare professionals out there doing
healthcare on a voluntary basis as well. So this is very
important and it needs to be completed so that we can get more
people out providing those services.
I have your commitment that you are going to make this an
absolute priority?
Admiral Weahkee. Yes, sir.
Senator Hoeven. Thank you.
Senator Murkowski. Thank you, Senator Hoeven.
Just to continue on with the recruitment and retention
issues. What is the current turnover rate with physicians
within IHS right now?
Admiral Weahkee. We are looking at between an 11 and 13
percent turnover rate currently, agency wide.
Senator Murkowski. Agency wide. And so, it was a difficult
exchange with you and Senator Tester there in terms of the
impact that this budget will have on your ability to recruit
and retain.
I think we all recognize that this has got to be a
priority. You have just given Senator Hoeven a commitment that
you will retain this as a priority.
Do you have the flexibility within IHS to offer competitive
salaries? Is that part of our issue?
Admiral Weahkee. We have a lot of tools in our tool belt,
our abilities to provide recruitment retention incentives. We
use the Federal system.
Senator Murkowski. Is salary a primary barrier?
Admiral Weahkee. We have been able to attract some of the
very best of the best. Some of my colleagues in the IHS are at
the top of their profession, top of their game.
I think it is not so much an inability to recruit the best
of the best. It is recruiting enough of the best of the best.
Senator Murkowski. Well, and it is also retention because
when you have turn over like this, it is one thing to get folks
out there. It is another thing to keep them.
I know in Alaska, housing is a big consideration. You go
out to many of our areas and there is no housing available. You
have your physicians that are effectively living in the
hospitals, living in the clinics.
How big of an issue is housing, for instance, in the Great
Plains areas that I was speaking about earlier in an effort to
recruit and retain your professionals?
HOUSING
Admiral Weahkee. Yes, ma'am.
I had the opportunity last year to live in Rosebud myself
for 5 months and to really assess the situation. Housing is
definitely a concern in Rosebud, Pine Ridge, and other rural,
remote locations.
Senator Murkowski. What are you doing to address that?
Admiral Weahkee. I know that we have been able to, with
resources provided, start to look at some innovative designs
and building some hotel-type facilities. Specifically, in Pine
Ridge and Rosebud, we have some 19-unit construction projects
that are underway.
I would like to ask if Mr. Hartz, who is our facility
construction expert, can weigh in more.
Senator Murkowski. Please.
Mr. Hartz. Thank you, Admiral Weahkee and thank you,
Senator Murkowski. Good to see you again.
What you have identified is definitely a need across all of
Indian country. In this past year, we have provided resources
to construct the apartment type complexes for permanent single
family, two bedroom units, as well as for itinerant people
coming into Pine Ridge, Rosebud, Chinle, and Crown Point on the
Navajo Reservation, also addressing some issues in the Hopi
Reservation.
With the resources that you folks provided to us in fiscal
year 2017, we are going to distribute money--I was going to say
we might have already even distributed it but--money will be
distributed to the three primary areas that have the greatest
need for housing and that is Alaska, Great Plains, and Navajo.
So we will be providing those resources from 2017 for that
purpose.
It relates back to ``build it and they will come,'' whether
it is in healthcare facility construction, whether it is having
the ability to house people in quarters that are not 60 years
old. It makes a difference.
Even the Senator who has left may acknowledge, but the best
program in the country is at the University of North Dakota
that has the INMED program. That school has graduated more
physicians, Indian physicians, than any other institution in
this country. And we have many, many of them across the
infrastructure of Indian healthcare delivery, Tribal and
Federal.
Housing need is something that we are addressing. We thank
you for the partnership of assisting us in getting those
quarters out there, and we will continue to do that in any way
we can.
We are even looking at the HUD program under Section 184
and whether there are ways we can develop private, Tribal, and
Federal partnerships to come up with a way to further
supplement this need that exists across Indian country.
Senator Murkowski. Well, and I think that is an important
part of what we need to look to when we try to understand what
is going on with recruitment and retention.
If you are out in the area where there is no housing or
where the housing is so substandard, there is a lot of
competition for doctors all over the country.
Mr. Hartz. Right.
Senator Murkowski. And it is not just within IHS. We are
still trying to get doctors within the V.A. system. We are
trying to get doctors throughout and so things like housing are
important.
But it takes me back to the budget that we are looking at.
This budget request proposes an 18 percent cut to the
facilities program. So whether we are talking about housing
initiatives, or recognizing that the facilities that are aiming
to meet the needs of our Native peoples are roughly four times
the age of their private sector counterparts, you have a
maintenance backlog that is also over half a billion dollars.
So I understand. I am on the appropriations committee. I
understand that we have an administration that is trying to
rein in our spending. We need to do that. We need to be
responsible to it, but we also have a trust responsibility to
our Native people. In order to meet that, we need to make
appropriate investments and those appropriate investments are
being overlooked, I think, in this budget.
I do not see that with this large backlog of construction
and maintenance projects we have that we can continue to do the
good work that I think you have outlined, Mr. Hartz. We are
making some progress.
How do we continue that progress when you have an 18
percent cut in your facilities budget here? Does anybody have
an answer? Mr. Hartz.
Mr. Hartz. Some people may say I have been around too long,
but I have seen a lot. As the budgets have gone up and the
budgets have gone down, we have had to come up with ways to
manage that within the confines of the resources we are
provided, ever mindful of the priority to serve the American
Indian and Alaska Native to the highest level that we can.
Regarding the M&I account, you mentioned that. The need is
in excess of half a billion dollars. No question about it. We
have taken the appropriations that we have received and coupled
that with Medicare, Medicaid, and private insurance
collections.
We have examples of areas taking 75 percent of project
funds going into some M&I work in the Portland area where
resources came from other than the M&I appropriation.
So we continue to work to see how we can best partner with
others, whether it is in sanitation facilities. We have done
the same thing in delivering sanitation facilities.
On the healthcare arena, it is pretty clear that
construction is tied to appropriations. Unless, of course, we
can get involved in the joint venture program, the small
ambulatory program that you helped us out with, again, this
past year. We appreciate that coming from the subcommittee.
Approximately a year ago, we submitted the second
facilities assessment report to the Congress and that report
indicates the needs that were determined; not only existing
authorities, but the new authorities that came with the
reauthorized Indian Healthcare law were incorporated in.
It already has been stated, I think, here at the hearing
that that existing authorities was over $10 billion of a need
for healthcare facilities. The new piece, new authorities is
another $4 billion plus.
So yes, we have these needs. We have managed exceedingly
well. We do not come back to the Congress for money for any of
our projects. We take a look at cost, scope, and schedule. We
work within that to make sure we deliver quality healthcare.
I can go to places in New Mexico. I can go to places in
Alaska where you and I have been for dedications. I can go to
Arizona. I can go to the places that we have tried to keep up
with the resources to deliver healthcare.
We have done a fantastic job and it helps recruitment. It
provides staffing at an 85 percent level and the balance is
covered by third party collections.
Senator Murkowski. Well, and Mr. Hartz, I am going to
interrupt because my time has expired. But your comment just
there, that it has been helped by the third party payers is
exactly why we need to get this information from you about the
impact, the benefit then that accrues to IHS through Medicaid
and Medicaid expansion.
If decisions are going to be made to make reductions in
this particular program, again, we need to understand what that
is going to be doing to the delivery of the services that are
expected.
Let me turn to Senator Udall.
Senator Udall. Thank you, Madam Chair.
I was pleased this subcommittee was able to secure
additional funding for alcohol and substance abuse programs in
the Omnibus, Miss Fowler. And I know that this funding is
critical to patch gaps in service like those we see in the
community of Gallup, New Mexico.
Miss Fowler, can you tell me how soon you expect an
announcement to be made about this funding?
Ms. Fowler. Yes, sir. We are working on a cooperative
agreement and we expect that to be awarded by the end of this
fiscal year.
Senator Udall. And how long after the announcement is made
will it take to get this funding on the ground to these areas
of greatest need?
Ms. Fowler. It would be immediately.
Senator Udall. Okay. Thank you.
Now, back to this issue of the CMS funds and the
information on Medicaid, as I understand, CMS keeps records of
what it pays for every Medicaid service in the country. I
believe it is called the CMS-64 and it has an entire column of
payments for IHS services.
Why does no one at the HHS, CMS, or IHS have that data file
to share with the subcommittee? And will you get that data file
and share it with the subcommittee?
Admiral Weahkee. Sir, we are happy to partner with CMS, and
assess what data they have available, and bring that back to
you.
Senator Udall. Am I correct about the CMS-64, that that
exists?
Admiral Weahkee. It is a little bit outside of my area of
expertise.
Senator Udall. Admiral Buchanan.
Admiral Buchanan. It is also out of my area of expertise.
Senator Udall. Okay. Well, find it and get it for us. Thank
you.
[The information follows:]
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Inpatient Hospital-- Inpatient Hospital-- Inpatient Hospital-- Mental Health
Reg. Payments Inpatient Hospital-- Sup. Payments GME Payments Total Facility Services--
State Total Computable DSH Total Total Computable Computable Reg. Payments Total
Computable Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama........................................ $1,784,832 $0 $0 $0 $340,412
Alaska......................................... $70,886,116 $0 $0 $0 $0
Amer. Samoa.................................... $0 $0 $0 $0 $0
Arizona........................................ $62,350,100 $0 $0 $0 $2,895,520
Arkansas....................................... $0 $0 $0 $0 $0
California..................................... $0 $0 $0 $0 $0
Colorado....................................... $0 $0 $0 $0 $0
Connecticut.................................... $0 $0 $0 $0 $0
Delaware....................................... $0 $0 $0 $0 $0
District of Columbia........................... $0 $0 $0 $0 $0
Florida........................................ $0 $0 $0 $0 $0
Georgia........................................ $0 $0 $0 $0 $0
Guam........................................... $0 $0 $0 $0 $0
Hawaii......................................... $0 $0 $0 $0 $0
Idaho.......................................... $0 $0 $0 $0 $0
Illinois....................................... $0 $0 $0 $0 $0
Indiana........................................ $0 $0 $0 $0 $0
Iowa........................................... $0 $0 $0 $0 $0
Kansas......................................... $0 $0 $0 $0 $0
Kentucky....................................... $0 $0 $0 $0 $0
Louisiana...................................... $0 $0 $0 $0 $0
Maine.......................................... $0 $0 $0 $0 $0
Maryland....................................... $0 $0 $0 $0 $0
Massachusetts.................................. $0 $0 $0 $0 $0
Michigan....................................... $0 $0 $0 $0 $0
Minnesota...................................... $573,906 $0 $0 $0 $15,446,913
Mississippi.................................... $256,848 $0 $0 $0 $0
Missouri....................................... $0 $0 $0 $0 $0
Montana........................................ $1,662,959 $0 $0 $0 $0
N. Mariana Islands............................. $0 $0 $0 $0 $0
Nebraska....................................... $0 $0 $0 $0 $0
Nevada......................................... $0 $0 $0 $0 $0
New Hampshire.................................. $0 $0 $0 $0 $0
New Jersey..................................... $0 $0 $0 $0 $0
New Mexico..................................... $19,188,586 $0 $0 $0 $0
New York....................................... $0 $0 $0 $0 $0
North Carolina................................. $332,541 $0 $0 $0 $0
North Dakota................................... $1,080,340 $0 $0 $0 $0
Ohio........................................... $0 $0 $0 $0 $0
Oklahoma....................................... $20,732,444 $0 $0 $0 $0
Oregon......................................... $0 $0 $0 $0 $0
Pennsylvania................................... $0 $0 $0 $0 $0
Puerto Rico.................................... $0 $0 $0 $0 $0
Rhode Island................................... $0 $0 $0 $0 $0
South Carolina................................. $0 $0 $0 $0 $0
South Dakota................................... $6,378,343 $0 $0 $0 $0
Tennessee...................................... $0 $0 $0 $0 $0
Texas.......................................... $0 $0 $0 $0 $0
Utah........................................... $124,881 $0 $0 $0 $0
Vermont........................................ $0 $0 $0 $0 $0
Virgin Islands................................. $0 $0 $0 $0 $0
Virginia....................................... $0 $0 $0 $0 $0
Washington..................................... $0 $0 $0 $0 $0
West Virginia.................................. $0 $0 $0 $0 $0
Wisconsin...................................... $0 $0 $0 $0 $0
Wyoming........................................ $0 $0 $0 $0 $736
--------------------------------------------------------------------------------------------------------
Totals:.................................... $185,351,896 $0 $0 $0 $18,683,581
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Intermediate Intermediate
Intermediate Care Facility Care Facility
Care Facility Services--Ind. Services--Ind.
Mental Health Nursing Facility Nursing Facility Services--Ind. with with
State Facility--DSH Services--Reg. Services--Sup. with Intellectual Intellectual
Total Computable Payments Total Payments Total Intellectual Disabilities: Disabilities:
Computable Computable Disabilities: Private Supplemental
Public Providers Providers Total Payments Total
Total Computable Computable Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama..................................... $0 $732,408 $0 $0 $0 $0
Alaska...................................... $0 $15,191,302 $0 $0 $0 $0
Amer. Samoa................................. $0 $0 $0 $0 $0 $0
Arizona..................................... $0 $13,734 $0 $0 $0 $0
Arkansas.................................... $0 $0 $0 $0 $0 $0
California.................................. $0 $0 $0 $0 $0 $0
Colorado.................................... $0 $0 $0 $0 $0 $0
Connecticut................................. $0 $0 $0 $0 $0 $0
Delaware.................................... $0 $0 $0 $0 $0 $0
District of Columbia........................ $0 $0 $0 $0 $0 $0
Florida..................................... $0 $0 $0 $0 $0 $0
Georgia..................................... $0 $0 $0 $0 $0 $0
Guam........................................ $0 $0 $0 $0 $0 $0
Hawaii...................................... $0 $0 $0 $0 $0 $0
Idaho....................................... $0 $0 $0 $0 $0 $0
Illinois.................................... $0 $0 $0 $0 $0 $0
Indiana..................................... $0 $0 $0 $0 $0 $0
Iowa........................................ $0 $0 $0 $0 $0 $0
Kansas...................................... $0 $0 $0 $0 $0 $0
Kentucky.................................... $0 $0 $0 $0 $0 $0
Louisiana................................... $0 $0 $0 $0 $0 $0
Maine....................................... $0 $0 $0 $0 $0 $0
Maryland.................................... $0 $0 $0 $0 $0 $0
Massachusetts............................... $0 $0 $0 $0 $0 $0
Michigan.................................... $0 $0 $0 $0 $0 $0
Minnesota................................... $0 $3,394,289 $0 $0 $0 $0
Mississippi................................. $0 $4,934,508 $0 $0 $0 $0
Missouri.................................... $0 $0 $0 $0 $0 $0
Montana..................................... $0 $0 $0 $0 $0 $0
N. Mariana Islands.......................... $0 $0 $0 $0 $0 $0
Nebraska.................................... $0 $4,680,194 $0 $0 $0 $0
Nevada...................................... $0 $0 $0 $0 $0 $0
New Hampshire............................... $0 $0 $0 $0 $0 $0
New Jersey.................................. $0 $0 $0 $0 $0 $0
New Mexico.................................. $0 $0 $0 $89,419 $76,935 $0
New York.................................... $0 $0 $0 $0 $0 $0
North Carolina.............................. $0 $3,009,471 $0 $0 $0 $0
North Dakota................................ $0 $0 $0 $0 $0 $0
Ohio........................................ $0 $0 $0 $0 $0 $0
Oklahoma.................................... $0 $423 $0 $0 $0 $0
Oregon...................................... $0 ($158) $0 $0 $0 $0
Pennsylvania................................ $0 $0 $0 $0 $0 $0
Puerto Rico................................. $0 $0 $0 $0 $0 $0
Rhode Island................................ $0 $0 $0 $0 $0 $0
South Carolina.............................. $0 $0 $0 $0 $0 $0
South Dakota................................ $0 $0 $0 $0 $0 $0
Tennessee................................... $0 $0 $0 $0 $0 $0
Texas....................................... $0 $0 $0 $0 $0 $0
Utah........................................ $0 $0 $0 $0 $0 $0
Vermont..................................... $0 $0 $0 $0 $0 $0
Virgin Islands.............................. $0 $0 $0 $0 $0 $0
Virginia.................................... $0 $0 $0 $0 $0 $0
Washington.................................. $0 $639,665 $0 $0 $0 $0
West Virginia............................... $0 $0 $0 $0 $0 $0
Wisconsin................................... $0 $1,915,211 $0 $0 $0 $0
Wyoming..................................... $0 $1,507,584 $0 $0 $0 $0
-----------------------------------------------------------------------------------------------------------
Totals:................................. $0 $36,018,631 $0 $89,419 $76,935 $0
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Physician & Physician & Physician & Outpatient Outpatient
Surgical Surgical Physician & Surgical Surgical Hospital Hospital
State Services--Reg. Services--Sup. Services--Evaluation Services--Vaccine Services--Reg. Services--Sup.
Payments Total Payments Total and Management Total Codes Total Payments Total Payments Total
Computable Computable Computable Computable Computable Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama................................ $1,103,338 $0 $0 $0 $354,884 $0
Alaska................................. $0 $0 $0 $0 $86,616,510 $0
Amer. Samoa............................ $0 $0 $0 $0 $0 $0
Arizona................................ $4,951,687 $0 $0 $0 $472,683,520 $7,711,397
Arkansas............................... $0 $0 $0 $0 $321,152 $0
California............................. $0 $0 $0 $0 $0 $0
Colorado............................... $0 $0 $0 $0 $0 $0
Connecticut............................ $0 $0 $0 $0 $0 $0
Delaware............................... $0 $0 $0 $0 $0 $0
District of Columbia................... $0 $0 $0 $0 $0 $0
Florida................................ $0 $0 $0 $0 $0 $0
Georgia................................ $0 $0 $0 $0 $0 $0
Guam................................... $0 $0 $0 $0 $0 $0
Hawaii................................. $0 $0 $0 $0 $0 $0
Idaho.................................. $0 $0 $0 $0 $0 $0
Illinois............................... $0 $0 $0 $0 $0 $0
Indiana................................ $0 $0 $0 $0 $0 $0
Iowa................................... $720,763 $0 $18,010 $656 $3,126 $0
Kansas................................. $0 $0 $0 $0 $0 $0
Kentucky............................... $0 $0 $0 $0 $0 $0
Louisiana.............................. $0 $0 $0 $0 $0 $0
Maine.................................. $0 $0 $0 $0 $0 $0
Maryland............................... $0 $0 $0 $0 $0 $0
Massachusetts.......................... $0 $0 $0 $0 $0 $0
Michigan............................... $0 $0 $866,104 $488 $0 $0
Minnesota.............................. $10,068,170 $0 $0 $0 $3,856 $0
Mississippi............................ $194,473 $0 $0 $0 $5,963,910 $0
Missouri............................... $0 $0 $0 $0 $0 $0
Montana................................ $0 $0 $0 $0 $61,946,583 $0
N. Mariana Islands..................... $0 $0 $0 $0 $0 $0
Nebraska............................... $0 $0 $0 $0 $3,850 $0
Nevada................................. $0 $0 $0 $0 $0 $0
New Hampshire.......................... $0 $0 $0 $0 $0 $0
New Jersey............................. $0 $0 $0 $0 $0 $0
New Mexico............................. $1,543,257 $56,011 $399 $0 $94,589,729 $0
New York............................... $0 $0 $0 $0 $0 $0
North Carolina......................... $1,034,202 $0 $0 $0 $8,388,862 $0
North Dakota........................... $16,046 $0 $0 $0 $5,527,363 $0
Ohio................................... $0 $0 $0 $0 $0 $0
Oklahoma............................... $2,877,356 $0 $0 $0 $41,906,818 $0
Oregon................................. $0 $0 $0 $0 $0 $0
Pennsylvania........................... $0 $0 $0 $0 $0 $0
Puerto Rico............................ $0 $0 $0 $0 $0 $0
Rhode Island........................... $9,306 $0 $0 $0 $0 $0
South Carolina......................... $10,142 $0 $0 $0 $0 $0
South Dakota........................... $0 $0 $0 $0 $1,116,994 $0
Tennessee.............................. $0 $0 $0 $0 $0 $0
Texas.................................. $0 $0 $0 $0 $55,036 $0
Utah................................... $3,115,412 $0 $0 $0 $87,084 $0
Vermont................................ $27 $0 $0 $0 $0 $0
Virgin Islands......................... $0 $0 $0 $0 $0 $0
Virginia............................... $0 $0 $0 $0 $0 $0
Washington............................. $5,709,652 $0 $0 $0 $0 $0
West Virginia.......................... $0 $0 $0 $0 $0 $0
Wisconsin.............................. $0 $0 $0 $0 $0 $0
Wyoming................................ $0 $0 $0 $0 $31,459 $0
----------------------------------------------------------------------------------------------------------------
Totals:............................ $31,353,831 $56,011 $884,513 $1,144 $779,600,736 $7,711,397
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Drug Rebate
Drug Rebate Offset--State MCO--National MCO--State Increased ACA
State Prescribed Drugs Offset--National Sidebar Agreement Total Sidebar OFFSET--Fee for
Total Computable Total Computable Agreement Total Computable Agreement Total Service--100%
Computable Computable Total Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama..................................... $1,856,101 ($398,330) ($20,776) $0 $0 $0
Alaska...................................... $19,149,671 ($9,938,455) $0 $0 $0 $0
Amer. Samoa................................. $0 $0 $0 $0 $0 $0
Arizona..................................... $0 $0 $0 $0 $0 $0
Arkansas.................................... $0 $0 $0 $0 $0 $0
California.................................. $0 $0 $0 $0 $0 $0
Colorado.................................... $1,221,828 $0 $0 $0 $0 $0
Connecticut................................. $0 $0 $0 $0 $0 $0
Delaware.................................... $0 $0 $0 $0 $0 $0
District of Columbia........................ $0 $0 $0 $0 $0 $0
Florida..................................... $0 $0 $0 $0 $0 $0
Georgia..................................... $0 $0 $0 $0 $0 $0
Guam........................................ $0 $0 $0 $0 $0 $0
Hawaii...................................... $0 $0 $0 $0 $0 $0
Idaho....................................... $166,011 $0 $0 $0 $0 $0
Illinois.................................... $0 $0 $0 $0 $0 $0
Indiana..................................... $0 $0 $0 $0 $0 $0
Iowa........................................ $410,211 ($134,987) ($7,456) ($18) $0 $0
Kansas...................................... $1,575 $0 $0 $0 $0 $0
Kentucky.................................... $0 $0 $0 $0 $0 $0
Louisiana................................... $0 $0 $0 $0 $0 $0
Maine....................................... $182,802 ($115,629) ($6,233) $0 $0 $0
Maryland.................................... $0 $0 $0 $0 $0 $0
Massachusetts............................... $0 $0 $0 $0 $0 $0
Michigan.................................... $4 $0 $0 $0 $0 $0
Minnesota................................... $27,218,864 ($798,557) ($52,694) $0 $0 $0
Mississippi................................. $0 $0 $0 $0 $0 $0
Missouri.................................... $0 $0 $0 $0 $0 $0
Montana..................................... $3,916,880 ($3,799,067) $0 $0 $0 $0
N. Mariana Islands.......................... $0 $0 $0 $0 $0 $0
Nebraska.................................... $337,192 $0 $0 $0 $0 $0
Nevada...................................... $0 $0 $0 $0 $0 $0
New Hampshire............................... $0 $0 $0 $0 $0 $0
New Jersey.................................. $0 $0 $0 $0 $0 $0
New Mexico.................................. $1,210,450 ($145,991) $0 $2,179,492 $0 $0
New York.................................... $28,896 $0 $0 $0 $0 $0
North Carolina.............................. $20,989 ($452,459) $0 $0 $0 $0
North Dakota................................ $4,975,951 $0 $0 $0 $0 $0
Ohio........................................ $0 $0 $0 $0 $0 $0
Oklahoma.................................... $17,784,129 $0 $0 $0 $0 $0
Oregon...................................... $1,063,358 $174,970 ($42,490) $0 $0 $0
Pennsylvania................................ $0 $0 $0 $0 $0 $0
Puerto Rico................................. $0 $0 $0 $0 $0 $0
Rhode Island................................ $0 $0 $0 $0 $0 $0
South Carolina.............................. $19,287 $0 $0 $0 $0 $0
South Dakota................................ $0 $0 $0 $0 $0 $0
Tennessee................................... $0 $0 $0 $0 $0 $0
Texas....................................... $0 $0 $0 $0 $0 $0
Utah........................................ $4,877,447 ($3,328,605) ($38,718) ($2,730,460) $0 $0
Vermont..................................... $0 $0 $0 $0 $0 $0
Virgin Islands.............................. $0 $0 $0 $0 $0 $0
Virginia.................................... $0 $0 $0 $0 $0 $0
Washington.................................. $139,773 ($30,828) $0 $0 $0 $0
West Virginia............................... $0 $0 $0 $0 $0 $0
Wisconsin................................... $1,217,888 ($1,895,482) ($77,906) $0 $0 $0
Wyoming..................................... $0 $0 $0 $0 $0 $0
-----------------------------------------------------------------------------------------------------------
Totals:................................. $85,799,307 ($20,863,420) ($246,273) ($550,986) $0 $0
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Other Other
Increased ACA Practitioners Practitioners Laboratory/
State OFFSET--MCO--100% Dental Services Services--Reg. Services--Sup. Clinic Services Radiological
Total Computable Total Computable Payments Total Payments Total Total Computable Total Computable
Computable Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama.................................... $0 $305,949 $69,467 $0 $49,371 $297,671
Alaska..................................... $0 $28,923,459 $0 $0 $143,206,019 $0
Amer. Samoa................................ $0 $0 $0 $0 $0 $0
Arizona.................................... $0 $217,723 $1,049,342 $0 $5,612,860 $635,587
Arkansas................................... $0 $0 $0 $0 $0 $0
California................................. $0 $0 $0 $0 $13,522,319 $0
Colorado................................... $0 $0 $0 $0 $0 $0
Connecticut................................ $0 $0 $0 $0 $0 $0
Delaware................................... $0 $0 $0 $0 $0 $0
District of Columbia....................... $0 $0 $0 $0 $0 $0
Florida.................................... $0 $0 $0 $0 $0 $0
Georgia.................................... $0 $0 $0 $0 $0 $0
Guam....................................... $0 $0 $0 $0 $0 $0
Hawaii..................................... $0 $0 $0 $0 $0 $0
Idaho...................................... $0 $0 $0 $0 $0 $0
Illinois................................... $0 $0 $0 $0 $0 $0
Indiana.................................... $0 $0 $0 $0 $0 $0
Iowa....................................... $0 $82,936 $25,778 $0 $0 $0
Kansas..................................... $0 $0 $0 $0 $32,982 $0
Kentucky................................... $0 $0 $0 $0 $0 $0
Louisiana.................................. $0 $0 $0 $0 $0 $0
Maine...................................... $0 $0 $0 $0 $2,060,924 $0
Maryland................................... $0 $0 $0 $0 $0 $0
Massachusetts.............................. $0 $0 $0 $0 $223,289 $0
Michigan................................... $0 $80,926 $0 $0 $2,687,664 $0
Minnesota.................................. $0 $4,196,203 $8,897,185 $0 $5,161,349 $349
Mississippi................................ $0 $3,896 $0 $0 $0 $0
Missouri................................... $0 $0 $0 $0 $0 $0
Montana.................................... $0 $0 $0 $0 $0 $0
N. Mariana Islands......................... $0 $0 $0 $0 $0 $0
Nebraska................................... $0 $0 $0 $0 $0 $0
Nevada..................................... $0 $0 $0 $0 $19,990,921 $0
New Hampshire.............................. $0 $0 $0 $0 $0 $0
New Jersey................................. $0 $0 $0 $0 $0 $0
New Mexico................................. $0 $1,205 $118,756 $0 $0 $4,766
New York................................... $0 $0 $0 $0 $511,231 $0
North Carolina............................. $0 $56,972 $0 $0 $0 $0
North Dakota............................... $0 $0 $0 $0 $0 $0
Ohio....................................... $0 $0 $0 $0 $0 $0
Oklahoma................................... $0 $0 $13,592 $0 $40,338,468 $28,947
Oregon..................................... $0 $0 $0 $0 $15,999,334 $0
Pennsylvania............................... $0 $0 $0 $0 $0 $0
Puerto Rico................................ $0 $0 $0 $0 $0 $0
Rhode Island............................... $0 $0 $0 $0 $0 $0
South Carolina............................. $0 $0 $0 $0 $0 $0
South Dakota............................... $0 $0 $0 $0 $61,138,157 $0
Tennessee.................................. $0 $0 $0 $0 $0 $0
Texas...................................... $0 $0 $0 $0 $0 $0
Utah....................................... $0 $628,237 $0 $0 $0 $0
Vermont.................................... $0 $0 $0 $0 $0 $0
Virgin Islands............................. $0 $0 $0 $0 $0 $0
Virginia................................... $0 $0 $0 $0 $0 $0
Washington................................. $0 $1,501,336 $37,682 $0 $43,609,620 $0
West Virginia.............................. $0 $0 $0 $0 $0 $0
Wisconsin.................................. $0 $0 $0 $0 $2,300 ($17)
Wyoming.................................... $0 $0 $0 $0 $9,103,050 $56
------------------------------------------------------------------------------------------------------------
Totals:................................ $0 $35,998,842 $10,211,802 $0 $363,249,858 $967,359
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Home Health
State Services Total Sterilizations Abortions Total EPSDT Screening Rural Health Medicare--Part A
Computable Total Computable Computable Total Computable Total Computable Total Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama..................................... $209,282 $21,200 $0 $166,164 $96,404 $0
Alaska...................................... $0 $0 $0 $0 $0 $0
Amer. Samoa................................. $0 $0 $0 $0 $0 $0
Arizona..................................... $4,668 $42,768 $0 $19,818 $0 $0
Arkansas.................................... $0 $0 $0 $0 $0 $0
California.................................. $0 $0 $0 $0 $34,988,770 $0
Colorado.................................... $0 $0 $0 $0 $3,425,564 $0
Connecticut................................. $0 $0 $0 $2,796 $0 $0
Delaware.................................... $0 $0 $0 $0 $0 $0
District of Columbia........................ $0 $0 $0 $0 $0 $0
Florida..................................... $0 $0 $0 $0 $0 $0
Georgia..................................... $0 $0 $0 $0 $0 $0
Guam........................................ $0 $0 $0 $0 $0 $0
Hawaii...................................... $0 $0 $0 $0 $0 $0
Idaho....................................... $0 $0 $0 $0 $0 $0
Illinois.................................... $0 $0 $0 $0 $0 $0
Indiana..................................... $0 $0 $0 $0 $0 $0
Iowa........................................ $186 $0 $0 $0 $0 $0
Kansas...................................... $0 $0 $0 $0 $0 $0
Kentucky.................................... $0 $0 $0 $0 $0 $0
Louisiana................................... $0 $0 $0 $0 $0 $0
Maine....................................... $0 $0 $0 $0 $0 $0
Maryland.................................... $0 $0 $0 $0 $0 $0
Massachusetts............................... $0 $0 $0 $0 $0 $0
Michigan.................................... $0 $0 $0 $54,897 $0 $0
Minnesota................................... $1,599,133 $67 $0 $84,512 $82 $0
Mississippi................................. $0 $0 $0 $532,843 $0 $0
Missouri.................................... $0 $0 $0 $0 $0 $0
Montana..................................... $0 $0 $0 $0 $0 $0
N. Mariana Islands.......................... $0 $0 $0 $0 $0 $0
Nebraska.................................... $0 $0 $0 $0 $0 $0
Nevada...................................... $0 $0 $0 $350 $0 $0
New Hampshire............................... $0 $0 $0 $0 $0 $0
New Jersey.................................. $0 $0 $0 $0 $0 $0
New Mexico.................................. $17,410,900 $0 $0 $100 $0 $0
New York.................................... $0 $0 $0 $0 $0 $0
North Carolina.............................. $56,364 $0 $0 $0 $0 $0
North Dakota................................ $468,338 $0 $0 $0 $0 $0
Ohio........................................ $0 $0 $0 $0 $0 $0
Oklahoma.................................... $399,021 $240,752 $0 $250,930 $0 $0
Oregon...................................... $0 $0 $0 $202,084 $0 $452
Pennsylvania................................ $0 $0 $0 $0 $0 $0
Puerto Rico................................. $0 $0 $0 $0 $0 $0
Rhode Island................................ $0 $0 $0 $0 $0 $0
South Carolina.............................. $0 $0 $0 $0 $0 $0
South Dakota................................ $0 $0 $0 $0 $0 $0
Tennessee................................... $0 $0 $0 $0 $0 $0
Texas....................................... $0 $0 $0 $0 $0 $0
Utah........................................ $0 $0 $0 $136,965 $0 $0
Vermont..................................... $0 $0 $0 $0 $0 $0
Virgin Islands.............................. $0 $0 $0 $0 $0 $0
Virginia.................................... $0 $0 $0 $0 $0 $0
Washington.................................. $0 $0 $0 $1,241,825 $0 $0
West Virginia............................... $0 $0 $0 $0 $0 $0
Wisconsin................................... $38,516 $0 $0 $76,777 $0 $0
Wyoming..................................... $0 $0 $0 $0 $0 $0
-----------------------------------------------------------------------------------------------------------
Totals:................................. $20,186,408 $304,787 $0 $2,770,061 $38,510,820 $452
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Medicaid MCO-- Medicaid MCO--
Medicare-- Part 120%-134% of Coinsurance Medicaid--MCO Evaluation and Vaccine Codes
State B Total Poverty Total Total Computable Total Computable Management Total Total Computable
Computable Computable Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama..................................... $0 $0 $0 $0 $0 $0
Alaska...................................... $0 $0 $0 $0 $0 $0
Amer. Samoa................................. $0 $0 $0 $0 $0 $0
Arizona..................................... $0 $0 $0 ($295,139) $0 $0
Arkansas.................................... $0 $0 $2,621 $0 $0 $0
California.................................. $0 $0 $0 $0 $0 $0
Colorado.................................... $0 $0 $0 $0 $0 $0
Connecticut................................. $0 $0 $0 $0 $0 $0
Delaware.................................... $0 $0 $0 $0 $0 $0
District of Columbia........................ $0 $0 $0 $0 $0 $0
Florida..................................... $0 $0 $0 $0 $0 $0
Georgia..................................... $0 $0 $0 $0 $0 $0
Guam........................................ $0 $0 $0 $0 $0 $0
Hawaii...................................... $0 $0 $0 $0 $0 $0
Idaho....................................... $0 $0 $0 $0 $0 $0
Illinois.................................... $0 $0 $0 $0 $0 $0
Indiana..................................... $0 $0 $0 $0 $0 $0
Iowa........................................ $0 $0 $43 $0 $0 $0
Kansas...................................... $0 $0 $0 $2,050,641 $0 $0
Kentucky.................................... $0 $0 $0 $0 $0 $0
Louisiana................................... $0 $0 $0 $0 $0 $0
Maine....................................... $0 $0 $208,767 $0 $0 $0
Maryland.................................... $0 $0 $0 $0 $0 $0
Massachusetts............................... $0 $0 $0 $0 $0 $0
Michigan.................................... $0 $0 $312 $0 $0 $0
Minnesota................................... $0 $0 $0 $0 $0 $0
Mississippi................................. $0 $0 $0 $0 $0 $0
Missouri.................................... $0 $0 $0 $0 $0 $0
Montana..................................... $0 $0 $0 $0 $0 $0
N. Mariana Islands.......................... $0 $0 $0 $0 $0 $0
Nebraska.................................... $0 $0 $3,985 $8,670,518 $0 $0
Nevada...................................... $0 $0 $0 $1,965,059 $0 $0
New Hampshire............................... $0 $0 $0 $0 $0 $0
New Jersey.................................. $0 $0 $0 $0 $0 $0
New Mexico.................................. $0 $0 $3,195,638 $44,000,544 $0 $0
New York.................................... $0 $0 $0 $0 $55,519,995 $0
North Carolina.............................. $0 $0 $5,268 $0 $0 $0
North Dakota................................ $0 $0 $0 $0 $0 $0
Ohio........................................ $0 $0 $0 $0 $0 $0
Oklahoma.................................... $0 $0 $0 $0 $0 $0
Oregon...................................... $0 $0 $0 $0 $0 $0
Pennsylvania................................ $0 $0 $0 $0 $0 $0
Puerto Rico................................. $0 $0 $0 $0 $0 $0
Rhode Island................................ $0 $0 $0 $0 $0 $0
South Carolina.............................. $0 $0 $0 $0 $0 $0
South Dakota................................ $0 $0 $0 $0 $0 $0
Tennessee................................... $0 $0 $0 $0 $0 $0
Texas....................................... $0 $0 $0 $0 $0 $0
Utah........................................ $0 $0 $1,390 $0 $0 $0
Vermont..................................... $0 $0 $0 $0 $0 $0
Virgin Islands.............................. $0 $0 $0 $0 $0 $0
Virginia.................................... $0 $0 $0 $0 $0 $0
Washington.................................. $0 $0 $0 $0 $0 $0
West Virginia............................... $0 $0 $0 $0 $0 $0
Wisconsin................................... $0 $0 $14,398 $0 $0 $0
Wyoming..................................... $0 $0 $14,871 $0 $0 $0
-----------------------------------------------------------------------------------------------------------
Totals:................................. $0 $0 $3,447,293 $56,391,623 $55,519,995 $0
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Medicaid MCO--
Preventive
Medicaid MCO-- Services Grade A Prepaid MCO PAHP-- MCO PAHP-- MCO PAHP--
State Community First OR B, ACIP Ambulatory Evaluation and Vaccine Codes Community First
Choice Total Vaccines and Health Plan Management Total Total Computable Choice Total
Computable their Admin Total Computable Computable Computable
Total Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama..................................... $0 $0 $0 $0 $0 $0
Alaska...................................... $0 $0 $0 $0 $0 $0
Amer. Samoa................................. $0 $0 $0 $0 $0 $0
Arizona..................................... $0 $0 $0 $0 $0 $0
Arkansas.................................... $0 $0 $0 $0 $0 $0
California.................................. $0 $0 $0 $0 $0 $0
Colorado.................................... $0 $0 $0 $0 $0 $0
Connecticut................................. $0 $0 $0 $0 $0 $0
Delaware.................................... $0 $0 $0 $0 $0 $0
District of Columbia........................ $0 $0 $0 $0 $0 $0
Florida..................................... $0 $0 $0 $0 $0 $0
Georgia..................................... $0 $0 $0 $0 $0 $0
Guam........................................ $0 $0 $0 $0 $0 $0
Hawaii...................................... $0 $0 $0 $0 $0 $0
Idaho....................................... $0 $0 $0 $0 $0 $0
Illinois.................................... $0 $0 $0 $0 $0 $0
Indiana..................................... $0 $0 $0 $0 $0 $0
Iowa........................................ $0 $0 $0 $0 $0 $0
Kansas...................................... $0 $0 $0 $0 $0 $0
Kentucky.................................... $0 $0 $0 $0 $0 $0
Louisiana................................... $0 $0 $0 $0 $0 $0
Maine....................................... $0 $0 $0 $0 $0 $0
Maryland.................................... $0 $0 $0 $0 $0 $0
Massachusetts............................... $0 $0 $0 $0 $0 $0
Michigan.................................... $0 $0 $0 $0 $0 $0
Minnesota................................... $0 $0 $0 $0 $0 $0
Mississippi................................. $0 $0 $0 $0 $0 $0
Missouri.................................... $0 $0 $0 $0 $0 $0
Montana..................................... $0 $0 $0 $0 $0 $0
N. Mariana Islands.......................... $0 $0 $0 $0 $0 $0
Nebraska.................................... $0 $0 $0 $0 $0 $0
Nevada...................................... $0 $0 $0 $0 $0 $0
New Hampshire............................... $0 $0 $0 $0 $0 $0
New Jersey.................................. $0 $0 $0 $0 $0 $0
New Mexico.................................. $0 $0 $0 $0 $0 $0
New York.................................... $0 $0 $0 $0 $0 $0
North Carolina.............................. $0 $0 $0 $0 $0 $0
North Dakota................................ $0 $0 $0 $0 $0 $0
Ohio........................................ $0 $0 $0 $0 $0 $0
Oklahoma.................................... $0 $0 ($78,373) $0 $0 $0
Oregon...................................... $0 $0 $0 $0 $0 $0
Pennsylvania................................ $0 $0 $0 $0 $0 $0
Puerto Rico................................. $0 $0 $0 $0 $0 $0
Rhode Island................................ $0 $0 $0 $0 $0 $0
South Carolina.............................. $0 $0 $0 $0 $0 $0
South Dakota................................ $0 $0 $0 $0 $0 $0
Tennessee................................... $0 $0 $0 $0 $0 $0
Texas....................................... $0 $0 $0 $0 $0 $0
Utah........................................ $0 $0 $0 $0 $0 $0
Vermont..................................... $0 $0 $0 $0 $0 $0
Virgin Islands.............................. $0 $0 $0 $0 $0 $0
Virginia.................................... $0 $0 $0 $0 $0 $0
Washington.................................. $0 $0 $0 $0 $0 $0
West Virginia............................... $0 $0 $0 $0 $0 $0
Wisconsin................................... $0 $0 $0 $0 $0 $0
Wyoming..................................... $0 $0 $0 $0 $0 $0
-----------------------------------------------------------------------------------------------------------
Totals:................................. $0 $0 ($78,373) $0 $0 $0
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
MCO PAHP-- MCO PIHP--
Preventive Preventive
Services Grade A Prepaid MCO PIHP-- MCO PIHP-- MCO PIHP-- Services Grade A
State OR B, ACIP Inpatient Health Evaluation and Vaccine Codes Community First OR B, ACIP
Vaccines and Plan Total Management Total Total Computable Choice Total Vaccines and
their Admin Computable Computable Computable their Admin
Total Computable Total Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama..................................... $0 $0 $0 $0 $0 $0
Alaska...................................... $0 $0 $0 $0 $0 $0
Amer. Samoa................................. $0 $0 $0 $0 $0 $0
Arizona..................................... $0 $0 $0 $0 $0 $0
Arkansas.................................... $0 $0 $0 $0 $0 $0
California.................................. $0 $0 $0 $0 $0 $0
Colorado.................................... $0 $0 $0 $0 $0 $0
Connecticut................................. $0 $0 $0 $0 $0 $0
Delaware.................................... $0 $0 $0 $0 $0 $0
District of Columbia........................ $0 $0 $0 $0 $0 $0
Florida..................................... $0 $0 $0 $0 $0 $0
Georgia..................................... $0 $0 $0 $0 $0 $0
Guam........................................ $0 $0 $0 $0 $0 $0
Hawaii...................................... $0 $0 $0 $0 $0 $0
Idaho....................................... $0 $0 $0 $0 $0 $0
Illinois.................................... $0 $0 $0 $0 $0 $0
Indiana..................................... $0 $0 $0 $0 $0 $0
Iowa........................................ $0 $0 $0 $0 $0 $0
Kansas...................................... $0 $0 $0 $0 $0 $0
Kentucky.................................... $0 $0 $0 $0 $0 $0
Louisiana................................... $0 $0 $0 $0 $0 $0
Maine....................................... $0 $0 $0 $0 $0 $0
Maryland.................................... $0 $0 $0 $0 $0 $0
Massachusetts............................... $0 $0 $0 $0 $0 $0
Michigan.................................... $0 $0 $0 $0 $0 $0
Minnesota................................... $0 $0 $0 $0 $0 $0
Mississippi................................. $0 $0 $0 $0 $0 $0
Missouri.................................... $0 $0 $0 $0 $0 $0
Montana..................................... $0 $0 $0 $0 $0 $0
N. Mariana Islands.......................... $0 $0 $0 $0 $0 $0
Nebraska.................................... $0 $0 $0 $0 $0 $0
Nevada...................................... $0 $0 $0 $0 $0 $0
New Hampshire............................... $0 $0 $0 $0 $0 $0
New Jersey.................................. $0 $0 $0 $0 $0 $0
New Mexico.................................. $0 $727,632 $0 $0 $0 $0
New York.................................... $0 $0 $0 $0 $0 $0
North Carolina.............................. $0 $0 $0 $0 $0 $0
North Dakota................................ $0 $0 $0 $0 $0 $0
Ohio........................................ $0 $0 $0 $0 $0 $0
Oklahoma.................................... $0 $0 $0 $0 $0 $0
Oregon...................................... $0 $0 $0 $0 $0 $0
Pennsylvania................................ $0 $0 $0 $0 $0 $0
Puerto Rico................................. $0 $0 $0 $0 $0 $0
Rhode Island................................ $0 $0 $0 $0 $0 $0
South Carolina.............................. $0 $0 $0 $0 $0 $0
South Dakota................................ $0 $0 $0 $0 $0 $0
Tennessee................................... $0 $0 $0 $0 $0 $0
Texas....................................... $0 $0 $0 $0 $0 $0
Utah........................................ $0 $0 $0 $0 $0 $0
Vermont..................................... $0 $0 $0 $0 $0 $0
Virgin Islands.............................. $0 $0 $0 $0 $0 $0
Virginia.................................... $0 $0 $0 $0 $0 $0
Washington.................................. $0 $0 $0 $0 $0 $0
West Virginia............................... $0 $0 $0 $0 $0 $0
Wisconsin................................... $0 $0 $0 $0 $0 $0
Wyoming..................................... $0 $0 $0 $0 $0 $0
-----------------------------------------------------------------------------------------------------------
Totals:................................. $0 $727,632 $0 $0 $0 $0
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Home & Community- Home & Community-
Home & Community- Based Services-- Based Services--
Medicaid--Group Medicaid-- Medicaid--Other Based Services-- St. Plan 1915(i) St. Plan 1915(j)
State Health Total Coinsurance Total Computable Reg. Pay. (Waiv) Only Pay. Total Only Pay. Total
Computable Total Computable Total Computable Computable Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama..................................... $0 $0 $0 $288,087 $0 $0
Alaska...................................... $0 $0 $0 $6,236,876 $0 $0
Amer. Samoa................................. $0 $0 $0 $0 $0 $0
Arizona..................................... $0 $0 $0 $0 $0 $0
Arkansas.................................... $0 $0 $0 $0 $0 $0
California.................................. $0 $0 $0 $0 $0 $0
Colorado.................................... $0 $0 $0 $0 $0 $0
Connecticut................................. $0 $0 $0 $0 $0 $0
Delaware.................................... $0 $0 $0 $0 $0 $0
District of Columbia........................ $0 $0 $0 $0 $0 $0
Florida..................................... $0 $0 $0 $0 $0 $0
Georgia..................................... $0 $0 $0 $0 $0 $0
Guam........................................ $0 $0 $0 $0 $0 $0
Hawaii...................................... $0 $0 $0 $0 $0 $0
Idaho....................................... $0 $0 $0 $0 $0 $0
Illinois.................................... $0 $0 $0 $0 $0 $0
Indiana..................................... $0 $0 $0 $0 $0 $0
Iowa........................................ $0 $0 $0 $0 $0 $0
Kansas...................................... $0 $0 $0 $0 $0 $0
Kentucky.................................... $0 $0 $0 $0 $0 $0
Louisiana................................... $0 $0 $0 $0 $0 $0
Maine....................................... $0 $0 $0 $0 $0 $0
Maryland.................................... $0 $0 $0 $0 $0 $0
Massachusetts............................... $0 $0 $0 $0 $0 $0
Michigan.................................... $0 $0 $0 $0 $0 $0
Minnesota................................... $0 $0 $23,210 $147,880 $0 $0
Mississippi................................. $0 $0 $0 $0 $0 $0
Missouri.................................... $0 $0 $0 $0 $0 $0
Montana..................................... $0 $0 $0 $0 $0 $0
N. Mariana Islands.......................... $0 $0 $0 $0 $0 $0
Nebraska.................................... $0 $0 $0 $0 $0 $0
Nevada...................................... $0 $0 $0 $0 $0 $0
New Hampshire............................... $0 $0 $0 $0 $0 $0
New Jersey.................................. $0 $0 $0 $0 $0 $0
New Mexico.................................. $0 $0 $660 $0 $0 $0
New York.................................... $0 $0 $0 $0 $0 $0
North Carolina.............................. $0 $0 $0 $0 $0 $0
North Dakota................................ $0 $0 $0 $0 $0 $0
Ohio........................................ $0 $0 $0 $0 $0 $0
Oklahoma.................................... $0 $0 $0 $295,016 $0 $0
Oregon...................................... $0 $0 $0 $0 $0 $0
Pennsylvania................................ $0 $0 $0 $0 $0 $0
Puerto Rico................................. $0 $0 $0 $0 $0 $0
Rhode Island................................ $0 $0 $0 $0 $0 $0
South Carolina.............................. $0 $0 $0 $0 $0 $0
South Dakota................................ $0 $0 $0 $0 $0 $0
Tennessee................................... $0 $0 $0 $0 $0 $0
Texas....................................... $0 $0 $0 $0 $0 $0
Utah........................................ $0 $0 $0 $0 $0 $0
Vermont..................................... $0 $0 $0 $0 $0 $0
Virgin Islands.............................. $0 $0 $0 $0 $0 $0
Virginia.................................... $0 $0 $0 $0 $0 $0
Washington.................................. $0 $0 $0 $0 $0 $0
West Virginia............................... $0 $0 $0 $0 $0 $0
Wisconsin................................... $0 $0 $0 $1,969,178 $0 $0
Wyoming..................................... $0 $0 $0 $0 $0 $0
-----------------------------------------------------------------------------------------------------------
Totals:................................. $0 $0 $23,870 $8,937,037 $0 $0
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Home & Community
Based Services Targeted Case
State Plan All-Inclusive Personal Care Personal Care Management Case Management--
State 1915(k) Care Elderly Services--Reg. Services--SDS Services--Com. State Wide Total
Community First Total Computable Payments Total 1915(j) Total Case-Man. Total Computable
Choice Total Computable Computable Computable
Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama.................................... $0 $0 $0 $0 $113,862 $0
Alaska..................................... $0 $0 $99,373 $0 $0 $0
Amer. Samoa................................ $0 $0 $0 $0 $0 $0
Arizona.................................... $0 $0 $79,435 $0 $0 $0
Arkansas................................... $0 $0 $0 $0 $0 $0
California................................. $0 $0 $0 $0 $0 $0
Colorado................................... $0 $0 $0 $0 $0 $0
Connecticut................................ $0 $0 $0 $0 $0 $0
Delaware................................... $0 $0 $0 $0 $0 $0
District of Columbia....................... $0 $0 $0 $0 $0 $0
Florida.................................... $0 $0 $0 $0 $0 $0
Georgia.................................... $0 $0 $0 $0 $0 $0
Guam....................................... $0 $0 $0 $0 $0 $0
Hawaii..................................... $0 $0 $0 $0 $0 $0
Idaho...................................... $0 $0 $0 $0 $0 $0
Illinois................................... $0 $0 $0 $0 $0 $0
Indiana.................................... $0 $0 $0 $0 $0 $0
Iowa....................................... $0 $0 $0 $0 $0 $48
Kansas..................................... $0 $0 $0 $0 $0 $0
Kentucky................................... $0 $0 $0 $0 $0 $0
Louisiana.................................. $0 $0 $0 $0 $0 $0
Maine...................................... $0 $0 $0 $0 $0 $0
Maryland................................... $0 $0 $0 $0 $0 $0
Massachusetts.............................. $0 $0 $0 $0 $0 $0
Michigan................................... $0 $0 $0 $0 $0 $0
Minnesota.................................. $0 $0 $0 $0 $0 $6,156,206
Mississippi................................ $0 $0 $0 $0 $0 $0
Missouri................................... $0 $0 $0 $0 $0 $0
Montana.................................... $0 $0 $0 $0 $0 $0
N. Mariana Islands......................... $0 $0 $0 $0 $0 $0
Nebraska................................... $0 $0 $0 $0 $0 $0
Nevada..................................... $0 $0 $0 $0 $0 $0
New Hampshire.............................. $0 $0 $0 $0 $0 $0
New Jersey................................. $0 $0 $0 $0 $0 $0
New Mexico................................. $0 $0 $0 $0 $0 $0
New York................................... $0 $0 $0 $0 $0 $0
North Carolina............................. $0 $0 $46,398 $0 $15,807 $0
North Dakota............................... $0 $0 $0 $0 $18,392 $0
Ohio....................................... $0 $0 $0 $0 $0 $0
Oklahoma................................... $0 $3,240,698 $0 $0 $0 $0
Oregon..................................... $0 $0 $0 $0 $0 $0
Pennsylvania............................... $0 $0 $0 $0 $0 $0
Puerto Rico................................ $0 $0 $0 $0 $0 $0
Rhode Island............................... $0 $0 $0 $0 $0 $0
South Carolina............................. $0 $0 $0 $0 $0 $0
South Dakota............................... $0 $0 $0 $0 $0 $0
Tennessee.................................. $0 $0 $0 $0 $0 $0
Texas...................................... $0 $0 $0 $0 $0 $0
Utah....................................... $0 $0 $0 $0 $0 $0
Vermont.................................... $0 $0 $0 $0 $0 $0
Virgin Islands............................. $0 $0 $0 $0 $0 $0
Virginia................................... $0 $0 $0 $0 $0 $0
Washington................................. $0 $0 $0 $0 $0 $0
West Virginia.............................. $0 $0 $0 $0 $0 $0
Wisconsin.................................. $0 $0 $0 $0 $0 $70
Wyoming.................................... $0 $0 $0 $0 $0 $0
------------------------------------------------------------------------------------------------------------
Totals:................................ $0 $3,240,698 $225,206 $0 $148,061 $6,156,324
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Emergency
Primary Care Services for Federally- Non-Emergency
State Case Management Hospice Benefits Undocumented Qualified Health Medical Physical Therapy
Total Computable Total Computable Aliens Total Center Total Transportation Total Computable
Computable Computable Total Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama..................................... $189,217 $57,343 $0 $283,952 $0 $23,115
Alaska...................................... $0 $0 $0 $0 $375,018 $0
Amer. Samoa................................. $0 $0 $0 $0 $0 $0
Arizona..................................... $0 $0 $0 $36,884 $7,499,635 $1,317
Arkansas.................................... $0 $0 $0 $0 $0 $0
California.................................. $0 $0 $0 $0 $0 $0
Colorado.................................... $0 $0 $0 $0 $0 $0
Connecticut................................. $0 $0 $0 $0 $0 $0
Delaware.................................... $0 $0 $0 $0 $0 $0
District of Columbia........................ $0 $0 $0 $0 $0 $0
Florida..................................... $0 $0 $0 $0 $0 $0
Georgia..................................... $0 $0 $0 $0 $0 $0
Guam........................................ $0 $0 $0 $0 $0 $0
Hawaii...................................... $0 $0 $0 $0 $0 $0
Idaho....................................... $0 $0 $0 $0 $0 $0
Illinois.................................... $0 $0 $0 $0 $0 $0
Indiana..................................... $0 $0 $0 $0 $0 $0
Iowa........................................ $0 $0 $0 $0 $0 $0
Kansas...................................... $0 $0 $0 $0 $0 $0
Kentucky.................................... $0 $0 $0 $0 $0 $0
Louisiana................................... $0 $0 $0 $0 $0 $0
Maine....................................... $29,608 $0 $0 $0 $0 $0
Maryland.................................... $0 $0 $0 $0 $0 $0
Massachusetts............................... $0 $0 $0 $0 $0 $0
Michigan.................................... $0 $0 $0 $56 $0 $0
Minnesota................................... $0 $0 $0 $5,447 $0 $441,435
Mississippi................................. $0 $0 $0 $0 $0 $0
Missouri.................................... $0 $0 $0 $0 $0 $0
Montana..................................... $225,607 $0 $0 $0 $0 $0
N. Mariana Islands.......................... $0 $0 $0 $0 $0 $0
Nebraska.................................... $0 $0 $0 $693,031 $0 $0
Nevada...................................... $0 $0 $0 $0 $0 $0
New Hampshire............................... $0 $0 $0 $0 $0 $0
New Jersey.................................. $0 $0 $0 $0 $0 $0
New Mexico.................................. $0 $0 $0 $508,747 $39,314 $0
New York.................................... $0 $0 $0 $0 $0 $0
North Carolina.............................. $0 $0 $0 $0 $40,984 $0
North Dakota................................ $34,560 $0 $0 $0 $3,942 $0
Ohio........................................ $0 $0 $0 $0 $0 $0
Oklahoma.................................... $459,243 $0 $11,709 $0 $797,370 $0
Oregon...................................... $0 $0 $0 $0 $0 $0
Pennsylvania................................ $0 $0 $0 $0 $0 $0
Puerto Rico................................. $0 $0 $0 $0 $0 $0
Rhode Island................................ $0 $0 $0 $0 $0 $0
South Carolina.............................. $0 $0 $0 $0 $0 $0
South Dakota................................ $0 $0 $0 $0 $0 $0
Tennessee................................... $0 $0 $0 $0 $0 $0
Texas....................................... $0 $0 $0 $0 $0 $0
Utah........................................ $0 $0 $0 $0 $918,544 $334
Vermont..................................... $0 $0 $0 $0 $0 $0
Virgin Islands.............................. $0 $0 $0 $0 $0 $0
Virginia.................................... $0 $0 $0 $0 $0 $0
Washington.................................. $0 $0 $0 $40,155,116 $0 $0
West Virginia............................... $0 $0 $0 $0 $0 $0
Wisconsin................................... $0 $0 $0 $17,115,834 $0 $0
Wyoming..................................... $0 $0 $0 $0 $0 $0
-----------------------------------------------------------------------------------------------------------
Totals:................................. $938,235 $57,343 $11,709 $58,799,067 $9,674,807 $466,201
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Preventive
Services for Prosthetic Diagnostic Services Grade A
Occupational Speech, Hearing Devices, Screening & OR B, ACIP Nurse Mid-Wife
State Therapy Total & Language Total Dentures, Preventive Vaccines and Total Computable
Computable Computable Eyeglasses Total Services Total their Admin
Computable Computable Total Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama..................................... $0 $1,701 $17,446 $0 $0 $170
Alaska...................................... $0 $0 $0 $0 $0 $0
Amer. Samoa................................. $0 $0 $0 $0 $0 $0
Arizona..................................... $0 $1,532 $0 $6,069 $0 $1,361,216
Arkansas.................................... $0 $0 $0 $0 $0 $0
California.................................. $0 $0 $0 $0 $0 $0
Colorado.................................... $0 $0 $0 $0 $0 $0
Connecticut................................. $0 $0 $0 $0 $0 $0
Delaware.................................... $0 $0 $0 $0 $0 $0
District of Columbia........................ $0 $0 $0 $0 $0 $0
Florida..................................... $0 $0 $0 $0 $0 $0
Georgia..................................... $0 $0 $0 $0 $0 $0
Guam........................................ $0 $0 $0 $0 $0 $0
Hawaii...................................... $0 $0 $0 $0 $0 $0
Idaho....................................... $0 $0 $0 $0 $0 $0
Illinois.................................... $0 $0 $0 $0 $0 $0
Indiana..................................... $0 $0 $0 $0 $0 $0
Iowa........................................ $0 $0 $0 $0 $0 $0
Kansas...................................... $0 $0 $0 $0 $0 $0
Kentucky.................................... $0 $0 $0 $0 $0 $0
Louisiana................................... $0 $0 $0 $0 $0 $0
Maine....................................... $0 $0 $0 $0 $0 $0
Maryland.................................... $0 $0 $0 $0 $0 $0
Massachusetts............................... $0 $0 $0 $0 $0 $0
Michigan.................................... $0 $0 $10,432 $0 $0 $0
Minnesota................................... $243,612 $11 $24,268 $0 $0 $297,118
Mississippi................................. $0 $0 $15,888 $0 $0 $0
Missouri.................................... $0 $0 $0 $0 $0 $0
Montana..................................... $0 $0 $0 $0 $0 $0
N. Mariana Islands.......................... $0 $0 $0 $0 $0 $0
Nebraska.................................... $0 $0 $0 $0 $0 $0
Nevada...................................... $0 $0 $0 $0 $0 $0
New Hampshire............................... $0 $0 $0 $0 $0 $0
New Jersey.................................. $0 $0 $0 $0 $0 $0
New Mexico.................................. $0 $655 $143 $4,929 $0 $0
New York.................................... $0 $0 $0 $0 $0 $0
North Carolina.............................. $0 $0 $0 $0 $0 $0
North Dakota................................ $0 $0 $0 $0 $0 $0
Ohio........................................ $0 $0 $0 $0 $0 $0
Oklahoma.................................... $0 $0 $0 $0 $0 $0
Oregon...................................... $0 $0 ($23) $0 $0 $0
Pennsylvania................................ $0 $0 $0 $0 $0 $0
Puerto Rico................................. $0 $0 $0 $0 $0 $0
Rhode Island................................ $0 $0 $0 $0 $0 $0
South Carolina.............................. $0 $0 $0 $0 $0 $0
South Dakota................................ $0 $0 $0 $0 $0 $0
Tennessee................................... $0 $0 $0 $0 $0 $0
Texas....................................... $0 $0 $0 $0 $0 $0
Utah........................................ $0 $0 $0 $0 $0 $0
Vermont..................................... $0 $0 $0 $0 $0 $0
Virgin Islands0............................. $0 $0 $0 $0 $0
Virginia.................................... $0 $0 $0 $0 $0 $0
Washington.................................. $0 $0 $0 $0 $0 $0
West Virginia............................... $0 $0 $0 $0 $0 $0
Wisconsin................................... $0 $0 $933 $0 $0 $0
Wyoming..................................... $0 $0 $0 $0 $0 $0
-----------------------------------------------------------------------------------------------------------
Totals:................................. $243,612 $3,899 $69,087 $10,998 $0 $1,658,504
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Emergency Nurse Rehabilitative
Hospital Critical Access Practitioner School Based Services (non- Private Duty
State Services Total Hospitals Total Services Total Services Total school-based) Nursing Total
Computable Computable Computable Computable Total Computable Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama..................................... $0 $0 $82,198 $0 $397,456 $0
Alaska...................................... $0 $0 $0 $0 $0 $0
Amer. Samoa................................. $0 $0 $0 $0 $0 $0
Arizona..................................... $0 $0 $176,757 $0 $13,167,925 $0
Arkansas.................................... $0 $0 $0 $0 $0 $0
California.................................. $0 $0 $0 $0 $0 $0
Colorado.................................... $0 $0 $0 $0 $0 $0
Connecticut................................. $0 $0 $0 $0 $0 $0
Delaware.................................... $0 $0 $0 $0 $0 $0
District of Columbia........................ $0 $0 $0 $0 $0 $0
Florida..................................... $0 $0 $0 $0 $0 $0
Georgia..................................... $0 $0 $0 $0 $0 $0
Guam........................................ $0 $0 $0 $0 $0 $0
Hawaii...................................... $0 $0 $0 $0 $0 $0
Idaho....................................... $0 $0 $0 $0 $0 $0
Illinois.................................... $0 $0 $0 $0 $0 $0
Indiana..................................... $0 $0 $0 $0 $0 $0
Iowa........................................ $0 $0 $0 $0 $0 $0
Kansas...................................... $0 $0 $0 $0 $0 $0
Kentucky.................................... $0 $0 $0 $0 $0 $0
Louisiana................................... $0 $0 $0 $0 $0 $0
Maine....................................... $0 $0 $0 $0 $0 $0
Maryland.................................... $0 $0 $0 $0 $0 $0
Massachusetts............................... $0 $0 $0 $0 $0 $0
Michigan.................................... $0 $0 $0 $0 $0 $0
Minnesota................................... $0 $0 $4,747,498 $0 $0 $0
Mississippi................................. $0 $0 $7,670 $0 $0 $0
Missouri.................................... $0 $0 $0 $0 $0 $0
Montana..................................... $0 $0 $0 $0 $0 $0
N. Mariana Islands.......................... $0 $0 $0 $0 $0 $0
Nebraska.................................... $0 $0 $0 $0 $0 $0
Nevada...................................... $0 $0 ($1,655) $0 $0 $0
New Hampshire............................... $0 $0 $0 $0 $0 $0
New Jersey.................................. $0 $0 $0 $0 $0 $0
New Mexico.................................. $0 $0 $0 $0 $0 $0
New York.................................... $0 $0 $0 $0 $0 $0
North Carolina.............................. $0 $0 $0 $0 $0 $0
North Dakota................................ $24,098 $0 $177 $0 $0 $0
Ohio........................................ $0 $0 $0 $0 $0 $0
Oklahoma.................................... $0 $0 $302 $0 $0 $0
Oregon...................................... $0 $0 $0 $0 $0 $0
Pennsylvania................................ $0 $0 $0 $0 $0 $0
Puerto Rico................................. $0 $0 $0 $0 $0 $0
Rhode Island................................ $0 $0 $0 $0 $0 $0
South Carolina.............................. $0 $0 $0 $0 $0 $0
South Dakota................................ $0 $0 $0 $0 $0 $0
Tennessee................................... $0 $0 $0 $0 $0 $0
Texas....................................... $0 $0 $0 $0 $0 $0
Utah........................................ $10,535 $0 $0 $0 $0 $0
Vermont..................................... $0 $0 $0 $0 $0 $0
Virgin Islands.............................. $0 $0 $0 $0 $0 $0
Virginia.................................... $0 $0 $0 $0 $0 $0
Washington.................................. $0 $0 $0 $0 $0 $0
West Virginia............................... $0 $0 $0 $0 $0 $0
Wisconsin................................... $0 $0 $0 $0 $0 $0
Wyoming..................................... $0 $0 $0 $0 $0 $0
-----------------------------------------------------------------------------------------------------------
Totals:................................. $34,633 $0 $5,012,947 $0 $13,565,381 $0
--------------------------------------------------------------------------------------------------------------------------------------------------------
IHS BY CATEGORY OF SERVICE
YEAR: 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
Health Home for
Freestanding Enrollees With Tobacco Other Care
State Birth Center Chronic Cessation for Services Total Total Total
Total Computable Conditions Total Preg. Women Computable Computable
Computable Total Computable
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama....................................................... $0 $0 $0 $47,078 $8,470,002
Alaska........................................................ $0 $0 $0 $16,366,151 $377,112,040
Amer. Samoa................................................... $0 $0 $0 $0 $0
Arizona....................................................... $0 $0 $0 $10,046,143 $590,270,498
Arkansas...................................................... $0 $0 $0 $0 $323,773
California.................................................... $0 $0 $0 $0 $48,511,089
Colorado...................................................... $0 $0 $0 $0 $4,647,392
Connecticut................................................... $0 $0 $0 $0 $2,796
Delaware...................................................... $0 $0 $0 $0 $0
District of Columbia.......................................... $0 $0 $0 $0 $0
Florida....................................................... $0 $0 $0 $0 $0
Georgia....................................................... $0 $0 $0 $0 $0
Guam.......................................................... $0 $0 $0 $0 $0
Hawaii........................................................ $0 $0 $0 $0 $0
Idaho......................................................... $0 $0 $0 $2,268,159 $2,434,170
Illinois...................................................... $0 $0 $0 $0 $0
Indiana....................................................... $0 $0 $0 $0 $0
Iowa.......................................................... $0 $0 $0 ($5) $1,119,291
Kansas........................................................ $0 $0 $0 $0 $2,085,198
Kentucky...................................................... $0 $0 $0 $0 $0
Louisiana..................................................... $0 $0 $0 $24,027 $24,027
Maine......................................................... $0 $0 $0 $1,685 $2,361,924
Maryland...................................................... $0 $0 $0 $0 $0
Massachusetts................................................. $0 $0 $0 $5,540 $228,829
Michigan...................................................... $0 $0 $0 $0 $3,700,883
Minnesota..................................................... $0 $0 $2,486 $1,459,050 $89,341,848
Mississippi................................................... $0 $0 $0 $130,583 $12,040,619
Missouri...................................................... $0 $0 $0 $0 $0
Montana....................................................... $0 $0 $0 $624,010 $64,576,972
N. Mariana Islands............................................ $0 $0 $0 $0 $0
Nebraska...................................................... $0 $0 $0 $64 $14,388,834
Nevada........................................................ $0 $0 $0 $0 $21,954,675
New Hampshire................................................. $0 $0 $0 $0 $0
New Jersey.................................................... $0 $0 $0 $0 $0
New Mexico.................................................... $0 $0 $0 $443,424 $185,245,700
New York...................................................... $0 $0 $0 $3,700 $56,063,822
North Carolina................................................ $0 $0 $0 $67,360 $12,622,759
North Dakota.................................................. $0 $0 $0 $1,170 $12,150,377
Ohio.......................................................... $0 $0 $0 $0 $0
Oklahoma...................................................... $0 $0 $0 $178,268 $129,477,113
Oregon........................................................ $0 $0 $0 $0 $17,397,527
Pennsylvania.................................................. $0 $0 $0 $0 $0
Puerto Rico................................................... $0 $0 $0 $0 $0
Rhode Island.................................................. $0 $0 $0 $0 $9,306
South Carolina................................................ $0 $0 $0 $0 $29,429
South Dakota.................................................. $0 $1,128,124 $0 $0 $69,761,618
Tennessee..................................................... $0 $0 $0 $0 $0
Texas......................................................... $0 $0 $0 $0 $55,036
Utah.......................................................... $0 $0 $0 $0 $3,803,046
Vermont....................................................... $0 $0 $0 ($623) ($596)
Virgin Islands................................................ $0 $0 $0 $0 $0
Virginia...................................................... $0 $0 $0 $0 $0
Washington.................................................... $0 $0 $0 $15,608 $93,019,449
West Virginia................................................. $0 $0 $0 $0 $0
Wisconsin..................................................... $0 $0 $0 $6,167 $20,383,867
Wyoming....................................................... $0 $0 $0 $0 $10,657,756
-----------------------------------------------------------------------------------------
Totals:................................................... $0 $1,128,124 $2,486 $31,687,559 $1,854,271,069
--------------------------------------------------------------------------------------------------------------------------------------------------------
Admiral Weahkee, you mentioned visiting Pine Ridge on your
second day on the job. Did that visit include a meeting with
the Tribal council?
Admiral Weahkee. Yes, sir. It did. In fact, we spent
probably two and a half hours or more sitting down with
President Weston from the Oglala Sioux Nation and four of his
council members.
Part of the Secretary's request was that we hear from them
firsthand what they have been experiencing with the care
provided at Pine Ridge and they definitely did not hold back.
Senator Udall. Yes, and they let you know how they felt
about it.
Admiral Weahkee. Yes, sir.
Senator Udall. Yes. Thank you.
Since you did not directly answer Senator Murkowski's
question about funding needed for the Great Plains, I am left
wondering would IHS have to pull resources from other service
areas to resolve this crisis?
Admiral Weahkee. Well, sir, we have had resources from
other locations such as staff members from Phoenix, subject
matter experts, if you will, providing their expertise to the
Great Plains area. We have had quality managers from the
Oklahoma City area.
So we are not moving money around, but we are definitely
sharing the expertise from throughout the rest of the agency
with the Great Plains, spreading those best practices and those
subject matter experts.
Senator Udall. Now at the Senate Indian Affairs hearing,
Admiral Buchanan, you told me that the leadership vacancies
were one of the main barriers to seeking CMS recertification at
the hospital.
Does Omaha Winnebago have a full leadership team in place?
Admiral Buchanan. They currently have a mixture of acting
and permanent in place currently.
Senator Udall. So they do have a full leadership team?
Admiral Buchanan. That is correct.
Senator Udall. Admiral Weahkee, can you assure this
subcommittee that IHS will seek CMS recertification of the
Omaha Winnebago Hospital before the end of the summer?
Admiral Weahkee. Just as quickly as we can, sir. I think
stable leadership is key. We are in a good place in Omaha
Winnebago in terms of conditions of participation. We are
close. End of summer we will be close.
Senator Udall. Yes, but you have it on an aggressive
timeline?
Admiral Weahkee. Yes, sir.
Senator Udall. Yes.
Admiral Weahkee. Absolutely.
CONSTRUCTION BACKLOG
Senator Udall. Mr. Hartz, I want to ask you a little bit
about the construction backlog.
I was pleased that this request includes $5 million to
support the design for a new facility in Alamo, New Mexico.
However, this budget cuts $99 million from facility's line
items when the IHS has an estimated backlog of $10 billion.
Some of the facilities on the bottom of the priority list,
including several in New Mexico, have been waiting for decades.
Others, like those in the Great Plains service area, have lost
accreditation because of the facility infrastructure issues.
Mr. Hartz, have you taken account of how far this cut sets
IHS back on getting through the priority list?
Mr. Hartz. Yes. Yes, I have.
You will note that in 2017, we got $117 million to address
projects and although funding the projects typically are being
phased, we were able to still stay on track with the projects
that we had identified to be moving along. That being the Rapid
City project, with a portion of the $100 million requested in
fiscal year 2018, will complete the funding needed for that
Rapid City facility. It will continue the funding for the
Dilkon Alternative Care facility.
As you have highlighted, Senator, we will have additional
resources going into Alamo that will allow us to wrap up the
design and take a look at any foundations work.
Because of the way Congress has provided us funding on many
of these projects on the phased approached, we look at how we
can move them along as that phased funding comes in. Because
with the priorities on healthcare delivery, it is really
difficult to fund $50 million, $150 million, a $200 million
facility project at one time.
So we have been able to manage this. It is a slow process
working down this list, but we really, really are making
inroads. We would be happy to share with you and the
subcommittee, how well we have progressed with the dollars we
have received over the years.
Senator Udall. Yes, and I am sure that if the $99 million
in cuts were restored to you, you could make progress on
additional items also.
VILLAGE BUILT CLINICS
Thank you very much, Madam Chair.
Senator Murkowski. Thank you, Senator Udall.
Let me ask about some of the Alaska-specific initiatives.
As you know, and I have discussed with many of your
predecessors here, Village Built Clinics have had an important
role in Alaska. We have about 150 in Alaska with most of these
being the only local option for healthcare. Most of them have
some pretty significant maintenance needs.
In the past, the agency took the view that the Tribes were
responsible for paying for these costs out of other funds that
they get from the Service.
In 2016, we included $2 million to help address this issue.
Last year, the administration put $11 million in its request
for these clinics, which this subcommittee fully funded. Then
this year's request takes us back to the 2016 amount of $2
million.
So a couple of questions here regarding VBC's is how the
agency plans to allocate the $11 million for fiscal year 2017?
When will these funds be distributed, and then just the
rationale for cutting back to the $2 million from the $11
million that had been requested?
What I am trying to figure out here is just what is a
sustainable level for us on an annual basis to fix the
maintenance issues that we have with these clinics? We felt
like we got our foot in the door back in 2016, but you cannot
do much with $2 million when you have a level of need as we
have within the State.
So if somebody can speak to the issue of where we are with
Village Built Clinics in this State?
Admiral Weahkee. Yes, ma'am. And definitely the VBC's or
the Village Built Clinics are an integral part of our Indian
Healthcare System.
I would like to ask Ms. Fowler to provide.
Senator Murkowski. Sure.
Ms. Fowler. So the $11 million, we do appreciate that those
funds were included in our fiscal year 2017 appropriation.
We have currently allocated $6 million to the Alaska area.
Two million dollars represents what was funded last year. And
so those are being allocated to the same clinics on a recurring
basis as last year.
The additional $4 million has been allocated to date. It is
undergoing Tribal consultation. There is about $6 million
specific to the Village Built Clinics.
There are additional Tribal clinic leases similar to the
Village Built Clinics that also require funding, and so that
meets the criteria for the funding.
The other $5 million in the meantime has been set aside to
determine, as we evaluate the need to fund those clinics, the
majority of which are in Alaska at this time. All of them are
in Alaska at this time.
And so, by the end of this fiscal year, we will be able to
give you a complete accounting of how those funds were
allocated.
Senator Murkowski. So do you think that by the end of the
fiscal year, you will have provided the schedule for the
remaining balance of the $5 million?
Ms. Fowler. Yes.
Senator Murkowski. Okay. And then to the question of what
do you believe could be a sustainable number on an annual basis
for meeting the maintenance needs for these Village Built
Clinics?
Ms. Fowler. So as I indicated, we have another group of
Tribal clinic leases that have emerged as funding need and we
are in the process of determining this, as some of the Village
Built Clinics actually cross over and are part of this other
group as well. And we are currently evaluating how much is
needed to fully fund those leases.
I believe that the last estimate for the Village Built
Clinics specifically was in the range of $16 million, if I am
not mistaken.
Senator Murkowski. So it would be helpful for me if we can
have that kind of an analysis in terms of what we have out
there, what the need is, and building a schedule if we can, so
that we can understand how we can best address this and mass
something going forward. I think that that would be helpful. So
if you would be willing to work with us on that.
AMBULATORY CARE PROGRAM
Ms. Fowler. We are willing to work with you on that.
Senator Murkowski. And then on our small ambulatory clinic
program, again, in fiscal year 2017 we had $5 million for the
small ambulatory clinic. This was the first time that we had
been successful in including money in the program since 2008.
It has been very helpful and successful as we have used funds
to construct facilities. We have them out in Chenega, Kay, and
Hooper Bay. We have also had many groups that are interested in
submitting proposals for the funds that are provided in fiscal
year 2017.
Can you tell me how many proposals you have received for
the funding and if any decisions on funding allocations have
been made yet?
Admiral Weahkee. Ma'am, we would like to ask Gary Hartz to
weigh in on this one
Senator Murkowski. Okay.
Mr. Hartz. Thank you, Senator.
As you indicated, the small ambulatory program is extremely
popular. And in fact in 2008, was when we did that last
solicitation, it is the competitive program as well. When we
did that solicitation, we got 67 applicants in varying levels
of need to complete their plans for small facilities.
Our dollars, which were appropriated to IHS for this
purpose, are often used to leverage other resources. And I can
come up with examples of leveraging that went up to six times
where $2 million was put in, which is the cap that we would
provide under this program, being part of a total funding
package that would run $10 to $12 million.
Where are we at on the solicitation for this year? I will
conservatively tell you that it will be on the street before
the end of the fiscal year. It will be done before that, but I
will tell you that based on the appropriations that passed and
the fact that it included money for small ambulatory, we are in
the final stages of review of the package to get it out on the
street for solicitations.
Senator Murkowski. Mr. Hartz, you have recognized that it
is popular, that there is a need. Unfortunately, the budget
proposal does not include funds in fiscal year 2018.
So again, this is an area where we think we have found a
way to help address some of the needs that we have,
particularly in our very remote and small areas. So I would
like to think that we would be able to continue a level of
support for our small ambulatory clinic program.
Mr. Hartz. All of the authorities provided are helpful in
addressing the needs across Indian country.
Senator Murkowski. Thank you.
Mr. Hartz. Thank you.
Senator Murkowski. Senator Udall.
Senator Udall. Admiral, I continue to have concern about
the Service's ability to effectively recruit and retain
qualified staff. I know that some of these facilities are
especially hard to recruit for since they are in extremely
remote areas.
I am disappointed that this budget does not invest more in
loan repayment and scholarship programs. I understand that
about one-third of qualified loan repayment candidates and 81
percent of scholarship applicants went unfunded in fiscal year
2015.
How many qualified applicants to the IHS loan repayment and
scholarship program were turned down because of lack of funding
in fiscal year 2016?
Admiral Weahkee. Sir, I do not have those numbers off the
top of my head. I can say that moving forward that we are
prioritizing the funding of both loans and scholarship awards
to individuals who are already in the pipeline, continuing
students.
I will ask Admiral Buchanan if he has any numbers off the
top of his head.
Admiral Buchanan. I am sorry. I do not have those numbers
off the top of my head, but we can definitely provide that
response for the record.
Senator Udall. Yes. Could you give us that for the record
and then also your best estimate on how many people on both
scholarship and the loan repayment program are not able to get
into that program?
[The information follows:]
how many people on both scholarship and loan repayment program are not
able to get into the program (under the budget proposal)
The fiscal year 2018 proposed budget includes a $5 million
reduction to the scholarship and loan repayment programs. In order to
prioritize direct healthcare services, these programs will scale back
on new awards and primarily focus on continuation of existing award
commitments. For example about 50 fewer scholarships would be awarded
to new awardees and about 100 fewer loan repayment contracts would be
executed.
Senator Udall. Thank you very much, Madam Chair.
Senator Murkowski. Thank you. I know that Senator Daines
has a time crunch, so we are going to let him in here.
Senator Daines. Thank you, Chair Murkowski, Ranking Member
Udall. Thank you. I appreciate it. Thanks for yielding too.
I share my colleague from Montana's outrage over the state
of affairs at IHS. Chairman Murkowski and Ranking Member Udall,
I am not sure I have met a Member yet who is satisfied
virtually in any way with IHS. And maybe we as leaders should
rename the agency Indian Health Suffering until they start
serving the people of Indian country again.
It is outrageous. It is heartbreaking. It is infuriating.
These are real families, single moms, single dads, aunts and
uncles, elderly Tribal leaders that are suffering greatly. It
is a tragedy.
As we look at Montana Tribes, these serious, sometimes dire
healthcare needs, they need adequate medical facilities. After
all, you cannot provide healthcare if you do not have
sufficient space to do it, as Chairman Murkowski and Ranking
Member Udall have just highlighted.
The Fort Belknap Indian Community, for example, needs
funding to expand their IHS clinic, which was constructed in
1998. It does not provide sufficient services according to an
IHS environmental health and engineering department evaluation
conducted just this May.
The Chippewa Cree Tribe, meanwhile, still needs millions to
rebuild much of their clinic, which was destroyed by a flood 7
years ago in 2010.
As you note in your budget justification, and I quote,
``The construction and modernization of IHS infrastructure
through healthcare facilities construction is essential to
improve healthcare, quality, safety, cost, and value.''
Admiral Weahkee, I know this has already been part of
today's discussion, but I would also like to ask, how do you
expect these needs to be met while proposing to cut funding to
the construction account? And what would you say to those
Tribes within enduring healthcare facilities construction
needs?
Admiral Weahkee. Thank you, Senator Daines.
I would like to first address what you started with, which
is the level of commitment within our agency. More than 70
percent of our staff of 15,400 employees are American Indians
and Alaska Natives themselves, so myself included.
The care that we are providing is very personal. It is our
families. It is our moms. It is our aunts. It is our daughters.
It is our wives. So we have one of the most committed
workforces that you can ever imagine.
Senator Daines. But let me just say, I do not dispute the
commitment. But having spent 28 years in business where I was
accountable for results, you can have the most committed team
in the world, and that is a good start. But what really matters
is outcomes and results, with all due respect.
Admiral Weahkee. Thank you, sir.
In terms of facility construction and maintenance costs, we
have our expert here who I will definitely turn to.
Again, drawing on my experience as a Chief Executive
Officer both in Phoenix and for a period at Rosebud, if you do
not have the funds available through your appropriated
accounts, you definitely rely on those third party resources to
take care of life safety, environment of care concerns.
I will ask Mr. Hartz if he has anything else to add in
terms of funding streams.
Mr. Hartz. Thank you, sir. Senator Daines, good to see you
again.
Senator Daines. Likewise.
Mr. Hartz. You and I probably think a whole lot alike as
engineers.
Senator Daines. We can form the geek caucus here, if you
would like.
FACILITIES
Mr. Hartz. We do provide products for the Indian Health
Service. The products that I provide are part of accessing
quality healthcare and that is the facilities that we build.
As you know, and all of you in the room probably know, 5-
plus years ago, the American Society of Civil Engineers put out
the report on the crumbling infrastructure across this country.
That covered roads. That covered wastewater treatment plants,
water plants. It covered everything related to infrastructure.
IHS has an infrastructure, as was pointed out earlier, in
the report to Congress that we provided in 2011 and that 5
years later we reported to Congress per the law and the
mandated report, we indicated what that need was for
facilities. It is $10.5 billion for existing plant for
replacement and expansion. And then the new authorities are
another $4-plus billion. So in that report a year ago, it
showed the need. There is no question about it.
When we come to presenting a budget, our priority is to
provide the highest level we can for healthcare to the American
Indian and Alaska Native with the resources available. You are
right. We had to look at where could we address.
Senator Daines. Yes, we are running out of time and thank
you for the civil engineering perspective here. I will be
working with the subcommittee----
Mr. Hartz. Okay.
Senator Daines [continuing]. For funding increases, so that
we can get the Chippewa Cree, the Fort Belknap, and the other
Montana Tribes' needs addressed.
INDIAN HEALTH BOARD--BILLINGS CONTRACT
As I am running out of time, I have one last question and
that is the Indian Health Board in Billings, Montana. On May 2,
the Indian Health Board of Billings closed until further notice
because the contract with IHS expired.
This program delivered ambulatory care, substance abuse
services, health education, and mental health and social
services to about 860 Tribal members living in the area.
When we can expect that to reopen?
Admiral Weahkee. Thank you, sir. I have become aware in the
first couple of weeks of this closure.
Admiral Buchanan is much closer to the specifics of the
Billings Urban Indian program and I would like to ask him to
respond.
Admiral Buchanan. Thank you, sir.
Of course, as you mentioned, the facility closed in April.
We have been working closely with those 846 patients that you
have identified. We have provided community and town hall
meetings to address some of their concerns. We provided
information and coordinated some of their care when the
facility closed. They are currently receiving care through
transporting them to the Crow service unit to provide that
care.
To specifically answer your question related to when will
that open. We are currently submitting a request for proposals
to reopen a similar type facility.
Senator Daines. When do we expect that to open, then?
Admiral Buchanan. It is currently going through the
contracting process.
Senator Daines. What is your best estimate?
Admiral Buchanan. It would just be a guess, so I would hate
to guess for you right now.
Senator Daines. A couple of months, a couple of years, a
couple hundred years?
Admiral Buchanan. Less than 2 months.
Senator Daines. Thank you. That brackets it. I appreciate
that.
Well, I urge you to get that back up and running as soon as
possible. Work with these affected Tribal members to ensure
they are receiving the care they need in the interim.
Thank you.
Senator Murkowski. Thank you, Senator Daines.
I just have a couple of more quick things and then we will
be able to wrap here.
MANILAAQ VS. BURWELL
There was a recent case involving a Tribal clinic in
Alaska. This is ``Manilaaq vs. Burwell,'' and it established
that Section 105(L) of the Indian Self-Determination Act
mandates payment of leasing costs when Tribal facilities are
used to operate IHS programs. But the budget proposal would
override this Section with the notwithstanding clause that
would make such lease payments entirely discretionary within
the agency.
Given that this language would affect one of the most
important statutes governing Indian country, the question to
you this morning is whether or not this proposal has been
shared with the Chairman and the Vice Chairman of the Senate
Indian Affairs Committee, both of whom are on this
subcommittee. Of course, Senator Udall is the Vice Chair and
Senator Hoeven is the Chair.
So has this been shared with the authorizing committee and
what is their view on this issue?
Admiral Weahkee. I am not quite up on the specifics of this
particular case. I will ask Miss Fowler to respond in our
behalf.
Senator Murkowski. Okay.
Ms. Fowler. Thank you for the question.
This is the group of leases that I mentioned in my response
about the Village Built Clinics. This has been emerging, it is
an emerging issue. It has not been shared with the authorizers
yet as we are still evaluating the impact and the full scope of
funding needs that would be associated.
Senator Murkowski. Let us separate it from the funding
needs. But do you think that it is reasonable that Indian
Tribes and Tribal organizations should essentially be required
to donate the use of their space to operate healthcare programs
that are a Federal responsibility according to this Federal
court decision?
Ms. Fowler. We do support the Indian Self-Determination and
Education Assistance Act fully. But the issue at this point is
the funding that is needed to implement it.
Senator Murkowski. Well, yes. Let us go back a little bit,
because we spent years arguing over Contract Support Costs.
What would happen is Contract Support Costs would be short-
changed, short-funded, and years of litigation, lots of money
spent on good lawyers to argue that case.
The Supreme Court comes back and says, ``Yes, in fact, you
do have to pay full funding for contract support costs.'' And
even with that directive, the budgets would come back at less
than full funding.
So we are finally, I think, beyond that where we have had
several years now of full funding. Again, I mention that we
have the language out there that says you cannot rob Peter to
pay Paul in the various accounts. So we have made headway
there.
I would like to think that we are not going to be going
down another path with the same situation where we acknowledge
that there is a Federal responsibility. There is a Federal
court decision that says, ``You need to do this.'' And we say,
``Well, we cannot do it because we are moving dollars in other
areas.''
So my hope is that we are not going to continue to spend a
lot of money with lawyers and courts, but that we will
recognize that there is a responsibility here on the Federal
side.
I am looking through the rest of my questions here and,
again, I come back to the concerns that so many of us have
raised on the panel here this morning. That with this budget,
whether it is the facilities and maintenance backlog that we
are dealing with and the real pressing need.
Whether it is the opioid crisis that is hitting our Native
people at astonishing rates; we see it all over the country. We
are looking at a 6 percent cut, almost $13 million, in the
budget for alcohol and substance abuse programs, within the
domestic violence initiatives.
Again, I think about the headway that we have been making,
that we must continue to make, and I find difficulty with this
budget in terms of how we can advance that.
So know that you have a lot of passion, a lot of energy, a
lot of purpose with this subcommittee to help you with delivery
of the services and the support for our Native people.
I look with great pride at what Alaska has done. You
mentioned the Nuka model. I think it is innovative and
pioneering in a way that the rest of the country should look.
If we want to reform our healthcare delivery, reduce costs,
increase satisfaction amongst patients and providers, look no
further than the Nuka model.
Unfortunately, we are not looking to the Nuka model. Other
nations are looking at it. But within our own IHS system, we
have allowed for that flexibility to do some astonishing and
great things.
With the joint venture program, we have some facilities
that are the model and the envy of providers and folks around
the country. You go to Nome. You go to Bethel. We have an
opportunity coming on in Bethel, but in other areas we have
seen some great things.
But I feel like within IHS, there are two worlds going on
here. Well, I have not had an opportunity to go out to Rosebud
or to Pine Ridge. It breaks my heart to think that we have such
disparities with how we are providing for healthcare for our
Native peoples. And so if it is greater flexibility that we
need, if we need to completely restructure the system.
I was speaking with my Ranking Member here. We have been on
the subcommittee here for a while. We both have been on Indian
Affairs, I think, since both of us came to the Senate. Year,
after year, after year, it is the same, sad story and the
frustration that Senator Tester has clearly portrayed here
today followed up by Senator Daines. We are not getting mad at
you as an individual.
There is anger. There is frustration, and rightly so,
because as a government, as an agency, we are failing these
people. And there is a lot of focus right now on healthcare
around the country and what we do to make it right. But in the
meantime, you have an injustice going on that is tucked away.
Look at how many people are in this hearing room. Ten. Who
is paying attention to the failures? Not enough and apparently,
that is why it is allowed to continue. But we cannot and we
will not. We have got to get the attention of some folks within
the administration. Maybe we need to get the President out to
Rosebud or Pine Ridge. Maybe that will make a difference.
But we cannot allow this to continue and there is a lot of
good will. I want to make sure that the people who have that
good will are reinforced, are given the support that they need,
and the belief in knowing that every day they are trying to do
the right thing.
So work with us on this. We have a lot to do.
Senator Udall, any follow up there?
Senator Udall. I think I am okay. Thank you very much.
Senator Murkowski. Okay. Thank you.
The hearing record will remain open for 10 days. Senators
may submit additional information or questions for the record
within that time if they would like. The subcommittee requests
all responses to questions for the record be provided in an
expedited manner.
CONCLUSION OF HEARINGS
Senator Murkowski. Thank you for being here and the
subcommittee stands adjourned.
[Whereupon, at 11:18 a.m., Wednesday, July 12, the hearings
were concluded, and the subcommittee was recessed, to reconvene
subject to the call of the Chair.]