[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.]