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


 
     DEPARTMENT OF THE INTERIOR, ENVIRONMENT, AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2019

                              ----------                              


                        WEDNESDAY, MAY 23, 2018

                                       U.S. Senate,
           Subcommittee of the Committee On Appropriations,
                                                    Washington, DC.

    The subcommittee met at 9:30 a.m., in Room SD-124, Dirksen 
Senate Office Building, Hon. Lisa Murkowski (Chairman) 
presiding.
    Present: Senators Murkowski, Daines, Udall, and Van Hollen.

                         INDIAN HEALTH SERVICE

STATEMENT OF REAR ADMIRAL MICHAEL D. WEAHKEE, ACTING 
            DIRECTOR
ACCOMPANIED BY:
        REAR ADMIRAL MICHAEL TOEDT, M.D., CHIEF MEDICAL OFFICER
        GARY HARTZ, DIRECTOR OF THE OFFICE OF ENVIRONMENTAL HEALTH AND 
            ENGINEERING
        ANN CHURCH, ACTING DIRECTOR OF THE OFFICE OF FINANCE AND 
            ACCOUNTING

              OPENING STATEMENT OF SENATOR LISA MURKOWSKI

    Senator Murkowski. Good morning, everyone. The subcommittee 
will come to order. Today we will examine the fiscal year 2019 
budget request for the Indian Health Service. I would like to 
thank Rear Admiral Michael Weahkee, the Acting Director for the 
Indian Health Service, for appearing before us today. I think 
we all know that the head of IHS is a tough job. It is a hard 
job, but it's also a very critical one for us, whether you're 
in Alaska, New Mexico, or wherever. Certainly, in Alaska, where 
healthcare for Alaska Natives is delivered through compacts 
between Tribal organizations and the IHS, we take a very keen 
look at all that goes on through IHS, and, Admiral, you 
certainly know that.
    Director Weahkee is accompanied by Rear Admiral Michael--am 
I saying it right, Toedt?
    Admiral Toedt. Yes.
    Senator Murkowski [continuing]. Who is the Chief Medical 
Officer at IHS. Gary Hartz has been before the subcommittee 
multiple times. He is the Director of the Office of 
Environmental Health and Engineering. And we're also joined by 
Ann Church, who is the Acting Director for the Office of 
Finance and Accounting. We welcome all of you.
    The IHS budget request for fiscal year 2019 is $5.4 billion 
for programs within this subcommittee's jurisdiction. This is a 
decrease of $114 million, which is 2 percent below last year's 
enacted level. The budget proposes to change the Special 
Diabetes Program, which provides $150 million annually from a 
mandatory spending program to one subject to the discretionary 
appropriations process. However, Congress has already passed 
legislation to maintain this program as mandatory funding for 
fiscal year 2018 and fiscal year 2019. This is a course going 
forward that I certainly support.
    I'm pleased that the budget request provides full funding 
for Contract Support Costs by maintaining the indefinite 
appropriations language that I first included in fiscal year 
2016 appropriations bill. This has helped provide certainty for 
Tribes and protected other IHS programs in case additional 
funds are needed to meet the Government's legal obligations.
    While this is an important area of agreement and this 
budget has less reductions than others we have seen in this 
subcommittee's jurisdiction, I am very concerned that the 
budget request does not adequately meet the needs for 
healthcare delivery in Indian Country.
    The facilities appropriation is cut by 42 percent from $867 
million to $506 million. This is a tough one for me to 
understand when we have a current backlog of facilities on the 
Service's construction list at over $2 billion. The total need 
for facilities construction across Indian Country is estimated 
at $14.5 billion. Again, you've got incredible need, and we're 
seeing a pretty significant cut being proposed.
    I'm also concerned that the budget does not adequately 
address the opioid epidemic. This has been especially acute for 
American Indians and Alaska Natives. Unfortunately, the 
statistics that we see are shocking, they're intolerable, and 
they must be addressed. According to the Service's budget 
justification, American Indians and Alaska Natives had the 
highest drug overdose death rates in 2015. Equally distressing, 
the justification shows a 519 percent increase in drug overdose 
deaths from 1999 to 2015, which is the largest percentage 
increase of any population out there. This population of our 
Native people are dying of overdose deaths at a greater rate 
and a greater percentage than any other population in the 
country.
    The CDC has also reported that American Indians and Alaska 
Natives consistently had the highest drug overdose death rate 
by race every year from 2008 to 2015. When we're looking at 
opioids specifically, overdoses have increased fourfold during 
this timeframe. I know it's an epidemic. It's hitting us all 
across America, but when we see the impact to this population, 
it does cause us to question what we are doing because it 
certainly is not adequate.
    Your budget request indicates that the IHS will receive 
$150 million if the overall $10 billion request for opioid 
treatment programs through the Department of Health and Human 
Services Department is provided. But given the scale of this 
problem in Indian Country, I would have preferred that these 
funds were requested directly within the IHS budget so that 
this subcommittee would have more control over ensuring that 
you have adequate resources to address this issue.
    For the last 2 years at these budget hearings, I have asked 
what steps the agency is taking to address the chronic problems 
with healthcare delivery in the Great Plains region, and I have 
yet to be convinced that the Service has put in place an 
effective plan to address this issue. At last year's budget 
hearing with you, Admiral Weahkee, we discussed at length an 
article that had just been published in the Wall Street 
Journal. It was an investigation that documented multiple 
instances of patient deaths and deplorable conditions at the 
Winnebago, Pine Ridge, and Rosebud Hospitals. The Centers for 
Medicare & Medicaid Services (CMS) removed the certification 
for some of those facilities so they could no longer bill 
Medicare or Medicaid. As of July of last year, the Winnebago 
Hospital had not received recertification from CMS, and the 
Rosebud and Pine Ridge Hospitals were still operating under 
System Improved Agreements with CMS. So I'll have an 
opportunity to ask further about that in my questions.
    In the omnibus appropriations bill, the subcommittee took a 
number of steps to address the situation in the Great Plains 
and elsewhere in IHS. We doubled the amount of funds to address 
accreditation emergencies from $29 million to $58 million. We 
provided $11.5 million for staffing quarters to alleviate 
housing shortages for healthcare professionals. And we gave the 
agency new statutory authority to directly pay for housing 
subsidies for medical personnel to help with recruitment and 
retention in remote locations like the Great Plains.
    I'll be asking you for an update on the situation there and 
what specific steps you're taking to address those problems. I 
think the reality is that this quality of care--and I wouldn't 
call it quality, I would say it's a shameful quality of care--
has gone on for far too long. I hope that this morning you'll 
be able to give some assurances to the subcommittee that the 
agency is on a path to finally resolve this situation. We have 
many questions for you. We appreciate your appearance before 
the subcommittee. I now turn to my friend and Ranking Member, 
the Senator from New Mexico.

                     STATEMENT OF SENATOR TOM UDALL

    Senator Udall. Thank you very much, Chairwoman Murkowski. 
And, Senator, you mentioned this whole issue of prescription 
drug and opioids, and I really look forward to working with you 
on that issue and working with our leaders at the Indian Health 
Service to see that we really tackle that issue.
    And I'm also happy to welcome the Acting Director of the 
Indian Health Service, Rear Admiral Michael Weahkee.
    Welcome back, Admiral Weahkee. I am very pleased to remind 
the subcommittee, my subcommittee colleagues, of your New 
Mexico roots.
    I'd like to acknowledge the other officials, which the 
Chairwoman also did, but I'll do it again: Rear Admiral Toedt, 
Rear Admiral Gary Hartz, and also Ms. Ann Church. Thank you all 
for being here with us today.
    I would also like to recognize the important work that my 
chair, Senator Murkowski, has done in support of the IHS 
budget. Since I joined this subcommittee in 2015, I'm proud 
that we have increased funding for the Indian Health Service by 
19 percent. We've done some good work, but we have much more to 
do.
    And speaking of that, let's turn to the budget. I 
appreciate that the administration's proposal for the IHS is 
relatively generous by comparison to the rest of the 
President's budget request, but the budget before us is still 
wholly insufficient to meet this Nation's trust and treaty 
responsibilities and provide quality healthcare to American 
Indians and Alaska Natives. All told, the budget decreases 
funding for the Indian Health Service by 2 percent.
    Within that amount, the budget does increase funding for 
contract support costs, which is very important. It also 
recognizes the need to pay for staffing for new healthcare 
facilities and the need to continue investments to address 
urgent accreditation issues at the IHS facilities in the Great 
Plains and, as of late last year, the Gallup Indian Medical 
Center in New Mexico.
    But to fund these priorities, the Executive takes an ax to 
other critical programs. Facilities programs are cut by 42 
percent. Line item construction funding that's needed to build 
hospitals and health centers for Tribal communities in New 
Mexico and other States have been waiting for decades is cut by 
two-thirds. Funding for the Indian Health Professions program, 
dollars that go directly towards filling vacancies and 
improving access to quality healthcare, are cut by 12 percent. 
Urban Indian programs, purchased and referred care, and self-
governance programs are all reduced. Preventive programs are 
cut in half, even though Native Americans face some of the 
biggest challenges when it comes to access to healthcare.
    And much to the dismay of many Tribes in New Mexico that 
I've heard from, the budget even proposes discontinuing Federal 
funding for community health representatives. These are Tribal 
members who provide essential healthcare services when health 
clinics are closed or too far away. These tradeoffs are 
unacceptable, especially when we think about the work that 
remains to improve health outcomes in Indian Country.
    Despite the fact that this subcommittee has fought to 
increase the Indian Health Service budget, we're still not 
where we need to be. We're still not providing all the 
resources on the ground we need to address preventive care or 
to attack the epidemic level of mental health and addiction 
issues that Native communities are fighting to overcome, which 
I think my chairman was very eloquent about in her opening. We 
still have an unacceptable number of facilities dealing with 
accreditation problems, a problem that seems to be growing 
instead of shrinking. We're still seeing double-digit vacancy 
rates for doctors, nurses, and other clinical personnel. And 
despite some important increases just gained in the omnibus, 
we're not making the progress we need to replace the Service's 
aging healthcare facilities. This is a matter of setting 
priorities, and my view is that this administration needs to 
work with Congress and make funding for Tribal health programs 
a greater priority.
    While we're talking about priorities, I also want to stress 
a subject that's important to all of us on this dais, and 
that's respect for government-to-government relationship that 
the United States Government has with Tribal nations. I have 
been deeply concerned by certain administration policies 
reflecting this relationship. This includes rejecting requests 
from Tribal leaders who ask to be exempted from State Medicaid 
proposals that would take healthcare coverage away from Tribal 
members who do not meet new work requirements.
    That's why I joined a number of Members in January of this 
year to write the Department. We questioned the Department 
rejecting the request based in part on the rationale that 
granting such requests would, and quote, this is the quote, 
raise civil rights issues, end quote. I recognize decisions 
related to Medicaid are made by the Centers for Medicare and 
Medicaid Services, and not the IHS, but the question of how the 
administration views government-to-government relationships 
with Tribes is much bigger and more significant than any one 
program or bureau. I want assurances that the Tribal leaders, 
and the Tribal leaders deserve assurances, that this 
administration views its relationship with Native Americans as 
trust-based, not race-based. Taking the latter position would 
reverse two centuries of law and Supreme Court decisions that 
have very firmly underscored the political nature of this 
unique relationship. That would be a nonstarter. I know that 
I'm not alone in this position, and I expect this 
administration will face stiff bipartisan opposition if it 
tries.
    It also bears emphasis that any changes that discourage 
Tribal participation in Medicaid would also impact the 
Service's bottom line. Thanks to Medicaid expansion under the 
Affordable Care Act, IHS has expanded access to healthcare for 
Tribal members and greatly increased its third-party 
reimbursements. So I would also have serious concerns, both 
legal and fiscal, and about any effort to limit the ability to 
use Medicaid funds to supplement IHS doctors--IHS dollars--and 
doctors, of course.
    I look forward to talking more about this issue and many 
others when it's time for questions.
    And thank you very much, Madam Chair. I yield back.
    Senator Murkowski. Thank you, Senator.
    With that, we will now turn to testimony.
    Admiral Weahkee, again welcome. And, ladies and gentlemen, 
thank you for being here.
    You may proceed, Admiral, with your comments. Do the other 
members of the panel also wish to make statements this morning?
    Admiral Weahkee. Just myself starting, ma'am.
    Senator Murkowski. Very good. Well, we will use them as 
your backup resources.
    Admiral Weahkee. Excellent.
    Senator Murkowski. Excellent. Why don't you proceed.

          SUMMARY STATEMENT OF REAR ADMIRAL MICHAEL D. WEAHKEE

    Admiral Weahkee. Thank you. Good morning, Chairman 
Murkowski, Ranking Member Udall, and Members of the 
subcommittee. I'm Rear Admiral Michael Weahkee, Acting Director 
of the Indian Health Service. I want to thank you for your 
support and for the opportunity to testify on the President's 
2019 budget.
    This budget advances our mission to raise the physical, 
mental, social, and spiritual health of American Indians and 
Alaska Natives to the highest level. And the IHS provides 
Federal health services to approximately 2.2 million American 
Indians and Alaska Natives from 573 federally recognized Tribes 
in 37 States.
    The President's fiscal year 2019 budget proposes $5.4 
billion in total discretionary budget authority for the IHS, 
which is an increase of $413 million above the continuing 
resolution, which was the comparison level at the time that the 
budget request was developed.
    The budget reflects the administration's strong commitment 
to Indian Country by protecting direct clinical healthcare 
investments. It increases IHS's discretionary budget authority 
by 8 percent. In order to prioritize direct clinical healthcare 
services, the budget also proposes to discontinue the Health 
Education Programs and the Community Health Representatives 
Program.
    The budget request includes $58 million to address 
accreditation emergencies within IHS and to improve the quality 
of care, $955 million for the Purchased and Referred Care 
program, $80 million for the construction of two facilities on 
the healthcare facility construction priority list, $159 
million to staff six new or replacement healthcare facilities, 
including three joint venture projects, and an estimated $822 
million to fully fund contract support costs, which remains a 
separate and definite appropriation to guarantee the full 
funding.
    The IHS remains committed to addressing behavioral health 
challenges, including high rates of alcohol and substance 
abuse, mental health disorders, and suicide in Native 
communities. The proposed budget for these services is $340 
million, and, further, the budget provides $10 billion across 
the entire Department of Health and Human Services to combat 
the opioid epidemic and serious mental illness. As part of this 
effort, the budget includes $150 million specifically for the 
IHS for grants based on need for opioid use prevention, 
treatment, and recovery support in Indian Country.
    The Special Diabetes Program for Indians is instrumental in 
improving access to diabetes treatment and prevention services 
in Indian communities. And diabetes-related health outcomes 
have improved significantly. The long-time trend of increasing 
rates of diabetes ended in the year 2011, and we've observed a 
54 percent decrease in new cases of kidney failure due to 
diabetes among Native adults. The budget continues funding for 
this program at $150 million.
    We're working aggressively to address the quality of care 
issues across our system, and in spite of ongoing challenges 
that we face involving recruitment and retention of providers, 
aging infrastructure, rural health facilities, we are able to 
report some progress.
    At the Pine Ridge Indian Hospital, a February CMS survey 
found the hospital to be in compliance with the condition of 
participation for emergency services. Since that time, the IHS 
has self-identified some additional deficiencies that will 
require more time for remediation before a full resurvey can 
occur.
    The Rosebud Indian Hospital satisfied the requirement of 
the Systems Improvement Agreement with CMS in September of 
2017. And we're now awaiting resurvey by the Joint Commission 
at that site.
    And at the Indian Health Service Omaha-Winnebago Hospital, 
we're actively working with both Tribes to discuss Tribal 
assumption of the hospital operations by this summer.
    We're also addressing concerns in the Navajo Area at the 
Gallup Indian Medical Center. Both the Joint Commission and the 
CMS have conducted surveys and found the hospital emergency 
department to be out of compliance with standards and 
conditions of participation. We moved quickly to address those 
findings, and efforts to restore accreditation of all their 
services surveyed by the Joint Commission continue. The 
facility is now awaiting results of a recent resurvey by CMS.
    We've achieved progress in the areas of oversight and 
management of quality at the national level and some key 
accomplishments include a credentialing and privileging, policy 
and process modernization, development of a standardized 
patient experience survey, and the establishment of primary 
care patient wait time standards.
    I'm proud of the efforts and commitment of the staff for 
the progress that has been made so far, and we're firmly 
committed to improving quality, safety, and access to 
healthcare for American Indians and Alaska Natives. We 
appreciate all of your support. And I'm happy to answer any 
questions that you may have. So thank you.

    [The information follows:]
         Prepared Statement of Rear Admiral Michael D. Weahkee
    Good morning Chairman Murkowski and Members of the subcommittee. I 
am Rear Admiral (RADM) Michael D. Weahkee, Acting Director of the 
Indian Health Service (IHS). Thank you for your support and for 
inviting me to speak with you this morning about the President's fiscal 
year 2019 budget request for the IHS. This budget supports and advances 
our mission to raise the physical, mental, social, and spiritual health 
of American Indians and Alaska Natives to the highest level.
    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 American Indians and Alaska Natives from 573 
federally recognized Tribes in 37 States. The IHS system consists of 12 
Area offices, which oversee 168 Service Units that provide care at the 
local level. Health services are provided through more than 850 
facilities managed directly by the IHS, by Tribes and Tribal 
organizations under authorities of the Indian Self-Determination and 
Education Assistance Act (ISDEAA), 41 Urban Indian health 
organizations, and through services purchased from private providers.
    Our budget plays a critical role in providing for a healthier 
future for American Indian and Alaska Native people. Likewise, it helps 
us maintain the progress we have made over the years. The President's 
fiscal year 2019 budget proposes $5.4 billion in total discretionary 
budget authority for IHS, which is $413 million above the fiscal year 
2018 Annualized Continuing Resolution, which was the comparison level 
at the time the budget request was developed. It also proposes Program 
Level funding of $6.6 billion, which is $263 million above the fiscal 
year 2018 Annualized Continuing Resolution.
               prioritizing clinical 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. The budget reflects the 
administration's strong commitment to Indian Country. Specifically, the 
budget protects direct clinical healthcare investments and increases 
IHS's discretionary budget authority by 8 percent. In order to 
prioritize direct clinical healthcare services and the staffing of 
newly-constructed healthcare facilities, the budget proposes 
discontinuation of the Health Education Program and Community 
Representatives Program.
    The budget requests an increased level of funding to address 
accreditation issues in the IHS system and improve quality of care. An 
additional $29 million is requested over the fiscal year 2018 
Annualized Continuing Resolution level for a total of $58 million in 
funding to assist IHS-operated hospitals that are at risk or out of 
compliance with the Centers for Medicare & Medicaid Services (CMS) 
Conditions of Participation. These funds will be used to address CMS 
findings and may be used to sustain operations of any affected service 
unit.
    The budget increases Purchased/Referred Care program funding that 
is essential for ensuring access to care by our patients by providing 
$955 million, which is $32 million above the fiscal year 2018 
Annualized Continuing Resolution. This program provides critical 
healthcare services through contracts with hospitals and other 
healthcare providers to purchase specialized or critical care when IHS 
and tribally-managed facilities are unable to provide the services 
directly. In addition, it supports high-cost medical care for 
catastrophic injuries and specialized care.
   alcohol and substance abuse, mental health disorders, and suicide
    The IHS remains committed to addressing behavioral health 
challenges, including high rates of alcohol and substance abuse, mental 
health disorders, and suicide in native communities. The proposed 
budget for these services is $340 million, which is $30 million above 
the fiscal year 2018 Annualized Continuing Resolution. Further, the 
budget provides $10 billion in new resources across HHS to combat the 
opioid epidemic and address serious mental illness. As part of this 
effort, the budget includes an initial allocation of $150 million for 
IHS to provide multi-year grants based on need for opioid abuse 
prevention, treatment, and recovery support in Indian Country.
                  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. These funds have been instrumental in improving access to 
diabetes treatment and prevention services for American Indians and 
Alaska Natives. Since 1997:

  --97 percent of American Indians and Alaska Natives have access to 
        diabetes clinical teams, a 67 percent absolute percentage 
        increase.
  --95 percent of American Indians and Alaska Natives have access to 
        culturally tailored diabetes education programs, a 59 percent 
        absolute percentage increase.

    These efforts have had an impact. Diabetes-related health outcomes 
have improved significantly in Indian communities since the inception 
of the SDPI. Within our communities, the longtime trend of increasing 
rates of diabetes ended in 2011. The diabetes program has proven 
successful and has contributed to a decline in new cases of kidney 
failure due to diabetes of 54 percent among Native adults from 1996 to 
2013. In addition, there has been an 8 percent reduction in the average 
blood sugar level of American Indians and Alaska Natives with diagnosed 
diabetes between 1997 and 2015. Improved blood sugar control reduces 
complications from diabetes.
    The SDPI grant program provides funding for diabetes treatment and 
prevention to 301 IHS, Tribal, and Urban Indian health programs. To 
ensure sustained and additional improvements for the health of American 
Indians and Alaska Natives, the fiscal year 2019 budget continues 
funding for this essential program at $150 million and shifts funding 
from mandatory to discretionary. Your continued support of these funds 
is saving lives, improving quality of life, and reducing the cost of 
care across Indian Country.
                    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. It also allows IHS to expand 
the provision of healthcare services by funding staff positions, 
purchasing new medical equipment, and maintaining and improving 
healthcare facilities.
 access to quality health care services through improved infrastructure
    The budget proposes $159 million for staffing of newly constructed 
healthcare facilities. This funding will support staffing and operating 
costs for three Joint Venture Construction Program (JVCP) projects: 
Muskogee (Creek) Nation Health Center, the Cherokee Nation Regional 
Health Center in Oklahoma, and the Yukon-Kuskokwim Primary Care in 
Alaska. Through JVCP agreements, IHS has partnered with the Tribes to 
provide funds for staffing and facility operations while the Tribes 
have invested in the design, construction, and equipment costs 
associated with the new facilities. These funds will allow the new 
facilities to expand access to healthcare.
    These funds also provide staffing for new or expanded IHS 
constructed facilities, including Hau'pal (Red Tail Hawk) Health Center 
in Arizona, the Fort Yuma Health Center Replacement, and the Northern 
California Youth Regional Treatment Center in California.
    The Health Care Facilities Construction budget includes funding to 
continue construction of two facilities on the priority list: the Alamo 
Health Center in New Mexico and the Dilkon Alternative Rural Health 
Center in Arizona. A total of $80 million is requested, $38 million 
below the fiscal year 2018 Annualized Continuing Resolution.
                  supporting indian self-determination
    The budget supports self-determination by continuing the separate 
indefinite appropriation account for contract support costs (CSC) 
through fiscal year 2019. 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 $822 million to fully fund CSC, which is $22 
million above the fiscal year 2018 Annualized Continuing Resolution 
estimate. 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.
                            quality of care
    We are working aggressively to address quality of care issues 
across our system. In spite of ongoing challenges involving recruitment 
and retention of providers, aging infrastructure, and rural health 
facilities, we are able to report progress.
    At the Pine Ridge Hospital, CMS notified us that its survey on 
February 13-15 found the hospital in compliance with the Condition of 
Participation for Emergency Services. Since that time, the IHS has 
self-identified additional deficiencies that will require time for 
remediation. We have also made several significant leadership changes. 
Following remediation activities, a full certification survey will be 
conducted by CMS to ensure compliance.
    At Rosebud Hospital, after satisfying the requirements of the 
Systems Improvement Agreement with CMS in September 2017, the hospital 
is preparing for Joint Commission accreditation this summer. Our 
application for survey was submitted to the Joint Commission in 
January, and we look forward to their review.
    The IHS Omaha-Winnebago Hospital is also in a transitional phase as 
discussions with local Tribes occur related to Tribal assumption of 
facility operations as early as this summer. We are actively working 
with Tribal leaders to discuss the status of the hospital and ensure 
maximum success as they exercise their self-determination rights for 
operation of the hospital.
    In the Navajo Area, we are addressing concerns at Gallup Indian 
Medical Center. Specifically, the concerns derive from a Joint 
Commission unannounced survey in November 2017 that also triggered a 
CMS survey in December 2017. The surveys found the hospital Emergency 
Department out of compliance with the Joint Commission standards and 
CMS Conditions of Participation. We moved quickly to address these 
issues, and the hospital remedied the findings. Efforts to restore 
accreditation of all services surveyed by the Joint Commission 
continue. The facility also shifted under CMS's survey authority for 
Medicare Program compliance and just received a full CMS survey.
    We developed the Quality Framework with Tribal input, and brought 
together people and expertise from across the Department of Health and 
Human Services to focus efforts on improving the quality of care and 
patient safety. The Quality Framework has been a blueprint for system 
level improvements of processes and infrastructure to improve quality 
and safety throughout the agency. We have achieved remarkable progress 
in the areas of oversight and management of quality, modernizing 
credentialing and privileging policy and processes (aided by new, 
system-wide software), accreditation master contracts for hospitals and 
ambulatory health centers, development of a standardized patient 
experience survey, and the establishment of primary care patient wait 
time standards. Following a year of implementation of the Quality 
Framework, IHS is moving toward sustainment of the gains and 
improvements with the development of a 5-year strategic plan to enhance 
quality in all aspects of agency operations.
    I especially want to thank the Congress for the funding that has 
been provided for accreditation emergencies. These funds have been 
critical to giving IHS the flexibility to address quality issues at 
impacted facilities and to offset lost third-party revenue, which is 
critical to the operating tempo of our facilities. The requested $58 
million will be used to build on the improvements we have made to date. 
IHS does not have another reserve of funding to meet any significant 
emergency or emergent issues, and our existing reserves are simply not 
designed to meet a challenge of this magnitude.
    Despite all of the challenges, we are firmly committed to improving 
quality, safety, and access to healthcare for American Indians and 
Alaska Natives, in collaboration with our partners in HHS, across 
Indian Country, and Congress. We 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.

                     RECERTIFICATION/ACCREDITATION

    Senator Murkowski. Thank you, Admiral. Let me begin; I'll 
just follow on what you have just now raised with regards to 
the facilities in the Great Plains. If I understand, Rosebud is 
in the process then of recertification, as well as Winnebago. 
Pine Ridge still has more work to be done before you can get to 
certification there. For purposes of the satisfaction of 
certification and then more work to be done, what kind of a 
timeline can you give me that these facilities are at a point 
that you would consider to be not only bare minimum, but that 
you're doing right by the Native people that you're serving 
there?
    Admiral Weahkee. Thank you, Senator Murkowski for that 
question. And I think it varies based on location. If you look 
at the Omaha-Winnebago site, I think our most challenging issue 
there has been with the recruitment and retention of permanent 
stable leadership. So the CEO position, the chief medical, 
chief nurse officer positions, really that's the top button for 
all of the other activities that need to be completed.
    So with the Winnebago Tribe proposing assumption of that 
site, they have already, through their own hiring process, 
obtained a new CEO, and they've got advertisements and plans 
together to bring on the rest of their C-Suite. Much of the 
work that has already been accomplished at the Omaha-Winnebago 
Hospital will prepare them to, very soon after assumption, 
obtain accreditation on their own.
    Senator Murkowski. We doubled the support for accreditation 
to address these accreditation emergencies, bumping it from $29 
million to $58 million in fiscal year 2018. Is this sufficient 
as you address these issues? Do you see the need for us to add 
to that or, because of the progress that you are seeing, will 
these costs that are required for this accreditation 
recertification decrease? I'm trying to understand where we 
need to be from a budget perspective.
    Admiral Weahkee. Thank you. Our current projections, we 
expect to utilize all of the funds that we've been provided, 
and this is somewhat of a difficult question to answer because 
we have a lot of unknowns out there. Again, the average age of 
our facilities being 40 years, many of the issues that we're 
contending with, a good example being at Pine Ridge, the 
heating and air conditioning system does not enable us to do 
enough air exchanges and maintain humidity controls, 
temperature controls, in the operating room suites, and this is 
a direct result of the facility being built in a previous era.
    The standards that we have to meet, the American Society of 
Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) 
standards, continue to get higher--continue to be a higher and 
higher bar. And so we have to meet the same standards in these 
40-year-old facilities that a facility that was just built 
yesterday has to meet. And so in some cases, that requires the 
complete renovation of the heating, ventilation and air 
conditioning (HVAC) system. So in a facility that's aged, 
Gallup being another great example, was built in the 1950s, our 
Phoenix facility was built in the late 1960s, at any time there 
could be a major catastrophic issue with a generating system or 
a heating and air conditioning system that is very expensive.

                                OPIOIDS

    Senator Murkowski. Let me shift to opioids. As I mentioned 
in my opening statement, what we're seeing with the opioid 
epidemic in Indian Country is just shocking. The efforts that 
you have outlined include $150 million devoted to opioids in 
the budget request. I mentioned that my concern is that these 
funds are not directly in your budget, but that you're relying 
on funds being appropriated to DHS, and then those funds being 
transferred to the agency. Is that correct?
    Admiral Weahkee. Not exactly. The funds that have been 
provided up to this point, the 2018 omnibus provided the 
Substance Abuse and Mental Health Services Administration----
    Senator Murkowski. Right.
    Admiral Weahkee [continuing]. With $50 million targeted to 
Indian Country. And we had been providing technical assistance 
to the Substance Abuse and Mental Health Services 
Administration (SAMHSA) about the mechanisms that we've used, 
the funding distribution formulas for our Special Diabetes 
Program for Indians (SDPI) program as an example, so that they 
can make the best use of those funds and get them out to help 
as much of Indian Country as possible. So there is no 
contemplation of moving that $50 million over to the Indian 
Health Service, but we are providing them with a lot of 
expertise and the way that we put money out to Indian Country.
    Senator Murkowski. Again, I'm not sure why we are not being 
more aggressive in this budget, in your budget, with regards to 
those resources directly to your budget rather than through 
DHS. My concern is if there is extraordinary need out there all 
over the country, and if you don't think that every one of us 
is not going to be fighting for a significant share of those 
dollars within the budget to go towards opioids, you know, you 
haven't talked to everybody else out there because it's very 
keen because the need is so high.
    My concern is that IHS will not get the resources that it 
needs. Again, we're talking about a population here that is 
more significantly impacted than any other population in the 
Nation right now. And so the fact that we would not be 
addressing it more aggressively to ensure that those dollars 
come here is a concern of mine.
    I have more that I want to speak to on this, but let me 
turn to my Ranking Member.
    Senator Udall. Thank you, Madam Chair.

                 GOVERNMENT-TO-GOVERNMENT RELATIONSHIP

    Admiral Weahkee, I mentioned in my opening statement that I 
am deeply concerned by some policy statements made by HHS 
officials that call into question the administration's views of 
the government-to-government relationship between the United 
States and Tribes. Specifically, I was alarmed to hear from a 
number of Tribal leaders earlier this year that CMS wrote a 
letter rejecting a Tribal-specific Medicaid request because it 
would, quote, ``raise civil rights issues''. I understand that 
CMS recently began walking back this statement as a 
mischaracterization, but I need, and the Tribes are rightfully 
demanding, more assurances that the administration understands 
the Federal Government's unique trust relationship with 
American Indians and Alaska Natives. And this is a pretty 
simple yes or no: Did you believe--do you believe that the 
Federal programs or policies undertaken for the benefit of 
Tribes are race-based?
    Admiral Weahkee. Thank you, Senator Udall. My simple yes/no 
answer would be, no, it's not only race-based, there is a 
special political and legal relationship between the Federal 
Government and American Indian Tribes.
    Senator Udall. And prior to Ms. Verma's most recent 
comments walking back CMS's civil rights issue statements, did 
you speak with her, Secretary Azar or anyone at HHS Office of 
General Counsel to educate them about the inaccuracy of 
describing Tribal-specific considerations as race-based?
    Admiral Weahkee. There has been robust conversation within 
the Department at all levels, including not only CMS, but also 
the Office of Civil Rights within HHS. We've also had our IHS 
Office of General Counsel heavily engaged in those 
conversations, educating and informing, and also at the 
Secretary's Tribal Advisory Committee meeting, of which he's 
had two since coming into office that he's participated in or 
that Deputy Secretary Hargan has participated in. There has 
been a lot of conversation with Tribes about this particular 
issue as well.
    Senator Udall. That's good. Well, I just--I would emphasize 
those of you in the Indian Health Service really educating the 
people in the rest of Government, especially CMS and HHS, which 
you work with all the time about these specific 
responsibilities and how, you know, this is in the 
Constitution, this is a relationship that's a longstanding one, 
and so we just--we just need to make sure they don't try to 
head down that road.

                        THIRD-PARTY COLLECTIONS

    This budget estimates that third-party collections at IHS 
will remain at $1.2 billion for fiscal year 2019 with more than 
two-thirds of that coming from Medicaid reimbursements. It's 
obvious that Medicaid, and specifically the Medicaid expansion, 
authorized under the Affordable Care Act, contributes 
significant funding toward Tribal healthcare. Medicaid is not a 
substitute for full funding for IHS, but until we can address 
funding shortfalls in the Service, Medicaid is one of the most 
important stopgaps we have. That's why I'm concerned that 
recent actions by CMS allowing some States to impose extra 
eligibility barriers would take away Medicaid access for Native 
communities.
    Admiral Weahkee, has IHS looked at the potential impact the 
proposals to take health coverage away from people who do not 
meet new work requirements could have on Native health systems? 
What about impacts on IHS's opioid response efforts or on 
Native families with school age children?
    Admiral Weahkee. Thank you, Senator Udall. Since last 
year's hearing, we've put a lot of investment and time and 
energy into the development of better business analytics, 
looking specifically at third-party reimbursements with a close 
eye on Medicaid reimbursements on a State-by-State and even at 
a facility-by-facility basis. We've leveraged some technology 
called Qlik, QlikView, which has enabled us to drill down into 
the data and look at the differences between Tribal programs 
that are within States that have expanded versus those that are 
not. And there's definitely--we can identify some trends in 
terms of better reimbursement in those States that did move 
forward with expansion.
    There are some anomalies in the data, a lot of asterisks 
and caveats, if you will. Our data is available through our 
fiscal intermediary, and only those Federal sites that report 
through that system are available to us, and a very small 
handful of Tribal sites.
    So a good anomaly to point out would be the State of 
Arizona, which had an expansion, and yet we saw a decline in 
our data in the amount of funding that was received, and that 
was a result of some of the large programs, like San Carlos and 
the Sells Hospital contracting or compacting their facilities. 
So they've moved outside of our datasets. And very likely if we 
had--if we were privy to their data, we would see an increase, 
but these are just the types of caveats that we've got to 
report.
    And, of course, we looked at the CMS data last year, and 
they don't get into the level of specificity that's helpful to 
us. They report out what is paid for American Indians and 
Alaska Natives at the State level regardless of which facility 
they receive their services in.
    Senator Udall. Yeah. And I also hope that you've spoken 
with CMS Administrator Verma about how the agency's efforts 
could repress healthcare access in Native communities. I think 
it's important for you and your team to educate them on how the 
Indian Health Service has really been lifted up by the 
Affordable Care Act.
    Thank you, Madam Chair.
    Senator Murkowski. Thank you, Senator.
    Senator Van Hollen.
    Senator Van Hollen. Thank you, Madam Chairman.
    And welcome to all of you.
    Admiral Weahkee, great to have you before the subcommittee. 
And I'm very proud of the fact that the Indian Health Service 
is based in Rockville, Maryland, and I look forward to 
continuing to work with you.

                           COMMISSIONED CORPS

    I have a couple questions as to how other parts of the 
administration's budget impact the operations for the Indian 
Health Service. One has to do with the role of the Public 
Health Service Commissioned Corps. I think the Ranking Member 
mentioned the large vacancy rate for clinicians at the Indian 
Health Service. The last data I've seen is for September 2016, 
which showed a 19 percent vacancy rate.
    So my first question is, Is there an updated figure for the 
vacancy rate with respect to clinicians? Are you still 
experiencing roughly 19 percent shortfall?
    Admiral Weahkee. Thank you, Senator. Yes, right about 20 
percent for all--all clinical professions, and much higher in 
some areas, such as physicians and PAs and nurse 
practitioners----
    Senator Van Hollen. Right.
    Admiral Weahkee [continuing]. Up to 34 percent in some 
cases.
    Senator Van Hollen. Thank you. My understanding is that in 
the last fiscal year, there were 1,869 members of the U.S. 
Public Health Service Commissioned Corps providing clinical 
care and managing IHS programs. There's not a line item 
anywhere in the entire budget for the Public Health Service 
Commissioned Corps. I just want to get your assessment of how 
important those officers are to providing health through the 
Indian Health Service.
    Admiral Weahkee. It cannot be overstated, in my opinion, 
sir. Being a member of the Commissioned Corps myself, three of 
the Members here at the table are either current or retired 
Commissioned Corps officers. We do employ approximately one-
third of all Commissioned Corps officers in the Federal 
Government within the Indian Health Service. And the manner in 
which those officers are paid are directly from the agency's 
budget or from the Tribes' budgets once they've 638'd their 
facilities. They pay through a memorandum of agreement, full 
cost recovery, for the use of those officers.
    Senator Van Hollen. Well, we're working in other 
subcommittees to make sure that the budget for the Public 
Health Service Corps is adequate.

                                MEDICAID

    I'm going to ask you a question that came up at the hearing 
last year with respect to the proposed administration cuts to 
Medicaid. The budget proposes getting rid of the Medicaid 
expansion. It also proposes deep cuts to Medicaid over the next 
10 years. It essentially tracks what is called the Graham-
Cassidy proposal on Capitol Hill. Every Member of this 
subcommittee, the Chairman, Ranking Member, myself, have been 
very concerned about the impact of Medicaid cuts on providing 
healthcare.
    And last year at this subcommittee hearing, I asked you, 
and I think Senator Tester asked you, for an analysis of the 
impact of the proposed administration Medicaid cuts on the 
services that are provided to individuals in Indian Country, 
because I believe--and let me know if this has changed--that 
about 70 percent of the third-party payers for healthcare come 
from Medicaid. Is that still correct?
    Admiral Weahkee. The most recent figure is 68 percent, sir.
    Senator Van Hollen. All right. So 68 percent of the third-
party payments come from Medicaid. So clearly cuts to the 
Medicaid program would have a harmful impact on providing 
healthcare through the Indian Health Service, right?
    Admiral Weahkee. We are very much reliant upon all third 
party including Medicaid specifically.
    Senator Van Hollen. So what I would like is an analysis, an 
actual analysis, of that impact. And last year I asked for that 
impact, and the Chairman of the committee said it would be 
important to have. It turns out that what we received was 
completely nonresponsive. I asked for an impact of the proposed 
administration Medicaid cuts, and the response I have, and I 
will share it with the Chairman and Ranking Member, didn't even 
mention Medicaid, right? It was just a reiteration of the 
budget of the Indian Health Service. So what I'm going to ask 
you today, and I hope the Chairman and Ranking Member will 
support this, is for you to give us, if you don't have it 
already handy, an analysis of what the impact of the Medicaid 
cuts proposed in this budget would be on your ability to carry 
out the mission of the Indian Health Service. Can we get that?
    Admiral Weahkee. As mentioned, there is a lot of variation 
State by State. We have invested heavily in our data analytics 
capabilities. We do have the ability to provide much better 
data than what was provided last year, and we'll be happy to 
provide you with a State-by-State or even facility-by-facility 
look.

    [The information follows:]
 medicaid reimbursements to indian health service--direct and tribally 
operated facilities as reported via cms 64 reports, fiscal year 2016 to 
                            fiscal year 2019
    For additional details regarding Medicaid, summary reports of each 
State's total IHS expenditures for the year from CMS, known as the 
``CMS 64 Reports,'' for fiscal year 2016-fiscal year 2019 has been 
prepared and is enclosed. The reports include Federal reimbursement to 
State Medicaid programs for services eligible for 100 percent Federal 
Medical Assistance Percentage provided by IHS and Tribal Health 
Programs operated under Public Law 93-638, the Indian Self-
Determination and Education Assistance Act. The reports identify State-
reported expenditures that include all adjustments for the year. 
Negative totals for the year may occur when the negative adjustments 
(amount of funds returned to CMS) are greater than expenditures claimed 
during that year. States may request adjustments in expenditures up to 
2 years after the respective quarter of expenditures. Regarding 
instances of relatively high year-to-year variability, States have 
flexibility in reporting expenditures to CMS and may need to make 
increasing or decreasing adjustment throughout the year which may 
affect the yearly total expenditures reported. In addition, as stated 
previously, States have up to 2 years to adjust their expenditure 
claims for prior quarters due to incorrect reporting issue or 
unreported claims.
    The enclosed report was created on December 2, 2019.

MEDICAID REIMBURSEMENTS TO INDIAN HEALTH SERVICE--DIRECT AND TRIBALLY OPERATED FACILITIES AS REPORTED VIA CMS 64
                                  REPORTS, FISCAL YEAR 2016 TO FISCAL YEAR 2019
                                             As of December 2, 2019
                                              [Amounts in Dollars]
----------------------------------------------------------------------------------------------------------------
                                                           Fiscal Year   Fiscal Year   Fiscal Year   Fiscal Year
                          State                               2016          2017          2018          2019
----------------------------------------------------------------------------------------------------------------
Alabama.................................................     8,470,002       435,062      -400,238         7,438
Alaska..................................................   377,112,040   557,109,533   678,881,269   718,667,999
Amer. Samoa.............................................             0             0             0             0
Arizona.................................................   590,270,498   684,469,755   667,663,919   750,806,090
Arkansas................................................       323,773       568,309       415,103       471,290
California..............................................    48,511,225    43,116,935    52,548,916    22,398,157
Colorado................................................     4,647,392     2,435,071     4,747,335     4,773,787
Connecticut.............................................         2,796         6,464        22,625        32,055
Delaware................................................             0             0        -1,076             0
Dist . Of Col...........................................             0             0             0             0
Florida.................................................             0             0             0             0
Georgia.................................................             0             0             0             0
Guam....................................................             0             0             0             0
Hawaii..................................................             0             0             0             0
Idaho...................................................     2,434,170     3,238,813     3,345,203     3,918,063
Illinois................................................             0           573             0             0
Indiana.................................................             0            -7             2             0
Iowa....................................................     1,119,291     1,620,331     1,829,339     2,500,777
Kansas..................................................     2,085,198     1,745,596     1,969,819       507,424
Kentucky................................................             0           -53             0             0
Louisiana...............................................        24,027           213           161         1,054
Maine...................................................     2,361,924     2,805,569     3,660,661     5,067,450
Maryland................................................             0             0             0             0
Massachusetts...........................................       228,829        23,723       235,281       469,195
Michigan................................................     3,700,883    14,296,929     8,753,307    17,843,628
Minnesota...............................................    89,341,848   101,903,551   144,506,324   155,425,892
Mississippi.............................................    12,040,619    11,847,852    11,338,167    11,662,456
Missouri................................................             0             0             0             0
Montana.................................................    64,576,972    91,531,956   116,875,715   128,589,320
N. Mariana Islands......................................             0             0             0             0
Nebraska................................................    14,388,834     6,427,877    11,853,911    16,352,794
Nevada..................................................    21,954,675    18,161,599    19,825,021    20,450,693
New Hampshire...........................................             0             0             0             0
New Jersey..............................................             0             0             0             0
New Mexico..............................................   185,245,700   308,778,309   160,660,683   194,165,488
New York................................................    56,063,822     1,958,788     2,050,730     2,142,373
North Carolina..........................................    12,622,759    13,582,123    16,809,483    19,762,701
North Dakota............................................    12,150,377    18,002,497    18,023,091    18,296,276
Ohio....................................................             0             0             0             0
Oklahoma................................................   129,477,113   184,245,949   218,388,948   242,473,797
Oregon..................................................    17,397,527    17,518,429    30,283,306    47,343,288
Pennsylvania............................................             0             0           -91        -5,759
Puerto Rico.............................................             0             0             0             0
Rhode Island............................................         9,306         4,048         1,104             0
South Carolina..........................................        29,429      -152,777       133,413        59,806
South Dakota............................................    69,761,618    71,644,245    84,500,585    95,059,750
Tennessee...............................................             0             0             0             0
Texas...................................................        55,036        36,104        57,936        50,512
Utah....................................................     3,803,046     8,158,050     5,160,024    10,792,539
Vermont.................................................          -596          -118             0             0
Virgin Islands..........................................             0           178             0             0
Virginia................................................             0             0      -266,685             0
Washington..............................................    93,019,449   110,365,845   138,328,274   141,366,086
West Virginia...........................................             0             0             0             0
Wisconsin...............................................    20,383,867    29,262,365    21,188,806    37,861,729
Wyoming.................................................    10,657,756    15,055,951    30,625,389    29,703,061
Other...................................................  ............  ............  ............  ............
                                                         -------------------------------------------------------
    Totals..............................................  1,854,271,20  2,320,205,63  2,454,015,76  2,699,017,20
                                                                     5             7             0             9
----------------------------------------------------------------------------------------------------------------


    Senator Van Hollen. Thank you. That would be very helpful. 
I know that you had just been recently sworn in last year, so 
I'm glad that in the meantime you've upgraded those 
capabilities because I really think it's important when we're 
having these conversations to know what the impact of a budget 
proposal will be. It may not be in this particular 
subcommittee, but it has a direct bearing, as you indicated----
    Admiral Weahkee. Yes.
    Senator Van Hollen [continuing]. Close to 70 percent, 68 
percent to be precise, of the payments that are received come 
from Medicaid. So I appreciate that and thank you for your--
thank you for your service, all of you.
    Admiral Weahkee. Thank you.
    Senator Murkowski. Senator, thank you for raising that. You 
know, just a year ago there was a lot of focus on various 
proposals that were being considered as we looked to address 
some aspects of the Affordable Care Act. One of my great 
frustrations at the time was trying to get exactly the data 
that you have referenced broken out that would be specific to 
my State, which has some unique issues when it comes to 
delivery of healthcare and the costs associated with it. And we 
could not get it--and it was not because people were 
stonewalling us, I think that they just really had not 
accumulated the data that was necessary to make an informed 
decision about the impact of the various proposals that were 
out there. As you know, I ultimately said I can't support any 
of them because I believe that this is not going to be good for 
me, but it could not be confirmed nor denied what that actual 
impact was going to be to our State. So being able to gather 
the data to be able to count on it, for CMS to be able to count 
on it, is very important, and I appreciate you raising that 
again.
    Senator Van Hollen. Thank you.

                                OPIOIDS

    Senator Murkowski. Let me go back to the issue of opioids 
and those issues that are facing us in Indian Country, and 
facing Alaska Natives. We talk about jobs and workforce 
development and education, but if we are dealing with a level 
of addiction that is debilitating to our communities, it makes 
it really hard to focus on a job, it makes it hard to focus on 
raising your kids, and it makes it hard to focus on education. 
Again, I mention my concerns about what we have in this budget 
with regards to specifically directed towards the opioid issue.

                  PRESCRIPTION DRUG MONITORING PROGRAM

    I want to raise an issue that has come to my attention 
based on conversations with providers up in the State of Alaska 
and in Senator Udall's State of New Mexico, relating to the 
Prescription Drug Monitoring Program. The PDMP, which is 
focused specifically on how we can deal with the problem of 
opioid prescriptions, and part of the problem is that if you 
don't know where an individual has gone before they have come 
to your facility in trying to access a prescription, then 
you're operating somewhat blindly. And we now have 
technologies, we now have the ability to interconnect within 
our systems to help us be smarter in how we track the 
prescriptions that are being written. And I think in Alaska, 
we're a pretty clear example of you have an IHS facility, 
you've got an emergency room out in the Mat-Su Valley, you've 
got a clinic, you've got a VA, a Community Based Outpatient 
Clinic (CBOC) that's there, and you could literally have an 
individual going from facility to facility to facility almost, 
if you will, venue shopping for prescriptions.
    It has come to my attention that within the State of 
Alaska, we've got the vast majority of hospitals and pharmacies 
that are participating in this system, they are being able to 
upload so that a doctor can tell when a patient already has a 
prescription. I'm told that within the VA, the DoD, and the 
IHS, there is reluctance to be a participant in what we are 
seeing in terms of the sharing through the PDMPs.
    DoD and VA we'll deal with. I understand they're coming 
along, but my information is that IHS has been resistant to 
participate. And the question is, is that so? And if so, why? 
Why would you not view this as a tool to really help those that 
are struggling with this addiction?
    If you can speak to that, Admiral, and tell me where we are 
and whether you believe that this could be an effective tool to 
combat opioid abuse.
    Admiral Weahkee. Well, thank you, Senator Murkowski. And 
just off the bat, I want to assure you that it's a misnomer 
that IHS is not supportive of reporting to PDMP and 
participating in a PDMP. In fact, back as far as 2016, we put 
in place a Prescription Drug Monitoring Program that requires 
all Federal Indian Health Service practitioners to check the 
PDMP.
    Dr. Toedt has participated in a panel specifically around 
opioids and can speak very specifically to our work in this 
area.
    Senator Murkowski. Okay.
    Admiral Toedt. Thank you for the question, Senator 
Murkowski. Certainly, IHS shares the concern about the opioid 
epidemic, and we appreciate all of the support that 
appropriators have given to IHS for connecting with PDMPs. We 
have--of our Federal pharmacies, 82 of the 83 pharmacies are 
connected, so we're all but one, and that last one we have a 
Memorandum of Agreement (MOA), or a Memorandum of Understanding 
(MOU), that's going through the process in Nebraska to connect 
our final Federal pharmacy. The connections for reporting 
happen, so the provider gives a prescription to the pharmacy, 
and the pharmacy reports that data to the State. And we know 
that in Alaska, our pharmacies are Tribal pharmacies, and we 
have checked with all of the Tribes in Alaska, and they are all 
able to connect and report their data to the PDMP.
    As far as the providers checking the PDMP to see 
prescriptions from other pharmacies and other providers, again, 
each of the States has a different process for access and 
different ability to do that. So the Alaska PDMP program, any 
licensed provider in the State of Alaska is able to register. 
Issues around perhaps individuals having licenses in other 
States or support staff and what delegations are allowed by 
what licenses. I think those are the details that need to be 
worked out. It's not just an IHS issue, it is a broader 
national issue about access.
    And also connectivity. So in border States, we know that 
the four corners area where you've got Colorado, Utah, Arizona, 
and New Mexico, that being able to access all of the data 
conveniently and in one way is extremely important.
    And it's much bigger than an IHS issue. We don't want to 
have a silo, separate, program that looks at our prescriptions. 
We entirely support connectivity and appreciate anything that--
you know, we will certainly participate and provide any 
technical assistance if there are additional resources.
    Senator Murkowski. Well, I appreciate that, and I would 
like to understand a little more clearly about how it all 
intersects, whether it's within Alaska or otherwise. I will 
just note that there's a couple people that have joined the 
subcommittee in the audience today, including emergency room 
physicians that are back here at a conference that were able to 
present to me yesterday, one from New Mexico, one from Alaska. 
And the information that I have received is a little bit out of 
sync with what you have outlined. So I would like to just 
better understand if it's an issue of licensure, or if there 
are things that we can do to again reduce these silos. 
Everything that I have seen leads me to believe that this is 
one tool, this is one way, that we can work cooperatively 
amongst our agencies with our providers, with our hospitals, 
with our pharmacies, to really get at this issue of 
prescription oversupply, if you will. If we can follow up with 
this and connect you with the folks that we've been talking to, 
I would greatly appreciate that. Thank you. Thank you.
    Senator Udall, and then we will go to Senator Daines.

                             MEDICAID CUTS

    Senator Udall. Thank you, Madam Chair. And let me just 
emphasize what was said earlier. You know, last year we all 
requested this information when it came to these Medicaid cuts 
and the impact repealing the Affordable Care Act would have. 
And when--it seems to me it's incumbent on you when you put 
forward a budget that has Medicaid cuts in it, you analyze all 
the impacts, and you're able to tell us specifically, very 
specifically, what impact is going to happen with specific 
facilities so that we can know what the result is going to be.

                       PREVENTIVE HEALTH FUNDING

    As I mentioned in my opening, I've heard from a number of 
Tribes in New Mexico who are particularly concerned about IHS's 
proposed budget that would cut preventive health funding by $81 
million from fiscal year 2018 levels, including a complete 
zeroing out of IHS Health Education and Community Health 
Representatives funding.
    As one pueblo leader recently reminded me, community health 
representatives come from the communities they serve, which 
means that they have the necessary cultural understanding to 
identify and respond to their members. That cultural 
understanding is key to addressing the toughest public health 
issues on the ground, including substance abuse and addiction. 
And I would note that one of the key pieces of combating the 
opioid epidemic is putting more resources towards prevention, 
both addiction prevention and prescription misuse.
    Admiral Weahkee, do you see a misalignment between the goal 
of addressing prevention as part of a comprehensive opioid 
response plan and cutting preventive healthcare funding at IHS? 
Could you talk about the importance of these preventive health 
programs in addressing the opioid crisis?
    Admiral Weahkee. Thank you, Senator Udall. And I'll start 
and then ask Dr. Toedt to support me in this as well.
    With regards to the proposed cuts for both the Community 
Health Representative and the Health Education Programs, there 
are some concerns that have been expressed internally with the 
data that was available to be able to justify that these 
programs were efficient, effective, and accountable. Since this 
proposal has been released, we've had robust discussions with 
Tribal leaders and other external stakeholders about the 
importance of the Community Health Representative (CHR) 
programs and how they play a major role in our interdependent 
system of care. And they are the ones who are out in the 
community checking on elders and others with chronic healthcare 
conditions in some of the most rural, remote locations.
    So I've come to realize that there's a significant concern 
with the workload not being reported adequately. And so we're 
not receiving a full picture of what's actually being done by 
the CHRs and the health educators. So our data identifies that 
we've had more than a million fewer encounters or patient 
visits. However, we do know that those 1,600-plus CHRs that are 
working hard every day are doing their jobs, but they may be 
documenting their visits on a paper, Patient Care Component 
(PCC) is what we call it. It's a paper document that identifies 
the work that they did. And that information may not be getting 
captured when they return to the service unit.
    Also, we have interconnectivity issues with different 
Electronic Health Records (EHRs) being used. Our CHR line, 
about 95 percent of the community health representatives have 
been contracted or compacted, and so the majority of that work 
is taking place in Tribal communities. And in the health 
education side, about 70 percent of the Health Education 
Program has been contracted and is being run by the Tribes. So 
I think we have a data issue in not being able to capture all 
of the work that is taking place. And I would ask Dr. Toedt to 
share a little bit more about some of the vital services that 
are provided by our CHRs and our system of care.

                    COMMUNITY HEALTH REPRESENTATIVES

    Admiral Toedt. So we definitely value our CHRs. So we have 
more than 1,600 community health representatives representing 
over 250 Tribes in all 12 areas. And we know that the services 
they provide include patient visits related to diabetes, 
dialysis, hypertension, nutrition, and heart services for 
elders. And we've heard loud and clear from Tribes that they 
value this program. The budget priorities were to prioritize 
direct care services and are no reflection on the value of the 
CHR program.
    Senator Udall. Yes. Thank you very much.
    And I would just emphasize again, I mean, I've heard from 
many of my Tribes, and I would just add--like to add several 
letters from my pueblos to the record, Madam Chair.
    Senator Murkowski. They will be included.

    [The information follows:]
        Letter From Dwayne Herrera, Governor, Pueblo de Cochiti

April 16, 2018

 
 
 
Congressman Steve Pearce                       Senator Tom Udall
2432 Rayburn House Office Building             110 Hart Senate Office
Washington, DC 20515                            Building
                                               Washington, DC 20510
 
Congresswoman Michelle Lujan Grisham           Senator Martin Heinrich
214 Cannon House Office Building               702 Hart Senate Office
Washington, DC 20515                            Building
                                               Washington, DC 20510
 
Congressman Ben Ray Lujan
2446 Rayburn HOB
Washington, DC 20515
 


Re:  The Elimination of IHS Community Health Representative (CHR) and 
Health Education programs in President's 2019 IHS Budget.

Dear Honorable Senators, Congresswoman, Congressmen:

    As the Governor of the Pueblo de Cochiti, I write this letter based 
on the understanding that the President's 2019 IHS Budget has 
eliminated the Community Health Representative (CHR) and the Health 
Education line items. In a small rural reservation like Cochiti Pueblo, 
I know the CHR program allows us the only health providers that we have 
to address almost all of our health issues. They are the only health 
providers that live in our community and provide all types of services 
or give the community the knowledge and access to services. This Pueblo 
only receives 2 primary care clinic days a week from the Indian Health 
Service. The CHRs are available for many and any health questions we 
have as Tribal leaders and educate us about Obamacare, Medicare, IHS, 
MCOs and any research and outside providers giving our community 
members healthcare. They have been doing this since the program was 
started in 1968. We recently testified about the CHR program 
elimination at the DHHS Tribal consultation but to date, have not heard 
any response from the agency. Therefore let me re-emphasize some 
critical points of both line items by the following points:

  --The CHR program is a 50 year old line item in the IHS. The CHR 
        program is authorized under the Indian Health Care Improvement 
        Act (IHCIA) and this legislation is now permanent Federal 
        legislation. Attached is the NMSCCHRA testimonies and the 
        Pueblo wholeheartedly support both testimonies. As Tribal 
        leaders we expect Federal agencies to follow funding guidelines 
        established by Appropriations Committees especially those line 
        items that have a significant Tribal impact nationally.
  --The CHR program is familiar to all Tribal members and use the CHRs 
        for their various health issues and needs. The Cochiti CHR 
        program has always been administered, operated and staffed by 
        `Community based' Tribal health providers under our Public Law 
        93-638 contract. The CHR program is a basic public health 
        service providing direct medical services, prevention and 
        intervention under the Pueblo's management structure. We have 
        daily access to our CHR staff as they speak our Tribal language 
        and know all the community members of Cochiti Pueblo. The 
        Cochiti staff serve as dental assistants, enrollment guides for 
        Medicaid, Medicare and Private insurance, Emergency Management 
        coordinators, health educators, transportation to dialysis/
        medical appointments, translators, homecare advocates and many 
        other community health services that are started and completed 
        by the staff.
  --Cochiti is a small Tribe and not a gaming Tribe. We rely on Federal 
        funds to not only provide services but also have benefitted 
        from the Public Law 638 funding including Contract Support 
        Costs funding--Direct Contract support and Indirect Cost on a 
        yearly basis. The overhead funds pays for the Tribal 
        leadership, HR, Finance, Housekeeping salaries in addition to 
        facilities and Other administrative costs such as audits, 
        trainings, travel, supplies out of Indirect costs. For a small 
        Pueblo like Cochiti, it sustains and impacts our Tribal 
        government immensely. I can attest to the fact that I rely on 
        the CHRs on assistance and clarification when outside health 
        agencies, governments, vendors, MCOs, IHS, Veterans 
        Administration and other interested health partners approach 
        our Tribal administration. Our staff are community members and 
        I trust their input on health matters and services.

    The elimination of the two line items will have a major impact to 
the Pueblo de Cochiti as our Public Law 638 contracted programs. As the 
Governor of Cochiti Pueblo, I respectfully request the CHR and Health 
Education line items remain in the IHS budget and be increased in the 
overall IHS budget. Furthermore, I support the two testimonies 
submitted by the NMSCCHRA which are attached with this letter.

Respectfully submitted,


Dwayne Herrera, Governor
Pueblo de Cochiti
                                 ______
                                 
        Letter From Glenn Tenorio, Governor, Pueblo of Santa Ana

May 7, 2018

 
 
 
Chairman Lisa Murkowski
Senate Interior Approps. Subcommittee
131 Dirksen Senate Office Building
Washington, DC 20510
                                             Chairman Ken Calvert
Ranking Member Tom Udall                     House Interior Approps.
Senate Interior Approps. Subcommittee         Subcommittee
131 Dirksen Senate Office Building           2007 Rayburn House Office
Washington, DC 20510                          Building
                                             Washington, DC 20515
 
 


Re:  Maintaining Community Health Representatives and Health Education 
Funding in the Fiscal Year 2019 Federal Budget

Dear Honorable Senators and Representatives,

    I write to you today on behalf of the Pueblo of Santa Ana to 
express our support for the Community Health Representative (CHR) and 
Health Education programs administered by the Indian Health Service 
(IHS) as part of its Preventive Health Services. CHR and Health 
Education programs provide critically needed and culturally responsive 
healthcare services to our Pueblo, as well as to American Indian and 
Alaska Native (AI/AN) communities across the Nation. To further the 
twin goals of promoting AI/AN health and advancing Tribal self-
determination, we respectfully urge you to maintain full funding for 
the CHR and Health Education programs in fiscal year 2019.
    Background. The CHR program is authorized under the Indian Health 
Care Improvement Act to advance community welfare through the 
development of an AI/AN paraprofessional healthcare workforce. Tribal 
governments contract with the IHS under Public Law 93-638 (638) 
contracts to manage the program and train CHRs to meet their Tribal 
members' specific needs. Today almost CHRs serve in over 250 Tribal 
communities across the country. CHRs provide medical assessment 
screening, vital signs monitoring, health education, and transportation 
to appointments, among other services. CHRs are seen as trusted sources 
of basic medical and disease prevention services because they are often 
recruited from and placed in their home communities. Their unique 
knowledge of local cultural norms and practices, coupled with their 
high-quality medical training, make CHRs an invaluable asset in the 
Indian healthcare system.
    CHRs Provide an Array of Critically Needed Services in Indian 
Country. Zeroed out or reduced funding of the CHR and Health Education 
programs would cause significant harm to the Santa Ana people, who 
already suffer from high rates of diabetes and other serious medical 
conditions along with a lack of reliable access to quality healthcare 
facilities. Given the chronic underfunding of the Indian healthcare 
system, access to CHRs has been critically important to our people. 
Congress has taken steps to diversify the types of services available 
in our home communities by establishing the CHR program within the IHS 
and granting Tribal nations the authority to administer and manage its 
services. CHRs reduce incidences of disease and illness by providing 
the following services, among others:

------------------------------------------------------------------------
                            Preventive Health
Direct Medical Services          Services          Intervention Services
------------------------------------------------------------------------
Patient home visits      Community health         Home safety
Diabetes monitoring       education                assessments
Emergency care           Promotion of health      Monitoring chronic
 coordination             literacy                 conditions
Immunization clinics     Educational campaigns    Child safety
Translation services      on:                      assessments
Transportation to          --Mental health        Traffic and playground
 appointments              --Behavioral health     safety
Health screenings          --Healthcare benefits  Medication monitoring
Community first aid        --Elder and child      Environmental
 training                 abuse                    assessments
Elder health monitoring    --Sexual health        Third-party payer
Caregiver and hospice      --Public health         issues
 support                  crises                  Insurance and federal
Medicaid/Medicare          --Disease prevention    services
 enrollment                                       Reporting patient
                                                   health
                                                  Motivation and
                                                   encouragement
------------------------------------------------------------------------

    The value of these services cannot be overstated. Access to care is 
a notorious and well-documented challenge in Indian Country, especially 
in rural and remote communities. Because they are based in the local 
community, CHRs are available--often around the clock--to provide care 
to Tribal members. CHRs also serve as the point of contact on behalf of 
patients with many outside healthcare providers, including the IHS, 
Department of Veterans Affairs, and managed care organizations.
    Elimination of CHRs and Health Education Programs Harms Tribal 
Communities. We are deeply troubled by the President's proposal to zero 
out the CHR and Health Education line items of the IHS budget in fiscal 
year 2019. CHR programs are only operated by Tribal governments 
pursuant to 638 contracts--there is no other CHR workforce within the 
IHS. As a result, elimination of the line item funding for CHRs and 
Health Education would shift the entire financial burden for operating 
these programs to Tribal governments that are already dangerously 
under-resourced in many cases. Without Federal funding, the health and 
welfare of our communities will necessarily be harmed as the 
fundamental core of our community health system will cease to exist.
    Support for the CHR Program Advances Tribal Self-Determination. 
Tribal nations have benefitted from Public Law 93-638 funding to manage 
and carry out critical services in Indian Country. Annual Contract 
Support Costs have been a financial engine in driving self-
determination projects, especially for smaller Tribal nations. 638 
funds support local Tribal governments, human resources, financial and 
administrative services, and the salaries of associated program staff, 
including CHRs. Maintaining full funding for the CHR program in fiscal 
year 2019 would further these efforts and advance the United States' 
policy of advancing the interests of Tribal nations on a government-to-
government basis.
    Stand with Tribal Health by Maintaining Full Funding for CHRs and 
Health Education in Fiscal Year 2019. CHRs serve as the cornerstones of 
health in Indian Country. If Federal funding for these positions is 
eliminated or significantly reduced, we are afraid that the entire 
healthcare system of our Pueblo will be destabilized, putting our 
people at unacceptable risk. We respectfully, yet strongly, urge you to 
reject these proposals and maintain full funding for the Community 
Health Representative and Health Education programs in the fiscal year 
2019 budget.
    On behalf of my people and my Pueblo, we thank you for the 
opportunity to share our deep concerns on these pressing issues. We 
appreciate your hard work and dedication to protecting the interests of 
Indian Country in the annual formulation of the Federal budget. Please 
know that our Pueblo stands ready to work with you on addressing these 
critical matters going forward.



                                 ______
                                 
          Letter From Russell Begaye, President, Navajo Nation

May 21, 2018

 
 
 
Chairwoman Lisa Murkowski                    Ranking Member Tom Udall
Senate Appropriations Committee              Senate Appropriations
Interior, Environment, and Related            Committee
  Agencies                                   Interior, Environmental,
131 Dirksen Senate Office Building            and Related
Washington, DC 20515                           Agencies
                                             131 Dirksen Senate Office
                                              Building
                                             Washington, DC 20515
 


Re:  Fiscal Year 2019 Budget Cuts to Community Health Representative 
Program

Dear Chairwoman Murkowski and Ranking Member Udall,

    On behalf of Navajo Nation, the largest land-based Tribe in the 
United States, I am requesting your support to fully fund the IHS 
Community Health Representative (CHR) and Health Education Programs in 
opposition to the President's Proposed budget fiscal year 2019 that 
recommends eliminating funding for the programs. The CHR program has 
been in existence since 1968 and has been highly effective for 
preventative health measures on the Navajo Nation.
    As the President of the Navajo Nation, we represent a Tribe that 
spans over 27,000 square miles across three separate States with over 
300,000 enrolled members. Today, the Nation suffers from unemployment 
rates of 42 percent and one third of our households have annual income 
levels dipping below $15,000. These shocking statistics illustrates our 
need for continued Federal funding for healthcare services for Navajo 
citizens, including the vital community-based CHR and Health Education 
programs.
    The Navajo CHR Outreach and Health Education programs initiated the 
extension of the Indian Health Service's (IHS) service delivery to the 
Navajo People who reside in 107 communities in eight Navajo Area IHS 
Service Units. In fiscal year 2017, the program treated about 8,000 
people and was highly successful in both preventing disease and 
promoting healthy lifestyle choices.
    Our CHR and Health Education program is the largest in Indian 
Country and includes the following programs: Community Health 
Representative (CHR) Program; Tuberculosis Control (TB) Program; Injury 
Prevention; Maternal Child Health education; Social Hygiene Program; 
Navajo Birth Cohort Study Project; Oral Health Initiative; Johns 
Hopkins Family Spirit, Emergency Response FEMA, Suicide Post-Vention 
Team; Substance Abuse Education Program; Youth Risk Behavior 
Surveillance Survey; and Sexually Transmitted Disease (STD) Prevention 
Program. Each of these programs represent necessary services delivered 
directly to Navajo people.
    In fiscal year 2018, IHS allocated $157 million to all federally 
recognized Tribes for preventative health services, including funding 
for CHR and Health Education. IHS allocated $18.3 million to Health 
Education and $58.9 million to CHR, which is $1.23 million increase 
above the fiscal year 2017 appropriation. However, in the President's 
fiscal year 2019 budget request, funding for both the Community Health 
Representative and Health Education programs has been eliminated. The 
elimination of this funding would have significant negative impacts on 
Navajo Nation. Currently, the CHR and Health Education Outreach Program 
is the only Tribal program that conducts STD/HIV/AIDS education, HIV 
Screening, Counseling, Referral, and correctional facilities services. 
Between 2014-2017, Navajo Health Education Program (NHEP) has exceeded 
target benchmarks in HIV Screening and Education by reaching over 
17,000 of our Navajo youth. Additionally, the program has provided more 
than 307,000 individuals with prevention education services during 
these same years that has resulted in keeping the infectious diseases 
(TB and STD) to a minimum and preventing outbreaks.
    These are only a few of the positive contributions that the Navajo 
CHR and Health Education Outreach Program has contributed to our 
community and reduction in healthcare costs through preventative 
measures. The Navajo Nation is thankful for the partnership and support 
of this vital program that provides the funding that is necessary for 
preventative health measures and health education for our citizens.
    We strongly advocate that the Community Health Representative and 
Health Education Program funding for fiscal year 2019 is not eliminated 
and it remains funded at current levels to make progress on 
preventative health measures. We appreciate your time and attention to 
this matter. If you have any questions, you or your staff can contact 
the Navajo Nation Washington Office executive director Jackson Brossy 
via email or phone: [email protected] or (202) 682-7390. Thank you.



    Senator Udall. Thank you.

                      GALLUP INDIAN MEDICAL CENTER

    A couple of questions about the Gallup Indian Medical 
Center. I know my time is running out here, but, Admiral 
Weahkee, I remain concerned about the continued identification 
of deficiencies in some IHS facilities, including the Gallup 
Indian Medical Center, which would put their accreditation 
status at risk. This subcommittee asked for a formal report and 
update on the situation in Gallup, and we look forward to 
getting that report, but I'd still like to get an update from 
you this morning on where things stand. So could you give me 
just a brief update on that? And then I'll follow up with some 
additional questions.
    Admiral Weahkee. Yes, sir. Thank you, Senator Udall. I 
think the best report is an objective report, which is we just 
recently had CMS in the facility 2 weeks ago. They came in with 
11 surveyors, a very robust team, and spent an entire 5 days 
onsite. At their verbal closeout, there were no reported 
EMTALAs, no reported immediate jeopardy findings. We are still 
awaiting their written report. There's not always congruence 
between the verbal closeout and the written report, but we are 
waiting to see what is put to print. A very thorough more than 
400 man-hours of review were conducted, and we believe we're on 
track to have both Joint Commission certification--or Joint 
Commission accreditation and CMS certification back in place at 
Gallup in the very near future.
    Senator Udall. Great. Thank you very much.
    Thanks, Madam Chair.
    Senator Murkowski. Senator Daines.
    Senator Daines. Thank you, Chairman Murkowski and Ranking 
Member Udall. I'm proud to join my colleagues in leading the 
charge to improve the IHS through the Restoring Accountability 
in the Indian Health Service Act. This bill would improve 
transparency, it would improve accountability, it would improve 
recruitment and retention of personnel within the IHS system. 
This is the most comprehensive legislation pending before 
Congress to reform a broken system, but it's going to need some 
bipartisan support to go anywhere in this chamber. I'm asking 
my colleagues on both sides to support this bill.
    Regarding the additional $150 million to combat opioid 
abuse, I see that Chairman Murkowski has already brought this 
up, and I want to ensure that the more pressing drug crisis 
among Montana's Tribes gets the attention it needs, and that's 
meth. Let me illustrate what this problem looks like for you in 
my State of Montana.

                            METHAMPHETAMINES

    The Fort Belknap Indian Community is currently in a state 
of emergency due to the meth crisis on the reservation. In 
discussing their healthcare needs, the Fort Peck Tribes 
describe their reservation as, and I quote, ``plagued by 
methamphetamine abuse,'' and then they state, ``this drug has 
destroyed families and is tearing at the very fabric of [their] 
society.'' That's why I introduced the Mitigating METH Act, 
which was the first bipartisan legislation to propose that 
Indian Tribes be included as direct beneficiaries of funding 
authorized by the 21st Century Cures Act to combat opioid 
abuse. My bill also proposes that that funding also be made 
eligible to combat meth.
    Admiral Weahkee, will any of the new proposed opioid 
funding help combat meth use, too?
    Admiral Weahkee. Thank you for the question, Senator 
Daines. One of the first objectives that we expect to conduct, 
should we receive the $150 million, is consultation with our 
Tribes to hear firsthand from them where they see the funds can 
best be used. And in the proposal, we identify use for 
prevention, treatment, and recovery support specific to opioids 
in this case, but through consultation, I would expect to hear 
needs such as those expressed by the Tribes in Montana. We also 
hear from other Tribes that heroin is still a significant 
concern as well as alcohol. So we know that we have a lot of 
afflictions within our communities.
    We also have an existing Substance Abuse and Suicide 
Prevention program, which is available to Tribes as a grant. We 
just kicked off consultation with our Tribes about putting 
those funds out through a different mechanism other than 
competitive grants. And, again, the Tribes have a lot of 
discretion in the use of those funds----
    Senator Daines. So just to be clear, if the Tribal 
consultation suggests that meth is the issue, and the resources 
need to be devoted toward fighting that epidemic, the answer is 
you would work with them to be able to do that?
    Admiral Weahkee. Yes, sir. I believe we have the discretion 
and latitude to be able to do it.
    Senator Daines. All right. Thank you.

                                SUICIDE

    I want to shift gears and talk about another very sobering 
issue, and it's not unrelated to the issue of meth in Montana 
in our Tribes, and that's suicide. Montana's Native youth ages 
11 to 24 commit suicide five times the statewide suicide rate 
for the same age group. And we also know that Native youth 
suicide goes underreported.
    The question for you, Admiral Weahkee, is suicide in Indian 
Country increasing or decreasing?
    Admiral Weahkee. I don't have the latest statistics off the 
top of my head, and I will turn to my colleague, Dr. Toedt, to 
see if he may. We do know that there continue to be significant 
concerns with social determinants--lack of available jobs, lack 
of housing, lack of--you know, on and on and on--which do 
impact upon people having hope and having other activities to 
be engaged in. We have engaged in partnerships with--for our 
youth with the Boys and Girls Clubs of America to begin to 
build strategies to help inspire our youth and to engage them 
in healthy activities.
    Dr. Toedt, do you have stats on suicide available?
    Admiral Toedt. So I don't have a broad number for the 
Indian Health Service, but I do want to make a comment about 
suicides. So certainly we know that suicides are affecting 
American Indians and Alaska Natives at a much greater rate, 
particularly in younger ages, than amongst other populations. 
So it is an area of great concern.
    One of the challenges that we have with data is the correct 
classification of race on death certificates. Another 
significant challenge is actually categorizing when 
unfortunately we lose a member of a Tribe to an opioid 
overdose. It could have been a suicide and could not be 
recorded as a suicide. So challenges in the accuracy of the 
data. But I will commit to following up on the statistics.
    Senator Daines. Yeah. The data that we've seen, in fact, a 
study from the CDC published just this last March, says 
American Indians and Alaska Natives have the highest rates of 
suicide of any demographic group in the U.S., and it states the 
rates of suicide among Native populations has been increasing 
steadily since 2003.
    I hear about the activities that are suggested to try to 
combat this, but the bottom line and the results is not 
improving. So with stats like this, my question, back to the 
Admiral, would you say the agency is accomplishing its mission 
with respect to suicide prevention?
    Admiral Weahkee. It definitely sounds like more work needs 
to be done and new strategies need to be developed, sir.
    Senator Daines. I would suggest a short answer to that 
would be no, in looking at the numbers.
    Admiral Weahkee, you have a long history of service, and 
the bureaucracy and brokenness of this agency predates your 
time, but it won't get you off the hook for moving the ball 
forward to fix it, to hit it head on. Frankly, I remain 
outraged, heartbroken, over the overall lack of care that IHS 
is providing Montana's Indian Tribes, especially when hearing 
after hearing we don't seem to see significant progress in 
provision and improvement of care or health outcomes.
    I've said it before, and I'll say it again, in reality, I 
think ``IHS'' stands for ``Indian Health Suffering.'' And I 
refuse to stand for this very harsh reality. I'm going to 
continue the charge in support of the Restoring Accountability 
in the IHS Act, and on behalf of Montana Tribes, I call on your 
agency to do better because I believe IHS is failing them.
    Thank you, Madam Chair.
    Senator Murkowski. Thank you, Senator. I think we all 
recognize, as you say, the sobering statistics, the sobering 
reality that far too many of our Native people around the 
country face, whether in Montana, New Mexico, or Alaska. It is 
not acceptable. And I think your challenge directly to IHS, 
that it is not acceptable and must be addressed is our 
challenge. You raise the issue of opioids, and where does meth 
fit? And heroin is part of it.
    But we had a community, a very small community, ask our 
Governor to declare a state of emergency to shut down a liquor 
store in an adjoining community because the village was dry, 
people were going into the larger community to get alcohol, and 
their resolution was pretty clear and pretty simple, ``Alcohol 
continues to kill us.''
    So while there's a great deal of focus right now on opioid 
and the opioid response, we can't lose sight of all of the 
other scourges that we're dealing with, and in your recognition 
that the suicide rate amongst our young people is shocking, but 
it is tied to what we are seeing with the drugs, with the 
alcohol, the substance abuse.
    When we say $150 million if the Department of Health and 
Human Services determines that they're going to shift this over 
here in the IHS account, to me that's not acceptable. I do 
think that there needs to be a more directed focus.
    In Alaska, I'm told that when it comes to suicide rates 
amongst young Alaska Native males, we're 10 times the national 
average. And we just kind of get to the point where it's like, 
oh, throw around these statistics, we're 10 times the average, 
we're 4 times the national average, and it doesn't even become 
real because it's just so out of check, out of alignment, and 
yet we're not able to get our arms wrapped around it.
    One of the challenges that we face when we think about 
suicide is the ability to provide behavioral health and mental 
health services, and we don't have it in our big communities, 
much less in our rural communities. This is something that I'm 
working with Senator Smith on the Indian Affairs Committee, 
behavioral health funding. We'd like to put it into the 
mandatory funding side of the ledger, just as the Special 
Diabetes Program was on the special side of the ledger, because 
we feel we've got an obligation to address some of these 
problems, and when it's discretionary, it's just exactly that, 
it's discretionary. So I thank you for raising these 
critically, critically important issues.
    Senator Daines. Madam Chair, thank you for your leadership 
and working with Ranking Member Udall. We must do better.
    Senator Murkowski. Yes, we do.
    Senator Daines. Yes. Thank you.

                  SPECIAL DIABETES PREVENTION PROGRAM

    Senator Murkowski. Let me ask on that, Admiral. You have 
mentioned that with the Special Diabetes Prevention Program, 
there's $150 million. You're continuing that, but you're moving 
that from the mandatory side to the discretionary side, and I'm 
assuming your rationale is you had indicated that diabetes 
health outcomes have improved. I have asked folks in Alaska if 
we have seen improvements sufficient to kind of take the foot 
off the gas when it comes to the efforts that I'm still waiting 
for, for more information.
    Can you provide information to us on what we're seeing with 
diabetes rates, not only in Alaska, but I think around the 
country, as it relates to American Indians/Alaska Natives? I 
worry that as we're making headway, that we're going to cut 
back on the funding and we're going to lose that. We just put 
this in place just several years ago. So if you have any 
comments that you'd like to make on that. Otherwise, I'll move 
on to my next question.
    Admiral Weahkee. Thank you, Senator Murkowski. Just a quick 
comment in terms of your characterization of taking the foot 
off the pedal. I think the administration fully acknowledges 
and supports that this is a successful program, and we desire 
to continue funding it at the $150 million mark. I think the 
move from the mandatory to discretionary is part of a greater 
administration proposal to move the macra extender funds over 
into the discretionary side to give the administration more 
discretion in addressing priority areas.
    Senator Murkowski. That might be something that we can 
visit on later again, not only as it relates to Special 
Diabetes Program, but some of the behavioral health issues that 
we're focused on.

     COMMUNITY HEALTH REPRESENTATIVE/COMMUNITY HEALTH AIDE PROGRAM

    Let me follow on a question that Senator Udall raised in 
regards to the Community Health Representative, the Community 
Health Aide Program. It seems to me that you have acknowledged 
that this is a valuable program; we need to do a little bit 
better job with regards to the data. And I certainly would 
agree with you.
    I just want to put on your radar the issue that we're 
dealing with in Alaska when it comes to connectivity issues. As 
you know, we have broadband in Alaska that is spotty at best. 
In some areas, you've got the machine in the corner of the 
room, but the hookup just doesn't work, it freezes, it's no 
value, and it is an issue for us. Hopefully, we're moving 
forward and we're going to see advances coming, but in the 
meantime, in the present day, what we have in Alaska are many 
of our rural clinics that are looking at a situation where 
their provider may no longer be providing them Internet because 
of issues within the FCC relating to the Rural Health Program 
and the subsidies. FCC hasn't distributed the payments to the 
providers for 11 months. The community of Cordova, not your 
area within IHS, has said that they may have to shut their 
hospital down because payments are being requested that would 
basically fill this gap. We've got a real issue at play.
    You mentioned that part of your problem in gaining data is 
people are relying on paper. Well, in many of our rural areas, 
paper is the only thing that you can rely on. And so I hope 
that we're able to work together in making sure that you get 
the data that you need, but, again, until we have a more 
reliable broadband system throughout our State and into our 
smaller villages, I worry about you getting the data there.
    I wanted to just confirm, though, that your focus on the 
Community Health Representative Program will not affect the 
CHAP program, the Community Health Aid Program, that is 
absolutely critical. You know the value to our State. CHAP 
isn't going to be impacted by this proposed reduction and 
elimination, will it?
    Admiral Weahkee. No, ma'am. And the CHAP program is funded 
separately out of the ``Hospitals and Clinics'' line item, so 
completely separate and distinct program.
    Senator Murkowski. Okay. I just wanted to make sure because 
we would completely erode the underpinnings of how we provide 
for healthcare in these villages if we didn't have CHAP. So 
thank you for that.
    Senator Udall.
    Senator Udall. Thank you, Madam Chair.

                      GALLUP INDIAN MEDICAL CENTER

    Back to the Gallup Indian Medical Center, Admiral Weahkee. 
First, were any services offered by Gallup Indian Medical 
Center ever suspended for any amount of time as a result of the 
findings of CMS and the Joint Commission?
    Admiral Weahkee. So not exactly tied to the findings of CMS 
and Joint Commission, although we have intermittently had to 
divert or suspend operating room procedures because of humidity 
control issues. So there have been episodic suspensions of 
service as a result of facilities issues.
    Senator Udall. And how were those cases handled then?
    Admiral Weahkee. Usually by staff onsite adjusting the 
system to reach the minimum threshold controls. And part of it 
is due to I guess the weather in Gallup.
    Senator Udall. Yes. Okay.
    Admiral Weahkee. I've got an engineer to my left who may be 
able to help us more here.
    Senator Udall. Mr. Hartz, do you want to weigh into this?
    Mr. Hartz. Actually, it's variable by----
    Senator Udall. Could you do your microphone, please?
    Mr. Hartz. I apologize.
    Senator Udall. Thank you.
    Mr. Hartz. It's actually very variable depending on, you 
know, the weather conditions. And it's really not common, but 
when the humidity might go up in Gallup, the capacity for the 
HVAC to deal with it isn't always as good as it should be.
    Senator Udall. Yes. I understand that CMS conducted a full 
hospital survey of the Gallup Indian Medical Center (GIMC) 
starting on May 9 to inspect whether previously found 
deficiencies have been corrected. First, are you confident that 
IHS has resolved all the items identified in last year's survey 
and outlined the Corrective Action Plan submitted to both the 
Joint Commission and CMS?
    Admiral Weahkee. So there are a number of items included in 
that list. Some were able to be taken care of on the spot. 
Others, the team took care of in very short order. One example 
was the waiting room for the Emergency Department (ED) had 
patients who were also waiting for primary care in the same 
waiting room. So they had to actually separate those two 
clinics. They did it over a weekend. And they are now providing 
services out of a different location in the hospital, so it 
resolved that finding. But some of the longer term fixes with 
the environment of care and life safety will take longer to 
remediate, and those are mainly with the facilities 
infrastructure with the heating and air conditioning and other 
renovation work that needs to take place.
    Senator Udall. Do you anticipate any new findings that will 
need to be addressed? And if so, could you share with us what 
your planned next steps are?
    Admiral Weahkee. With specificity, probably not at this 
point since we don't have CMS's report back to us. I think 
we're expecting that to come within the next couple of days, 
and then we'll have 90 days to develop the Corrective Action 
Plan for those longer term fixes. But we'd be happy to have a 
side conversation with some additional detail.
    Senator Udall. Okay. Should CMS identify additional 
deficiencies, how will you pay for the needed improvements? Are 
you confident that the $58 million proposed in your fiscal year 
2019 budget is sufficient to meet these needs and still address 
other accreditation emergencies? Would the proposed reductions 
to the facilities have any impact on your ability to respond to 
these accreditation issues?
    Admiral Weahkee. Thank you, Senator Udall. Well, with 
regards to Gallup specifically, and I think as a result of the 
expanded reimbursements through Medicaid, that facility has 
additional financial reserves that some of the other facilities 
in South Dakota did not have access to. And so they have a 
greater ability to take care of some of their own needs. But we 
do and would also have available the accreditation emergency 
funds should there be a large-ticket item that needs to be 
addressed.
    Senator Udall. Okay. Admiral Weahkee, I can't emphasize 
enough how important it is to address any remaining issues at 
the Gallup Indian Medical Center and address them promptly and 
completely. I'd like your commitment that you will provide the 
report that this subcommittee requested on time, and that you 
will work with me to provide updates and make sure that this 
facility has the resources it needs to address these challenges 
going forward. Will you make that commitment to me?
    Admiral Weahkee. Yes, sir, I will.
    Senator Udall. Thank you very much.

                      ALCOHOL AND SUBSTANCE ABUSE

    Madam Chair, let's see, I'm also encouraged to hear--
shifting over now to substance abuse and the Na Nizhoozhi 
Center Inc. (NCI) Detox--I'm encouraged to hear that the 
Preventing Alcohol-Related Deaths program has contributed 
critical resources, the Oglala Sioux Tribe and the City of 
Gallup, through the NCI Detox to combat alcohol and substance 
abuse. I understand that IHS officials recently convened with 
both programs in Gallup to conduct a site visit. Can you 
briefly update us on the progress these programs have made as a 
result of this funding and technical assistance from IHS? And 
comment briefly on how the new high-risk unit established by 
NCI Detox, which coordinates with the Gallup Indian Medical 
Center to provide medically complex patient triage has been 
helpful to improving patient care?
    Admiral Weahkee. Thank you, Senator Udall. We did have 
members of our headquarters behavioral health team there in 
Gallup. They brought Oglala Sioux down and had a joint meeting 
to share best practices across the two sites, as you 
identified. Dr. Toedt is going to provide a little more 
specificity. In general, the visit went very well, and both 
locations are doing great. We do expect to provide the next 
year's funding by the end of this fiscal year, so nothing that 
we saw that would get in the way of that continued support for 
those two programs.
    Admiral Toedt. Yes, sir. We definitely appreciate the 
funding in the Preventing Alcohol-Related Deaths program. And 
absolutely the site visits show that there are promising signs 
of increasing access to treatment, and good quality, high 
quality, culturally appropriate care. We were really encouraged 
to see the collaboration between the programs and the sharing 
of best practices as well.
    Senator Udall. Great. Thank you very much.
    Thank you, Madam Chair.
    Senator Murkowski. Thank you, Senator.

                VILLAGE BUILT CLINICS AND 105(L) LEASES

    Let me raise the issue that I raise every year, Village 
Built Clinics. We've had this conversation a lot. For so many 
of the clinics built by IHS, we've got 150 of them in Alaska, 
so many of them are really the only option for any level of 
care out there. Most have serious maintenance needs. In prior 
years, the agency took the view that Tribes were responsible 
for paying these costs out of other funds that they got from 
the Service. We have included $11 million in the 2018 omnibus 
to help address this issue.
    So a couple questions this morning. First, how are you all 
planning to allocate the $11 million? And when will the funds 
be distributed? And then further to this is the concern that 
has been raised that some of these funds are now being used to 
pay for other leasing costs because of the legal case that came 
out of--it was the Maniilaq v. Burwell case that mandates 
payment of leasing costs when Tribal facilities are used to 
operate IHS programs. So how much of this $11 million is being 
used to pay for these new legal obligations versus the 
traditional Village Built Clinic arrangement? If someone can 
please address that and give me an update.
    Admiral Weahkee. Thank you, Senator Murkowski. And I'll 
start, and I'll ask Ms. Church to provide some additional 
specificity.
    Of the $11 million, we currently, through Tribal 
consultation with the Tribes in Alaska, have identified $6 
million of that to go specifically to Village Built Clinics, 
and the remaining $5 million to be available for 105(l) leases. 
And the majority of those 105(l) leases have been, up to this 
point within the State of Alaska, we are starting to receive 
105(l) lease requests from the lower 48 and now have several 
Tribes who have requested leases in Navajo, Nowell Phoenix, 
Portland, and Nashville areas.
    So I'll ask Ms. Church to provide a little more specificity 
in terms of when and the impacts of the 105(l) objections.
    Ms. Church. Thank you for that question. Consistent with 
the distribution in 2017 when we first received the $11 
million, which we greatly appreciate the support of this 
subcommittee in receiving those funds, as Admiral Weahkee 
mentioned, we are using $6 million for the Village Built 
Clinics, and we have the $5 million for this other additional 
lease requirement under the Indian--or the ISDEAA.
    So we do know that within Alaska in particular, we have 
seen a bit of a shift in how the Village Built Clinics are 
electing to move forward with these leases, and so far, we've 
seen about 33 of those Village Built Clinics shift from that 
standard formula under the Village Built Clinics, and moving 
over to this other leasing opportunity. As Admiral Weahkee 
mentioned, we are beginning to see additional interest from 
other areas throughout the United States, and we do see the 
financial impact of that increasing exponentially over time.
    Senator Murkowski. As I understand the budget proposal, it 
effectively overrides the 105(l) with this ``notwithstanding'' 
clause that would make these lease payments entirely 
discretionary within the agency, effectively overturning the 
Maniilaq decision. This is a pretty significant shift because 
it would impact probably one of the most important statutes 
that govern Indian Country. I have not had a conversation with 
the Chairman of the Indian Affairs Committee, but this is 
something that from the authorizer's perspective, does beg the 
question as to whether or not this proposal has been shared 
with the Chairman and the Vice Chairman, and then further to 
the point, what their view is of this. Have those discussions 
been had?
    Ms. Church. There have been some preliminary discussions 
with the staff of our authorizing committees to talk about this 
issue. The language I think that you're referring to is 
proposed in our 2018 congressional justification as well as 
2019, and we would hope that this would be a starting point for 
discussions about an appropriate way to ensure that we can 
honor the commitment for this unfunded requirement and come up 
with a good solution moving forward.
    Senator Murkowski. Let me ask what that good solution might 
be because it's my understanding that the budgetary impact of 
this decision nationwide is going to blow things out of the 
water, that you've indicated that in Alaska, we've got some 33 
Tribes.
    Admiral, you mentioned that several nationwide are looking 
to this. What's going to happen?
    Admiral Weahkee. I believe projection-wise, it could be in 
the hundreds of millions of dollars mark if something is not 
done.
    Senator Murkowski. Well, okay. So if something is not done, 
what would you propose that we do? Because hundreds of millions 
of dollars, we're sitting here looking at the needs and 
recognizing that you've got a budget that at least the Ranking 
Member and I are looking at, and certain categories are simply 
not adequate, and now we're talking about something that could 
shift the priorities dramatically. What--help us out here.
    Admiral Weahkee. Well, right now the agency's only 
discretion is with those direct service funds for the Federal-
operated facilities that we have oversight for. Some 
possibilities might include a separate funding line for this 
particular cost or to make the contract support costs available 
for lease payments, just a couple off the top of my head. I'll 
turn to Ms. Church.
    Any ideas you might have as a financial expert within the 
agency?
    Ms. Church. Aside from additional funds, other discussions 
could be related to some sort of legislative discussion that we 
would be open to conversations on how that might work. But as 
it currently stands, there would be a need for additional 
resources to cover this issue.
    Senator Murkowski. So what you're telling me now is that 
with the 2018 funds, $11 million total, $6 million is going to 
go to the Village Built Clinic (VBCs), $5 million then to these 
105(l)s, but that is just a drop in the bucket in terms of what 
we may be facing next year. And we clearly don't have enough to 
address it with these fiscal year 2018 funds either, right?
    Admiral Weahkee. Correct.
    Senator Murkowski. Yes.
    Admiral Weahkee. Yes, ma'am.
    Senator Murkowski. And so I don't know if you told me when 
the funds would be distributed, the $11 million?
    Ms. Church. We're working on getting those funds out as we 
speak.
    Senator Murkowski. So how do you prioritize the $5 million 
then amongst the 33 Alaska Tribes that have sought to use those 
funds, and then the several that are being considered from 
other Tribes around the country?
    Ms. Church. As the lease proposals are coming in, they're 
being addressed in as timely a fashion as we can. It involves 
negotiations to make sure that we have full understanding of 
what's included in the proposal and going through all of the 
different items that have been included for assessing those 
reasonable costs.
    So at the moment, we are proceeding as they come in, in 
that priority order. And so right now we have been able to use 
the $11 million at this point exclusively for the Alaska 
proposals that are coming in. We're still working on additional 
proposals from other locations.
    Senator Murkowski. Well, I would suggest that this is one 
of those issues that we need to engage as many of you within 
the agency that are involved from a policy perspective. We need 
to be sitting with you from the appropriating perspective 
because we've got an issue that is very readily moving out of 
control from a spending perspective. How we work together to 
address it is going to be something that we need a little 
coordination on, and I hope you would agree with that.
    Admiral Weahkee. We'd be happy to provide any technical 
assistance or coordination needed, yes, ma'am.
    Senator Murkowski. Thank you.
    Senator Udall.
    Senator Udall. Thank you very much, Madam Chair.
    And as we know, I mean, this case was originally Alaska, 
but it's starting to have an impact, I think, all over the 
country. And we haven't had, Chairwoman Murkowski, the extended 
conversations we need to have with IHS. We need you to come 
back and talk to us and give us the specifics here. We haven't 
gotten updates about the impacts of this case. And we would 
encourage you very much to talk with us also at Indian 
Affairs--both of us are on the Indian Affairs Committee--and 
give us an update as well as this subcommittee here.

                 HEALTH FACILITIES CONSTRUCTION FUNDING

    On the health facilities construction funding for New 
Mexico, I'm very pleased that this subcommittee was able to 
provide the largest ever appropriation for facilities 
construction and maintenance programs in fiscal year 2018. 
There are a number of projects in New Mexico that have been 
waiting a very long time for funding, including health clinics 
in Alamo and Pueblo Pintado, as well as facilities in 
Albuquerque and Gallup, an obvious priority, given the issues 
we have already discussed today. Can you please provide an 
update of what the fiscal year 2018 funding level will mean for 
these specific facilities?
    Admiral Weahkee. Thank you, Senator Udall. And I know that 
Admiral Hartz has been dying to share some good news, so I'd 
like to----
    Senator Udall. Go ahead, please, Admiral Hartz. That would 
be good.
    Mr. Hartz. I thought I was going to get a break today.
    [Laughter.]
    Mr. Hartz. I, first of all, thank you very much for the 
question, Senator. And thank you for the opportunity to speak 
to the subcommittee.
    We--Indian Country and the Indian Health Service much 
appreciate the increases to the facilities appropriation in 
2018. And following down the priority list that we've worked 
with this subcommittee and the authorizing committees for some 
time and present annually, there will be funds, for Alamo, with 
the 2018 appropriations that will wrap up the needed funding 
that will be going into that project, and we can provide, for 
the record, the details of the dollar amounts, but that will be 
wrapped up with that $48 million, so it will be ready to move 
forward as long as they--the site--we don't have unusual site 
conditions. And Pueblo Pintado, the resources going in there, 
we'll be ready to finalize the planning and initiate the site 
selection review activities there, about $10 million. And then 
for the Albuquerque Central and satellite facility, we've put 
about three-quarters of $1 million in each one to proceed 
forward with the planning for those.
    Essentially, a broader answer to your question is that we 
now have resources in all of the outpatient facilities on the 
priority list. There are resources to move along on every 
project on that list from an ambulatory standpoint.

                   SANITATION FACILITIES CONSTRUCTION

    Senator Udall. Now, this subcommittee nearly doubled 
funding for sanitation facilities construction in the recent 
omnibus, and I know that this funding is very important for 
Alaska Native villages in the Chairwoman's State, and that we 
also have particularly significant sanitation needs in New 
Mexico, including a large number of homes on the Navajo area 
that lack access to clean drinking water and waste disposal 
facilities. Could you talk about the impact that these 
additional funds will have from a public health perspective? 
How many additional homes will you serve with these funds?
    Admiral Hartz, I think you're a good one to jump into that 
there.
    Mr. Hartz. Well, there's no question that we will make 
significant inroads with that additional $90 million that you 
provided to the Indian Health Service for this purpose. The 
exact number of those homes are actually yet to be determined, 
sir, and we will provide that for the record. The projects have 
been identified, and they're now going down the priority list 
to submit that information to us. We'll have that at year end. 
We may be able to get it sooner. But we will definitely provide 
that for the record.
    Senator Udall. Great. Please do. Thank you very much.
    Mr. Hartz. You bet.

                                OPIOIDS

    Senator Udall. I was pleased that we were able to fund $50 
million for Tribal opioid grants through the Substance Abuse 
and Mental Health Services Administration budget in last year's 
omnibus. And I note that the budget request includes additional 
funding for the Office of the Secretary to fund opioid-related 
needs, what appears to be missing in the direct resources for 
the Indian Health Service's own budget, however. Could you tell 
us what impact the opioid crisis has had on the Service's 
budget and what the greatest operating need you have as a 
result? Has the IHS worked with SAMHSA to ensure that the grant 
resources that Congress provided are being used for the highest 
priority needs?
    Admiral Toedt. Thank you for the question, Senator Udall. 
The Indian Health Service has been making its Substance Abuse 
and Suicide Prevention funds, which was formerly the 
Methamphetamine and Suicide Prevention Initiative (MSPI), 
available for, among other conditions, methamphetamine, heroin, 
opioid abuse, suicide prevention activities. So that amount for 
previous funding has been at $27.9 million. And the majority of 
those projects are focused on youth and youth suicide and 
substance abuse prevention.
    The funding for the President's budget that is the $150 
million proposed for IHS, we absolutely want to get the voice 
of Tribes, so as we stated before, we would have consultation 
with the Tribes about how we can best use that money to serve 
their communities.
    With respect to the Substance Abuse and Mental Health 
Services Administration (SAMHSA) funding, the $50 million, and 
the coordination with getting the money to Tribes, we have had 
several meetings with SAMHSA leadership, and we've been having 
conversations about funding distribution methodology that the 
IHS uses and sharing those ideas and techniques with SAMHSA. 
Also, on Monday I was at a joint listening session with SAMHSA 
and NIH in Minneapolis addressing the opioid issue, and SAMHSA 
was directly consulting with Tribes with IHS present as well.
    Senator Udall. Great.
    Thank you, Madam Chair.
    Senator Murkowski. Thank you.

                                STAFFING

    Let me ask about staffing packages. Again this is kind of 
an annual question for me, just making sure that we're 
tracking. Last year, the agency really underestimated the 
staffing packages need in the President's request. It was $20 
million when the actual need was over $60 million. We 
ultimately provided that in the omnibus.
    As you know, we are close to finishing the facility up in 
Bethel. This is operated by the Yukon-Kuskokwim Health 
Corporation (YKHC). This was selected as a joint venture 
project, and we've obviously seen great success with our Joint 
Venture (JV) projects, but we need to make sure that IHS 
provides for the funds for staffing the facility is going to be 
your end of the arrangement here. But really this has proven to 
be a good way, a great way, to lower the cost of building these 
new facilities for the government. Can you assure me that the 
full amount needed by YKHC for fiscal year 2019 for the 
staffing package is going to be sufficient?
    Admiral Weahkee. Thank you, Senator Murkowski. And with 
regards to the YKHC facility, we've identified $57.3 million. 
That is our best estimate as of the current date, and as we get 
closer to beneficial occupancy and the opening of that 
facility, we will revise those numbers. But with all 
information provided to the agency as of this date, that number 
represents full funding of their staffing needs.
    Senator Murkowski. Okay. Good. That's good to hear.
    The Yakutat Tlingit Tribe also has a joint venture project 
under development. I was briefed by them just a few weeks ago 
now. I don't see a staffing package for them in the fiscal year 
2019 request. Can you give me an update or a status on that 
project?
    Admiral Weahkee. Thank you, Senator. We also recently met 
with the Yakutat, and Admiral Hartz would like to provide 
feedback here.
    Senator Murkowski. Great. Thank you.
    Mr. Hartz. In the initial joint venture agreement that we 
signed with the Yakutat Tribe, their projections were for the 
first quarter of fiscal year 2020, for the completion of the 
facility and the staffing package. We recognize, based on the 
meeting that we had with the Tribe, that they're projecting 
sooner, but at the same time, they also appear to be--still 
looking for financing. And we're not aware that there's been 
groundbreaking yet on the facility nor an award. So, as Admiral 
Weahkee said, we will want to continue to monitor that, 
Senator, and, you know, communicate accordingly, depending on 
how that project does develop.
    Senator Murkowski. All right. Well, I appreciate that. 
They're very anxious, as you probably realized when you were 
discussing with them. I told them it's great to get that 
building, but you have to have the staffing that goes with it. 
We just want to make sure that we are in line with you so that 
when it is timely, that they are in that queue. So thank you 
for your engagement on that.
    Mr. Hartz. Yes. And we will do that. Thank you.
    Senator Murkowski. Good.

                        SMALL AMBULATORY CLINICS

    We included $15 million in the omnibus for the Small 
Ambulatory Clinic Program. This was built on funding that we 
provided for the first time in fiscal year 2017. Well, it 
wasn't the first time, but it was the first time since 2008. 
This has been a very important program in some of our smaller 
villages as we've seen Tribes in places like Toksook Bay, 
Chenega, Kake, and Hooper Bay take advantage of that. Can you 
tell me how many proposals you receive for funding through the 
Small Ambulatory Clinic Program and if we've got any updates 
with regards to awards for the programs and how funds might be 
allocated going forward?
    Mr. Hartz. Thank you, Senator, for the question. And we did 
receive 20 applicants when we did the solicitation based on the 
fiscal year 2017 appropriation, considering when the resources 
came, it was late in the year, and we decided that for the 
amount that we had there, we would, depending on what happened 
in fiscal year 2018, and thank you again for those resources--
we merged the two for the $20 million to be available for the 
distribution. And after an objective review team, of which 
there were no members from any area that had submitted an 
application.
    So we have completed all of that, and all of the recipients 
of the awards have been notified. They were notified either 
late last week or early this week. And I'll just quickly run 
through the numbers. Later, I can give specifics as to the 
location. And there was no representative from the Alaska area, 
nor Albuquerque area, on the review team that did this. Alaska 
has five recipients that will receive this. One of them will be 
partial amount because of the total amount, we were not able to 
get to all five in Alaska. New Mexico has three; and then we go 
California, one; Utah, one; Arizona, one; and Washington State, 
one. And that is--that accounts for 12 of the 20 applicants 
that will receive resources.
    Senator Murkowski. Let me ask the question because you had 
submissions that clearly indicate that this is a valued 
program, and yet the budget request doesn't include any funds 
going forward in fiscal year 2019. What's the rationale for not 
funding the Small Ambulatory Clinic Program?
    Mr. Hartz. The Small Ambulatory Program is part of the 
appropriation under the ``Healthcare Facility Construction'' 
line item. And as you note, it has significantly been reduced, 
and that is consistent with our desire to maintain the high 
priority for healthcare delivery, and that's always been the 
case over the many years of facilities. But, once again, we 
really want to thank you for the inroads we've been able to 
make with the increases in fiscal year 2018.
    Senator Murkowski. Well----
    Mr. Hartz. And why did we put the $79.5 million into the 
two projects that are identified on the list that we've 
requested? And the reason is, is one of them will complete the 
quarters for the Dilkon projects so we can--you know, if we get 
those resources we will then proceed forward with a contract to 
get those constructed. And then the other $20 million will be 
to move along as we get further into the design for Pueblo 
Pintado, that we will be able to then move toward construction.
    Senator Murkowski. Well, know that when we see programs 
like this that are designed to help, again, some of these very 
small clinics in very remote areas where healthcare options are 
simply not available, it's this or nothing, know that I am 
going to continue to place a priority from a budget 
perspective. This is the beauty of being on the Appropriations 
Committee and being able to set these priorities out there.
    When I look at what you have done in other areas of the 
budget to reduce funds, whether it's the facilities 
construction or the maintenance accounts, and then I see good 
programs with clearly a level of interest that is making a 
difference in these smaller communities, I'm concerned that we 
are once again shortchanging the IHS system.
    We haven't really talked about the shortages that we face 
in the healthcare workforce, but I would contend that when you 
have subpar facilities, places that not only people don't want 
to go for their care, but no provider wants to work there, it's 
really difficult to do right by the men and women that we're 
serving and their families. So I'm going to keep fighting for 
the small and ambulatory clinics, and I would just encourage 
you to work with us on some of these priorities.
    I'm well over my time, Senator Udall.
    Senator Udall. Thank you, Madam Chair.

                       INDIAN HEALTH PROFESSIONS

    Admiral Weahkee, I'm perplexed by the decision in this 
budget to cut funding from the Indian Health Professions 
Program by 12 percent. These are programs that provide 
scholarships and loan forgiveness to recruit the next 
generation of providers at IHS facilities. It's my 
understanding that even at current funding levels, IHS is 
turning away students seeking assistance. Could you please 
share with us what number of qualified applicants to the 
scholarship and loan forgiveness programs are going unfunded at 
current levels? And wouldn't your budget request mean that even 
fewer applicants would make the cut?
    Admiral Weahkee. Thank you, Senator Udall. I also want to 
reference as part of my remarks some of the proposals that 
we've made which would help to provide greater numbers of both 
scholarships and loans, one of which is to deal with the 
taxability issue of our scholarships and loans. Right now, a 
lot of our funding is going towards reducing the tax burden on 
recipients, and we'd like to have the same parity with the 
Armed Forces scholarship loan program, National Health Service 
Corps, and make those nontaxable. That would enable us to 
provide more scholarships and loans.
    But to get specifically to your question and what we've 
received this year, for the loan repayment program, we had 
1,267 health professionals receive IHS loan repayment. That's 
434 new 2-year contracts, and 396 1-year extension contracts, 
with 437 starting their second year. So we had 788 applicants 
go unfunded at an estimated cost of $39.4 million.
    And then for scholarships, we had 805 new applicants. Three 
hundred thirty-one of these were eligible for scoring, and of 
those, 108 were awarded.
    An estimated $3.3 million would have been the need to fund 
all of the qualified new applicants. So we had 154 continuation 
awards funded in that most recent year.
    Senator Udall. Yes. Thank you for that answer.

                            IT MODERNIZATION

    I want to shift over here with a final couple of questions 
on the IHS and health IT modernization. I know that health 
records and billing IT needs at the IHS have grown over the 
years, and I've heard from Tribes concerning about what IHS's 
plan is to replace the Resource and Patient Management System 
(RPMS) since the VA will discontinue support of it soon. This 
year's budget request acknowledges RPMS replacement as one of 
IHS's top IT challenges. And I quote here from the budget, The 
loss of the VA as a source of software code will raise the cost 
of continuing to use the RPMS system and require IHS to procure 
commercial off-the-shelf replacements for RPMS, end quote 
there. It goes on to say that efforts are underway to look at 
replacement systems.
    Admiral Weahkee, what specific efforts are underway at IHS 
to replace the RPMS?
    Admiral Weahkee. Thank you, Senator Udall. And our IT 
office has been in very robust conversations with internal HHS 
stakeholders and directly with the VA and the DoD on their 
experience in evaluating electronic health record solutions.
    As an agency, we put out a Request for Information for the 
public to provide us with their thoughts on what the IHS should 
do. We received responses from the big ticket vendors who were 
interested in coming in and replacing RPMS. We also had a 
number of responses for people who were willing to come in and 
maintain the existing RPMS system for us. And we've also 
received a number of add-ons, if you will, bells and whistles 
that could be added onto RPMS to make it more interoperable or 
provide better reports.
    So I would characterize our current situation as doing 
robust evaluation. We are watching closely, and we saw just 
last week that VA signed the contract with Cerner, so they are 
all in, if you will. But we do continue to have robust 
conversations with our HHS Chief Technology Officer about what 
IHS and HHS should do moving forward.
    One last thought and some additional conversation we've had 
is with our Tribes. And many of them have already made the 
investment and have moved forward to go on to commercial off-
the-shelf EHRs already, and so we are leveraging the lessons 
that they've learned in making those conversions and also the 
investment information, how much it's cost them to make those 
transitions to help inform our future budget requests and how 
we'd like to move forward.
    Senator Udall. Given the budgetary concerns outlined in the 
budget justification, does the administration's fiscal year 
2019 health IT requests reflect RPMS replacement planning?
    Admiral Weahkee. For the stage of evaluation that we're in 
currently, I believe that we are still predecisional in being 
able to justify a specific amount, but we will be closing up 
this initial phase of evaluations soon, and we'll be able to 
provide some harder and justifiable dollar amounts to proceed 
forward.
    Senator Udall. Admiral Weahkee, based on your summary of 
IHS's efforts to look at RPMS replacements, do you think the 
agency has done enough to preplan as much as possible for the 
difficulties of an IT systems deployment?
    Admiral Weahkee. I believe that there is a lot of planning 
that will be needed, and we are--we are operating on a 
shoestring within our existing IT, and to be able to go through 
as robust of a transition as will be needed, we will need 
additional resource, either contracts or a surge in capacity on 
our IT side of the house. So additional resources will be 
needed.
    Senator Udall. Yeah. Well, I think it's really important 
that you make clear the resources you need to do this because 
it's obviously very important in going through the stage we're 
going through.
    Admiral Hartz, did you have anything to say here?
    [No audible response.]
    Senator Udall. That's fine.
    Admiral Weahkee. Actually, Dr. Toedt is our previous CMIO--
--
    Senator Udall. Dr. Toedt.
    Admiral Weahkee [continuing]. So he may have some 
additional insights.
    Senator Udall. Oh, good. Well, that would be great.
    [Laughter.]
    Admiral Toedt. Thank you, Senator. We know that there are 
significant challenges with RPMS. We have them at our Federal 
sites. We've heard from Tribes. And we know that the VA, having 
made its decision, you know, just last week gives us even more 
incremental clarity on some of the issues surrounding it. So 
having a robust and accurate proposal is the work that we're 
undergoing right now to make sure that when we put a request 
forward, that it has sufficient information. But I concur that 
significant additional resources would be required to make a 
transition.
    Senator Udall. Yeah. Thank you very much, Madam Chair.
    Senator Murkowski. Thank you. Thank you, Senator. It's a 
good thing we didn't have more of our colleagues show up 
because----
    Senator Udall. We had a lot to do.
    Senator Murkowski [continuing]. We had plenty to talk about 
here this morning.

                 HEALTH FACILITIES CONSTRUCTION FUNDING

    I just have a couple more if I may. And I want to take it 
back to the facilities and facilities construction and 
maintenance and my concern. I mentioned the backlog in my 
opening statement at over $2 billion for the facilities that 
are currently on the priority list. The total need for 
construction is estimated to be over $14 billion. Your own 
budget justification indicates that the facilities are roughly 
four times the age of their private sector counterparts. The 
maintenance backlog is also over a half a billion dollars.
    I don't understand how, in all good conscience, you can 
recommend such a significant reduction to this account, over 40 
percent. I guess the question that I would ask is, do we all 
agree that the maintenance--the construction and maintenance--
well, let's start with the construction, that the need is over 
$14 billion? Is that what we acknowledge? It's a lot.
    Mr. Hartz. The answer is affirmative.
    Senator Murkowski. Affirmative. And with the backlog also 
over a half a billion dollars?
    Mr. Hartz. $569 million for backlog of essential 
maintenance, alteration, and repair.
    Senator Murkowski. And that's over half a billion. The age 
of most of the facilities is far in excess of the age of other 
private sector facilities. So the need, we all acknowledge that 
the need is clearly there.
    Mr. Hartz. Yes.
    Senator Murkowski. When we look at a reduction to this 
account, as significant as this is, is it a prioritization that 
we're going to place dollars elsewhere in the budget? And do we 
have a longer term plan that is perhaps not shared with us 
about how we're going to address this? What's the plan going 
forward? Because the need is clearly there, it's clearly 
established.
    Admiral Weahkee. Yes. And thank you, Senator. And 
definitely it's a prioritization of direct healthcare services 
and basically kicking the can down the road on expansion, 
capacity expansion, greater access. We know that our needs will 
continue to grow, and the $104 to $208 million that we would 
ideally be putting aside for facilities maintenance, you know, 
it will end up resulting in the situations like we have at 
Gallup and in the Great Plains with HVAC systems going down, 
generating systems going down. So without the additional 
funding, we can expect to see those problems persist and need 
to have additional funds such as through the Accreditation 
Emergency Fund.
    Senator Murkowski. Well, it seems to me that we know what 
the answer is here. You've got these facilities in the Great 
Plains that have just been struggling. You mentioned that you 
can't get the certification that you need if you can't get the 
HVAC system up to where it needs to be. So you spend a lot of 
money throwing good money after bad with a facility that is 
costing more to maintain to try to get it up to standards, and 
if you can't get it up to standards, then you're not able to 
provide the service here. So it just seems to me that there has 
to be a longer term plan.
    When it comes to one of our other accounts, we have 
jurisdiction over our national parks. Our national parks have a 
maintenance backlog that is--what?--you know, $11, $12 billion, 
not insignificant. I don't know why we get stuck with all of 
the maintenance backlog issues that are so significant in this 
country. I don't know that we should say we're stuck with them, 
but where we're struggling with them.
    And what we've been trying to do with the Secretary there 
is to figure out the longer term plan. What are the proposals 
that could help us have a funding stream to address it? But it 
doesn't seem to me that we have a plan here. And we have been 
the beneficiary of some good efforts in the State through the 
likes of the joint venture program that allows the Tribes to 
pay for the construction of new facilities. That has helped us 
there. But I'm not seeing that we have a strategy. And if we 
don't have a strategy, I take it back to what Senator Daines 
challenged us all with, right now what is being provided to our 
Native people around the country is not adequate, and we must 
do better.
    I don't know if you can address what the longer term 
strategy is or whether it's a wish and a prayer that we have 
more money that comes our way, but you can't have a 
construction backlog of $14 billion and a maintenance backlog 
of over half a billion dollars if you're just limping by year 
to year and hoping that you're going to be able to keep your 
facilities open.
    Admiral Weahkee. Thank you, Senator. And I want to assure 
you that we do have very thorough plans, prioritized plans, for 
both our healthcare facilities construction and our backlogs. 
They're needs based----
    Senator Murkowski. Can you get to that plan with a 40 
percent reduction in funding?
    Admiral Weahkee. Not immediately, no, ma'am.
    Senator Murkowski. Can you get to it even in the long term? 
How do you get to it if you're going downwards instead--you're 
not even holding steady.
    Admiral Weahkee. Right. It's a growing need. It's a growing 
need.
    Senator Murkowski. It doesn't work. I think you just have 
to admit it doesn't work. We need to work to address that, but 
I can't have you defending a 40 percent reduction and saying, 
``You know, we'll figure it out.'' We're going to have to 
address it.

                             STAFF QUARTERS

    One more question, and this is relating to housing. I 
mentioned that when it comes to our healthcare professionals, 
you simply cannot attract them if you have substandard 
facilities, and you can't attract them if you have housing 
issues. And far too many places in Alaska, there is no place to 
rent, there is no place to buy, and so staffing quarters are an 
important thing.
    We provided $11.5 million for staffing quarters in the 
fiscal year 2018 omnibus. Once again, we're working to make 
these good things happen. And I appreciate my colleague and 
teaming up with us, but with that, that was new authority to 
directly subsidize housing costs for medical personnel.
    So can you give me an update as to how the funds for these 
quarters have been allocated, whether they're going to help 
with some of the issues in the Great Plains, kind of where you 
are with that?
    Admiral Weahkee. Thank you, Senator. Of the $11.5, we have 
looked across the agency at the areas of greatest need and have 
identified the Great Plains area, Navajo area, and the Alaska 
area as the locations with the greatest housing deficiency need 
currently. With the Navajo area, we had a site whose housing 
unit actually burned down, and so that's an acute need. So 
we've identified $3 million of that $11.5 to go to the Navajo 
area, another $3 million to the Great Plains area for their 
area of greatest need, and the Alaska allocation would be $5.5, 
and our thought is that that would go to the Barrow region.
    Mr. Hartz. Yes. There are some great needs there, and the 
costs are much higher in Alaska. And the one in the Navajo was 
an apartment building burned down. So that gives you, you know, 
a general idea of--well, not general, a specific idea--excuse 
me--of where we're looking to put that $11.5 million. And thank 
you very much for providing that to us. Much needed.
    Senator Murkowski. Much needed. I think we would all 
acknowledge wholly inadequate in terms of being able to meet 
the needs and the costs, but again that's an area where we will 
just continue to work with you on.
    Admiral, you're in a difficult job. You know that. We know 
that. I just get very frustrated because it doesn't seem to 
make a difference whether we have a Republican administration 
or whether we have an administration that's led by a Democrat 
leader. Our reality is that we have not done right by American 
Indians, Alaska Natives, and Native Hawaiians. We have not done 
right when it comes to funding through the IHS and through our 
programs, whether it's BIA or BIE, we have not done what we 
need to do in order to meet our trust responsibilities.
    I've been on the Indian Affairs Committee for the full 15 
years that I've been here in office, and I've been on the 
Appropriations Committee now for about a half dozen years. It 
seems that we have the same conversations and we express the 
same level of frustrations. Good men and women come in front of 
us and try to make a case for budgets that simply do not 
address the need.
    I know that part of your job is to defend a budget that 
your heart might not be into. I don't know how you do that 
because I'm sure all of you care for those that you are 
serving, but this budget does not help to address the true 
needs when it comes to so many who are in a very vulnerable 
place, and we keep them in that vulnerable place when we don't 
make the funding commitments that we need to them.
    So know that we're going to continue to work in this 
Committee as well as Indian Affairs, where Senator Udall is 
again a very strong leader there. We will keep at it, but I 
would like to have some further conversations with you and your 
team on some of these issues that we've raised here today.
    With that, final comments? You get the last word, Senator.
    Senator Udall. No, I'm not going to do the last word. You 
should have the last word, but----
    Senator Murkowski. You're getting it.
    Senator Udall. Yes. Just--I--and I think she said it very, 
very strongly, that when we get in this backlog area, it is--
you know, consistently it just gives us the sense we're not 
moving. And historically, I've kind of seen--and it doesn't 
matter Democrat or Republican--some administrations have 
stepped forward with 5-year plans to wipe out backlogs, and, 
you know, that's the kind of leadership I think we need from 
the administration, is just stepping forward and saying, you 
know, ``We're going to take care of this backlog within a 
certain period of time and we're going to ask the Congress, 
we're going to make a proposal and we're going to ask the 
Congress to participate with us and try to wipe it out.'' But 
we need that kind of leadership, and I really appreciate your 
comment on that.
    So I'm not trying to get the last word, I'm just trying to 
fold into the words that you said, which were really the last 
words.
    Senator Murkowski. Well said.

                         CONCLUSION OF HEARINGS

    With that, the subcommittee stands adjourned.
    [Whereupon, at 11:55 a.m., Wednesday, May 23, the hearings 
were concluded, and the subcommittee was recessed, to reconvene 
subject to the call of the Chair.]