[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.]