[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]






 
                 NATIVE VETERANS' ACCESS TO HEALTHCARE

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                      WEDNESDAY, OCTOBER 30, 2019

                               __________

                           Serial No. 116-42

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
       
       
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                    Available via http://govinfo.gov
                    
                    
                    
                    
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             U.S. GOVERNMENT PUBLISHING OFFICE 
41-247             WASHINGTON : 2022                    

                    
                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tennessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York

                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

                         SUBCOMMITTEE ON HEALTH

                 JULIA BROWNLEY, California, Chairwoman

CONOR LAMB, Pennsylvania             NEAL P. DUNN, Florida, Ranking 
MIKE LEVIN, California                   Member
ANTHONY BRINDISI, New York           AUMUA AMATA COLEMAN RADEWAGEN, 
MAX ROSE, New York                       American Samoa
GILBERT RAY CISNEROS, JR.,           ANDY BARR, Kentucky
    California                       DANIEL MEUSER, Pennsylvania
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                         C  O  N  T  E  N  T  S

                              ----------                              

                      WEDNESDAY, OCTOBER 30, 2019

                                                                   Page

                           OPENING STATEMENTS

Honorable Julia Brownley, Chairwoman.............................     1
Honorable Jack Bergman, Acting Ranking Member....................     2
Honorable Mark Takano, Chairman, Full Committee..................    12

                               WITNESSES

Andrew C. Joseph Jr., Immediate Past Member-at-large & Portland 
  Area Representative, National Indian Health Board (NIHB).......     3
Kevin J. Allis, CEO, National Congress of American Indians (NCAI)     5
Sonya M. Tetnowski, CEO, National Council on Urban Indian Health 
  (NCUIH)........................................................     7
Chief William Smith, Vice Chairperson, Alaska Native.............     8
Marilynn Malerba, Chief, Mohegan Tribe of Connecticut, Indian 
  Health Service Tribal Self-Governance Advisory Committee (IHS 
  TSGAC).........................................................    10
Dr. Kameron Matthew, Deputy Under Secretary for Health for 
  Community Care, Veterans' Health Administration................    24

        Accompanied by:

    Dr. Thomas Klobuchar, Executive Director, Office of Rural 
        Health, Department of Veterans Affairs

    Stephanie Birdwell, Director, Office of Tribal Government 
        Relations
Benjamin Smith, Deputy Director for Intergovermental Affairs, 
  Indian Health Service..........................................    27

                                APPENDIX
                     Prepared Statements of Witness

Andrew C. Joseph Jr. Prepared Statement..........................    37
Kevin J. Allis Prepared Statement................................    43
Sonya M. Tetnowski Prepared Statement............................    47
Chief William Smith Prepared Statement...........................    49
Marilynn Malerba Prepared Statement..............................    53
Dr. Kameron Matthews Prepared Statement..........................    58
Benjamin Smith Prepared Statement................................    60

                        Statement For The Record

United South and Eastern Tribes, Inc.............................    65
California Rural Indian Health Board.............................    67
California Consortium for Urban Indian Health....................    69
Sault Ste. Marie Tribe of Chippewa Indians.......................    70
Standing Rock Sioux Tribe........................................    72

                 Additional Submissions For The Record

Treaties Submitted by Representative Gallego.....................    77
U.S. Department of Veterans Affairs and Indian Health Service 
  Memorandum of Understanding Annual Report Fiscal Year 2018.....    80
Department of Veterans Affairs Tribal Consultation Policy........    87
Memorandum of Understanding Between the Department of Veterans 
  Affairs (VA) and Indian Health Service (IHS)...................    94
Indian Health Service and Tribal Health Program Monthly Report-
  June 2019......................................................   100


                 NATIVE VETERANS' ACCESS TO HEALTHCARE

                              ----------                              


                      WEDNESDAY, OCTOBER 30, 2019

              U.S. House of Representatives
                             Subcommittee on Health
                             Committee on Veterans' Affairs
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:06 a.m., in 
room 210, House Visitors Center, Hon. Julia Brownley 
[chairwoman of the subcommittee] presiding.
    Present: Representatives Brownley, Lamb, Cisneros, Sablan, 
Dunn, Bergman, and Steube.
    Also present: Representatives Takano, Haaland, Cunningham, 
Gallego, and Gianforte.

        OPENING STATEMENT OF JULIA BROWNLEY, CHAIRWOMAN

    Ms. Brownley. Good morning and welcome to the Subcommittee 
on Health's hearing on Native Veterans Access to Care.
    Before we begin, a little business, and I would like to 
request unanimous consent for Congresswoman Haaland Congressman 
Gallego to join us for today's hearing.
    Without objection--oh, and Congressman Gianforte to join us 
for today's hearing as well. We welcome the three Members on 
the committee and three additional Members to today's 
committee, and I appreciate your attendance very much.
    Today is a historic day in Washington, DC. as it is the 
first time in at least 30 years that either chambers' Veterans' 
Affairs Committee has held a hearing solely on the health care 
needs of our Native Veterans. I know Mr. Bergman had a hearing 
in his district, but this is the first one in Washington, DC. 
in 30 years.
    American Indian and Alaska Native Peoples have served in 
the United States Armed Forces since the Revolutionary War, and 
served without being acknowledged as citizens until 1924. 
Native People serve at consistently higher rates than any other 
racial or ethnic group. The rates are even greater for Indian 
and Alaska Native women, who serve as disproportionately higher 
rates than Native men and non-Native women.
    This hearing is different than most this committee holds as 
it is an examination not only of VA and the health status of 
Native Americans, but of VA as a part of a Federal Government 
that has a solemn duty to uphold trust and treaty obligations 
to tribal people.
    In exchange for land and resources, the United States 
promised members of Indian tribes safety, economic opportunity, 
and health care. The Federal provisions of health care is not a 
handout, it is a payment on a debt, and that debt, sadly, has 
continuously been defaulted on by the United States.
    It is essential that we recognize this Federal obligation 
does not stop at the doors of the Indian Health Service (IHS), 
it is an obligation of all parts of our Government. For that 
reason, we have called this hearing to hear from tribes and 
tribal organizations to learn how the VA is meeting its Federal 
Trust Responsibility and where do they need to do better.
    We know that while Native People serve more than anyone 
else, they have the lowest health status of any other race or 
ethnicity in the United States. Native Veterans are more likely 
to have service-connected disabilities, experience sexual 
assault and post-traumatic stress, and die by suicide.
    In 2010, the VA and Indian Health Service (IHS) established 
a Memorandum of Understanding (MOU) to improve the health 
status of American Indian/Alaska Native Veterans through 
coordination, improved services, and resource sharing between 
VA, IHS, and federally recognized tribes.
    This year, VA and IHS plan to revise the 2010 MOU. We would 
like to check in on the progress made over the past 9 years; 
what went well, what did not, and what is needed in the new MOU 
to ensure we truly are improving the health status of American 
Indian and Alaska Native Veterans.
    Before we move on to our first panel, I want to express to 
you my great disappointment that Dr. Stone, who will be the 
signatory of this new MOU, is not here today to speak to these 
issues. Secretary Wilkie spoke many times this summer, with 
several dozen news articles to show for it, that Native 
Veterans' access to health care is one of his top priorities.
    Now, while I do not doubt that, I do not doubt his 
commitment of the program offices, I do not doubt that the 
commitment of the program officers here today, I know that 
the--I am sorry.
    Now, while I do not doubt the Secretary's commitment, I am 
concerned about the progress we are making in a successful 
conclusion to a negotiation with the MOU.
    With that, I would like to recognize Acting Ranking Member 
General Bergman for 5 minutes for any opening remarks he may 
wish to make.

    OPENING STATEMENT OF JACK BERGMAN, ACTING RANKING MEMBER

    Mr. Bergman. Thank you, Chairwoman Brownley. It is an honor 
to be with you all today and filling in for Dr. Dunn, who is 
the ranking member, and he and I sat down and chatted about the 
importance of this hearing. As you all know, he had a conflict, 
but he will be here as soon as he can.
    In the meantime, it is a great, again, honor to be here in 
his place to recognize the committed service of so many of our 
American Indian and Alaska Native Veterans. There is perhaps no 
better hearing that we could be having as we prepare to return 
to our districts for the Veterans Day time period here than the 
hearing we are having today.
    The numbers show that there is no other ethnic group that 
steps up to serve the United States in the United States Armed 
Forces more than Native Americans. My district, the First 
District of Michigan, is home to eight federally recognized 
tribes, and their deeply embedded patriotism and commitment to 
service is a credit to our community and an inspiration to all.
    As we will learn this morning, Native Veterans often face 
unique barriers to care and we still have a long way to go in 
ensuring that they receive the care, benefits, and services 
that they deserve as veterans.
    I look forward to hearing about how the Department of 
Veterans Affairs is working with Indian Health Service, tribal 
organizations, and other important stakeholders, many of whom 
are represented here today, to identify, break down, and 
eliminate the barriers to success.
    I am glad to hear that VA is actively working on a new 
memorandum of understanding with IHS, but that MOU will only be 
effective if; number one, it includes measurable metrics and 
improved coordination of care, particularly where referrals to 
specialty care services are concerned; number two, is developed 
with a direct involvement and engagement of those will be most 
impacted by it, that is, the Native American Veterans 
themselves; and, three, is supported by an ongoing commitment 
to cultural respect, sensitivity, and trust and relationship-
building.
    I appreciate the many tribal nations and communities that 
are represented here today either as witnesses or through the 
statements for the record that have been provided. I am very 
much looking forward to listening to your testimony today, and 
I want you to know that your service has not and will never be 
forgotten. Thank you for that.
    With that, I yield back.
    [Audio malfunction in hearing room.]
    Ms. Brownley.--Andrew C. Joseph, Jr., Immediate Past 
Member-at-Large and Portland Area Representative for the 
National Indian Health Board. Next we have Kevin J. Allis, 
Chief Executive Officer for the National Congress of American 
Indians, followed by Ms. Sonya Tetnowski, Vice President of the 
National Council of Urban Indian Health.
    In addition, we are joined by Chief William F. Smith on 
behalf of Alaska Native Health Board. Finally, Chief Marilynn 
Malerba on behalf of the Indian Health Service Tribal Self-
Governance Advisory Committee.
    With that, I now recognize Mr. Joseph for 5 minutes, and 
welcome.

               STATEMENT OF ANDREW C. JOSEPH, JR.

    Mr. Joseph. Good morning, Chairman Brownley and members of 
the subcommittee. On behalf of the National Indian Health 
Board, thank you for the invitation to testify on health 
services for Native Veterans.
    [Speaking native language.] Badger is my name, I am Andy 
Joseph, Jr. I am an enrolled member of the Confederate Tribes 
of the Colville and I am an Army veteran. I can speak firsthand 
about ongoing challenges in Native Veterans' health.
    Native Veterans have served in every U.S. military conflict 
of the past 200 years, yet today's hearing is the first ever on 
health care access for Native Veterans. Thank you for this 
step.
    On behalf of the National Indian Health Board and as a 
veteran, I am disappointed that Secretary Robert Wilkie and 
Rear Admiral Weoki [phonetic] will not be here today. Both 
Secretary Wilkie and the Rear Admiral have spoken about their 
desire to better serve the health needs of Native Veterans and 
we are counting on them and this Administration to Native 
Veterans.
    The Federal Government has a dual responsibility to Native 
Veterans on one obligation because of our political status as 
Native people and one because of our military service. Our 
people served in the military at higher rates than any other 
ethnicity in America. We continue to hold up our end of the 
bargain.
    There are many challenges that Native Veterans face in 
receiving quality health care. Please allow me to share some 
policy recommendations. All equally important, these are 
discussed in detail in our written testimony.
    One, tribal consultation can help remedy many issues for 
Native Veterans. We invite the VA to engage in regular tribal 
consultation with the Native Veterans.
    Two, there are limited options within the VA for culturally 
appropriate programs and services tailored for Native Veterans; 
that needs to change.
    Three, make advance investments directly to tribes for 
Native Veterans mental health care. Native Veterans are twice 
as likely as other veterans to return home with post-traumatic 
stress disorder. Depression, alcohol and drug use disorders are 
significantly higher among our veterans. The same is true with 
suicide. These issues and transition from active service back 
home needs sufficient investment.
    Four, we ask the VA committee to actively support advance 
appropriations for the Indian Health Service and other 
programs. Our people are still suffering from the most recent 
35-day government shutdown. It has been a decade since the VA 
has benefited from advance appropriations, it is IHS's turn. We 
ask you for your active support.
    Five, Indian Health Services is a payer of last resort. We 
strongly recommend that Congress makes explicit in law that VA 
is required to reimburse IHS and tribes for services under 
purchase and referred care.
    Six, Congress should exempt Native Veterans from co-pays 
and deductibles consistent with trust responsibility for health 
care for all Native people.
    Seven, when it comes to health IT modernization, Congress 
must ensure parity in appropriations and technical assistance 
to tribes to ensure interoperability between the VA and IHS. It 
is shameful that Native Veterans are forced to hand carry 
health records between their IHS and a VHA provider.
    Eight, we need a tribal technical advisory committee to the 
VA. We strongly request that the VA committee favorably act on 
the bipartisan H.R. 2791, introduced by Representative Haaland.
    Nine, tribal leaders and veterans continue to request that 
the VA create written guidelines and policies to clarify 
referral process under the VA and IHS memorandum of 
understanding; the VA has yet to do so. This recommendation was 
also made in 2019 Government Accountability Office.
    In conclusion, on behalf of the National Indian Health 
Board, thank you for holding this important hearing. We have a 
long way to go together to improve care for Native Veterans, we 
will serve as the--and this way as well.
    Thank you.

    [The Prepared Statement Of Andrew C. Joseph, Jr. Appears In 
The Appendix]

    Ms. Brownley. Thank you, Mr. Joseph.
    [Audio malfunction in hearing room.]

                  STATEMENT OF KEVIN J. ALLIS

    Mr. Allis. Thank you. Chairman Brownley and Acting Ranking 
Member General Bergman, and members of the subcommittee, on 
behalf of the National Congress of American Indians (NCAI), I 
would like to thank you for holding this important hearing 
today to discuss the many issues affecting Native Veterans 
across health care.
    I really do appreciate the comments that everybody has made 
here today and also Mr. Joseph. There is a commonality, there 
are many things we will touch on together, which shows that we 
start from a strong foundation of being on the same page.
    I serve currently as the Chief Executive Officer of NCAI 
and I am an enrolled member of the Forest County Potawatomi 
Community in Northern Wisconsin. I look forward to working with 
members of the subcommittee and other Members of Congress to 
better fulfill the Federal Government's commitment to provide 
for the well-being of American Indian and Alaska Native 
Veterans when they return home.
    Founded in 1944, NCAI is the oldest and the largest 
national organization composed of tribal nations and their 
citizens. Tribal leaders created NCAI in response to 
termination and assimilation policies that threatened the 
existence of tribal nations.
    Since then, NCAI has fought hard to protect and enhance 
tribal treaty rights, sovereign rights, secure tribal 
traditional laws and customs of our tribal nations, promote the 
common understanding of tribal nations' roles in the family of 
American Governments, and improve the quality of life of all 
Native Americans across the country.
    American Indians and Alaska Natives, as mentioned here 
already, have a long history of distinguished service to this 
country. Per capita, American Indians and Alaska Natives serve 
at a higher rate in the Armed Forces than any other group of 
Americans that have served in all the Nation's wars since the 
Revolutionary War. In fact, in periods when we were not even 
U.S. citizens, our American Indian Natives participated as 
veterans for this country. Despite this esteemed service, 
Native Veterans have lower personal incomes, higher 
unemployment rates, and are more likely to lack necessary 
health insurance.
    The Federal Government's responsibility, as you mentioned, 
to provide quality health care to Native Veterans comes from 
two places: their service to this country and the Federal 
obligations that are owed to Indian country due to giving up so 
much land back in the last two centuries. The United States 
must honor its commitments to Native Veterans by ensuring 
Federal policy addresses its unique needs. There is no way to 
accomplish this, though, without us being at the table and 
being in the conversations where decisions are made.
    Right now, the Department of Veterans Affairs and the 
Indian Health Service are negotiating a new memorandum of 
understanding that will impact Native Veterans for many years 
to come. The VA and IHS must ensure that Indian country has a 
voice in these discussions, so that this next MOU fully 
addresses the need Native Veterans have regardless of whether 
they are living on rural reservations or in major urban areas.
    Ensuring Native Veterans are getting the health care they 
deserve requires communication and cultural competency. On the 
ground, this means streamlining processes for tribal nations to 
become tribal veterans service organizations that provide 
access to culturally appropriate assistance for Native Veterans 
when they are pursuing VA benefit claims. In Washington, DC. it 
means passing and implementing legislation that will ensure 
Native Veterans' voices are heard by the highest offices in the 
VA.
    Accordingly, I encourage you all and every member of this 
subcommittee to support H.R. 2791, the Department of Veterans 
Affairs Tribal Advisory Committee Act of 2019. This bipartisan 
legislation, which was introduced by Congresswoman Deb Haaland, 
and would establish a tribal advisory committee to advise the 
Secretary on how to improve programs and services for American 
Indian and Alaska Native Veterans.
    In addition, to improving engagement with Native Veterans, 
Federal policymakers must make it easier for Native Veterans to 
access health care through increased coordination between the 
VA and IHS system.
    For reasons ranging from cultural competency to 
significantly reduced travel times, Native Veterans often 
prefer to receive care at IHS, tribal or Urban Indian 
Organization facilities. Therefore, NCAI calls on Congress and 
the Administration to ensure referrals through the Purchase 
Referred Care Program and services provided to Native Veterans 
by Urban Indian Organizations are reimbursable by the VA.
    Additionally, we must eliminate VA's co-sharing for Native 
Veterans, as the Federal Government has treaty and trust 
obligations to provide health care to American Indian and 
Alaska Native people.
    Finally, I want to briefly emphasize the importance of 
advance appropriations for IHS and the Bureau of Indian 
Affairs. IHS is often responsible for providing health care to 
Native Veterans, and access to IHS and VA facilities often 
depends on services provided by the BIA. Protecting funding for 
these agencies from uncertainties in the Federal budget process 
will improve access to vital health care for Native Veterans
    I want to close my testimony by expressing my sincere 
gratitude for the service and sacrifice of all the veterans, 
especially our Native Veterans, many of whom are tribal leaders 
across Indian country. It is incumbent upon us all to ensure 
the Federal Government to honor its solemn commitments to 
Indian country.
    Thank you again for this opportunity to testify and I would 
be happy to answer any questions when it is over.

    [The Prepared Statement Of Kevin J. Allis Appears In The 
Appendix]

    Ms. Brownley. Thank you, Mr. Allis.
    I now recognize Ms. Tetnowski for 5 minutes.

                STATEMENT OF SONYA M. TETNOWSKI

    Ms. Tetnowski. Good morning. My name is Sonya Tetnowski. I 
am an enrolled member of the Makah tribe, a U.S. Army Veteran 
Paratrooper, and the CEO of the Indian Health Service of Santa 
Clara Valley. I am also the Vice President of the National 
Council of Urban Indian Health (NCUIH) and the President of the 
California Consortium of Urban Indian Health. Urban Indian 
Organizations (UIOs) provide high-quality, culturally competent 
care to urban Indians, which consists of about 75 percent of 
all American Indians and Alaska Natives (AI/AN).
    I would like to thank Chairwoman Brownley, Mr. Bergman, and 
other distinguished members of the subcommittee for holding 
this important hearing.
    It is my pleasure to testify today regarding H.R. 4153, the 
Health Care Access for Urban Native Veterans Act. We ask that 
the Department of Veterans Affairs fully implement the VA and 
IHS MOU, and reimbursement agreement for direct care services. 
This action would allow UIOs to be reimbursed for providing 
health care to AI/AN veterans. Most AI/AN veterans live in 
urban areas and would benefit from the culturally competent 
care provided by UIOs.
    Despite the history between tribal people and the United 
States Government, American Indians and Alaska Natives continue 
to serve this country at a higher rate than any other group in 
the Nation. We have a responsibility to protect the land of our 
ancestors, respect their teachings, and pass that knowledge on 
to generations that follow us. I am sad to report that 
according to a 2014 Minority Veterans Report conducted by the 
National Center for Veterans Analysis and Statistics, it 
clearly states that American Indians and Alaska Natives have 
the highest poverty rate and the highest uninsured rate. This 
seems out of balance. We serve, we protect, but yet we struggle 
to have parity in the system.
    We ask you to help us complete the Indian Health Service/
Tribal Health Program/Urban Indian Organization (I/T/U) system 
of care. In order to begin to address the health disparities of 
urban Native communities, I ask that this committee take into 
account the national health care spending average of $9,523 and 
the $19,228 that VA spends in Santa Clara County per patient 
served, compared to the $3,688 currently allocated to me to 
serve that same patient. UIOs are efficient and effective, and 
we deserve parity.
    We also ask that medication delivery and dispensing be 
included in the agreement this time, as many of our veterans 
are homeless and do not have addresses to receive their 
medication. As these are our community members, we do what we 
can to help them overcome these obstacles.
    The balance of traditional and Western medicine is vital to 
the healing of many of us, which is why my UIO, the Indian 
Health Center of Santa Clara Valley, provides an annual Wiping 
of the Tears ceremony, so that my fellow soldiers and I can 
stand together and grieve and heal as only another soldier 
would understand. For many urban Indians, the UIOs are the only 
place where they can receive cultural and traditional services.
    Bring parity to the system and together let us wrap our 
soldiers in culturally competent care, help us strengthen our 
I/T/U system of care.
    Again, NCUIH strongly recommends, pursuant to Section 
405(c) of the Indian Health Care Improvement Act, that the VA-
IHS MOU include reimbursement for care provided by the UIOs.
    I would like to present you with this medicine, which 
consists of abalone shells, sage, cedar, and sweet grass to 
remind you what traditional medicine has done for me and my 
fellow soldiers. Our traditions keep us grounded and provide 
that support needed to heal the invisible wounds that we all 
have from serving and protecting this country.
    With that, I ask you to support my work and the work of all 
Urban Indian programs to bring support for that healing to our 
communities.
    Thank you for holding these hearings today and for the 
committee's support of parity in the I/T/U system of care and 
H.R. 4153. My full testimony has been provided for the record 
and thank you again for the opportunity to speak.

    [The Prepared Statement Of Sonya M. Tetnowski Appears In 
The Appendix]

    Ms. Brownley. Thank you, Ms. Tet--Tetnowski----
    Ms. Tetnowski. Tetnowski.
    Ms. Brownley.--I am not sure why I am having a hard time 
with that, but I am. I apologize, but I do also want to thank 
you for your service. Being a paratrooper is--just it is 
amazing and thank you very much.
    I now recognize Chief Smith for 5 minutes.

                STATEMENT OF CHIEF WILLIAM SMITH

    Chief Smith. [Speaking native language.] Chief Bill.
    Good morning, my name is Chief Bill, Chief of Eyaks. My 
mother was the last full-blooded Eyak speaker, my father was a 
World War II veteran. I am also the Vice President of the 
Valdez Native Tribe, Executive Committee member of the Alaska 
Native Health Board and Vice Chair of the National Indian 
Health Board, and a Vietnam Vet.
    On behalf of the Alaska Native Health Board, thank you, 
Chairman Brownley, Ranking Member Dunn, and distinguished 
members of the House Committee on Veterans' Affairs 
Subcommittee on Health for the opportunity to speak with you 
today. For the record, I have provided a written statement, 
which gives more background and details on the issues that I 
can share with you today. I hope mostly to honor our veterans, 
lift our government-to-government relationships between tribes 
and Federal Government involved in the Federal Trust 
Responsibility, and provide a description of the Alaska Tribal 
Health System and our Tribal Sharing Agreements.
    I too am also disappointed that today we are not sitting 
with Rear Admiral Weocki or Secretary Wilkie or Dr. Stone for 
this important hearing recognizing the government-to-government 
relationship and to start a strong partnership between the 
tribes and the VA and Indian Health Service. It is my hope that 
we will continue to have tribal representatives on the IHS VA 
MOU team.
    In our written comments, we also provide details on issues 
including, but not limited to, support of H.R. 2791 and S. 524, 
Department of Veterans Affairs Advisory Committee Act of 2019, 
including tribal representatives on Indian Health Service and 
the VA leadership team on renewing the MOUs reflecting the 
government-to-government relationships; review and revise of 
the VA Tribal Consultation Policy; build parity between the VA 
and the Indian Health Service; exempt Native Veterans from co-
pay and deductions in recognition of the unique political 
status of American Indians and Alaska Natives on the Federal 
Trust Responsibility; and I support the Tribal Veterans 
Representative model.
    I would like to start with the Tribal Sharing Agreement. 
Before the agreement, Alaska Veterans only had six points of 
access for care through the VA in an area that would cover the 
Lower 48 from coast to coast, and from the northern borders to 
the southern borders. Most vets went years, if not decades 
without care. After signing the agreement, veterans for the 
first time had access to care closer to home, from six 
locations to over 200, with little or no capital expense 
carried out by the VA, and even non-Native Veterans can be 
served at a Veterans Hospital that we have in Alaska.
    As I was at the Alaska--recently at the Alaska Native 
Federal AFN meeting in Fairbanks, tribal delegates shared with 
the VA a need to go out to the cabins. When I say go out to the 
cabins, when the VA comes to Alaska they usually go to the 
hubs, Kotzebue, Fairbanks, Anchorage, and they say everything 
is good. What the veterans would like to see is them fly into 
Dillingham, get off the plane in Dillingham, get down to a 
skiff and go up river 50 miles, get out of that skiff at 50 
miles, and go on a snow machine or a four-wheeler or dog sled 
and talk to the veteran in the cabin that has not got his 
share, that has come home from Vietnam, come home from Iraq, 
Afghanistan, and everything else, and ask him if he is Okay, 
because they are out there. I for one as a Vietnam Vet took 35 
years to talk to my brother that was there before I was, or to 
even get care from the VA.
    We support the Tribal Veteran Representative, the one way 
to help develop outreach, but support the Tribal Sharing 
Agreements, offer direct access to care with providing veterans 
with their families. That is the only way we are going to get 
the veterans out of the woods is through the Tribal Veterans 
Representatives, their aunts, their uncles, their kids that are 
going to tell that veteran this is a new VA; this is something 
that they can come home to, this is something that will welcome 
and take care of them.
    Like I say, it took me 35 years to seek help, and I talked 
to my brother and he was there. It was a fireworks in Anchorage 
on the Fourth--I mean New Year's Eve and he was sitting there 
watching it, next thing you know he was on the deck. He was not 
there, he was back in Vietnam, he was out there on patrol and 
those were not fireworks, those were bombs and everything else 
coming in. That is what we have. We are still 19 years old, we 
are still in Vietnam; we come home, but Vietnam come home with 
us and, not only did that, Agent Orange come home with us. If 
we had to build a Vietnam wall from the people that passed away 
since then with Agent Orange exposure, that wall would be 
tenfolds.
    In conclusion, many veterans have broken the faith of the 
VA system, some have not accessed care in decades, like I said. 
Tribes in Alaska and across the Nation are working with the VA 
to help restore their faith. In Alaska, we have over 34,000 
vets enrolled and out of an estimated 75,000 to 90,000 vets. 
More work needs to be done to reach the brothers and sisters 
when we work together with the VA and Health Service through 
consultation, with recognition of the strength of their tribes 
and Tribal Health Organizations bringing it to the table.
    An important step would be to allow us for longer Tribal 
Sharing Agreements periods, support continuous care over time, 
allow for Tribal Representatives to join the leadership teams 
reflected in the government-to-government relationships, and 
will provide the best results for the meeting and need to honor 
our veterans.
    Alaska Native Health Board thanks the subcommittee and 
looking forward to further support of members and their work on 
the veterans health care issues, and the Alaska Native Health 
Board welcomes any questions.
    Thank you.

    [The Prepared Statement Of Chief William Smith Appears In 
The Appendix]

    Ms. Brownley. Thank you. Thank you very much, Chief Smith, 
and I thank you also for your service to our country.
    Last, but not least, I now recognize Chief Malerba for 5 
minutes.

                 STATEMENT OF MARILYNN MALERBA

    Ms. Malerba. [Speaking native language.] Good morning, 
Chairwoman Brownley, Acting Ranking Member General Bergman, and 
members of the subcommittee.
    [Speaking native language.] My name is Chief, Many-Hearts-
Lynn Malerba of the Mohegan Tribe. On behalf of the Indian 
Health Service Tribal Self-Governance Advisory Committee, it is 
a great honor for me to present our testimony before you today. 
Our formal written testimony has been submitted to the 
subcommittee for the record.
    Native Veterans, as you have heard, have a uniquely special 
status with the United States. Our American Indian and Alaska 
Natives have fought for the U.S. Armed Forces in every war 
since colonial times; in fact, 39 Mohegan men fought at Bunker 
Hill. In exchange for the cession of lands, treaties between 
our Native governments and U.S. included health care for our 
people. As warriors for this Nation, Native Veterans are 
deserving of the best health care we can provide.
    The VA reports that there are 145,000 Native Veterans 
living in the United States with an average life expectancy 4 
years shorter than the general U.S. population and who are more 
likely than other veterans to experience social and economic 
difficulties that impact their health.
    Tribal nations that elect to administer health programs and 
services under a self-governance agreement to their citizens 
are effective, because tribal nations know the needs of their 
communities and are in the best position to provide culturally 
appropriate solutions to address those local needs. However, 
Tribal Health Programs (THPs) are limited due to limitations 
imposed by the VA.
    In recognition of the shared responsibility to provide 
better care, an MOU between the U.S. VA and IHS was implemented 
to access VA funding for services provided to our Native 
Veterans. There is a tremendous opportunity for all to work 
collaboratively to update the MOU and identify components that 
will ensure Native Veterans receive timely access to quality 
health care, the services that they are owed.
    The Tribal Self-Governance Advisory Committee (TSGAC) 
strongly advocates for the following improvements. Veterans 
often require additional specialty services that are not 
available at IHS or THPs. If a Native Veterans needs a 
referral, that same patient must then be seen within the VA 
system before a referral can be secured. Veterans are then 
forced to maneuver a very complex health care system. Our 
recommendation is that the VA should accept referrals made by 
IHS and THPs and to ensure best services to our veterans. 
Further, the VA should include Purchased Referred Care (PRC) in 
the IHS THP reimbursement agreements to eliminate rationing of 
health care and delays in care.
    Native Veterans who seek health care services at a VA 
facility are assessed with copayments, which is in direct 
opposition to the Federal Trust Obligation; we recommend the 
discontinuation of this practice.
    The VA does not accept provider credentialing from THPs. 
Our recommendation is that they be accepted by the VA to ensure 
care coordination is effective and efficient.
    IHS and THPs have significant workforce challenges due in 
part to most facilities being located in rural and remote 
locations. Our recommendation is that IHS and tribes be 
included in the planning of GME pilot program to ensure that 
any future regulations or policies work optimally in Indian 
country.
    Only those IHS and Tribal Health Programs that use the 
Resource and Patient Management System (RPMS) system have 
access to CMOP, the Consolidated Mail Order Pharmacy. We 
recommend that information technology systems experts from both 
VA and IHS ensure that all systems used by Tribal Health 
Programs are compliant and compatible with the CMOP system.
    The TSGAC is supportive of quality measures that provide 
further tracking of meaningful outcomes; however, we oppose the 
prospect of developing either data reporting requirements that 
affect reimbursements to IHS and THPs or that require new 
collection of data and reporting systems. Our recommendation is 
the VA and IHS work together and consult with tribes to develop 
evaluation measures for assessing the progress toward MOU 
goals.
    Additionally, the VA should not oppose any additional 
quality programs upon IHS THPs because it is burdensome, 
costly, and unnecessary due to the fact that there are already 
quality requirements in place.
    The VA belongs to a National Health Information Exchange 
and it reported to the GAO this year that IHS and THPs could 
join the exchange to access information about common veteran 
patients; however, IHS reported to GAO that testing and on-
boarding costs to participate were prohibitive. We recommend 
that local VA health care facilities work with their local THPs 
to ensure health information can be exchanged through local 
health information exchanges rather than one national health 
exchange.
    We recommend that the VA work in coordination with tribes 
to establish a tribal advisory board, because we know that 
those are effective forms to resolve issues in a government-to-
government fashion.
    In March 2019, the GAO reported that the MOUs signed by the 
VA and IHS lacked sufficient measures for assessing its goals. 
We recommend that Federal agencies focus their limited 
resources on actions that improve the health of Native Veterans 
by ensuring that the measures are focused on health care 
outcomes. They should be measured, developed, and agreed upon 
jointly.
    In closing, the VA, IHS and Tribal Health Programs have 
made progress and have demonstrated a willingness to improve 
quality access to care for our Native Veterans, deservedly so, 
but as you see in our statement, there still are significant 
opportunities for improvement.
    [Speaking native language.] I thank you very much for 
hearing my comments today.

    [The Prepared Statement Of Marilynn Malerba Appears In The 
Appendix]

    Ms. Brownley. Thank you, Chief Malerba.
    I first want to recognize Chairman Takano has joined us. 
Chairman Takano chairs the Full VA Committee. Welcome, and 
thank you for being here.
    Would you like to make any comments?

   OPENING STATEMENT OF MARK TAKANO, CHAIRMAN, FULL COMMITTEE

    Mr. Takano. Just an opening statement.
    Good morning and thank you so much, Congresswoman Brownley, 
for holding this important hearing.
    I want to thank our witnesses from the National Indian 
Health Board, the National Congress of American Indians, the 
National Council on Urban Indian Health, the Alaska Native 
Health Board, and the IHS Tribal Self-Governance Advisory 
Committee. To those of you who served, thank you for your 
service.
    It is critical that this subcommittee hears your voices and 
the voices of the tribal members that you represent. While we 
know Native Americans serve at higher rates than anyone else, 
they also endure the lowest health status of anyone else. This, 
frankly, is a national shame and a terrible violation of the 
Trust Responsibility the United States Government is obligated 
to uphold. We must do better.
    VA must do more to ensure the goal of improving the health 
status of American Indian and Alaska Native Veterans is 
accomplished. I am disappointed to see that Under Secretary Dr. 
Stone is not here. While I commend the work of the program 
officers here to testify, I know the needs of all Native 
Veterans cannot be met by these three program offices alone. 
This must be a priority VA-wide.
    Again, I can not thank you enough for sharing your time 
with us, and I assure you that as part of my VA 2030 Vision 
this committee is dedicated to ensuring marginalized veterans 
are receiving access to the health care and benefits that they 
have earned. This is just the beginning of this committee's 
work on these issues.
    I yield back, Madam Chair.
    Ms. Brownley. Thank you, Chairman Takano, and, again, thank 
you for joining us this morning.
    I will recognize myself for 5 minutes for questions. I 
wanted to open by just saying that our Native Veterans, in my 
opinion, should be receiving actually the very best health care 
in our country, because they have been promised from two 
sources their health care, both from our country in our 
commitment to the health care of our Native Indians, including 
our Native Veterans, in addition to VA's commitment to our 
Native Veterans. If you compile those two pieces together, you 
should be getting the very best health care in our country, and 
clearly that is not the case.
    It is very clear to me that there is much to work on and 
much to improve upon, which leads me to the place of the 
upcoming MOU. All of you have talked about issues, including 
the Advisory Committee that Ms. Haaland is leading on, issues 
around co-pays, issues about reimbursements for services, the 
duplicity of services that have been received, but all of these 
components need to be ironed out and worked through in this new 
MOU. We have learned a lot over the last 9 years and now it is 
time to really rectify that through a successful negotiations 
with the MOU.
    My question is for each and every one of you on the panel. 
I want to and this committee wants to be assured that you are 
at the table for these negotiations. If you could comment on 
that for me, whether you feel assured that you will be at the 
table or you have concerns about being at the table.
    I can just start with--I am sorry, I do not have my glasses 
on--we can start Chief--Mr. Joseph.
    Mr. Joseph. Well, I am glad that you are asking the 
question and, you know, and part of the testimony, with the IHS 
funded the way that it is, it is discretionary and the recent, 
you know, Government shutdowns that I spoke to in my testimony 
really impact the services that would be provided to any of our 
veterans that come to our facilities, be it IHS or a tribal 
facility. It would be really good to be at the table, you know, 
when they are making those recommendations.
    I testified in the Senate Committee on Veterans, you know, 
prior to the MOU being put in there and one of my asks was that 
the VA set up an Office of Indian Affairs in the VA, and they 
did that. Then the second one was to have the VA deploy doctors 
and nurses to our facilities, because the IHS is so far behind 
in actually having health care providers to provide the 
services, and the H.R. system that they deal with is causing a 
lot of issues, you know, on getting good quality providers that 
come to IHS facilities. There is----
    Ms. Brownley. Mr. Joseph, thank you. I only get 5 minutes 
myself, so I want to hear from all of the others on the panel--
--
    Mr. Joseph. Okay.
    Ms. Brownley.--but I want to make sure whether you have a 
sense of whether you would be at the table for these 
negotiations around the MOU.
    Mr. Joseph. I imagine that the National Indian Health Board 
would definitely have someone at the table there. Thank you.
    Ms. Brownley. Thank you.
    Mr. Allis.
    Mr. Allis. Yes, Chairwoman. My answer is, I certainly hope 
so. I do not feel comfortable right now with the situation and, 
as Mr. Joseph mentioned, there are other organizations that 
certainly are plugged into this.
    I will say this, consultation should be going on right now 
about this. It has been the practice where, you know, these 
things get put together, these agreements get shaped, and then 
they bring them to Indian country after the decisions have 
already been made. I also note that the March 2019 GAO report 
mentioned that there used to be 12 work groups that discussed 
this and tribes only participated in three of them, but at 
least they were participating. Now there are three work groups 
and there is no tribal participation.
    There is some level of concern for us there that in the 
crafting of this language addressing the issues that we all 
addressed today and that you acknowledge are properly being 
discussed at the table.
    Ms. Brownley. Thank you, sir.
    Ms. Tetnowski.
    Ms. Tetnowski. Thank you. We would welcome the opportunity 
to sit on the panel and be a part of a working group to discuss 
the parity issues that we continue to have in serving our 
Native Veterans in the urban community.
    Thank you.
    Ms. Brownley. Thank you very much.
    Chief Smith.
    Chief Smith. Yes, that would be the right thing to do if we 
could be on the panel to help, because when we had the MOU in 
Alaska with the VA, they come to the Alaska Native Health Board 
and we had consultation. I can tell you right now that it 
worked out great, because my doctor I have had with the Indian 
Health Service for 15 years and with the VA I have had three 
doctors in 1 year. My doctor knows me at the Indian Health 
Service, but the VA also needs to pick up their fair share, 
because it is something that I earned and it can make our 
Indian Health Service money go a lot further for those that are 
on it.
    Yes, if I could be there, I will be there.
    Ms. Brownley. Thank you, Chief Smith.
    Chief Malerba.
    Ms. Malerba. I hope so, but I am not sure that that is the 
case. I do not know that we have been given any assurances 
about that, but I will say this, consultation is more than just 
asking the question; consultation is actually doing something 
with the information you received during consultation. Had the 
VA and I just listened to the previous consultations around 
these topics, we probably would not be sitting with you today 
talking about the ways that we can improve this program.
    Ms. Brownley. Thank you so much.
    I have very little time left, but I do want to mention that 
a constituent of mine in my district is a dual user of VA and 
the Santa Barbara Indian Clinic--I am from California--and he 
uses as it seems like a lot of Native Veterans do, he uses the 
clinic, the Indian clinic for his primary care and then uses 
the VA for his specialty care. We know that his records are not 
going back and forth, and they seem to have--the VA providers 
specifically have limited to know understanding of his cultural 
needs. In fact, he told me and he told my staff that when he 
went to the VA, the VA staff responded by ``I did not know 
Indians lived in this city.''
    This whole issue of cultural competency and a welcoming 
from the VA I think really does need to be addressed and I 
certainly would like your feedback on it, but my time has 
expired, but we can have further conversations about that 
offline.
    I now welcome Dr. Dunn and recognize Dr. Dunn for 5 
minutes. Thank you for joining us.
    Mr. Dunn. Thank you very much, Madam Chair, and I apologize 
for being tardy. We have another committee meeting scheduled 
precisely at the same time.
    I want to thank General Bergman for sitting in for me. 
Thank you very much, General Bergman.
    With that, I will yield the remainder of my time to General 
Bergman.
    Mr. Bergman. Thank you. Thank you, Dr. Dunn, and thank you, 
Chairwoman Brownley.
    You know, God puts us where he wants and when he wants us 
there, it is up to us to figure out the why. Listening to your 
comments, I know why I was here today pinch-hitting for Dr. 
Dunn at the beginning is to hear your words.
    Chief Smith, thank you for your service, welcome home. As I 
look at our fellow Vietnam Veterans, because you mentioned 
something that--the Vietnam wall--I am not going to ask you to 
provide comment, but I am guessing I will maybe get some 
nodding of heads that maybe--not maybe, I know for a fact that, 
as a country, if we had started welcoming our brothers and 
sisters home 50 years ago, we would not have some of the mental 
health, depression, suicidal issues we have amongst our 
veterans period from Vietnam, but especially those tribal 
members.
    Right now we are trying here in the committee as a whole to 
get the Improve Act, which is a bipartisan bill that 
Representative Chrissy Houlahan and I have put out there to get 
it to the committee, to get it--to get it out there, so that we 
can reach out to, I am guessing your tribal members are the 
majority of that 70 percent of the veterans outside the VA 
systems who take their lives on a daily basis, and the purpose 
of the Improve Act is to reach out and make contact with you 
and your tribal members.
    Now, having said that, when you try to put something into 
place, we have a lot of acronyms in the world and, you know, I 
like logjam. We all can visualize what a logjam is. Well, in 
this case, it is layers of Government is the log. When we start 
putting in new layers, we do not necessarily increase output 
and better results.
    Would any of you care to comment on what is preventing the 
VA and the tribes from sitting down and hammering out for 
specific credentialing metrics, so we can get providers 
credentialed in both sides? Anyone care to comment?
    Chief Smith. I know when I meet with the VA and I meet with 
the Indian Health Service what I tell them to do is to tear 
down their towers. They have got to work together, that is the 
most important thing. To me, I see two different towers, just 
like I see with the VA, there are three, but the VA and the 
Indian Health Service needs to remove all other walls and start 
working together to help our Native Veterans.
    Like you say on our Vietnam brothers and sisters, yes, it 
is nice to be welcomed home and that is why we are there when 
the rest of our brothers and sisters do come back from war, 
because we will never want that to happen to any other 
generation ever again.
    My main thing is, they started the listening sessions, but 
it needs to go farther than that. They need to tear their walls 
down and work together to help our people.
    That is my opinion.
    Mr. Bergman. Thank you very much. You know, I yield back. 
As--well, before I yield back, we have already made some 
progress in my district with trying to figure out ways--you got 
the Tribal Health Clinic, you got extra office space, you got 
different things, why ca not we combine Indian Health Service, 
VA services? Because when you live in not only a rural 
district, but a remote district, that can be a center of health 
care for the entire population run by the tribe.
    Anyway, thank you. I appreciate the time and thank you for 
allowing me to be in here, and I yield back.
    Ms. Brownley. Thank you very much.
    Mr. Cisneros, you are recognized for 5 minutes.
    Mr. Cisneros. Thank you, Madam Chairwoman. Thank you all 
for being here today.
    You know, I became aware of a report of a Native American 
Marine Corps veteran who was denied being put on the transplant 
list for a kidney and the reason that was given was a cognitive 
impairment basically, because I guess a test that he was given 
saying that he would not remember, be able to remember the care 
that he needed to be able to provide to himself. After 
investigation, he did eventually get the transplant and get on 
the list, but it took so long because of this. What they found 
out when they investigated was that there was--the reason he 
was denied was because of this cognitive impairment, but really 
what it was was a barrier, either a language barrier or a 
cultural barrier.
    Have you all seen other examples of this where people are 
being denied treatment, especially whether it be a kidney or a 
liver, something that they need, because of this cultural bias? 
Anyone.
    Chief Smith. I do not know if it was the culture and 
everything else, but I know that it was too late for my 
brother, because he needed his lungs. He passed away in 2017. 
We could not get him healthy enough in Alaska to transport him 
to the Lower 48 secondary to Agent Orange exposure. He took his 
last breath and his lungs just quit working, and he did not get 
well enough to be able to have me transport him down to Seattle 
to get a new set of lungs.
    There are things in there like, oh, you need to get down--
he was at 209, he had to get down to 200 pounds, they said. For 
nine pounds, my brother--my brother could have lived 5 more 
years with a new set of lungs, but we could not get him well 
enough when he went downhill to get him down to Seattle to get 
a new set of lungs.
    That is all I can say. He was--he was my hero.
    Mr. Allis. Congressman, no specific situations, but the 
scenario that you point out is common across Indian country in 
a lot of different areas. When you look at not taking--you 
know, agency folks or the Government not taking the time to 
look at the uniqueness of these communities, you know, not only 
the location, but the traditional customs and culture, and the 
language barriers that could exist that are not taken into 
consideration. It is definitely an issue with treating our 
veterans, especially that might have, you know, brain injuries 
or head injuries and revert to their traditional languages 
because it is much easier to communicate, because that is how 
they were raised.
    We see this with health care, we see it with voting, we see 
it with, you know, signing up. All that kind of stuff is we 
need people to pay more attention and to take the time to learn 
about the uniqueness of our communities in a way where they can 
connect, we can connect, and things can get accomplished.
    Mr. Cisneros. Yes, ma'am.
    Ms. Malerba. Well, and I think that that is what we were 
talking about before. When we have to refer somebody outside of 
our system, you do not have anyone helping them to navigate 
that system, whereas if you are within the Tribal Health 
Program or the IHS system, you will have people there that are 
culturally competent, that can understand what some of the 
barriers are to that person accessing care, and sometimes it is 
that they just have a reluctance to go outside their own 
community.
    I think that that is why we want to make sure that we do 
not have to send them back into another system for a referral 
to care, because chances are likely that they would not access 
that, they will just give up and they would not access that 
care.
    Mr. Cisneros. Right. Just--I have got one minute left here, 
but just to followup on some other things. You have all talked 
about the MOU between the VA and IHS. In some of these remote 
areas where there is no VA, you know, and veterans are going 
there to seek services, have we had situations because of lack 
of the MOU where they have been denied services or that the VA 
has said we are not going to pay for that service because they 
are not enrolled?
    Anybody can answer that one. Go ahead, yes.
    Ms. Tetnowski. We have had situations where the VA would 
not accept our referral. Similar to what Chief Malerba was 
talking about is that the VA--it is hard enough to get our 
veterans to come to any facilities to seek that additional 
support and once we have to then transfer them out of our 
facilities into another system without a patient navigator or a 
tribal navigator inside the system, we tend to lose them in the 
process. Many times, even as an urban facility, our nearest VA 
hospital is about an hour and a half to two hours away, and so 
during that time without that referral acceptance we lose them 
in the process, because they do not want to go again.
    It is like a lot of the response that I get is, I already 
went through those tests with you, why do I have to go there 
and do it again, and that is a fair statement. We should be 
able to transfer our medical records into the VA system and not 
put our community members through that again.
    Mr. Cisneros. Right.
    Ms. Malerba. One of the things with the MOU is that it 
limits the services that non-Native Veterans can access at IHS, 
even though typically we would allow certain services covered. 
They do not allow non-Native pregnant women with Native 
children to access care there, even when they are connected to 
the veteran, and especially in cases where the IHS and THP are 
the only facility in close proximity to the veteran.
    We think that we need to make sure that all services are 
covered and that they are not limited, because in some cases 
those are the only facilities that are available.
    Mr. Allis. If I may make one more comment? This is the 
importance of really look at the regulatory burdens that are in 
the way of tribes with respect to tribal veterans service 
organizations and being able to put those up, the tribes have 
to go through so much. They have to establish and fund an 
organization before somebody can get accredited, be able to 
manage that, and work with the community folks on going through 
the process of their claims and tracking their services.
    There really needs to be a look at that.
    Mr. Cisneros. All right. Go ahead, Chief Bill.
    Chief Smith. Yes, the other thing too is, like Alaska has 
over 70 to 90,000 veterans and only 30,000 of them are 
registered for the health care. A lot of them are Vietnam Vets 
and a lot of them that have not trusted the VA enough to come 
back to the system, and that is where you need to have the 
tribal veterans, our veterans being able to talk to them and 
saying that this is the new VA. They earned everything that 
they had, but they have never trusted the VA enough to come 
back to the table, and that is half our veterans up in Alaska 
are still in the bush and still need to come home.
    Mr. Cisneros. Right. Well, I am out of time, but thank you 
all for your answers. Thank you.
    Ms. Brownley. Thank you, Mr. Cisneros.
    Mr. Lamb, you are recognized.
    Mr. Lamb. Thank you, Madam Chairwoman, and thank you to all 
the witnesses for making this long trip here to educate us.
    I had a question to begin with for Chief Smith. In your 
testimony I noticed you talked about exempting tribes and THPs 
from the establishment and consolidation of the community care 
networks; are you referring to under the MISSION Act?
    Yes, sorry, I did not mean to catch you off guard there.
    Chief Smith. Yes.
    Mr. Lamb. Could you just talk me through, to the extent you 
are able, what impact you see the MISSION Act as having on the 
Alaskan system and on your tribes and community, if any. If you 
think there should be interaction based on the MISSION Act or 
if everything is supposed to be separate, I am just trying to 
see where you stand on that. Thank you.
    Chief Smith. As a veteran from the MISSION Act to the 
Choice program to everything else, it is just another thing 
coming down the pike to us. As a veteran, we just have to see 
how it is going to work out, because what we need is health 
care and, like we have been talking about, health care between 
deals. Because I can get my blood tests for my diabetes 
secondary to Agent Orange exposure and I can get it at Indian 
Health Service and it costs thousands of dollars, and I have to 
go right across the street to the VA in Anchorage and get the 
same tests, and I have to travel 300 and some miles to get my 
nearest VA. That is a little bit shorter than my dad did. My 
dad had to go to Portland, Oregon from Cordova, Alaska to the 
VA when he passed away.
    As a veteran, you know, the MISSION Act, the Choice 
program, everything else, what the veteran needs to do is being 
able to treat where the veteran knows he is going to get the 
best service for himself, for himself or herself. Is that 
closer to home? Just like we were talking about the MOUs, if 
you lived in Dutch Harbor, Alaska, it cost you over 1500 bucks 
to fly one way into Anchorage and then you need an escort, and 
then that is the VA is picking it up, but if you get treated 
right at Dutch Harbor, if you get treated with your doctor, you 
do not have to pay that travel cost and that veteran gets 
treated closer to home. Not everybody likes to go to the big 
village just to spend the day.
    Mr. Lamb. Yes. Well, I think what I was trying to figure 
out was, could the MISSION Act--and anyone can answer this, if 
they have an opinion--could the MISSION Act be a vehicle for 
basically saving you that trip and helping you get care in your 
actual community if the VA had already made that provider part 
of their network, is that a possibility or is there something 
that prevents that?
    Chief Smith. It would be a very good possibility, but last 
time I used my VA Choice when I first got given my VA card, I 
had to have a scope job and it cost me 1500 bucks by using the 
VA myself. I have no--I needed it in writing first that the VA 
is going to pick up the bill, because I tried it and so has a 
lot of other veterans.
    We need to be able to know that they are going to take care 
of us.
    Mr. Lamb. It all goes to how the network is designed and 
implemented.
    If we could--Ms. Tetnowski and Chief Malerba, and then I 
will probably be out of time.
    Ms. Tetnowski. Just a quick comment on that. The Choice 
system tends to be the place where the VA refers us to and at 
the end of the day, more often than not, it is already out of 
money. We end up with what happened to Chief Smith there where 
they want you to go there, but it is not available. Again 
another barrier. Now it becomes the veteran's responsibility to 
cover those costs and they are supposed to be receiving this 
service as part of their benefits for service.
    Mr. Lamb. Okay, got it. Thank you.
    Chief Malerba.
    Ms. Malerba. I think that is where credentialing comes into 
play. If there was reciprocity and full faith and credit for 
the THPs and IHS provider, then there would be no barrier.
    Mr. Lamb. Right. Whether that happened through an MOU or 
the MISSION Act, I guess that is what I was trying to figure 
out, does it make a difference, it sounds like probably not.
    Mr. Joseph.
    Mr. Joseph. You know, I think it would be really good if, 
you know, an MOU or the act, if you pass an act that would 
shift the funds directly to IHS or to tribes to allow our 
providers to be able to provide for our veterans.
    Like Chief Smith talked about, some of our veterans, you 
know, were forced to go to war and drafted, and they do not 
trust VA. The new VA sounds really good, but, you know, a lot 
of our people want to be seen at home by the providers that 
they are used to. And if you compare the IHS budget to what the 
VA gets per patient, you would see a big, big difference and 
the need for the IHS to have the funding. I spoke about the 
Government shutdown and impacts there.
    Mr. Lamb. Right, I noticed those numbers in your testimony 
as well. Thank you very much. I am out of time.
    Madam Chairwoman, I yield back.
    Ms. Brownley. Mr. Gianforte, welcome. You have just sat 
down, but because we are trying to go back and forth, you are 
recognized.
    Mr. Gianforte. Thank you, Chair. First, I want to thank you 
and the ranking member for letting me join this hearing. Thank 
you for our panelists here today, so we can learn more about 
this subject.
    I appreciate the opportunity to speak with you regarding 
Native American veterans' access to health care. Native 
Americans make up nearly 10 percent of Montana's population and 
they overwhelmingly answer the call to serve. This is why I 
have introduced the bill in front of us today, to ensure our 
Native Veterans have access to the care that they deserve.
    In 2012, the Indian Health Service of the Department of 
Veterans Affairs established a reimbursement agreement which 
allowed rural IHS providers to supplement VA care. In classic 
Washington bureaucratic fashion, Urban Indian Health Centers 
were left out of the agreement. In Montana, Urban Indian Health 
Centers provide care to 60 percent of Native Americans who are 
not located on a reservation.
    My bill, the Health Care Access for Urban Native Veterans 
Act, will ensure that our Native Veterans have access to care 
that works best for them and will cut wait times at VA clinics 
for all veterans.
    This committee has worked tirelessly to ensure we keep our 
promise to our veterans who have sacrificed so much for this 
country and my bill continues this good work.
    Ms. Tetnowski, Urban Indian Centers receive limited funds 
from IHS to provide their services. What would be the impact on 
these urban centers if they were to receive reimbursement from 
the VA?
    Ms. Tetnowski. Thank you so much. The impact would be 
significant. As you stated yourself, 60 percent in Montana 
receive services at their local urban center, same goes with my 
facility in Santa Clara County.
    We provide support, we have 41 Urban Indian Health Centers 
throughout the Nation, and these centers provide that support 
where a tribal facility may not be located. In most cases these 
urban centers are located in places where relocation centers 
occurred, so that was the purpose of creating our Urban Health 
Centers. I think the impact would continue to allow us to 
provide that culturally competent care and increase our ability 
to meld both traditional and Western medicine to provide the 
support that our veterans need in these urban centers.
    Mr. Gianforte. Okay. We have five of these centers in 
Montana, in Missoula, Great Falls, Billings, Butte, and Helena. 
If this bill became law, you are saying they would be able to 
better care for our Native Veterans. Okay.
    One follow-on question, if I could. What has been done to 
leverage telehealth in any of these centers? Is that something 
that you are looking at and what impacts have you had?
    Ms. Tetnowski. We have attempted to get through the process 
to allow telehealth to be available in our urban centers, but 
many of our urban health centers have capacity to continue to 
serve. Telehealth, other than specialty care, may not be 
necessary. Most of them have behavioral health services, we 
have medical and dental and other support services inside our 
facilities, but telehealth would add additional ability to get 
that specialty care to those urban centers.
    Mr. Gianforte. Yes. This is--I have been advocating for 
telehealth, because we have many rural communities, we can not 
have----
    Ms. Tetnowski. Yes.
    Mr. Gianforte.--every specialist in every community. 
Telehealth is a way to provide better care at higher quality. I 
would just----
    Ms. Tetnowski. It would be a wonderful way also for us to 
continue to partner with our local tribal communities as well 
to provide support for each other----
    Mr. Gianforte. Again----
    Ms. Tetnowski.--because we are one community.
    Mr. Gianforte.--not to substitute for local care, but it is 
just an enhancement.
    I just want to thank the chair and ranking member again for 
letting me join this hearing today, and I yield back the 
remainder of my time.
    Ms. Brownley. Thank you, Mr. Gianforte, and I thank you for 
raising the important issue around our Native Veterans who live 
in cities, because I think it is abundantly clear that we are 
not servicing them the way they need to be serviced and we have 
got a lot of work to do in that area, so thank you for bringing 
that up.
    Mr. Sablan, you are recognized for 5 minutes.
    Mr. Sablan. Yes, thank you very much, Madam Chair. Thank 
you very much for holding today's hearing.
    To the witnesses, I know what it is to fly a distance to 
come to Washington. I live the furthest away from Washington, 
DC. as a member here. I live out in the Northern Mariana 
Islands and that part of a place called Micronesia. That is a 
bunch of over 3,000 islands spread out over the size equal to, 
if not larger than, the 48 contiguous states. We talk about 
remoteness, yes, I am very remote as well. Thank you for 
coming.
    A friend of mine, actually a personal friend who lives on 
Saipan actually is on contract with a company that he is a 
physician's assistant and he provides his services, he is on 
contract and assigned to a part of Alaska where he serves, he 
provides health--medical services to residents of that 
particular--so far away removed, I think he said you can 
actually see Russia from where he is at. I do not know if it is 
just for Native Americans, but I think he said it is for the 
residents of that village. A smaller area, but so far removed.
    I looked at the fact sheets about some of the culture 
Native Americans have, we have the very same culture where say 
if my father were to be giving me a lecture on something, even 
if he is--I think he is wrong, I would have to keep my mouth 
shut and allow him to tell me what is on his mind. For many 
times I think--I thought I was smarter than him and now I know 
that actually, no, he was smart, much, much smarter than I am.
    You know, our history is so far back that we go through 
oral history, that when Western civilization was still trying 
to find the spices so they could cure their meat, my people 
were already traversing the wide-open ocean based on nothing 
but the stars and the currents, and they were traveling. When 
Ferdinand Magellan got lost at sea, he landed on Guam. One of 
the things he found, according to the log of the--was rice, 
that we had rice in the Mariana Islands when rice was supposed 
to be exclusive to Asia. But so much of your culture is in my 
culture.
    Let me also thank the chairwoman, because I think this is 
one of the very few times when we have a hearing for the Native 
Americans. I am not fully immersed in the VA issues for Native 
Americans. I am immersed, much more immersed in the issue of 
the Indian education. I chaired the subcommittee on elementary 
and secondary education, and the BIE, the Department of 
Interior's Bureau of Indian Education. The services they 
provide in terms for Native Americans is a disgrace, it is a 
shame. Where there would be school facilities in some of the 
coldest part of the country and they would have buildings that 
have heaters that do not work or that they would not have 
enough tables and desks for students, and the schools are in a 
complete lack of maintenance, and it is a disgrace. If the VA 
provides as much service to Native Americans as they do for 
their BIE, then we got a lot of work ahead of us.
    I came here to thank you for being here today. I am also 
actually in a markup on higher education, so I will need to 
leave, but I just came to thank you guys for--all of you for 
being here.
    I know that there is a VA representative in the room, so we 
have got a lot of work to do.
    Thank you, Madam Chair, for holding today's hearing. I 
yield back.
    Ms. Brownley. Thank you, Mr. Sablan. I had the privilege to 
travel to the American territories with you, including going to 
your home in the Mariana Islands. I will just say that there 
are very many parallels in terms of the challenges of 
delivering health care in our territories very similarly to the 
challenges we are facing with our Native Veterans.
    Mr. Sablan. Right.
    Ms. Brownley. We have a lot of work----
    Mr. Sablan. Madam Chair, if I may interrupt, if I may. 
Actually--and I am not taking credit for what happened, but it 
was not until I got elected to this office that the VA actually 
set up a VA fee-based, contracted a physician to provide 
services to veterans.
    Sir, you are right, our Vietnam Veterans, for some reason 
they refuse to sign up with VHA. I have had research fairs. 
When Choice happened, I brought the CEO of Choice, we had 20 
providers, we increased that to 81, but for some reason, sir, 
my Vietnam Veterans also and others after Vietnam, they do not 
want to sign up for VHA. I am having a really tough time trying 
to get a Community Based Outpatient Clinic (CBOC) established 
in my district, but I am not going to give up.
    Thank you, everyone.
    Madam Chair, I am being disrespectful, that is not allowed 
in my culture and in Native American culture, but I apologize 
profusely and I thank you.
    Ms. Brownley. Very respectfully, your time has expired.
    [Laughter.]
    Ms. Brownley. And I will now recognize Dr. Dunn.
    Mr. Dunn. Thank you very much, Madam Chair.
    Chief Smith, during my time in service in the Army as a 
Sergeant, I interacted with a number of different IHS systems 
around the country and one that seemed to work better than 
most, in fact quite well, was the health and dental services in 
Alaska, and it strikes me that that is an area where there are 
more challenges, not less challenges than perhaps in other 
areas.
    I wonder if you would address for us, you know, what you do 
to integrate that kind of care, make that work so well in 
Alaska and many different tribes, a lot of area to cover, both 
urban and remote, and what can we learn, what can we take away 
from that for the rest of the country?
    Chief Smith. Talk to us, consult, and work with the Indian 
tribes to work with the health services. That seems to work, I 
know when Susan Yeager come to the last Alaska Native Health 
Board to talk about health issues.
    You know, we are trying to do things like dental aides to 
start a program, so we can teach our people how to do it, 
because there is not enough dentists up in Alaska to take care 
of everybody. We have dental aides that go out and take care of 
our kids with teeth.
    I mean, when I was a kid, they just put a temporary filling 
in with the stainless steel pins, and about a week later the 
temporary nikem-pucki [phonetic] that they put in there 
dissolved, and then you had to take a file and file off the 
little stainless steel pins, and now today you can get new 
teeth and better care. One dentist told me, he says, if he 
could do something for the villages, he would stop at the 
airport and he would destroy every can of pop that was ever 
delivered out there. I agree with him, it is education. They 
just need to know that it is better to drink the water than it 
is to drink the soda and, you know, it is back to nature and 
back to our ideals.
    I just want to make one comment to this gentleman over here 
about Vietnam Vets. It is probably because of the way we were 
treated when we come home and it is hard to bring a veteran 
back to the table, a Vietnam Vet. It takes another vet to talk 
to him and it takes another grandchild or whatever to drag that 
grumpy old Vietnam Vets out of the woods saying you have got to 
come back, because you are dying and this is the reason, and 
they can actually help you today, and welcome home.
    Up in Alaska, just consulting with tribes and deals on 
health care, because with the Alaska Native Health Board we 
have 229 tribes, and we talk together to work on our health 
issues. I know down here you are trying to follow some of our 
programs that we started up there and it works. The only thing 
that I would appreciate is, if it works in Alaska and you bring 
it down here, do not do too many changes and send it back to 
Alaska, because we already worked out the bugs.
    [Laughter.]
    Mr. Dunn. Thank you very much, Chief. I appreciate those 
insights. I was just--I remember being sort of impressed with 
how well it was working there. Obviously, there are some 
hiccups and you have highlighted that. Thank you very much.
    With that, Madam Chair, I yield back.
    Ms. Brownley. Thank you, Dr. Dunn.
    Welcome, Mr. Gallego. I understand that you have questions 
for the second panel, so we are going to proceed there.
    I want to thank the panel for being here, each and every 
one of you, we appreciate it very, very much. Your testimony 
helps to really raise all of the issues that need to be 
wrestled with and helps to raise awareness, not only for this 
committee, but for the entire Congress on the issues that we 
face. We appreciate your presence very, very much. Thank you.
    I will excuse you and the second panel will join us.
    [Pause.]
    Ms. Brownley. Thank you to the second panel for being here 
this morning. We are joined by Dr. Kameron Matthews, the Deputy 
Under Secretary for Health for Community Care for the Veterans 
Health Administration, accompanying her is Dr. Thomas 
Klobuchar, the Executive Director of the Office of Rural Health 
of the Department of Veterans Affairs; and Stephanie Birdwell, 
the Director of the Office of Tribal Government Relations at 
the VA. Joining us from Indian Health Service is Benjamin 
Smith, the Deputy Director for Intergovernmental Affairs.
    With that, I now recognize Dr. Kameron Matthews for 5 
minutes. Welcome.

                 STATEMENT OF KAMERON MATTHEWS

    Dr. Matthews. Good morning, Chairwoman Brownley, Ranking 
Member Dunn, and members of the subcommittee, tribal leaders 
and tribal representatives. I appreciate the opportunity to 
discuss how care at the Department of Veterans Affairs and our 
partnership with Indian Health Service positively impact our 
Native Veterans.
    I am accompanied today by colleagues Ms. Stephanie 
Birdwell, Director for the Department of Veterans Affairs 
Office of Tribal Government Relations, and Dr. Thomas 
Klobuchar, Executive Director for Veterans Health 
Administration Office of Rural Health.
    I would like to tell you a little bit about my background, 
as you can understand why health care for Native Veterans is so 
important to me. I am a family physician from outside 
Philadelphia that has focused my career on helping vulnerable 
populations. From my work in correctional health to community 
health centers, I value the relationship with primary care, and 
seek to expand access to care for those communities that are 
faced with disadvantages and inequities.
    I have trained and worked in Chicago and I am very familiar 
with urban health issues, racial and ethnic health disparities, 
and the impact of social determinants for health. As an 
advocate for my patients and communities, I am here now at the 
VA to listen, learn, and serve those who have served our 
Nation.
    Of a special note, I am proud to have visited the Alaska 
Native Tribal Medical Center in May 2018 and was indeed 
impressed by its amazing services.
    As Secretary Wilkie has shared during his meetings with 
Native American veterans and tribal leaders across the country, 
our goal at VA is to shorten the distance between people in 
need of veterans' services. While the Secretary and Executive 
in Charge could not be here today, I am proud to be here on 
behalf of the Department discussing such a vital group within 
our veteran population.
    Native Americans have participated in every American 
conflict dating back to the Revolutionary War, and they serve 
in the military at a higher per capita rate than any other 
ethnic group. The importance of Native servicemembers has only 
grown in this country over time, and we strive to honor this 
community with the quality, culturally competent care that they 
deserve.
    As Secretary Wilkie recently stated, we at VA will continue 
to provide vital reimbursements to tribal health programs and 
Indian Health Service. To that end, a memorandum of 
understanding originally signed in 2003 and updated again in 
2010, established the Indian Health Service and VA can 
coordinate, collaborate, and share resources between the 
departments.
    This partnership resulted in the establishment of shared 
goals and, in order to achieve said goals, VHA has piloted and 
subsequently adopted several programs. In 2012, VA started 
establishing reimbursement agreements with Indian Health 
Service and 114 tribal health programs so far in order to 
address access to care, achieve effective partnerships, and 
ensure the availability of resources.
    In addition to these reimbursement agreements, local VA 
medical centers have established, where appropriate, several 
agreements with tribal health programs and Indian Health 
Service facilities to deliver tele-mental health to Native 
Veterans.
    The program serves tribal communities through Indian Health 
Service facilities in Alaska, Montana, Wyoming, and Oklahoma. 
The Office of Rural Health, Veterans Rural Health Resource 
Center in Salt Lake City has an active portfolio of innovations 
in Native Veterans health care, including the creation of a 
Rural Veteran Tribal Navigator Program that will connect Native 
Veterans with the benefits and care they have earned.
    Furthermore, the VA Video Connect pilot program is 
currently being deployed nationwide. VA Video Connect will 
allow rural Native Veterans to access VA health care in their 
homes or local communities via cellular or wireless 
capabilities. The Office of Rural Health is currently working 
to tailor this program to Native Veterans communities, creating 
a model that will weave together Western medicine, traditional 
Native healing, and rural Native community strengths through 
four main components: mental health care, technology, care 
coordination, and a tailored implementation/facilitation 
strategy.
    In addition to these programs, the office is also piloting 
programs to establish tribal VHA partnerships in suicide 
prevention, and developing content regarding Native Veterans in 
the VA Community Provider Toolkit.
    While the 2010 MOU has opened the door to these great 
successes, the March 2019 GAO report cites challenges in 
obtaining the MOU goals, specifically around establishing 
targets for outcome metrics to assess progress. Thus, in Fiscal 
Year 2019, VHA and Indian Health Service MOU leadership agreed 
that the 2010 MOU was no longer meeting the agency's needs and 
required modification to create the flexibility needed to move 
the interagency relationship forward to a new level.
    To address the shortcomings associated with the 2010 MOU 
metrics noted by GAO, VA and IHS have brought in metrics 
experts from each agency to the MOU development process.
    Once the draft is finalized and tribal consultation, most 
importantly, is complete, the process of creating new targets 
and metrics to meet the requirements outlined by GAO will take 
place as new programs and pilots are developed under the new 
instrument.
    We are confident that the evolution of this MOU will be 
successful, as it is happening in tandem with the MISSION Act. 
This transformative legislation will entail the most 
comprehensive change in VA's history. The MISSION Act 
consolidated community care programs, as you know, to make it 
easier for all veterans, families, community providers, and 
employees to navigate.
    The health and well-being of our Nation's veterans is of 
utmost importance. We strive consistently to provide high-
quality care to all veterans, and continue to make significant 
strides in enhancing the practice and culture of the Department 
to be more accessible to our Native Veterans. Working with many 
diverse sovereign tribes is essential to successfully achieve 
the goals of the MOU. VA is committed to ensuring that our 
goals align with IHS and that the needs of our Native Veterans 
are met.
    I apologize for going over and I do thank the committee for 
hosting this hearing. I want to thank the tribal leaders and 
tribal representatives, and all valued partners here who joined 
today.
    My colleagues and I prepared to answer any questions that 
you have.

    [The Prepared Statement Of Kameron Matthews Appears In The 
Appendix]

    Ms. Brownley. Thank you, Dr. Matthews.
    I now recognize Mr. Smith.

                  STATEMENT OF BENJAMIN SMITH

    Mr. Smith. Good morning, Chairwoman Brownley, Ranking 
Member Dunn, and members of the subcommittee. My name is 
Benjamin Smith, I serve as the Deputy Director for 
Intergovernmental Affairs at the Indian Health Service. Thank 
you for the opportunity to testify on Native Veterans' access 
to health care.
    I want to begin with the Indian Health Service mission, 
which is to raise the physical, mental, social, and spiritual 
health of American Indians and Alaska Natives to the highest 
level.
    As an agency within the Department of Health and Human 
Services, the Indian Health Service provides Federal health 
services to approximately 2.6 million American Indians and 
Alaska Natives from 573 federally recognized tribes in 37 
states through a network of over 605 health care facilities 
that include hospitals, clinics, health stations, and other 
facility types.
    The American Indian and Alaska Native population 
experiences health and other disparities that 
disproportionately affect their quality of life. American 
Indians and Alaska Natives have an average life expectancy of 5 
years shorter than that of the U.S. general population, and are 
more likely than people of other races or ethnicities to 
experience social and economic difficulties that may impact 
their health or wellness, such as lower income, lower 
educational levels, and higher unemployment.
    As health needs change, new approaches to care emerge. The 
Indian Health Service, the Department of Veterans Affairs, and 
our tribal partners will continue to combine expertise, 
resources, and efforts to assist the nearly 145,000 American 
Indian and Alaska Native Veterans living in the United States.
    The Indian Health Service and the Veterans Affairs Veterans 
Health Administration continue to work to provide eligible 
American Indian and Alaska Native Veterans with access to care 
that is closer to their homes, promote cultural competence and 
quality health care, and focus on increasing coordination, 
collaboration, and resource sharing between our agencies.
    One way that we are doing this is by revising the Indian 
Health Service and VA memorandum of understanding that was most 
recently updated in 2010. We have a goal to revise the MOU by 
fall of 2020 and to look at updating the related performance 
measures, and we plan to do this using consultation and by 
conferring with urban Indian organizations.
    We want to underscore that this collaboration really 
started back in the late 1980's when Congress directed both of 
our Federal agencies to explore the feasibility of entering 
into an arrangement for sharing of medical facilities and 
services, and this requirement was actually memorialized in the 
Indian Health Care Improvement Act. Our results were reported 
to Congress and our coordination led to an initial memorandum 
of understanding that was executed in 2003.
    After close to a decade of collaboration, we updated the 
memorandum of understanding in 2010, and in that same year the 
Patient Protection and Affordable Care Act was enacted and 
permanently reauthorized the Indian Health Care Improvement 
Act. This act authorized the Indian Health Service to enter in 
or expand arrangements for the sharing of medical facilities 
and services between Indian Health Service, Indian tribes and 
tribal organizations, and the VA. The law directs the VA to 
reimburse the Indian Health Service, Indian tribes, or tribal 
organizations for services provided to eligible beneficiaries 
of either department in the respective facility.
    Since implementing this provision in 2012, and that is the 
reimbursement agreement authority that I am citing to, VA has 
reimbursed over $103 million for direct-care services provided 
in either Indian Health Service or tribal health programs, 
covering approximately 10,645 unique American Indian and Alaska 
Native Veterans.
    Currently, Indian Health Service and VA operate under a 
national reimbursement agreement, so that includes over 70 of 
our Federal IHS-operated facilities. As we just heard, there 
are 114 tribal health programs that have entered into 
individual reimbursement agreements under this authority to be 
reimbursed for direct care services.
    We believe in the five main goals, which are to increase 
access to care and services for American Indians and Alaska 
Native Veterans; to promote patient-centered collaboration and 
communication; to improve health promotion and disease 
prevention; and to consult with tribes at the regional and 
local levels; and to ensure appropriate resources are 
identified and available.
    We look forward to any questions that you may have as we 
are here today before this committee.
    Thank you.

    [The Prepared Statement Of Benjamin Smith Appears In The 
Appendix]

    Ms. Brownley. Thank you very much. Thank you both for your 
testimony and I will recognize myself for 5 minutes.
    The first question I have is to Dr. Matthews. In your 
written testimony, you said that ``in early Fiscal Year 2019 
the VHA and IHS leadership team agreed that the 2010 MOU was no 
longer meeting the agency's needs and required modifications to 
create the flexibility to move the interagency relationship 
forward to a new level.''
    You said that the leadership team drafted a new MOU and 
conducted a first-listening session with tribal leaders on May 
15th of 2019.
    Then you go on to say that that tribal input from the 
session was incorporated into the draft MOU and so--and as this 
additional input is now being considered for inclusion in the 
draft MOU.
    I am curious to know, what was that input? You said that 
you got a lot of input, but you did not say what the input was.
    Dr. Matthews. Great question. I am going to defer to my 
colleague, Dr. Klobuchar.
    Dr. Klobuchar. Thank you for that question. The tribal 
consultation was conducted in concert with the Indian Health 
Service in Albuquerque, and many of the questions that came up 
were around inclusion of urban Indian health care in the 
umbrella that the MOU will provide for the creation of new 
programs. There was also some focus on referred care that, 
while we have not incorporated that into the MOU itself, it 
will certainly be a program or a look that the VA will take as 
they move forward under the new MOU, which, again, is just an 
umbrella for the creation of new programs, methods for 
consultation, and so on and so forth, ongoing consultation.
    I think those are the--that is the important elements that 
made it into the new draft of the MOU was around the inclusion 
of urban Indians and around the importance of ongoing 
consultation as we move forward.
    Ms. Brownley. When you talk about the referral, you are 
talking about the Native Veteran going to an IHS facility and 
then needs specialty care, and then has to go back to the VA, 
repeat the same process again to ensure that they get specialty 
care, but you are not sure whether that is going to be actually 
in the drafted MOU or not?
    Dr. Klobuchar. It would be a program that we would report 
on under the umbrella MOU.
    One of the issues--and if I can go into some detail on the 
MOU itself--one of the issues that we found with the 2010 MOU 
was that many of its provisions we had either fulfilled or we 
found that they had been overcome by events. When we took the 
decision to redraft the MOU, the idea was to create a broader, 
more general MOU that would allow us to create new programs 
underneath the MOU and would satisfy the GAO findings around 
reporting and targets and outcomes, and so on and so forth. 
Those individual programs will take place and be reported on 
under that broader MOU.
    Did that answer your question, ma'am?
    Ms. Brownley. More or less.
    Dr. Klobuchar. Okay.
    Ms. Brownley. I just want a short answer and to followup on 
this MOU process and how important it is going to be. I want to 
hear from the VA some assurances that our Native Veterans will 
be at the table with you through that negotiation.
    Dr. Matthews. Yes, you have our assurances.
    Ms. Brownley. Thank you. Dr. Matthews, also on this, the 
issue that has been raised about this referral again piece, you 
said that one of the obstacles, I guess, is that you may lose 
track of the care of the veteran. I do not know, that just 
seems to me not a really good obstacle, because I think if you 
are doing the reimbursements and everything that you are 
supposed to do, you should have track of where the veteran is, 
whether it is in an IHS facility or within a VA facility. 
Obviously you have heard the concerns around this and why many 
veterans will then just not pursue the specialty care that they 
need, and certainly, from a taxpayer perspective simply, it is 
duplicative and unnecessary.
    Can you speak to that?
    Dr. Matthews. I definitely can. It is an excellent question 
and one that I agree as a clinician, the duplication of--
honestly, how VA has formally handled referrals from any of our 
partners outside of VA is untenable. Especially under the 
MISSION Act, we see ourselves really as a coordinator of care 
at the bequest of the veterans. In helping them receive care 
through the First Nations, through their partners, we 
definitely see that as the veteran is staying at the center and 
needing to coordinate that care.
    I agree that the referral of a veteran back to the VA for 
repeat visits or procedures is unnecessary and that we actually 
hope to find through tribal consultations we can work through 
those issues, we can develop a referral process that is more 
administrative so that we can track.
    The issue currently about paying reimbursements, whether 
that is directly to the community provider or to the tribe 
themselves, I think we can work through through consultation. 
We do want to take the veteran out of the middle of that, we do 
not want repetitive services, and I think we can move to really 
support the tribes through establishing appropriate referral 
guidelines, actually as was discussed during the first panel.
    I admit that prior to now it has not been streamlined, but 
as you guys have given us the authority to consolidate the 
community care programs and simplify those processes, I think 
we have a real path forward.
    Ms. Brownley. As you try to wrestle with that, will you 
wrestle with the co-pays?
    Dr. Matthews. Oh, definitely, yes. I think that needs to be 
acknowledged. We currently do not charge co-pays for veterans 
being seen under the reimbursement agreements, it is when they 
have to return to the VA or are seen in community care they are 
charged a co-pay, but no veteran seen under the reimbursement 
agreements are charged co-pays.
    Ms. Brownley. We do not believe that the veteran should 
receive--require the co-pay in the other circumstance.
    Dr. Matthews. Understood, and I commit to looking into that 
issue.
    Ms. Brownley. Thank you.
    My time is up. Dr. Dunn, you are recognized.
    Mr. Dunn. Thank you very much, Madam Chair.
    Most of the witnesses have cited concerns regarding 
specialty care, referral care, and I want to address that. Let 
me see if I can back out of the weeds a bit and ask some basic 
questions.
    I think this is to Mr. Smith, you tell me if I am wrong, 
does the VA accept referrals for VA specialty care made by the 
IHS and THP?
    Mr. Smith. I will defer to our VA colleagues on that 
question.
    Dr. Matthews. I am sorry, Dr. Dunn, just to clarify the 
question, a referral coming from the----
    Mr. Dunn. From the IHS----
    Dr. Matthews. Yes.
    Mr. Dunn.--for specialty care to the VA, are those patients 
accepted?
    Dr. Matthews. Those referrals are accepted. I can not 
necessarily speak for every facility's procedures at this 
point, as they are currently being streamlined as to whether or 
not they may require a visit, but those referrals are accepted.
    Mr. Dunn. Is that only for veterans or for any patient from 
the IHS?
    Dr. Matthews. For----
    Mr. Dunn. Veterans in the VA.
    Dr. Matthews. Veterans in the VA, yes.
    Mr. Dunn. You have got some patients in the IHS----
    Dr. Matthews. Right.
    Mr. Dunn.--and they get referred for specialty care to the 
VA, if they are a veteran, they are accepted by the VA?
    Dr. Matthews. An enrolled veteran, yes.
    Mr. Dunn. If they are not a veteran?
    Dr. Matthews. No.
    Mr. Dunn. That is interesting to me, because when we were 
in the service, I mean, we treated the Army, we treated the IHS 
patients no matter whether or not they were veterans. Is that 
something that has gone away?
    Dr. Matthews. That is not something that is currently 
included within our reimbursement agreements, no, sir.
    Mr. Dunn. Is the VA--all right. Things have changed since I 
was on active duty, apparently.
    How well coordinated is the MISSION Act by use of the 
MISSION Act with the IHS referrals to the VA? Can the VA then 
enact the MISSION Act for these IHS patients, the ones they do 
accept?
    Dr. Matthews. Yes, their eligibility can be verified, 
determined, and the veteran then of course has choice based on 
their eligibility to opt in or out of community care.
    Mr. Dunn. They get straight through the system, as good as 
the system is, right?
    Dr. Matthews. Right.
    Mr. Dunn. All right, so that is an interesting thing.
    All right. Well, I will yield back with that, Madam Chair. 
Thank you.
    Ms. Brownley. Thank you, Dr. Dunn.
    Welcome, Mr. Gallego, and you are recognized for 5 minutes.
    Mr. Gallego. Thank you, Chairman Brownley, for holding this 
hearing and for allowing me to join on the dias.
    I was very lucky to serve with many Native American Marines 
in Iraq and I know firsthand the patriotism and bravery they 
have shown in service to this Nation, not just in current 
conflicts, but in the past. That is why as Chairman of the 
Subcommittee for Indigenous Peoples it has been very 
frustrating to see over and over again how our Federal 
Government is failing Native Americans and Native Veterans, 
namely that our trust and treaty responsibilities are not being 
upheld.
    Ms. Matthews, a yes-or-no question: are you familiar with 
the Federal Government's unique trust responsibility where it 
concerns Native Americans?
    Dr. Matthews. Yes, I am.
    Mr. Gallego. Great. Then you also know that providing 
Native Americans with health care free of cost is part of this 
legal trust responsibility, for which rests in the treaty 
powers in Article II of the U.S. Constitution, and is confirmed 
by numerous laws and Supreme Court decisions.
    Between 1778 and 1868, the U.S. ratified almost 400 
treaties, many of which explicitly guaranteed tribes health 
care, in addition to all proper care and protection, in return 
for the seizure and occupation of their land.
    I have three examples of such treaties with me right now 
that I would like permission to enter into the record in case 
our witnesses would like to consult them later.
    Ms. Matthews--thank you.

    [The Treaties Appears In The Submissions For The Record]

    Mr. Gallego. Ms. Matthews, given this well-documented legal 
responsibility to provide health care to Native Americans free 
of cost, would you agree that it is a breach of our trust 
responsibility to charge cost-sharing payments to Native 
Veterans when they receive care at the VA?
    We have had this discussion going on prior to this.
    Dr. Matthews. I would agree it is an issue that we need to 
look into as we do currently charge co-pays.
    Mr. Gallego. Okay. With what I just told you, so would you 
agree that--are we violating that trust then? I know you are 
going to look into it, I heard you say that before, but do you 
agree that we are violating our trust responsibilities in that 
case?
    Dr. Matthews. I would agree that VA is following its own 
regulations to charge co-pays, we do not currently have an 
exception on the books.
    Mr. Gallego. The highest regulation there is are treaties 
approved by Congress, so I would hope you would actually 
understand that and send it back to your leadership.
    Moving on. Ms. Matthews, given this well-documented legal 
responsibility to provide health care to Native Americans free 
of cost, would you--sorry.
    Skipping forward. Myself and sovereign tribes think it is a 
pretty clear violation and that is why I am introducing Native 
American Veteran Pact Act, to prohibit the VA from charging 
copayments to Native Veterans in line with our treaty 
obligations.
    Well, I am thankful for all the witnesses here and I know 
this is not an easy subject, I know it involves a lot of 
jurisdictional issues. I am disappointed that the VA Secretary 
and the Under Secretary for Health, the leaders that actually 
signed the MOU that impacts Native Veterans' ability to receive 
care declined to attend today's hearing. Instead, Ms. Matthews, 
you are accompanied by the Director of your Office of Rural 
Health.
    As a Representative from Phoenix, Arizona, it is home to 
one of the largest urban Indian populations in this country. I 
am concerned about the VA's lack of attention to urban Indians 
in the MOU and, despite over 70 percent of indigenous people 
living in urban areas today--and I do use the VA for services 
too, so I actually--physically, actually will see this--there 
is no program office responsible for ensuring that the goals of 
the VA-IHS MOU reach urban Native Veterans.
    Just two more questions, Ms. Matthews. In what specific 
ways is the VA prepared to strengthen a new MOU when it comes 
to improving access to care for urban Indian veterans?
    Dr. Matthews. I would have to defer actual questions about 
the MOU to Dr. Klobuchar, but before he speaks, we are 
definitely committed to working closely with the urban Indian 
health organizations and even enrolling them, as some of the 
questions earlier, under the MISSION Act into our new networks, 
we truly believe in working with these organizations.
    Mr. Gallego. Mr. Klobuchar--Dr. Klobuchar.
    Dr. Klobuchar. The current State of the draft MOU includes 
urban--mention of urban Indian services in the text of the MOU.
    Mr. Smith, do you want to make any comment on that?
    Mr. Smith. Yes, I think the most important point about the 
MOU is it really is the expression of how our Federal agencies 
intend to collaborate to achieve these goals. Where we have 
heard most of the areas of confusion arise are some of the 
goals around executing some of the new authorities, such as 
reimbursement authority, for example, equating that 
reimbursement authority to the MOU itself. The goals of 
expressing ourselves as Federal agencies and our mutual goal to 
collaborate together is not the same thing as entering into a 
binding agreement to reimburse for certain services. We are 
trying to make that distinction as we go through this.
    Mr. Gallego. Thank you. I yield back my time.
    Ms. Brownley. Thank you, Mr. Gallego, and thanks for being 
here and advocating, and also thank you for your service to our 
country.
    Well, there are no other members here for further 
questioning. Before I conclude, I know, Ms. Birdwell, we did 
not ask any questions of you, but I recognize and the committee 
recognizes the good work that you have been doing and 
accomplish. So we thank you for that and we thank you for your 
service.
    Ms. Birdwell. Thank you, Chairwoman, I appreciate that.
    Ms. Brownley. Also I want to acknowledge the good work that 
you and the Office of Tribal Government Relations have done to 
facilitate the relationships between tribes and VA and the 
Office of Community Care for facilitating reimbursement 
agreements. As been already said, but over 10,000 Native 
Veterans have received culturally competent care in their 
tribal or IHS program and been relieved of potentially grueling 
and dangerous journeys to the VA. This is critical to ensuring 
veterans are not hesitating to pursue treatment, and the work 
of rural health is certainly not lost on me. Your research and 
grant programs are important, but you are three offices with 
specific responsibilities solely to Indian country and we need 
the same kind of focus for veterans who live in our cities and 
urban areas.
    The MOU to improve Native Veterans' care was not specific 
to rural tribes or Indians receiving care on reservations, it 
was to improve all Native Veterans' health status. These 
veterans must be a priority in every program office and that 
must be led by VA leadership. You three alone cannot direct the 
services and programs necessary to improve Native Veterans' 
health status across the board.
    This new MOU, which is going to be extremely important, 
will be approved by the Secretary and signed by the Under 
Secretary. You are part of the institution and not part of its 
leadership, but we are going to count on your leadership to 
convey to the Secretary and to the Under Secretary everything 
that has been raised here today and what will be important from 
our perspective and for our Native Veterans across the country, 
what is important to them to be in this MOU.
    We have heard a lot today regarding--Ms. Haaland is not 
here, she had to leave to go to another committee hearing, but 
I am sure, if she were here, she would be asking about the 
advisory committee and how important that will be as we move 
forward. Co-pays, reimbursement of services, duplicity of 
services, urban Indian services, these are all issues that we 
hope are specifically addressed in this MOU as we move forward. 
I am going to count on you to pass that along and I want to 
assure you that this committee will be watching closely.
    This is extremely important to us. We know we have a long 
journey ahead; we have made some progress, but we still have a 
lot of work ahead of us to do.
    As I said, we will be watching closely, and I thank you all 
for being here, we appreciate it very much.
    I will ask if the ranking member would like to offer any 
closing remarks?
    Well, without that, again, thank you again for being here.
    With that, all members will have 5 legislative days to 
revise and extend remarks, and include extraneous materials.
    Without objection, the subcommittee stands adjourned.

?

      
      
      
      
      
      
      
      
      
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                         A  P  P  E  N  D  I  X

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                    Prepared Statements of Witnesses

                              ----------                              


                Prepared Statement of Andrew Joseph Jr.

    Chairwoman Brownley, Ranking Member Dunn, and Members of the 
Subcommittee, thank you for holding this important hearing on health 
care access for Native Veterans. On behalf of the National Indian 
Health Board (NIHB) and the 573 federally recognized sovereign Tribal 
Nations we serve, I submit this testimony for the record. The Federal 
Government's trust responsibility to provide quality and comprehensive 
health services for all American Indian and Alaska Native (AI/AN) 
Peoples extends to every Federal agency and department, including the 
Department of Veterans Affairs (VA).
    By current estimates from the VA, there are roughly 146,000 AI/AN 
Veterans, with Native Servicemembers enlisting at higher rates than any 
other ethnicity nationwide. Indeed, the Department of Defense continues 
to acknowledge the indispensable role of AI/AN Servicemembers 
throughout American history. Native Veterans are highly respected 
throughout Indian Country, in recognition of what they have sacrificed 
to protect Tribal communities and the United States. Yet despite the 
bravery, sacrifice, and steadfast commitment to protecting the 
sovereignty of Tribal Nations and the entire United States, Native 
Veterans continue to experience among the worst health outcomes, and 
among the greatest challenges in receiving quality health services.
    Over the course of a century, sovereign Tribal Nations and the 
United States signed over 300 Treaties requiring the Federal Government 
to assume specific, enduring, and legally enforceable fiduciary 
obligations to the Tribes. The terms codified in those Treaties-
including for provisions of quality and comprehensive health resources 
and services-have been reaffirmed by the United States Constitution, 
Supreme Court decisions, Federal legislation and regulations, and even 
Presidential executive orders. These Federal promises have no 
expiration date, and collectively form the basis for what we now refer 
to as the Federal trust responsibility. Moreover, the United States has 
a dual responsibility to Native Veterans-one obligation specific to 
their political status as members of federally recognized Tribes, and 
one obligation specific to their service in the Armed Services of the 
United States.
    In 1955, Congress established the Indian Health Service (IHS) in 
partial fulfillment of its constitutional obligations for health 
services to all AI/ANs. The IHS is charged with a similar mission as 
the VHA as it relates to administering quality health services, with 
the exception of the following differences: (1) the Federal Government 
has Treaty and Trust obligations to provide health care for all 
American Indians and Alaska Natives; (2) IHS is severely and 
chronically underfunded in comparison to the VHA, with per capita 
medical expenditures within IHS at $4,078 in Fiscal Year (FY) 2017 
compared to $10,692 in VHA per capita medical spending that same year 
\1\; and (3) unlike IHS, the VHA has been protected from government 
shutdowns and continuing resolutions (CRs) because Congress enacted 
advance appropriations for the VHA a decade ago.\2\
---------------------------------------------------------------------------
    \1\  The full IHS Tribal Budget Formulation Workgroup 
Recommendations are available at https://www.nihb.org/docs/04242019/
307871_NIHB%20IHS%20Budget%20Book_WEB.PDF
    \2\  See 38 U.S.C. 117; P.L. 111-81

---------------------------------------------------------------------------
Health Outcomes among Native Veterans and AI/ANs Overall

    Destructive Federal Indian policies and unresponsive human service 
systems have left Native Veterans and their communities with unresolved 
historical and intergenerational trauma. From 2001 to 2015, suicide 
rates among Native Veterans increased by 62 percent (50 in 2001 to 128 
in 2015).\3\ In Fiscal Year 2014, the Office of Health Equity within 
VHA reported significantly higher rates of mental health disorders 
among Native Veterans compared to non-Hispanic White Veterans, 
including in rates of PTSD (20.5 percent vs. 11.6 percent), depression 
symptoms (18.7 percent vs. 15.2 percent), and major depressive disorder 
(7.9 percent vs. 5.8 percent).\4\
---------------------------------------------------------------------------
    \3\  VA, Veteran Suicide by Race/Ethnicity: Assessments Among All 
Veterans and Veterans Receiving VHA Health Services, 2001-2014 (Aug. 
2017) (citing CDC statistics).
    \4\  Lauren Korshak, MS, RCEP, Office of Health Equity and Donna L. 
Washington, MD, MPH, Health Equity-QUERI National Partnered Evaluation 
Center, and Stephanie Birdwell, M.S.W., Office of Tribal Government 
Relations
---------------------------------------------------------------------------
    Native Veterans are 1.9 times more likely to be uninsured than non-
Hispanic White Veterans, and are significantly more likely to delay 
accessing care due to lack of timely appointments and transportation 
issues.\5\ Among all Veterans, Native Veterans are more likely to have 
a disability, service-connected or otherwise.\6\ Native Veterans are 
exponentially more likely to be homeless, with some studies showing 
that 26 percent of low-income Native Veterans experienced homelessness 
at some point compared to 13 percent of all low-income Veterans.\7\ 
There exists a paucity of Native Veteran specific health, housing, and 
economic resources and programs that are accessible and culturally 
appropriate. It is essential that the VHA work with IHS and Tribes to 
create more resources specifically for Native Veterans.
---------------------------------------------------------------------------
    \5\  Johnson, P. J., Carlson, K. F., & Hearst, M. O. (2010). 
Healthcare disparities for American Indian veterans in the United 
States: a population-based study. Medical care, 48(6), 563-569. 
doi:10.1097/MLR.0b013e3181d5f9e1
    \6\  U.S. Department of Veterans Affairs. (2015a). American Indian 
and Alaska Native Veterans: 2013 American Community Survey. Retrieved 
from https://www.va.gov/vetdata/docs/SpecialReports/AIANReport2015.pdf
    \7\  US Department of Housing and Urban Development, US Department 
of Veterans Affairs, National Center on Homelessness Among Veterans. 
Veteran Homelessness: A Supplemental Report to the 2010 Annual Homeless 
Assessment Report to Congress. Washington, DC.2011:56
---------------------------------------------------------------------------
    According to IHS, AI/ANs born today have a life expectancy that is 
on average 5.5 years less than the national average.\8\ In states like 
South Dakota, however, life expectancy for AI/ANs is as much as two 
decades lower than for Whites. Health outcomes among AI/ANs have either 
remained stagnant or become as AI/AN communities continue to encounter 
higher rates of poverty, lower rates of healthcare coverage, and less 
socioeconomic mobility than the general population. According to the 
Centers for Disease Control and Prevention, in 2016, AI/ANs had the 
second highest age-adjusted mortality rate of any demographic 
nationwide at 800.3 deaths per 100,000 people.
---------------------------------------------------------------------------
    \8\  Indian Health Service. 2018. Indian Health Disparities. 
Retrieved from https://www.ihs.gov/newsroom/includes/themes/
responsive2017/display_objects/documents/factsheets/Disparities.pdf
---------------------------------------------------------------------------
    In addition, AI/ANs have the highest uninsured rates (25.4 
percent); higher rates of infant mortality (1.6 times the rate for 
Whites); higher rates of diabetes (7.3 times the rate for Whites); and 
significantly higher rates of suicide deaths (50 percent higher). AI/
ANs also have the highest Hepatitis C mortality rates nationwide (10.8 
per 100,000); and higher rates of chronic liver disease and cirrhosis 
deaths (2.3 times that of Whites). Further, while overall cancer rates 
for Whites declined from 1990 to 2009, they rose significantly for AI/
ANs. For instance, from 1999 to 2015 AI/ANs encountered a 519 percent 
increase in drug overdose deaths-the highest rate increase of any 
demographic nationwide.\9\ All of these health determinants of health 
and poor health status could be dramatically improved with adequate 
investment into the health, public health and health delivery systems 
operating in Indian Country.
---------------------------------------------------------------------------
    \9\  Mack KA, Jones CM, Ballesteros MF. Illicit Drug Use, Illicit 
Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and 
Nonmetropolitan Areas--United States. MMWR Surveill Summ 2017;66(No. 
SS-19):1-12. DOI: http://dx.doi.org/10.15585/mmwr.ss6619a1
---------------------------------------------------------------------------
    The VA's Veteran Outreach Toolkit lists AI/ANs as an ``at-risk'' 
population, citing this troubling suicide rate. Additionally, AI/ANs 
grapple with complex behavioral health issues at higher rates than any 
other population--for children of AI/AN veterans, this is compounded by 
the return of a parent who may suffer from post-traumatic stress 
disorder (PTSD). Outreach events for AI/AN communities should be a VA 
priority to increase wellness, decrease stigma, and prevent suicide. It 
is essential that the VHA continue to engage with Tribal leaders, 
through consultation, to assist in carrying out these activities.

Funding Levels for IHS versus VHA: The Need for Advance Appropriations

        1. Tribes and NIHB strongly urge Congress to pass bipartisan 
        legislation that would enact advance appropriations for Indian 
        programs

    By the most recent estimates, federally operated IHS facilities, 
Tribally operated health facilities and programs, and urban Indian 
health programs collectively serve roughly 2.6 million AI/ANs 
nationwide. In comparison, the VHA serves roughly 6.9 million Veterans 
through 18 regional networks. In Fiscal Year 2019 discretionary 
appropriations for IHS equaled roughly $5.8 billion; in comparison, 
spending within the VHA totaled over $76 billion. In effect, this means 
that while the VHA service population is roughly only three times the 
size of the Indian health system, its discretionary appropriations are 
approximately 13 times higher than for IHS.
    According to the IHS Tribal Budget Formulation Workgroup, IHS 
appropriations must reach nearly $38 billion-phased in over 12 years-in 
order to fully meet current health needs. In other words, even if today 
IHS were fully funded at the level of need identified by sovereign 
Tribal Nations, it would only equal half the total Fiscal Year 2019 
discretionary appropriation for the VHA. Indeed, the Federal 
Government's continued abrogation of its trust responsibility for 
health services for AI/ANs is clearly exemplified by the gravity of the 
divide in health funding for the VHA versus IHS.
    Although the IHS budget has nominally increased by 2-3 percent each 
year, these increases are barely sufficient to keep up with rising 
medical and non-medical inflation, population growth, facility 
maintenance costs, and other expenses. According to a 2018 report by 
the Government Accountability Office (GAO-19-74R), from 2013 to 2017, 
IHS annual spending increased by roughly 18 percent and per capita 
spending increased by roughly 12 percent; in comparison, annual 
spending under the VHA increased by 32 percent and per capita spending 
increased by 25 percent during the same time period.\10\ The widening 
gap in funding levels between IHS and the VHA only serves to perpetuate 
the disproportionately higher levels of health disparities experienced 
by Native Veterans and AI/ANs overall.
---------------------------------------------------------------------------
    \10\  Government Accountability Office. 2018. Indian Health 
Service: Spending Levels and Characteristics of IHS and Three Other 
Federal Health Care Programs. Retrieved from https://www.gao.gov/
assets/700/695871.pdf
---------------------------------------------------------------------------
    Unequivocally, the U.S. Federal Government has a moral and ethical 
obligation to ensure all U.S. Veterans can access quality health 
services-and it must continue to honor this responsibility. But the 
U.S. also has a Trust obligation to ensure all AI/ANs, including Native 
Veterans, can receive quality health services, that it continuously 
fails to honor. It is long past due for the Federal Government to make 
good on its constitutional obligation to Native Veterans an all AI/AN 
Peoples.
    The discrepancies do not end with chronic underfunding of IHS. Of 
the four major Federal healthcare entities, IHS is the only one subject 
to the devastating impacts of government shutdowns and continuing 
resolutions (CRs). This is because Medicare and Medicaid receive 
mandatory appropriations, and the VHA was authorized by Congress to 
receive advance appropriations nearly a decade ago. As a result, the 
VHA has been insulated from every government shutdown, CR, and 
discretionary sequestration over the past decade. While it is true that 
no sector of government is fully spared by the repercussions of endless 
shutdowns and CRs, those repercussions are neither equal nor 
generalizable across all entities. In fact, the worst consequences are 
levied on Indian Country.
    For instance, during the 2013 Federal budget sequester, the IHS 
budget was slashed by 5.1 percent--or $221 million-levied on top of the 
damage elicited by that year's government shutdown. In fact, IHS was 
the only federally funded healthcare entity that was subject to full 
sequestration because Congress had already exempted the VHA when it 
authorized it to receive advance appropriations. Once again, during the 
most recent 35-day government shutdown-the Nation's longest and most 
economically disastrous-IHS was the only Federal healthcare entity to 
be shut down. While direct care services remained non-exempt, providers 
were not receiving pay. Administrative and technical support staff-
responsible for scheduling patient visits, conducting referrals, and 
processing health records-were furloughed. Contracts with private 
entities for sanitation services and facilities upgrades went weeks 
without payments, prompting many Tribes to exhaust alternative 
resources to stay current on bills.
    Several Tribes shared that they lost physicians to hospitals and 
clinics not impacted by the shutdown. Some Tribal leaders even shared 
how administrative staff volunteered to go unpaid so that the Tribe had 
resources to keep physicians on the payroll. These are just a few 
examples of the everyday sacrifices and ongoing struggles that widen 
the chasm between the health services afforded to AI/ANs and those 
afforded to the Nation at large. While it is impossible to measure the 
full scope of adversity brought on by the 35-day government shutdown, 
one reality remains clear-Indian Country was both unequivocally and 
disproportionately impacted.
    In 2018, GAO released a report examining the benefits of 
authorizing advance appropriations for the IHS and thus establishing 
parity between IHS and the VHA (GAO-18-652). The report outlined how 
Congress has been forced to use short-term or full-year CRs in all but 
four of the last 40 years. In fact, only once in the past two decades-
in Fiscal Year 2006-has Congress successfully passed the Interior, 
Environment, and Related Agencies appropriations package (which funds 
IHS) before the end of the fiscal year. As a result, year after year, 
the Indian health system is curtailed from making meaningful 
improvements toward the availability and quality of health services and 
programs, further restraining efforts to advance quality of life and 
health outcomes for AI/ANs.
    While a CR is always preferable to a government shutdown, they are 
not devoid of obstacles that directly impact patient care. Because of 
budget authority constraints under a CR, IHS is prohibited from 
initiating any new activities or projects that were not expressly 
authorized or appropriated in the previous fiscal year. In addition, 
under a CR, IHS must exercise significant precaution over expenditures, 
and is generally limited to simply maintain operations as opposed to 
improve them. When you compound the impact of chronic underfunding and 
endless use of CRs, the inevitable result are the chronic and pervasive 
health disparities seen across Indian Country. As such, Tribal Nations 
and NIHB strongly urge Congress to pass bipartisan legislation that 
would authorize advance appropriations for Indian programs.

Lack of IHS and VHA Care Coordination and Reimbursement Agreements

        1. NIHB recommends that Congress clarify statutory language 
        under section 405(c) of the Indian Health Care Improvement Act 
        and make explicit the VHA's requirement to reimburse IHS and 
        Tribes for services under Purchased/Referred Care (PRC).

    By law, an AI/AN Veteran is eligible for services under both the 
VHA and IHS. A 2011 report showed that approximately one-quarter of 
IHS-enrolled Veterans use the VHA for health care, commonly receiving 
treatment for diabetes mellitus, hypertension or cardiovascular disease 
from both Federal entities.\11\ According to the VA, more than 2,800 
AI/AN Veterans are served at IHS facilities.\12\ In instances where an 
AI/AN veteran is eligible for a particular health care service from 
both the VA and IHS, the VA is the primary payer. Under section 2901(b) 
of the Patient Protection and Affordable Care Act (ACA), health 
programs operated by the IHS, Tribes and Tribal organizations, and 
urban Indian organizations (collectively referred to as the ``I/T/U'' 
system) are payers of last resort regardless of whether or not a 
specific agreement for reimbursement is in place.
---------------------------------------------------------------------------
    \11\  Kramer, BJ, Wang M, Jouldjian S, Lee ML, Finke B, Saliba D. 
Healthcare for American Indian and Alaska native veterans: The roles of 
the veterans health administration and the Indian Health Service. 
Medical Care.
    \12\  VA/IHS listening session held on May 15, 2019
---------------------------------------------------------------------------
    Section 407(a)(2) of the Indian Health Care Improvement Act (IHCIA) 
reaffirms the goals of the 2003 Memorandum of Understanding (MOU) 
between the VHA and IHS established to improve care coordination for 
Native Veterans. In addition, during permanent reauthorization of 
IHCIA, section 405(c) was amended to require the VHA to reimburse IHS 
and Tribes for health services provided under the Purchased/Referred 
Care (PRC) program. In 2010, the VHA and IHS modernized their 2003 MOU 
to further improve care coordination for Native Veterans by bolstering 
health facility and provider resource sharing; strengthening 
interoperability of electronic health records (EHRs); engaging in joint 
credentialing and staff training to help Native Veterans better 
navigate IHS and VHA eligibility requirements; simplifying referral 
processes; and increasing coordination of specialty services such as 
for mental and behavioral health.
    According to a 2019 GAO report (GAO-19-291), since implementation 
of the 2010 MOU, the VHA has reported entering into 114 signed 
agreements with Tribal Health Programs (THPs), along with 77 
implementation agreements to strengthen care coordination. While a 
single national reimbursement agreement exists between federally 
operated IHS facilities and the VHA, THPs continue to exercise their 
sovereignty by entering into individual agreements with the VHA. From 
2014 to 2018, those reimbursement agreements with THPs alone increased 
by 113 percent.
    VA reimbursements to IHS and THPs overall during that same time 
period increased by 75 percent, reaching $84.3 million in total. Yet 
these increased reimbursements still represent just a fraction of 1 
percent of the VA's annual budget. While recent increases in the 
quantity of agreements and reimbursements demonstrates a positive 
trend, there continue to be significant challenges in care coordination 
between the VHA and IHS. The 2019 GAO report highlighted three 
overarching challenges related to care coordination: ongoing issues in 
patient referrals between I/T/U facilities and the VHA; significant 
problems in EHR interoperability; and high staff turnover within both 
VHA and IHS. These complications continue to stifle Native Veterans' 
access to health care, erodes patient trust in both IHS and VHA health 
systems, and obstructs efforts to improve health outcomes.
    These issues are exacerbated by VHA claims that no statutory 
obligation exists for reimbursement of specialty and referral services 
provided through IHS or THPs. To clarify, the VHA currently reimburses 
IHS and THPs for care that they provide directly under the MOU. Despite 
repeated requests from Tribes, the VA has not provided reimbursement 
for PRC specialty and referral care provided through IHS/THPs. This is 
highly problematic, as AI/AN Veterans should have the freedom to obtain 
care from either the VA or an Indian health program. If a Veteran 
chooses an Indian health program, that program should be reimbursed 
even if the service could have been provided by a VA facility or 
program in the same community.
    But because that doesn't happen, it creates greater care 
coordination issues and burdensome requirements for Native Veterans. 
For example, if a Native veteran goes to an IHS or THP for service and 
needs a referral, the same patient must be seen within the VA system 
before a referral can be secured. This means the VHA is paying for the 
same services twice, first for those primary care services provided to 
the Veteran in the IHS or THP facility, and then again when the patient 
goes back to the VHA for the same primary care service to then receive 
a VHA referral. This is neither a good use of Federal funding, nor is 
it navigable for veterans. In order to provide the care that Native 
Veterans need, many THPs are treating Veterans or referring them out 
for specialty care and paying for it themselves so that they can be 
treated in a timely and competent manner. For those Veterans that do go 
back to the VHA for referrals, there is often delayed treatment and a 
significantly different standard of care provided.
    As a step toward mitigating the confusion surrounding reimbursement 
for care provided by the VHA, NIHB recommends the VHA include PRC in 
future IHS/THP reimbursement agreements, so that there is no further 
rationing of health care provided by IHS and THPs to Native Veterans 
and other eligible AI/ANs. Ultimately, however, NIHB recommends that 
Congress clarify the statutory language under section 405(c) of IHCIA 
and make explicit VHA's requirement to reimburse under PRC.

        2. NIHB also strongly supports the GAO recommendation that the 
        VHA work with IHS to create written policy or guidelines to 
        clarify how referrals from IHS and THP facilities to VHA 
        facilities for specialty care should be managed, and to 
        establish specific targets for measuring action on MOU 
        performance measures.

    The GAO report cited how, for example, facilities reported 
conflicting information about the processes for referring Native 
Veterans from IHS or Tribal facilities to VHA, and VA headquarters 
officials confirmed that there is no national policy or guide on this 
topic. One of the leading collaboration practices identified by GAO is 
to have written guidance and agreements to document how agencies will 
collaborate. Without written policy or guidance documents on how 
referrals should be managed, neither agency can ensure that VHA, IHS, 
and Tribal facilities have consistent understanding of the options 
available for referral of Native Veterans for specialty care.
    As is currently the case, the result is duplicative care for Native 
Veteran and duplicative costs for the Federal Government. NIHB has 
heard that some Native Veterans prefer to simply hand carry their EHR 
records from their IHS provider to their VHA provider to avoid having 
to receive the same care twice. In short, lack of written policy 
perpetuates this burdensome, pointless, and complicated process that 
only serves to frustrate patients, worsen administrative red tape, and 
increase expenditures.
    For numerous Tribes, and especially for the Veterans themselves, it 
is an undue barrier to constantly have to refer patients back and forth 
to the VA that ultimately wastes time and delays access to care. The 
GAO identified that IHS and VA lack sufficient measures for 
quantifiable assessments of progress toward MOU goals and objectives. 
Although the VHA and IHS have created 15 performance measures, no 
specific targets or indicators have been established that allow Tribes 
to measure progress toward achieving the goals and objectives of the 
MOU.

        3. Tribes and NIHB have strongly recommended that the VHA 
        consult with Tribes and work through their MOU with IHS to 
        create and publish a living list of available Veterans 
        Liaisons/Tribal Veterans Representatives across all IHS and VHA 
        regions

    The VHA must do more outreach and education with Native Veterans to 
improve care coordination. Tribes and NIHB have consistently stressed 
the need for VHA to create toolkits and guides to assist Native 
Veterans in navigating care access. The paucity of currently available 
newsletters, outreach workers and liaisons such as Tribal Veteran 
Service Officers (TVSOs), and online resources specifically for Native 
Veterans also sends the message that care for Native Veterans is not a 
priority. But despite repeated Tribal demands, the agency has yet to 
implement this request.
    A closely related issue is the fact that Native Veterans are still 
charged copays and deductibles when receiving services under the VHA. 
The Federal Government's trust responsibility for health services 
extends to all Native Veterans. In recognition of this, AI/ANs do not 
have copays or deductibles for services received at an I/T/U facility. 
Additionally, the ACA further affirmed the trust responsibility when it 
included language at Section 1402 to exempt all AI/ANs under 300 
percent of the Federal poverty level from co-pays and deductibles on 
plans purchased on the health insurance Marketplace.

        4. Congress should pass legislation exempting Native Veterans 
        from copays and deductibles

    Section 222 of IHCIA prohibits cost sharing of AI/ANs in cases 
where an AI/AN receives a referral from the from an IHS or THP under 
the PRC program. Like IHS and the Marketplace, the VHA is another means 
by which the Federal Government must uphold its trust responsibility to 
AI/ANs. As such, it is imperative that Congress enact legislation that 
requires the VHA to similarly exempt AI/AN Veterans from copays and 
deductibles in the VA system in recognition of the Federal trust 
responsibility. Importantly, copay costs should not be shifted to IHS 
or Tribes. The VHA must absorb these costs on behalf of AI/AN Veterans 
in recognition of their Trust and Treaty obligations to AI/AN Peoples.

        5. Congress should pass the bipartisan H.R. 2791 - Department 
        of Veterans Affair Tribal Advisory Committee Act of 2019

    Tribal Nations and NIHB have also strongly advocated for the 
seating of a Tribal Advisory Committee (TAC) within the Office of the 
Secretary at the VA. Establishing a Veteran TAC is essential for 
strengthening the government-to-government relationship, and improving 
VA accountability to Native Veteran health needs. Through the seating 
of a TAC, top VA officials would have the ability to hear directly from 
Tribal leaders about the unique health priorities and challenges that 
impact Native Veterans. In addition, it would help prevent the 
development of new rules or policies that would adversely affect care 
for Native Veterans. As such, Tribes and NIHB strongly support the 
bipartisan H.R. 2791, introduced by Representative Deb Haaland, and 
urges the House VA Committee to vote to pass this significant 
legislation.

EHR Interoperability and Health Information Technology (IT) 
    Modernization

        1. Congress must ensure parity between the VA and IHS in 
        appropriations and technical assistance for health IT 
        modernization

    The Resource and Patient Management System (RPMS)-which is the 
primary health IT system used across the Indian health system-was 
developed in close partnership with the VHA and has become partially 
dependent on the VHA health IT system, known as the Veterans 
Information Systems and Technology Architecture (VistA). The RPMS is an 
early adoption of VistA for outpatient use, and the legacy system was 
designed with the decision to keep the same underlying code 
infrastructure as VistA. IHS began developing different clinical 
applications for their outpatient services, and the VHA adopted code 
from RPMS to provide this functionality for VistA.
    RPMS eventually began to use additional VistA code as the need for 
inpatient functionality increased. This type of enhancement and support 
for both the IHS and VHA was made possible because VistA's software 
components were designed as an Open Source solution. The RPMS suite is 
able to run on mid-range personal computer hardware platforms, while 
applications can operate individually or as an integrated suite with 
some availability to interface with commercial-off-the-shelf (COTS) 
software products.
    Currently, the RPMS manages clinical, financial, and administrative 
information throughout the I/T/U, although, it is deployed at various 
levels across the service delivery types. However, in recent years, 
many Tribes and even several Urban Indian Health Programs (UIHPs) have 
elected to purchase their own COTS systems that provide a wider suite 
of services than RPMS, have stronger interoperability capabilities, and 
are significantly more navigable and modern systems to use. As a 
result, there exists a growing patchwork of EHR platforms across the 
Indian health system.
    When the VA announced its decision to replace VistA with a COTS 
system in 2017 (Cerner), concentrated efforts to re-evaluate the Indian 
Health IT system accelerated, and arose significant concerns as to how 
VHA and I/T/U EHR interoperability would continue. In 2018, IHS 
launched a Health IT Modernization Project to evaluate the current I/T/
U health IT framework, and to, through Tribal consultation, key 
informant interviews, and national surveys, develop a series of next 
steps and recommendations toward modernizing health IT in Indian 
Country.
    Difficulties in achieving IT interoperability among VA, IHS, and 
THP facilities pose significant problems for Native Veterans' care 
coordination. Unfortunately, the VHA and IHS have yet to identify a 
systemic solution toward increasing EHR interoperability between I/T/U 
and VHA hospitals, clinics, and health stations. A resulting scenario 
includes situations where a THP provider-having treated a Veteran and 
referred them to the VHA for specialty care-would not receive the 
Veteran's follow up records as quickly as if they had streamlined 
access to each other's systems.
    Now that the VHA is transitioning to the Cerner system, it has 
worsened concerns around care coordination and sharing of EHRs between 
I/T/U and VHA systems. The fact is, Native Veterans are suffering today 
from the lack of health IT interoperability. It is shameful that Native 
Veterans are put in a position where they have to find their own 
solutions to streamline EHR sharing, most shockingly exemplified by 
anecdotes of AI/AN Veterans hand carrying their health records between 
their IHS and VHA provider.
    Congress must ensure that the Indian health system is fully 
integrated across the development and implementation of the VHA's 
transition to Cerner; however, thus far it has failed to do so. By the 
most current estimates, the transition to Cerner will take up to 10 
years to fully implement, with a current price tag of roughly $16 
billion. None of the existing estimates include calculations of how 
much it will cost to include IHS in this transition; however, through 
its Health IT Modernization Project, IHS is attempting to arrive at an 
estimated dollar figure for this cost.
    Tribes and NIHB were pleased to see that the Fiscal Year 2020 
President's Budget included a request for a new $20 million line item 
in the IHS budget to assist with health IT modernization, and that this 
request was included in the House-passed Fiscal Year 2020 Interior 
Appropriations package. But in comparison, the Fiscal Year 2020 House 
Military Construction Appropriations bill budgeted $1.6 billion to 
assist VHA in its transition. Ensuring EHR interoperability between I/
T/U and VHA health systems will be impossible if Congress fails to 
establish parity in appropriations for VHA and IHS health IT 
modernization.

Conclusion

    The Federal Government has a dual responsibility to Native Veterans 
that continues to be ignored. As the only national Tribal organization 
dedicated exclusively to advocating for the fulfillment of the Federal 
trust responsibility for health, NIHB is committed to ensuring the 
highest health status and outcomes for Native Veterans. We applaud the 
House VA Subcommittee for Health for holding this important hearing, 
and stand ready to work with Congress in a bipartisan manner to enact 
legislation that strengthens the government-government relationship, 
improves access to care for Native Veterans, and raises health 
outcomes.
                                 ______
                                 

                  Prepared Statement of Kevin J. Allis

    On behalf of the National Congress of American Indians (NCAI), 
thank you for the opportunity to provide testimony on the topic of 
American Indian and Alaska Native (AI/AN) veterans' access to 
healthcare. I serve as the Chief Executive Officer of NCAI, and I look 
forward to working with members of this Subcommittee and other Members 
of Congress to better fulfill the Federal Government's commitment to 
provide for the well-being of AI/AN veterans when they return home.
    Founded in 1944, NCAI is the oldest and largest national 
organization composed of tribal nations and their citizens. Tribal 
leaders created NCAI in 1944 in response to termination and 
assimilation policies that threatened the existence of tribal nations. 
Since then, NCAI has fought to preserve the treaty and sovereign rights 
of tribal nations, advance the government-to-government relationship 
between tribal nations and the Federal Government, and remove historic 
structural impediments to tribal self-determination.
    AI/ANs have a long history of distinguished service to this 
country. Per capita, AI/ANs serve at a higher rate in the Armed Forces 
than any other group of Americans and have served in all the Nation's 
wars since the Revolutionary War. In fact, AI/AN veterans served in 
several wars before they were even recognized as U.S. citizens. Despite 
this esteemed service, AI/AN veterans have lower personal incomes, 
higher unemployment rates, and are more likely to lack health insurance 
than other veterans.
    The United States must honor its commitments to AI/AN veterans. The 
Federal Government's responsibility to provide quality healthcare to 
AI/AN veterans comes both from their service to this country and the 
Federal Government's treaty and trust obligations to AI/AN people. NCAI 
calls on Congress and the Administration to ensure that Federal policy 
addresses the unique needs and circumstances of AI/AN veterans and that 
Federal agencies coordinate closely to deliver the best possible 
services to AI/AN veterans, regardless of whether they are living on 
rural reservation lands or in major urban areas.

Cultural Competency at the Department of Veterans Affairs

    NCAI's Veterans Committee provides a forum for discussing issues 
that impact AI/AN veterans and helps develop NCAI policy priorities to 
improve the lives of veterans across Indian Country. Participants in 
the NCAI Veterans Committee continue to highlight cultural competency 
issues across the Department of Veterans Affairs (VA) system. This 
directly impacts the provision of healthcare and can affect how 
veterans' claims are processed and whether they are approved. For 
example, the VA's generic Post Traumatic Stress Disorder (PTSD) 
Disability Benefits Questionnaire does not address cultural issues. 
This lack of consideration leads to many AI/AN veterans being denied 
benefits or receiving benefits that are insufficient given the severity 
of their conditions. Additionally, aging veterans and those with 
certain types of traumatic brain injuries affecting language that have 
reverted to their traditional languages face a lack of translation 
services.
    Given the importance of cultural competency, the NCAI Veterans 
Committee has expressed the need to increase access to Tribal Veterans 
Service Organizations (TVSOs) to assist AI/AN veterans with benefits 
claims and accessing other VA services. Unfortunately, the current 
regulations require that for a tribal nation to have representatives 
trained and accredited through the VA, it must establish and fund an 
organization that has the primary purpose of assisting veterans and 
survivors with their claims. Requiring a tribal nation to establish and 
fund a separate organization fails to recognize tribal sovereign 
decisionmaking and creates unnecessary regulatory burdens. This 
burdensome regulatory structure is the reason only a handful of 
tribally affiliated groups have applied for accreditation-and why even 
fewer have received accreditation. We urge members of this Subcommittee 
to examine ways to ensure tribal nations are able to establish TVSOs to 
better assist AI/AN veterans with the preparation, presentation, and 
prosecution of benefits claims.

VA-IHS Memorandum of Understanding and GAO-19-291

    In 2010, the VA and the Indian Health Service (IHS) signed a 
Memorandum of Understanding (2010 MOU) ``to establish coordination, 
collaboration, and resources-sharing between the [VA and IHS] to 
improve the health status of [AI/AN] Veterans.'' \1\ The MOU includes 
five goals:
---------------------------------------------------------------------------
    \1\  U.S. Gov't Accountability Office, GAO-19-291, Actions Needed 
to Strengthen Oversight and Coordination of Health Care for American 
Indian and Alaska Native Veterans (2019).

      Increase access to and improve quality of healthcare and 
services to the mutual benefit of both agencies. Effectively leverage 
the strengths of the VA and IHS at the national and local levels to 
---------------------------------------------------------------------------
afford the delivery of optimal clinical care.

      Promote patient-centered collaboration and facilitate 
communication among VA, IHS, AI/AN veterans, tribal facilities, and 
Urban Indian clinics.

      In consultation with tribal nations at the regional and 
local levels, establish effective partnerships and sharing agreements 
among VA headquarters and facilities, IHS headquarters and facilities, 
tribal facilities, and Urban Indian Health Programs in support of AI/AN 
veterans.

      Ensure that appropriate resources are identified and 
available to support programs for AI/AN veterans.

      Improve health promotion and disease prevention services 
to AI/AN veterans to address community-based wellness.\2\
---------------------------------------------------------------------------
    \2\  Id.

    In furtherance of the 2010 MOU, VA enters reimbursement agreements 
with IHS and tribal health program facilities. These agreements allow 
AI/AN veterans to receive VA-eligible healthcare services at IHS and 
tribal facilities without prior VA approval. There is a single national 
reimbursement agreement between VA and IHS, which was extended in June 
2018 through June 30, 2022. VA negotiates individual reimbursement 
agreements with tribal facilities.
    In March 2019, the U.S. Government Accountability Office (GAO) 
published a report to provide updated information on implementation of 
the 2010 MOU. GAO found that since its last report on this issue, 
reimbursements by VA for healthcare services have increased, 
particularly at tribal health facilities. It also noted an increase in 
the number of VA-tribal health facility reimbursement agreements and 
the number of veterans served under reimbursement agreements.
    GAO also identified challenges that continue to hinder full 
implementation of the 2010 MOU. Specifically, the report found that 
performance measures established by the agencies do not include targets 
to track progress and there is no national policy or guidance on 
referring AI/AN veterans from IHS and tribal facilities to VA for 
services, potentially causing duplicative tests and services.
    GAO made the following recommendations: (1) ``[a]s VA and IHS 
revise the MOU and related performance measures, the Secretary of 
Veterans Affairs should ensure these measures are consistent with the 
key attributes of successful performance measures, including having 
measurable targets''; (2) ``[t]he Secretary of Veterans Affairs should, 
in consultation with IHS and tribes, establish and distribute a written 
policy or guidance on how referrals from IHS and THP facilities to VA 
facilities for specialty care can be managed''; and (3) ``[a]s VA and 
IHS revise the MOU and related performance measures, the Director of 
IHS should ensure these measures are consistent with the key attributes 
of successful performance measures, including having measurable 
targets.'' \3\
---------------------------------------------------------------------------
    \3\  Id.
---------------------------------------------------------------------------
    VA and IHS are in the process of re-negotiating the 2010 MOU. In 
addition to calling on VA and IHS to ensure tribal stakeholders are at 
the table for those negotiations, NCAI would like to highlight several 
issues raised in the GAO report that continue to be tribal priorities 
for inclusion in the VA-IHS MOU.
    Currently, VA does not reimburse for services provided by external 
providers paid for by IHS or tribal health facilities through the 
Purchase/Referred Care program. Instead, AI/AN veterans must be 
referred by VA facilities to be eligible to receive reimbursable 
specialty care. This is overly burdensome, results in duplicative 
processes that limit access to care for AI/AN veterans, and wastes 
Federal resources. VA reimbursement of Purchased/Referred Care must be 
included in the re-negotiated MOU.
    A specific focus of the 2010 MOU is the interoperability of the VA 
and IHS systems ``to facilitate sharing of information on common 
patients and populations.'' Nine years later, there still is not 
interoperability between VA and IHS electronic health information 
technology systems. NCAI urges VA and IHS to ensure interoperability of 
their health information as they evaluate and implement new electronic 
health record systems.
    Finally, AI/ANs do not have cost-sharing for services received 
through IHS. However, AI/AN veterans are subject to the same copayments 
as other veterans when they receive care at the VA. In Fiscal Year 
2017, approximately 30 percent of AI/AN veterans were charged co-
payments, averaging approximately $281.56 per veteran.\4\ This 
represents a significant barrier to care for AI/AN veterans. 
Accordingly, NCAI calls on Congress and the Administration to honor the 
treaty and trust obligations to provide healthcare to AI/ANs by 
eliminating VA co-payments for AI/AN veterans.
---------------------------------------------------------------------------
    \4\  Id.

Pass the Department of Veterans Affairs Tribal Advisory Committee Act 
---------------------------------------------------------------------------
    of 2019

    AI/AN veterans, tribal leaders, and GAO have expressed the need for 
VA to engage with tribal stakeholders when assessing, developing, and 
implementing policy affecting AI/AN veterans. Establishing a VA Tribal 
Advisory Committee (VATAC) will help achieve this goal. Specifically, 
the VATAC would advise the Secretary on how to improve programs and 
services for AI/AN veterans, identify timely issues related to VA 
programs, propose solutions to identified issues, provide a forum for 
discussion, and help facilitate getting useful feedback from Indian 
Country. Building a strong relationship between the VA and tribal 
nations will increase awareness and understanding across the VA of the 
unique issues affecting AI/AN veterans in tribal communities. This 
awareness paired with more direct interaction with tribal leaders who 
regularly hear from AI/AN veteran constituents will ultimately produce 
faster solutions and better services for AI/AN veterans.
    Legislation has been introduced in the House (H.R. 2791) and the 
Senate (S. 524) to create a VATAC that would provide vital 
opportunities for collaboration, communication, and coordination 
between the VA and tribal nations to help AI/AN veterans access the 
services they earned through their service to this country. NCAI 
supports this legislation via Resolution #REN-19-033, ``Supporting the 
Department of Veterans Affairs Tribal Advisory Committee Act.'' 
Accordingly, NCAI urges Congress to act swiftly to enact legislation 
establishing a VATAC.

Authorize IHS and BIA Advance Appropriations to Provide Certainty for 
    AI/AN Veterans

    Congress must uphold its solemn obligations to tribal nations by 
protecting programs serving Indian Country--especially those serving 
AI/AN veterans--from uncertainty in the Federal budget process.
    Following the 2019 government shutdown, NCAI adopted Resolution 
#ECWS-19-001, which calls on Congress to pass legislation authorizing 
advance appropriations for IHS and the Bureau of Indian Affairs (BIA). 
This resolution expands on NCAI Resolution#ANC-14-007, which calls for 
advance appropriations for IHS.
    Preventing Federal budget impasses from jeopardizing the health, 
safety, and well-being of AI/AN veterans and all those living in tribal 
communities is a major priority for Indian Country. Although the 
Veterans Health Administration receives advance appropriations to 
prevent Federal budget impasses from affecting or interrupting 
healthcare for veterans, IHS does not receive the same treatment--even 
though IHS is often the primary agency responsible for providing 
critical healthcare services to AI/AN veterans. Additionally, services 
provided through the BIA impact AI/AN veterans' access to health care 
both at IHS and VA facilities. For instance, BIA is responsible for 
construction and maintenance of roads across Indian Country, and lapses 
in related funding can prevent AI/AN veterans from traveling to 
healthcare appointments at the VA or Indian health system facilities. 
Authorizing advance appropriations for IHS and BIA will ensure that 
medical attention and resources that AI/AN veterans earned through 
their military service are available when the Administration and 
Congress cannot agree on spending priorities.
    There are currently two bills pending in the U.S. House of 
Representatives that provide advance appropriations for tribal 
programs. H.R. 1128, the Indian Programs Advanced Appropriations Act 
was introduced by Representative Betty McCollum and authorizes advance 
appropriations for several accounts at IHS and BIA. This legislation 
has a Senate companion bill, S. 229, and nearly 40 bipartisan co-
sponsors. H.R. 1135, the Indian Health Service Advance Appropriations 
Act, was introduced by Representative Don Young and authorizes advance 
appropriations for several accounts at IHS. This legislation has a 
Senate companion bill, S. 2541, and nearly 30 bipartisan co-sponsors.
    NCAI supports H.R. 1128 and H.R. 1135, and NCAI strongly urges 
every member of this Subcommittee and the entire House of 
Representatives to join in supporting advance appropriations for Indian 
Country.

Pass the Health Care Access for Urban Native Veterans Act

    Urban Indian Organizations (UIOs) are an important part of the 
Indian healthcare delivery system. Given that a majority of AI/ANs live 
off reservation, many of our AI/AN veterans utilize the UIO system. AI/
AN veterans often prefer to use Indian healthcare providers, including 
UIOs, for reasons such as cultural competency, community and familial 
relations, and VA wait times.
    Although the 2010 MOU recognizes that VA and IHS must meet the 
needs of Urban Indian health programs, UIOs are currently ineligible to 
be reimbursed for the services they provide to AI/AN veterans. Allowing 
reimbursement for UIO services would not only help alleviate broader 
issues with wait times at VA facilities, but also would provide AI/AN 
veterans the opportunity to seek culturally competent care when living 
away from their own tribal communities, which will help reduce overall 
health disparities in Indian Country.
    NCAI strongly supports addressing this gap in the IHS-VA MOU. 
Legislation has been introduced in the House (H.R. 4153) and the Senate 
(S. 2365) to amend the Indian Health Care Improvement Act to provide 
Native veterans coverage by the VA for services at urban Indian health 
centers. NCAI's membership passed Resolution #REN-19-034, which calls 
on Congress to pass this important legislation.

Address Data Collection on Suicide among AI/AN Veterans

    AI/ANs experience high rates of depression and psychological 
distress, which contributes to Native people having one of the highest 
suicide rates of any group in the United States. While the VA 
acknowledges suicide as a national health crisis that affects all 
Americans and publishes reports each year on suicide data, it continues 
to omit data specific to AI/AN veterans. When VA does disaggregate 
suicide data by race/ethnicity, AI/AN veterans fall under the category 
of ``other.'' Capturing data specific to AI/AN veteran suicide is 
essential for developing effective policy and initiatives to generate 
improved outcomes. Therefore, NCAI urges Congress and the 
Administration to work to develop policies and procedures that ensure 
the collection of AI/AN veteran suicide data so that Federal and tribal 
policymakers have the necessary information to address the suicide 
crisis among AI/AN veterans.

Invest in Tribal Infrastructure, Road Systems, and Tribal Transit 
    Systems

    Although outside this Committee's jurisdiction, supporting a strong 
surface transportation reauthorization bill for Indian Country also 
would help address some of the issues AI/AN veterans face when trying 
to access VA services. NCAI urges Congress to provide significant 
increases for the Tribal Transportation Program, the Tribal Transit 
Program, the BIA Road Maintenance Program, and other programs that will 
improve road conditions and promote road safety in Indian Country. 
Increased investment in these programs will enhance the ability of AI/
AN veterans to travel to VA services.

Conclusion

    Thank you for the opportunity to testify regarding AI/AN veterans' 
access to quality, culturally appropriate healthcare. We greatly 
appreciate the work of this Committee to address the many challenges 
and barriers faced by AI/AN veterans. We loforward to working with this 
Subcommittee on a bipartisan basis to advance Federal policies that 
support those who have served our country.
                                 ______
                                 

                 Prepared Statement of Sonya Tetnowski

    My name is Sonya Tetnowski, I am a member of the Makah tribe, a 
U.S. Army Paratrooper Veteran, and the Chief Executive Officer of the 
Indian Health Center of Santa Clara Valley in California. I'm also the 
Vice President of the National Council of Urban Indian Health (NCUIH), 
which represents 41 Title V Urban Indian Health Organizations (UIOs) 
across the Nation, as well as the President of the California 
Consortium for Urban Indian Health (CCUIH). UIOs provide high-quality, 
culturally competent care to urban Indian populations, which constitute 
more than 78 percent of all American Indians and Alaska Natives 
(AIANs). I would like to thank Chairwoman Brownley, Ranking Member 
Dunn, and other distinguished members of the subcommittee for holding 
this important hearing. It is my pleasure to testify today regarding 
H.R. 4153, the Health Care Access for Urban Native Veterans Act.
    H.R. 4153 is a necessary and critical piece of legislation, one 
that will make a real meaningful difference in the funding for health 
care services provided by UIOs across the United States. Just last 
month, I came to Washington D.C. to advocate and give in person 
testimony on this very issue before the House Indigenous Peoples of the 
United States Subcommittee Legislative Hearing on held on September 25, 
2019 and to voice my support of H.R. 4153.
    I cannot express more urgently, that the single most important 
thing the Department of Veterans Affairs (VA) can do to improve 
healthcare to AI/AN Veterans, is to fully implement the VA and Indian 
Health Services' Memorandum of Understanding (VA-IHS MOU) and 
Reimbursement Agreement for Direct Health Care Services. This would 
allow UIOs to be reimbursed for providing culturally competent care to 
AI/AN Veterans residing in urban areas. Despite an embattled history 
between tribal people and the U.S. Government, and as an inherited 
responsibility to safeguard the lands of their ancestors, AI/ANs serve 
this country at a higher rate than any other group in the Nation. A 
significant number of these Veterans live in urban areas and seek out 
the high-quality, culturally competent care at their local UIO.
    UIOs were formally recognized by Congress following the end of the 
Termination Era in 1976 under the Indian Health Care Improvement Act to 
fulfill the Federal Government's health care-related trust 
responsibility to Indians who live off the reservations. Each UIO is 
led by a Board of Directors that must be majority Indian. They are 
collectively represented by the National Council of Urban Indian Health 
(NCUIH), which is a 501(c)(3), member-based organization devoted to the 
development of quality, accessible, and culturally sensitive healthcare 
programs for AIANs living in urban communities. UIOs are a critical 
part of the Indian Health Service (IHS), which uses a three-prong 
approach to provide health care: Indian Health Services, Tribal 
Programs, and Urban Indian Organizations commonly referred to as the I/
T/U.

VA-IHS MOU Historical Background

    In February 2003, the VA and IHS signed a Memorandum of 
Understanding (MOU) and updated this MOU in October 2010. The very 
first paragraph of the MOU states:
    `` the intent of this MOU (is) to facilitate collaboration between 
IHS and VA, and not limit initiatives, projects, or interactions 
between the agencies in any way. The MOU recognizes the importance of a 
coordinated and cohesive effort on a national scope, while also 
acknowledging that the implementation of such efforts requires local 
adaptation to meet the needs of individual tribes, villages, islands, 
and communities, as well as local VA, IHS, Tribal, and Urban Indian 
health programs.''
    In December 2012, the two agencies signed a reimbursement agreement 
allowing the VA to financially compensate IHS for health care provided 
to AIANs that are part of the VA's system of patient enrollment. While 
this MOU has been implemented for IHS and Tribal providers, it has not 
been implemented for UIOs, despite the fact that UIOs are explicitly 
mentioned in the original language of the 2010 MOU, and provide 
healthcare within IHS's own I/T/U system. Leaving out UIOs is a 
violation of the MOU since the agencies agreed to ``not limit 
initiatives, projects, or interactions between the agencies in any 
way.'' Not reimbursing UIOs for services provided to Native Veterans is 
limiting this vulnerable, underserved population from the healthcare 
they need and deserve. NCUIH and UIO leaders have been testifying 
before Congress for years that the MOU is not being recognized for 
UIOs. Members have said this is an ``easy fix,'' and ``an oversight,'' 
so we are happy to see that there is now a bill to address this issue 
once and for all. We maintain that as part of the I/T/U, the VA already 
has the authority to reimburse title V UIOs, but we are happy Congress 
is taking the next step to address this important issue.
    Between 2012 and 2015, the VA reimbursed over $16.1 million for 
direct services provided by IHS and Tribal Health Programs covering 
5,000 eligible Veterans under the IHS-VA MOU. In spite of the Federal 
trust responsibility to AIANs, the VA had decided to deem UIOs 
ineligible to enter into the reimbursement agreement under the IHS-VA 
MOU. For context, UIOs are already extremely underfunded and receive 
less than $400 per patient from IHS, versus national health expenditure 
rates of almost $10,000 per patient. In 2018, UIOs received a total of 
$51.3 million to support 41 programs, and that is before IHS's 
administrative costs are removed. UIOs only receive one line-item 
appropriation in the IHS budget-the urban Indian health line item. UIOs 
don't receive purchase and referred care dollars, Federal Tort Claims 
Act coverage, 100 percent FMAP, or facilities funding. In fact, a few 
UIOs temporary closed during the shutdown due to the lack of parity 
within the IHS system. VA reimbursement, even half of the $16.1 
million, would drastically help our facilities. It is time to fix this 
issue for good.
    The VA's position is that UIOs are not identified in 25 U.S.C. 
Sec. 1645(c) as one of the organizations it may reimburse. However, it 
is important to note that two UIOs are covered under the IHS-VA MOU 
because VA officials report that those programs function as a service 
unit as defined in 25 U.S.C. Sec. 1603(20).
    There have been several Government Accountability Office (GAO) 
reports conducted on the VA-IHS MOU--two reports on VA and IHS 
implementation and oversight of the MOU were released in 2013 and 2014. 
In March 2019, the GAO released a study entitled ``VA AND INDIAN HEALTH 
SERVICE Actions Needed to Strengthen Oversight and Coordination of 
Health Care for American Indian and Alaska Native Veterans''. The GAO 
was asked to provide updated information related to the agencies' MOU 
oversight. This report examines (1) VA and IHS oversight of MOU 
implementation since 2014, (2) the use of reimbursement agreements to 
pay for AI/AN veterans' care since 2014, and (3) key issues identified 
by selected VA, IHS, and tribal health program facilities related to 
coordinating AI/AN veterans' care. In this report the GAO report makes 
the recommendation to both the VA Secretary and IHS Director to ensure 
measureable targets to track and measure performance, and has jump 
started efforts by VA to conduct consultation and confer. The VA is 
currently working with IHS to revise the MOU, stating their goals for 
this revision: increase access and quality of care for AI/AN veterans, 
improve health promotion and disease prevention, encourage patient 
centered collaboration and communication, consult with Tribes at the 
regional and local levels, ensure appropriate resources for services 
for AI/AN Veterans. Furthermore, the VA in a 2018 report to Congress 
stated themselves that UIOs under IHCIA are ``eligible, capable, and 
are entitled to receive reimbursement for healthcare services they 
provide to AI/AN veterans from any payer'' as part of the IHS I/T/U 
system. They also acknowledge that they have no current legal authority 
to allow for expanding existing reimbursement agreements to include 
UIOs. If the goal is to increase access to care for AI/AN veterans, 
then now is the time for the VA to finally recognize that UIOs are a 
critical part of the Indian Health Service (IHS), acknowledge the needs 
of the significant amounts of AI/AN veterans who live in urban areas 
and expand the reimbursement agreement to include UIOs.
    Both the legislative and executive branches strongly support 
efforts to increase timely access of healthcare for Veterans. 
Recognition of the MOU for UIOs and urban Indian Veterans would be 
highly consistent with those efforts. NCUIH has worked closely with the 
National Congress of American Indians who recently passed a resolution 
in support of our efforts to ensure parity for UIOs. This resolution is 
being submitted as a part of my testimony today.

In Conclusion

    We strongly recommend that the VA reimburses UIOs for services 
rendered to Native Veterans. These reimbursements must be companied by 
outreach and advocacy resources to ensure that Native Vets are aware of 
all the health care options available to them in their communities. The 
VA is known for its challenging wait times, yet we all agree access to 
care for Veterans is a priority. UIOs can provide excellent, culturally 
competent primary care, dental, and behavioral health services to 
Veterans, while reducing the burden on the VA and allowing it to focus 
on the specialty services it provides best.
    Our national interest of serving Veterans will be best carried out 
when we extend the collaborative arrangements already agreed to by the 
VA and IHS to include the bulk of our Nation's Native American 
Veterans--who either are or could be served by a UIO.
    NCUIH strongly recommends, pursuant to Section 405(c) of the Indian 
Health Care Improvement Act, that the VA-IHS MOU be expanded to include 
reimbursement for care provided by the UIOs. Thank you for holding this 
hearing today and for the Committee's support of urban Indian 
healthcare issues. We strongly support H.R. 4153 and look forward to 
working with Congress to serve as an expert resource regarding this 
legislation.
                                 ______
                                 

                 Prepared Statement of William F. Smith

    The Alaska Native Health Board (ANHB) thanks Chairwoman Brownley, 
Ranking Member Dunn, and Distinguished Members of the House Committee 
on Veterans' Affairs Subcommittee on Health for the opportunity to 
provide this written statement to augment Chief William F. Smith's oral 
testimony. The ANHB was established in 1968 and serves as the statewide 
voice of the Alaska Tribal Health System (ATHS) on Alaska Native health 
issues. ANHB represents 229 federally recognized Alaska Tribes that 
provide health services to over 177,000 Alaska Native people and 
thousands of veterans (Native and non-Native alike) spread across the 
greater than 660,000 square miles that Alaska encompasses. Please 
accept this statement providing background and context and a listing of 
our issues and priorities pertinent to this hearing.

Honoring Our Veterans

    Alaska Natives and American Indians are the highest represented 
population in the armed forces per capita. Tribal leadership stands 
beside them and by their Non-Native brothers and sisters who have 
served in the military and believe they should be encouraged and 
enabled to utilize the benefits promised them by the Federal 
Government. Tribal sharing agreements and engagement with the Tribal 
health system provides a method for the Federal Government and agencies 
to meet those promises. These individuals have sacrificed for our 
security and our freedom and are to be lifted and celebrated. However, 
sadly many veterans do not have faith and trust in the VA after past 
experiences with delays in enrollment, denial of care or lack of access 
to VA services. The Alaska VA is to be commended for the strides it has 
taken in partnership with tribes to remedy these barriers. Its 
partnership with tribes is a key component in its success.

Background:

Trust Responsibility

    Established in numerous Treaties and the Constitution, the Trust 
Responsibility forms a unique government-to-government relationship 
between the Federal Government and American Indian and Alaska Native 
(AI/AN) people. These actions form the legal basis by which the United 
States has committed to protecting the health and well-being of 
America's first citizens in perpetuity. Alaska Tribes have taken over 
our programs and services through a contracting and compacting process 
and now carry out nearly all of the functions previously administered 
by the IHS. Collectively, the Alaska Tribal Health System forms an 
integrated statewide health network, providing health care services at 
village clinics, regional hubs and the Alaska Native Medical Center. In 
taking on this responsibility, Alaska Tribes operate on the principle 
of self-determination and intertribal cooperation, and in doing so have 
achieved remarkable advances in strengthening the health and well-being 
of our people.

The Alaska Tribal Health System

    The Alaska Tribal Health System (ATHS) is a truly comprehensive 
statewide system of health care. It is a voluntary affiliation of over 
30 Alaskan tribes and tribal organizations providing health services to 
over 177,000 Alaska Natives/American Indians. Each tribe or tribal 
health organization is autonomous and serves a specific geographical 
area; and, many are the only health provider in their respective 
community. This fact makes the ATHS an integral part of the Alaska 
Public Health System. It is a finely tuned network that provides 
services through:
      180 small community primary care centers
      25 sub regional mid-level care centers
      4 multi-physician health centers
      6 regional hospitals
      Alaska Native Medical Center tertiary care
      Referrals to private medical providers and other states 
for complex care
    The infrastructure of the ATHS, including facilities and staffing, 
make the ATHS a critical partner for the VA. And in most rural 
locations the ATHS is the only health care provider available, making 
the ATHS a necessary partner in providing veterans living in rural 
Alaska the care they have earned through service.
[GRAPHIC] [TIFF OMITTED] T1247.039

 Figure 1 Scaled map of Alaska with ATHS referral patterns imposed over 
    the contiguous US.

Alaska Tribal Sharing Agreements

    The Alaska Tribal Sharing Agreements were established in 12 as a 
part of an initiative known as ``Care Closer to Home.'' As a result, 
Alaska veterans were found to not have to endure the same wait-times as 
their compatriots in the contiguous United States. Furthermore, prior 
to the establishment of the Tribal Sharing Agreements, Alaska's 
veterans, especially in rural Alaska, had limited or no access to 
health care services supported by the VA. Alaska has the highest per 
capita representation of veterans in the Nation; the ATHS is an 
essential partner in the VA's mission to ``care for him who shall have 
borne the battle and his widow and orphan.'' The Alaska model has 
unequivocally expanded access to care to veterans, who have benefited 
immensely in the years subsequent to the agreements as a result of the 
partnership between Tribal Health Programs (THPs) and the VA. The 
tribal sharing agreements also support an integral partnership for 
enrollment and outreach to Alaska veterans. In Alaska, prior to this 
partnership between the Alaska VA and the ATHS, the VA had six access 
points of care to Alaska veterans. Since 2012, the VA's footprint now 
matches that shown in Figure 1. Protecting and renewing these 
agreements are of utmost importance to our partnership with the VA.

The Issues:

Support for H.R. 2791 and S. 524

Department of Veterans' Affairs Advisory Committee Act of 2019

    ANHB encourages the full Committee to support H.R. 2791, the 
Department of Veterans' Affairs Advisory Committee Act of 2019, 
introduced by Congresswoman Debra Haaland of New Mexico. The companion 
bill, S. 524, was introduced in the Senate by Senator Dan Sullivan of 
Alaska, and is cosponsored by Senator Lisa Murkowski, also of Alaska. 
Creating a VA Tribal Advisory Committee (TAC) would reflect the 
government-to-government relationship and improve communications with 
tribal partners. Alaska Tribes note that a VA TAC would augment (not 
supplant) the consultative process. The creation of the VA TAC could 
coincide with and support an update to the VA's Tribal Consultation 
Policy and Process which would allow tribes to provide input on a 
tribal consultation policy that better reflects the government-to-
government relationship they have with the VA. The VA TAC would play an 
important role for the VA to provide regular feedback to tribes and 
THPs about what actions have been taken based on tribal consultations.

Tribal Representation on the IHS VA Leadership Team on the MOU

    Tribal and THP representatives need to be included in the Indian 
Health Service (IHS)-VA Memorandum of Understanding (MOU) Leadership 
Team and in any oversight committees which monitor its implementation 
in order to honor the government-to-government relationship between the 
Tribes and the Federal Government. The services provided under this MOU 
are predicated on the Federal Trust Responsibility. And in 
consideration of the Government Accountability Office (GAO) report 
(GAO-19-291) assessing the MOU and the planning to update the 
agreement, it is important to include tribal voices upfront, in the 
design, which will have definite impacts on their programs. This will 
also benefit the VA in seeking how to followup and implement 
recommendations brought forward from tribal consultations. We ask that 
Congress encourage the VA and IHS to include tribes and THPs IHS-VA MOU 
Leadership Team in order to address challenges and to reflect the 
government-to-government relationship in which collaboration has 
already mutually benefited the VA and Tribes and THPs. On these 
principles we also ask that tribes and THPs serve an active role in 
reviewing, revising and evaluating the 15 performance measures 
identified by the two agencies and in setting associated targets for 
the selected and revised measures.

Tribal Consultation

    The current Department of Veterans Affairs' Tribal Consultation 
Policy was signed in 2011, ANHB recommends that the VA as a practice 
work with Tribes to update this policy on a regular basis. The Policy 
as it stands offers on page 5 subparagraph 7.d., provides ``through 
reviewing proposed plans, policies, rules, or other pending and 
proposed programmatic actions, recognizes the need to assess whether 
such actions may impact Indian Tribes and/or American Indian and Alaska 
Native Tribes. Consultation should take place prior to any actions that 
may have the potential to significantly affect tribal resources, 
rights, or land. VA strives to notify appropriate Tribal Officials 
about such actions in an effort to provide Tribal Officials the 
opportunity to pursue and/or engage in the consultation process.'' 
There are many areas where the VA can benefit from consulting with 
Tribes, from implementing the VA Mission Act of 2018 to the renewal of 
the VA memorandum of understanding (MOU) with the Indian Health Service 
(IHS).

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


Build Parity Between the VA and IHS

    Congress must give the IHS and its tribal partners parity with the 
VA. For example, in Fiscal Year 17, VA spending per user was $7,600 
\1\, whereas for the same year, IHS spending per user was $3,332.\2\ 
The IHS spends half what the VA spends per user. When Native veterans 
are treated in IHS and THPs, that means that they are accessing a 
system that is funded at half the rate of direct care VHA facilities. 
The IHS is also subject to government shutdowns because it lacks the 
advance appropriations authority given to the VHA. This causes 
instability in care for Native veterans who receive their care in 
tribal facilities. It is vital that we achieve parity with the VA to 
ensure our heroes receive the care they deserve.
---------------------------------------------------------------------------
    \1\  Golding, H. ``Potential Spending on Veterans' Health Care: 18-
28'', Congressional Budget Office. Slide 7. Accessed: (https://
www.cbo.gov/system/files/2018-11/54690-presentation_0.pdf)
    \2\  ``The National Tribal Budget Formulation Workgroup's 
Recommendations on the Indian Health Service Fiscal Year 2020 Budget'', 
National Indian Health Board. Page 3. Accessed: (https://www.nihb.org/
docs/03012018/TBFWG%20FY%202020%20Recommendations%20Brief.pdf)

---------------------------------------------------------------------------
VA Copayments and Deductibles

    The IHS and THPs do not charge co-payments or deductibles to AN/AI 
beneficiaries as part of the Federal Trust Responsibility to provide 
healthcare to AN/AIs. The same Trust Responsibility extends to Native 
veterans who receive their care through the VHA. In recognition of the 
Federal Trust Responsibility, the VA should eliminate all deductibles 
and co-pays for Native veterans. Congress should clarify in statute 
that the Trust Responsibility does not end at the IHS' doors but 
extends to VA programs for Native veterans as well.

Alaska's Tribal Veteran Representative Model

    There are many barriers to seeking care for Native veterans, 
including stigmas around care; prior denials of application; distance 
to care; and lack of awareness of benefits and services they are 
entitled to receive. The Tribal Veterans Representative (TVR) program 
was developed to reach Native veterans in their communities through 
trusted community members. TVRs are volunteers, who are veterans and 
tribal community members who reach out to unenrolled Native veterans, 
provide them with information on VA health care services and benefits, 
and assist them with the enrollment process. The program has proved 
very successful, and Congress should continue to support this important 
program.

In Conclusion:

    Many veterans have broken faith in the VA system, some having not 
accessed care in decades. Tribes in Alaska and across the Nation are 
working with the VA to help restore that faith. The issues we have 
raised in this testimony can continue the work of restoring trust in 
the VA for veterans, Native and non-Native alike. Our collaborative 
relationship with the VA can be strengthened through further 
consultation and policy development that eases access to care for all 
veterans through Indian health programs.
    As Congress continues its review of health care access for 
veterans, we should build on programs and institutional supports which 
are proven. An important step would be to allow for longer Tribal 
Sharing Agreement periods, where the agreements support step up and 
step down of capacity building and support continuity of care over 
time. Allowing for tribal representation and consultation are effective 
methods for ensuring that policies and programs do not leave Native 
veterans behind. Supporting access for veterans through culturally 
engaged methods has demonstrated time and again through increased 
Native veteran participation the importance that this approach 
provides. Finally, building parity between the VA and IHS lifts up 
veterans, especially Native and rural/remote veterans, who seek care 
through tribal facilities.
    ANHB thanks the subcommittee and looks forward to further 
supporting the members in their work on veterans' health care issues, 
and ANHB welcomes questions at [email protected].
                                 ______
                                 

                 Prepared Statement of Marilynn Malerba

    Chairwoman Brownley, Ranking Member Dunn, and Members of the 
Subcommittee,
    On behalf of the Indian Health Service (IHS) Tribal Self-Governance 
Advisory Committee (TSGAC), it is an honor to submit the following 
formal written testimony on the unique barriers that Native veterans 
face when seeking access to quality, culturally competent care. 
Established in 1996, the TSGAC provides information, education 
advocacy, and policy guidance for the implementation of Self-Governance 
within the IHS.
    Native Veterans have a uniquely special status with the United 
States. Our American Indian and Alaska Natives have fought alongside 
the colonial government beginning with the Battle of Bunker Hill, and 
they have subsequently fought for the United States armed forces in 
every war and conflict, at higher rates per capita than any other group 
in the United States.
    Treaties between our native governments and the United States 
included health care for our people. Our Native veterans, as warriors 
on behalf of this Nation are deserving of the best health care we can 
provide. All veterans, Native and non-Native, alike have sacrificed 
much for this country and are owed the best health care that we can 
provide.
    The United States Commission on Civil Rights notes in the report 
titled ``Broken Promises: Continuing Federal Funding Shortfall for 
Native Americans'' ``the United States expects all nations to live up 
to their treaty obligations and it should live up to its own.'' It 
specifically recommends that the Federal Government should provide 
steady, equitable and non-discretionary funding directly to Tribal 
nations to support the public safety, health care, education, housing, 
and economic development of Native Tribes and people.
    One way to enhance the funding for the health of our Native 
veterans was implemented with the Memorandum of Understanding (MOU) 
between the U.S. Department of Veterans Affairs (VA) and the U.S. 
Department of Health and Human Services' (HHS) Indian Health Service 
(IHS). In fact, given the inequity of funding for our Native people 
within the Federal system, the ability to access VA funding for 
services provided to our Native veterans provides better care for our 
veterans and provides some relief for a very economically challenged 
Indian health care system. In 2017, the funding per person per year for 
an American Indian was $3,332 while the Veterans Health Administration 
funding per person was $8,759.

    The TSGAC would specifically like to comment on the effectiveness 
of this MOU and provide solutions to overcome the systematic health 
inequities experienced by Native veterans as a means to improve Native 
veterans' health status and well-being.

    As reported by the U.S. Government Accountability Office (GAO) in 
2019, Federal Indian policy has promoted Tribal self-government--the 
practical exercise of Indian tribes and nations' inherent sovereign 
authority--for more than four decades The Indian Self-Determination and 
Education Assistance Act of 1975 (ISDEAA), as amended, authorizes 
federally recognized tribes to assume the administration of a variety 
of Federal programs--or portions thereof--that were previously managed 
by the Indian Health Service. In effect, the Tribes are fulfilling the 
trust and treaty obligations of the United States through contractual 
arrangements with the Federal Government.
    Since enactment of ISDEAA, Tribal nations have demonstrated and 
proven that a government-to-government relationship based on respect of 
sovereignty and the inherent right of Tribes to self-govern is an 
effective and successful approach for both the delivery of services to 
Tribal communities and to uphold the United States' trust 
responsibility to Tribal Nations and their citizens.
    The VA reports there are 145,000 Native Veterans living in the 
United States. The VA also reported that Native Veterans have an 
average life expectancy 4 years shorter than that of the general U.S. 
population and are more likely than Veterans of other ethnicities to 
experience social and economic difficulties that may impact their 
health or wellness, such as lower income, lower education levels and 
higher unemployment. Native veterans are eligible to receive health 
care services from the VA, IHS, and Tribal nations and Tribal 
organizations that operate under a Self-Governance agreement (referred 
to as Tribal Health Providers or THPs).
    Tribal Nations that elect to administer health programs and 
services under a Self-Governance agreement to their citizens and 
communities are effective, in part, because Tribal Nations know the 
needs of their communities and are in the best position to provide 
culturally appropriate solutions tailored to address those local needs. 
Many THPs have significant experience serving veterans in their 
communities and have entered into reimbursement agreements with the VA, 
pursuant to Section 405(c) of the Indian Health Care Improvement Act 
(IHCIA).\1\
---------------------------------------------------------------------------
    \1\ Section 405 (c) of the IHCIA provides that...the Service, 
Indian tribe, or Tribal organization shall be reimbursed by the 
Department of Veterans Affairs or the Department of Defense (as the 
case may be) where services are provided through the Service, an Indian 
tribe, or a Tribal organization to beneficiaries eligible for services 
from either such Department, notwithstanding any other provision of 
law.
---------------------------------------------------------------------------
    As Native veterans return home and seek to access the benefits they 
are entitled to, healthcare services often fall short to meet their 
needs. Factors, such as, residing in remote rural communities, poverty, 
mental health conditions, historical mistrust and a limited number of 
culturally competent healthcare providers create barriers to care and 
lead to Native veterans experiencing greater health disparities 
compared to other veterans. Other social determinants of health impact 
the overall health of our Native veterans including lack of running 
water, lack of indoor plumbing, overcrowded housing and in some cases 
lack of fully functioning kitchen facilities for nutrition.
    Further, regulatory barriers exacerbate Native veterans' ability to 
access care. Restrictions on specialty care, assessment of co-pays, 
duplicative processes, overly burdensome administrative requirements 
and lack of coordination of care delay access to care and have caused 
irreparable harm to veterans.
    Native Veterans reside in rural areas in greater proportions when 
compared to Veterans of other races--with nearly 40 percent of Native 
veterans residing in rural areas, often on geographically dispersed 
reservations or Tribal lands which are often remote, isolated and 
considered highly rural. THPs are often one of few, if any, health 
providers in rural areas. As such, THPs are a critical partner for 
increasing access to quality healthcare to all veterans, both Native 
and non-Native. IHCIA Section 405(c) provides the authority for Tribes 
to receive reimbursement for services provided to non-Native veterans 
but THPs are limited from playing a greater role in providing increased 
access to healthcare because VA limits the services that IHS can 
provide to non-Native veterans.
    In recent years, the VA and IHS made some progress overcoming these 
challenges to ensure eligible veterans can access efficient adequate 
health services in their own communities through THP's. However, the VA 
limits the types of care that can be provided at IHS and does not cover 
non-Native veterans who would otherwise routinely receive services 
through IHS, such as non-Native women pregnant with Native children; 
even in cases where the IHS or THP is the only facility in close 
proximity to the veteran. Limiting the services that IHS can provide in 
turn limits the services that Tribally administered healthcare programs 
can provide to their communities.

Coordination Between VA and IHS

    In 2010, VA and IHS expanded upon a 2003 memorandum of 
understanding (MOU) to improve the health status of American Indian and 
Alaska Native veterans through coordination and resource sharing among 
VA, IHS, and Tribal Nations. This 2010 MOU outlined mutual goals for VA 
and IHS collaboration and coordination of resources and health care 
services provided to AI/AN veterans. For example, it included 
provisions for joint contracts and purchasing agreements, sharing 
staff, ensuring providers in VA and IHS could access the electronic 
health records of shared patients, and the development of reimbursement 
policies and mechanisms to support care delivered to AI/AN veterans 
eligible for care in both systems.
    In December 2012, VA and IHS signed a reimbursement agreement that 
facilitates reimbursement from VA to IHS facilities for the direct care 
services they provide to eligible Native veterans. VA has established 
similar reimbursement agreements with individual Tribally administered 
healthcare programs. The VA and IHS are now in the process of updating 
the MOU. This process provides a tremendous opportunity for the VA, 
IHS, and Tribal governments to work collaboratively to identify 
activities that will help ensure Native Veterans are receiving the 
quality healthcare services they are owed.

    The current MOU between VA and IHS includes the following five 
primary goals:

        1. Increase access to care and services for American Indian and 
        Alaska Native Veterans

        2. Promote patient-centered collaboration and communication

        3. Improve health-promotion and disease prevention

        4. Consult with Tribes at the regional and local levels

        5. Ensure appropriate resources are identified and available.

    In accordance with these five goals, the MOU contains specific 
areas in which VA and IHS agreed to collaborate and coordinate on, 
including:

      Reimbursement: development of payment and reimbursement 
policies and mechanisms to support care delivered to dually eligible 
Native veterans.

      Sharing staff: sharing of specialty services, joint 
credentialing and privileging of health care staff, and arranging for 
temporary assignment of IHS Public Health Service commissioned officers 
to VA.

      Staff training: providing systematic training for VA, 
IHS, THP, and Urban Indian Health Program staff on VA and IHS 
eligibility requirements to assist them with appropriate referrals for 
services.

      Information Technology Interoperability: interoperability 
of systems to facilitate sharing of information on common patients, and 
establishment of standard mechanisms for VA, IHS, and THP providers to 
access records for patients receiving care in multiple systems.

    We offer the following comments and recommendations that are 
related to several of the goals and/or areas of agreed collaboration 
and coordination:

Patient Referrals

    As VA, IHS, and Tribal Nations work to build greater partnerships, 
we must address issues with regard to coordination of care. Failing to 
adequately coordinate care is magnified by VA's unwillingness to 
reimburse referral services. For example, if a Native veteran goes to 
an IHS or Tribal facility for service and needs a referral, the same 
patient must then be seen within the VA system before a referral can be 
secured. This is a not an efficient use of Federal funding as it is 
duplicative, fails to acknowledge similarly credentialed providers and 
makes care navigation difficult for Native veterans.

    Recommendation: The VA should accept referrals made by IHS and THPs 
in order to provide the best services to our veterans.

Reimbursement of Purchased and Referred Care

    Although the MOUs and agreements with VA have demonstrated success 
in facilitating patient care for veterans, neither the current national 
agreement nor the Tribal agreements include reimbursement for Purchased 
and Referred Care (PRC) at IHS or Tribal healthcare facilities. 
Consequently, veterans are forced to maneuver through a complex 
healthcare system and an elaborate administrative process.
    Veterans often require additional services that are not available 
at IHS or THPs. In many instances eligible veterans are also eligible 
for PRC services. The PRC program authorizes Indian Healthcare 
facilities to purchase services from a network of private providers. 
IHS and THPs are the payors of last resort, which require that all 
other sources of obtaining health services must be exhausted prior to 
receiving care through the PRC program. These services may include 
primary or specialty care that is not available at an IHS and/or Tribal 
healthcare facility. Many THPs have existing provider networks to 
ensure veteran's complex healthcare needs are met.
    The VA, however, will not reimburse THPs for their referrals but 
instead insist that the veteran in need of specialty care return to the 
VA health system for a VA referral for care. In certain instances, this 
level of care may be directly available and provided under the current 
reimbursement agreements and reimbursed by the VA. However, because the 
mix of direct versus purchased care varies across the Indian health 
system, some IHS or Tribal health programs may purchase more care from 
outside providers, which currently is unreimbursed by VA.
    This illogical and inconsistent management of care is inefficient, 
a waste of resources (both time and money) and fails to prioritize the 
healthcare needs of Native veterans. THPs work hard to provide a 
seamless health care experience. Lack of coordination of care for 
specialty care and other medically necessary care paid by PRC creates 
more barriers for our veterans. This creates misalignment with the VA's 
mission for care which strives for improved access to all types of 
care.

    Recommendation: VA should include PRC in the IHS/THP reimbursement 
agreements to eliminate further rationing of health care provided by 
IHS and THPs to Native veterans and other eligible veterans and to 
ensure timely quality healthcare.

Native Veterans Co-Pays

    Native veterans who seek health care services at a VA facility are 
assessed co-payments which is in direct opposition to the Federal trust 
obligation to provide health care for all American Indians and Alaska 
Natives. IHS and THPs are the payor of last resort (section 2901(b) of 
the ACA) whether or not there is a specific agreement in place for 
reimbursement. Therefore, neither the Native Veteran nor the IHS should 
be responsible for any co-payments.

    Recommendation: The TSGAC recommends the discontinuation of the 
practice of collecting co-payments from Native Veterans.

Tribal Provider Credentialing

    Although stated in the MOU, the VA does not accept provider 
credentialing from THPs. Tribes that administer their health programs 
through Self-Governance agreements have the right to choose and operate 
their own credentialing system or to leverage the credentialing system 
administered by IHS.
    VA acceptance of IHS/THP-credentialed providers facilitates care 
coordination by allowing IHS/THP primary care providers to refer 
directly into the VA system for either continued care to be provided in 
a VA facility, or for care to be purchased through outside providers. 
This would eliminate the duplicative primary care visit and referral 
and ensures that the Veteran continues with their primary care provider 
of choice who coordinates their care and receives all reports and 
results from other providers. VA has attempted in some local areas to 
re-credential IHS/THP providers under the VA system, but the length of 
time required for a provider to proceed through the entire VA 
credentialing process is not practical or timely.

    Recommendation: To ensure care coordination is effective and 
efficient, VA should accept provider credentialing from IHS/THPs, upon 
the provider releasing the credentialing package to VA.

Graduate Medical Education (Tribal Medical Residency Programs)

    IHS and THPs have significant workforce challenges due, in part, to 
most facilities being located in rural and/or remote locations. The HHS 
Health Resources and Services Administration (HRSA) automatically 
designates IHS, Tribally operated and Urban Indian Health programs as 
Health Professionals Shortage Areas (HPSAs) and Medically Underserved 
Area and Medically Underserved Population (MUA/MUP) for these reasons. 
Several THPs currently have Tribal medical residency programs.
    TSGAC was very encouraged to review the provisions of the recent VA 
Mission Act, specifically Section 403 which included a ``Pilot Program 
on Graduate Medical Education and Residency.'' This new pilot includes 
facilities operated by Tribes, Tribal Organizations and IHS as 
``covered facilities'' for purposes of the program and requires such 
facilities have a priority in placement of residents.

    Recommendation: VA should include IHS and Tribes in the planning of 
the pilot program to ensure that any regulations or policies that may 
be developed in the future for the pilot work optimally in Indian 
Country.

Access to Consolidated Mail Order Pharmacy (CMOP)

    Currently only those IHS and Tribal Health Programs that use the 
RPMS system have access to CMOP. This is an important means of 
improving compliance with prescriptions when those medicines are 
delivered directly to the Veteran's homes. This reduces barriers to 
effective disease management

    Recommendation: Information Technology Systems experts from both VA 
and IHS need to ensure that all systems used by Tribal Health programs 
are compliant and compatible with the CMOP system.

Quality Measures

    The TSGAC is supportive of quality measures that provide for 
tracking of meaningful outcomes. However, the TSGAC would be very 
disturbed at the prospect of developing either data reporting 
requirements that affect reimbursements to IHS/THPs, or that require 
new collection of data and reporting systems in addition to those 
already imposed on IHS/THPs. All IHS/THPs receiving reimbursement from 
VA are required to be accredited by a nationally recognized health 
accreditation agency, which assures quality standards are being 
maintained. The VA also conducts quality monitoring, and visits IHS/THP 
programs regularly for review, even though this is not a requirement of 
the statute. Finally, all IHS/THPs participating in Medicare and 
Medicaid must comply with all of their quality and performance programs 
and reporting, as applicable. The VA itself is not required to comply 
with this level of accountability to external agencies.

    Recommendation: The IHS and VA should work together and consult 
with the Tribes to develop evaluation measures for assessing the 
progress toward MOU goals. Additionally, the VA should not impose any 
additional quality programs upon IHS/THPs, because it is very 
burdensome, costly, and unnecessary because there are sufficient 
quality requirements already in place.

Health Information Exchange

    VA belongs to the eHealth Exchange--a national health information 
exchange--and it reported to GAO in March 2019 that IHS or THPs could 
join the exchange to access information about common veteran patients. 
However, IHS reported to GAO that although the agency explored 
connecting to the eHealth Exchange several years ago, testing and 
onboarding costs to participate were prohibitive. THPs that GAO spoke 
with reported being a part of other, more locally based health 
information exchanges, but noted that VA was not part of these 
exchanges.

    Recommendation: Local VA health care facilities should work with 
their local THPs to ensure health information can be exchanged at the 
local levels through local health information exchanges rather than one 
national health information exchange.

Tribal Advisory Board

    Tribal advisory committees provide an effective forum for Tribes 
and Federal agencies to work together as government-to-government 
partners to address policy, legislative, budget, program and service 
issues and formulate recommended actions. In response to GAO's March 
2019 report, VA stated that it will establish a Tribal advisory group 
that will make recommendations related to care coordination guidance 
and policies. The VA set a target completion date for establishing this 
group is spring 2020.

    Recommendation: The VA should work in coordination with Tribes to 
establish a Tribal Advisory Board. Tribal leaders have significant 
experience serving on Tribal advisory committees/boards at Federal 
agencies and can provide crucial input on key components and 
characteristics that make an effective advisory board.

GAO's Review of Coordination Between VA and IHS

    The TSGAC fully supports the development of specific, measurable 
metrics by which to evaluate the progress being made under the MOU. 
Although there are a number of measures identified in annual reports 
issued by the IHS and VA, they are largely process measures which 
report on the number of veterans served, amount of reimbursements, 
number of trainings or events, etc.
    In March 2019, GAO reported that the MOU signed by the VA and IHS 
lacks sufficient measures for assessing progress toward its goals. 
Specifically, GAO reported that the agencies established 15 performance 
measures, but they did not establish targets against which performance 
could be measured. For example, while the number of shared VA-IHS 
trainings and webinars is a performance measure, GAO noted that there 
is no target for the number of shared trainings VA and IHS plan to 
complete each year. Two of the three recommendations GAO made to the VA 
and IHS focus on the lack of performance measures and one focuses on 
the lack of written policy and guidance.

    Recommendation: Federal agencies should focus their limited 
resources on actions that will directly improve the health and well-
being of Native veterans and should ensure that measures they develop 
are focused on outcomes rather than counting administrative activities 
that should already occur as part of routine operations. Additionally, 
these outcome measures should be developed and agreed upon jointly.
    In closing, VA and IHS have made progress and have demonstrated a 
willingness to improve quality access to care for Native Veterans. But, 
as you see in my statements here, there are still significant 
opportunities for improvement. The TSGAC truly appreciates the 
opportunity to provide the Subcommittee with these written 
recommendations. Thank you.
                                 ______
                                 

                 Prepared Statement of Kameron Matthews

    Good morning, Chairwoman Brownley, Ranking Member Dunn, and Members 
of the Subcommittee. I appreciate the opportunity to discuss how care 
at the Department of Veterans Affairs (VA) and our partnership with 
Indian Health Service (IHS) positively impact our Native American 
Veterans. I am accompanied today by my colleagues Ms. Stephanie 
Birdwell, Director for the Department of Veterans Affairs' Office of 
Tribal Government Relations and Dr. Thomas Klobucar, Executive Director 
for Veterans Health Administration's (VHA) Office of Rural Health 
(ORH).

Introduction

    As Secretary Wilkie has shared during his meetings with Native 
American Veterans and tribal leaders across the country, our goal at VA 
is to shorten the distance between people in need of Veterans services. 
VA is working to increase our reach into tribal communities through 
telehealth, visits from VA representatives, and closer cooperation 
between VA and IHS. VA is committed to ensuring our Native American 
Veterans, more specifically our American Indian and Alaska Native (AI/
AN) Veterans, receive and find access to quality, culturally competent 
care from VA and tribal health systems.

Five Goals of the Memorandum of Understanding between VA and IHS

    A Memorandum of Understanding (MOU), originally signed in 2003 and 
updated again in 2010, established that IHS and VA can coordinate, 
collaborate, and share resources between the Departments. Five mutual 
goals were agreed upon when the MOU was signed:

      Increase access to and improve quality of health care and 
services to the mutual benefit of both agencies by effectively 
leveraging the strengths of VA and IHS at the national and local levels 
to afford the delivery of optimal clinical care;

      Promote patient-centered collaboration and facilitate 
communication among VA, IHS, AI/AN Veterans, Tribal facilities, and 
Urban Indian Clinics;

      Establish effective partnerships and sharing agreements 
among VA headquarters and facilities, IHS headquarters, and IHS, 
Tribal, and Urban Indian health programs in support of AI/AN Veterans;

      Ensure that appropriate resources are identified and 
available to support programs for AI/AN Veterans; and

      Improve health-promotion and disease-prevention services 
to AI/AN to address community-based wellness.

    To achieve these goals, VHA has piloted and subsequently adopted 
several programs. To address access to care, achieve effective 
partnerships, and ensure the availability of resources, in 2012 VA 
began to establish a national reimbursement template with IHS which led 
to over 112 Tribal Health Programs (THP) agreements.
    In addition to these reimbursement agreements, local VA medical 
centers have established, where appropriate, several agreements with 
THPs and IHS facilities to deliver telemental health care to AI/AN 
Veterans. The program serves tribal communities in Alaska, Montana, 
Wyoming, and Oklahoma. ORH's Veterans Rural Health Resource Center, 
Salt Lake City (VRHRC SLC) has an active portfolio of innovations in 
AI/AN Veteran health care, including the creation of a Rural Veteran 
Tribal Navigator program that will connect AI/AN Veterans with the 
benefits and care they have earned.
    In addition, VA Video Connect (VVC) is a pilot program currently 
being deployed nationwide. VVC will allow rural AI/AN Veterans to 
access VA health care in their homes or local communities via cellular 
and wireless capabilities. VRHRC SLC is currently working to tailor 
this program to AI/AN Veteran-communities, creating a model that will 
weave together the evidence-based Western medicine, traditional Native 
Healing, and rural Native communities' strengths through four main 
components: mental health care, technology (access), care coordination, 
and a tailored implementation facilitation strategy. In addition to 
these programs, VRHRC SLC is piloting programs to establish Tribal-VHA 
Partnerships in Suicide Prevention and developing Native Veteran 
Content for the VA Community Provider Toolkit.
    One of the great successes in achieving the 2010 MOU goals was the 
establishment of the VA/IHS Consolidated Mail Order Pharmacy Program 
(CMOP) that sends prescription medications to AI/AN Veterans' homes. In 
2018 alone, CMOP processed 840,000 prescriptions for AI/AN Veterans, up 
17 percent from the previous year. Since its inception, CMOP has 
processed more than 3.6 million prescriptions for AI/AN Veterans served 
by IHS and THP programs.
    The March 2019 Government Accountability Office (GAO) report ``VA 
and Indian Health Services: Actions Needed to Strengthen Oversight and 
Coordination of Health Care for American Indian and Alaska Native 
Veterans'' cites challenges in obtaining the MOU goals, specifically 
around establishing targets for outcome metrics to assess progress. 
Specifically, the inadequacies found in performance metrics could limit 
the agencies' ability to measure progress toward MOU goals and 
ultimately impact decisions about programs or activities.
    In early Fiscal Year 2019, VHA and IHS MOU leadership agreed that 
the 2010 MOU was no longer meeting the agencies' needs and required 
modification to create the flexibility needed to move the interagency 
relationship forward to a new level. The leadership team drafted a new 
MOU and conducted a first listening session with tribal leaders on May 
15, 2019. Tribal input from that session was incorporated into the 
draft VHA-IHS MOU and VA and IHS conducted a subsequent consultation 
session at the National Indian Health Board annual meeting on September 
16, 2019. This additional input is now being considered for inclusion 
in the draft MOU. After the IHS and VA MOU leadership team reaches 
agreement on the draft MOU, it will enter formal clearance channels for 
approval by IHS and VA. The approved draft MOU document will be posted 
in the Federal Register and further tribal consultation for a period of 
no less than 60 days. Tribal input will be incorporated into the draft 
document and it will move forward for final approval and signature.
    The challenges found in the 2010 MOU performance metrics may have 
limited the ability of VA and IHS managers to gauge progress and make 
decisions about whether to expand or modify programs or activities 
because the agencies did not have information on the effectiveness of 
the programs in supporting MOU goals. VA and IHS also acknowledge that 
the performance metrics contained weaknesses and that refining them is 
a top priority.
    To address the shortcomings associated with the 2010 MOU metrics 
noted by GAO, VA and IHS have brought in metrics experts from each 
agency to the MOU development process. Once the draft is finalized, the 
process of creating new targets and metrics to meet the requirements 
outlined by GAO will take place as new programs and pilots are 
developed under the new instrument.

Reimbursement Agreements

    Since the Summer of 2012, VA has signed individual reimbursement 
agreements with THPs to provide direct care services to eligible AI/AN 
Veterans closer to their homes in a culturally sensitive environment. 
In December 2012, VA signed a national reimbursement agreement with 
IHS. Today, the national reimbursement agreement with IHS covers 75 IHS 
sites. There are also 114 individual reimbursement agreements with THPs 
of which 26 are in Alaska and cover AI/AN Veterans and Non-Native 
Veterans.
    From August 2012 through August 2019, VA has reimbursed IHS and 
THPs over $103 million covering approximately 10,645 AI/AN Unique 
Veterans. Of the $103 million, VA has reimbursed approximately $32.2 
million to Alaska THPs for covering an estimated 1,513 AI/AN Unique 
Veterans. Additionally, VA has reimbursed Alaska THPs approximately 
$27.7 million for approximately 4,787 Unique Non-Native Veterans.
    IHS and several THPs have requested that the agreements be expanded 
to cover reimbursements for purchased referred care (PRC) under which 
IHS and THPs can refer AI/AN Veterans to their contracted community 
care. They feel this will enhance care coordination. VA is also looking 
to enhance care coordination with IHS and THP facilities. However, VA 
has the primary responsibility for care provided to Veterans and 
related care coordination. If VA approves PRC for AI/AN Veterans under 
the reimbursement agreements, VA may lose track of that care provided 
to Veterans. As a result, VA is developing a standardized care 
coordination process that will enhance care coordination for AI/AN 
Veterans. Initial steps include establishing an Advisory Board for care 
coordination and inviting Tribal Officials to be members on the Board. 
The Board's main scope will be to implement the standardized care 
coordination process and to improve care coordination between VA and 
IHS/THP sites for the benefit of Veterans.

Conclusion

    The health and well-being of all our nations' Veterans is of the 
utmost importance. We strive to consistently provide high quality care 
to all Veterans and continue to make significant strides in enhancing 
the practice and culture of the Department to be more accessible to our 
Native American Veterans. Working with many diverse, sovereign tribes 
is essential to successfully achieve the goals of the MOU. VA is 
committed to ensuring that our goals align with IHS and that the needs 
of our Native American Veterans are met. I want to thank the Committee 
for hosting this hearing. This concludes my written testimony.
                                 ______
                                 

                  Prepared Statement of Benjamin Smith

    Good morning, Chairwoman Brownley, Ranking Member Dunn, and Members 
of the Subcommittee. I am Benjamin Smith, Deputy Director for 
Intergovernmental Affairs, Indian Health Service (IHS). Thank you for 
the opportunity to testify on native veterans' access to health care. 
The IHS mission is to raise the physical, mental, social, and spiritual 
health of American Indians and Alaska Natives to the highest level. As 
an agency within the Department of Health and Human Services 
(Department), the IHS provides Federal health services to approximately 
2.6 million American Indians and Alaska Natives from 573 federally 
recognized tribes in 37 states, through a network of over 605 health 
care facilities, including hospitals, clinics, health stations, and 
other facility types.
    The American Indian and Alaska Native population experiences health 
and other disparities that disproportionally affect their quality of 
life. American Indians and Alaska Natives have an average life 
expectancy of 5 years shorter than that of the general U.S. population 
and are more likely than people of other races or ethnicities to 
experience social and economic difficulties that may impact their 
health or wellness, such as lower income, lower education levels, and 
higher unemployment.\1\
---------------------------------------------------------------------------
    \1\  IHS Disparities Fact Sheet, April 2018: https://www.ihs.gov/
newsroom/factsheets/disparities/.
---------------------------------------------------------------------------
    As health needs change and new approaches to care emerge, the IHS, 
Department of Veterans Affairs (VA), and their tribal partners will 
continue to combine their expertise, resources, and efforts to help the 
nearly 145,000 American Indian and Alaska Native veterans living in the 
United States.\2\ The IHS and VA's Veterans Health Administration (VHA) 
continue work to provide eligible American Indian and Alaska Native 
veterans with access to care closer to their homes, promote cultural 
competence and quality health care, and focus on increasing care 
coordination, collaboration, and resource-sharing between the agencies. 
Revising the IHS-VA Memorandum of Understanding (MOU) signed in 2010 
will help accomplish this goal. Our plan to complete revisions to the 
MOU and its related performance measures by fall 2020 includes tribal 
consultation with tribal leaders and native veterans, and conferring 
with urban Indian organizations.
---------------------------------------------------------------------------
    \2\  VA Veteran Population Projection Model, 2018: https://
www.va.gov/vetdata/veteran_population.asp.
---------------------------------------------------------------------------
    In the late 1980's, Congress directed the IHS and VA to explore the 
feasibility of entering into an arrangement for sharing of medical 
facilities and services, as required by the Indian Health Care 
Improvement Act (IHCIA).\3\ The results of this collaboration led to 
our initial MOU in 2003. The Patient Protection and Affordable Care Act 
of 2010 permanently reauthorized the IHCIA, and authorized IHS to enter 
into (or expand) arrangements for the sharing of medical facilities and 
services between IHS, Indian tribes, and tribal organizations and the 
VA.\4\ The law also directs the VA to reimburse the IHS, Indian tribes, 
or tribal organizations for the services provided to eligible 
beneficiaries of either Department in the respective facility.
---------------------------------------------------------------------------
    \3\  Indian Health Service and Department of Veterans Affairs 
health facilities and services sharing (25 U.S.C. Sec.  1680f).
    \4\  Sharing arrangements with Federal agencies (25 U.S.C. Sec.  
1645).
---------------------------------------------------------------------------
    Since implementing this provision in 2012, VA has reimbursed over 
$103 million for direct care services provided by IHS and Tribal Health 
Programs (THP), covering approximately 10,645 unique American Indian 
and Alaska Native veterans. Currently, IHS and VA operate under a 
national reimbursement agreement, inclusive of 75 IHS Federal 
facilities. Likewise, the VA has entered into 114 individual 
reimbursement agreements with THP. We are aware of an additional 42 
tribes working with VA's Office of Community Care to enter into a 
reimbursement agreement for direct care services.
    In March 2019, the Government Accountability Office (GAO) released 
a report entitled, VA and Indian Health Service: Actions Needed to 
Strengthen Oversight and Coordination of Health Care for American 
Indian and Alaska Native Veterans (GAO-19-291). In its report, GAO 
recommended that VA and IHS revise the MOU and related performance 
measures to ensure consistency with key attributes of successful 
performance measures, including having measurable targets.

IHS-VA MOU

    In 2003, IHS and VA entered into the initial MOU to improve access 
and health outcomes for American Indian and Alaska Native veterans. To 
maximize resources and deliver an integrated approach that supports the 
health and well-being of the American Indian and Alaska Native veterans 
living in the United States, the IHS and VA signed a revised MOU in 
2010.\5\ The updated MOU built upon a decade of successful 
collaboration and further established mutual goals to advance 
collaboration, coordination and resource-sharing between VA and IHS 
``to improve the health status of American Indian and Alaska Native 
Veterans.'' The IHCIA affirms the goals of the MOU.\6\
---------------------------------------------------------------------------
    \5\  IHS-VA Memorandum of Understanding, October 2010: https://
www.ihs.gov/sites/vaihsmou/themes/responsive2017/display_objects/
documents/VA_IHS_MOU_508c.pdf.
    \6\  See 25 U.S.C. Sec.  1647(a)(2).
---------------------------------------------------------------------------
    Together, the IHS and the VA Veterans Office of Tribal Government 
Relations and Office of Rural Health form a MOU leadership team. The 
leadership team meets quarterly and is responsible for review and 
oversight of the MOU collaboration on care coordination, reimbursement, 
workforce training, and cultural competency that align with the five 
overarching goals to:

        1. Increase access to care and services for American Indian and 
        Alaska Native veterans.

        2. Promote patient-centered collaboration and communication.

        3. Improve health-promotion and disease prevention.

        4. Consult with tribes at the regional and local levels.

        5. Ensure appropriate resources are identified and available.

    In Fiscal Year (FY) 2018, the VA-IHS MOU leadership team conducted 
an in-depth revision of the existing MOU to reflect changes in law, as 
well as, the evolving health care and health information technology 
landscape. The VA-IHS MOU leadership team focused on areas concerning 
health and its social determinants for Native Veterans, including 
prescription services, transportation, housing services, workforce 
training and consultation with tribal communities. In addition, the 
team concentrated on revising the 2010 MOU to reflect progress made to 
date under the new Administration's leadership priorities. Our vision 
of a revised MOU contemplates a more comprehensive and flexible 
structure to support and adopt to the needs of both agencies and the 
veterans they serve well into the future.
    The IHS-VA workgroups completed several MOU-related activities, 
which are now a routine part of each department's operations, 
including:
      Workforce Training: To better coordinate on training and 
recruitment efforts, VA and IHS opened their training resources to each 
organization's staff. In Fiscal Year 2018, they shared 256 online and 
in-person training events focused on mental health, clinical support, 
oral health, diabetes and more.

      Access to Care: Since their inception in Fiscal Year 
2012, the VA-IHS and VA-THP reimbursement agreements provided $103 
million to IHS and THP for care of approximately 10,645 unique American 
Indian and Alaska Native veterans. In Fiscal Year 2018 alone, VA paid 
IHS and THP $20 million for the care of nearly 5,300 enrolled American 
Indian and Alaska Native veterans.

      Access to Medication: The VA Consolidated Mail Outpatient 
Pharmacy Program (CMOP) processed 840,000 prescriptions, an increase of 
17 percent from 2017. Since its inception in Fiscal Year 2010, CMOP 
processed more than 3.6 million prescriptions for VA-IHS patients.

      Housing Assistance: The Tribal Housing and Urban 
Development-Veterans Affairs Supportive Housing (HUD-VASH) program 
increased tribal engagement in Fiscal Year 2018 from 23 to 26 tribes 
that used the program to find homes for Veterans. As a result, the 
program found homes for 130 American Indian and Alaska Native veterans.

    As part of the process for revising the MOU, the IHS and VA 
conducted an initial listening session to solicit tribal input for the 
MOU on May 15, 2019, as part of the National Indian Health Board's 10th 
Annual National Public Health Summit. On September 4, 2019, IHS sent a 
letter to tribal and urban Indian organization leaders to initiate 
tribal consultation and urban confer on the MOU and related performance 
measures. The IHS and VHA held their first in-person session on
    September 16, 2019 in Temecula, California in conjunction with the 
National Indian Health Board's Tribal Health Conference. The IHS and 
VHA continue to deliberate on adjusting consultation and confer plans 
to increase national awareness of the goals of the MOU in order to 
gather meaningful input.
    The IHS remains firmly committed to improving quality and access to 
health care for American Indian and Alaska Native veterans. We 
appreciate all your efforts in helping us provide the best possible 
health care services to the veterans we serve. Thank you, and I am 
happy to answer any questions you may have.

?

      
      
      
      
      
      
      
      
      
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                       Statements for the Record

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


                       Statements for the Record

                              ----------                              


 Prepared Statement of The United South and Eastern Tribes Sovereignty 
                            Protection Fund

    The United South and Eastern Tribes Sovereignty Protection Fund 
(USET SPF) is pleased to provide the House Committee on Veterans' 
Affairs Subcommittee on Health with the following statement for the 
record of the oversight hearing entitled, ``Native Veterans' Access to 
Healthcare.'' USET SPF is appreciative of the Subcommittee's commitment 
to examining and addressing the unique barriers that American Indian 
and Alaska Native (AI/AN) veterans face when seeking the healthcare to 
which they are entitled. Whether delivered through IHS or the VA, AI/AN 
veterans have pre-paid for their healthcare, both through the cession 
of Tribal homelands and the defense of our Nation. We remind the 
Subcommittee of the unique Federal trust responsibility to Tribal 
Nations and urge the Subcommittee and Congress to improve access to 
quality and culturally competent healthcare for AI/AN veterans.
    USET SPF is a non-profit, inter-tribal organization representing 27 
federally recognized Tribal Nations from Texas across to Florida and up 
to Maine \1\. Both individually, as well as collectively through USET 
SPF, our member Tribal Nations work to improve health care services for 
American Indians. Our member Tribal Nations operate in the Nashville 
Area of the Indian Health Service, which contains 36 IHS and Tribal 
health care facilities. Our patients receive health care services both 
directly at IHS facilities, as well as in Tribally operated facilities 
under contracts with IHS pursuant to the Indian Self-Determination and 
Education Assistance Act (ISDEAA), P.L. 93-638.
---------------------------------------------------------------------------
    \1\  USET SPF member Tribal Nations include: Alabama-Coushatta 
Tribe of Texas (TX), Aroostook Band of Micmac Indians (ME),Catawba 
Indian Nation (SC), Cayuga Nation (NY), Chitimacha Tribe of Louisiana 
(LA), Coushatta Tribe of Louisiana (LA), Eastern Band of Cherokee 
Indians (NC), Houlton Band of Maliseet Indians (ME), Jena Band of 
Choctaw Indians (LA), Mashantucket Pequot Indian Tribe (CT), Mashpee 
Wampanoag Tribe (MA), Miccosukee Tribe of Indians of Florida (FL), 
Mississippi Band of Choctaw Indians (MS), Mohegan Tribe of Indians of 
Connecticut (CT), Narragansett Indian Tribe (RI), Oneida Indian Nation 
(NY), Pamunkey Indian Tribe (VA), Passamaquoddy Tribe at Indian 
Township (ME), Passamaquoddy Tribe at Pleasant Point (ME), Penobscot 
Indian Nation (ME), Poarch Band of Creek Indians (AL), Saint Regis 
Mohawk Tribe (NY), Seminole Tribe of Florida (FL), Seneca Nation of 
Indians (NY), Shinnecock Indian Nation (NY), Tunica-Biloxi Tribe of 
Louisiana (LA), and the Wampanoag Tribe of Gay Head (Aquinnah) (MA).
---------------------------------------------------------------------------
    As the Subcommittee is likely aware, AI/AN veterans serve in the 
military at higher rates per capita than any other group in the Nation. 
In addition, the VA has found that AI/AN veterans are more likely to 
have a service-connected disability than non-Indian veterans. AI/AN 
veterans face significant disparities in care when compared to other 
veterans. In the USET SPF region, AI/AN veterans are often faced with 
access to only either the limited services provided by the chronically 
underfunded IHS and Tribally operated facilities or no services at all. 
As the Subcommittee seeks to help improve access to quality healthcare 
for AI/AN veterans, USET SPF requests the exercise of this body's 
oversight functions to ensure VA's actions reflect and uphold the 
Federal trust responsibility and obligations unique to our population. 
This includes working to institute programs that address historical 
trauma, provide culturally competent treatment, and provide greater 
access to behavioral health programs. We provide additional 
recommendations below to the Subcommittee on how to meet the Federal 
trust obligation to AI/AN veterans.

IHS-VA MOU

    USET SPF is appreciative of the Subcommittee's efforts to bring 
together Tribal Nations as well as IHS and the VA to discuss the 2010 
memorandum of understanding (MOU) between the VA and IHS. The intention 
of the MOU was to better facilitate patient care for AI/AN veterans 
across country within both agencies. However a report by the Government 
Accountability Office (GAO) in 2019, ``Actions Needed to Strengthen 
Oversight and Coordination of Health Care for American Indian and 
Alaska Native Veterans'', found that more action is needed to 
strengthen oversight and coordination between IHS and the VA regarding 
implementation of the MOU.

        Preservation of Existing Reimbursement Agreements

        The existing reimbursement agreements within MOU have 
        demonstrated success in facilitating patient care for AI/AN 
        veterans. As both agencies seek to expand the existing MOU or 
        establish new agreements, the VA must continue to uphold and 
        preserve the existing agreements within the MOU which should 
        serve as a template for the VA to enter into similar agreements 
        within the Indian Healthcare System. Specifically, USET SPF 
        underscores the importance of preserving the IHS All-Inclusive 
        rate on reimbursements for outpatient services for AI/AN 
        veterans delivered through IHS. Preservation of the All-
        Inclusive rate within the MOU will ensure critical dollars 
        remain within the Indian Health System to be able to continue 
        support the facilities and services provided to AI/AN veterans.

        Reimbursement Agreements for PRC

        IHS and Tribal health programs are not always able to directly 
        provide AI/AN veterans with all necessary health care services. 
        Like other AI/ANs, many of these veterans receive essential 
        health services through the Purchased/Referred Care (PRC) 
        program, which authorizes the purchase of services from a 
        network of private providers when care is not available at IHS 
        or Tribal facilities. PRC is an integral part of IHS and Tribal 
        health care systems, as it facilitates access to care that the 
        Federal Government has failed in providing the funding to 
        deliver directly.
        However, the VA does not currently reimburse IHS or Tribal 
        programs for services provided using PRC funds. Instead, the VA 
        requires that veterans in need of care return to the VA for a 
        referral instead-an inefficient and time consuming process. 
        USET SPF asserts that this policy fails to prioritize the 
        healthcare necessities of AI/AN veterans by creating additional 
        and unnecessary burdens. The continued lack of coordination of 
        care between the VA and the Indian Healthcare System for the 
        full complement of health care services will only continue to 
        create additional barriers in access to care for our veterans.
        This limitation is further contrary to the plain language of 
        Section 405(c) of the Indian Health Care Improvement Act, which 
        provides for reimbursement ``where services are provided 
        through the [Indian Health] Service, an Indian Tribe, or a 
        Tribal organization ...'' (emphasis added) without limitation 
        to direct services. It is also in conflict with Section 2901(b) 
        of the Affordable Care Act, which specifies that health 
        programs operated by IHS, Tribal Nations, Tribal organizations, 
        and UIOs are payers of last resort. Through these provisions, 
        Congress clearly intended to shield IHS and Tribal PRC dollars 
        from being used to pay for services when other sources of 
        funding are available, including funding from VA. Accordingly, 
        VA should reimburse for all services provided by or through 
        Tribal health programs.

        Ensuring UIOs are Eligible to Bill VA for AI/AN Veterans Care

        Approximately 78 percent of AI/ANs do not live on Tribal 
        reservations. However, the MOU does not include Urban Indian 
        Organizations (UIOs) as eligible to for inclusion in the 
        reimbursement agreements even though UIOs provide critical 
        healthcare services to AI/AN veterans residing in urban areas. 
        While the VA has successfully implemented the MOU for IHS and 
        Tribal facilities, the VA has made a discretionary decision to 
        deem UIOs ineligible for inclusion in the MOU, excluding UIOs 
        from entering into reimbursement agreements. The Federal trust 
        responsibility to provide healthcare to AI/ANs in perpetuity is 
        not limited to where an AI/AN veteran resides. USET SPF 
        encourages the Subcommittee to use its authority to address 
        this discrepancy by ensuring the MOU, including eligibility for 
        reimbursement agreements, is extended to UIOs. We remind the 
        Subcommittee that Congress created the UIO system to honor a 
        Federal trust obligation and assert that UIOs are well-
        positioned to play a vital role in closing the gap in service 
        to AI/AN veterans.

Exempt AI/AN Veterans from VA Copays

    USET SPF highlights that AI/AN veterans are currently subject to 
standard copays for services received within the VA. When healthcare is 
received through IHS or Tribally operated facilities, AI/AN veterans 
are not subject to any cost-sharing. However, AI/AN veterans are 
subject to certain copayments, such as for urgent care services, when 
they are receiving care from VA facilities. Subjecting AI/AN veterans 
to any copayments as a condition of healthcare access is a violation of 
the Federal trust responsibility, which all Federal agencies share in 
equally. Further, AI/AN veterans may be discouraged from seeking 
critical and life-saving healthcare if they are subject to copays for 
certain VA services. We recommend the Subcommittee work with the VA to 
waive any and all copays for AI/AN veterans in a manner that upholds 
current law authorizing IHS as the agency of ``payer of last resort.''

Improved VA-IHS EHR Interoperability

    Since 2018, the VA has been working to replace the agency's current 
electronic health record (EHR) system, VistA, to an off-the-shelf EHR 
known as Cerner Millennium. Since then, IHS has been considering either 
maintaining its current system, the Resource and Patient Management 
System, or implementing a new EHR system altogether-previously, IHS and 
the VA participated in cost sharing for necessary periodic updates. 
While the VA and IHS committed to facilitate the interoperability of 
health information data systems between both agencies to share 
information on common patients, the differences in EHR systems have led 
to challenges with regard to information technology interoperability. 
These challenges have made it difficult for healthcare providers to 
have access important patient information within one another's EHR 
systems. USET SPF underscores to the Subcommittee that interoperability 
between both EHR systems be prioritized as healthcare providers for AI/
AN veterans must have access to real-time, life-saving data.

Conclusion

    There is great potential in the MOU and care coordination between 
IHS and the VA. However, it is critical that VA do more to recognize 
its unique obligations to AI/AN veterans. Left unaddressed, AI/AN 
veterans will continue to face many ongoing challenges when it comes to 
accessing quality healthcare and resulting disparities. The Federal 
trust obligation to provide comprehensive healthcare to Tribal Nations 
and AI/AN veterans exists in perpetuity and is shared by all Federal 
entities including IHS, the VA, as well as the Subcommittee. It is 
incumbent upon the whole of the Federal Government to remove barriers 
in accessing healthcare for AI/AN veterans, and we encourage the 
Subcommittee to work to address these problems, as well as strengthen 
existing partnerships between the VA and the Indian Healthcare System.
                                 ______
                                 

     Prepared Statement of The California Rural Indian Health Board

    My name is Mark LeBeau, CEO for the California Rural Indian Health 
Board, Inc. (CRIHB). CRIHB has a network of 19 Tribal Health Programs 
(THPs) that provide health care support and services to members of 59 
Tribes in California (CA).
    I would like to thank Chairwoman Brownley, Ranking Member Dr. Dunn, 
Representative Takano, and other distinguished members of the Veteran's 
Affairs Committee, Subcommittee on Health for holding this important 
hearing. It is my pleasure to submit a written statement regarding the 
Memorandum of Understanding (MOU) between the U.S. Department of 
Veteran's Affairs (VA) and the Indian Health Service (IHS).
    The Federal Government's trust responsibility to provide health 
care to all American Indians/Alaska Natives (AI/AN) extends across all 
departments and agencies of the United States (U.S.) and includes the 
VA. And yet, although AI/ANs serve in the U.S. military at higher rates 
than any other population, they are underrepresented among Veterans who 
access the services and benefits they have earned. AI/AN Veterans are 
also more likely to lack health insurance and to have a disability, 
service-connected or otherwise, than Veterans of other races.
    In 2003, a MOU was established between the IHS and the VA to 
improve the health status of AI/AN through the coordination and 
resource sharing among VA, IHS, and Tribes. The MOU was expanded in 
2010 to outline mutual goals for VA and IHS collaboration and 
coordination of resources and health care services provided to AI/AN 
Veterans.\1\
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    \1\  Government Accountability Office, Report 19-291 Action Needed 
to Strength Oversight and Coordination of Health Care for American 
Indian and Alaska Native Veterans Page 1 (Washington, DC. March 2019) 
https://www.gao.gov/assets/700/697736.pdf
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    The MOU is an ideal mechanism for the Federal Government to 
preserve and build on the existing excellent relationships that the VA 
has with IHS and THPs.
    For Tribes in the CRIHB membership, it is particularly challenging, 
as CA has no IHS-funded hospitals and is designated as a Purchased/
Referred Care (PRC) Dependent Area. Tribes in the CA service area must 
use their extremely limited PRC funding to cover the costs of placing 
patients in non-IHS/Tribal hospitals and/or buying other specialty care 
services. Before the PRC program provides payment, AI/AN patients must 
exhaust all payer of last resort health care resources.
    According to a 2019 GAO Report, many THPs were denied 
reimbursement, as the VA noted, ``there is no statutory requirement for 
them to include the PRC program in the reimbursement agreements.'' \2\ 
Although CA has the largest population of AI/ANs compared to any other 
State, under the MOU, the reimbursement agreements are not 
grandfathered in.
---------------------------------------------------------------------------
    \2\  Government Accountability Office, Report 19-291 Action Needed 
to Strength Oversight and Coordination of Health Care for American 
Indian and Alaska Native Veterans Page 1 (Washington, DC. March 2019) 
https://www.gao.gov/assets/700/697736.pdf Pg 23.
---------------------------------------------------------------------------
    Having said that, THPs have and continue to utilize their resources 
to establish reimbursement agreements with the VA for direct services 
to AI/AN veterans.
    Many of the CA AI/AN Veterans live in rural areas and seek out the 
high-quality, culturally competent care at their THPs. As it currently 
states in the MOU between IHS and the VA, THPs cannot be reimbursed for 
providing services paid for with PRC funds. There are a few challenges 
in seeking treatment at a VA hospital that may pose several barriers 
for CA AI/AN Veterans.

      Access to Care: Transportation is extremely difficult, if 
available. Many Tribes are located great distances from VA facilities. 
Getting to and from appointments can take up 2 days and increases the 
patient's discomfort.

      Duplication of Services: Many AI/AN Veterans are referred 
to specialty care upon receiving initial assessment services by the 
physician at their local THP. Upon arriving to the VA hospital for that 
specialty care, the AI/AN Veterans are often required to have an 
additional assessment conducted by the VA physician, resulting in a 
duplication of services.

      Wait Times: The VA is known for its challenging wait 
times. This often requires the patients to spend extensive time waiting 
to be seen by a provider.

      Cultural barriers: AI/AN Veterans raise concerns 
regarding being misdiagnosed by practitioners who may not know the 
health history of the AI/AN Veteran.

      Registration: Several AI/AN Veterans do not register 
because of the complexity of the application process.

      War designation: The VA requires patients to specify if 
they are post-9/11 or non-post-9/11 Veterans. This is viewed as 
downplaying Veterans of other wars and they may be less apt to seek 
care.

      Behavioral Health: At times, the VA has not provided 
adequate Mental Health and Counseling Services for AI/AN Veterans.

      Lack of Coordination of Care: AI/AN Veterans cannot 
choose their specialist for specialty care services.

    Our national interest of serving AI/AN Veterans will be best 
achieved when we extend the collaborative arrangements already agreed 
to by the inherent Federal trust responsibility. In order to improve 
care to AI/AN Veterans, CRIHB strongly recommends the VA support:

      The establishment of Reimbursement Agreements with THPs 
through the authority granted to Tribes under the Indian Self-
Determination and Education Assistance Act, resulting in an increase to 
access to care.

      IHS and Tribal providers to be reimbursed for services 
provided under the PRC program.

      Exempting all AI/AN Veterans from copays and deductibles 
in accordance with the Federal trust responsibility.

      Legislation authorizing a Tribal Advisory Committee at 
the VA.

      THP reimbursement of non-AI/AN Veterans as referenced in 
the Indian Health Care Improvement Act Section 405 (c) \3\

    \3\  Indian Health Care Improvement Act (1976) https://
legcounsel.house.gov/Comps/
Indian%20Health%20Care%20Improvement%20Act.pdf
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                                 ______
                                 

Prepared Statement of The California Consortium For Urban Indian Health

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  Prepared Statement of The Sault Ste. Marie Tribe Of Chippewa Indians

    Dr. Aaron Payment, n'dizhnikaaz. Sault Ste. Marie Tribe of Chippewa 
Indians ndoo-debendaagoz. Kina Baawaa'ting Anishinaabek Omaa go nda 
Onji-kida. I am Dr. Aaron Payment. As the elected Chairman of the Sault 
Ste. Marie Tribe of Chippewa Indians, I am speaking on behalf of my 
Tribe. With over 45,000 members, my Tribe is the largest Tribe east of 
the Mississippi River. My testimony today will focus on the barriers 
American Indian and Alaska Native (AI/AN) veterans face when seeking 
access to quality, culturally competent care from the Veterans 
Administration (VA) and from Tribal health systems. It will also 
recommend solutions.
    It is important to begin this testimony with the statement about 
Tribal sovereignty and treaty obligations. Tribes are governments, pre-
dating the United States. The U.S. Constitution recognizes Tribes as 
``distinct governments,'' along with foreign nations and the several 
States. The U.S. Supreme Court has described their status as ``domestic 
dependent nations'' in which Tribal governments have retained nation 
status and inherent powers of self-government, but are subservient to 
U.S. Federal Government powers. The United States entered into more 
than 370 treaties with the Tribes. Within these treaties, Tribal 
governments retained their sovereignty rights, and ceded millions of 
acres of land and natural resources to the Federal Government in 
exchange for peace. The specifics of each treaty are unique, but for 
purposes of this testimony, it is important to recognize that they all 
contained health and general welfare provisions.
    It is also important to begin with a statement regarding the 
Federal trust responsibility. As noted by the Department of Interior, 
the Federal trust responsibility is a legal obligation under which the 
United States ``has charged itself with moral obligations of the 
highest responsibility and trust'' toward Indian Tribes (Seminole 
Nation v. United States, 1942). This obligation was first discussed by 
Chief Justice John Marshall in Cherokee Nation v. Georgia (1831). Over 
the years, the trust doctrine has been at the center of numerous other 
Supreme Court cases, thus making it one of the most important 
principles in Federal Indian law. The Federal Indian trust 
responsibility is also a legally enforceable fiduciary obligation on 
the part of the United States to protect tribal treaty rights, lands, 
assets, and resources, as well as a duty to carry out the mandates of 
Federal law with respect to American Indian and Alaska Native tribes 
and villages.

American Indian and Alaska Native Veterans:

    American Indians and Alaska Natives serve in the United States 
Armed Forces at higher rates than any other ethnicity. Despite this, 
they are significantly underrepresented among Veterans who access the 
services and benefits they have earned. Often, this is due to barriers 
created by distance, poverty, mental health symptoms, historical 
mistrust, and a lack of culturally competent providers.\1\ Native 
Veterans are also less likely than Veterans of other races to have 
health insurance and more likely to have a disability.
---------------------------------------------------------------------------
    \1\  National Indian Health Board. 2019.
---------------------------------------------------------------------------
    To combat these problems, the VA has entered into memoranda with 
the Department of Health and Human Services (HHS), Indian Health 
Service (IHS) and Tribal health organizations. Overall, the use of 
Memorandum of Understanding (MOUs) and Agreement (MOAs) between the IHS 
and Tribal providers have been an excellent method of ensuring health 
care delivery to AI/AN Veterans. These memoranda created scaffolding 
that enable Veteran health care services reach American Indian and 
Alaska Native Veterans that have earned them. Today, however, there is 
a need to improve upon existing memoranda.

Barriers and Recommendations:

      All Native Veterans should be exempted from copays and 
deductibles at the VA in accordance with the Federal trust 
responsibility.

    The health and general welfare provisions within the Treaties, as 
well as the Federal trust responsibility to the Tribes, obligate the 
Federal Government to provide health care treatment to Tribal members. 
This is why American Indians and Alaska Natives do not owe copays or 
deductibles for services received at Indian health facilities. 
Similarly, it is the reason the Patient Protection and Affordable Care 
Act exempts AI/ANs from various cost-share requirements. \2\ The 
Federal trust responsibility and the US Treaty obligations apply to all 
aspects of the Federal Government, including the VA. For this reason, 
my Tribe recommends Native Veterans be exempted from copays and 
deductibles at the Veterans Administration.
---------------------------------------------------------------------------
    \2\  42 U.S. Code 18071(d).
---------------------------------------------------------------------------
      Allow IHS and Tribal providers to be reimbursed by the VA 
for services provided under the purchased/referred care program.

    The VA currently reimburses IHS and THPs for primary care under the 
IHS/VA Memorandum of Understanding (MOU), but the VA has not provided 
reimbursement for specialty and referral care provided by IHS/THPs. 
This creates care coordination issues and burdensome requirements for 
the AI/AN veteran patient. For example, this is what typically happens 
to Native Veterans seeking treatment in the First District of Michigan: 
If a Native Veteran goes to a Tribal Health Services facility in Sault 
Ste. Marie or Manistique for service and needs a referral, the same 
patient must be seen within the VA system before a referral can be 
secured. This means that the patient will need to go to the Veterans 
Health Administration medical center service this area, located in Iron 
Mountain, which involves 3-5 hours of travel. Thus, the VA is paying 
for the same services twice, first for those primary care services 
provided to the veteran in the Tribal health program facilities (same, 
if the Native Veteran started at an IHS facility) and then again when 
the patient goes back to the VA for the same primary care service to 
receive a VA referral. This is a not a good use of Federal funding, nor 
is it navigable for veterans. In order to provide the care that AI/AN 
veteran's need, many Tribal Health Programs are treating veterans or 
referring them out for specialty care and paying for it themselves so 
that veterans can be treated in a timely and competent manner. For 
those veterans that do go back to the VA for referrals, there is often 
delayed treatment and a significant different standard of care that is 
provided. Therefore we recommend that the IHS and Tribal providers 
should be exempted from any value-based reimbursement scheme for other 
VA providers.

      The VA should reimburse Urban Indian Health Programs.

    The 2010 reimbursement MOU has been extended and been implemented 
for IHS and Tribal Providers, however it has not been implemented for 
Urban Indian Health Programs.\3\ This needs to be addressed. My Tribe 
strongly recommends utilizing Urban Indian Health Programs within the 
parameters of the MOU. AI/AN Veterans often prefer Native health care 
providers for reasons related to performance, cultural competency, and/
or the availability of non-health care-related services, and as a 
result, are more likely to receive care from these institutions. Urban 
Indian Health Programs provide these services, off Tribal lands and 
within urban settings. AI/veterans can obtain their health care in 
culturally appropriate ways and Urban Indian Health Programs can assist 
the Department of Veterans Affairs meet its demand for services.
---------------------------------------------------------------------------
    \3\  Fiscal Year 2021 Budget Recommendations. The National Tribal 
Budget Formulation Workgroup's Recommendations on the Indian Health 
Service Fiscal Year 2021 Budget. April 2019. Page 29.

      Ensure Health IT and Telehealth upgrades at IHS are made 
in tandem with the VA, and ensure Tribal Health Programs have adequate 
---------------------------------------------------------------------------
access, as well.

    As both the Indian Health Service and the Veterans Administration 
are updating their Health Information Technology systems, my Tribe 
recommends Congress require the IHS and the VA work closely together to 
coordinate on upgrades for the Electronic Health Record systems at the 
respective agencies, and make upgrades in tandem.
    The IHS, the VA, and the DoD should be encouraged to ensure that 
the IT systems continue to operate together. My Tribe recommends 
Congress do this, via adequate appropriations. We recommend the VA and 
the HIS prioritize interoperability between the IHS Health IT system 
and the VA.
    My Tribe recommends that the IHS and the VA work to assist Tribal 
health programs in obtaining and adopting systems that are 
interoperable with the IHS/VA systems.

      Create a Tribal Advisory Committee for the VA.

    AI/AN Veterans experience multiple barriers to receiving treatment 
from the VA. Creation of a Tribal Advisory Committee (TAC) for the VA 
will work to ensure that the VA fulfills its trust responsibility to 
AI/AN Veterans in a culturally competent manner.
    Often, perhaps unknowingly, the VA acts in a manner that negatively 
impacts Native Veterans. A TAC can educate VA officials and work to 
ensure that policy changes do not adversely affect the Indian health 
care system. It can provide insight and assistance to maintaining and 
strengthening the implementation of the Memorandum of Understanding 
Agreements between the VA, the IHS, and Tribal Health Programs. The TAC 
can provide critical assistance to the VA in improving its outreach and 
communication to Native Veterans. A fully functioning TAC can provide 
VA leadership with information and insight into Indian Country, the 
Federal trust responsibility, and Tribal sovereignty; assist in the 
identification and implementation of policies that meet the Federal 
Government's obligations to the Tribes, and improve the government-to-
government relationship between the VA and the Tribal Nations.
    The ``Department of VA Tribal Advisory Committee Act of 2019'' 
currently stands before the House Committee on Veterans' Affairs (HR 
2791) and its Senate counter-part (S 524) is before the Senate 
Committee on Veterans Affairs. Designed to create a VA Tribal Advisory 
Committee, both bills have strong bi-partisan support. My Tribe 
strongly supports this legislation.
    If you have any questions or need additional information, please do 
not hesitate to contact me or the Sault Ste. Marie Tribe of Chippewa 
Indians Legislative Director, Mike McCoy at [email protected].
                                 ______
                                 

          Prepared Statement of The Standing Rock Sioux Tribe
          
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                 Additional Submissions for the Record

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                       Submissions for the Record

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           Treaties Submitted by The Honorable Ruben Gallego
           
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]           
           


     U.S. Department of Veterans Affairs and Indian Health Service 
       Memorandum of Understanding Annual Report Fiscal Year 2018
       
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    


       Department of Veterans Affairs Tribal Consultation Policy
       
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]       

Memorandum of Understanding Between the Department of Veterans Affairs 
                  (VA) and Indian Health Service (IHS)
                  
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]                  


  Indian Health Service and Tribal Health Program Monthly Report-June 
                                  2019
                                  
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