[Senate Hearing 116-80]
[From the U.S. Government Publishing Office]


                                                      S. Hrg. 116-80

  THE PRESIDENT'S FISCAL YEAR 2020 BUDGET REQUEST FOR INDIAN PROGRAMS

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

                                HEARING

                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 8, 2019

                               __________

         Printed for the use of the Committee on Indian Affairs

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                      
                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
38-137 PDF                  WASHINGTON : 2019                     
          
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                      COMMITTEE ON INDIAN AFFAIRS

                  JOHN HOEVEN, North Dakota, Chairman
                  TOM UDALL, New Mexico, Vice Chairman
JOHN BARRASSO, Wyoming               MARIA CANTWELL, Washington
LISA MURKOWSKI, Alaska               JON TESTER, Montana,
JAMES LANKFORD, Oklahoma             BRIAN SCHATZ, Hawaii
STEVE DAINES, Montana                CATHERINE CORTEZ MASTO, Nevada
MARTHA McSALLY, Arizona              TINA SMITH, Minnesota
JERRY MORAN, Kansas
     T. Michael Andrews, Majority Staff Director and Chief Counsel
       Jennifer Romero, Minority Staff Director and Chief Counsel
                            
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on May 8, 2019......................................     1
Statement of Senator Barrasso....................................    28
Statement of Senator Cantwell....................................    39
Statement of Senator Cortez Masto................................    30
Statement of Senator Daines......................................    40
Statement of Senator Hoeven......................................     1
Statement of Senator McSally.....................................    35
Statement of Senator Moran.......................................    32
Statement of Senator Smith.......................................    34
Statement of Senator Tester......................................    37
Statement of Senator Udall.......................................    27

                               Witnesses

Buchanan, Rear Admiral Chris, Deputy Director, Indian Health 
  Service, U.S. Department of Health and Human Services..........     7
    Prepared statement...........................................     9
Joseph Jr., Hon. Andrew, Portland Area Representative, National 
  Indian Health Board............................................    20
    Prepared statement...........................................    21
Keel, Hon. Jefferson, President, National Congress of American 
  Indians........................................................    11
    Prepared statement...........................................    13
Sweeney, Hon. Tara Mac Lean, Assistant Secretary, Indian Affairs, 
  U.S. Department of the Interior................................     2
    Prepared statement...........................................     4

                                Appendix

American Indian/Alaska Native Health Partners, prepared statement    51
National Indian Health Board (NIHB), prepared statement..........    54
Response to written questions submitted by Hon. Catherine Cortez 
  Masto to Hon. Tara Mac Lean Sweeney............................    82
Response to written questions submitted by Hon. Martha McSally to 
  Hon. Tara Mac Lean Sweeney.....................................    69
Response to written questions submitted by Hon. Tom Udall to:
    Hon. Andrew Joseph Jr........................................    65
    Hon. Tara Mac Lean Sweeney...................................    71
United South and Eastern Tribes Sovereignty Protection Fund (USET 
  SPF), prepared statement.......................................    60

 
  THE PRESIDENT'S FISCAL YEAR 2020 BUDGET REQUEST FOR INDIAN PROGRAMS

                              ----------                              


                         WEDNESDAY, MAY 8, 2019


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:30 p.m. in room 
628, Dirksen Senate Office Building, Hon. John Hoeven, 
Chairman of the Committee, presiding.

            OPENING STATEMENT OF HON. JOHN HOEVEN, 
                 U.S. SENATOR FROM NORTH DAKOTA

    The Chairman. We will call the hearing to order.
    We do have votes going on right now. We will get started. 
Then Vice Chairman Udall will be back. He is going to stay and 
do the first two votes. Then I will go vote. So we will work it 
out. We are sorry for the inconvenience but we really 
appreciate all of you being here.
    With that, I will call the hearing to order. Today, the 
Committee will receive testimony on the President's fiscal year 
2020 budget request for Indian programs. On March 11th, 2019, 
Congress received the President's budget request for fiscal 
year 2020. Today's hearing provides the Committee an 
opportunity to examine the Administration's request for funding 
Indian programs.
    The President's budget request provides a look at the 
Administration's priorities for the following fiscal year and 
beyond. Through varying initiatives and programs, the 
Administration has created over 5 million new jobs, decreased 
the unemployment rate, and made it easier for tribes to 
participate in a renewed economy.
    While making programs more effective and efficient, we must 
consider the President's budget request priorities and its 
effect on the fiscal status of our government. During the past 
few weeks, Committee staff have met with various Executive 
Branch agencies and tribal organizations on the budgetary 
priorities for Indian programs.
    Understanding that financial adjustments are to be made in 
our annual budget request, we can't forget that Indian programs 
require appropriate funding to operate and maintain services to 
the millions of American Indian, Alaska Native and Native 
Hawaiians living in the United States.
    We also can't forget that many buildings, facilities and 
roads are in dire need of maintenance, repair or replacement. 
For instance, the President's budget request calls on Congress 
to set aside money for addressing the deferred maintenance of 
Bureau of Indian Education schools. The Department of the 
Interior estimates the BIA schools deferred maintenance backlog 
at $634 million.
    Although there is much work needed to fulfill our treaty 
and trust responsibility to Indian tribes, progress has been 
made in addressing health care needs for American Indian and 
Alaska Natives. For example, through the Special Diabetes 
Program for Indians implementation, American Indian and Alaska 
Natives have seen a 54 percent decrease in the prevalence of 
end stage renal disease.
    Additionally, previous budget requests include this year's 
request of increased funding for maintenance and infrastructure 
for IHS buildings, facilities and clinics. These funds are the 
primary source for providing maintenance, repair and 
improvement of heath care facilities. Adequate funding is 
important, since the average age of an IHS facility is 37 years 
old.
    Today's hearing is the first step in the long process of 
appropriating money for these vital Indian programs. We will 
hear from two Federal witnesses and two tribal organizations 
today regarding the President's budget request for fiscal year 
2020 and how these Indian programs are upholding the trust and 
treaty responsibility to Indian tribes. One notable department 
is not here today, but the Department of Justice will be here 
next week to give testimony on their budget request.
    At this point, I would normally turn to Vice Chairman Udall 
for his opening statement. He will provide that when he returns 
from the votes.
    I would ask, Senator Smith, did you have any opening 
statement to make?
    Senator Smith. No.
    The Chairman. Then we will proceed to our witnesses today.
    We will begin with the Honorable Tara Mac Lean Sweeney. She 
is Assistant Secretary, Indian Affairs, U.S. Department of the 
Interior. We will also hear from Rear Admiral Chris Buchanan, 
Deputy Director of Indian Health Service, U.S. Department of 
Health and Human Services. Then the Honorable Jefferson Keel, 
President, National Congress of American Indians, and the 
Honorable Andy Joseph Jr., Portland Area Representative, 
National Indian Health Board.
    I want to remind witnesses your full written testimony will 
be made a part of the official record. So if you would please 
keep your statements to five minutes so there is time for 
questions.
    We will begin with Secretary Sweeney.

 STATEMENT OF HON. TARA MAC LEAN SWEENEY, ASSISTANT SECRETARY, 
            INDIAN AFFAIRS, U.S. DEPARTMENT OF THE 
                            INTERIOR

    Ms. Sweeney. Chairman Hoeven and members of the Committee, 
my name is Tara Mac Lean Sweeney. I am the Assistant Secretary 
of Indian Affairs at the U.S. Department of the Interior. Thank 
you for this opportunity to testify.
    During my service at Interior, I have focused on three 
critical components to improve economic development and quality 
of life in and for Indian Country. First, analyzing the current 
state of operations and executing administrative adjustments to 
improve service delivery. It is the responsibility of Indian 
Affairs to deliver efficient and effective services to Indian 
Country, as we continue to work to meet our trust 
responsibilities and treaty obligations.
    Second, addressing the social challenges in our 
communities, specifically building a strategy to address our 
Native American-focused cold cases, violent crimes and missing 
and murdered Native people.
    Finally, taking a proactive approach to building an 
economic road map for development and growth within Indian 
Country. This must be done in partnership with our tribal 
leadership, our tribal enterprises, Alaska village and regional 
corporations, Native-owned financial institutions, the 
financial sector and Congress.
    This year will be the first year we have separate budget 
requests for both BIA and BIE. This change increases 
transparency, accountability and autonomy of BIE and separates 
congressional justification for each of the two organizations. 
The net effects will be that BIE will gradually assume direct 
responsibility for acquisition, safety and facilities 
management. These funds will support implementation of a model 
that will allow Indian Affairs to leverage financing to address 
infrastructure needs more quickly and foster economic 
development in Indian Country.
    The 2020 President's budget for Indian Affairs is $2.8 
billion. This budget supports the Administration's commitment 
to empower tribal communities and help Interior maintain a 
strong and productive government-to-government relationship 
with tribes.
    The request for BIE is $936.3 million. This total provides 
$867.4 million for operations and it includes $726.8 million to 
provide base funding for the 169 BIE schools and 14 dormitories 
providing educational services to 47,000 individual students in 
23 States.
    This budget proposes $20.9 million for early child and 
family development and $14.3 million for education program 
enhancements. The budget continues to promote educational self-
determination for tribal communities and requests $81.5 million 
to fully fund tribal grant support costs for tribes who choose 
to operate BIE-funded schools.
    The request preserves funding for core services and 
reflects the full transition of Haskell and SIPI to forward 
funding. The request also includes $42.6 million for education 
management. Funding includes $32.3 million for education 
program management, an increase of $7.3 million which will 
enable BIE to build much-needed capacity in acquisition, school 
safety and repairs, performance tracking and technical 
assistance to the field.
    In addition to the support through the Administration's 
public lands infrastructure legislative proposal, the 2020 
budget includes $68.9 million in annual funding for education 
construction focused on facility improvement and repair. 
Available funding from prior years will complete school 
construction on the 2004 school replacement list and continued 
design build construction for schools on the 2016 replacement 
list.
    The 2020 budget for BIA and AS-IA is $1.9 billion. Compared 
to the 2019 proposed budget, you will find that this is an 
increase of $391 million demonstrating the President's support 
for Indian Affairs. The request prioritizes base funding for 
tribes and fully funds contract support costs at $285.9 million 
and provides an additional $2.5 million for law enforcement 
priorities such as opioids. The request meets our legal 
obligations for enacted water settlements by including $45.6 
million.
    The 2020 budget includes $326 million for programs that 
support tribal governments including $178.9 million for self-
governance compacts and $75.3 million to support consolidated 
tribal government programs. The budget also includes $34.9 
million for road maintenance to support pavement and gravel 
maintenance, remedial work on roads, bridges and snow and ice 
control.
    I am committed to empowering Indian Country in utilizing 
taxpayer dollars to support this goal as efficiently and 
effectively as possible. I look forward to working with this 
Committee, Congress and the Administration to accomplish these 
goals.
    Thank you.
    [The prepared statement of Ms. Sweeney follows:]

Prepared Statement of Hon. Tara Mac Lean Sweeney, Assistant Secretary, 
            Indian Affairs, U.S. Department of the Interior
    Good afternoon Chairman Hoeven, Vice Chairman Udall, and Members of 
the Committee, Thank you for the opportunity to testify on behalf of 
the Department of the Interior (DOI) regarding the President's Budget 
Request for Fiscal Year 2020.
    The President's 2020 budget for Indian Affairs is $2.8 billion--
this total includes funding for BIA, BIE and the Office of the 
Assistant Secretary for Indian Affairs (AS-IA). As the Assistant 
Secretary--Indian Affairs, I oversee the program offices within the 
Bureau of Indian Affairs (BIA), the Bureau of Indian Education (BIE), 
and additional programmatic functions within the immediate AS-IA 
Office. I also wanted to acknowledge that during the 2019 appropriation 
process, DOI requested and Congress approved the transfer of the Office 
of the Special Trustee for American Indians from the Office of the 
Secretary to the Office of the Assistant Secretary--Indian Affairs. 
This re-alignment within the Department will enhance planning and 
coordination of policies and services related to Indian Country and I 
look forward to making this transition a smooth one.
    Indian Affairs is the principal Executive Branch component 
entrusted to fulfill Federal trust and treaty responsibilities to the 
573 federally recognized Indian Tribes. In doing so, our programs 
directly serve the nearly two million individual American Indians and 
Alaska Natives in the United States--including trust asset management, 
social service programs, and law enforcement services. Indian Affairs 
is a principal funding source for Tribes and tribal entities executing 
self-determination contracts and self-governance compacts under the 
Indian Self-Determination and Education Assistance Act. Our programs 
are a core component of community development and social provision in 
Indian Country. We strive to implement our programs in a manner that 
respects tribal sovereignty and fosters strong government-to-government 
relations.
    Our leadership at the Bureau of Indian Education works tirelessly 
to provide quality education to all native youth. The BIE manages a 
school system which includes 169 elementary and secondary schools and 
14 dormitories. Our Indian education program delivers education 
services to 47,000 students across 23 States. Additionally, the BIE 
also operates two post-secondary schools and administers grants for 31 
post-secondary institutions. Our BIE Director, and supporting staff, 
are all committed public servants dedicated to delivering the best 
education possible, in a culturally relevant manner, to our tribal 
students.
    One significant highlight of our 2020 budget is the separate 
requests submitted for BIA and BIE. This is the first time each bureau 
has had a separate budget submissions. Our rationale for doing so is to 
address the cumbersome processes by which simple, yet critical, 
operations are implemented within the BIE school system. Early in my 
tenure as the Assistant Secretary--Indian Affairs, my staff and I 
determined the BIE has not been sufficiently empowered to manage its 
own operation and maintenance functions. This is a key contributing 
factor to our native students experiencing subpar education and 
unacceptable school conditions. In many instances, simple procurement 
or service processes required direct action from every major component 
of Indian Affairs'--the BIE, BIA, and the AS-IA Office. This budget 
separation will empower both the BIE and the BIA to more directly, and 
independently, focus on their respective core missions while avoiding 
redundancy and duplication.
    I know many of these issues are familiar to the committee and the 
resulting operational difficulties have been identified many times by 
Congressional committees and the Government Accountability Office. To 
that end, I am committed to working with you, Chairman Hoeven and Vice-
Chairman Udall, along with the rest of the Committee to advance our 
shared priorities for Indian Country, and to improve education and 
service delivery to our native students, tribal governments, and 
individual tribal citizens nationwide.
Bureau of Indian Education
    The FY 2020 budget request for the Bureau of Indian Education 
programs within the Department totals $936.3 million.
Operation of Indian Education Programs
    The 2020 budget provides $867.4 million for Operation of Indian 
Education Programs. This newly created account includes existing 
programs formerly in the Operation of Indian Programs BIE activity. In 
2020, priority is given to programs that directly support classroom 
operations at BIE-funded elementary and secondary schools and post-
secondary tribal colleges and universities, consistent with BIE's 
Strategic Direction.
    Elementary and Secondary Programs--The request includes $726.8 
million to support base funding for the 169 BIE elementary and 
secondary schools and 14 dormitories providing educational services to 
47,000 individual students in 23 States. The budget proposes $20.9 
million for Early Child and Family Development and $14.3 million for 
Education Program Enhancements. The budget continues to promote 
educational self-determination for tribal communities and requests 
$81.5 million to fully fund the calculated Tribal Grant Support Costs 
need for Tribes that choose to operate BIE-funded schools.
    Post-Secondary Programs--The request includes $98.0 million for 
Post-Secondary programs to operate two post-secondary institutions, 
administer grants to 29 tribal colleges and universities, and fund two 
tribal technical colleges. The request preserves funding for core 
services, and reflects the full transition of Haskell and SIPI funding 
to forward funding.
    Education Management--The request includes $42.6 million for 
education management. Funding includes $32.3 million for Education 
Program Management (EPM), an increase of $7.3 million, which will 
enable BIE to build much-needed capacity in acquisition, school safety 
and repairs, performance tracking, and technical support to the field. 
The request also includes $10.3 million for information technology to 
support the wide area network infrastructure and other systems used by 
BIE-funded schools.
    Tribal Priority Allocations--The 2020 budget proposes Tribal 
Priority Allocation funding of $16.1 million.
Education Construction
    In addition to support from the Administration's Public Lands 
Infrastructure Fund legislative proposal, the President's budget 
includes $68.9 million in annual funding for Education Construction. 
The budget includes $62.8 million for facility improvement and repair 
at existing schools. Available funding from prior years will complete 
school construction on the 2004 school replacement list and continue 
design/build construction for schools on the 2016 school replacement 
list. The budget includes $5.1 million for BIE employee housing repair 
and new funding of $1.0 million for employee housing replacement. In 
2020, BIE will continue to manage new construction activities through a 
reimbursable agreement with Indian Affairs.
Fixed Costs
    Fixed costs of $1.9 million are fully funded in this request.
    This FY 2020 budget supports classroom instruction, and prioritizes 
programs serving the broadest number of students. The 2020 budget 
request aligns resources with management responsibilities, addresses 
recommendations of the Government Accountability Office and the DOI 
Office of the Inspector General and will provide BIE the autonomy and 
accountability needed to improve service delivery to, and by, BIE-
funded schools.
Bureau of Indian Affairs
    The mission of the Bureau of Indian Affairs is to enhance the 
quality of life, promote economic opportunity, and carry out the 
Federal responsibility to protect and improve the trust assets of 
American Indians, Indian Tribes, and Alaska Natives.
    The request for BIA and the AS-IA Office is $1.9 billion in current 
appropriations. Within this total, the budget prioritizes base funding 
for Tribes and provides full funding for estimated Contract Support 
Costs, a total of $285.9 million; an additional $2.5 million for law 
enforcement priorities such as combating opioids; and $45.6 million for 
water settlements to enable the Department to meet Federal 
responsibilities outlined in enacted settlement with Indian Tribes.
    Operation of Indian Programs--The 2020 budget for the Operation of 
Indian Programs account is $1.5 billion. In general, the 2020 budget 
gives priority to base program funding.
Promote Tribal Self-Determination
    The 2020 budget provides $326.0 million for programs that support 
tribal government activities. Within this, the budget includes $178.9 
million for self-governance compact activities for self-governance 
Tribes and $75.3 million to support Consolidated Tribal Government 
Programs for Tribes operating under P.L. 93-638 contracts.
    New Tribes Funding--The budget includes $1.3 million to continue 
Federal support for six Virginia Tribes federally recognized by an act 
of Congress in January 2018.
    Contract Support Costs--The 2020 funding for Contract Support Costs 
is $285.9 million. The request fully supports estimated needs assuming 
BIA program funding at the 2020 request. The President's budget 
continues to request funding for CSC in a separate indefinite current 
account to ensure full funding for this priority.
Protect Indian Country
    Public Safety Programs--The 2020 budget includes $409.2 million for 
Public Safety and Justice Activities, of which $376.7 million directly 
supports 191 law enforcement programs and 96 corrections programs run 
both by Tribes and direct services. The budget includes $30.9 million 
for Tribal Courts and $22.3 million for Tribal Justice Support 
programs, which include Violence Against Women Act training and 
implementation strategies critical to the protection of women in Indian 
communities.
    Specifically with regards to the opioid epidemic plaguing out 
communities, the President has made it a focal point of his 
Administration to address and combat this crisis. This request also 
includes $10.0 million, a $2.5 million increase, to address the opioid 
crisis, which has been particularly devastating in Indian Country. This 
initiative expands BIA capacity to address the increase in drug-related 
activities through interdiction programs to reduce drug use, 
distribution, and drug-related crime. The initiative will also support 
the Office of Justice Services participation in intra- and inter-agency 
initiatives. Targeting opioid and substance abuse prevention efforts 
will, enable BIA to better align, leverage, and coordinate with other 
Federal efforts and resources to combat the opioid crisis.
Support Indian Communities
    Support Economic Opportunities--In support of efforts on domestic 
energy dominance and economic development, the 2020 budget funds the 
Community and Economic Development activity at $44.4 million and 
features investments in Indian energy activities, including development 
on tribal lands. Income from energy and minerals production is the 
largest source of revenue generated from natural resources on trust 
lands, with energy and mineral revenue of over $1.0 billion paid to 
tribal governments and individual mineral rights owners in 2018.
    Human Services Programs--Sustaining families is critical to 
fostering thriving Indian communities. The Human Services activity 
includes $143.0 million for programs providing social services which 
includes $74.7 million for Welfare Assistance, and $64.9 million for 
Social Services and Indian Child Welfare Act protections.
Manage Trust Resources and Lands
    Natural Resource Programs--The 2020 budget proposes $184.1 million 
for natural resource management programs which include agriculture, 
forestry, water resources, and fish, wildlife and parks activities.
    The budget includes $54.8 million for BIA Forestry programs 
supporting the Administration's active forest management reforms 
through management of Indian forest lands by 300 Tribes across 18.7 
million acres. The funding supports the development, maintenance, and 
enhancement of forest resources in accordance with sustained yield 
principles included in forest management plans. The budget also 
includes $14.5 million for Fish, Wildlife and Parks to support tribal 
activities in fisheries operations and maintenance, outdoor recreation, 
public access, and conservation enforcement and $10.6 million for Water 
Resources management activities. The budget includes $14.0 million for 
the Irrigation Operation and Maintenance program to support operation, 
maintenance, and rehabilitation of Indian irrigation project 
infrastructure, including the Navajo Indian Irrigation Project; 
payments required by established legal directives; reimbursement to the 
Bureau of Reclamation for water storage costs; and continued delivery 
of water by and to irrigation systems.
    Real Estate Services Programs--To meet our fiduciary trust 
responsibilities, the 2020 budget proposes $122.0 million for real 
estate services programs. The budget supports the processing of Indian 
trust-related documents such as land title and records and geospatial 
data to support land and water resource use, energy development, and 
protection and restoration of ecosystems and important lands. The 
budget includes $12.7 million for probate services to determine 
ownership of Indian trust assets essential to economic development and 
accurate payments to beneficiaries.
Land and Water Claims Settlements
    The 2020 budget proposes $45.6 million to meet Indian settlement 
commitments. Settlements resolve tribal land and water rights claims 
and ensure Tribes have access to land and water to meet domestic, 
economic, and cultural needs. Many of the infrastructure projects 
supported by these agreements improve the health and well-being of 
tribal members, preserve existing communities, and, over the long-term, 
bring the potential for jobs and economic development.
Infrastructure Investment
    Construction--The Indian Affairs 2020 budget proposes $58.5 million 
for Construction activities, including funding for deferred maintenance 
projects for public safety and justice facilities, resources management 
infrastructure such as irrigation projects and dams, and regional and 
agency offices serving tribal programs and operations in Indian 
Country. Beginning in 2020, funding for Education Construction will be 
requested in a separate account established in the Bureau of Indian 
Education. The budget proposes $17.8 million for Safety of Dams 
projects, $13.1 million for irrigation projects, and $12.0 million for 
construction related to telecommunications and regional and agency 
offices serving tribal programs and operations in Indian Country.
    Indian Country Roads--The BIA maintains nearly 29,000 miles of 
paved, gravel, and earth surface roads; and more than 900 bridges. The 
2020 budget includes $34.9 million for Road Maintenance to support 
pavement and gravel maintenance, remedial work on improved earth roads, 
bridge maintenance, and snow and ice control.
Concluding Statement
    This FY 2020 budget supports the Administration's commitment to 
empower tribal communities, improve quality of life, create economic 
opportunities, promote efficient and effective governance, preserve and 
foster cultural heritage, and steward natural resources. Interior's 
programs maintain strong and productive government-to-government 
relationships with Tribes, helping to promote tribal nation-building 
and self-determination.

    The Chairman. Thank you, Secretary Mac Lean Sweeney.
    I will now turn to Rear Admiral Buchanan for your 
testimony, please.

  STATEMENT OF REAR ADMIRAL CHRIS BUCHANAN, DEPUTY DIRECTOR, 
  INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

    Mr. Buchanan. Good afternoon, Chairman Hoeven and members 
of the Committee.
    I am Rear Admiral Chris Buchanan, Deputy Director of the 
Indian Health Service and a member of the Seminole Nation of 
Oklahoma.
    Thank you for your support and for the opportunity to 
testify on the President's fiscal year 2020 budget. The budget 
advances the Indian Health Service mission to raise the 
physical, mental, social and spiritual health of American 
Indians and Alaska Natives to the highest level.
    The President's fiscal year 2020 budget proposes $5.9 
billion for the Indian Health Service. This includes $25 
million to eliminate Hepatitis C and end the HIV epidemic in 
Indian Country. With the resources and tools that we have 
available today, we have an unprecedented opportunity to make a 
real difference in reducing hepatitis and HIV transmission.
    The budget also provides $25 million to begin transitioning 
to a new and modernized replacement of the IHS electronic 
health record system. Our current aging system exists as more 
than 400 separate instances that are maintained at individual 
local facilities across the Country. Replacing this antiquated 
system with a single, modern, national system would enable IHS 
to enhance medical quality, maximize the time that our doctors, 
nurses and other health care professionals are providing direct 
patient care and increase security of our patients' medical 
records.
    We have also requested $20 million to launch a national 
expansion of our paraprofessional program, the Community Health 
Aide Program. This program of certified health, behavioral 
health and dental health aides will enable us to fill critical 
gaps throughout Indian Country. This program has been used for 
decades in Alaska with great success. I believe this expansion 
into the rest of the Country would be extremely beneficial.
    Our budget proposes an additional $8 million to recruit and 
retain medical professionals critical to addressing gaps in 
care. To complement this increase, legislative changes are also 
proposed to provide tax exemptions to IHS scholarship and loan 
repayment programs, allowing us to provide $7 million in 
additional rewards and provide discretionary use of all Title 
38 personnel authorities, which would provide parity with our 
Federal health care providers like the VA.
    The budget prioritizes direct clinical health care services 
and maintains commitments for staffing newly constructed health 
care facilities which require some difficult choices, including 
a reduction in facilities investment, phasing out of the 
funding for the Community Health Representatives Program and 
two proposed program discontinuations in our Health Ed Program 
and our Tribal Management Grant Program.
    The budget will enable us to implement our new IHS 
Strategic Plan for fiscal year 2019 to 2023. The Strategic Plan 
includes three overarching goals which include access to care, 
improving the quality of care, and strengthening our management 
and operations. Our plan is the result of robust collaboration 
with both tribes and our urban Indian organization partners. It 
is our first overarching strategic plan for the agency in 
almost a decade.
    The IHS has also realized significant improvements to 
quality of care including the establishment of the new Office 
of Quality at the Indian Health Service headquarters level, 
implementing a new standardized provider credentialing and 
privileging software system that is used agency-wide and 
includes the packets for all licensed, independent 
practitioners. We have recently awarded a new adverse events 
reporting and tracking system that replaces the older legacy 
system known as Websident.
    I am also happy to report that since October of 2018, we 
have had 16 IHS facilities undergo survey, all of which were 
successful. With the support of the Office of Quality, we 
expect continued improvements and enhanced quality of care for 
American Indians and Alaska Natives across the system.
    Regarding the recent media reports on patient abuse by a 
former Indian Health Service employee, Rear Admiral Weahkee 
recently met with tribal leaders in both of the impacted 
communities to discuss steps that IHS has taken to ensure the 
protection of patients at IHS health care facilities. Rear 
Admiral Weahkee expressed his regrets that children were 
victimized by those entrusted to care for them and he made it 
absolutely clear that IHS will not tolerate sexual assault or 
abuse in any of our facilities.
    Our work force understands how serious this issue is. I am 
proud of the efforts and commitment of our staff for the 
progress that we have made. We will continue to press forward 
on this issue.
    IHS remains fully committed to improving quality, safety 
and access to health care for American Indians and Alaska 
Natives. We appreciate all of your efforts in helping us 
provide the best health care services to the people that we 
serve.
    With that, I am happy to answer any questions you may have.
    [The prepared statement of Admiral Buchanan follows:]

  Prepared Statement of Rear Admiral Chris Buchanan, Deputy Director, 
  Indian Health Service, U.S. Department of Health and Human Services
    Good afternoon, Chairman Hoeven, Vice-Chairman Udall, and Members 
of the Senate Committee on Indian Affairs. I am RADM Chris Buchanan, 
Deputy Director of the Indian Health Service (IHS). Thank you for your 
support and for the opportunity to testify on the President's Fiscal 
Year (FY) 2020 Budget. The Budget advances our mission 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 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 hospitals, clinics and health stations.
    The President's FY 2020 Budget proposes $5.9 billion in total for 
IHS, which is $392 million above the FY 2019 annualized continuing 
resolution funding level, or $140 million above the FY 2019 
Consolidated Appropriations Act. The President's Budget grows the 
resources available to meet the nation's commitment to American Indians 
and Alaska Natives in a constrained budget environment, reflecting a 
strong commitment to Indian Country. Specifically, the budget 
prioritizes direct clinical health care, providing a 7 percent increase 
and makes crucial investments in the fight against Hepatitis C and HIV/
AIDS, launches a national expansion of our health paraprofessional 
program and provides resources for planning and key infrastructure 
improvements for a replacement electronic health record system (EHR). 
The Budget also proposes to extend our successful Special Diabetes 
Program for Indians (SDPI) through FY 2021, at $150 million per year.
    The President's Budget provides $25 million to expand partnerships 
between IHS and Native communities to eliminate Hepatitis C and end the 
HIV epidemic in Indian Country. With the resources and tools we have 
available today, we have an unprecedented opportunity to make a real 
difference in reducing hepatitis and HIV transmission. I'm pleased that 
IHS is taking part in the ``Ending the HIV Epidemic: A Plan for 
America'' initiative.
    The Budget also provides $25 million to begin transition to a new 
and modernized replacement of IHS's electronic health record system, 
Resource and Patient Management System (RPMS). These resources are 
critical to allow IHS to conduct planning for this transition and 
address key infrastructure gaps necessary to implement a modern EHR. 
Our current system exists as more than 400 separate local instances 
rather than a single system, hobbling our efforts to share medical 
information efficiently, improve monitoring of medical quality, and 
recover critical third party financial resources.
    A modern system would enable IHS to enhance medical quality, 
maximize the time our doctors, nurses and other health professionals 
are providing direct patient care, and increase the security of our 
patients' medical records. I believe this transition represents an 
opportunity to meaningfully impact the care received by our patients.
    We have also requested $20 million to launch a national expansion 
of our paraprofessional program, the Community Health Aide Program 
(CHAP). This program of certified health, behavioral health, and dental 
aides will enable us to fill critical care gaps. This program has been 
used for decades in Alaska to great success and I believe its expansion 
into the rest of the country will be beneficial and an important tool 
in meeting the health needs of American Indians and Alaska Natives, as 
part of a mix of services determined at the local level.
    In addition to these key initiatives, our FY 2020 Budget includes:

   $147 million to expand direct clinical health services, 
        including dental, mental health, alcohol and substance abuse 
        services;

   $8 million to recruit and retain medical professionals, 
        critical to addressing gaps in care;

   $2 million to bolster the Office of Quality;

   $11 million to fund the health care of six newly federally 
        recognized tribes;

   $98 million to fully fund staffing at four newly completed 
        or expanded health care facilities, including 3 joint venture 
        facilities and a youth regional treatment center;

   $69 million to support current services, including pay 
        costs, inflation, and population growth;

   $855 million for contract support costs, which currently 
        aligns with our estimate of those costs.

    The Budget prioritizes funding for key investments in support of 
direct clinical health services, and in doing so, proposes some program 
adjustments. A net reduction of $66 million in Facilities ensures 
continued priority focus on maintaining existing facilities and 
addressing continuing sanitation facilities construction projects. 
Phase out of funding for the CHR program is contemplated with a funding 
level of $24 million, as part of proposed reforms to current community-
based care. The President's Budget also proposes two program 
discontinuations, including the Health Education and Tribal Management 
Grants programs, which total $23 million.
    The Budget will enable us to implement our newly released Indian 
Health Service Strategic Plan for fiscal year 2019-2023. The Strategic 
Plan will improve the management and administration of the IHS and sets 
the strategic direction of the agency over the next five years. The 
Strategic Plan includes three goals that will guide our efforts--access 
to care, quality of care, and strengthening management and operations. 
The final plan is the result of collaboration with our tribal and urban 
Indian organization partners who offered their feedback and expertise.
    Aligning with the IHS Strategic Plan, four legislative proposals 
are included within the Budget to increase access to care by: providing 
tax exemption for IHS scholarship and loan repayment programs, 
providing discretionary use of all Title 38 personnel authorities, 
meeting loan repayment and scholarship service obligations on a half-
time basis, and providing Federal Tort Claims Act coverage for IHS 
volunteers. These proposals focus on parity with authorities provided 
to other federal agencies providing health care services and seek to 
strengthen agency efforts to recruit and retain healthcare 
professionals.
    The IHS has also realized significant improvements to quality care 
for American Indians and Alaska Natives, including:

   Establishing the Office of Quality as an elevated national 
        oversight component within IHS Headquarters;

   Implementing a new standardized professional provider 
        credentialing and privileging software agency-wide for all 
        applicants;

   Awarding a new contract for an adverse events reporting and 
        tracking system that replaces an older legacy system.

    I can also report to you that since October 2018, 16 IHS health 
care facilities have had surveys by either the Centers for Medicare & 
Medicaid Services (CMS), the Joint Commission (TJC) or the 
Accreditation Association for Ambulatory Health Care (AAAHC). All 
surveys have resulted in CMS certification or TJC and AAAHC 
accreditation. This includes both Rosebud and Rapid City hospitals, and 
the IHS is preparing to send a request to CMS for a certification of 
the Pine Ridge Hospital.
    Lastly, I want to take this opportunity to talk about an important 
issue to all of us at the IHS. Regarding the recent media reports on 
patient abuse by a former IHS employee, we have taken every opportunity 
to speak with our tribal and urban partners, as well as our federal 
employees, about how this conduct is unacceptable and will absolutely 
not be tolerated at IHS.
    Recently, RADM Weahkee met with the Oglala Sioux Tribal Council in 
Pine Ridge, South Dakota, to discuss steps IHS has taken to ensure the 
protection of patients at IHS health care facilities. He expressed his 
sincere regret that children were victimized by those entrusted to care 
for them and made it absolutely clear that IHS will not tolerate sexual 
assault and abuse in its facilities.
    This opportunity followed a similar meeting RADM Weahkee had in 
February with the Blackfeet Nation in Montana. These two communities 
were victimized by the actions of the former IHS employee. I want to 
thank the leadership of the Oglala Sioux Tribe and the Blackfeet Nation 
for their partnership as we work to re-establish trust with our 
patients.
    As shared in an October 2018 letter to tribal leaders, I can 
promise you that IHS will continue our efforts to ensure safe and 
quality care for our patients. We are committed to doing whatever it 
takes and will continue to work closely with our tribal and urban 
Indian partners in transforming health care for American Indians and 
Alaska Natives across the Country. Some of the actions already taken 
include implementing new professional standards and stronger 
requirements for IHS employees to report suspected sexual abuse and 
exploitation of children. The implementation of our new centralized 
credentialing system will enable us to monitor the practice history of 
licensed health care professionals across the agency.
    The Presidential Task Force on Protecting Native American Children 
in the Indian Health Service System announced last month will 
complement our ongoing efforts to identify areas for improvement and 
implement changes to strengthen our systems. IHS is in the process of 
identifying an outside, independent contractor to conduct a medical 
quality assurance review to examine whether laws, policies and 
procedures have been followed, and to identify any further improvements 
IHS can implement to better protect patients. The HHS Office of the 
Inspector General has also been tasked with reviewing the effectiveness 
of the actions we have taken.
    I assure you that our workforce understands how serious this issue 
is, and I am proud of the efforts and commitment of our staff for the 
progress we've made, and we continue to press forward. We remain firmly 
committed to improving quality, safety, and access to health care for 
American Indians and Alaska Natives, in collaboration with our partners 
in HHS, across Indian country, and Congress. We appreciate all your 
efforts in helping us provide the best possible health care services to 
the people we serve.
    Thank you, and I am happy to answer any questions you may have.

    The Chairman. Thank you, Admiral Buchanan.
    President Keel.

STATEMENT OF HON. JEFFERSON KEEL, PRESIDENT, NATIONAL CONGRESS 
                      OF AMERICAN INDIANS

    Mr. Keel. Good afternoon. Thank you, Chairman Hoeven and 
members of the Committee.
    On behalf of the National Congress of American Indians, I 
want thank you for holding this hearing on the President's 
budget request for 2020 for Indian Programs.
    My name is Jefferson Keel. I am the Lieutenant Governor of 
the Chickasaw Nation and President of the National Congress of 
American Indians.
    Tribal Nations seek only those things promised by the 
solemn treaties and agreements reached between tribal Nations 
and the United States of America. Funding decisions made by the 
Federal Government are an expression of this Country's policy 
priorities and its commitment to honoring its obligations to 
American Indian and Alaska Native people.
    The recent publication of the U.S. Commission on Civil 
Rights' Broken Promises Report is a stark reminder of the need 
for increased funding of tribal programs. The Broken Promises 
Report is a follow-up to the 2003 Quiet Crisis Report which 
found that Federal funding for services to tribal communities 
was disproportionately lower than services to other 
populations. Today, programs serving Indian Country remain 
chronically underfunded.
    Tribal Nations also face significant challenges from 
uncertainty in the Federal budget process. The 2019 government 
shutdown is the most recent example. However, short term 
continuing resolutions cause uncertainty in program 
administration and make planning more difficult. Congress must 
prevent political impasses from jeopardizing the provision of 
quality services in tribal communities such as health care, law 
enforcement and child welfare by passing legislation 
authorizing advance appropriations for the Indian Health 
Service and the Bureau of Indian Affairs.
    Funding for the Census is a major tribal priority in fiscal 
year 2020 because an accurate count will ensure fair 
distribution of billions of dollars to tribal Nations over the 
course of the next decade. In 2010, the Census Bureau estimates 
that American Indians and Alaska Natives living on reservations 
or in Native villages were undercounted by approximately 4.9 
percent which is more than double the undercount of the next 
closest population group.
    Unfortunately, the President's budget request for the 
entire Census Bureau was significantly lower than the estimates 
of overall costs for the Census. I urge Congress to ensure 
sufficient funding for a successful 2020 Census by providing 
$8.5 billion for the Census Bureau with at least $7.5 billion 
in direct funding for the 2020 census operations.
    The Administration and Congress must uphold their treaty 
and trust obligations to tribal Nations through the Federal 
budget process. NCAI was again alarmed that the Administration 
has proposed cuts to many programs of importance to Indian 
Country as well as eliminating funding altogether for programs 
like the Indian Community Development Block Grant, the 
Community Development Financial Institutions Fund, the Bureau 
of Indian Education Replacement School and Facility 
Construction and the BAI Housing Improvement Program just to 
name a few.
    NCAI urges Congress to reject these proposed cuts and 
eliminations and instead make significant advancements in the 
program deemed most important by tribal Nations. As part of the 
fiscal year 2020 budget formulation process, tribal Nations 
from each BIA region completed a survey to outline which budget 
lines they would prefer to provide increased funding to and 
why. The top 11 programs are contained in my written testimony.
    I would also like to express our sincere gratitude to 
Congress for providing a direct funding stream for tribal 
governments from the Crime Victims Fund for the first time in 
2018 and again in 2019. As it has for several years, the 
President's budget proposes bill language that would streamline 
and consolidate tribal programs within the Office of Justice 
Programs by allocating 7 percent from all discretionary 
programs to address Indian Country public safety and justice 
needs. NCAI wholeheartedly supports this proposal.
    Thank you for the opportunity to testify at this hearing. I 
will gladly answer any questions you may have at this time.
    [The prepared statement of Mr. Keel follows:]

Prepared Statement of Hon. Jefferson Keel, President, National Congress 
                          of American Indians
Introduction
    On behalf of the National Congress of American Indians (NCAI), 
thank you for holding this hearing on the President's Fiscal Year (FY) 
2020 Budget Request for Indian Programs. Founded in 1944, NCAI is the 
oldest and largest representative organization serving the broad 
interests of tribal nations and communities. Tribal leaders created 
NCAI in 1944 in response to termination and assimilation policies that 
threatened the existence of American Indian and Alaska Native (AI/AN) 
tribal nations. Since then, NCAI has fought to preserve the treaty and 
sovereign rights of tribal nations, advance the government-to-
government relationship, and remove historic structural impediments to 
tribal self-determination.
    Like all other governments, tribal nations strive to build strong 
economies and ensure the health and wellbeing of their citizens and all 
those who reside in their communities. As part of tribal nations' 
responsibilities to their people, tribal nations provide a range of 
governmental services. These include education, law enforcement, 
judicial systems, health care, environmental protection, natural 
resource management, and basic infrastructure such as housing, roads, 
bridges, sewers, public buildings, telecommunications, broadband and 
electrical services, and solid waste treatment and disposal. Tribal 
nations are assuming greater levels of governmental responsibility to 
meet their citizens' needs in culturally appropriate ways, but receive 
inadequate federal funding for roads, schools, police, and other public 
services.
    Tribal nations seek only those things promised to them and their 
citizens by the solemn treaties and agreements reached between tribal 
nations and the United States. When tribal nations agreed to accept 
smaller land bases, the federal government promised to safeguard their 
right to govern themselves, and to provide them adequate resources to 
deliver essential services effectively. These obligations are the 
foundation of the government-to-government relationship that exists 
between tribal nations and the United States.
    Funding decisions made by the Administration and Congress are an 
expression of this country's policy priorities, and the federal budget 
for tribal governmental services reflects the extent to which the 
United States honors its obligations to AI/AN people. The treaty and 
trust responsibilities commit the federal government to the protection 
of Indian lands; protection of tribal self-governance; and the 
provision of social, medical, and education services to Native people. 
NCAI calls on Congress and the Administration to uphold these solemn 
responsibilities to Indian Country by rejecting the cuts proposed in 
the President's FY 2020 budget request and instead providing 
significant increases for programs serving tribal nations.
    This testimony addresses several overarching funding issues and 
provides focused analysis on certain specific areas of the President's 
FY 2020 budget request. To ensure Congress considers what it means to 
fund the federal treaty and trust obligations across the federal 
government, NCAI collaborates each year with national, regional, and 
issue specific tribal organizations to develop the comprehensive 
recommendations included in an Indian Country Budget Request. 
Therefore, we request that the FY 2020 Indian Country Budget Request 
titled, Winds of Change: Protecting our Nations and People into the 
Future, be entered into the record of this hearing.
Broken Promises Report
    In 2003, the U.S. Commission on Civil Rights issued its report, A 
Quiet Crisis: Federal Funding and Unmet Needs in Indian Country. The 
Quiet Crisis report found that funding for programs serving Indian 
Country were ``disproportionately lower than funding for services to 
other populations.'' \1\ In May 2015, a bipartisan group of twenty 
House members sent a letter to the U.S. Commission on Civil Rights 
requesting an update to the 2003 A Quiet Crisis report. \2\ In its 
letter, House members highlighted several ongoing funding concerns that 
contribute to the crisis throughout Indian Country and requested the 
updated report ``to help ensure that the federal government is making 
progress in fulfilling its trust and treaty responsibilities.'' \3\
---------------------------------------------------------------------------
    \1\ U.S. Commission on Civil Rights, Broken Promises: Continued 
Federal Funding Shortfall for Native Americans, https://www.usccr.gov/
pubs/2018/12-20-Broken-Promises.pdf
    \2\ Letter from Rep. Derek Kilmer to then-Chair Castro, Vice Chair 
Timmons-Goodson, and Commissioners on May 14, 2015; https://
kilmer.house.gov/news/press-releases/-kilmer-seeks-to-shine-a-
spotlight-on-disparities-facing-tribal-communities
    \3\ Id.
---------------------------------------------------------------------------
    In December 2018, the U.S. Commission on Civil Rights released its 
report titled, Broken Promises: Continuing Federal Funding Shortfall 
for Native Americans. The Broken Promises report found that in the past 
15 years, efforts undertaken by the federal government have resulted in 
only minor improvements across Indian Country. Additionally, the report 
noted that federal programs serving Indian Country continue to be 
underfunded and in some ways, federal initiatives for Native Americans 
have regressed. Specifically, the Commission found that:

         Federal programs designed to support the social and economic 
        wellbeing of Native Americans remain chronically underfunded 
        and sometimes inefficiently structured, which leaves many basic 
        needs in the Native American community unmet and contributes to 
        the inequities observed in Native American communities. The 
        federal government has also failed to keep accurate, 
        consistent, and comprehensive records of federal spending on 
        Native American programs, making monitoring of federal spending 
        to meet its trust responsibility difficult. Tribal nations are 
        distinctive sovereigns that have a special government-to-
        government relationship with the United States. Unequal 
        treatment of tribal governments and lack of full recognition of 
        the sovereign status of tribal governments by state and federal 
        governments, laws, and policies diminish tribal self-
        determination and negatively impact criminal justice, health, 
        education, housing and economic outcomes for Native Americans. 
        \4\
---------------------------------------------------------------------------
    \4\ U.S. Commission on Civil Rights, Broken Promises: Continued 
Federal Funding Shortfall for Native Americans, https://www.usccr.gov/
pubs/2018/12-20-Broken-Promises.pdf

    Congress and the Administration must uphold its treaty and trust 
obligations to tribal nations through the federal budget process. The 
Broken Promises report provides a series of recommendations to make 
good on these promises to Indian Country. A key recommendation in the 
report is that Congress should pass a spending package to address all 
unmet needs, focusing immediately on the most critical items like core 
infrastructure. NCAI urges Congress and the Administration to give the 
report's recommendations serious consideration as they consider funding 
levels in FY 2020 and beyond.
    Additionally, the President and members of Congress have recently 
reengaged discussing funding for a comprehensive infrastructure 
package. Consistent with the Broken Promises report, the federal 
government must honor its treaty and trust obligations to tribal 
nations by ensuring any infrastructure package provides significant 
direct investment in Indian Country and provides tribal nations the 
same financing and partnership incentives as state and local 
governments.
Authorize Advance Appropriations for Tribal Programs
    Due to fluctuations in federal funding and the uncertain federal 
budget process, many tribal nations have faced continued emergencies in 
meeting the public service needs of their citizens. \5\ The 2019 
government shutdown--the longest in United States history--is only the 
most recent example of the federal budget process jeopardizing the 
health, safety, and wellbeing of tribal citizens. Tribal nations 
regularly must overcome uncertainty when planning and providing 
services to their citizens because of political impasses related to 
federal spending. For instance, since FY 1998, there has only been one 
year (FY 2006) in which the Interior, Environment, and Related Agencies 
Appropriations bill has been enacted before the beginning of the new 
fiscal year.
---------------------------------------------------------------------------
    \5\ See NCAI Resolution ATL-14-084: Recommendations for Address the 
State of Emergency in Federal Underfunding of the Trust Responsibility
---------------------------------------------------------------------------
    These often partisan debates affecting the appropriations process 
have an outsized impact on the daily lives of AI/AN people who already 
face underfunding of health care, education, and backlogs in physical 
infrastructure--all of which fall under the federal trust 
responsibility. The Indian Health Service (IHS) and the Bureau of 
Indian Affairs (BIA) provide core governmental services for tribal 
nations, including but not limited to hospitals, law enforcement, child 
welfare programs, and social services. Congress must protect tribal 
citizens from the negative effects of uncertainty in the federal budget 
process. NCAI calls on Congress to pass legislation authorizing advance 
appropriations for the IHS and BIA.
The President's FY 2020 Budget Request
    The President released his budget request on March 11, 2019. The 
budget proposes reducing FY 2020 non-defense discretionary (NDD) 
funding by $54 billion (9 percent) below the FY 2019 level, and by $69 
billion (11 percent) after adjusting for inflation. The proposed amount 
follows the cap set by the Budget Control Act (BCA) of 2011, which was 
lowered through sequestration. The proposed decreases to NDD accounts 
would undermine the ability of the federal government to meet its 
treaty and trust obligations, with the proposed budget cutting BIA and 
Bureau of Indian Education (BIE) by about 10.5 percent compared to the 
2019 continuing resolution (CR) level. Other agencies would see cuts, 
including 12 percent for the Department of Health and Human Services, 
18 percent for Housing and Urban Development, and 31 percent for the 
Environmental Protection Agency.
    NCAI is strongly opposed to these drastic reductions in spending 
that will jeopardize the provision of programs and services that 
support the federal treaty and trust obligations to tribal nations. 
Although we are deeply concerned about the proposed cuts in the 
President's budget request, it is Congress that has final say on 
discretionary spending. Accordingly, we urge members of this Committee 
to work with their colleagues throughout the Senate to ensure that FY 
2020 appropriations bills make significant investments in federal 
programs serving Indian Country.
U.S. Census Bureau
    The census is a critical and powerful information source that will 
significantly influence American policy for the coming decade. An 
accurate count is necessary to ensure the fair distribution of billions 
of dollars to tribal nations and AI/AN people across the United States. 
Certain population groups are at higher risk of being missed in the 
decennial census--groups considered hard-to-count. Native people 
especially on reservations and in Alaska Native villages have been 
historically underrepresented in the census. In the 2010 Census, the 
Census Bureau estimates that AI/ANs living on reservations or in Native 
villages were undercounted by approximately 4.9 percent, more than 
double the undercount rate of the next closest population group.
    The President's budget request was significantly lower than 
Secretary Ross's estimates of overall costs, and we urge Congress to 
ensure sufficient funding for a successful 2020 Census, including 
funding for Questionnaire Assistance Centers, which currently are not 
included in the Census Bureau's operational plan. With only half the 
number of Regional Census Centers and local census offices across the 
country, it will be important to expand the field footprint, to provide 
`safe space' for people who do not have reliable Internet access, are 
wary of using the telephone to respond, or need assistance filling out 
a paper form, to meet with sworn Census Bureau employees near where 
they live. NCAI recommends that Congress provide the Census Bureau with 
at least $8.45 billion in FY 2020.
Bureau of Indian Affairs and Bureau of Indian Education
    The BIA is one of the primary agencies responsible for providing 
services throughout Indian Country, either directly or through compacts 
or contracts with tribal governments. Unlike previous years, the 
President's FY 2020 budget proposes to establish the BIE as an 
independent bureau with a separate budget structure, and we look 
forward to working with the Committee to examine the merits of this 
proposal. The President requested $1.85 billion for BIA and $936 
million separately for BIE. However, when combined, the budget proposes 
$2.789 billion for BIA and BIE, a reduction in overall funding of 
approximately 10.5 percent when compared to the 2019 CR level.
    Moreover, the President's budget proposes cuts across many BIA 
budget lines and would eliminate altogether funding for the Indian 
Guaranteed Loan Program, the Housing Improvement Program, Small and 
Needy Tribes, and Tribal Climate Resilience. A few programs would 
receive increases, including New Tribes funding to continue support for 
the six Virginia tribes recognized by Congress in January 2018, as well 
as an additional $2.5 million for Law Enforcement Special Initiatives 
to expand BIA capacity to address the opioid crisis in Indian Country.
    As part of the FY 2020 budget formulation process, tribal nations 
from each BIA region completed a survey to outline which budget lines 
they would prefer to provide increased funding to and why. The results 
of this process show that BIA Social Services, Indian Child Welfare Act 
(ICWA), Tribal Courts, Aid to Tribal Government, Scholarships and Adult 
Education, Criminal Investigations/Policing, Road Maintenance, Housing, 
Johnson O'Malley, Detentions and Corrections, and Welfare Assistance 
made up the top eleven.
    For Public Safety and Justice Programs, one of the most fundamental 
aspects of the federal government's trust responsibility is the 
obligation to protect public safety on tribal lands. Congress and the 
United States Supreme Court have long acknowledged this obligation, 
which Congress most recently reaffirmed in the Tribal Law and Order Act 
expressly acknowledging ``the federal nexus and distinct federal 
responsibility to address and prevent crime in Indian Country.'' \6\ In 
2018, the U.S. Commission on Civil Rights found that there continues to 
be ``systematic underfunding of tribal law enforcement and criminal 
justice systems, as well as structural barriers in the funding and 
operation of criminal justice systems in Indian Country'' that 
undermine public safety. \7\ Recent experience demonstrates that 
addressing the lack of justice funding can make rapid and dramatic 
strides toward improving public safety. \8\ Tribal justice systems 
simply need the resources to put their tools to work so they can 
protect women, children and families, address substance abuse, 
rehabilitate first-time offenders, and put serious criminals behind 
bars.
---------------------------------------------------------------------------
    \6\ 34 U.S.C.  10381(j)(1)
    \7\ U.S. Commission on Civil Rights, Broken Promises: Continued 
Federal Funding Shortfall for Native Americans, https://www.usccr.gov/
pubs/2018/12-20-Broken-Promises.pdf
    \8\ Michael S. Black, Acting Assistant Secretary--Indian Affairs, 
U.S. Department of the Interior, Testimony, Briefing Transcript, p. 
136; see also Dep't of the Interior, press release, March 4, 2014, 
https://www.bia.gov/sites/bia.gov/files/assets/public/press_release/
pdf/idc1-025752.pdf (announcing Tiwahe Initiative to promote the 
stability and security of Native American families)
---------------------------------------------------------------------------
    The underfunding of tribal law enforcement and justice systems is 
well-documented. Most recently, the BIA submitted a report to Congress 
in May 2018 estimating that to provide a minimum base level of service 
to all federally-recognized tribes: $1 billion is needed for tribal law 
enforcement, $1 billion is needed for tribal courts, and $241.8 million 
is needed to adequately fund existing detention centers. \9\ Based on 
recent appropriation levels, BIA is generally funding tribal law 
enforcement at about 22 percent of estimated need, tribal detention at 
about 41 percent of estimated need, and tribal courts at a dismal 4.5 
percent of estimated need.
---------------------------------------------------------------------------
    \9\ Bureau of Indian Affairs, Office of Justice Services. ``Report 
to Congress on Spending, Staffing, and Estimated Funding Costs for 
Public Safety and Justice Programs in Indian Country,'' May 2, 2018, 
available at https://www.bia.gov/sites/bia.gov/files/assets/bia/ojs/
ojs/pdf/2016_TLOA_Report_FINAL.pdf
---------------------------------------------------------------------------
    NCAI recommends an increase in base funding for tribal courts, for 
a total of $83 million, which would include courts in PL 280 
jurisdictions. NCAI also recommends an increase to BIA Law Enforcement 
of $200 million, for a total of $573 million.
    BIA Social Services help to address the underlying conditions such 
as drug addiction, poverty, and violence that tend to create and 
perpetuate the circumstances that produce victims. Sub-activities 
include services in the areas of family and domestic violence, child 
abuse and neglect, and protective services. However, many tribes' 
Social Services departments are understaffed and experience high 
turnover rates. As an example, in FY 2017, Osage Nation case workers 
averaged 25-30 cases a month each. This exceeds the standard of one 
case worker for every 15 cases administered. A lack of increased yearly 
funding tends to hinder these protective services. NCAI recommends $55 
million for BIA Social Services in FY 2020.
    In addition to public safety and human services, infrastructure 
remains an area of high need. A transportation program that is vital to 
infrastructure in Indian Country is the BIA Road Maintenance Program, 
which is funded and authorized under the Department of the Interior. 
The BIA Road Maintenance Program is critical to BIA owned roads and 
facilities. Currently, BIA is responsible for maintaining approximately 
29,400 miles of roads in Indian Country, including 900 bridges. The 
condition of these roads is increasingly concerning for tribal citizens 
and all surrounding communities. The lack of sufficient transportation 
infrastructure also hampers economic development opportunities for 
tribal nations and their citizens.
    According to a recent GAO Report published in May 2017, Better Data 
Could Improve Road Management and Inform Indian Student Attendance 
Strategies, \10\ BIA did not provide adequate documents on road 
maintenance and no process exists for tribal nations to properly report 
on road maintenance. The BIA conducted a road maintenance survey, which 
found that the cost of road maintenance more than doubled the allocated 
amount of funding for proper maintenance in FY 2018 and that deferred 
maintenance had risen to $392 million for BIA roads. Further data on 
road maintenance is needed to adequately address the deferred 
maintenance of roads throughout Indian Country. Increased funding for 
the BIA Road Maintenance program is needed in order to begin to address 
public safety and commercial activity concerns that affect all 
Americans. $50 million is requested to begin to address the deferred 
roads maintenance need in Indian Country.
---------------------------------------------------------------------------
    \10\ U.S. Government Accountability Office, 2017, Publication 
No.GAO-17-423
---------------------------------------------------------------------------
    As mentioned above, the President's budget proposes funding BIE at 
$936 million for FY 2020. It also proposes eliminating programs 
including Scholarships and Adult Education, Special Higher Education 
Scholarships, and Science Post Graduate Scholarships. Of particular 
note, the President's budget would zero out Replacement School 
Construction, Replacement Facility Construction, and reduce Facilities 
Improvement and Repair and Employee Housing Repair funding levels. 
Instead, the Administration has again proposed legislation establishing 
a Public Lands Infrastructure Fund to support infrastructure 
improvements in National Parks, National Forests, Wildlife Refuges, and 
for BIE schools. Not only would the funding limits under this proposal 
produce insufficient resources for BIE Education Construction when 
compared to current funding levels, they could fluctuate considerably 
based on energy development revenue. Congress must provide consistent 
funding to fully address the dilapidated and unsafe conditions of BIE 
school facilities, and any new methods of funding school construction 
and maintenance must supplement rather than supplant existing 
appropriations avenues--especially considering the great need for 
school infrastructure in Indian Country
    The budget proposes a few increases for BIE programs, including 
$7.2 million for Education Management to optimize learning 
opportunities for students of all ages. NCAI recommends the funding 
levels in the following table for BIE programs.

             DOI Appropriations Bill--Interior, Environment
------------------------------------------------------------------------
                                                            NCAI FY 2020
                          Program                              Request
------------------------------------------------------------------------
Tribal Education Departments (DOI)                           $10,000,000
Construction/Repair of Bureau of Indian Education (BIE)     $430,000,000
 Schools
Johnson O'Malley                                             $42,000,000
Student Transportation                                       $73,000,000
Tribal Grant Support Costs (Administrative Cost Grants)      $90,000,000
Facilities Operations (BIE)                                 $109,000,000
Facilities Maintenance (BIE)                                 $76,000,000
Indian School Equalization Formula                          $431,000,000
Education Management: Education IT                           $40,000,000
BIE Immersion Demonstration Grants                            $5,000,000
Juvenile Detention Education                                    $620,000
Tribal Colleges and Universities' Institutional              $81,696,000
 Operations, Titles I, II, and III of the Tribally
 Controlled Colleges and Universities Assistance Act
Institute of American Indian Arts and Center for Lifelong    $10,210,000
 Education & Museum (AIANNH Culture and Art Development
 Act)
Haskell Indian Nations University & Southwestern Indian      $25,000,000
 Polytechnic Institute (Snyder Act)
Tribally Controlled Career and Technical Institutions,       $10,000,000
 Title V of the Tribally Controlled Colleges and
 Universities Assistance Act
Tribal Colleges and Universities Infrastructure              $31,000,000
 Improvement
------------------------------------------------------------------------

    Overall, BIA and BIE provide funding for many public safety, 
education, human services, and natural resource programs that cannot be 
addressed fully in this testimony. NCAI supports the funding requests 
of other national tribal organizations, such as the National Indian 
Child Welfare Association, National Indian Education Association, 
American Indian Higher Education Consortium, and others who have also 
developed rigorous requests to address the treaty and trust obligations 
funded in the Interior-Environment spending bill.
U.S. Department of Education
    Access to quality education is vital for competing and thriving in 
today's economy. It is an essential strategy for creating jobs and 
securing the nation's future prosperity--particularly in tribal 
communities. An educated citizenry serves as a catalyst to boost tribal 
economic productivity and growth through a more highly-skilled 
workforce, which can attract new businesses, reduce unemployment, 
stimulate reservation economies through direct spending, and foster 
growth in small businesses owned by tribal citizens as a path to 
individual and familial self-sufficiency.
    For FY 2020, the President requested $64 billion in discretionary 
funding for the Department, which is a decrease of $7 billion or nearly 
10 percent based on the 2019 CR levels. Cuts at the Department of 
Education will have adverse impacts for Indian Country, as the 
President's budget proposes reducing funding for most of the programs 
serving Native students, and even proposes eliminating (or not 
reauthorizing) several programs serving Alaska Natives and Native 
Hawaiians. NCAI is particularly concerned that the President's FY 2020 
budget eliminates funding for the Alaska Native Education Program and 
the Native Hawaiian Education Program. The Alaska Native Education 
Program is an essential program that funds the development of curricula 
and education programs that address the unique educational needs of 
Alaska Native students, as well as the development and operation of 
student enrichment programs in science and mathematics. The Native 
Hawaiian Education Program empowers innovative, culturally appropriate 
programs to enhance the quality of education for Native Hawaiians. NCAI 
recommends funding the Alaska Native Education Assistance Program at 
$40 million and the Native Hawaiian Education Program at $40 million 
for FY 2020.
    NCAI opposes cuts to Indian education programs and instead 
recommends that Congress make a strong investment in the future of 
Indian Country by appropriating the amounts listed in the table below 
for programs at the Department of Education.

------------------------------------------------------------------------
      Department Education Programs             NCAI FY 2020 Request
------------------------------------------------------------------------
Title 1, Part A (Local Education Agency    $20,000,000,000
 Grants)
State-Tribal Education Partnership (STEP)  $5,000,000
 Program
Title VII funding, ESEA (Impact Aid        $2,000,000,000
 Funding)
Title VI funding, Every Student Succeeds   $198,000,000
 Act (ESSA)
Native Hawaiian Student Education (Title   $40,000,000
 VI, Part B)
Alaska Native Education Equity Assistance  $40,000,000
 Program (Title VI, Part C)
Indian Education Language Immersion        $5,000,000
 Grants (Title VI, Part D)
Special Programs for Native Student,       $67,900,000
 Including Native Youth Community
 Projects
Title III-A Grants under the Higher        $65,000,000
 Education Act for Tribal Colleges and
 Universities
Tribal Colleges and Universities: Adult/   $8,000,000
 Basic Education
Tribally Controlled Post-Secondary Career  $10,000,000
 and Technical Institutions and Technical
 Institutions
Native American-Serving, Non-Tribal        $10,000,000
 Institutions (Higher Education Act,
 Title III-F)
Tribal Education Departments (Dept. of     $10,000,000
 Ed)
    Total:                                 $22,458,900,000
------------------------------------------------------------------------

Indian Health Service
    The President's FY 2020 budget request for IHS is $5.9 billion, 
which is $392 million or 7 percent above CR levels (2 percent above FY 
2019 appropriations). The budget request places an emphasis on Clinical 
Services, with investments in Hospitals and Health Clinics, 
Accreditation Emergencies, and Purchased/Referred Care. The budget also 
requests $356 million for Mental Health, Alcohol, and Substance Abuse 
programs, which is $27 million above the 2019 CR levels. However, the 
President's budget also proposes reductions in Preventative Health 
Education and Community Health Representatives, the Tribal Management 
Grant Program, and Health Care Facilities Construction. While NCAI is 
encouraged by increases to overall IHS funding, the elimination or 
reduction of IHS programs is not a position that NCAI can support--
especially considering that in FY 2017 the IHS per capita expenditures 
for patient health services were just $3,332, compared to $9,207 per 
person for health care spending nationally.
    For FY 2020, the IHS Tribal Budget Formulation Workgroup requested 
$7.03 billion. This amount would include an increase to maintain 
current services and other binding obligations and allow for program 
expansions, as listed in the Workgroup's FY 2020 report. NCAI 
appreciates the bipartisan support for the IHS budget in Congress, and 
we look forward to ongoing support for providing much needed increases 
for the IHS budget.
    Addressing health care issues in Indian Country extends beyond 
funding for the IHS. NCAI has additional funding recommendations for 
improving health care in tribal communities in its FY 2020 Indian 
Country Budget Request.
U.S. Department of Agriculture (USDA)
    NCAI would again like to thank Chairman Hoeven, Vice-Chairman 
Udall, and our many other champions in the effort to ensure the 2018 
Farm Bill included tribal priorities. The final bill created new 
authorities and improved existing programs in ways that will benefit 
tribal nations and citizens for years to come. Congress must now ensure 
that the significant progress for Indian Country embodied in the 2018 
Farm Bill receives sufficient funding.
    The President's budget proposes significant cuts that could impact 
the implementation of these hard-fought victories. When compared to the 
2019 CR levels, the Food Distribution Program on Indian Reservations 
(FDPIR) would see a cut of $23 million. FDIPR currently serves 
approximately 276 tribal nations and is a critical food assistance 
program, particularly in areas that do not have easy access to 
Supplemental Nutrition Assistance Program (SNAP) offices or authorized 
food stores. Since FY 2013, FDPIR participation has risen more than 17 
percent. Between FY 2015 and FY 2017 alone, monthly participants rose 
from 88,000 to 100,000. The FDPIR program is projected to have no 
change in participation in 2020.
    Reducing funding for FDPIR will increase food insecurity in tribal 
communities and will provide fewer resources for USDA to implement the 
expansion of Indian Self-Determination and Education Assistance Act 
contracting authority (638 authority) for the FDPIR program. 
Additionally, the President's budget proposes significant cuts to the 
SNAP program, which will make matters more challenging, as reduced SNAP 
resources have historically meant increased stress on the FDPIR 
program.
    As such, Congress should appropriate not less than $200 million for 
FDPIR, appropriate $5 million to develop a traditional foods market for 
FDPIR, and appropriate $5 million for the 638 Tribal Self-Governance 
Demonstration Program for Tribal Organizations. Congress should also 
provide a minimum of $1.5 million for the Office of Tribal Relations 
and ensure sufficient funding for implementation of Tribal Forest 
Protection Act program 638 authority and the establishment of the 
Secretary's Tribal Advisory Council.
Department of Justice
    The public safety problems that continue to plague tribal 
communities are the result of decades of gross underfunding for tribal 
criminal justice systems; a uniquely complex jurisdictional scheme; and 
the historic failure by the federal government to fulfill its public 
safety obligations on AI/AN lands. Crime rates in tribal communities 
are among the highest in the nation and AI/ANs experience rates of 
violent crime that are 2.5 times the national average. Residents and 
visitors on tribal lands deserve the safety and security that is taken 
for granted outside of Indian Country. As discussed above, funding for 
public safety at the BIA is insufficient, and as a result, tribes are 
increasingly relying on competitive grant programs at the Department of 
Justice to address these funding shortfalls.
    The Crime Victims Fund (CVF) is the federal government's primary 
funding source for providing services to victims of crime. NCAI 
expresses our sincere gratitude to appropriators for providing a direct 
funding stream for tribal governments from the CVF for the first time 
in FY 2018 and again in FY 2019. For this funding to achieve its 
purpose, however, it needs to be recurring funds that tribal 
governments can plan on in order to ensure program stability for 
victims for the long term. We urge appropriators to keep disbursements 
from the CVF at the increased level and to direct an amount equal to 5 
percent of overall CVF disbursements to tribal governments, which is 
the level requested in the President's Budget.
    As it has for several years, the President's Budget also proposes 
bill language that would streamline and consolidate OJP tribal programs 
by allocating seven percent from all discretionary OJP programs to 
address Indian country public safety and tribal justice needs. In the 
FY 2020 President's Budget, this would amount to $127.064 million, an 
increase of $37.5 million from enacted FY 2019 funding levels. In past 
years, both the House and Senate CJS Subcommittees have supported this 
request, but it has never been enacted. One of the biggest shortcomings 
of DOJ tribal funding is that it is administered as competitive 
funding. In order to obtain this funding, tribal nations--on behalf of 
their tribal justice systems--must compete against each other under 
priorities and guidelines established by DOJ. As a result, tribal 
nations must develop projects that align with changing DOJ priorities 
and cannot count on funding continuing beyond the current grant period. 
A streamlined OJP tribal allocation would significantly improve the 
federal funding process by which tribal nations receive resources to 
establish tribal courts; assist in developing detention facilities; 
provide legal assistance; develop and maintain juvenile delinquency 
prevention programs; and provide substance abuse prevention programs. 
Further, the tribal allocation would give tribal nations the 
flexibility to develop a detailed strategic plan on how best to spend 
those resources. NCAI supports the President's Budget request for a 7 
percent tribal set-aside from across OJP discretionary programs and a 5 
percent set-aside from the CVF. NCAI also supports restoring funding 
for the Tribal Youth Program, which is zeroed out in the President's 
Budget, to its FY 2010 level of $25 million and to significantly 
increase funding for tribal law enforcement programs under the COPS 
program, which was funded at $27 million for FY 2019 and at $8 million 
in the President's Budget.
Department of Treasury
    Of great concern to Indian Country is the budget's proposal to 
eliminate funding for the Community Development Financial Institutions 
Fund's (CDFI Fund) discretionary grant and direct loan program. The 
President's proposal would eliminate funding for the Native American 
CDFI Assistance program (NACA) and the three other discretionary CDFI 
Fund grant programs.
    The Native Initiative of the CDFI Fund is an important program that 
expands access to capital for individuals and small businesses in 
Indian Country. Each year, Congress funds the NACA program, which 
includes financial and technical assistance components. The NACA 
program makes awards that assist community development financial 
institutions (CDFIs) in increasing their lending services and financial 
products, and in building their own internal capacity to serve their 
target markets. Native CDFIs provide a wide range of loans to 
microenterprises, small businesses, consumers, and for housing and 
homeownership. Native CDFIs also offer financial education and 
entrepreneurial development training, homebuyer education and 
foreclosure prevention counseling, credit counseling, small business 
planning, debt relief counseling, counseling to improve financial 
capability, match savings programs called Individual Development 
Accounts, and free tax preparation services in Native communities 
across the country. In many areas, Native CDFIs provide the only 
affordable alternative to predatory financial services providers.
    NCAI urges Congress to provide a minimum of $20 million for the 
NACA program in FY 2020 and make permanent the waiver of the non-
federal match requirement for the NACA financial assistance program.
Conclusion
    Thank you for the opportunity to testify on the President's FY 2020 
budget and share our recommendations on how the federal government can 
uphold its treaty and trust obligations to tribal nations through the 
federal budget. We look forward to working with this Committee on a 
bipartisan basis to ensure federal commitments to Indian Country are 
honored in the FY 2020 budget.

    The Chairman. Thank you, President Keel.
    I will turn now to Representative Andrew Joseph, Jr. Thank 
you for being here.

      STATEMENT OF HON. ANDREW JOSEPH JR., PORTLAND AREA 
          REPRESENTATIVE, NATIONAL INDIAN HEALTH BOARD

    Mr. Joseph. Chairman Hoeven, Vice Chairman Udall, and 
members of the Committee, thank you for holding this hearing on 
the President's fiscal year 2020 budget request for Indian 
programs.
    [Phrase in Native tongue]. My name is Andy Joseph, Jr. I am 
the Portland Area Representative for the National Indian Health 
Board and the Vice Chairman of my tribal council, the 
Confederated Tribes of the Colville Indian Reservation in 
Washington State. I also co-chair the National IHS Budget 
Formulation Workgroup.
    As the Committee is aware, historical trauma, poverty and 
lack of adequate resources continue to plague tribal 
communities. If we are to make measurable changes to the health 
outcomes of American Indians and Alaska Natives, the funding 
levels that make it to the tribal communities needs to be 
adequate.
    Tribes are concerned about the cuts to domestic spending, 
especially at the Department of Health and Human Services, 
which would go down by 12 percent. There are many programs 
within the agency that are a matter of life and death for many 
American Indians and Alaska Native people. Therefore, Congress 
should reject these cuts.
    We have been grateful for the recent increases to the IHS 
appropriation over the last several years and to see another 
increase in the President's fiscal year 2020 budget 
recommendations. However, these increases have not allowed for 
expanded services and have mainly just kept up with inflation, 
contracts of work costs obligations, and population growth. We 
need to do more.
    The chronic underfunding of the Indian Health system is one 
of the biggest factors contributing to the poor health status 
of tribal communities. On average, the government spends just 
over $4,000 per IHS user compared to almost $10,000 per person 
nationally. Many of the health disparities we see in the tribal 
communities could improve with more investment in the public 
health and health delivery system.
    One of the biggest recommendations that has recently become 
more important to the Indian Health system this year is advance 
appropriations for the Indian Health Service. This has been a 
longstanding request of NIHB and the recent 35-day partial 
government shutdown only increases the need. The shutdown 
destabilized Native health delivery and health care access. It 
hurts tribal government, families and children. Tribes across 
the Country were forced to cut services and ration care.
    With an already underfunded system, tribes do not want to 
go through another shutdown or lapse in the government funding 
and have to wonder if we have the resources necessary for our 
people. We are urging you to work with us as partners to ensure 
that services are preserved.
    Tribes have also requested $36.8 billion to fully fund the 
IHS over a 12-year period. To start that process, the request 
of fiscal year 2020 is $7 billion. Top priorities in the IHS 
budget include hospitals and clinics, purchased and referred 
care, mental health, alcohol and substance abuse services, 
dental services and facilities construction.
    We are excited about the Administration's proposal to 
invest $20 million to expand the Community Health Aide Program. 
However, to make the most of the investment, there needs to be 
consultation with the tribes to develop a plan for this 
transition.
    We are especially disappointed to again see zeroing out of 
the Health Education Program and a $39 million cut to the 
Community Health Representative Program. Investments in new 
programs should not come at the expense of others that have 
been proven critical to tribes.
    The trust responsibility to tribes does not stop at IHS, 
but spans across all Federal agencies. Many tribes do not see 
the funding from public health grants provided by other 
agencies because they generally go to States instead. Congress 
should provide direct funding to tribes and work with us to 
address the critical health needs.
    Thank you again for the opportunity to testify here today. 
Indian Country is truly grateful for the work that has been 
done in this Committee. There is still more to do to ensure the 
Federal Government fulfills its trust responsibility to tribal 
Nations and ends the health disparities experienced nationwide.
    We look forward to continuing our work with this Committee.
    [The prepared statement of Mr. Joseph follows:]

      Prepared Statement of Hon. Andrew Joseph Jr., Portland Area 
              Representative, National Indian Health Board
    Greetings Chairman Hoeven and Vice Chairman Udall, and Members of 
the Committee. My name is Andy Joseph, Jr., and I serve as Vice Chair 
on the Colville Business Council, as a Co-Chair of the IHS National 
Tribal Budget Formulation Workgroup, and as Chairman of the Northwest 
Portland Area Indian Health Board. (NPAIHB). I thank you for the 
opportunity to provide testimony on ``The President's FY 2020 Budget 
Request for Indian Programs.''
    Established in 1972, the NPAIHB is a tribal organization 
established under the Indian Self-Determination and Education 
Assistance Act (ISDEAA), P.L. 93-638, advocating on behalf of the 43 
federally-recognized Indian Tribes in Idaho, Oregon, and Washington on 
specific health care issues. NPAIHB operates the Northwest Tribal 
Epidemiology Center (NWTEC) and a variety of important health programs 
on behalf of our member tribes and national programs that serve Indian 
country. For twenty-eight years, NPAIHB has conducted an annual 
detailed analysis of the IHS budget. \1\ It is an honor to present you 
with our recommendations for FY 2020.
---------------------------------------------------------------------------
    \1\ NPAIHB Resource Library, available at: http://www.npaihb.org/
resource-lib/ (last visited Feb. 26, 2019).
---------------------------------------------------------------------------
Indian Health Service (IHS)
    FY 2019 Enacted Level Funding for IHS is Inadequate. In FY 2019, 
IHS received an overall increase of $162 million or 3.4 percent above 
FY 2018 enacted level for program and services, not including 
indefinite appropriation for Contract Support Costs (CSC) of $104 
million. I would like to thank the Senate for its support of the 
Community Health Representative program, Health Education and Tribal 
Management Grants in FY 2019. In our annual analysis for FY 2019, we 
determined that a $268 million increase was needed above FY 2018 
enacted level to cover population growth and medical inflation for 
current services (not including CSC). \2\ The final appropriated amount 
for FY 2019 fell short by $106 million. The IHS budget has not received 
adequate annual increases, with a few exceptions, to maintain the costs 
of current services (inflation, population growth, and pay act 
increases).
---------------------------------------------------------------------------
    \2\ NPAIHB, FY 2019 Indian Health Service Budget: Analysis and 
Recommendations--28th Annual Report, http://www.npaihb.org/resource-
lib/ (last visited Feb. 26, 2019).
---------------------------------------------------------------------------
    Maintain Current IHS Services. The fundamental budget principle for 
Northwest Tribes is that the basic health care program must be 
preserved by Congress. Preserving the IHS base program by funding the 
current level of health services should be a basic budget principle by 
Congress. Otherwise, unmet needs will never be addressed. We estimate 
for FY 2020 that in order to maintain current services a minimum of 
$195 million over FY 2019 enacted level is needed to cover medical 
inflation and population growth. Unfortunately, IHS and Tribal health 
programs will suffer consequences if IHS appropriations do not include 
medical inflation, population growth and pay act increases. For FY 
2020, NPAIHB recommends that IHS be funded at least $195 million to 
cover population growth and medical inflation to maintain current 
services with commitment that appropriate program increases be 
designated for IHS and Tribal health programs and not reprogrammed by 
IHS to cover ISDEAA 105(l) lease obligations. \3\
---------------------------------------------------------------------------
    \3\ RADM Michael D. Weahkee, Letter on decision to reprogram a 
portion of FY 2018 funding (Sept. 14, 2018), https://www.ihs.gov/
newsroom/includes/themes/responsive2017/display_objects/documents/
2018_Letters/DTLL_DUIOLL_ISDEAA_09142018.pdf.
---------------------------------------------------------------------------
    Phase in Full Funding for IHS Over 12 Years. Tribal leaders on the 
National Tribal Budget Formulation Workgroup (Workgroup), representing 
all twelve IHS areas, provide recommendations on the IHS budget 
annually through the IHS Budget Formulation process. As I mentioned 
above, I serve as a co-Chair of the Workgroup and am the Portland Area 
representative. The Workgroup provided recommendations for FY 2020 
requesting an end to the growing health disparities by fully funding 
IHS at $36.8 billion, phased in over 12 years. \4\ This recommendation 
is supported across Indian country as a recommendation that honors 
treaty and trust obligations of the United States to provide health 
care to Indian people. Consistent with the Workgroup's recommendation, 
NPAIHB recommends that IHS be funded at $7 billion for FY 2020 to get 
IHS on track for full funding in 12 years. \5\
---------------------------------------------------------------------------
    \4\ 1National Tribal Budget Formulation Workgroup Recommendation, 
FY 2020 Summary Recommendations, https://www.nihb.org/legislative/
budget_formulation.php (last visited May.17, 2019).
    \5\ Id.
---------------------------------------------------------------------------
    Support Advance Appropriations for IHS. The recent partial 
government shutdown caused undue hardship to AI/AN people in the 
Northwest--from federal employees not being able to put food on their 
tables to reduced patient access to care due to clinics cutting their 
hours. Some Northwest Tribes were considering closing their clinics due 
to lack of funding. This is unconscionable treatment of AI/AN people 
and must not be repeated in the future. For these reasons and in 
recognition of the trust and treaty obligations, NPAIHB requests 
legislation that would provide advance appropriations to the Indian 
Health Service.
    Indefinite Appropriation for ISDEAA Section 105(l) Lease Costs. 
Section 105(l) of ISDEAA requires IHS, upon tribal request, to enter 
into a lease for a facility owned or leased by the tribe or tribal 
organization and used to carry out its ISDEAA agreement. As established 
in the Maniilaq case, IHS must compensate the tribe or tribal 
organization fully for its reasonable facility expenses under Section 
105(l) of ISDEAA. \6\ IHS's reprogramming of inflation increases to pay 
the lease costs negatively impacts our IHS and Tribal facilities. IHS/
Tribal facilities rely on inflation increases to maintain current 
services. Unless additional funding is provided in the IHS 
appropriation, then the additional funds required to fund 105(l) leases 
will come at the expense of the health of our people with cuts in 
services for both direct service and self-governance tribes. NPAIHB 
recommends that Congress fund ISDEAA Section 105(l) lease costs as an 
indefinite appropriation.
---------------------------------------------------------------------------
    \6\ See Maniilaq Ass'n v. Burwell, 170 F. Supp. 3d 243 (D.D.C. 
2016).
---------------------------------------------------------------------------
    Oppose Funding Cuts Proposed in President's FY 2020 Budget Request. 
NPAIHB opposes the President's proposed recommendations for several 
critical programs, including: $39 million cut to Community Health 
Representatives (CHRs); elimination of Health Education funding (funded 
at $20.5 million in FY 2019); elimination of Tribal Management funding 
(funded at $2.4 million in FY 2019); $2.5 million cut to Urban Indian 
Health of $2.5 million; $14 million cut to the Indian Health 
Professions (funded at $57.3 million in FY 2019); cut of $1 million to 
Self-Governance; and cut of $657 thousand to Environmental and 
Facilities.
    Fund Clinical Services-Electronic Health Record System in the 
amount of $25 million. NPAIHB recognizes there will need to be a 
substantial investment in information technology (IT) infrastructure 
and software in order for IHS to transition to another system. For FY 
2020, NPAIHB supports the President's Request for $25 million to fund 
``Electronic Health Record System'' planning, phased-in replacement, 
and technical assistance of IHS RPMS. NPAIHB also requests that 
activities be directed by tribes through ongoing tribal consultation.
    Fund Elimination of HIV and HCV in the amount of $25 million. It is 
estimated that there are at least 40,000 AI/AN people, served by IHS, 
with a current Hepatitis C (HCV) infection, according to the IHS 
National Data Warehouse. AI/ANs are disproportionately affected by HCV 
and have both the highest rate of acute HCV infection and the highest 
HCV-related mortality rate of any US racial/ethnic group. The AI/AN 
HCV-related mortality rate in Idaho, Oregon and Washington is over 
three times that of non-Hispanic whites. As to HIV, while rates of new 
HIV diagnoses are not elevated in AI/AN compared to some other race/
ethnicities, there are notable concerns: 1) new HIV diagnoses among AI/
AN increased by 70 percent from 2011 to 2016; 2) AI/AN patients have 
had the lowest survival rates of any race/ethnicity after an AIDS 
diagnosis; and 3) both male and female AI/AN had the highest percent of 
estimated diagnoses of HIV infection attributed to injection drug use 
(IDU). NPAIHB supports the President's Request for funding to Eliminate 
HIV and HCV in the amount of $25 million as an initial step to phased 
in funding, but have recommendations for the following years.
    However, the NPAIHB seeks to carry out the NPAIHB/California Rural 
Indian Health Board (CRIHB) joint resolution #17-04-11 to eliminate HCV 
among AI/AN people by ``providing access to HCV treatment without 
restrictions'' which was also enacted by the Affiliated Tribes of 
Northwest Indians (ATNI) and the National Congress of American Indians 
(NCAI). Lack of drug access to costly new medications (that reduce 
liver-related deaths, prevalence of hepatocellular carcinoma and 
decompensated cirrhosis and liver transplants) is the single most 
important barrier to a scale-up of HCV treatment and liver disease 
prevention. These HCV drugs are on the IHS formulary, but no funding 
has been appropriated to IHS for these drugs, so clinicians must spend 
considerable time mounting often unsuccessful attempts to get third-
party payers such as private insurers, Medicaid, and patient-assistance 
programs to pay for them. Even with the proposed increase of 25 million 
for HIV/HCV elimination, this will treat only a fraction of the 
patients with chronic HCV (2,083/40,000). Therefore, NPAIHB recommends 
the ``Ending the HIV Epidemic: A Plan for America'' includes phased in 
funding for IHS of $120 million for HCV for five years ($600 million 
needed to treat all AI/ANs served by IHS) beginning in FY 2021 and $30 
million for HIV beginning in FY 2021. These funds are the minimum 
amount needed for clinical prevention, treatment and management of HIV/
HCV at I/T/U clinics and NPAIHB supports these these funds be retained 
at a national level for a coordinated effort for treatment. Any funds 
that needed for community level prevention, outreach and education at 
the Tribal level would need additional allocation of funds.
    Fund Expansion of Community Health Aide Program for a minimum of 
$20 million. In the past few years, NPAIHB has been at the forefront, 
with Portland Area Tribes, to get Northwest tribal members trained in 
Dental Health Aide Therapy (DHAT) in Alaska and placed in Oregon, 
Washington and Idaho (this fall). NPAIHB has also been planning for and 
is in the process of establishing a Community Health Aide Program 
(CHAP) certification board; creating and implementing an education 
program for Behavioral Health Aides (BHAs); and implementing a Dental 
Therapy Education Program in partnership with a local community 
college, the Swinomish Indian Tribal Community and Seattle Indian 
Health Board. An IHS interim CHAP policy is currently out for tribal 
consultation (closes June 7) and is expected to allow Areas the ability 
to move forward with CHAP implementation. NPAIHB supports the 
President's Request of $20 million for CHAP but more is funding is 
needed. NPAIHB does not support the proposed cut to the CHR program to 
fund expansion of the CHAP program. Both programs should be fully 
funded.
    Increase Dental Health by $20 million. AI/AN people have a higher 
prevalence of dental caries and untreated tooth decay in all age groups 
compared to the general United States population, with many AI/AN 
children experience high rates of dental caries between the ages of 2 
to 5. \7\ For FY 2020, NPAIHB recommends and increase of $20 million to 
Dental Services to address the growing oral health needs and dental 
professional shortage in Indian Country.
---------------------------------------------------------------------------
    \7\ Phipps KR and Ricks TL, The oral health of American Indian and 
Alaska Native adult dental patients: results of the 2015 IHS oral 
health survey, Indian Health Service data brief, 2016.
---------------------------------------------------------------------------
    Increase Mental Health by $152.5 million. NPAIHB is particularly 
concerned about the mental health of our AI/AN children and youth. 
Suicide is the second leading cause of death for AI/AN adolescents and 
young adults. AI/AN suicide mortality in this age group (10-29) is 2-3 
greater than that for non-Hispanic whites. For FY 2020, NPAIHB 
recommends $75 million to expand funding for pilot projects for 
aftercare services for Native youth discharged from residential 
substance use treatment. More Youth Residential Treatment Centers and 
Tribes must be funded to develop approaches to aftercare, recovery, and 
other support services for Native youth that can be used across other 
IHS/Tribal facilities, YRTCs and in Tribal communities. An additional 
$75 million is needed to expand the Special Behavioral Health Pilot 
Program for Indians, appropriated $10 million in FY 2019. However, 
NPAIHB recommends the option for Tribal shares instead of grant awards. 
Lastly, $2.5 million is needed to fund Area Health Boards/Tribal 
Epidemiology Centers for the provision of technical assistance to 
Tribes and to collect and evaluate Special Behavioral Health Pilot 
Program.
    Increase Alcohol and Substance Abuse by $152.5 million. Alcohol and 
substance abuse, particularly among our AI/AN children and young 
adults, continues to be one of the highest priorities identified by 
Tribal leaders and Health Directors in the Portland Area and across 
Indian country. For FY 2020, NPAIHB recommends $25 million to expand 
funding for pilot projects for aftercare services for Native youth 
discharged from residential substance use treatment; $75 million to 
expand the Special Behavioral Health Pilot Program for Indians, with an 
option for Tribal shares; $2.5 million to fund Area Health Boards/
Tribal Epidemiology Centers for the provision of technical assistance 
to Tribes and to collect and evaluate Special Behavioral Health Pilot 
Program; and $50 million to fund critical detoxification and recovery 
services.
    Increase Purchased and Referred Care (PRC) by $50 million. Without 
IHS/Tribal hospitals in the Portland Area, Northwest Tribes rely on the 
PRC program for all specialty and inpatient care. Because of this, the 
PRC program makes up over one-third of the Portland Area budget and 
when less than adequate inflation and population growth increases are 
provided, Portland Area Tribes are forced to cut health services to 
absorb these mandatory costs. The level funding of PRC in FY 2016 
further diminished the purchasing power of Portland Area Tribes. Those 
IHS areas that have inpatient care can absorb PRC funding shortfalls 
more easily than PRC dependent areas with their larger size staffing 
packages and infrastructure. For FY 2020, NPAIHB recommends a program 
increase of $50 million for Purchased and Referred Care (PRC).
    Increase Indian Health Professions by $10 million. Given the 
recruitment and retention issues of health care providers in many of 
our Northwest Tribal communities, NPAIHB passed a resolution supporting 
an increase for Indian Health Professions to fully fund scholarships 
for all qualified applicants to the IHS Scholarship Program and to 
support the Loan Repayment Program to fund all physicians, nurse 
practitioners, physician's assistants, nurses and other direct care 
practitioners (NPAIHB Resolution18-03-07). For FY 2020, NPAIHB requests 
a program increase of $10 million for Indian Health Professions.
    No Increase to New Healthcare Facilities Construction But Increase 
Small Ambulatory Program (SAP) by $25 million and Increase Joint 
Venture Construction Program (JVCP). The 2016 IHS/Tribal Health Care 
Facilities Needs Assessment Report to Congress stated that the current 
Priority List will not be complete until 2041 and at the current rate 
of construction appropriations and the replacement timeline, a new 2016 
facility would not be replaced for 400 years. Many tribes and tribal 
organizations have had to assume substantial debt to build or renovate 
clinics for AI/AN people to receive IHS-funded health care. For these 
reasons, NPAIHB does not support funding for new Health Care Facilities 
Construction until the current funding mechanism is changed. NPAIHB 
recommends that the Government Accountability Office (GAO) be 
instructed to review and issue a report on the IHS Facilities 
Construction Priority System, including historical and current funding 
distribution inequities. (NPAIHB/CRIHB Joint Res No. 17-04-12). In 
addition, for FY 2020, NPAIHB recommends a program increase of $25 
million for the Small Ambulatory Program (SAP) with funding for 
staffing packages; and increased funding for the Joint Venture 
Construction Program (JVCP).
    Increase Funding for Special Diabetes Program for Indians. Congress 
established the Special Diabetes Program for Indians (SDPI) in the 
Balanced Budget Act of 1997 to provide for the prevention and treatment 
services to address the growing problem of diabetes in Indian Country. 
SDPI expires on September 30, 2019. The SDPI provides a source of 
funding to address diabetes in tribal communities. Prevention and 
treatment services for AI/ANs under SDPI have resulted in short-term, 
intermediate, and long-term positive outcomes. In addition, most 
Northwest Tribes have SDPI programs with demonstrated positive 
outcomes. We recommend reauthorization of SDPI at $200 million per year 
with medical inflation rate increases annually thereafter. We also 
recommend re-structuring of SDPI funding in the future so funding can 
also be available to tribes through tribal shares and not through 
grants.
    Substance Abuse and Mental Health Services Administration (SAMHSA)
    Increase Tribal Opioid Response Funding and Eliminate GPRA 
Reporting Requirement. In the Portland Area a race-corrected analysis 
found the age-adjusted drug overdose death rate for AI/ANs for opioid, 
prescription drug, and all drug overdoses to be twice that of non-
Hispanic whites. This disparity in opioid and drug overdoses has 
persisted in Idaho, Oregon, and Washington since 1997. NPAIHB 
appreciates the inclusion in FY 2019, particularly the $50 million set-
aside for tribes and tribal organizations for Tribal Opioid Response 
(TOR) funding and the $10 million set aside for Medication Assisted 
Treatment (MAT) for tribes, which is crucial for tribal clinics to 
administer MAT. However, this it is not enough funding to enact change 
in healthcare and outcomes. NPAIHB recommends continued SAMHSA TOR non-
competitive funding for tribes in the amount of $75 million for FY 2020 
with continued direct funding to tribes, funding in parity with states, 
and an increase of funding term to at least three to five years. In 
addition, we recommend that TOR funding be flexible to address other 
and co-occurring substance use issues (alcohol, methamphetamines, 
heroin, etc.) and mental health issues. Lastly, we recommend a $15 
million set aside for MAT for tribes in FY 2020.
    SAMHSA should reconsider TOR GPRA reporting for all tribes and 
tribal organizations receiving SAMHSA TOR and Medication Assisted 
Treatment (MAT) funding. The instrument is lengthy and takes 35-45 
minutes per patient to complete; and is required to be completed with 
each patient at 0, 6 and 12 months for MAT and other activities. This 
is a burden on staff of our tribes and tribal organizations and impacts 
patient care. NPAIHB recommends that GPRA reporting be optional, not 
mandatory, and consistent with IHS GPRA reporting requirements for 
self-governance tribes.
    Fund Tribal Epidemiology Centers to Support Tribes TOR and MAT 
Activities. Thirty-four (34) tribes in the Portland Area are receiving 
TOR funding; and twenty-three (23) of the 34 tribes applied through the 
Northwest Portland Area Indian Health Board because they did not have 
the time or capacity to apply on their own. Many tribes found the 
application to be time-consuming, burdensome and were concerned that 
the funding was not adequate to meet the TOR reporting requirements. 
Portland Area Tribes relied on our Tribal Epidemiology Center to 
coordinate the consortium of 23 tribes and to provide technical 
assistance which tribes funded through their TOR funds. There should be 
a specific set-aside for Tribal Epidemiology Centers to coordinate 
consortiums and to provide training and technical assistance to Tribes 
when requested. We recommend a set-aside for Tribal Epidemiology 
Centers of $2.5 million for administration of TOR consortiums, data 
collection, evaluation and/or training and technical assistance.
Office of the Secretary
    Continue Funding for Minority HIV/AIDS Funding formerly known as 
Secretary's Minority AIDS Initiative Fund (SMAIF). Congress 
appropriates an average of $50 million to the Office of the HHS 
Secretary for General Department Management (GDM) to SMAIF. The HHS 
Secretary delegates these funds to other agencies to be used for MAI-
related activities, which support programs that distinctly target 
communities of color. In FY 2018, $3.6 million (1.5 percent) of SMAIF 
dollars were allocated to IHS for HIV/AIDS and HCV prevention, 
treatment, outreach and education--out of the total $53.9 million of 
SMAIF dollars. Continued appropriation to SMAIF and inclusion of Indian 
Country in allocation of these dollars is necessary to maintain 
staffing, capacity, and organizational infrastructure to address health 
disparities for not only our Northwest Tribes, but also Tribes across 
Indian Country. For FY 2020, for SMAIF, we recommend at least $57.5 
million to SMAIF, a $3.6 million increase, so that amount allocated to 
IHS can be increased from $3.6 million to $7.2 million.
    National HIV Elimination Strategy. President Trump announced in his 
State of the Union remarks a commitment to end HIV transmissions within 
10 years. NPAIHB supports a national effort to end HIV but cautions 
that the plan will succeed only if it addresses all people living with 
HIV and all people at risk of HIV. We urge the Administration to 
provide concrete next steps for the plan to end HIV transmission within 
10 years that includes tribes and AI/AN people. While rates of new HIV 
diagnoses are not elevated in AI/AN compared to some other race/
ethnicities, there are notable concerns: 1) new HIV diagnoses among AI/
AN increased by 70 percent from 2011 to 2016; 2) AI/AN patients have 
had the lowest survival rates of any race/ethnicity after an AIDS 
diagnosis; and 3) both male and female AI/AN had the highest percent of 
estimated diagnoses of HIV infection attributed to injection drug use 
(IDU). In addition, most of Indian Country is rural, where barriers to 
HIV education can exacerbate stigma, and reaching specialists for HIV 
is more problematic than in an urban setting. https://www.cdc.gov/hiv/
pdf/group/racialethnic/aian/cdc-hiv-natives.pdf.
    Given this data, we recommend a significant increase of HIV funding 
to Indian Country to increase our Tribal Nations' ability to maintain 
and increase ongoing HIV prevention, treatment, and outreach efforts. 
Moreover, funding for ``Ending the HIV Epidemic: A Plan for America'' 
should not be limited to jurisdiction 1 locations, and should be 
available to all tribes and tribal organizations to end the HIV 
epidemic. Importantly, Congress should ensure that HHS and its agencies 
work with IHS to determine what funding would be needed to eliminate 
HIV in Indian Country per the President's Plan.
Centers for Disease Control and Prevention (CDC)
    Fund Good Health and Wellness in Indian Country (Under Racial and 
Ethnic Approaches to Community Health (REACH)) at $32 million. The Good 
Health and Wellness in Indian Country initiative supports efforts by 
American Indian and Alaska Native communities to implement holistic and 
culturally adapted approaches to reduce tobacco use, improve physical 
activity and nutrition, and increase health literacy. NPAIHB recommends 
that Good Health and Wellness in Indian Country program be funded at 
$32 million. We also recommend that the program be expanded to address 
the health needs of women prior to conception, during pregnancy, post-
partum including breastfeeding and throughout the entire lifecycle for 
prevention of chronic disease.
    Include Tribes in HIV/HCV Funding Opportunities. The NPAIHB would 
like to see base funding for HCV testing, prevention, and treatment in 
Tribal communities. As sovereign nations, Tribes share a unique 
relationship with the federal government. However, funding for HIV/HCV 
prevention and education generally flows to states via block grants. 
This system leaves many Tribes with limited resources, and forces 
Tribes to compete with states for funding. Base funding for HCV in 
Indian Country would further the goals of the U.S. National Viral 
Hepatitis Action Plan for 2017-2020, which identifies AI/ANs as one of 
the primary target populations for reducing new HCV infections and HCV-
related deaths. Base funding for HIV in Indian Country would support 
tribes and tribal organizations to realize the President's plan titled, 
``The Ending the HIV Epidemic: A Plan for America.'' Therefore, we 
recommend an appropriation of direct, formula-based funding to Tribal 
governments for HIV and HCV prevention, testing, and treatment in FY 
2020.
Centers for Medicare and Medicaid Services (CMS)
    Opposition to Medicaid State Block Grant and Per Capita Programs. 
NPAIHB disagrees with the President's proposal for FY 2020 to change 
the Medicaid program to state block grants or per-capita program. This 
change would essentially shift the trust responsibility from the 
federal government to states. This responsibility must remain with the 
federal government to uphold treaty and trust obligations and ensure 
that tribes continue to receive Medicaid reimbursement. We recommend 
that IHS/Tribal/Urban Indian programs be exempt from any Medicaid block 
grant or per capita program.
    Exempt IHS Beneficiaries from Medicaid Work Requirements. Since 
2017, tribes have been engaged in discussions with HHS and CMS 
leadership as to Medicaid work requirements and have repeatedly 
requested an exemption for IHS beneficiaries. While Tribes appreciate 
the recent decision by CMS to allow an exemption for members of 
federally recognized tribes in Arizona, it does not address tribes' 
request for a national exemption of IHS beneficiaries from state 
imposed Medicaid work requirements. NPAIHB recommends a national 
exemption for IHS beneficiaries from state Medicaid work requirements.
    Support Patient Protection and Affordable Care Act (ACA)/Indian 
Health Care Improvement Act (IHCIA). The Patient Protection and 
Affordable Care Act (ACA) has provided an incredible opportunity for 
increased access to health insurance for tribal members in our area. 
Many Northwest Tribes implemented premium sponsorship programs for 
their tribal members. The increased access for AI/AN people to health 
care through the Marketplaces has improved the health of many AI/ANs, 
while the increase of third party revenue to IHS and tribal facilities 
(I/T) has expanded programs and services at I/Ts. There are also 
several important Indian-specific provisions in the ACA that are 
critical to the Indian health system. Section 2901(b) ensures that IHS, 
tribal and urban Indian programs (I/T/Us) are the payers of last 
resort; Section 2901(c) simplifies eligibility determinations for AI/AN 
enrolling in CHIP when seeking services from Indian providers; Section 
2902 authorizes I/T/Us reimbursement for Medicare Part B services; and 
Title IX, Section 9021 ensures that health benefits provided by a tribe 
to tribal members are not counted as taxable income. In addition, 
IHCIA, permanently reauthorized under the ACA, has created 
opportunities to improve access and financing of health care services 
for AI/ANs. NPAIHB respectfully asks that the ACA and IHCIA be 
protected and strengthened to ensure tribes and AI/ANs continue to reap 
the benefits of these laws.
    I thank the Senate Committee on Indian Affairs for this opportunity 
to provide recommendations on ``The President's FY 2020 Budget Request 
for Indian Programs.''

                 STATEMENT OF HON. TOM UDALL, 
                  U.S. SENATOR FROM NEW MEXICO

    Senator Udall. [Presiding.] Thank you very much, Vice 
Chairman Joseph.
    Welcome to all of you. We tried to move this along so you 
could give your testimony. I am going to give my opening and 
then we will start questioning with everybody that is here 
today.
    Today's hearing is not only an opportunity to consider the 
specific proposals put forward by the Administration, but it is 
also an opportunity to examine whether the current budgeting 
process is serving tribes and whether, as one tribal leader 
said it best, Congress is truly fulfilling its Federal 
commitments and promises to tribal Nations.
    Today's hearing comes on the heels of the longest 
government shutdown in history, a painful reminder of the 
harmful impacts of the 2013 sequestration cuts to Indian 
programs and the damage caused by budgetary stalemate and 
uncertainty. Whether it was tribal child welfare programs at 
risk of closing down or tribes struggling to keep ambulance 
services and police vehicles running, the impacts of the 
shutdown this past winter were far-reaching. Indian Country 
can't thrive and the Federal trust responsibility can't be 
fulfilled in a budget environment filled with setbacks of 
sequestration and stop and start government shutdowns.
    That is why I am hopeful that we can all come together to 
agree on a budget deal and why I was proud to introduce 
legislation, S. 229, the Indian Programs Advance Appropriations 
Act, to provide funding certainty for the Indian Health Service 
and the Bureau of Indian Affairs by authorizing their budgets 
to be funded a year in advance. I urge my colleagues to listen 
to our tribal witnesses today and take to heart the need for us 
to work together on a bipartisan basis to reform the tribal 
budget process and provide more certainty for Indian Country. I 
hope you all will join me in support of S. 229.
    I would like to touch on another budget process issue that 
I hope we can consider today, the disconnect between tribal 
consultation and the Administration's budget formulation. At 
our 2019 budget oversight hearing, I spoke about this 
Administration's assertion that budget proposals are, at their 
core, messaging documents, a phrase used by the Office of 
Management and Budget Director Mulvaney. If that is the case, 
the Administration is continuing to send a very concerning 
message about its regard for tribal consultation and its 
priorities for Indian Country.
    The fiscal year 2020 request fails to meaningfully include 
tribes in its marquee proposals and cuts programs identified as 
priorities for Indian Country through budget consultations. In 
fact, just as with fiscal year 2019 proposals, the President's 
budget would cut the Tribal Interior Budget Council's top 
three-ranked programs, social services, tribal courts and 
Indian child welfare, by millions of dollars.
    In the Indian Health Service, this Administration's budget 
once again tries to gut the Community Health Representative 
Program, a program that tribes in New Mexico and across the 
Country have made clear is central to their communities' health 
care. These misalignments between tribal priorities and the 
budget raise serious concerns. I expect the Administration 
witnesses today to explain why I do not see tribal priorities 
reflected in the Administration's fiscal year 2020 request.
    Effective advocacy for tribal budget priorities within the 
Administration depends on strong leadership. Assistant 
Secretary Sweeney, you pledged during your confirmation hearing 
to be an advocate for Indian Country, not only from within the 
halls of Interior but also across the Executive Branch. 
Unfortunately, the Administration's proposed budget does not 
appear to reflect such advocacy. I look forward to hearing from 
you, in particular, about how you have advanced Indian 
Country's budget priorities since assuming your role as the 
highest-ranking Senate-confirmed official in Indian Affairs.
    I thank the Chairman for calling this hearing.
    Senator Udall. Do any of the Senators have opening 
statements? Senator Barrasso?

               STATEMENT OF HON. JOHN BARRASSO, 
                   U.S. SENATOR FROM WYOMING

    Senator Barrasso. Senator Moran was here first. I was going 
to quote the wonderful job your dad did when he came to Wyoming 
in 1963.
    Thank you so much for you all being here. I appreciate the 
testimony from the panel today regarding funding for Indian 
programs for the upcoming fiscal year.
    Admiral Buchanan, I would like to begin with you, if I may. 
As you know, I have worked on legislation with members of this 
entire Committee for the last several years to ensure the 
Indian Health Service had the tools it needs to improve access 
to quality of health care and facilities.
    One month ago on April 8, Chairman Hoeven, Senator Thune 
and I sent a letter to Director Weahkee and Secretary Azar 
requesting the Indian Health Service answer some basic 
questions. One was how the agency manages staff and appointment 
records; how background checks are completed to ensure patients 
are safe; and how the Indian Health Service addresses 
allegations of provider misconduct because that has certainly 
been in the news. Those are questions that our staff first 
posed to the agency in February. I want to submit for the 
record a copy of that letter.
    Senator Barrasso. I would urge you to prioritize a response 
to our letter, because it addresses some of the key failures 
that have placed human health and basic human safety at risk in 
the past. I know I speak for all of us when I say I want to 
work with you to ensure that catastrophic failures in patient 
care do not continue.
    I would like to give you a chance to respond.
    Mr. Buchanan. Thank you, Senator Barrasso, and for your 
leadership to this Committee.
    We have prioritized that letter and the responses. I can 
assure you, I was hopeful to have that letter with me today but 
it is currently under departmental review. We will make it a 
priority.
    Senator Barrasso. Secretary Sweeney, it is good to see you. 
I appreciate the job you are doing. I have appreciated working 
with you and with Secretary Bernhardt to address deferred 
maintenance in the Indian irrigation systems.
    When the bill I originally sponsored and many members of 
this Committee have co-sponsored, the IRRIGATE Act, was enacted 
several years ago, it required Interior to submit a report to 
Congress discussing the first two years of implementation. The 
deadline date was December 2018. Since it is now May, Congress 
is beginning the appropriations process. Do you know when we 
should expect to receive the report on the IRRIGATE Act?
    Ms. Sweeney. I believe the current status of the IRRIGATE 
Act report is going through our internal review process. It is 
moving along through that process.
    Senator Barrasso. I know you have had some change in 
leadership in the department, so anything you can do to 
expedite that, we would really appreciate. Thank you.
    Additionally, Secretary Sweeney, the Bureau of Indian 
Affairs has a number of active agreements with tribes that 
operate certain programs under self-determination contracts. 
There have been a number of cases over the past several years 
where the Interior Inspector General has found that the BIA 
failed to adequately oversee contracts. Some cases were the 
result of poor staff training, some were due to ill-timed 
financial reviews of tribal expenditures.
    The President's budget request for fiscal year 2020 
provides increased funding for the BIA. What steps are you 
taking to improve staff training and oversight to ensure the 
agency and tribes are complying with Federal law?
    Ms. Sweeney. Thank you for your question.
    With respect to the various reports, the high-risk reports 
that have been issued for Indian Affairs, we are taking their 
recommendations seriously. We have concurred with a number of 
them.
    We are working with our Self Governance Division inside of 
Indian Affairs to ensure that they have the appropriate tools 
to carry out their responsibility to their self-governance 
participants. That includes training, that includes working 
with our financial arm to ensure that we can accurately track 
the funding. That includes improving the technology so that 
they can push out money the door faster.
    Senator Barrasso. The GAO recently published their latest 
High-Risk List for government programs. The Bureau of Indian 
Affairs, the Bureau of Indian Education, and the Indian Health 
Service all are included on this list of high-risk government 
programs.
    I appreciate the progress you have made in addressing the 
GAO's recommendations so far. Staff capacity and retention, I 
know, have hampered much of your progress over the past year or 
so. Do you believe the creation of the new Operation of Indian 
Education Programs account will help to address staff stability 
and recruitment issues?
    Ms. Sweeney. I believe that the separation of the BIA and 
the BIE budgets is a great first step in the right direction. 
With respect to the GAO High-Risk Report that you are 
referencing, BIA is collaborating with our partners to address 
the remaining GAO recommendations.
    Senator Barrasso. Thank you.
    Mr. Keel. your testimony focused a bit on transportation 
needs across Indian Country, something you and I have worked 
with over the last decade. While there are a number of programs 
that address tribal transit for patients, the Federal Highway 
Administration administers the Tribal Technical Assistance 
Program, TTAP. Can you talk to me a bit about how tribes have 
used this TTAP over the last several years and whether it has 
improved project planning and delivery on the ground?
    Mr. Keel. Thank you for the question, Senator Barrasso.
    Tribes do utilize those resources. It does assist them in 
advance planning and looking at refining their transportation 
needs. Unfortunately, it is often underfunded and there are 
just not enough resources to go around. It does, in fact, 
assist the tribal leaders when they look at their annual plans 
and refine them. It does allow them some resources to get some 
outside advice and look at the community needs as well as their 
own tribal needs.
    Senator Barrasso. Thank you. Senator Udall.
    Senator Udall. Thank you.
    Senator Cortez Masto.

           STATEMENT OF HON. CATHERINE CORTEZ MASTO, 
                    U.S. SENATOR FROM NEVADA

    Senator Cortez Masto. Thank you. I appreciate the 
opportunity to be here with all of you.
    Let me start with Rear Admiral Buchanan. The President's 
budget includes a 7 percent increase in funding for the Indian 
Health Service. I appreciate that attention to the needs of 
Indian Country, but it is not a pattern that extended to other 
Federal health programs. In fact, I am concerned that cuts 
proposed elsewhere in this budget will outweigh any benefit 
derived from increased IHS funding.
    Let's take, for example, the Medicaid Block Grant proposal. 
Over time, block grants erode in value. If States are unable to 
continue covering expansion populations, will IHS have enough 
money to make up for the decrease in Medicaid reimbursements 
for care sought by tribal members in the Medicaid expansion 
populations?
    Mr. Buchanan. Thank you for the question, Senator Cortez 
Masto.
    Medicaid is part of our third-party collections. Medicaid 
is, I believe, 68 percent of third-party collections that we 
recoup. We utilize those collections to provide additional 
services into the IHS system. Any decreases we get in our 
third-party collections will impact our health care delivery.
    Senator Cortez Masto. If DOJ is successful in validating 
the ACA, which is what I see happening right here, 
unfortunately, with this Administration, IHS will become an 
expired Federal authorization. How will you respond?
    Mr. Buchanan. It will have a huge impact if we are not able 
to access our Medicaid dollars, that is for sure. We will not 
be able to provide the services. We use those Medicaid dollars 
to address, as I mentioned in my opening statement, we had 16 
health care surveys for accreditation. Any deficiencies that we 
found, we use those Medicaid dollars to increase and address 
those services that might have been found deficient. It will 
have an impact.
    Senator Cortez Masto. Thank you very much.
    Assistant Secretary Sweeney, do I read this correctly that 
there is a proposal cutting $2 million from tribal courts 
compared to the previous fiscal year 2019? Is that correct?
    Ms. Sweeney. The tribal courts were level funded against 
the 2019 CR when we formulated the budget.
    Senator Cortez Masto. So what does that mean? That means $2 
million was decreased out of their fiscal year 2019 budget, is 
that right? Or no? Am I reading that wrong?
    Ms. Sweeney. Yes, you are not reading it right. Compared to 
the enacted budget.
    Senator Cortez Masto. There is a $2 million decrease?
    Ms. Sweeney. Yes.
    Senator Cortez Masto. I guess my concern is if I read your 
testimony correctly, you described a BIA report estimating that 
$1 billion is needed for tribal courts; $1 billion is needed 
for tribal courts across the Country. Yet, there is a massive 
funding gap from the current $32 million.
    Describe for me how the tribal courts are going to operate, 
literally. If there is a need for more and we keep cutting, 
what does that mean to our communities, particularly to the 
tribal courts?
    Ms. Sweeney. When you look at the Indian Affairs budget, we 
certainly have budget constraints. It is a very tight budget. 
We have to prioritize programs that continue to maintain 
ongoing operations. There is a need for tribal courts and a 
holistic approach to dealing with the social issues that 
challenge our Native communities. Tribal courts are an 
important component of that. However, when we look at our 
overall obligations, we have to, and I have to, take a very 
balanced approach in how I look at managing this budget.
    So the proposal that is before Congress is the proposal 
that I thought would help us serve the greater good in Indian 
Country with the breadth of the services that we do provide 
while maintaining current operations.
    Senator Cortez Masto. Thank you.
    I notice I am almost out of time. I will defer to my 
colleagues. Thank you.
    Senator Udall. Thank you.
    Senator Moran.

                STATEMENT OF HON. JERRY MORAN, 
                    U.S. SENATOR FROM KANSAS

    Senator Moran. Ranking Member, thank you very much. Thank 
you all for being here this afternoon.
    Let me start first with Secretary Sweeney. Secretary, 
Haskell University, you mentioned in your testimony will 
receive forward funding. I think that is good news. I want to 
highlight an issue that we have had a desire to work with 
Haskell on for a long time, several years.
    Haskell can't establish an endowment. In my conversations 
with folks across the Country, there is recognition of the 
value of Haskell and the willingness to contribute dollars 
toward an endowment that would help Haskell and its students.
    How can we attract private support for tribal colleges and 
universities and help supplement the Federal dollars? Again, we 
understand the law does not currently allow them to have an 
endowment or a foundation.
    Ms. Sweeney. Thank you for your question.
    I am actually traveling to Haskell tomorrow to provide the 
commencement address on Friday. I am very, very excited.
    Senator Moran. Thank you very much. We welcome you to 
Kansas.
    Ms. Sweeney. Thank you.
    I need to first understand why they are not able to 
establish an endowment. If there is a lack of authorization, 
that certainly is a different conversation. Outside of that, if 
we are moving towards authorizing Haskell to set up an 
endowment, then Indian Affairs can serve as a conduit between 
the philanthropic sector and our Haskell University to start 
those discussions on what an effective endowment would look 
like.
    Senator Moran. Secretary, I thank you for that answer. I 
would encourage you if you can provide some leadership on this 
issue. It has been a topic of conversation in Indian Country 
for a long time but very few concrete steps taken to accomplish 
the goal. Please consider me an ally in that effort. I would 
welcome your report. Perhaps this is something that you can 
explore in your time in Kansas. I have given graduation 
speeches. The challenge is that no one is listening, at least 
in my case. I hope you fare better than me.
    Ms. Sweeney. Thank you.
    Senator Moran. Admiral, a question I would like to raise 
with you, on June 6th, the Mission Act, we are talking about 
the Department of Veterans Affairs, the Mission Act will become 
effective. It allows veterans across the Country to access care 
outside the VA system when it is in the best interest of that 
veteran.
    My question to you is, is there is any coordination between 
the Bureau of Indian Affairs and tribal Country as well as the 
Department of Veterans Affairs in making certain that this 
provision that Native Americans who are veterans can access 
care closer to home because it is in their best interests, or 
because they need specialized care and treatment?
    My question in general is, is there not a way we can put 
some more resources into Indian health care utilizing the VA 
programs now particularly that it is not necessary to go, and, 
in fact you could utilize a Bureau of Indian Affairs health 
care facility and perhaps be compensated by the VA for doing 
so? Do you know the story? Are there any plans in the works 
that would be helpful to health care for veteran Indians?
    Mr. Buchanan. Thank you for the question, Senator Moran.
    I would be remiss if I did not say I had connections to 
Kansas. I was the Haskell CEO for about three or four years. I 
appreciated my time in Kansas.
    Senator Moran. Thank you very much. We never understand 
when I meet somebody who lived in Kansas while they no longer 
live there. And Admiral, there is not a lot of water in our 
State, except at the moment it is flooding.
    Mr. Buchanan. I understand.
    We have been in close contact with the VA and with BIA as 
it relates to the Mission Act. We have had ongoing 
communications. Your idea of having the veterans come into the 
clinics and get services, we have actually been doing those 
things. As I mentioned earlier, we have third party resources, 
which include Medicare, Medicaid and private insurance. The 
other piece that is actively gaining ground is VA 
reimbursements. We have seen a dramatic increase of 
reimbursements. We are currently engaged with them.
    Senator Moran. So the VA can reimburse?
    Mr. Buchanan. That is correct. We see those numbers 
continuing to grow over time as our partnerships continue to 
increase. We have not only engaged with them on those 
activities, we have been engaged with them with our electronic 
health records, trying to learn from their lessons learned in 
implementing those.
    Senator Moran. If you discover any difficulties, I would be 
willing to assist in any way I can in dealing with the 
Department of Veterans Affairs to bring the two together.
    Mr. Buchanan. Excellent. Thank you, sir.
    Senator Moran. Thank you, Admiral.
    Just a brief comment, perhaps, President Keel. With the 
proposed increases in the Department of Justice funding for 
tribal programs, would you wish to highlight anything for me? I 
chair the Appropriations Subcommittee that includes the 
Department of Justice. Anything that I should know in that 
regard?
    Mr. Keel. Thank you, Senator Moran. Anything we can get 
that will help tribal courts and tribal policing in tribal 
jurisdictions is a great help. We need those resources.
    When you look at the Crime Victims Fund, the Violence 
Against Women Act, all those things, and giving jurisdiction 
for the tribal courts to punish those, to prosecute and punish 
those perpetrators, that is a great help. Yes, absolutely we 
can always use that. We would be happy to come and work with 
your staff to bring you the information and statistics that we 
have.
    Senator Moran. Thank you. I hope that is one of the issues 
we do not have this time in the reauthorization of VAWA.
    Thank you.
    Senator Udall. Thank you, Senator Moran.
    Senator Tina Smith.

                 STATEMENT OF HON. TINA SMITH, 
                  U.S. SENATOR FROM MINNESOTA

    Senator Smith. Thank you, Mr. Chair.
    I understand that Senator Cantwell has a short time frame.
    Senator Cantwell. The Senator has been waiting. Go ahead.
    Senator Smith. Okay. Thank you very much. I would like to 
start with Secretary Sweeney.
    Secretary Sweeney, as you are aware, there is a terrible 
crisis of missing and murdered indigenous women in this 
Country. In fact, I think many of us, several of us here today 
under the leadership of Senator Udall took to the Senate Floor 
to raise awareness of this issue. I know that Senator Tester, 
Senator Cortez Masto and I all did, as we were talking about 
this issue and its relationship to reauthorizing the Violence 
Against Women Act.
    I know this issue came up the last time you came before 
this Committee. I believe you told us the department is working 
to develop some strategies to address this crisis. Could you 
give us an update on where you are with those strategies and 
what progress you have made?
    Ms. Sweeney. Indian Affairs has been actively engaged in 
discussions with the White House. As you may have noted, over 
the weekend the President issued a Presidential Proclamation 
declaring May 5th Missing and Murdered American Indian and 
Alaska Native Women and Children Awareness Day. That is one 
example of the type of work and the conversations we have been 
involved with across the board with our Federal partners and 
with the Administration.
    We continue to exercise our leadership on the Opioid Task 
Force. As you know, when we move in the direction of working to 
combat illegal narcotic activities within Indian Country, that 
has an effect on violent crimes in our communities.
    Senator Smith. I am certainly glad that the White House is 
contributing to raising awareness of this issue, but I hope 
that your strategies will include more than just raising 
awareness. Because as you well know, women and men in Indian 
Country have been working on this issue and raising awareness 
on this issue for years. I think we are going to need more.
    Let me ask you about another thing if I could. This past 
year, Native communities were among the hardest hit in the 
Federal Government shutdown, which I think was a terrible waste 
and was particularly challenging to tribal communities.
    When the Federal Government does not live up to its trust 
responsibilities with these lapses of Federal funding, tribes 
are forced to suspend really important medical services, child 
care services, other services. I have heard from many Minnesota 
tribes, all Minnesota tribes about the impact the shutdown had 
on their operations.
    In the wake of that, I helped with the bill led by Vice 
Chairman Udall to provide advance appropriations for critical 
funding in Indian Country. This bill would authorize funding 
one year in advance of the fiscal year for programs within the 
Indian Health Service and the Bureau of Indian Affairs. Could 
you tell us whether the Administration supports advance 
appropriations for Indian Country programming?
    Ms. Sweeney. With the effects of the shutdown, we learned 
the importance of improving our internal processes, getting 
additional funding out the door faster in the environment of 
short term CRs, and also improving our communications with 
tribal communities. We understand the breadth of the impact the 
shutdown has had.
    Senator Smith. Let me just ask you. Does the Administration 
support advanced appropriations as we have with Veterans 
Affairs and other programs within the Departments of Education 
and Labor and Housing and Urban Development? Does the 
Administration support advanced appropriations here?
    Ms. Sweeney. I can't speak for the Administration as a 
whole. What I can tell you about Indian Affairs is that we are 
currently looking at that legislative proposal and the existing 
advanced appropriation language to understand the potential for 
any sort of complications that may arise to budget execution 
and the funds allocation.
    I do not have a clear answer for you today. What I can tell 
you is that we are currently and actively looking at that 
language.
    Senator Smith. Can you think of any reason why it would not 
be a good idea?
    Ms. Sweeney. No, not at this time.
    Senator Smith. We will look forward to continuing to work 
on that because I think it is extremely important. I appreciate 
President Keel raising this in your testimony.
    Thank you, Mr. Chairman.
    Senator Udall. Thank you, Senator Smith.
    Senator Martha McSally.

               STATEMENT OF HON. MARTHA McSALLY, 
                   U.S. SENATOR FROM ARIZONA

    Senator McSally. Thank you, Ranking Member Udall. I 
appreciate all the witnesses today.
    Part of the Federal Government's Indian trust 
responsibility is providing quality health care. Indian Health 
Service facilities in Arizona provide critical care and 
services to some of the poorest and most geographically 
isolated areas around the Country.
    Because of the unique challenges that our Native American 
tribes experience in accessing health care in Arizona, it is 
essential that their facilities have the resources they need. 
The fiscal year 2020 request for construction of facilities is 
$77 million below the previous year's enacted level.
    I am concerned such a cut may affect scheduled construction 
for health facilities in Arizona that are both planned and 
underway such as the Bodaway Gap and Dilkon facilities on the 
Navajo, the Sells Hospital on the Tohono O'odham and the 
Phoenix Indian Medical Center.
    Admiral Buchanan, can you commit to me that IHS will devote 
the resources necessary to construct these facilities, those 
that are planned and underway as scheduled and promised to the 
tribes?
    Mr. Buchanan. I can commit to you. We have a grandfathered 
list.
    Senator McSally. Did you say can, just to be clear?
    Mr. Buchanan. I can commit to you, yes. We have several 
projects in place in different phases, so yes, I can commit to 
you that we will move those projects forward.
    Senator McSally. Great. Thank you. I appreciate it.
    Assistant Secretary Sweeney, I want to talk to you about 
rural broadband, the broadband access challenges. A 2018 study 
by the Census Bureau found just 53 percent of households on 
tribal lands with a computer had access to high speed Internet 
compared to 82 percent of households nationally.
    Many residents on tribal lands in Arizona use mobile phones 
to access the Internet, but in the areas of expansive deserts 
and forests and canyons, reliable cell coverage is sparse as 
well. What is the Bureau of Indian Affairs doing to help close 
the broadband access gap? We do have, in Arizona, tribal 
communications carriers like Navajo Nation, Gila River Telecom, 
Hopi Telecom, San Carlos Apache Telecom and others and private 
partners that are trying and eager to expand broadband access, 
but there are some unique obstacles.
    I want to hear your perspectives on that.
    Ms. Sweeney. Thank you for your question, Senator.
    Broadband access in Indian Country is a priority of mine, 
it is a priority of the Department of the Interior. As we all 
know, it is a priority of the Administration as well.
    We are actively engaged with our Federal partners. We are 
currently working with them to convene our tribal enterprises, 
our tribal leadership, tech companies and service providers 
with our Federal partners to develop a road map on how to 
bridge that digital divide in Indian Country.
    One of the things that I commissioned when I first started 
with Indian Affairs was, I wanted to understand where the 
energy transmission lines were across the Country, along with 
the broadband coverage, and overlay that over Indian Country. 
What I found was there are doughnut holes with the energy 
transmission and broadband all around Indian Country.
    You talk about very remote places. I have been to Sells 
several times. We have areas in Indian Country that have no 
electricity. We are leaving a generation of children behind if 
they can't connect to the Internet and they can't go home to 
turn on a laptop or their iPad to do homework because they have 
no electricity.
    We are actively engaged in this across the Federal 
Government with Federal partners and looking to map out a way 
forward.
    Senator McSally. Great. Thank you. I appreciate it.
    I have a number of other questions. I will submit them for 
the record.
    Thank you, Mr. Ranking Member.
    Senator Udall. Thank you, Senator McSally.
    Senator Tester.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Mr. Chairman.
    I want to thank everybody who has testified today. I 
appreciate this hearing. It is an important one.
    I want to start with you, Assistant Secretary Sweeney. It 
kind of dovetails off of Senator Smith's questions.
    You said you could not speak for the Administration when it 
comes to the advanced approach. Do you believe in advanced 
appropriations for the BIA since they do have special trust 
responsibilities that no other agency within the Federal 
Government have?
    Ms. Sweeney. We are having discussions with our Federal 
partners like HHS.
    Senator Tester. Yes, but do you support the advance 
appropriations? Because quite frankly we have things like 
government shutdowns. We don't live up to our trust 
responsibility at all.
    Ms. Sweeney. I understand what you are saying. I do see the 
benefits in advanced appropriations.
    Senator Tester. Thank you.
    The missing and murdered indigenous women crisis is huge. 
We have had hearings in this Committee. On Monday, I sent a 
letter, along with Chairman Hoeven and Vice Chairman Udall, 
bipartisan members of this Committee asking the GAO to conduct 
a study on how the BIA and other Federal agencies respond to 
reports of missing and murdered indigenous women, and improving 
reporting protocols, work with other law enforcement agencies. 
I believe the GAO is going to do this important study.
    I hope you will commit today to working with the GAO to 
provide information they need to put together that 
comprehensive report, either one of you?
    Ms. Sweeney. Absolutely.
    Senator Tester. Ed nods yes.
    You talked about raising awareness. Have you done anything 
specifically with taking steps to improve reports and 
communication between the U.S. Marshals Service, FBI, and 
tribal law enforcement?
    Ms. Sweeney. Thank you for your question.
    We have increased the number of our drug agents and canine 
teams in Indian Country. We also have provided and executed 
tribal community training and awareness events in Indian 
Country.
    Again, we are improving our Federal partnerships to more 
effectively focus on this very, very important issue. When you 
talk about the partnerships between the Office of Justice 
Services and other Federal partners, access to data is key. We 
need to improve that process.
    Senator Tester. Are you in the process of improving the 
data sharing?
    Ms. Sweeney. By we, I mean Indian Affairs and those other 
agencies need to learn to collaborate in a more efficient and 
effective fashion.
    Senator Tester. I got you.
    Ms. Sweeney. To answer your question, the answer is yes.
    Senator Tester. Quite frankly, the FBI has all sorts of 
fish to fry out there. They may not even be aware of what is 
going on, quite frankly, to the extent that you are.
    Ms. Sweeney. Yes.
    Senator Tester. It is not unlike a lot of things, 
consultations with Indian tribes. You guys understand that 
support. Other agencies, it is no big deal. Why do we have to 
talk? It creates problems. If you guys can help lead the charge 
on this, it would be very, very helpful.
    In Montana, like the Northern Cheyenne Tribe, for example, 
has 450,000 acres and one officer. That can be repeated 
throughout Indian Country, in Montana and probably with most, 
if not all, the large land-based tribes.
    Does this budget have adequate funding levels to be able to 
hire the law enforcement that is needed in Indian Country by 
the BIA?
    Ms. Sweeney. Thank you for your question.
    Again, as I explained earlier, we have budget constraints. 
I am looking at maintaining current operations.
    Senator Tester. You are talking about this budget will 
maintain law enforcement but not increase the number of 
officers on the ground?
    Ms. Sweeney. This budget will maintain ongoing operations.
    Senator Tester. Okay, so I would say this. You are a very 
good person. You came here with high marks. We confirmed you. 
If we do not have people like you fighting for more law 
enforcement in Indian Country, it ain't going to happen. It is 
just not going to happen.
    I am telling you the reason we have drugs, crime that is 
over the top, is driven by a lot of things, poverty, bad water, 
no housing, all that stuff that we have to deal with on this 
Committee. But if they do not have law enforcement, it becomes 
a no man's land. I am just telling you that you have to step it 
up.
    I want to talk about hemp. I have 30 seconds. I think there 
is an opportunity with hemp in agriculture. It is a crop that 
we can use in rotation, nothing is worth any more because of 
these tariffs that have been thrown on that are killing 
agriculture right now and it is going to kill rural America.
    Can you update me on the work that you are doing to ensure 
the BIA hemp regulations reflect the 2018 Farm Bill in which we 
addressed hemp, and BIA training of law enforcement officers to 
be compliant with the 2018 Farm Bill, with industrialized hemp? 
Different than the stuff you smoke.
    Ms. Sweeney. Thank you for that clarification. And thank 
you for your answer.
    Senator Tester. That is the question. I am looking for the 
answer.
    Ms. Sweeney. Your question, excuse me.
    We are waiting for the USCA to issue their regulations, but 
we have been working with the Natural Resource Conservation 
Service and the Farm Service Agency to develop an MOU that 
outlines collaboration and consultation to ensure the 
applicable Farm Bill is consistent with Federal and tribal laws 
and regulations.
    Senator Tester. That is good. Let us see if the rubber hits 
the road. Are there tribal land leases currently permitted to 
grow hemp this year?
    Ms. Sweeney. No, not at this time.
    Senator Tester. Okay, so we have to do better. I will just 
tell you why. Montana is one of the last ones to plant and 
planting season is just about over. We have to move forward, if 
you could.
    Thank you very much. We appreciate all of your service. I 
am sorry I just picked on Tara. I should have picked on the 
rest of you too.
    Senator Udall. Thank you, Senator Tester.
    Senator Cantwell.

               STATEMENT OF HON. MARIA CANTWELL, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Cantwell. Thank you.
    I would like to join my colleague from Montana in saying 
how important it is that we fully support Public Law 280 States 
and that the Federal Government do its role and responsibility 
here. My colleague, the Vice Chairman of the Committee, did a 
great job yesterday in helping lead all of us on a Floor 
discussion about how important Savanna's Law is and how 
important it is that we reauthorize the Violence Against Women 
Act. My colleagues, Senator Cortez Masto and Senator Murkowski, 
are leading the charge in the Senate.
    Having two cities that are at the tip of the spear of this 
problem, Seattle and Tacoma, is just something--we need the 
Federal support. We have to get the Federal Government to play 
its role and responsibility. I am very much in line with what 
my colleague from Montana had to say about this.
    Rear Admiral Buchanan, I would like to hear from you on the 
challenges of delivering health care in some of our most rural 
environments. I understand that IHS intends to reopen 
applications on the Joint Venture Facility Construction Program 
later this year. In prior years, they have penalized tribal 
applications for the program if the proposed facility would be 
located within a certain distance of non-Indian hospitals, even 
if tribal members were not able to utilize those hospitals with 
their tribal pay visits for IHS.
    The Colville Tribe, very northeast and central part of our 
State, was informed that the primary reason their application 
did not go forward during the last round in 2014 was this issue 
I just mentioned about location to other facilities. They 
definitely need a new OMAK clinic. The tribe is currently 
operating in an outdated, modular building that can't meet the 
patients' needs and is understaffed. The Joint Venture Program 
is the only way the Colville will be able to make the community 
updates they need.
    Will you reevaluate the criteria of this next round? Will 
you talk about Colville and how, I mean, if there are other 
ideas besides the Joint Venture Program, I would like to hear 
them, but how can they benefit from moving forward and getting 
a facility in the OMAK area?
    Mr. Buchanan. Thank you, Senator Cantwell.
    Specifically to facility purchases or construction, we 
recently had a solicitation for small ambulatory clinics. I 
think that solicitation closes in June, if I am not mistaken. I 
believe the total funding award for that is around $2 million, 
if I am not mistaken.
    I have been to OMAK at the request of Chairman Joseph so I 
understand the facility they are operating out of. I understand 
that, we have a system when we talk about joint projects. We 
utilize a ranking system to score applicants.
    Our Joint Venture Program is a very, very successful 
program. Having participated in a joint venture project working 
with the tribe, I understand the challenges related to that. I 
can commit to you that our headquarters office, our Portland 
office, will assist the Colville Tribe in working with those 
applications.
    The concerns you raise regarding the hospital close by, and 
the tribes' desire to build a clinic nearby, I think we can 
assist the tribe in meeting those application requirements.
    Senator Cantwell. Mr. Joseph, do you have anything to add 
to that?
    Mr. Joseph. Earlier you talked about the historical 
grandfathered list. The Portland area tribes would never see a 
facility in over 20 years if we have to stay by that list. And 
if you make it on that list you would never see a facility in 
over 400 years after that.
    Our tribe, the Colville Tribe, has built three of the four 
facilities, actually about two and a half. But the OMAK 
facility, if it was built, would receive a staffing package 
that would help with the historical staffing shortage we have 
dealt with.
    IHS has never given us the staffing increase in the time 
IHS came about. In the 1950s, our tribe had five doctors. We 
still have only five doctors. Sometimes we have less than that 
because of the hardship area that we live in to have providers. 
So a joint venture would give us the doctors we need. OMAK 
right now has 13 staff. If it had gotten a joint venture, we 
would have 115 Federal-paid physicians. That is how far behind 
we are in staffing for our facilities.
    Senator Cantwell. Rural economic infrastructure investment 
means having rural health care. I hope we can get this worked 
out. I am glad to hear, Rear Admiral, that you actually have 
been to OMAK. That way I don't have to give you an explanation 
about how broad the Colville territory is.
    I know my time has expired. If I could just express my 
objection to the Administration eliminating funding for Native 
CDFI funds, maybe we can follow up on the record. I can't 
understand why you would eliminate investment opportunities to 
Indian Country.
    Thank you. It is good to see you, Mr. Keel. Thank you for 
your leadership.
    The Chairman. [Presiding.] Senator Daines.

                STATEMENT OF HON. STEVE DAINES, 
                   U.S. SENATOR FROM MONTANA

    Senator Daines. Thank you, Mr. Chairman.
    This past Sunday, May 5th, was the national day of 
awareness for missing and murdered indigenous women. We picked 
that day because that was Hanna Harris' birthday. Hanna was a 
member of the Northern Cheyenne Tribe in Montana. She would 
have been 27 on May 5th. She had a ten-month old baby when she 
was brutally raped and murdered near Lame Dear.
    As we all know, the indigenous women face murder rates ten 
times that of the national average. As I travel around Montana 
and hear from families affected by this tragic crisis like 
Kimberly Loring, sister of Ashley Loring Heavy Runner, that one 
of the most frustrating experiences for families is the lack of 
information that is shared from Federal law enforcement 
agencies. It seems like there is a black hole with zero follow-
through sometimes back to the families, let alone making 
information public.
    Assistant Secretary Sweeney, making sure that law 
enforcement is effectively communicating with families and the 
public is I think a key part of addressing this crisis. Does 
the Office of Justice Services currently have access to 
reports, lab results, photos or other evidence on missing 
persons or cold cases with the Department of Justice?
    Ms. Sweeney. Senator, thank you for your question.
    What I can tell you is that if BIA Office of Justice 
Services is the lead investigative bureau on a case, then we do 
have access. If there are cases where the FBI is the lead and 
is conducting an investigation within Indian Country, we can do 
a better job of information sharing.
    Senator Daines. Does that mean they do have access or they 
don't, if it is FBI?
    Ms. Sweeney. Not always.
    Senator Daines. In fact, when I was just recently meeting 
with some law enforcement back in Montana, we have a number of 
members who have worked on these cases for years and we are 
working on getting a protocol put together, literally step by 
step, here is what they do in the important 72 hours after the 
information comes in, whether it is cell phone, social media 
records, across a number of items. We are working on that to 
put out some kind of standardized protocol for law enforcement, 
no matter which particular agency you are with, so we can all 
operate on the same standard procedures.
    I want to thank you for being a staunch ally on this issue 
and I offer any assistance here in Congress to help better 
foster communication among the families and the public, because 
I am hearing a lot of that from these families especially.
    Ms. Sweeney. Thank you, Senator. I just also would like to 
note that we are currently in discussions with the Department 
of Justice to address the communication challenges that our 
bureaus may have, and also taking a look at a more holistic 
approach in terms of providing feedback to the families that 
may be affected.
    Senator Daines. One of the other pieces of feedback I hear 
from families is that once a case gets sent to the FBI, there 
seems to be a bottleneck. The BIA understands Indian Country 
because they live there. The question is what can be done to 
facilitate more involvement, more engagement and more 
coordination with BIA and Indian Country?
    Ms. Sweeney. I think that there is a lot that can be done 
facilitating conversations across the Federal Government with 
agencies and bureaus who have a direct involvement in missing 
and murdered cases, as well as violent crimes, sexual assault, 
and domestic violence. So in addition to the Department of 
Justice and the Department of the Interior, bringing in HHS as 
well, and having that dialogue to look at what truly are the 
needs, what are the challenges, and what role does the 
Administration, does Congress plays in closing that information 
gap.
    Senator Daines. Thank you. I know there is a lot of work 
left to be done. I look forward to working with you and various 
members of the law enforcement agencies to get better in that 
area.
    Let's switch gears to Rear Admiral Buchanan. Stanley Weber 
has left an impact on Montana tribes and children. IHS had 
suspicions of his actions for 21 years and willfully ignored 
multiple reports of his horrendous actions.
    I want to thank Admiral Weahkee for taking the time to 
visit the Blackfeet Nation in February and work with them to 
reestablish trust between IHS and the tribe. Last week, we had 
Admiral Weahkee, he discussed getting an outside contractor to 
look over IHS to identify improvements to protecting patients 
like the victims of these monsters like Stanley Weber. You 
mentioned it again in your testimony. When can we expect a 
contractor to be assigned and is there a timeline for the 
review?
    Mr. Buchanan. I do not have a timeline but I was hoping to 
have a positive response to this particular question should it 
come up. I would say that award is imminent.
    Senator Daines. Is imminent seconds, minutes, days, months, 
years, decades, centuries? Like bureaucracies in D.C., 
sometimes centuries can be imminent.
    Mr. Buchanan. Right. I will say less than days.
    Senator Daines. Less than days?
    Mr. Buchanan. Yes.
    Senator Daines. Thank you.
    I recently introduced legislation that going forward would 
strip government pensions from pedophiles like Stanley Weber 
who are convicted of child molestation. We must do what we can 
to make sure this never, ever happens again and hold those who 
have committed these crimes accountable. So I want to thank you 
for your work in helping us in this regard. This is somebody 
who should never see his government pension.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Daines.
    Vice Chairman Udall.
    Senator Udall. Thank you, Mr. Chairman.
    Senator Daines raised the issue of Mr. Weber. I just want 
to reiterate my condemnation of Weber's conduct and the way IHS 
handled the situation. I think we really need the IHS 
management to be accountable and to make sure individuals who 
are a danger to patients aren't allowed to stay hidden in the 
IHS.
    I have talked Admiral Weahkee about this several times. I 
want to make clear that we are calling for a review of IHS 
management's misuse of transfers, reassignments and 
administrative leave. We are drafting a GAO letter and asking 
other members of this Committee to join us as a requester on 
that.
    Assistant Secretary Sweeney, as Senator Smith mentioned, we 
spoke on the Floor yesterday about the link between MMIW and 
the need for greater public safety resources in Indian Country, 
including restoring the tribes' authority to prosecute all 
offenders who pose a threat to their communities. I understand 
you hope to use your position at DOI to address the missing and 
martyred Indian women crisis.
    Yet, when I see the department's fiscal year 2020 funding 
request, you would cut tribal courts by almost 5 percent, as 
Senator Cortez Masto observed, and you flatline tribal justice 
support activities. I can't help but feel there is disconnect 
between your goals and the funding request. How do the proposed 
cuts to tribal courts and tribal justice support activities 
align with your stated priority of addressing the MMIW crisis?
    Ms. Sweeney. Thank you, Senator, for your question. I want 
to be clear. Are we talking about social services and ICWA 
funding? Because those funding lines reflect transfers by 
tribes to the Consolidated Tribal Governments Program?
    Senator Udall. We are not talking about those line items. 
We are talking about tribal courts and tribal justice support.
    Ms. Sweeney. So as I stated earlier, the tribal courts were 
level funded against the 2019 CR.
    Senator Udall. Yes, well, it is a cut. It is a big cut and 
you admitted to Senator Cortez Masto it is a cut.
    What we did in the 2013 legislation is restore to the 
tribes the ability to prosecute under VAWA. So I am sure, and I 
am going to ask President Keel in a minute, I am sure what the 
tribes expected when we did that was that we were going to give 
them the resources to prosecute. It seems like we are headed in 
the other direction. We would hope that you would advocate for 
that.
    Mr. Keel. do you agree that tribes need more funding, not 
less, for programs to prosecute violent offenders in Indian 
Country?
    Mr. Keel. Absolutely. NCAI wholeheartedly endorses that. I 
would go back to the Tribal Law and Order Act that was passed 
several years ago. The Tribal Law and Order Act, in their 
report, outlined the very need for increased funding for tribal 
courts in jurisdictions that would allow tribes to prosecute 
those offenders, those people who commit violent acts in tribal 
communities. So any time we have level funding or flat funding, 
it hinders their ability to perform those vital services.
    Senator Udall. Thank you, President Keel.
    Assistant Secretary Sweeney, I am sure you are aware that 
the crime statistics for Indian Country, especially against 
Native women, are staggering. Public safety facilities such as 
tribal courts and jails are in need of repair and replacement. 
There is still a great need for more law enforcement resources 
to ensure the safety of tribal communities and helping victims 
achieve justice.
    Yet, this budget request cuts funding for law enforcement 
training at the Indian Policy Academy and public safety 
construction. Madam Assistant Secretary, what are the national 
vacancy levels for law enforcement and corrections personnel 
within the BIA? Briefly, what is the estimated backlog for 
public safety facilities construction?
    Ms. Sweeney. Senator, I am going to have to get back with 
you on the precise numbers.
    Senator Udall. Okay, but vacancy levels are not very good, 
are they?
    Ms. Sweeney. Again, I am going to have to get back with you 
in the statistics.
    Senator Udall. Please do those both for the record. I don't 
think they are going to show a very hopeful trend.
    Mr. Keel. do you believe the Administration's budget, 
including its cuts of the Indian Police Academy and public 
safety employee housing, exacerbates law enforcement shortages 
in Indian Country?
    Mr. Keel. Yes, Senator, and thank you for that question.
    NCAI does wholeheartedly agree that it will hinder our 
ability. Indian Country historically has been underfunded and 
it does inhibit our ability to police our own communities. The 
Police Academy provides BIA police officers to go and serve in 
communities. We desperately need them.
    You heard the Senator mention the large land-based 
organizations, the tribes that operate large land base areas. 
They are very limited. For one or two policemen to patrol that 
vast area is just unthinkable.
    We have been unable to increase the number of police to 
help us and the same with tribal courts, as I said earlier. So, 
yes, we desperately need that. Thank you.
    Senator Udall. President Keel, the Indian Programs Advance 
Appropriations Act would move both BIA and IHS to an advance 
appropriations cycle. While the concept of forward funding for 
IHS has been around a while, a similar need for BIA is 
relatively new by comparison. Can you elaborate, President 
Keel, on the essential services BIA provides for Indian Country 
and explain why its programs should be included in the advanced 
appropriations discussion?
    Mr. Keel. Thank you, Senator, for the question.
    When we talk about the need for sustained programs and 
consistent provision of services, the shutdown last year, this 
past shutdown we went through, outlined several needs, 
everything from plowing snowed roads to police who were laid 
off. We do have such a need. The advance appropriations would 
prevent that, would guarantee that we did not have a shutdown.
    In terms of how they would do that, the VA is already doing 
it. There is a model they could use at the IHS and the BIA 
could use for advance appropriations. It would guarantee there 
would not be an interruption of services, not for one day. When 
we talk about the need for reimbursements, that sort of thing, 
from the VA, the VA has a model and the Indian Health Service 
has a memorandum agreement with the VA for reimbursement.
    I believe the BIA could develop a model. Senator, I believe 
it is just a matter of want-to. There is a need. We urge the 
Administration to support advance appropriations. Again, I 
appreciate the commitment and service that this Committee has 
done over the years to help protect and preserve the Indian 
communities' funding and the services that we provide. Thank 
you for that.
    Senator Udall. Thank you, President Keel. I really 
appreciate that.
    I know that during the shutdown, you heard from many, many 
tribes about, we just can't have this, 35 days with no funding 
and the impact it had. I know Assistant Secretary Sweeney had a 
letter asking what was going on. I am sure she heard a mouthful 
from all of the tribes about how horrible this situation was 
and we should never go back there.
    Mr. Keel. Absolutely.
    Senator Udall. Thank you.
    The Chairman. Secretary Sweeney, I may ask some things that 
have been asked, and I apologize because I was out for some of 
the votes, if that happens.
    What is the Administration's plan to address deferred 
maintenance on BIE schools?
    Ms. Sweeney. I had stated in my testimony, the Public Lands 
Infrastructure Fund as a supplement to the budget request 
submitted.
    The Chairman. Are there public-private partnerships that 
can help as well?
    Ms. Sweeney. We are certainly open to exploring those types 
of partnerships and any other innovative funding mechanisms to 
support the safety of our schools for the children that we 
serve, the students we serve.
    The Chairman. Talk about how you are using law enforcement 
funding specifically to target things like drug enforcement, 
violent crime and also obviously the very serious problem of 
missing and murdered Indian women and children.
    Ms. Sweeney. The law enforcement, our Office of Justice 
Services is doing a phenomenal job with the resources they do 
have with the collaboration with the Opioid Task Force, the 
leadership they have provided, making a difference in Indian 
Country, working with the Bureau of Indian Education on 
improving school safety and the physical safety of our 
students, also collaborating with Federal partners on drug 
interdiction efforts inside of Indian Country.
    The Chairman. Admiral Buchanan, how do you intend to 
address funding for facility leases for IHS and also the 
electronic health record system? Both of those are obviously 
important issues. Do you have enough funding to address both of 
those issues and how do you intend to address them?
    Mr. Buchanan. We will start with the 105(l) leases. The 
2020 budget request was developed before we received a final 
budget for fiscal year 2019. Currently, we are going through 
tribal consultation. We have asked tribes to assist us with 
short and long range solutions going forward. The current need 
right now, as of April, was $54 million. It has been in the 
past, I believe with the assistance of Congress, we received 
$25 million.
    The Chairman. You need more funding there. What about the 
electronic records?
    Mr. Buchanan. Electronic health records, we are currently 
actively doing an EHR modernization project with the chief 
technologies officers in the department. It is a year-long 
project that will evaluate the needs of IHS and the tribes in 
urban programs.
    We are currently in the stage of evaluating self-
governance, direct service tribes, urban tribes, to see what 
the needs are. Part of that plan is to develop a funding 
strategy going forward. I am happy to provide updates to the 
Committee as we continue to move the project forward.
    The Chairman. Yes, we would ask you to do that. The 
strategic plan includes three goals: access to care, quality of 
care and strengthening management and operations. You are 
saying you are implementing that strategic plan right now?
    Mr. Buchanan. Yes, sir.
    The Chairman. Does it adequately address making sure that 
we don't have any kind of recurrence of child sex abuses like 
occurred with Stanley Patrick Weber?
    Mr. Buchanan. The strategic plan was developed, as I had 
mentioned in my comments, over a long process in consultation 
with tribal leaders and our urban Indian programs and our 
stakeholders. The program was designed to be basically a living 
document so that, as was mentioned earlier, the presidential 
task force that is ongoing as it relates to Stanley Patrick 
Weber, the Secretary's request for OIG to do a review, and also 
the medical quality assessment that we mentioned earlier, also, 
all those findings we can incorporate into our strategic plan 
going forward.
    We recently stood up the Office of Quality. The Office of 
Quality will be led by Jonathan Merrell as the Deputy Director, 
he will oversee that contract.
    The Chairman. That has already started, the Medical Quality 
Assurance Review? That has already started?
    Mr. Buchanan. The contracting process has started. 
Selection will be made within days as mentioned to Senator 
Daines.
    The Chairman. President Keel, how has the NCAI worked with 
BIA to address the issue of turnover rates and understaffing in 
the BIA?
    Mr. Keel. Thank you for the question, Mr. Chairman. I am 
really glad you asked that because the turnover rate across the 
Federal Government regardless whether it is BIA or IHS or any 
other agency, is really troublesome. We work with those 
agencies, and the best way we can help them is to come and 
advocate and help them to testify at hearings like this.
    We need a strong Federal budget. We work with them to try 
to help them increase and find ways to justify the increase so 
that they can attract the right people and sustain those levels 
of employees.
    The Chairman. We have to do more, no question about it. 
Thanks for your part and your advocacy. That is very important.
    How about your role as far as consultation with the 
Department of Commerce on the 2020 census count? That is 
another area where obviously it is very important that you play 
a role.
    Mr. Keel. Thank you again, Mr. Chairman. NCAI has worked 
with the Census Bureau. We are doing webinars to train those 
people to go out and conduct the census. We are working with 
them, asking them to come to our meetings and get their staff 
onboard so that we can help with that.
    We are really wanting to get qualified or Native people to 
go out in the Native communities, particularly in remote areas 
where it is really difficult to get an accurate count. We see 
this as an extremely important role. We are working with them 
to do the best we can.
    The Chairman. There is a sense that you can make a 
difference, in terms of the trust factor and getting people to 
make sure they are counted for the census, that you can 
actually play a role in terms of making sure people have the 
confidence that they can come forward and be counted.
    Mr. Keel. And actually fill out the survey, actually fill 
out the forms so that they can be counted. We are trying very 
hard to do that.
    The Chairman. Right. And it is not just a factor of the 
census takers getting out to all those folks, where obviously 
you can play a role in helping get that done, but getting 
people to respond and having that comfort level that they will 
respond.
    Mr. Keel. Absolutely.
    The Chairman. So I think it is very important that you are 
included in that effort in order to get an accurate count.
    Representative Joseph, can you explain how the Community 
Health Representative Program is beneficial and how the program 
is different from the Community Health Aide Program?
    Mr. Joseph. My area is a purchase and referred care 
dependent area, so we don't have hospitals. So a CHR, what they 
do is transport our poorest patients to the hospital that might 
be a 200-mile roundtrip or maybe even a 300-mile roundtrip.
    The Community Health Aides are different. They are more 
like an Army medic or a PA, kind of a transition between that 
and an EMT where they administer services in emergency 
situations. You might have a mental health provider that would 
work on going out to talk to people who are suicidal to bring 
them in for the services that our mental health providers, and 
alcohol program providers, would deal with. The dental aide 
therapist does preventive care for patients.
    Cutting the CHRs, I have eight on my reservation. If we got 
down to four, we would probably lose a whole lot of people to 
not being able to get to the doctors. Right now, we bury so 
darned many of our people because they don't have a ride to go 
to the doctor, they don't have the transportation, or the 
ability to drive themselves because they are disabled and not 
really wealthy enough to get a ride to the doctor.
    They are totally different programs. I totally wouldn't 
want any of our CHRs to lose their positions and be traded off 
to a new program. The new program is really needed because we 
could grow our own CHAP Program. But IHS really needs to 
consult with tribes before they think about taking our CHRs 
away, because that would cost a lot of lives.
    The Chairman. Vice Chairman?
    Senator Udall. Thank you, Mr. Chairman. I am going to 
follow up with Chairman Joseph on that in a second.
    Secretary Sweeney, the President recently indicated support 
for a $2 trillion infrastructure package, but his reported 
strong interest in the infrastructure investment does not 
appear to be reflected in the proposed budget, certainly not 
for Indian Country.
    Indian Country's housing needs is a perfect example of this 
disconnect. HUD's budget cuts to NAHASDA funds for $50 million 
and BIA's budget zeros out the Housing Improvement Program 
known as HIP. That is a big budgetary hit to the housing 
dollars Indian Country needs to ensure safe, affordable housing 
for its membership.
    As you have said yourself, your role as Assistant Secretary 
is both ambassador and advocate for Indian Country's 
priorities, an ambassador between Interior and other agencies 
such as HUD, and an advocate within the halls of Interior. But 
based on the proposed budgets for housing infrastructure across 
agencies, I am concerned that your message isn't landing and 
isn't penetrating. I have been here for a long time and I have 
heard a lot of Administration witnesses say a program is 
duplicative or redundant. I know you are not here as a 
representative of HUD, but the proposed elimination of the HIP 
Program is troubling, especially since the HIP Program is 
directly under your budget purview.
    Do you believe your budget adequately reflects Indian 
Country's housing needs, so there is no longer a need for the 
HIP Program?
    Ms. Sweeney. Senator, thank you. We are not a housing 
agency. The expertise does lie within HUD and their housing 
programs. They will have to become that agency that tribes can 
turn to for their housing needs.
    Senator Udall. The HIP Program is under your budget 
purview, correct?
    Ms. Sweeney. Yes, it is.
    Senator Udall. Do you believe there is no longer a need for 
HIP?
    Ms. Sweeney. I believe that I have an extremely tight 
budget and I have to maintain operations. The expertise for 
housing lies within the HUD program.
    Senator Udall. That is not answering my question. Do you 
believe there is no longer a need for the HIP Program?
    Ms. Sweeney. I believe that program belongs over at HUD and 
not within Indian Affairs.
    Senator Udall. You want to give away the program to 
somebody else that doesn't know nearly as much about Indian 
affairs as you do?
    Ms. Sweeney. I believe that the program belongs within HUD. 
Again, we are not a housing agency. The expertise for housing 
lies within the authorities of HUD.
    Senator Udall. President Keel, what do you think of that?
    Mr. Keel. Thank you, Senator Udall. I disagree. I believe 
that if you look at the Housing Improvement Act, the HUD 
programs, when you look at mutual help homes that started back 
in the 1960s, those houses were over 50 or 60 years old. 
Imagine having a family being told you are going to get one 
house, this is the only house that you are ever going to get, 
and after 25 or 30 years, you have to maintain it on your own 
once it is paid off, because they have to pay for it. Then they 
don't have the means to maintain that.
    The Bureau of Indian Affairs and the Department of the 
Interior Housing Improvement Program has provided some 
assistance to that, although it is not enough. Whether or not 
the expertise for housing improvement or housing remains in 
HUD, I disagree with that. It is the management of a program 
that assists tribal citizens. I believe it should remain where 
it is. I think it just would be better managed. I think it 
needs to be improved and improve funding for that.
    Senator Udall. I could not agree more.
    Assistant Secretary Sweeney, can you share the steps you 
are taking to coordinate with other agencies and the White 
House to ensure Indian Country has a seat at the table during 
budgetary discussions, given the need for things like housing?
    Ms. Sweeney. I do appreciate your question, Senator.
    I can tell you that we are actively engaged with the 
Administration and the Federal partners on a regular basis 
having discussions. I came from the White House earlier this 
morning after spending some time with all of our Federal 
partners talking about Indian Country, the challenges in Indian 
Country, and what we can do as collective Federal partners to 
address those challenges. This is not the first discussion but 
it is in the beginning stages of a very long, long discussion.
    Senator Udall. I hope the message gets through from you to 
the other partners and all the way up to the White House that 
the needs in Indian Country are very, very high and at times, 
desperate.
    The White House really needs to step in, especially the 
Office of Management and Budget, and not restrain things, but 
target resources to really do something about both the BIA, the 
IHS, housing and many of the other areas we have talked about 
today.
    Vice Chairman Joseph, I received numerous letters last year 
from tribes across the Country. This is related, it is a little 
different question from what the Chairman asked, but letters 
from across the Country opposed the Administration's fiscal 
year 2019 request to defund the Community Health 
Representatives Program. Yet, the Administration's fiscal year 
2020 request proposes not only cutting the CHR Program by more 
than 60 percent, but also using a portion of those fund cuts to 
expand the Community Health Aide Program, which currently 
operates only in Alaska. As I noted last week at the Interior 
Appropriations Subcommittee hearing on IHS, I believe the CHAP 
expansion is a worthy goal, but I also believe that Indian 
Country needs a strong CHR Program.
    So, Vice Chairman Joseph, did IHS consult with tribes about 
cutting the CHR Program?
    Mr. Joseph. No, they never did.
    Senator Udall. Or did they consult about the best way to 
carry out expansion of CHAP outside of Alaska?
    Mr. Joseph. I also belong to the CHAP Workgroup. The 
Portland area has really been moving to look at what is going 
on in Alaska and bring it to the lower 48. To me, it is a 
really good program that could help a lot of people.
    But it does not give the rides to the providers that we 
need to get our patients to. The CHRs would actually be 
bringing our patients probably to some of the CHAP providers to 
provide some of the services that they need. They are totally 
different programs. I wouldn't want to take away our CHRs to 
start a new program. A new program should be funded with 
additional dollars, so that it could be administered in both 
direct services tribes and self-governance tribal facilities.
    The Alaska model is really a good model to follow. We also 
need to be able to bill for those services, as well as funding 
to provide the training that those services would be 
administering. To me, it would be a really good program for our 
tribes to have. But we need both of them.
    Senator Udall. Vice Chairman Joseph, the Alaska model is 
really where CHR and CHAP are complementary; they complement 
each other, rather than cutting one to the benefit of another. 
Isn't that correct?
    Mr. Joseph. Yes. The CHRs up there have to probably 
transport their patients a whole lot further than any other 
area. My tribe is considered a large land-based tribe. Just to 
get in to a provider, those CHRs are very important.
    Senator Udall. President Keel, would you agree with that?
    Mr. Keel. Yes, I do agree. I think the programs should be 
complementary. The CHR Program has been the backbone of the 
Indian Country health issues for, well, that was back in the 
1970s when we started. It is an important program, but they 
should complement each other. I think the Community Health 
Aides in Alaska are a little more advanced. They have different 
types of training and different needs and their priorities are 
a little different but yes, we need both programs. We should 
not cut the CHR Program.
    Senator Udall. In my visits to Indian Country, especially 
in New Mexico, I have seen the work that the CHR folks do. It 
is very, very important work. I hope, Assistant Secretary 
Sweeney, you will take that into the halls where you are 
calling people together, advocating and being an ambassador, 
how important both of these programs are and how they 
complement each other rather than trying to savage one of them 
to stand up another.
    Thank you very much, Mr. Chairman. I really appreciate the 
courtesies.
    The Chairman. You bet. All right, if there are no more 
questions for today, members may also submit follow-up, written 
questions for the record. The hearing record will be kept open 
for two weeks.
    With that, I want to thank all of you again for being here 
and for your testimony. We appreciate it.
    Our hearing is adjourned.
    [Whereupon, at 4:27 p.m., the Committee was adjourned.]

                            A P P E N D I X

Prepared Statement of the American Indian/Alaska Native Health Partners
    The American Indian/Alaska Native Health Partners thanks the 
Committee for allowing us to submit testimony on the FY 2020 
appropriation for the Indian Health Service (IHS).
    The AI/AN Health Partners is a coalition of health organizations 
dedicated to improving health care for American Indians and Alaska 
Natives (AI/ANs). AI/ANs face substantial health disparities, and 
higher mortality and morbidity rates than the general population. The 
Indian Health Service (IHS) is a critical aspect of how they can access 
health care. However, the IHS must have sufficient resources to meet 
its mission to raise the physical, mental, social, and spiritual health 
of American Indians and Alaska Natives to the highest level.
    The Partners recognize the budget constraints the committee faces, 
but we are also aware that for too many years federal funding for 
tribal health programs has fallen woefully short. A December 2018 GAO 
report found that the IHS per capita spending was $4,078 as compared to 
$8,109 for Medicaid, $10,692 for veterans and $13,185 for Medicare.
    Being able to access health care when needed is key to erasing the 
disparity of care for AI/ANS. In a March 2016 GAO report, ``Actions 
Needed to Improve Oversight of Patient Wait Times,'' IHS facility staff 
pointed to three things that were necessary to improve timely access to 
health care for American Indians and Alaska Natives (AI/ANs):

         ``. . .facility staff stated that a lack of sufficient primary 
        care providers, as well as aging infrastructure and equipment 
        are significant obstacles to ensuring that patients receive 
        timely care.''

    To address these concerns, for FY 2020, the AI/AN Health Partners 
recommends that Congress:

   Increase the funding for loan repayment and scholarships by 
        $32,000,000,

   Increase funding for staff housing by $30,000,000, and

   Increase funding for modern medical equipment by $10,000,000

Increase the Health Professions account by $32,300,000 to $89,363,000
    Having an adequate staff of healthcare providers is a key factor 
for reducing the disparity of disease and care in Indian country. 
Currently, there are over 1,330 vacancies for healthcare professionals 
in the Service. Loan repayment has proven to be an effective 
recruitment and retention tool for Indian health programs. In FY 2018, 
1,325 health professionals were receiving IHS loan repayment. However, 
844 healthcare providers sought and were denied loan repayment. Of 
those applicants, 399 did not take an assignment with any IHS or tribe 
facility. The Health Professions account also provides scholarship 
funding for American Indian/Alaska Native health care students. In FY 
2018, 426 students were considered eligible for scholarships, but only 
155 received an award. With additional funding the Service could 
substantially increase the number of AI/AN providers educated, 
recruited and retained in Indian health programs.
Increase funding for housing for health care providers by $30,000,000 
        to $89,363,000
    Providing decent housing, especially in remote areas, is essential 
for attracting and keeping health care providers in Indian country. In 
2018, the Navajo Nation opened a new housing complex for health care 
workers. Navajo Nation President Russell Begaye explained at the 
dedication the importance of the building:

         ``In healthcare facilities across Navajo, we have a 30-percent 
        vacancy rate for professional staff, including medical doctors, 
        nurses and technicians,'' President Begaye said. ``The No. 1 
        reason is that we don't have this type of [ housing] building 
        on the Nation. We need more of these. We want doctors to walk 
        in to these buildings at the end of the day and feel at home.''

    Current funding for staff quarters is $10,000,000. The Service 
estimates it would require at least $40,000,000 to address 
approximately 10-percent of the need for staff quarters.
Increase funding for medical equipment by $10,000,000 to $33,706.000
    Accurate clinical diagnosis and effective medical treatment depends 
in part on health care providers using modern equipment/systems to 
assure the best possible outcomes. Today's health care providers train 
with modern digital equipment. However, many IHS and tribal health care 
facilities are using outdated equipment like analog mammography 
machines and telecommunications equipment with an insufficient number 
of lines for scheduling patient appointments. In some cases, they are 
using equipment that is no longer manufactured. Outdated equipment also 
makes it difficult to attract and retain new graduates who are used to 
working with the newest technolog.
    According to the IHS, ``A sustainable medical equipment program for 
the IHS should be funded in the $100 to $150 million annually range to 
cover replacement and maintenance.'' Examples of immediate need 
include:

   The Phoenix facility needs a Nurse Call System to monitor, 
        track, and log patient information and monitor their health, a 
        hand hygiene system (monitors hygiene compliance, fill levels, 
        etc) and a pharmacy security/monitoring system.

   The Gallup Medical Center is using a portable X-Ray machine 
        that has exceeded its Useful Life. Use of old x-ray technology 
        results in a reduced Medicare reimbursement rate.

In addition to the above FY 2020 appropriations requests, the Partners 
        also support the Administration's request to make Indian Health 
        Service (IHS) loan repayment and scholarship programs tax free
    Loan repayment and scholarship money has proven to be a successful 
tool to recruit and retain health care providers in Indian country. 
This is critical given the significant need for providers serving this 
population. While the IHS currently has funding for scholarships and 
loan repayment for health care providers, these programs are not tax 
exempt like the National Health Service Corps and Armed Forces Health 
Professions loan repayment programs. As a result, the IHS provides tax 
payments for health care providers and students from the Health 
Professions account. According to the Service's FY 2020 budget 
justification, making these programs tax free would free up an 
additional $9,187,927 that could be used to bring more providers to 
Indian country.
    Thank you for allowing the AI/AN Health Partners to share with the 
Committee our recommendations for improving health care in Indian 
country.
    Our organizations look forward to working with the Committee to 
improve the health care for American Indians and Alaska Natives,

        American Academy of Pediatrics
        American Association of Colleges of Nursing
        American Association of Nurse Anesthetists
        American College of Obstetricians and Gynecologists
        American Dental Association
        American Optometric Association
        American Physical Therapy Association
        Association of American Indian Physicians
        Association of American Medical Colleges
        Commissioned Officers Association of the U.S. Public Health 
        Service, Inc. (COA)
        National Kidney Foundation

Health statistics for American Indians/Alaska Natives
Diabetes

   At 16.1 percent, the American Indian and Alaska Native (AI/
        AN) population has the highest age adjusted prevalence of 
        diabetes among all U.S. racial and ethnic groups.

   The prevalence of diabetes varies among different tribes and 
        regions, but it is growing in all Indian Health Service areas.

   AI/AN mortality from diabetes is three times higher than 
        that of the general U.S. population.

Eye and Vision Health

   In 2017, 4 percent of American Indian and Alaska Native 
        adults reported significant vision loss or visual disability, 
        almost double the U.S. average of 2.3 percent.

   Research has suggested that American Indian and Alaska 
        Native children experience higher rates of astigmatism that 
        other American children.

   American Indian and Alaska Native adults are at an increased 
        risk for diabetes-related blindness because they suffer from 
        diabetes at more the twice the rate of the American population 
        and because only half receive the annual eye exam necessary for 
        diagnosis and treatment.

Heart Disease

   Among American Indians or Alaska Natives, 13.7 percent have 
        heart disease, 6.0 percent have coronary heart disease.

   In 2013, CVD caused 3,895 deaths among American Indians or 
        Alaska Natives.

Infant Mortality and American Indians/Alaska Natives

   American Indian/Alaska Natives have 1.6 times the infant 
        mortality rate as non-Hispanic whites.

   American Indian/Alaska Native babies are twice as likely as 
        non-Hispanic white babies to die from sudden infant death 
        syndrome (SIDS).

   American Indian/Alaska Native infants are 70 percent more 
        likely than non-Hispanic white infants to die from accidental 
        deaths before the age of one year.

Maternal Mortality

   In 2014, American Indian/Alaska Native mothers were 2.5 as 
        likely to receive late or no prenatal care as compared to non-
        Hispanic white mothers.

   According to one state report, from 2014-2015, the rate of 
        pregnancy-associated maternal death among American Indian/
        Alaska Native women is more than eight times higher than for 
        non-Hispanic white women

Mental Health--PTSD and Suicide

   American Indians and Alaska Natives had significantly higher 
        rates compared with national data rates for post-traumatic 
        stress disorder ranging from two to three times the national 
        rate.

   For the years 2002-2004, AI/ANs committed suicide at a rate 
        of 17.9 per 100,000 population, a rate that has remained fairly 
        stable for 25 years. For 2003, this was 1.7 times the U.S. All 
        Races rate of 10.8 per 100,000.

   Suicide is the second leading cause of death for Native 
        people ages 10-34. For American Indians and Alaska Natives ages 
        15-34, the suicide rate is 1.5 times higher than the national 
        average. In some tribal communities, the youth suicide rate is 
        10 times greater than the national average.

Mental Illness and Substance Use Disorder

   Individuals living with serious mental illness and substance 
        use disorder face an increased risk of having chronic medical 
        conditions. Adults in this population die on average 25 years 
        earlier than others, largely due to treatable medical 
        conditions.

   American Indian and Alaska Native populations had the second 
        highest overdose rates from all opioids among racial/ethnic 
        groups in the US.

Oral Health

   Over 80 percent of American Indian and Alaska Native 
        children ages 6-9 and 13-15 years old have tooth decay, 
        compared to less than 50 percent of children of American 
        children in the same age categories.

   American Indian and Alaska Native adults have more than 
        double the prevalence of untreated tooth decay as the general 
        U.S. population.

   The rate of severe periodontal disease in American Indians 
        and Alaska Natives adults is almost double that of the general 
        U.S. population
                                 ______
                                 
     Prepared Statement of the National Indian Health Board (NIHB)
    Chairman Hoeven, Vice Chairman Udall, and Members of the Committee, 
the National Indian Health Board (NIHB) thanks you for holding this 
hearing on, ``The President's FY 2020 Budget Request for Indian 
Programs.'' On behalf of NIHB and the 573 federally-recognized Tribes 
we serve the National Indian Health Board submits this testimony for 
the record. NIHB is a 501(c)3, not for profit, national Tribal 
organization founded by the Tribes in 1972 to serve as the unified, 
national voice for American Indian and Alaska Native (AI/AN) health in 
the policy-making arena. Our Board of Directors is comprised of 
distinguished and highly respected Tribal leaders in AI/AN health. They 
are elected by the Tribes in each region to be the voice of the Tribes 
at the national level.
The Federal Trust Responsibility
    The federal promise to provide Indian health services was made long 
ago. Since the earliest days of the Republic, all branches of the 
federal government have acknowledged the nation's obligations to the 
Tribes and the unique trust relationship between the United States and 
Tribes.
    The Indian Health Service (IHS) is the primary agency by which the 
federal government meets the trust responsibility for direct health 
services. IHS provides services in a variety of ways: directly, through 
agency-operated programs and through Tribally-contracted and operated 
health programs; and indirectly through services purchased from private 
providers. IHS also provides limited funding for urban Indian health 
programs that serve AI/ANs living outside of reservations. Tribes may 
choose to receive services directly from IHS, run their own programs 
through contracting or compacting agreements, or they may combine these 
options based on their needs and preferences.
    Today the Indian Health Service system is comprised of 45 hospitals 
(26 IHS operated, 19 Tribal) and 531 outpatient facilities (76 IHS 
operated, 476 Tribal). At these facilities there were an estimated 
39,367 inpatient admission and 13.8 million outpatient visits in 2018. 
\1\ When specialized services are not available at these sites, health 
services are purchased from public and private providers through the 
IHS-funded purchased/referred care (PRC) program. Additionally, 34 
urban programs offer services ranging from community health to 
comprehensive primary care. To ensure accountability and provide 
greater access for Tribal input, IHS is divided into 12 geographic 
Service Areas, each serving the Tribes within the Area. It is important 
to note that Congress has funded IHS at a level far below patient need 
since the agency's creation in 1955. In FY 2017, national health 
spending was $9,726 per capita while IHS spending was only $4,076 per 
patient.
---------------------------------------------------------------------------
    \1\ Source: Indian Health Service. IHS Profile Fact Sheet. Located 
at: https://www.ihs.gov/newsroom/factsheets/ihsprofile/
---------------------------------------------------------------------------
    The federal government has yet to live up to the trust 
responsibility to provide adequate health services to our nation's 
indigenous peoples. Historical trauma, poverty, lack of access to 
healthy foods, loss of culture and many other social, economic and 
environmental determinants of health as well as lack of a developed 
public health infrastructure in Indian Country all contribute to the 
poor state of American Indian and Alaska Native (AI/AN) health. This 
underfunding of the IHS is clearly visible when examining the health 
disparities for AI/ANs. A national study looking at death certificate 
data reported that AI/AN experienced the highest prescription opioid 
death rate of any demographic in 2017 at 7.2 deaths per 100,000. From 
1999 to 2015 drug overdose deaths overall rose by 519 percent for AI/
ANs. \2\ According to the Office of Minority Health, from 2009-2013, 
AI/AN men were almost twice as likely to have liver and inflammatory 
bowel disease (IBD) cancer as non-Hispanic White men and are 1.6 times 
as likely to have stomach cancer as non-Hispanic White men, and are 
over twice as likely to die from the same disease. AI/AN women are 2.5 
times more likely to have, and almost twice as likely to die from, 
liver and IBD cancer, as compared to non-Hispanic White women. In 2015, 
AI/ANs were three times more likely to die from hepatitis C than non-
Hispanic whites, and twice as likely to die from hepatitis B. In 2016, 
AI/ANs had the highest overall suicide death rate at 21.39 deaths per 
100,000. \3\ According to National Violent Death Reporting System data 
analyzed by CDC across 18 states, AI/AN suicide rates in those states 
were at 21.5 per 100,000--more than 3.5 times the rate among 
demographics with the lowest rates. \4\
---------------------------------------------------------------------------
    \2\ 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
    \3\ Suicide Prevention Resource Center. Racial and Ethnic 
Disparities. Retrieved from http://www.sprc.org/racial-ethnic-
disparities
    \4\ Leavitt RA, Ertl A, Sheats K, Petrosky E, Ivey-Stephenson A, 
Fowler KA. Suicides Among American Indian/Alaska Natives--National 
Violent Death Reporting System, 18 States, 2003-2014. MMWR Morb Mortal 
Wkly Rep 2018;67:237-242. DOI: http://dx.doi.org/10.15585/mmwr.mm6708a1
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    In FY 2017, the IHS per capita expenditures for patient health 
services were just $4,076, as compared to $8,109 for Medicaid, $10,692 
for VHA, and $13,185 for Medicare. The Veterans' Health 
Administration's direct health care budget is 14 times that of the IHS 
yet served only 4 times the population with direct care services.
    Tribes are grateful for the recent increases to the IHS 
Appropriation over the last several years, but note that the increases 
have not allowed for significantly expanded services or improvements in 
equipment, buildings or staffing. While the IHS annual appropriated 
budget has incrementally grown by $2.2 billion (about 52 percent) since 
FY 2008, much of this increase simply covers needs associated with 
population growth, inflation, full funding of Contract Support Costs 
and maintaining current services. This leaves little funding for actual 
improvements in health services or to build public health 
infrastructure for American Indians and Alaska Natives. We are only 2 
percent of the population. Congress, please take the courageous and 
ethical step of adequately funding health care for this country's first 
peoples in fulfilment of the Trust Responsibility.
    The following testimony reflects the IHS Tribal Budget Formulation 
Workgroup recommendations for FY 2020. \5\ The Tribal workgroup is 
comprised of American Indian and Alaska Native Tribal leaders, 
technicians and researchers, nationwide, who come together each year to 
form Indian Country's priorities as they relate to IHS. Through this 
process and product, this testimony reflects, therefore, the national 
Tribal voice.
---------------------------------------------------------------------------
    \5\ The full FY 2020 Tribal Budget Request is available at https://
www.nihb.org/legislative/budget_formulation.php
---------------------------------------------------------------------------
Indian Health Service Budget
    Tribes recommend $36.8 billion to fully fund IHS, to be phased in 
over 12 years. This includes amounts for personal health services, 
wrap-around community health services, facilities, and capital 
investments. For FY 2020 this includes: $189.1 million for full funding 
of current services; $275 million for binding fiscal obligations; \6\ 
$1.5 billion for program increases for the most critical health issues 
(36 percent above FY 2017 enacted). The Workgroup's top 5 areas for 
program expansion at IHS for FY 2019 include:
---------------------------------------------------------------------------
    \6\ Includes placeholder estimates for Contract Support Costs (CSC) 
and staffing for new facilities and new Tribes.

        1) Hospitals and Clinics (+ $409 Million)
        2) Purchased/Referred Care (+ $407 Million)
        3) Mental Health (+ $157.2 Million)
        4) Alcohol and Substance Abuse (+ $123.8 Million) and;
        5) Dental Services (+ $98.3 Million)

    Hospitals and Clinics--For FY 2020, Tribes recommend $2.5 billion 
for Hospitals and Clinics (H&C) which is $409 million over the FY 2017 
enacted level. Adequate funding for the Hospitals & Clinics (H&C) line 
item is the top priority for fiscal year 2020, as it provides the base 
funding for the 650 hospitals, clinics, and health programs that 
operate on Indian reservations, predominantly in rural and frontier 
settings. This is the core funding that makes available direct medical 
care services to AI/ANs. Increasing H&C funding is necessary as it 
supports medical care services provided at IHS and Tribally-operated 
facilities, including emergency care, inpatient and outpatient care, 
medically necessary support services, such as laboratory, pharmacy, 
digital imaging, information technology, medical records and other 
ancillary services. In addition, H&C funds provide the greatest 
flexibility to support the required range of services needed to target 
chronic health conditions affecting AI/ANs such heart disease and 
diabetes, treatment and rehabilitation due to injuries, maternal and 
child health care and communicable diseases including influenza, HIV/
AIDS, and hepatitis.
    Health IT: One area within the H&C line item is the area of Health 
Information Technology (HIT). IHS does not receive dedicated and 
sustainable funding for the agency to adequately support health IT 
infrastructure, including full deployment of electronic health records 
(EHRs). The current Resource and Patient Management System (RPMS) is a 
comprehensive suite of applications that supports virtually all 
clinical and business operations at IHS and most Tribal facilities. The 
President's Budget for FY 2020 requests $25 million for IHS, ``to begin 
to transition to a new and modernized Electronic Health Record 
System.'' It notes that the funding will help ``lay the groundwork'' 
for improving Health IT at the agency. This recommendation is 
appreciated due to the lack of funding that has resulted in a mass 
exodus of Self Governance Tribes who have opted to withdraw their IT 
shares to seek other commercial HIT solutions which promise to more 
readily address their needs. Without a viable solution, IHS Health IT 
system will be left behind, and IHS patients will be put at risk. With 
the VA's move toward a commercial-off the shelf EHRs, it is critical 
that IHS receive parallel appropriations to facilitate the replacement 
of RPMS, since our system is based on VA's VistA program. It is 
unlikely that appropriate funding will be available only through 
Interior Appropriations; therefore, alternative sources of funding must 
be secured.
    Purchased/Referred Care--In FY 2020, Tribes recommend $1.39 billion 
for the Purchased/Referred Care (PRC) program. This is $407 million 
above the FY 2017 enacted level. The PRC budget supports essential 
health care services from non-IHS or non-Tribal providers. In FY 2015, 
PRC denied over $423.6 million in services--that is 92,354 needed 
health care services that AI/ANs were denied from receiving. This core 
funding is still a top priority for the Tribes, as some service Areas 
rely heavily on PRC dollars, and we hope to see it continued as a 
priority in FY 2020. These deferrals impact real lives and constitute 
health care rationing for American Indian and Alaska Native patients. 
The shortage of PRC funds directly contributes to the opioid crisis in 
Tribal communities as evidenced through pain management regiments vs. 
needed treatment for painful injuries--such as those that could be 
treated through othoepadic care. Indeed, the deferrals of care due to 
funding and workforce shortages has pushed more and more Tribal members 
towards prescription opioids to treat health conditions that would 
otherwise successfully be treated with non-opioid therapies. This 
endless cycle of deferral and opioid dependency is a direct result of 
the underfunding of the IHS system, and must be addressed.
    Mental Health--In FY 2020, Tribes are recommending $254,730 
million. This is $157.2 million above FY 2017 enacted. This increase 
would mean a 167 percent increase in funding for behavioral health 
services in Indian Country. A significant increase is needed to enhance 
the capacity of Tribal communities to develop innovative and culturally 
relevant prevention programs that are greatly needed in Tribal 
communities. Research has shown that AI/ANs do not prefer to seek 
mental health services that rely solely upon Western models of care; 
which suggests that AI/ANs are not receiving the services they need. 
\7\ For example, NIHB spoke with a young woman from the Pine Ridge 
Reservation who courageously shared her story about her multiple 
suicide attempts. She went to an inpatient psychiatric facility in 
Rapid City, but did not feel that she received healing. It wasn't until 
she attended a Lakota cultural healing camp that her life turned 
around. She said, ``It made me feel powerful. I got to learn about my 
culture and it made me feel closer to who I am.'' But the camp operates 
through donations and community support. Congress should provide 
dedicated funding for these types of culturally relevant and effective 
treatment options. The geographic remoteness of most Tribal communities 
demands unique and innovative treatment options to address 
comprehensive mental health, substance abuse and psychiatric services.
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    \7\ Beals, J., Novins, D.K., Whitesell, N.R., Spicer, P., & 
Mitchell, C.M., & Manson, S.M. (2005). Prevalence of mental disorders 
and utilization of mental health services in two American Indian 
reservation populations: Mental Health disparities in a national 
context. American Journal of Psychiatry, 162, 1723-1732; Walls, M. L., 
Johnson, K. D., Whitbeck, L. B., & Hoyt, D. R. (2006). Mental health 
and substance abuse services preferences among American Indian people 
of the northern Midwest. Community Mental Health Journal, 42, 521-535.
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    Alcohol and Substance Abuse--In FY 2020, Tribes recommend $351,237 
million for the Alcohol and Substance Abuse budget. This is $123.7 
million above the FY 2017 enacted level. Of the challenges facing AI/AN 
communities and people, no challenge is more far reaching than the 
epidemic of alcohol and other substance abuse. For instance, the state 
of Minnesota reported that pregnant AI/AN women were 8.7 times more 
likely to be diagnosed with maternal opioid dependency, and that AI/AN 
infants were 7.4 times more likely to be born with neonatal abstinence 
syndrome (NAS)--meaning that the repercussions and trauma of this 
crisis are intergenerational. When IHS programs are not able to receive 
patients when an addict is ready, this is where he or she falls through 
the cracks. We need these funds to increase access to care when and 
where it is needed. Adult and youth residential facilities and 
placement contracts with third party agencies are funded through IHS 
budget for alcohol and substance abuse treatment. Successful treatment 
approaches include traditional healing techniques that link the 
services provided to cultural practices and spiritual support. However, 
we now know that inadequate funding for alcohol and substance abuse 
services has a ripple effect on other services, such as overloading the 
agency's outpatient clinics, urgent care departments, and emergency 
departments with unnecessary visits (typically funded by Hospitals and 
Health Clinic funds and third party collections).
    Dental Health--For FY 2020, Tribes recommend $288 million for 
Dental Health. This is $98.3 million above the FY 2017 enacted level. 
In the general U.S. population, there is one dentist for every 1,500 
people, but in Indian Country, there is only one dentist for every 
2,800 people. Nationally, American Indian children have the highest 
rate of tooth decay than any population group in the country. On the 
Pine Ridge Reservation, the W.K. Kellogg Foundation found that 40 
percent of children and 60 percent of adults suffer from moderate to 
urgent dental needs, including infections and other problems that could 
become life-threatening. Nationally, 59 percent of AI/AN adult dental 
patients have untreated decay, this is almost three times as much as 
U.S Whites. It is not uncommon to hear stories of elderly patients 
waiting out in the cold for one of just a few dental appointments 
available in one day. Or, for patients to wait for months to get an 
appointment. Patients get frustrated with this system and often abandon 
the search for care altogether. This delayed or deferred care has long-
term impacts over a patient's overall health and wellbeing. NIHB and 
the Tribes continue to support the expansion of Dental Therapists (DTs) 
to Tribes outside of Alaska as a safe, reliable, cost-effective means 
for Tribal members to access oral health services. Some Tribes in the 
lower 48 have created programs outside of IHS funding to allow them to 
utilize DTs, but sadly, provisions in the Indian Healthcare Improvement 
Act (IHCIA) \8\ make it difficult to use IHS resources to use these 
effective providers. People with healthy teeth and healthy smiles feels 
better about themselves and experience better overall health outcomes. 
Our communities need our people and especially our youth to smile 
again. We encourage the Committee to work with the other relevant 
authorizing Committees to repeal this section of the law so that IHS 
and Tribes can utilize scarce discretionary dollars in the most cost-
effective way possible.
---------------------------------------------------------------------------
    \8\ 25 U.S.C. 1616l(d).
---------------------------------------------------------------------------
    Facilities: Tribes recommend prioritizing facilities funding in FY 
2020. On average, IHS hospitals are 40 years of age, which is almost 
four times more than other U.S. hospitals with an average of 10.6 
years. \9\ A 40 year old facility is about 26 percent more expensive to 
maintain than a 10-year facility. The facilities are grossly 
undersized--about 52 percent--for the identified user population, which 
has created crowded, even unsafe, conditions among staff, patients, and 
visitors. Increases will be used to increase maintenance and 
improvement on IHS facilities, speed up the funding of projects on the 
IHS Healthcare priority list, and improve sanitation conditions in 
Tribal communities. Investments in facilities will allow the care 
provided in our communities to be on par with other health systems in 
the United States. In Alaska, for example over 5,000 rural homes are 
considered unserved by running water and wastewater. Individuals, 
instead, must rely on ``honey buckets'' to dispose of waste. This is 
just unacceptable. The FY 2020 Budget Request proposes a decrease of 
nearly $66 million from the FY 2019 annualized continuing resolution 
(CR). NIHB emphatically opposes this decrease and encourages Congress 
do continue to build funding for facilities in FY 2020.
---------------------------------------------------------------------------
    \9\ Almanac of hospital financial & operating indicators: a 
comprehensive benchmark of the nation's hospitals (2015 ed., pp. 176-
179): https://aharesourcecenter.wordpress.com/2011/10/20/average-age-
of-plant-about-10-years/
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Advance Appropriations:
    As in past years, NIHB continues to request that the Administration 
support Advance Appropriations for IHS in its FY 2020 Budget Request. 
The 35 day partial government shutdown at the start of 2019 had a 
devastating impact the I/T/U system and the people it serves Tribes 
throughout the country reported rationed care, reduced services, loss 
of health care providers and some facilities closed altogether. This 
reckless shutdown destabilized Native health delivery and health care 
provider access; as well as Tribal Governments, families, children and 
individuals.
    We uniformly request advance appropriation of IHS funding that 
becomes available one year or more after the year of the appropriations 
act in which it is contained. Thus, advanced appropriation provides 
more certainty to operate the Indian health care delivery system. This 
change in the appropriations schedule will allow Indian Health programs 
to effectively and efficiently manage budgets, coordinate care, enter 
into contracts, and improve health quality outcomes for AI/ANs. Advance 
appropriations for IHS would support the ongoing treatment of patients 
without the worry if--or when--the necessary funds would be available. 
Health care services require consistent funding to be effective. 
Advanced appropriations will help the federal government meet its trust 
obligations to Indian Country and bring parity to this federal health 
care system at no additional cost.
FY 2020 President's Budget Request
    The FY 2020 President's Budget Request includes $5.945 billion for 
the Indian Health Service. This represents a $140 million increase from 
the FY 2019 enacted amount of $5.804 billion. While we appreciate the 
increase funding for Hospitals and Clinics and Purchased/Referred Care, 
several items in the FY 2020 request are of particular concern for NIHB 
and the Tribes.
Community Health Aide Program/Community Health Representatives
    The President's Budget Request for FY 2020 proposes to phase out 
the Community Health Representatives Program (CHR) and replace it with 
the National Community Health Aide Program (CHAP). It cuts the CHR 
program by $39 million and invests $20 million for the CHAP program. 
The CHAP program has shown much success however, its expansion should 
not come at the expense of this critical, and already highly successful 
program. If this request were to be accepted, services provided would 
fall flat and neither program would likely be able to effectively 
operate. Furthermore, for generations, CHRs have been integral to the 
fabric of health delivery in Indian Country and Tribes do not wish to 
see this historic program discontinued. Ninety-six percent of CHR 
programs are operated by the Tribes in partnership with the IHS and 
provides one of the best examples of the Nation to Nation relationship 
between the Tribes and the Federal government. CHRs provide services 
like in-home patient assessment of medical conditions, providing 
glucose testing or blood pressure tests to determine if the patient 
should seek further care, and providing transportation for medical 
care. They also help interpret prescriptions which is critical to 
patient safety and the elimination of this program would be detrimental 
to the health and wellbeing of many Tribal communities. There are more 
than 1,600 CHRs representing over 250 tribes in all 12 IHS Areas and 
exported CHR program data in FY 2016 demonstrated that CHRs conducted 
340,270 home visits and provided 1,102,164 patient contacts/services on 
a variety of health related conditions. However, it is likely that 
there are far more contacts are made in reality but not reflected in 
data due to reporting challenges associated with the RPMS system.
    The NIHB recommendation for this line item would be to increase 
funding for the sole purpose of service delivery of CHR program 
services and functions. The CHAP program is also supported as a 
separate recommendation. Tribes also look forward to meaningful 
consultation with the federal government in the event that significant 
alterations to life-changing Indian health programs are being 
considered.
    In FY 2020, the NIHB recommends CHRs are funded at $83.2 million, 
which is an increase of $18.9 million above the FY 2017 enacted level.
Health Education Program
    The President's FYs 2019 and 2020 budget proposed to discontinue 
funding the program and instead direct funds to health care services 
and staffing newly constructed facilities. Eliminating the health 
education program would create gaping holes in care for many Tribal 
communities. Too often, the Indian Health system does not have enough 
staff to meet the demand for its services and many AI/ANs rely on 
health education resources as their primary source of information about 
the Indian health system. The loss of health education funding would 
dissolve many opportunities for an AI/AN patient to receive 
communications regarding their own healthcare, while also limiting 
their access to available resources and information designed to assist 
them in making informed choices. Additionally, minimizing resources 
that effectively coordinate care for patients also greatly reduces the 
ability for IHS and Tribes to effectively maximize their resources and 
treat patients.
    NIHB recommends funding the Health Education program at $39.7 
million. This is an increase of $20 million from FY 2017 enacted.
Special Diabetes Program for Indians:
    NIHB recommends that the Administration propose permanent enactment 
of the Special Diabetes Program for Indians (SDPI). In recent years, 
the highly successful program has only been renewed in short 1-2 year 
increments (and in 2017-18 just a few months!). This creates 
instability in the program, to the detriment of staff recruitment and 
retention, long-term planning, and overall effectiveness. The current 
authorization expires on September 30, 2019. In addition, SDPI has not 
received an increase in funding since FY 2004 which means the program 
has effectively lost about 25 percent in programmatic value over the 
last 15 years due to corresponding to inflation and the significantly 
increased costs of diabetes care. Any renewal or permanent enactment 
should ensure that inflation is built into final funding levels.
    Few programs are as successful as SDPI at addressing chronic 
illness and risk factors related to diabetes, obesity, and physical 
activity. SDPI has proven itself effective, especially in declining 
incidence of diabetes-related kidney disease. The incidence of end-
stage renal disease (ESRD) due to diabetes in American Indians and 
Alaska Natives has fallen by 54%--a greater decline than for any other 
racial or ethnic group. Treatment of ESRD costs almost $90,000 per 
patient, per year, so this reduction in new cases of ESRD translates 
into significant cost savings for Medicare, the Indian Health Service, 
and third party payers. We believe that permanent enactment of SDPI is 
a common-sense approach.
Support Funding of Tribes outside of a grant-based system
    The health needs of Indian people are chronic and multi-faceted; 
such needs deserve to be addressed through committed, stable funding. 
In contrast, grant programs are temporary, unreliable, non-recurring, 
and unable to address the ongoing critical needs of Tribal communities. 
Under the grant making process, some Tribes receive assistance and 
benefit from somewhat consistent increases, while other Tribes do not. 
This creates two pools of Tribes--those that have technical experience 
and financial resources receive funding, while many others without this 
capacity see no benefit in appropriated increases. The strings attached 
to federal grants in terms of reporting, limitations on use of funds, 
and timelines distract from patient care. Since 2008, 50 percent (about 
$40 Million) of the increases to the total Behavioral Health budget 
(Mental Health and Alcohol & Substance Abuse Programs) is due to a 
growth in special grant programs and initiatives rather than increases 
to existing Behavioral Health programs. Instead of project or disease 
specific grant funds, the IHS needs to prioritize flexible, recurring 
base funds.
    Grants create a ``disease de jour'' approach, where the funding is 
tied only to an identified hot topic issue. For instance, if a patient 
presents with an ``unfunded'' diagnosis that is not covered by grants 
for specific disease categories that patient is left without many 
alternatives. This does not bode well for the many chronic diseases 
from which AI/ANs disproportionately suffer. For example, a large focus 
on the methamphetamine epidemic 10 years ago may have distracted from 
the rise in patients addicted to prescription pain medicine, thus 
contributing to the opioid crisis in Indian Country today. While the 
United States generally is now facing an opioid crisis, a particular 
service unit in one IHS area may struggle most with alcohol addiction 
and under the grant making process cannot redesign the available 
programs and services to meet Tribal community needs. As such, IHS 
should never use a grant program to fund ongoing critical Indian Health 
needs.
    Funding for ongoing health services in FY 2020 should be 
distributed through a fair and equitable formula rather than through 
any new grant mechanism or existing grant program. Across Indian 
Country, the high incidence of chronic health conditions like heart 
disease, suicide, substance abuse, diabetes, and cirrhosis is well 
documented. Grant funding used to address any Indian health issue 
creates limited and restrictive funding and access to culturally 
appropriate care.
Other Sources of Indian Health Funding
Medicaid
    While the above recommendations address the IHS budget, the federal 
trust responsibility for health extends beyond the IHS. Proposals in 
the President's FY 2020 Budget Request, will have major fiscal impacts 
on IHS and Tribal health reimbursements that would devastate Tribal 
health. We urge the administration to work with Tribes and strengthen 
its Tribal Consultation practices on issues like Medicaid work 
requirements and block grants, so that fiscal strain doesn't 
unintentionally fall back to the IHS and Tribal Health programs. 
Decreasing Medicaid decreases scarce resources available to cover our 
cost of care, and further restrict the eligible patient population. 
This puts an unequal burden on the IHS budget which is so reliant on 
these resources to make up our funding shortfalls. American Indians and 
Alaska Natives already have access to health care through the IHS, so 
work requirements only serve to inhibit the use of Medicaid in Tribal 
communities.
Good Health and Wellness in Indian Country
    The President's FY 2020 Budget request for the Centers for Disease 
Control and Prevention (CDC) is approximately $763 million below the FY 
2019 enacted level. This includes a zeroing out the Good Health and 
Wellness in Indian Country (GHWIC) program (currently funded at $21 
million). The Good Health and Wellness in Indian Country Program is 
CDC's largest investment in the wellbeing of American Indian and Alaska 
Natives. GHWIC funding must be restored. The thirty-five Tribes 
participating in the program have utilized community-driven, culturally 
adapted strategies to improve public health in their communities. GHWIC 
is a lifeline for these communities who would otherwise have no public 
health investment. In fact, it is the only dedicated funding for AI/ANs 
at CDC. Given the success of the program, NIHB recommends that this 
program be increased to $32 million in FY 2020 to build public health 
infrastructure in Indian Country
Food Distribution Programs
    The President's Budget for FY 2020 would also make major changes to 
the Supplemental Nutrition Assistance Program (SNAP) including $17.4 
billion in cuts--amounting to one-fifth of the total SNAP budget. It 
would impose mandatory work requirements for all able-bodied 
individuals between 18 and 65 and reintroduces the controversial 
``Harvest Box'' idea from last year, which would use a portion of 
benefits to buy and deliver a package of commodities to SNAP 
households. Approximately 25 percent of Native households currently 
utilize SNAP, but in some Tribal communities, over 50 percent of 
households are recipients of the program.
    The President's FY 2020 Budget also proposes a $23 million cut to 
the Food Distribution Program on Indian Reservations (FDPIR) and 
proposes total elimination of the $998,000 FDPIR Nutrition Education 
program--the only Tribally-specific nutrition program in existence.
Conclusion
    Thank you again for holding this important hearing and for the 
opportunity to offer testimony for the record. You can find a more 
detailed FY 2020 IHS Budget Request at www.nihb.org.
                                 ______
                                 
 Prepared Statement of the United South and Eastern Tribes Sovereignty 
                       Protection Fund (USET SPF)
    The United South and Eastern Tribes Sovereignty Protection Fund 
(USET SPF) is pleased to provide the Senate Committee on Indian Affairs 
with testimony for the record of its oversight hearing on the 
President's shameful Budget Request for Fiscal Year (FY) 2020. USET SPF 
represents 27 federally-recognized Tribal Nations from Texas to Florida 
to Maine. \1\ USET SPF member Tribal Nations are within the Eastern 
Region and Southern Plains Region of the Bureau of Indian Affairs (BIA) 
and the Nashville Area of the Indian Health Service (IHS), covering a 
large expanse of land compared to other regions. Due to this large 
geographic area, USET SPF Tribal Nations have great diversity in 
cultural traditions, land holdings, and resources. This allows our 
region to mirror the great diversity found in Indian Country 
nationwide.
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    \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).
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Legal and Constitutional Basis for the Fiduciary Trust Responsibility
    From the earliest days of the United States, the Founders 
recognized the importance of America's relationship with Tribal Nations 
and Native peoples. They wove important references to those 
relationships into the Constitution (e.g., Art. I, Section 8, Cl. 3 
(Indian Commerce Clause); Article II, Section 2, Cl. 2 (Treaty Clause).
    Tribal Nations influenced the Founders in the development of the 
Constitution as recognized by the 100th Congress, when the Senate and 
the House passed a concurrent resolution acknowledging the ``historical 
debt'' the United States owes to Tribal Nations.

         ``[O]n the occasion of the 200th Anniversary of the signing of 
        the United States Constitution, acknowledges the historical 
        debt which this Republic of the United States of America owes 
        to the Iroquois Confederacy and other Indian Nations for their 
        demonstration of enlightened, democratic principles of 
        government and their example of a free association of 
        independent Indian nations;. . ..'' \2\
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    \2\ S. Con. Res. 76, 100th Congress

    One has only to walk the halls of the Capitol to see many works of 
art and sculpture that depict the central role that Tribal Nations have 
played in the development of America's national identity. Not depicted 
on the walls of the Capitol are many of the injustices that Native 
peoples have suffered as a result of federal policy, including federal 
actions that sought to terminate Tribal Nations, assimilate Native 
people, and to erode Tribal territories, learning, and cultures. Where 
these injustices are depicted, our tragedies are romanticized \3\ and 
told through a revisionist lens. The true story involves the cession of 
vast land holdings and natural resources, oftentimes by force, to the 
United States out of which grew an obligation to provide benefits and 
services in perpetuity to Tribal Nations. These resources are the very 
foundation of this nation, and have allowed the United States to become 
the wealthiest and strongest world power in history. Federal 
appropriations to Tribal Nations and Native people are simply a 
repayment on this perpetual debt.
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    \3\ See https://www.aoc.gov/capitol-hill/native-americans-art
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    The Indian provisions in the Constitution were given immediate life 
in treaties that the United States entered into with Tribal Nations 
beginning with the Treaty with the Delaware in 1778 and continuing 
through another 373 treaties. Additionally, in the first decades of the 
United States, numerous laws were enacted addressing the details of the 
Federal-Tribal relationship (e.g., Trade and Intercourse Acts of 1790, 
1793, 1796, 1799, 1802, and 1834), even as the Federal courts defined 
the Federal government's trust obligation to Indian nations (e.g., 
Cherokee Nation v. Georgia (1831)). This period reflected an 
acknowledgement of and respect for our independent and sovereign 
existence, with the United States taking action within our lands only 
after securing our consent, including through treaty-making.
    As it became more powerful and maintaining strong relations with us 
became less necessary, the United States quickly moved from an approach 
based on consent to an approach based upon the notion of domestic 
dependency and plenary authority. Notwithstanding the Constitutional 
foundation, the federal government engaged in many actions that 
betrayed the treaties and trust obligation to Tribal Nations, such as 
the seizure of Tribal lands and the forced assimilation efforts of the 
Indian boarding school system. Fortunately, Tribal efforts to exert our 
sovereign rights in collaboration with our federal partners have led to 
more enlightened policies since the boarding school era, reflected in a 
host of laws that support Tribal sovereignty and are critical to the 
vitality and well-being of Tribal communities. Regrettably, these laws 
are rarely funded to the level necessary to achieve their intended 
purposes.
    The chronic underfunding of federal Indian programs continues to 
have disastrous impacts upon Tribal governments and Native peoples. As 
the United States continues to break its promises to us, Indian Country 
and Tribal citizens experience some of the greatest disparities among 
all populations in this country--including those in health, economic 
status, education, and housing. This is not a question about addressing 
poverty and needs across Indian Country. Our relationship is much more 
than this. This is ultimately a question about honor, about fulfilling 
commitments and promises. A nation's exceptionalism is grounded in 
these principles.
The Unique Role of the Senate Committee on Indian Affairs
    While USET SPF takes a firm position that all members of Congress 
have an obligation to Tribal Nations, the members of this Committee 
have a greater role in understanding and working toward fulfillment of 
this obligation. As members of the only full Congressional Committee 
charged with, ``study[ing] the unique problems of American Indian, 
Native Hawaiian, and Alaska Native peoples and. . .propos[ing] 
legislation to alleviate these difficulties,'' it is incumbent upon 
every Senator on this Committee to advocate for and demand the 
inclusion of Indian Country's priorities in all relevant legislation 
before the Senate. While we appreciate the amplification of these 
priorities through the work of the Committee via hearings, letters, and 
relevant legislation, it is equally, if not more, important, that the 
Members of this Committee use this role to elevate our voices in 
Congress' other Committees, as well as on the Senate floor. Indian 
Country expects and demands that you carry our messages into 
conversations with colleagues who may be less familiar with the trust 
obligation.
    As leaders who have consistently demonstrated a true understanding 
of this commitment and obligation, we implore you to lead the change 
within Congress that is necessary to improve how the United States 
views, honors, and fulfills its promises to Indian Country. The federal 
budget is a reflection of this commitment. We recognize that there are 
many causes and issues that this body considers. However, we ask that 
you always remember this nation's first promise to its First People--
the promise that resulted in an exchange responsible for the vast 
wealth, power, and influence of this country.
The President's FY 2020 Request for Indian Programs Violates the Trust 
        Responsibility
    In his 2017 Native American Heritage Month proclamation, the 
President stated,

         ``My Administration is committed to tribal sovereignty and 
        self-determination. A great Nation keeps its word, and this 
        Administration will continue to uphold and defend its 
        responsibilities to American Indians and Alaska Natives. 
        Together, we will strengthen the relationship between the 
        United States Government and Native Americans.''

    A great nation does keep its word. The first step toward 
fulfillment of America's promises is not just words, but action. While 
this Administration professes to prioritize Indian Country, this Budget 
Request reveals otherwise. At all levels of the Administration, from 
the Office of Management and Budget (OMB) to BIA to IHS, Tribal Nations 
and others objecting to another draconian budget request are being told 
that the request is just a ``messaging document.''
    While we understand that only Congress has the power to appropriate 
funds, the Administration is sending a powerfully negative message to 
Indian Country. In reducing, eliminating, and calling into question the 
constitutionality of federal Indian programs, this Administration is 
ignoring and undermining its trust responsibility to Tribal Nations. 
Moreover, the message that this sends to all American citizens is one 
of disregard and dishonor, further exacerbating the challenges we face 
in educating the nation on our history, sovereignty, and the continued 
obligation to Tribal Nations. Finally, the agencies most directly 
charged with delivering on the fiduciary trust responsibility--BIA and 
IHS--continue to demonstrate no accountability for budget request 
numbers or policy changes and instead, are directing Tribal Nations to 
advocate for funding with Congress. This is a failure on the part of 
the Administration to take seriously its role as trustee.
    Nonetheless, we are once again asking Congress to honor the 
commitments made to Tribal Nations by the United States. This 
Committee, appropriators, and the entirety of Congress must again 
reject the President's proposed cuts, program and agency eliminations, 
and policy changes, as you have in the past. Instead, USET SPF urges 
this Committee to work to ensure FY 2020 appropriations more fully 
reflect the trust obligation, as well as Tribal guidance and 
priorities. This includes working toward the full funding of the United 
States' fiduciary obligation to Tribal Nations.
Broken Promises Report
    The Broken Promises report released in December 2018 by the U.S. 
Commission on Civil Rights (USCCR) comes after years of advocacy from 
Tribal Nations and organizations seeking an update to the 2003 Quiet 
Crisis report, which found deep failures in the delivery of federal 
fiduciary trust and treaty obligations. The Broken Promises report 
confirms what we in Indian Country already know--with the exception of 
some minor improvements, the U.S. continues to neglect to meet its 
``most basic'' obligations to Tribal Nations. The report reveals that 
very little has changed in the 16 years since the issuance of the Quiet 
Crisis report. With little exception, the funding of the federal trust 
responsibility and obligations remains ``grossly inadequate'' and a 
``barely perceptible and decreasing percentage of agency budgets.'' 
Though these chronic failures have persisted throughout changes in 
Administration and Congress, it is time that both the legislative and 
executive branches confront and correct them.
    And yet, despite the findings and recommendations within the Broken 
Promises and Quiet Crisis reports, subsequent Administrations have 
continued to request budgets that fall far short of the federal trust 
responsibility and obligations, including the FY 2020 Request. In order 
to begin delivering upon the recommendations of the Broken Promises 
report, the Administration must propose and Congress must demand 
budgets containing full funding for federal Indian agencies and 
programs. All branches of the federal government must take action to 
right these wrongs and this work must begin immediately.
    With this in mind, we urge this Committee and others in Congress to 
hold oversight hearings with federal witnesses from all agencies and 
departments, including the Department of the Interior, the Indian 
Health Service, and the Office of Management and Budget, to examine 
plans for ensuring the federal government honors its treaty and trust 
obligations to Tribal Nations, including through the budget and 
appropriations process.
Funding Requests and Mechanism do not Reflect Trust Obligations
    Because of our history and unique relationship with the United 
States, the trust obligation of the federal government to Native 
peoples, as reflected in the federal budget, is fundamentally different 
from ordinary discretionary spending and should be considered mandatory 
in nature. Inadequate funding to Indian Country needs to be viewed as 
unfilled treaty and trust obligations and should not be vulnerable to 
year to year ``discretionary'' decisions by appropriators. This year, 
during the longest federal government shutdown in history, members of 
this Committee, and all of Congress, saw first-hand the deleterious 
impacts of this funding mechanism in Indian Country. The health, 
safety, and wellbeing of Tribal Nations, the federal trust 
responsibility and obligations, was jeopardized as the legislative and 
executive branches debated an issue unrelated to their sacred duty to 
our governments.
    Shutdowns and delays in the appropriations process continue to 
impede progress and service-delivery in Indian Country. Since FY 1998, 
there has only been one year (FY 2006) in which appropriated funds for 
the IHS were released prior to the beginning of the new fiscal year. 
This must change. At a minimum, Congress must act to insulate federal 
Indian funding from political impasses and failures to otherwise 
complete the appropriations process prior to the end of the fiscal 
year. In the short-term, USET SPF calls for the passage of S. 229, the 
Indian Programs Advance Appropriations Act, legislation that would 
provide advance appropriations for IHS and BIA. In the long-term, we 
seek mandatory funding for all federal Indian programs, as this is more 
consistent with the federal trust obligation.
    We further note the long-lasting effects of continued underfunding 
for federal Indian programs. The FY 2020 Budget Request fails to 
reflect a prioritization of trust obligations and the related promises 
that are at the core of our special and unique relationship. These 
unfulfilled treaty and trust obligations will ultimately lead to 
hearings by this very Committee, as the consequences of this Request 
results in the problems and difficulties that SCIA is charged with 
addressing.
Constitutionality of Federal Indian Programs
    Several times now, this Administration has called into question the 
constitutionality of programs or targeted accommodations for American 
Indians and Alaska Natives. As this Committee well knows, all federal 
Indian programs are based on a political, government-to-government 
relationship between the U.S. and Tribal Nations. Appropriations that 
support programs and services such as this are provided in perpetuity 
in exchange for the millions of acres of land and natural resources 
ceded, often times by force, to the U.S. In addition, the Executive 
Branch, regardless of party, has a decades-long history of policy-
making that includes exemptions or accommodations from federal actions 
for Tribal Nations and Native people.
Infrastructure Plan
    For generations, the federal government--despite abiding trust and 
treaty obligations--has substantially under-invested in Indian 
Country's infrastructure, evident in the breadth and severity of its 
unmet infrastructure needs as compared to the rest of the nation. While 
the United States faces crumbling infrastructure nationally, there are 
many in Indian Country who lack even basic infrastructure, such as 
running water and passable roads. According to a report released in 
2017 by National Congress of American Indians, there exists at least 
$50 billion in unmet infrastructure obligations across Indian Country. 
Decades of chronic underfunding of the federal government's trust 
obligations has resulted both in a dangerous lack of infrastructure, as 
well as infrastructure that is severely degraded.
    If this Congress and Administration intend to modernize and repair 
infrastructure throughout the country, the deep infrastructure needs of 
Indian Country must be addressed. It is critical that Tribal Nations 
have direct access to any funding available via an infrastructure 
package. We must not be restricted to partnering or competing with 
another entity in order to be in receipt of infrastructure dollars. 
Additionally, in support of Tribal self-determination, these dollars 
should be eligible for inclusion in Self-governance contracts and 
compacts.
    With a renewed focus on domestic issues and putting America first, 
this focus must also include a commitment to rebuilding the sovereign 
Tribal Nations that exist within the domestic borders of the United 
States. Much like the U.S. investment in the rebuilding European 
nations following World War II via the Marshall Plan, this Congress and 
Administration should commit to the same level of responsibility to 
assisting in the rebuilding of Tribal Nations, as our current 
circumstances are, in large part, directly attributable to the shameful 
acts and policies of the United States.
    Tribal governments must be consulted in any infrastructure project 
planning or permitting on ancestral lands. Any infrastructure build-out 
in Indian Country and beyond must not occur at the expense of Tribal 
consultation, sovereignty, sacred sites, or public health. Consultation 
must include Tribal consent for projects that significantly impact or 
threaten Tribal interests. This point should be strengthened in the 
law, and not just in regulations. In the short term, we must move 
beyond the requirement for Tribal consultation via Executive Order to a 
strengthened model achieved via statute. In the long term, we must 
return to the achievement of Tribal Nation consent for federal action 
as a recognition of sovereign equality.
Interior Reorganization
    USET SPF is deeply concerned that the reorganization of the 
Department of the Interior (DOI) continues to move forward in the 
absence of Tribal consultation. Nearly a year and a half after its 
announcement, Indian Country continues to have more questions than 
answers from DOI on this massive undertaking. The near-complete lack of 
information provided to Tribal Nations is unacceptable, regardless of 
whether the BIA is included in the reorganization. We continue to 
request that DOI provide clarity regarding reorganization logistics, 
purpose, and effects on Indian Country, and to consult with Tribal 
Nations on these details. While we await the answers, USET SPF urges 
this Committee and this Congress to withhold any funding for Interior 
reorganization pending confirmation that the Reorganization will not 
impact funding to Indian Country or inherent federal functions, as well 
as meaningful consultation with Tribal Nations.
Role of Office of Management and Budget in Inadequate Budget Requests
    The Office of Management and Budget (OMB) asserts that over $21 
billion in federal dollars funds Indian Country annually. From the 
perspective of Tribal advocates, including those who serve on budget 
formulation committees for federal agencies, this number seems to be an 
over-estimate, with far less actually reaching Tribal Nations and 
Tribal citizens. We suspect that OMB arrives at this figure by tallying 
the amount for which Tribal Nations and entities are eligible, 
regardless of whether these dollars actually reach Indian Country. The 
Tribal Interior Budget Council has asked OMB for a full accounting of 
federal funding distributed to Indian Country. To date, OMB has not 
responded to this request and continues to take the position that as an 
extension of the Executive Branch, it does not have the same 
consultative responsibilities as other federal agencies. USET SPF 
requests that in the spirit of transparency, this Committee consider 
supporting report language that would ensure OMB provides Indian 
Country with an accurate inventory of its own federal funding on an 
annual basis. In addition, USET SPF contends that Indian Country would 
be better-served by an Indian-specific desk at OMB rather than analysts 
with portfolios that include other interests.
Conclusion
    While USET SPF recognizes this Committee's strong, long-standing 
commitment to Indian Country, we cannot accept funding for federal 
Indian programs that continues to fall far short of fiduciary trust 
obligations, and other shameful failures to acknowledge our government-
to-government relationship and sovereign status. This Committee must 
use its influence to ensure that Congressional appropriators uphold the 
fiduciary trust obligation to Tribal Nations in FY 2020 and beyond. In 
pursuit of a relationship more reflective of this obligation, USET SPF 
urges this Committee, Congress, and all branches of the federal 
government to ensure that full funding for the trust obligation is 
realized in our lifetimes. USET SPF looks forward to partnering with 
the Committee to bring this to fruition.

                   Additional Testimony from USET SPF
DOJ Mishandled VOCA Tribal Set Aside Distribution
    As this Committee well knows, Indian Country currently faces some 
of the highest rates of crime, with Tribal citizens 2.5 times more 
likely to become victims of violent crime and Native women, in 
particular, subject to higher rates of domestic violence and abuse. And 
yet, until FY 2018 appropriations were enacted, Tribal Nations did not 
have direct access to funding that would allow us provide victim 
services to our citizens. After years of advocacy from Tribal Nations, 
Congress enacted a 3 percent (or $133 million) Tribal Set-Aside in FY 
2018 within the Crime Victims Fund for the very first time.
    Out of the 3 percent FY 2018 set-aside, $110 million was made 
available to Tribal Nations and Tribal organizations through grants 
with a cap of $720,000 per Tribal Nation, and with discretion for DOJ 
to include increases. While DOJ consulted with Tribal Nations on the 
distribution of these dollars and USET SPF, along with other Tribal 
Nations and organizations, urged maximum flexibility, the Agency's 
outreach, solicitation, and grant requirements did not reflect this 
guidance. As a result, many Tribal Nations did not apply for the grant.
    Moreover, rather than work with Tribal Nations to improve 
applications, DOJ opted not to fund a full 20 percent of applicants--
with only 154 out of 195 receiving grant awards of just $88 million. 
Rather than find a way to distribute remaining funds, DOJ returned $24 
million in unobligated dollars to the Crime Victims Fund. There have 
been no efforts on the part of DOJ to reissue these funds to Tribal 
Nations.
    Despite failures in the FY 2018 process, DOJ appears to be 
repeating these mistakes as it seeks to distribute FY 2019 funds. In 
February 2019, Crime Victims Tribal Set-Aside funding for FY 2019 was 
provided in the amount of $167.5 million (a 5 percent increase from FY 
2018) under the Coordinated Tribal Assistance Solicitation (CTAS). 
Despite the increase in funding, DOJ capped funding for each 
application at $500,000. Due to the short deadline, stringent 
eligibility requirements, and small funding cap, many Tribal Nations 
did not seek this funding. As a result, only 59 Tribal Nations applied.
    While we have been informed that an additional FY 2019 funding 
opportunity will be announced soon, USET SPF is deeply concerned that 
DOJ will again fail to obligate the entirety of funding. Again, this is 
not because these dollars are not critically important to Tribal 
Nations, but rather because DOJ is failing to recognize its obligations 
to Tribal Nations, including making every effort to ensure resources 
reach Indian Country.
Tribal Set-Aside for FY 2020 and Beyond
    In the long-term, DOJ must be required to change its distribution 
methods in accordance with Tribal Nation guidance. This involves 
implementing this guidance following the conclusion of its Tribal 
consultation on the distribution of the VOCA set-aside in July. USET 
SPF continues to urge DOJ to provide maximum flexibility, both during 
the application process and in usage of funds, including, to greatest 
extent possible, relaxing and simplifying any application and reporting 
requirements associated with the funding.
    The equitable distribution of funding to all interested Tribal 
Nations must be the guiding principle of the Department throughout the 
award process. It is with this in mind that USET SPF strongly urges 
Congress to support the distribution of these dollars via non-
competitive formula-based funding. Grant funding fails to reflect the 
unique nature of the federal trust obligation and Tribal sovereignty by 
treating Tribal Nations as non-profits rather than governments. A non-
competitive, formula-based methodology will provide each of the 573 
federally-recognized Tribal Nations with the opportunity to access this 
set aside, ensuring the entirety of funds are obligated each year. We 
also call upon DOJ and Congress to consider how this funding might be 
delivered via Indian Self-Determination and Education Assistance Act 
contracting and compacting.
Conclusion
    The VOCA set aside was designed to provide Tribal Nations and 
Tribal organizations, in parity with states, resources to deliver 
comprehensive services and compensation to crime victims within Tribal 
communities. However, since 2018, $162.5 million in Tribal set aside 
funding has not been allocated to Tribal Nations. As an agency of the 
federal government, DOJ has a trust obligation to ensure Tribal Nations 
have access to resources to address crime in Indian Country. The 
failure in ensuring these critical funds are delivered to Tribal 
Nations is a violation of that obligation. USET SPF urges SCIA and 
Congressional appropriators to ensure DOJ takes the appropriate steps 
to distribute the total set-aside in Indian Country as intended.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                         Hon. Andrew Joseph Jr.
Budgetary Certainty
    Question 1. As you described in your written testimony, the partial 
government shutdown negatively impacted Tribes reliant on the Bureau of 
Indian Affairs (BIA) and Indian Health Service (IHS) services and 
funding to keep essential public welfare services operational. My bill, 
S. 229, the Indian Programs Advance Appropriations Act, would address 
the essential service program distribution in Indian Country caused by 
government shutdowns by providing advance funding and budgetary 
certainty for BIA and IHS programs. Can you summarize the areas where 
the government shutdown impacted IHS and Tribes the worst?
    Answer. The 35-day government shutdown disproportionately impacted 
the Indian health system. Of the four federal agencies charged with 
providing healthcare services, the Indian Health Service (IHS) was the 
only agency that was impacted by the shutdown. This is because Medicare 
and Medicaid receive mandatory appropriations that are unaffected by 
yearly budget negotiations, while the Veterans Health Administration 
has been receiving advance appropriations since 2011. \1\
---------------------------------------------------------------------------
    \1\ Pub. L. No. 111-81, 123 Stat. 2137 (2009) (codified as amended 
at 31 U.S.C.  1105(a)(37) and 38 U.S.C.  117). This authority took 
effect with the budget submissions for fiscal year 2011.
---------------------------------------------------------------------------
    Congress created the IHS in part to fulfill the federal 
government's treaty and trust obligations for health care for all 
American Indians and Alaska Natives (AI/ANs). Yet chronic underfunding 
of IHS coupled with yearly budget uncertainty and looming threats of 
government shutdowns and budget sequestration levy undue and 
significant hardships on the Indian health system. As a result of these 
hardships, IHS's capacity to carry forth its mission and to deliver 
quality care is severely diminished, thus contributing to the pervasive 
health disparities impacting AI/ANs.
    The impacts of the government shutdown on delivery of care within 
the Indian health system were multi-pronged and complex. Because IHS 
provides services involving the safety and preservation of human life, 
by law, many IHS employees are considered ``excepted'' employees. As a 
result, IHS direct care facilities remained open during the government 
shutdown; however, all administrative services--including those 
provided in a clinical setting--were not considered excepted and were 
thus furloughed. Inaccessibility of administrative staff during the 
shutdown lead to significant burdens on services such as scheduling 
doctor's appointments, conducting patient follow-up and referral, and 
other ancillary services that nonetheless impacted patient care.
    But while direct services at IHS facilities remained available, IHS 
payments to Tribally-operated health facilities and programs were 
suspended. Given that roughly two-thirds of IHS operations are operated 
under Tribal self-determination contracts and compacts, this meant that 
the majority of health system operations in Indian Country during the 
shutdown continued without any direct funding from IHS. As a result, 
Tribes were forced to make incredibly difficult decisions about the 
delivery of health services. While some Tribes had the flexibility to 
cobble together disparate resources to keep services and operations 
afloat, other Tribes were forced to curtail services, furlough staff, 
or make other costly and burdensome adjustments in their operations. 
Unequivocally, the government shutdown destabilized the Indian health 
system and jeopardized the health and safety of AI/AN individuals and 
families.

    Question 1a. Do you believe that Congress would have difficulty 
meeting its trust responsibility to Tribes during a government shutdown 
if it doesn't move Indian programs to an advance appropriations cycle?
    Answer. Absolutely. While enacting advance appropriations would not 
solve the chronic underfunding of the Indian health system, it would 
instill necessary and effective guardrails that can at least provide 
certainty of funding for IHS from year to year. Because the IHS 
receives yearly discretionary appropriations, it is inevitably subject 
to budget fluctuations from year to year, the threat of government 
shutdowns and budget sequestration, and the limitations imposed by use 
of continuing resolutions (CRs). However, the situation is particularly 
unique for the IHS for three reasons. Number one, the IHS was 
established by Congress and charged to help fulfill the federal 
government's treaty and trust obligations to Tribal Nations and AIAN 
Peoples. But IHS cannot fulfill this sacred and constitutional 
obligation under a discretionary appropriations process that does not 
fund the agency at the level of need, nor shields it from the 
devastating impacts of government shutdowns.
    Number two, the IHS is the only federal healthcare entity that is 
not insulated from shutdowns, CRs, or budget sequestration. These ever-
looming challenges impose significant barriers towards engaging in 
long-term planning, recruiting and retaining high quality providers, 
ensuring the accessibility of care, and building and improving internal 
infrastructure and operations. Number three, enacting advance 
appropriations for IHS would establish parity between the agency and 
the Veterans Health Administration (VHA), which has received advance 
appropriations for nearly a decade. As a sister agency to IHS, both 
agencies work closely together on many fronts to coordinate care for 
AI/AN Veterans. It is often said that the federal government has a dual 
obligation to AI/AN service members--one obligation due to their status 
as AI/ANs, and one due to their sacrifice in service to protect and 
defend the United States. As such, it is imperative that Congress 
establish parity between IHS and VHA by ensuring that IHS also receive 
advance appropriations.
Recruitment, Retention, and Staffing
    Question 2. The President's FY2020 budget would increase support 
for staffing needs at new Joint Venture IHS facilities. It also 
proposes $8 million for recruitment and retention incentives, including 
$2 million to pay for housing subsidies, $2 million to pay for 
incentives, $1.8 million for loan repayment programs. However, the 
proposed budget would also reduce funding for the Indian Health 
Professions program by $14 million from the FY2019 enacted level. Does 
NIHB support these proposed recruitment, retention, and staffing 
proposals put forward in the President's FY2020 budget request?
    Answer. The Indian Health Professions budget is one of the ways 
that IHS can recruit and retain qualified providers to the Indian 
health system. The President's FY 2020 request to cut funding for this 
program by 23 percent will likely lead to even higher vacancies at IHS 
and lower care for AI/AN patients. Recruitment and retention of medical 
personnel is one of the most serious challenges at IHS. Additional 
investments will help enhance care. Increasing the use of Title 38 will 
help IHS be more competitive when recruiting providers.
    The IHS system competes with the private sector in recruiting and 
maintaining health providers. However, there are few tools available to 
the IHS and Tribes that provide unique advantages in recruitment, 
principal among them--the IHS Scholarship and Loan Repayment Programs. 
Despite these unique opportunities, IHS is limited in its use of the 
programs due to significant underfunding and administrative policy. For 
example, in FY 2017, 788 health professionals--nurses, behavioral 
health providers, dentists, mid-level providers and pharmacists--who 
applied for the Loan Repayment Program (LRP) were not funded. It is 
estimated that an additional $39.4 million would be needed to fund the 
788 unfunded health professional applicants.
    We support the proposals outlined in the President's Budget to 
allow scholarship and loan repayment for part time employees and tax 
exempt status for IHS student loan repayment program. These would help 
increase the amount of funding available for these programs and open 
the programs up to more individuals, thereby improving health access 
for American Indians and Alaska Natives. However, there is much more to 
be done.

    Question 2a. Would NIHB propose any additional ways to support 
recruitment and retention of clinical staff in Indian Country?
    Answer. There are several pathways in which Congress can further 
meet its treaty and trust obligations for health services to Tribes and 
AI/ANs. One option would be to ensure that the IHS Loan Repayment 
Program is tax exempt. Unlike loan repayment programs offered by the 
VA, or through the National Health Service Corps, the IHS Loan 
Repayment Program is subject to federal taxes. In fact, the IHS is 
spending upwards of 20 percent of its Health Professions account for 
taxes. \2\ Making the program tax exempt can ensure that every dollar 
can be maximized for the recruitment and retention of high quality 
providers. In addition, fully funding all line items within the IHS 
budget at the level of need--including the Health Professions line 
item--will guarantee that the Indian health system has the necessary 
resources to rectify its chronic provider shortages.
---------------------------------------------------------------------------
    \2\ IHS Loan Repayment Program Fact Sheet. Retrieved from https://
www.integration.samhsa.gov/workforce/
Indian_Health_Service_LRP_ParticipantGuide.pdf 
---------------------------------------------------------------------------
    In addition, Congress can strengthen the role of Medicaid in 
fulfilling the trust responsibility and increasing AI/AN access to 
healthcare. This can be achieved by authorizing Indian Health Care 
Providers (IHCP) in all states to receive Medicaid reimbursement for 
all services authorized under Medicaid and specified services 
authorized under the Indian Health Care Improvement Act-referred to as 
Qualified Indian Provider Services-when delivered to AI/ANs. Further, 
Congress can address the ``four walls'' limitation on IHCP clinic 
services by removing the restriction that prohibits billing for 
services provided outside a clinic facility. Moreover, Congress can 
extend full federal funding through a 100 percent Federal Medical 
Assistance Percentage (FMAP) rate for Medicaid services furnished by 
Urban Indian Organizations to AI/ANs, in addition to services furnished 
by IHS/Tribal providers to AI/ANs.
    Finally, IHS and Tribal facilities are in immediate need of major 
reforms to health IT and telehealth infrastructure in order to better 
address the shortage of medical providers. Expansion of telehealth 
services can be critical for communities with limited access to medical 
care while also reducing costs of healthcare delivery. The IHS utilizes 
the Resource and Patient Management System (RPMS), which is a health 
information system offering a comprehensive suite of applications 
supporting virtually all business and clinical operations at IHS and 
some Tribal facilities. However, recent technological advancements with 
Commercial Off-the-Shelf (COTS)--EHR systems coupled with I/T/U 
challenges in keeping up with new advancements have pushed more and 
more Tribes to abandon RPMS for more modern systems.
    Nevertheless, the outdated nature of RPMS has placed additional 
burdens on IHS and Tribal providers given the system's limited 
interoperability and reliance on an increasingly antiquated broadband 
infrastructure. According to a 2019 Congressional Research Service 
report, 32 percent of citizens living on Tribal lands lacked access to 
standard fixed terrestrial broadband speeds compared to only 6 percent 
of the total U.S. Thus, NIHB strongly encourages Congress to fully fund 
critical infrastructure investments similar to that offered to Veterans 
Administration and Department of Defense. Specifically, NIHB requests 
funding for full implementation of health IT and interoperable EHR 
systems and telehealth capacity at $3 billion over ten years, and $15 
billion over ten years for health facilities construction and 
equipment.
Electronic Health Records
    Question 3. The President's FY2020 Budget requests $25 million for 
IHS to initiate replacement of its RPMS electronic health records (EHR) 
system. This new EHR system must not only improve patient experiences 
at federally-operate IHS facilities, but also be interoperable with 
tribal EHRs and other federal EHRs utilized by the Department of 
Veterans Affairs to ensure continuity of care for IHS patients that use 
multiple federal systems. Has IHS engaged in adequate consultation and 
urban confers to date regarding replacement of the RPMS?
    Answer. No. As you note, the current IHS health information system 
is the Resource and Patient Management System (RPMS), which is the same 
system utilized by the VA. Although the VA is taking steps to overhaul 
its system for electronic health record exchange by transitioning to 
the Cerner system, this has forced the IHS, which is largely dependent 
on VA IT, to re-evaluate its own health IT needs. Because IHS is not 
given its own line item for EHR improvements in its congressional 
appropriations, as the VA is, the IHS runs the risk of being left 
behind with an unsupportable EHR system. While the agency has examined 
alternatives for several years, the consultation with Tribes and 
confers with Urban Indian Health Organizations has been insufficient to 
develop a long term solution. NIHB strongly recommends that Congress 
provide IHS with the same tools, resources, and oversight in improving 
its Health IT system that it provides the VA.

    Question 3a. Does NIHB believe that telecom and IT infrastructure 
limitations in Indian Country will negatively impact Tribal and IHS EHR 
modernization efforts?
    Yes. It is critical that Congress provide resources necessary for 
the IHS (including Tribally run facilities) and other federal health 
providers like the Veterans Health Administration to make serious 
upgrades to their health information technology infrastructure in 
Indian Country. Failure to do so puts patients at risk and will leave 
IHS behind unequipped for the 21st Century healthcare environment. The 
biggest barrier to achieving this has been the lack of dedicated and 
sustainable funding to adequately support health information technology 
infrastructure, including full deployment and support for EHRs. 
Resources in Indian Country, including workforce and training, have 
been inadequate to sustain clinical quality data and business 
applications necessary to provide safe quality health services. The 
information systems that support quality health care delivery are 
critical elements of the operational infrastructure of hospitals and 
clinics.) RPMS is a comprehensive suite of applications that supports 
virtually all clinical and business operations at IHS and most (but not 
all) Tribal facilities, from patient registration to billing. The 
explosion of Health IT capabilities in recent years, driven in large 
part by federal regulation, has caused the IHS health information 
system to outgrow the agency's capacity to maintain, support and 
enhance it. To remedy this situation, NIHB recommends that Congress:

   Provide a separate, dedicated funding stream to improve 
        Health IT at IHS, as the President's budget and the House 
        Interior Appropriations Bill for Fiscal Year 2020 do.

   Provide dedicated authorized funding for major Health IT and 
        Telehealth upgrades at IHS and exercise oversight over the 
        spending of these funds, as Congress has done for the VA.

   Require IHS to work closely with the Veterans Administration 
        to coordinate on upgrades for the EHR systems at the respective 
        agencies, and make upgrades in tandem.

   Appropriate resources for Tribes that maintain systems 
        separate from RPMS. These Tribes are implementing IT systems to 
        serve their people without support from the IHS, Congress, or 
        any entity of the federal government. In some IHS Areas, up to 
        half of Tribes utilize non-RPMS Health IT systems.

    Question 4. The President's FY2020 Budget includes a 1 percent 
increase for the equipment program, which funds equipment replacement 
at existing tribally operated and direct service facilities, for a 
total of $23.9 million. I have heard from Tribal stakeholders that the 
actual estimated annual need for the program is more in the $50-70 
million range or higher. Please estimate what the annual equipment 
replacement needs are at IHS direct service, tribal, and urban Indian 
health facilities.
    Answer. The Tribal request is for a program increase of $24.058 
million for a total of $48.3 million for Equipment. This number 
represents the minimal amount necessary to address critical medical 
equipment needs at health facilities managed by the IHS and Tribes. IHS 
and Tribes manage approximately 90,000 biomedical devices consisting of 
laboratory, medical imaging, patient monitoring, pharmacy, and other 
biomedical, diagnostic, and patient equipment valued at approximately 
$500 million. Increased support is necessary to replace outdated, 
inefficient and unsupported equipment with newer electronic health 
record-compatible equipment to enhance speed and accuracy of diagnosis 
and treatment. Accurate clinical diagnosis and effective therapeutic 
procedures depend in large part on healthcare providers using modern 
and effective medical equipment/systems to assure the best possible 
health outcomes.
    Average Equipment useful life is approximately 6 to 8 years. To 
replace the equipment on a 7 year cycle would require approximately $70 
million annually. In the United States, a facility's annual medical 
equipment maintenance costs should be between 5 percent and 10 percent 
of medical equipment inventory value, which would equate to $25 to $50 
million annually for the IHS. This fund also supports transfer of 
excess Department of Defense medical equipment (TRANSAM) to IHS/Tribal 
programs, replaces ambulances, and provides equipment funding for 
Tribal facilities constructed with non- funding.

    Question 4a. Please summarize the problems that these facilities 
face in providing adequate care given their existing medical equipment 
resources.
    Approximately 5 percent of the U.S. annual health expenditures are 
investments in health care facilities construction. In 2013, that $118 
billion investment in facilities construction equaled $347 per capita 
compared with IHS construction appropriation of $77 million-or only $35 
per AI/AN. The Nations annual investment in health care facilities 
construction is 10 times the amount per capita for the general 
population compare to IHS facility construction. Resulting in negative 
patient outcomes and greater need for investment in to IHS facilities.
    On average, IHS hospitals are 40 years of age, which is almost four 
times more than other U.S. hospitals with an average age of 10.6 years. 
A 40 year old facility is about 26 percent more expensive to maintain 
than a 10-year facility. The facilities are grossly undersized--about 
52%--for the identified user populations, which has created crowded, 
even unsafe, conditions among staff, patients, and visitors. In many 
cases, the management of existing facilities has relocated ancillary 
services outside the main health facility; often times to modular 
office units, to provide additional space for primary health care 
services. Such displacement of programs and services creates 
difficulties for staff and patients, increases wait times, and creates 
numerous inefficiencies within the health care system. Furthermore, 
these aging facilities are largely based on simplistic, and outdated 
design which makes it difficult for the agency to deliver modern 
services.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Martha McSally to 
                         Tara Mac Lean Sweeney
Road Maintenance
    The BIA road maintenance program has been severely underfunded for 
years, and is inadequate to meet the needs of tribes across Arizona. 
The terrible road conditions endanger tribal members, as well as tribal 
and federal law enforcement officers carrying out their duties.
    Question 1. Why does the President's budget reduce the BIA road 
maintenance request by $900,000 from FY 2019 enacted levels? Will this 
request be adequate to meet maintenance needs of Arizona's tribes?
    Answer. Since Fiscal Year (FY) 2017, the Bureau of Indian Affairs 
(BIA) Road Maintenance program received above requested amounts as 
temporary funding for school bus routes and the Native American Tourism 
and Improving Visitor Experience Act, P.L. 114-221. These temporary 
set-asides were combined in the enacted funding which gave the 
impression of significant increases to the BIA Road Maintenance program 
nationwide. The Administration's FY 2020 Budget Request reflects the 
discontinued temporary funding.
Bureau of Indian Education Construction
    Question 2. The Administration's FY20 Budget Request contains a 
sizable cut to construction funding in Indian programs which is 
concerning. Particularly concerning is the $216 million cut to 
education construction, which is about 78 percent of the total cuts to 
the Bureau of Indian Education Funding. There are about 8-10 schools on 
the Navajo Nation that are supposed to be on the replacement list. Will 
the Administration's proposed negatively affect the schedule for Navajo 
school replacement?
    Answer. Using currently available funds, Indian Affairs will 
continue construction of the three remaining 2004 list replacement 
schools and fully fund the design-build construction of the first four 
schools from the 2016 replacement school list (which includes Dzilth-
Na-O-Dith-Hle Community School (Navajo)). The fifth school, Lukachukai 
Community School (Navajo), is 93 percent funded with the remaining 
funds to be provided with future appropriations. The remaining five 
schools on the 2016 replacement school list, all of which are for 
Navajo, will be funded for design-build construction as funds become 
available.
Tribal Police/Law Enforcement
    Question 3. The lack of safe and secure public safety facilities 
handcuffs tribal justice systems, and contributes to the already 
staggering violent crimes rates that exist on many reservations. Many 
tribal police officials arc forced to work in crumbling facilities or 
inadequate temporary structures.
    In Arizona, the BIA condemned the San Carlos police and courts 
building--known as BIA Building 86--in 2009. Tribal police and court 
officials worked in this condemned building until 2015 when the BIA 
provided them with temporary trailers, which are now rapidly 
deteriorating. In FY18 and FY19, Congress appropriated $18 million for 
new and replacement public safety and justice construction funding 
however the BIA dedicated all funding to tribal jails and none to 
replace police facilities. The Department's budget proposes elimination 
of new and replacement public safety construction for FY20 and includes 
no funding in your five-year plan for justice facilities construction.
    If Congress restores a new and replacement public safety 
construction line item, will you and BJA work to dedicate the necessary 
portion of FY20 funding to replace tribal police and courts buildings 
that the BIA has condemned?
    Answer. We understand that the intent of the appropriation language 
is to ensure that the highest priority public safety facility projects 
are funded. Our shared goal with Congress is to ensure resources are 
applied to areas where the need is greatest, and in a manner that makes 
sense programmatically and financially. As funding becomes available, 
the BIA will continue to replace public safety facilities in the order 
listed on the BIA Office of Justice Services (OJS) priority list. 
Public safety facilities at San Carlos will be considered for placement 
on the priority list and ranked appropriately.

    Question 4. The budget request for FY20 safety and justice 
activities is a decrease from FY 19. Tribal law enforcement and 
detention funding must be allocated the funds necessary to address the 
significant challenges the Nation and other tribes face, including: 
additional law enforcement staff and better equipment and training to 
address increased drug and violent crime; support for tribal law 
enforcement working with federal authorities to meet the United States' 
border security responsibilities. How will a decreased budget request 
address these challenges?
    Answer. The Administration's FY 2020 budget includes:

   $419.6 million for Public Safety and Justice Activities, of 
        which $313.1 million directly supports 191 law enforcement 
        programs and 96 corrections programs run both by tribes and as 
        direct services;

   $22.3 million for Tribal Justice Support Programs, which 
        include VA W A training and implementation strategies critical 
        to the protection of women in Indian communities;

   An increase of $2.5 million to address the opioid crisis in 
        Indian Country. This initiative will expand BIA's capacity to 
        address the increase in drug-related activities through 
        interdiction programs to reduce drug use, distribution, and 
        drug-related crime and supports OJS participation in intra- and 
        inter-agency initiatives targeting opioid and substance abuse 
        prevention efforts;

   $3.0 million for Phase II of housing construction plans at 
        two detention center locations and funding to complete six 
        units at Lower Brule Detention Center in Lower Brule, SD and 
        three units at Standing Rock Detention Center in Fort Yates, 
        ND;

   An additional $4.0 million to be accessible for allocation 
        to public safety facilities for Facilities Improvement and 
        Repair, which will fund advanced planning and design, condition 
        assessments, environmental and demolition projects, and 
        emergency repairs; and

   $3.1 million accessible for allocation to public safety 
        facilities for the Fire Protection program for priority 
        replacements and repair of non-working fire alarm and fire 
        sprinkler systems and assessing existing fire protection 
        systems.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                         Tara Mac Lean Sweeney
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
Response to Written Questions Submitted by Hon. Catherine Cortez Masto 
                        to Tara Mac Lean Sweeney
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 

    *RESPONSES TO THE FOLLOWING QUESTIONS FAILED TO BE 
SUBMITTED AT THE TIME THIS HEARING WENT TO PRINT*

           Written Questions Submitted by Hon. Tom Udall to 
                          Hon. Jefferson Keel
Tribal Historic Preservation Office Resources
    1. Since its creation in 1992, the Tribal Historical Preservation 
Office (THPO) program at the National Park Service has grown from 12 
participating Indian Tribes to more than 183 Tribal programs today. 
However, the President's FY2020 budget proposes cutting THPO program 
funding to $5.7 million for all183 tribal programs--a 50 percent 
reduction from FY20 19 enacted levels.
    a. Does NCAI support the proposal to cut funding for the THPO 
program?
    b. Has funding for the THPO program kept pace with increased Tribal 
participation?
Budgetary Certainty
    1. As you described in your testimony, the partial government 
shutdown negatively impacted Tribes reliant on Bureau of Indian Affairs 
(BIA) and Indian Health Service (IHS) services and funding to keep 
essential public welfare services operational. My bill, S.229, the 
Indian Programs Advance Appropriations Act, would address the essential 
service program disruption in Indian Country caused by government 
shutdowns by providing advance funding and budgetary certainty for BIA 
and IHS programs.
    Support for S.229 is growing among the Members of Congress, but my 
staff and I have run into questions from a number of folks who don't 
fully understand why BIA should be included in the advance 
appropriations discussion. I have provided background guidance on this 
issue, but more input on this particular issue from Tribal stakeholders 
is needed and welcome.
    a. What essential services does Indian Country utilize BIA for?
    b. Does NCAI believe BIA should be included in the Indian Programs 
advance appropriations discussion? If so, please explain why.

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