[Senate Hearing 116-183]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 116-183
 
                 RECOGNIZING THE SACRIFICE: HONORING A  
                 NATION'S PROMISE TO NATIVE VETERANS TO 
                 RECEIVE TESTIMONY ON S. 1001,  TRIBAL 
                 VETERANS HEALTH CARE ENHANCEMENT ACT AND
                 S. 2365, HEALTH CARE ACCESS FOR URBAN
                     NATIVE VETERANS ACT OF 2019   
                 

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

                                HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           NOVEMBER 20, 2019

                               __________

         Printed for the use of the Committee on Indian Affairs
         
         
         
         
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]         




                            ______                  


              U.S. GOVERNMENT PUBLISHING OFFICE 
 40-402 PDF             WASHINGTON : 2020 


                      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 November 20, 2019................................     1
Statement of Senator Cortez Masto................................    19
Statement of Senator Daines......................................    17
Statement of Senator Hoeven......................................     1
Statement of Senator McSally.....................................    11
Statement of Senator Murkowski...................................    14
Statement of Senator Smith.......................................    16
Statement of Senator Tester......................................    13
Statement of Senator Udall.......................................     9

                               Witnesses

Buchanan, Rear Admiral Chris, Deputy Director, Indian Health 
  Service, U.S. Department of Health and Human Service...........    23
    Prepared statement...........................................    24
Dupree, Hon. Jestin, Councilman, Fort Peck Assiniboine and Sioux 
  Tribes.........................................................    30
    Prepared statement...........................................    32
Fox, Hon. Mark, Chairman, Mandan, Hidatsa, and Arikara Nation....    26
    Prepared statement...........................................    28
Wilkie, Hon. Robert L., Secretary, Veterans Affairs, U.S. 
  Department of Veterans Affairs.................................     2
    Prepared statement...........................................     4

                                Appendix

National Indian Health Board (NIHB), prepared statement..........    43
Response to written questions submitted by Hon. Catherine Cortez 
  Masto to:
    RADM Chris Buchanan..........................................    63
    Dr. Kameron Matthews.........................................    56
    Hon. Robert L. Wilkie........................................    52
Response to written questions submitted by Hon. Tom Udall to:
    RADM Chris Buchanan..........................................    62
    Dr. Kameron Matthews.........................................    60
Tetnowski, Sonya, Vice-President, National Council of Urban 
  Indian Health, prepared statement..............................    41
United South and Eastern Tribes Sovereignty Protection Fund (USET 
  SPF), prepared statement.......................................    50


   RECOGNIZING THE SACRIFICE: HONORING A NATION'S PROMISE TO NATIVE 
 VETERANS TO RECEIVE TESTIMONY ON S. 1001, TRIBAL VETERANS HEALTH CARE 
   ENHANCEMENT ACT AND S. 2365, HEALTH CARE ACCESS FOR URBAN NATIVE 
                          VETERANS ACT OF 2019

                              ----------                              


                      WEDNESDAY, NOVEMBER 20, 2019


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:38 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 this hearing to order. We are 
having a vote right now, so members are working their way back 
and forth.
    We truly appreciate the Secretary joining us. Thank you for 
being here, Mr. Secretary.
    Mr. Wilkie. Yes, sir.
    The Chairman. We are going to get rolling, so that you have 
time to give your testimony and still some time for Q&A from 
some of the members before you need to depart.
    Again, I call this oversight and legislative hearing to 
order. In our first panel, the Committee will receive testimony 
on Recognizing the Sacrifice: Honoring a Nation's Promise to 
Native Veterans. We will hear from the Honorable Robert Wilkie, 
Secretary of the U.S. Department of Veterans Affairs. Secretary 
Wilkie was nominated by President Trump to serve as the tenth 
Secretary of Veterans Affairs. He was confirmed by the United 
States Senate on July 23rd, 2018, and sworn in on July 30th, 
2018.
    Secretary Wilkie is the son of an Army artillery commander, 
and spent his youth at Fort Bragg. Today, he is a Colonel in 
the United States Air Force Reserve assigned to the Office of 
the Chief of Staff.
    Before joining the Air Force, he served in the United 
States Navy Reserve with the Joint Forces Intelligence Command, 
Naval Special Warfare Group Two, and Office of Naval 
Intelligence. So you have Army, Air Force, and Navy.
    Mr. Wilkie. Yes, sir.
    The Chairman. Still working on the Coast Guard and Marine 
piece of it?
    Mr. Wilkie. Yes, sir.
    [Laughter.]
    The Chairman. Secretary Wilkie holds an honors degree from 
Wake Forest University, a Juris Doctor from Loyola University 
College of Law in New Orleans, Master of Laws in International 
and Comparative Law from Georgetown, and a Master's in 
Strategic Studies from the United States Army War College. 
Secretary Wilkie is the first sitting VA Secretary to testify 
in front of the Indian Affairs Committee since the Committee 
became a permanent committee 35 years ago. For that, we are 
deeply appreciative.
    We are fortunate to have recently hosted Secretary Wilkie 
in North Dakota, where he was able to see firsthand the good 
work of our Fargo VA Healthcare Center, which does an excellent 
job, just an excellent job. You don't have to take my word for 
it; talk to a veteran from North Dakota or Minnesota, and they 
will tell you the same thing.
    With that, accompanying Sectary Wilkie is Dr. Richard 
Stone, Executive in Charge for the Veterans Health 
Administration. With that, Mr. Secretary, again, thank you for 
being here and we will turn to your testimony.

        STATEMENT OF HON. ROBERT L. WILKIE, SECRETARY, 
         VETERANS AFFAIRS, U.S. DEPARTMENT OF VETERANS 
AFFAIRS; ACCOMPANIED BY: RICHARD STONE, EXECUTIVE IN CHARGE FOR 
 THE VETERANS HEALTH ADMINISTRATION AND DR. KAMERON MATTHEWS, 
            DEPUTY UNDERSECRETARY FOR COMMUNITY CARE

    Mr. Wilkie. Mr. Chairman, thank you, and thank you for the 
honor. It means a great deal to me. I also want to thank 
Senator Moran and Senator McSally.
    I appreciate the fact that I am the first Secretary of this 
department to appear in front of this distinguished Committee. 
As you know, in our conversations, I spent a great deal of my 
childhood on the Great Plains, southwestern Oklahoma, amongst 
the Great Nations of the southern plains. I learned of 
traditions and sacrifices.
    We were taught as young children the proper protocols when 
we approached the gravesites of Geronimo and the last of the 
great scouts, I-See-O. I would watch my father command honor 
details at the graves of both. And in that part of Oklahoma, we 
are reminded of the courage of the 45th Infantry Division, the 
Thunderbirds, comprising 50 tribes up and down the Plains. One 
of the most decorated units in the history of the United States 
Army.
    I made a commitment when I was asked to come to VA that I 
would reach out, reach out to rural Native America, the two 
places in our Country that have the highest per capita rate of 
service of any groups in America. There are 31,000 Native 
Americans on active duty and 140,000 are veterans. Per capita, 
they have the highest rate of award, of the medal of honor. And 
to this day, serve at all ranks and add testament to a very, 
very glorious history.
    So I wanted to come today and talk about where we are at 
VA, how we are reaffirming our commitment to the sovereignty of 
the tribes, the Great Nations of the United States. I have had 
the pleasure of spending time all the way from Alaska, as you 
know, to the Dakotas. We will be in Kansas with Senator Moran 
next week. We will be in Montana with Senator Tester in two 
weeks, and we will be headed to New Mexico and Arizona at the 
beginning of next year.
    Our pledge at VA is to continue to work with tribal 
governments to face the unique challenges that accompany life 
in America's Native communities. We are redefining our 
partnership with IHS and we are currently in the process of 
updating that MOU that we have with them to keep up with the 
changing needs of veterans. And we know the importance of 
consulting with tribal leaders and the National Indian Health 
Board as we undertake this project.
    I want all Native veterans and their communities to know we 
are listening to their concerns as we work on this, and that as 
I said earlier, we have the greatest respect for the 
sovereignty of their communities.
    One counterintuitive fact about Native America is that 53 
percent of the population is urban. That still leaves close to 
half the population in rural areas. We are finding ways to 
reach them.
    One solution that we had pursued is tele-health. VA has its 
own tele-health facilities in the western States, Alaska, 
Montana, Oklahoma, and Wyoming. They are helping us to give 
care to veterans who don't live that short drive away from a VA 
facility. We are partnering with Wal-Mart to expand this 
capability even further, as we have found that Wal-Mart 
locations coincide with the majority of the rural veterans we 
are trying to reach.
    Along those lines, we established the VA-IHS consolidated 
mail order pharmacy program, which sends prescription 
medications directly to Native homes. Last year, the program 
processed 840,000 prescriptions for Native veterans, up 17 
percent from the previous year.
    The MISSION Act is also helping all veterans access care. 
As you know, President Trump's PREVENTS initiative aims to 
bring together governments, faith-based groups, veterans 
organizations and the private sector who might be struggling 
with mental health, addiction, or homelessness problems that 
could pose a heightened risk of the greatest threat to our 
veteran population, and that is suicide. So much of that work 
involves getting veterans the help they need in rural areas, 
either inside VA or in their communities.
    As you know, VA is more than just healthcare. Our Benefits 
Administration is helping Native Americans on issues like job 
training and housing. And our National Cemetery Administration 
is a key partner in the Library of Congress' Warrior Spirit 
project. This is a year-long curriculum development project 
that honors our Nation's Indian veterans by profiling the 
sacrifice and patriotism of Native Americans who are 
memorialized across this Country.
    There is always more that can be done. If I might, I would 
encourage Congress to take two steps that would help VA connect 
with Native America. First, I would urge you to consider a 
bipartisan bill in this chamber that will help VA directly fund 
State and local groups that are in a position to help prevent 
veteran suicide. Some of your Committee members are sponsors of 
the legislation, and it is something that we believe can make 
an immediate difference in veterans' lives.
    Secondly, I would note that VA supports legislation 
sponsored by Senator Tester to establish a VA advisory 
committee on tribal and Indian affairs. We believe that this 
will provide a formal structure and forum for VA to engage with 
tribal leadership and create many opportunities for 
collaboration to improve VA services to Native American 
veterans.
    I will leave you with one story that I gave at the 
groundbreaking for the National Native American Veterans 
Memorial at the Museum here in Washington. In 1865, as Robert 
E. Lee was surrendering to General Grant, he was approached by 
General Grant's most trusted aide, E. Lee Parker, a Seneca War 
Chief. As he approached General Lee, the Confederate General 
looked up at Grant and said, finally, we have a real American 
here, General, to which Colonel Parker snapped to attention and 
said, General Lee, we are all Americans here.
    That is probably the most genuine American response given 
at any time in our history. As a result of that, it is our 
mission to ensure that Colonel Parker's admonition in 1865 
becomes a reality, and it is our mission to ensure that all 
Native Americans know that this VA belongs to them as well.
    I thank you very much, sir, for your courtesy.
    [The prepared statement of Mr. Wilkie follows:]

   Prepared Statement of Hon. Robert L. Wilkie, Secretary, Veterans 
              Affairs, U.S. Department of Veterans Affairs
    Good afternoon, Chairman Hoeven, and Vice Chairman Udall. I 
appreciate the opportunity to discuss how care at the Department of 
Veterans Affairs (VA) and our partnership with Indian Health Service 
(IHS) positively impact our Native Veterans. I am accompanied today by 
my colleagues Dr. Richard Stone, Executive in Charge for the Veterans 
Health Administration (VHA); Dr. Kameron Matthews, Deputy Under 
Secretary for Community Care; and Ms. Stephanie Birdwell, Director for 
VA's Office of Tribal Government Relations.
Introduction
    As I have shared during my engagements with Native Veterans and 
tribal leaders across the country, our goal at VA is to shorten the 
distance between people in need of Veterans services. Native Americans 
have participated in every American conflict dating back to the 
Revolutionary War, and they serve in the military at a higher per 
capita rate than any other ethnic group. The importance of Native 
Servicemembers has only grown in the country over time, and we strive 
to honor this community with the quality, culturally competent care 
that they deserve. The American Indian and Alaska Native (AI/AN) 
populations experience health and other disparities that 
disproportionally affect their quality of life. VA is working to 
increase our reach into tribal communities through telehealth, visits 
from VA representatives, and closer cooperation between VA and IHS.
Five Goals of the MOU between VA and IHS
    An MOU, originally signed in 2003 and updated again in 2010, 
established that IHS and VA can coordinate, collaborate, and share 
resources between the Departments. Five mutual goals were agreed upon 
when the MOU was signed:

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

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

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

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

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

    To achieve these goals, VHA has piloted and subsequently adopted 
several programs. To address access to care, achieve effective 
partnerships, and ensure the availability of resources, in 2012 VA 
established a national reimbursement template with IHS which led to 114 
Tribal Health Programs (THP) agreements.
    In addition to these reimbursement agreements, local VA medical 
centers have established, where appropriate, several agreements with 
THPs and IHS facilities to deliver telemental health care to Native 
Veterans. The program serves tribal communities in Alaska, Montana, 
Wyoming, and Oklahoma. VA's Office of Rural Health's Veterans Rural 
Health Resource Center, Salt Lake City (VRHRC SLC) has an active 
portfolio of innovations in Native Veteran health care, including the 
creation of a Rural Veteran Tribal Navigator program that will connect 
Native Veterans with the benefits and care they have earned.
    VA Video Connect (VVC) is a pilot program currently being deployed 
nationwide. VVC will allow rural Native Veterans to access VA health 
care in their homes or local communities through cellular and wireless 
capabilities. VRHRC SLC is currently working to tailor this program to 
Native Veteran communities, creating a model that will weave together 
the Western medicine, traditional Native Healing, and rural Native 
communities' strengths through four main components: mental health 
care, technology, care coordination, and a tailored implementation 
facilitation strategy. In addition to these programs, VRHRC SLC is 
piloting programs to establish Tribal-VHA Partnerships in Suicide 
Prevention and developing Native Veteran Content for the VA Community 
Provider Toolkit.
    One of the great successes in achieving the 2010 MOU goals was the 
establishment of the VA/IHS Consolidated Mail Order Pharmacy Program 
(CMOP) that sends prescription medications to Native Veterans' homes. 
In 2018 alone, CMOP processed 840,000 prescriptions for Native 
Veterans, up 17 percent from the previous year. Since its inception, 
CMOP has processed more than 3.6 million prescriptions for AI/AN 
Veterans served by IHS and THP programs.
    In early Fiscal Year 2019, VHA and IHS MOU leadership agreed that 
the 2010 MOU was no longer meeting the agencies' needs and required 
modification to create the flexibility needed to move the interagency 
relationship forward to a new level. The leadership team drafted a new 
MOU and conducted a first listening session with tribal leaders on May 
15, 2019. Tribal input from that session was incorporated into the 
draft VHA-IHS MOU, and VA and IHS conducted a subsequent consultation 
session at the National Indian Health Board annual meeting on September 
16, 2019. This additional input is now being considered for inclusion 
in the draft MOU. After the IHS and VA MOU leadership team reaches 
agreement on the draft MOU, it will enter formal clearance channels for 
approval by IHS and VA. The approved draft MOU document will be posted 
in the Federal Register and further tribal consultation for a period of 
no less than 60 days. Tribal input will be incorporated into the draft 
document and it will move forward for final approval and signature.
    We are confident that the evolution of this MOU will be successful 
as it is happening in tandem with the MISSION Act. This transformative 
legislation will entail the most comprehensive change in VA's history. 
The MISSION Act consolidated community care programs to make it easier 
for all Veterans, families, community providers, and employees to 
navigate.
Reimbursement Agreements
    Since the Summer of 2012, VA has signed individual reimbursement 
agreements with THPs to provide direct care services to eligible Native 
Veterans closer to their homes in a culturally sensitive environment. 
In December 2012, VA signed a national reimbursement agreement with 
IHS. Today, the national reimbursement agreement with IHS covers 74 IHS 
sites. There are also 114 individual reimbursement agreements with THPs 
of which 26 are in Alaska and cover Native Veterans and Non-Native 
Veterans.
    From August 2012 through September 2019, VA has reimbursed IHS and 
THPs over $104 million covering approximately 10,645 unique Native 
Veterans. Of the $103 million, VA has reimbursed approximately $38 
million to Alaska THPs for covering an estimated 1,523 unique Native 
Veterans. Additionally, VA has reimbursed Alaska THPs approximately 
$27.9 million for approximately 4,825 unique Non-Native Veterans.
    IHS and several THPs have requested that the agreements be expanded 
to cover reimbursements for purchased referred care under which IHS and 
THPs can refer Native Veterans to their contracted community care. They 
feel this will enhance care coordination. VA is also looking to enhance 
care coordination with IHS and THP facilities. At the request of the 
Veteran, VA has the primary responsibility for care provided to 
Veterans and related care coordination. As a result, VA is seeking to 
develop a standardized care coordination process that will enhance care 
coordination for Native Veterans. Initial steps include establishing an 
Advisory Board for care coordination and inviting Tribal Officials to 
be members on the Board. The Board's main scope will be to implement 
the standardized care coordination process and to improve care 
coordination including community referrals between VA and IHS/THP sites 
for the benefit of Veterans.
Tribal Department of Housing and Urban Development--VA Supportive 
        Housing (HUD-VASH)
    Tribal HUD-VASH, is a partnership between VHA, HUD's Office of 
Native American Programs, and tribes, which provides permanent 
supportive housing in Indian areas to homeless and at risk of 
homelessness Native Veterans. The program currently serves 26 tribes 
with expansion in the next 6 months. VA provides case management and 
supportive services to promote tenancy in housing supported by HUD 
grant funding for rental assistance. VA case managers work with local 
resources and the appropriate VA employment programs to assist Native 
Veterans to access employment when appropriate for the Veteran.
Housing Programs for Native American Veterans
    VA is authorized under the Native American Direct Loan (NADL) 
program to make loans to eligible Native American Veterans who reside 
on trust land. The Veteran's tribal or other sovereign governing body 
must enter into an MOU with VA before VA can offer the program to a 
Veteran. Once the MOU is in place, the Veteran applies directly to VA 
for a loan. The Veteran can apply for up to a 30-year fixed-rate loan 
to purchase, build, or improve a home located on trust land.
    The NADL program is a loan and not a grant; therefore, the Veteran 
must repay it. If eligible, the Veteran can also refinance a previous 
NADL to lower the interest rate. The NADL program offers many 
advantages, such as no down payment, no private mortgage insurance, a 
low fixed interest rate, low closing costs, and the option for multiple 
uses.
    Since 1992, VA has entered into 108 MOUs with Federally Recognized 
Tribes or Native Hawaiian, Pacific Islander, or Alaska Native 
communities, and made 1,040 loans to Native Veterans, totaling over 
$137.9 million. VA staff are required each year to contact all entities 
that can, or already have, agreed to an MOU. All Federally Recognized 
Tribes, Villages, Nations, Bands, and Communities, as well as 
communities of the Hawaiian Homelands, American Samoa, Guam, and the 
Commonwealth of the Northern Marianas Islands are part of VA's outreach 
efforts. VA staff also participate in tribal consultations to provide 
information about the availability of this program and to seek input 
from tribal leaders on how to improve benefit delivery. VA staff attend 
stakeholder conferences to discuss Federal housing issues germane to 
American Indian Veterans. For properties not located on trust land, 
Native Veterans can use the VA-Guaranteed Home Loan program.
Other VA Services
    In addition to these initiatives, VA provides vocational 
rehabilitation and employment (VR&E) services to Native American 
Veterans who meet eligibility and entitlement criteria. VR&E's mission 
is to increase independence in daily living and to assist Veterans with 
service-connected disabilities prepare for, obtain, and maintain 
suitable employment. These services are provided by highly trained 
Vocational Rehabilitation Counselors who recognize the cultural 
differences and issues impacting the Native American population. VR&E 
beneficiaries are eligible for any needed health care services, 
provided by VHA, to help them meet all identified rehabilitation goals. 
By addressing these specific needs--independence in daily living and 
employment--the VR&E program is another VA resource available that 
positively impacts our Native American Veteran population.
Legislation
    Mr. Chairman, we know the Committee is also interested in our 
comments on two pieces of legislation. We offer the following broad 
comments, and I know our second panel will be ready to talk to them in 
more detail.
S. 1001 Tribal Veterans Health Care Enhancement Act
    S. 1001 would amend the Indian Health Care Improvement Act to 
authorize IHS to pay the cost of copayments assessed by VA to certain 
eligible Indian Veterans for covered medical care. Covered medical care 
would consist of any medical care or service that is authorized for an 
eligible Indian Veteran (as such term would be defined) under the 
contract health service and referred by IHS and administered at a VA 
facility. This would include any services rendered under a contract 
with a non-VA health care provider.
    VA does not support S. 1001 as written. We note that VA business 
processes related to copayment collections and interagency transfers of 
funds could present technical challenges, so we look forward to 
discussing with the Committee the best way to create parity with regard 
to copayments for eligible Veterans who are referred from IHS to VA for 
care. We look forward to discussing the bill in more detail with the 
Committee.
    We also note that the Congressional Budget Office concluded that a 
similar bill from the 115th Congress would cost less than $500,000 over 
the 5-year period from 2017 through 2021 (letter from the Congressional 
Budget Office to Chairman John Hoeven regarding S. 304 (115th Congress) 
dated May 2, 2017, reproduced in Senate Report 115-112 (June 15, 
2017)).
S. 2365 Health Care Access for Urban Native Veterans Act of 2019
    As background, VHA has entered into reimbursement agreements with 
IHS and THPs under which VHA reimburses IHS and THP for direct health 
care services provided in IHS and THP facilities. These reimbursement 
agreements are authorized by 38 United States Code (U.S.C.)  8153 and 
25 U.S.C.  1645. The latter authority refers specifically to IHS, 
Indian tribes, and tribal organizations, and excludes urban Indian 
organizations.
    S. 2365 would amend 25 U.S.C.  1645 by adding references to urban 
Indian organizations in subsections (a) and (c), thus authorizing VA to 
enter into reimbursement agreements with urban Indian organizations.
    VA does not object to the bill but would appreciate the opportunity 
to discuss with the Committee the differences between reimbursement 
agreements and other methods of procuring health care that are 
available. VA cannot project costs with specificity for S. 2365, but 
believes the net cost impact would be minimal, given the number of 
potentially covered Native Veterans.
Conclusion
    The health and well-being of all our nations' Veterans is of the 
utmost importance. We strive to consistently provide high quality care 
to all Veterans and continue to make significant strides in enhancing 
the practice and culture of the Department to be more accessible to our 
Native American Veterans. Working with many diverse, sovereign tribes 
is essential to successfully achieve the goals of the MOU between VA 
and IHS. VA is committed to ensuring that our goals align with IHS and 
that the needs of our Native American Veterans are met. I want to thank 
the Committee for hosting this hearing. This concludes my written 
testimony.

    The Chairman. Thank you, Mr. Secretary. We are deeply 
appreciative of your being here, and your commitment to all 
veterans, and of course, being here today, reflecting your 
commitment to Native American veterans. As you know, Native 
Americans serve in our military, as a group, at a higher 
percentage than any other group. It is a remarkable, amazing 
thing, isn't it?
    Mr. Wilkie. It is.
    The Chairman. It really is. Along those lines, right behind 
you, and you may have had a chance to meet him on the way in, 
we have not only the Chairman of the Three Affiliated Tribes, 
Mandan, Hidatsa, and Arikara, Mark Fox, who is a Marine Corps 
veteran. Semper Fi. We appreciate him being here.
    He brought with him Ms. Harriet Good Iron, and she is the 
matriarch of a Gold Star family. Maybe you could stand up so 
everybody can see you. Thank you.
    [Applause.]
    The Chairman. Her son, Army Colonel Nathan Good Iron, was 
killed in a firefight 13 years ago in Afghanistan. I was 
actually Governor at that time. I remember attending the 
funeral. It was on the reservation, but it was one of the most 
amazing funerals, because it combined Native American culture 
and religion with non-Native culture and religion. It was one 
of the most moving, amazing funerals that I have ever attended. 
Of course, it was for one of our heroes, your son, your amazing 
son. And you and your husband have been such incredible 
supporters of all of our veterans and all of our events. His 
spirit lives on. Corporal Good Iron is here with us today in 
spirit, even as we are here in body.
    God bless you, and thank you.
    Mr. Secretary, I am going to start with a couple of 
questions, and then turn things over to the Vice Chairman. 
Members will be filing back in now, as they have had a chance 
to vote.
    Mr. Wilkie. Senator Tester missed my endorsement of his 
legislation.
    The Chairman. I know. I can't believe how you raved about 
him. That will be stricken from the record.
    [Laughter.]
    The Chairman. We have already stricken that from the 
record.
    [Laughter.]
    The Chairman. He really did say nice things about you, he 
is not kidding.
    Senator Tester. I am sorry I missed it.
    The Chairman. We will bold it in the record.
    Mr. Secretary, during last month's groundbreaking for the 
National Native American Memorial at the Smithsonian's National 
Museum of the American Indian, you spoke about the 
contributions of Native American service men throughout the 
history of the U.S. military. I know you are a student of 
history. So again, I appreciate that commitment to outreach.
    Would you highlight the Department's priorities in working 
with tribal veterans, as well as provide some examples of how 
the VA is working to help our tribal veterans when they return 
home from the battlefield?
    Mr. Wilkie. I will start with our Veteran Benefits 
Administration. As you pointed out in many of our 
conversations, more than half of the budget at VA goes to 
benefits. It has been my first goal to expand the number of 
claims clinics that can reach tribal governments across the 
Country. There were 30 claims events just in this last year, 
involving 24 tribes and serving well over 1,000 veterans. I 
want to expand that.
    I mentioned expanding tele-health, to cut across the great 
lengths of the American West. Senator Tester and Senator 
Murkowski have listened to me talk about the inability of many 
leaders in this town to comprehend the scale of the places in 
which you live.
    For us, that means two things. One, expanding tele-health, 
our tele-health budget is now at $1.1 billion. I expect it to 
grow. The other is getting our mobile facilities out into 
tribal communities. That is pharmacies, clinics, nutrition 
vehicles as well as the benefits trucks. And enhancing our 
relationship with IHS.
    I made it a point to the President and to the Secretary of 
the Interior that without IHS, we can't deliver everything that 
we need to our veterans. I am looking at ways that we can 
further enhance their ability to deliver.
    The other thing is memorial. There is no community in the 
Country that believes more in maintaining the faith with those 
who have come before. We are expanding the number of grants 
that we give to tribal communities, not only to preserve, but 
to create new memorials, new cemeteries. I take that to heart.
    In the last year, we have undergone the beginning of 13 new 
tribal veteran cemeteries across the Country. That is part of a 
comprehensive program.
    Last thing I will say, suicide prevention. Twenty veterans 
a day take their lives. Sixty percent of those we don't see. In 
my discussion, particularly in Alaska, and Senator Murkowski 
was listening remotely last year, I asked the Federation of 
Natives to help us in doubling the number of tribal VA 
representatives that they have to get out into the farthest 
reaches of Alaska, to find those veterans we can't see. I have 
said the same thing to the leaders of the Southern Plains and 
in North and South Dakota.
    We are opening the aperture in terms of financial support 
to tribal communities, so that they can be better prepared and 
they have the resources to go places that we are not. So it is 
a very comprehensive list of programs, but I think we are in a 
much better place than we have been in the last few years.
    The Chairman. One of the important programs is the Native 
American Direct Loan Program that was established in 1992. 
There has been more than $137 million made in those types of 
loans.
    This really is an opportunity to use that VA loan guarantee 
on Federal lands. Housing is such an important issue across the 
board, it is particularly challenging on the reservation. How 
do we get the word out and get more usage of that program for 
Native American vets?
    Mr. Wilkie. In the past 15 years, there have been 108 MOUs 
dealing with the National Direct Loan Program. I want to see 
more. We certainly have had more when it comes to other MOUs on 
everything from medical services, as I said, to Native 
cemeteries. The benefit of the Direct Loan Program is that, 
obviously, no down payment, no PMI, minimal closing costs.
    It is my goal that we make sure that every tribal community 
in the Country has an MOU in place with us, so that we have 
them making sure that any information that we give on the 
National Direct Loan Program is sent out to all of its members. 
Communication is the key. I think we are in a better place than 
we have been, and it is a vital program.
    The Chairman. Thank you, Mr. Secretary. I will turn to Vice 
Chairman Udall.

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

    Senator Udall. Thank you, Mr. Chairman. Thank you, Mr. 
Secretary, for being here, and all of your good work on behalf 
of veterans. I am going to go directly to questions, because I 
know there are many Senator here who want to question you for 
the time period that you are here.
    We really appreciate your being here. All Federal agencies 
have a part to play in upholding the United States' trust and 
treaty responsibilities to Native Americans. You no doubt 
understand your agency's mission to ``provide veterans the 
world class benefits they have earned.'' But I want to use this 
opportunity to ask you about your role as trustee, in the role 
of executing the trust responsibility to Native Americans.
    What is your understanding of the Federal trust and treaty 
responsibilities to Native Americans, and what is the VA's role 
in fulfilling it?
    Mr. Wilkie. Senator Udall, while you were voting, I talked 
about my upbringing in southwestern Oklahoma. You and I have 
actually had this discussion in your office, and I have said 
this publicly in Alaska. Coming from the world I come from, I 
always affirm the tribal sovereignties, sovereignty of all the 
Nations and Tribes of the United States. It is a government to 
government relationship. I am dealing with sovereign entities.
    My job is in honoring that relationship to not only provide 
as many resources as I can, but also to ensure that there is a 
free flow of information, which is why I mentioned Senator 
Tester's legislation earlier. It is long past time that we have 
a VA tribal council that is on a day to day basis feeding us 
information on what is going on in those sovereign lands.
    Senator Udall. Thank you. Secretary Wilkie, our shared 
trust and treaty responsibilities to tribes and their members 
exists with equal force both on the reservation and off the 
reservation. In a report accompanying the first reauthorization 
of the Indian Health Care Improvement Act in 1988, this 
Committee stated very directly, ``The responsibility for the 
provision of healthcare arising from treaties and laws does not 
end at the borders of the Indian reservation.'' This is still 
the policy of the United States Government.
    Is the VA committed to working with this Committee and the 
Indian Health Service to ensure our shared trust and treaty 
responsibilities to all Native American veterans, including 
those who live on or off the reservation, are fulfilled?
    Mr. Wilkie. Yes, sir, absolutely. What is hard for many in 
this town to comprehend is that 53 percent of Native Americans 
live in urban centers. That relationship should be as robust as 
the relationship we have with Native peoples in rural areas. So 
absolutely.
    Senator Udall. Thank you very much for that answer and for 
that commitment.
    I would just note here, my bill, S. 2365, would correct a 
legislative oversight and would ensure that the VA is able to 
administer its IHS reimbursement program consistently for all 
Native veterans, in alignment with the principles of Federal 
Indian Health policy.
    Mr. Wilkie. And I support that legislation as it pertains 
to urban Indian organizations, sir. I do.
    Senator Udall. [Presiding.] Thank you, Mr. Secretary.
    Senator Murkowski, I recognize you.
    Senator Murkowski. I think it is Senator McSally.
    Senator Udall. Senator McSally, pardon me. She gave me a 
note, as always, it is the Senator that screws up, it is the 
staff that gets it right. Go ahead.

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

    Senator McSally. It is all good. Thank you so much, Senator 
Udall.
    Secretary Wilkie, it is great to see you again. Arizona has 
a proud history of Native Americans serving in our military. 
One of the most amazing is the Code Talkers, Navajo and Hopi. I 
will tell you, one of the highlights of my life was this summer 
being out on the Navajo Nation and meeting four of the five 
remaining Code Talkers for National Navajo Code Talker Day. I 
will tell you, there was not a dry eye in the place as one of 
them stood up and broke out in the Marine Corps song in Navajo. 
It was just an extraordinary experience.
    And they are passing this on to the next generation, to 
continue to serve. It is just amazing. We have 22 federally 
recognized tribes in Arizona. But they are in very rural areas 
across Arizona, major land masses, over 26,000 veterans, 
according to the 2017 Census.
    So access is a significant issue, as you talked about. But 
broadband and connectivity is also an issue. That is something 
this Committee has been focusing on, and we are really attuned 
to. So tele-medicine just may not be an option for many of 
them. And taking long trips into where there may be health care 
or VA, other facilities, or even using the VA MISSION Act into 
the rural community, they just may not have the specialties 
that they need.
    So what are the options? I would really like to explore 
more in Arizona of bringing services to them, with mobile units 
and specialties and mental health providers. Because tele-
medicine just isn't going to work until we fix the broadband 
and connectivity issue.
    Dr. Stone. Senator, you are exactly correct. We have a 
program called VA Video Connect, which uses telephonic 
transmission rather than the broadband transmission. Even then, 
it is not adequate, and therefore, the need to use--we have 
just placed in Montana a mobile unit from Phillips in a VFW 
hall, and we look forward to expanding that. Literally, it is a 
remote clinic that we provide the infrastructure to. We will be 
expanding that dramatically, we hope, in the near future. That 
is a pilot program in an effort to reach these remote areas.
    Our mobile units, it is so geographically dispersed that 
even our mobile units are not enough, and therefore we think 
that these kinds of partnerships with the VFW and Phillips is 
one we must go to. We had about 19,000 remote visits through VA 
Video Connect in our tele-health program in the Native American 
communities in both the lower 48 and Alaska last year. But it 
must expand dramatically. We will need your help to get the 
infrastructure built to do that.
    Senator McSally. Absolutely. I would love to partner with 
you on this specifically in Arizona.
    Other partnerships, I remember getting briefed by one of 
the private sector health organizations who received a grant 
and is doing more on some of the Native American communities. 
Are you also partnering with them to see where others are 
already getting out there with educational programs and other 
things to figure out how you can partner with them and not 
reinvent the wheel? It is such a challenging access issue. We 
don't need to be duplicating efforts.
    Dr. Stone. That is correct. In fact, this year, we funded a 
Rural Native American Navigator Program that we are engaging 
individual tribes in, and members who will act as navigators 
for other veterans to bring them into the system and to help 
them understand what is available to them.
    Senator McSally. Great, thanks.
    Mr. Wilkie. I would add one other thing, Senator. We are 
looking to expand the number of MOUs with Indian Health. One of 
the focuses that I have is making sure that our mail order 
pharmacy service is robust and is serving the needs of Native 
communities in a way that it sometimes has not in the past.
    Senator McSally. Thanks. I know recently in my office we 
met with representatives from Navajo. My understanding is that 
the VA is exploring, studying the possibility of bringing a 
community-based outpatient clinic there. I don't know if you 
can answer now or for the record what the status of that is. 
There are 10,000 veterans on the Navajo Nation. So it is a 
pretty big deal.
    Dr. Stone. We will take that for the record, and come back 
to you. I can't answer that right now for you.
    Senator McSally. Great, thank you.
    And then one last thing. I appreciate, Secretary Wilkie, 
your focus on veteran suicide. This is just unacceptable. We 
deploy, and those who took their oath of office, we are willing 
to put our lives on the line. Then they are coming home, 
surviving battle, and taking their own lives. More has to be 
done. Business as usual, more of the same, insanity is doing 
the same thing over and over again and expecting a different 
result.
    Specifically for Native Americans, though, my understanding 
is that even in the data collection they are listed as 
``other.'' So we don't even understand what the scope of the 
problem is specifically for Native American veterans who are at 
risk of suicide or committed suicide. So if you just want to 
follow up on updating and even how we got any data, if we don't 
know what the problem is, we don't know how to fix the problem.
    Mr. Wilkie. Mr. Chairman, may I beg your indulgence?
    Senator Udall. Yes, please.
    Senator McSally. Yes, I know, we are over.
    Senator Udall. We need to ask questions to you.
    Mr. Wilkie. This is a number one clinical priority. I come 
from a military family. My formative experiences were watching 
the aftereffects of Vietnam. A father, senior officer in the 82 
Airborne Division, couldn't wear his uniform off post. The 
majority of veterans who take their lives are from Vietnam. 
Lyndon Johnson left Washington, D.C. 50 years ago in January. 
That is how long some of these have been germinating.
    The other tragedy, this involves the American west, is that 
the Department of War started taking statistics on veteran 
suicide in 1892. We have never had a national conversation 
about suicide, particularly amongst veterans. So we do have the 
first national task force. We just are supporting legislation 
that some on this Committee are supporting that opens the 
aperture, so that we get resources to tribal governments, so 
that they can find those 50, those 60 percent that we don't 
see.
    Senator McSally. Right.
    Mr. Wilkie. That is the biggest hurdle for us. Finally, 
finally we are addressing it, finally we are having a 
conversation about mental health that is long overdue.
    Senator McSally. Thank you. Thank you, Mr. Chairman.
    Senator Udall. Senator Tester is recognized.

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

    Senator Tester. Thank you, Mr. Ranking Member. I want to 
echo Senator McSally's statement on high speed internet being 
necessary for tele-medicine in Indian Country. As the Senate 
and the House, we need to step up and make sure that 
infrastructure is there and if you are going to be able to 
deliver it in areas. I always point out the fact that I don't 
have very good internet in my area, but if you go 25, 30 miles 
east of me on Rocky Boy Indian Reservation, they have none. So 
it is really, really important.
    First of all, I want to thank you both for being here. For 
the folks that aren't familiar with the VA, it is the second 
largest agency within the government. Secretary Wilkie and Dr. 
Stone do a great job. I would tell you that if everything went 
perfect, I could still find something wrong. So thank you very 
much for what you are doing.
    I just want to give you a little bit of advice, and it 
makes my life a lot simpler, if you do this. Manchin is not a 
crazy guy. He is not. And there are some people that died or 
were murdered in that VA facility. We have to figure it out. 
Joe is not doing anything that any of the others of us wouldn't 
do. If something had happened in Montana, we would be asking 
for answers.
    Quite frankly, since it happened in a VA facility, we have 
to get answers from the VA to make sure that we know what 
happened, and make sure that it doesn't happen again. You don't 
have to answer to that. What I am saying is that if we are 
going to keep that committee together and not blow it up, this 
is a big one, guys. Joe has to be responded to in a very, very 
professional, civil way.
    You go ahead, Secretary.
    Mr. Wilkie. I will respond. I agree with your sentiment. I 
also make the point that this investigation began before I was 
Secretary.
    Senator Tester. Absolutely. I am not pointing fingers at 
anybody.
    Mr. Wilkie. Because of the nature of those investigations, 
I am precluded from even knowing what happened. But Dr. Stone 
has been with Senator Manchin, he has been to West Virginia. We 
are doing everything we can within the parameters of the law. 
But you are absolutely right, we have to keep the confidence of 
our veterans. I am committed to that.
    Senator Tester. That is just important. Joe talks to me 
every time I see him, and I think there is good reason for it.
    I just want to ask you one question, then I will let 
somebody else go. Secretary Wilkie, you talked about suicide 
being a big problem, and it is. Sixty percent of the folks you 
never see, that commit suicide.
    In Indian Country, especially in large land-based tribes, 
it is a long way between houses. Are you doing some things 
specifically for Indian Country when it comes to outreach? Let 
me just give you an example. Campaigns are a fine example. If 
we are going to go out and try to influence Native Americans, I 
can't have a bunch of white folks with me to get that done. I 
need to have folks with that tribe to come in, and then you can 
make some influences.
    So the question is, what are you doing to make that 
outreach happen? Because it is different there than in Big 
Sandy, Montana, or somewhere else.
    Mr. Wilkie. Absolutely, sir. Before Dr. Stone answers, I 
testified in front of the House Veterans Committee today. This 
was the subject. You are absolutely right. Me showing up is no 
good. That is why I have to get resources, to the tribal 
governments, to make sure that they are the ones on the tip of 
the spear.
    Senator Tester. And you are doing that.
    Mr. Wilkie. And that is what we are doing with our new 
budget. That is what the PREVENTS Act will do, the PREVENTS 
task force, I know that is what they will recommend. So you are 
absolutely right. Cultural sensitivity, for me, has been 
incredibly important in my time at VA.
    Senator Tester. Okay.
    Dr. Stone. Senator, we have funded, in the last number of 
years, a rural health tribal effort in order to embed suicide 
culturally climatized individuals with the tribes, trying to 
bring more veterans in. It is the same as your colleague's 
questions earlier, the remoteness of this, as we try to 
approach it.
    That said, we know, since you have graciously funded, 
through your effort, tremendous expansion of our behavioral 
health providers, from 10,000 a few years ago to 25,000 today. 
Much of the problems are facing is not mental health. It is 
isolation. It is loneliness. It is separation. It is grief. It 
is financial problems. Therefore, the effort that we have 
going, that you are well aware of on the Senate side and on the 
House side, we are strongly in support those, our ability to 
give grants to communities that would engage a community us 
effectively.
    Mr. Wilkie. That is why I said that your legislation is 
long overdue, because it can be the foundation for the 
expansion of what Dr. Stone is talking about.
    Senator Tester. Thank you.
    Senator Udall. Senator Murkowski is recognized.

               STATEMENT OF HON. LISA MURKOWSKI, 
                    U.S. SENATOR FROM ALASKA

    Senator Murkowski. Thank you, Mr. Chairman. Gentlemen, 
thank you. Mr. Secretary, I want to truly thank you for the 
efforts that you have made in the State of Alaska, your visits, 
just the engagement that you have had with us, whether it is 
the Alaska Native Veterans Allotment Act, your support on the 
VA MISSION Act, to make sure that the Alaska-specific 
provisions in there that kind of move us away from this one 
size fits all approach to health care, that they work.
    I think we are seeing some very significant gains on the 
ground, the ability to just recruit, to retain physicians at 
the CBOCs there in and around the State. More than 100 new 
employees within the Alaska VA healthcare system dealing with 
the issue that we had, the appointment referrals, and basically 
getting them back to the local VA.
    So we are seeing some real gains on the ground. It has to 
be heartwarming for you, because it certainly is for me, when I 
am hearing from our veterans who are saying, you know, I have 
never really been very happy with the care of the service, but 
things are turning around, and they are seeing the difference. 
I truly believe that you are helping to facilitate in that 
effort.
    Mr. Wilkie. Thank you.
    Senator Murkowski. But we are also seeing the partnership 
with the tribes benefit as well. I think we are seeing some of 
the previous barriers kind of be pushed back, the delays in 
enrollment that we have, the denial of care, the lack of access 
to VA services. I do think these partnerships are yielding the 
benefits.
    I too want to focus on the mental health, the behavioral 
health side of this, because with the issues related to 
suicide, and particularly with our Native people, this is 
significant for us. The high rates of suicide amongst Natives 
generally, but then you bring into it the mix with our 
veterans.
    Senator McSally addressed this, and you really didn't speak 
to it, but with the published report that the VA puts out every 
year on suicide data, it does just put our veterans, our Native 
veterans into a ``other'' category. I think what we are 
learning is, that lack of data being able to differentiate that 
makes it more challenging than to develop policy responses. 
Later this afternoon here, we are going to be moving out two 
bills, Savanna's Act, and Not Invisible, that are focused on 
diving into the actual data as it relates to murdered and 
missing indigenous women, murdered and missing trafficked 
women. But until we know the numbers, we are not able to better 
define the solution sets.
    Will the Bureau work with us to be publish the Native 
veteran suicide data to help us? Because it seems to me, if we 
can get a better handle on that, it might help us in our 
initiatives.
    Dr. Stone. Senator, we certainly pledge to you to pull that 
data out. As you know, we obtain from the National Death Index, 
the Traumatic Index, from the CDC.
    Senator Murkowski. Right.
    Dr. Stone. It takes us about a year to separate out the 
overarching veteran numbers. It took us, in preparation for 
this study, a fair length of time to separate Native American 
data out. I think you identify a real weakness in the way we 
have approached this. If we are going to identify 
subpopulations, which clearly this is one, it appears that the 
Native American population has a suicide death rate of over 44 
per 100,000, some of the highest in the Nation. There is a 
dramatic difference in the female Native American veteran.
    We would be happy to go through that with you, and we 
pledge our participation with you.
    Senator Murkowski. I appreciate that. I think it is 
something that we need to be really drilling down a little bit 
more into. Because it is within the Department of Justice as 
well. Senator Cortez Masto and I have learned this, that if we 
don't collect the data this way, it is tough for us, when we 
ask you the question, and you are not able to give it to us, 
not because you don't want to, but because we haven't 
differentiated it that way. So I think it is something that we 
need to work on.
    Mr. Secretary, you mentioned the doubling of the VA reps, 
our Native VA reps around the State. I so thank you for that. I 
so appreciate it. I do think it will make a difference. But we 
also know that in a State like mine, where 80 percent of our 
communities are not connected by roads, these are small, small 
isolated villages. You have to have the travel budget that goes 
with it.
    This is not a nice, cushy vacation for anybody. This is 
getting to work. So being able to provide for those resources 
is so appreciated.
    Mr. Wilkie. Senator Murkowski, you are absolutely right. 
Two things. I will work on that categorization.
    Senator Murkowski. Thank you.
    Mr. Wilkie. I agree with you about the word ``other.''
    Second, there is legislation that Senator Boozman and 
Senator Warner have, it is Bergman and Houlahan in the House, 
it is bipartisan, that will do what you described. It will 
allow us to take grant money and get that money out into those 
communities, into those tribal representatives, so that they 
are funded to do those outreach efforts.
    It is absolutely essential, because it is community based, 
and it is people who know their fellow citizens.
    Senator Murkowski. That is so important, I so appreciate 
it. I know that Senator Tester, coming from a big State like 
Montana, it is going to make a difference to them as well. 
Thank you.
    Thank you, Mr. Chairman.
    The Chairman. [Presiding.] Senator Smith.

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

    Senator Smith. Thank you, Chair Hoeven, and Vice Chair 
Udall, for holding this hearing today, and thank you very much. 
I appreciate your being here.
    Mr. Wilkie. Thank you.
    Senator Smith. I also want to just note, I am really 
pleased that we are joined here today by White Earth Secretary 
Treasurer, Alan Roy, who is a U.S. Army Veteran and here in the 
audience with us today. Thank you, Secretary Treasurer, for 
being with us today.
    The Chairman. This will have to be the last question, 
because the Secretary does have to go.
    Senator Smith. Absolutely. I have one question. And that 
has to do with the issue that Senator McSally raised, which has 
to do, I have heard it from Secretary Roy as well, which is now 
Native American veterans can access their benefits. We have 
talked a little bit about this, the billion dollars, and 
Federal funding to expand veterans access to healthcare through 
tele-health. I would like to hear a little bit more, 
understanding you have challenges with broadband, how that 
billion dollars is being used on tribal lands to serve Native 
veterans.
    Dr. Stone. I talked a little bit about our Phillips 
partnership and trying to reach that and taking areas where the 
infrastructure is built. Our other options are to bring in 
mobile units with satellite transmission, which we have a large 
number for our emergency operations work around the Country. We 
can bring in and use that to create connectivity.
    But it is about connecting very rare, difficult to recruit, 
mental health services. Now, this is where the beauty of our 
Indian Health Service relationship goes to, and where we are so 
pleased at what the IHS and the Public Health Service brings to 
us, as well as our relationships with the other tribal health 
programs. We have 114 relationships with tribal health 
programs. We are working on an additional 40 in order to reach 
individually.
    But still, it is about taking difficult to recruit, remote 
services, and getting them into remote areas when there is not 
much infrastructure.
    Senator Smith. Thank you. Thank you, Mr. Chair.
    The Chairman. It is my understanding that Dr. Stone can 
stay and answer some additional questions, is that correct?
    Dr. Stone. Yes.
    The Chairman. With that, Mr. Secretary, thank you so much 
for being here and for extending. We understood earlier you had 
to leave at 3:00, so we greatly appreciate the additional time.
    Mr. Wilkie. Thank you. Thank you very much for what you do, 
and thank you for the honor of being first.
    The Chairman. It is great to have you here. Thank you, sir.
    Senator Udall. Thank you very much.
    The Chairman. Senator Smith, do you have any other 
questions for Dr. Stone? Okay.
    I think next in the queue is Senator Daines.

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

    Senator Daines. Dr. Stone, thank you for being here today.
    It pains me to talk about an issue that we are dealing with 
when it comes to our veterans today. Unfortunately, our 
veterans have become targets by scam artists and criminals who 
are looking to swindle their pensions. Unfortunately, even if 
these criminals hurting our veterans are caught, there is no 
penalty.
    This sad reality was brought to my attention by a widow in 
Montana who was getting a fraction of her pension. That is why 
I introduced the Free Veterans Act. This will ensure that 
people who scam our veterans, of which I am a son of a U.S. 
Marine, will serve time in jail or pay a fine or better yet, 
both.
    Dr. Stone, as you might recall, there was a recent GAO 
report that indicated that VA could be doing more to assist the 
Department of Justice and the Federal Trade Commission, 
stopping these scams and these criminals. I was pleased to see 
this report come out literally just as I was introducing my 
bill. And everything described in that IG report is laid out in 
the bill that I have introduced.
    So my question is this. Are you committed to working with 
me, along with the Secretary, to combat this pension poaching 
that is plaguing our veterans?
    Dr. Stone. Sir, as a veteran, as the son of a veteran, 
absolutely we are committed. My dad just turned 101, and I will 
tell you, the frequency of this type of poaching on our elderly 
veterans and our vulnerable veterans, we need to do a better 
job of protecting them from this.
    These are bright individuals who have served with honor. 
But their information has to be protected. We are absolutely 
committed to working alongside of you.
    I am familiar with the GAO report. It is a complex report, 
I am not going to tell you we agree with every piece of it. But 
it does highlight a number of things that are in your bill. We 
look forward to working with you.
    Senator Daines. Dr. Stone, I couldn't ask for a better 
response. Thank you, and I look forward to working together to 
protect our veterans and their benefits.
    I want to shift gears here about Montana, about our Native 
populations. We have a legacy that is incredible as it relates 
to service to our Country. In fact, we have one of the highest 
population of veterans per capita in the Nation. That includes 
our Native American veterans who bravely serve in uniform so we 
get to live in a free country.
    Many people don't know this. We know that back in Montana, 
though, leading up to 9-11, Native American veterans served at 
a higher percentage compared to veterans of all other races. 
While many of our tribal veterans have gone on to lead 
extraordinary lives after their service, there are many who are 
left struggling with issues that can be unique to Indian 
Country.
    One issue impacting our tribal communities and veterans is 
combating Mexican cartels and their illegal meth distribution. 
In fact, Attorney General Barr will be in Montana Friday with 
me to talk about this very issue. Dr. Stone, as you know, 
serious physiological distress and mental health issues have 
been linked to substance abuse for our veterans. What outreach 
and programs has the VA offered to tribal veterans to guard 
against our veterans turning to drugs like meth?
    Dr. Stone. You portrayed the problem very well, Senator. We 
know in the American population about 9 percent of the American 
population has substance use disorder. Amongst the Native 
American population, it is at 13 percent, fully 45 percent 
higher, than the rest of the American population.
    Reaching that population is what we have been talking about 
with a number of your colleagues. Reaching them using tele-
medicine, our relationships with the Indian Health Services, 
our relationships with tribal health programs, with the Alaska 
Native health programs, are what we are looking for to expand 
relationships to reach into this population.
    But part of fixing that substance use disorder problem is 
also ensuring that we take care of the other health problems, 
including dramatically higher rates of PTSD, higher rates of 
diabetes, higher economic challenges because of unemployment 
rates, all contribute to fixing this problem of substance use 
disorder and those who prey on this population.
    Senator Daines. Dr. Stone, I appreciate your looking into 
the root cause, from what drives folks to move to meth. Years 
ago, in Montana, it was homemade meth with about a 25 percent 
purity. Today, this Mexican cartel is 95 percent pure. Very 
addictive, the price has gone down, distribution is widespread. 
Indian Country is getting hit particularly hard by this. I 
think getting back to the core issues of mental health is one 
good place to provide assistance.
    Thank you for your testimony. There is a lot more to talk 
about, but I appreciate your good answers, and happy birthday 
to your father.
    Dr. Stone. Thank you, sir.
    The Chairman. Senator Cortez Masto.

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

    Senator Cortez Masto. Thank you. And I will be quick, 
because a lot of my colleagues have echoed similar concerns for 
the State of Nevada and our rural communities and our 28 
tribes. Tele-medicine is great. We are glad that you have the 
funding for that. But if we don't have broadband, we can't get 
it into the communities. I know in Nevada, there are over 4,500 
Native American vets, and they are in all rural parts of our 
communities.
    So I look forward to working with you and reaching out and 
making sure that we are addressing those issues. Nevada also 
has, unfortunately, a similar concern with mental health and a 
high suicide rate.
    So let me ask you this. As we talk with our tribes around 
the State, they are often unable to receive the VA training to 
become accredited veteran service officers. So it is something 
we are looking into in Nevada. I am curious, is there a way for 
the VA to provide grants to help tribes cover expenses 
associated with these VSO? Is there something the VA is 
exploring?
    Dr. Stone. Senator, I cannot answer that question, and I 
would ask the second panel to approach it. If they can't, we 
will take it for the record and come back to you, on how we 
certify those. All through our rural health program, which for 
the Native American community we run out of Salt Lake City, we 
have a number of programs trying to reach into the tribes to 
help. But how we certify those action officers, I cannot answer 
the question. If the second panel can't do it, we will make 
sure that we get that for the record.
    Senator Cortez Masto. I appreciate that, thank you. And of 
all the concerns that we have talked about, besides the mental 
health piece of it, there is in general the poor health that we 
have seen from overweight, or obesity, diabetes, cardiovascular 
disease. Much of the information that I have seen is anecdotal. 
There is not a lot of data. And I know Senator Murkowski talked 
about data is key.
    But what I am curious about is whether or not you have data 
on really the delta between eligible service members and those 
who are actually using their coverage. Let me add one more 
thing that I am interested in. Do you have data on the dual 
eligibility of Native service members for other health 
programs, like Medicare and Medicaid?
    Dr. Stone. Yes, we do. That data breaks down, and I will 
give you a very high-level view, and we will be happy to give 
you a deeper breakdown.
    Senator Cortez Masto. Thank you.
    Dr. Stone. We know that there are 145,000 Native American 
veterans. A little over 62,000 are enrolled in health care. 
About 19,000 receive their health care directly from a VA 
facility. About 10,000 are receiving health care through the 
IHS and a tribal health program.
    The delta between that 60 some thousand that are enrolled 
and the 30,000 I just gave you is what we are struggling with. 
Where are they, how are they using, are they going to IHS 
directly? Are they in urban areas and we can't see them because 
we aren't engaged with the urban tribal health clinics? That is 
what we are trying to get to.
    We do know that about 85 percent of that population have 
other health insurance. They may not be identifying themselves 
as Native Americans as they come through the program. 
Therefore, we can't see them.
    Senator Cortez Masto. So there is an attempt, though, to 
try to identify them through outreach, education, more 
opportunity to engage?
    Dr. Stone. Yes. And there is a request to the sovereign 
nations that when people come in that they do identify 
themselves as Native Americans, so that we can help identify 
the exact needs.
    We do know there is a massive problem, over a quarter of 
the population has diabetes. We are working on a number of 
studies across the entire veteran population to take unique 
approaches to diabetes and obesity. As we approach this risk 
group, it would be great if we could identify more effectively. 
We look forward to a partnership with you in order to figure 
out ways to approach this community more effectively.
    Senator Cortez Masto. I do, too. Thank you. Thank you for 
all the good work, Doctor. We appreciate your being here.
    The Chairman. Thank you, Dr. Stone, for being here, and 
answering questions. We appreciate you and appreciate what you 
do.
    At this point, we are going to gavel out of this hearing 
and then have a business meeting, then we will come back into 
this hearing session for our second panel.
    [Whereupon, at 3:32 p.m., the Committee was recessed, to 
reconvene following a business meeting.]
    [4:00 p.m.]
    The Chairman. We will now reconvene our earlier hearing and 
proceed to our second panel.
    According to the Veterans Administration, Native Americans 
continue to serve in the Armed Services at a higher per capita 
rate than any other ethnic group in the United States. In 2010, 
the United State Census identified over 150,000 American Indian 
and Alaska Native veterans in the United States.
    Today's oversight hearing coincides with recognizing Native 
American Heritage Month. I, along with Vice Chairman Udall and 
30 co-sponsors, introduced Senate Resolution 414, which 
recognizes November as the month when the Nation celebrates the 
heritage, culture, and contributions of Native Americans, 
including the service of our Native American veterans.
    The hearing today will examine how the United States can 
fulfill its promise to Native American veterans for the 
sacrifice they made in defense of our Country. The many 
contributions Native Americans have played in the Country are 
historic. As of 2010, there have been 3,469 medals of honor 
awarded to combat veterans, 29 of which have been awarded to 
Native Americans.
    In 2016, the VA held a series of tribal consultations to 
identify the priorities of Native American veterans. The top 
priorities identified by the Native American veterans were 
homelessness and housing, access to healthcare, and job 
training and employment. We need to address these issues.
    That is why on January 29th, 2019, I, along with Senators 
Udall, Isakson, and Tester, introduced S. 257, the Tribal HUD-
VASH Act of 2019. S. 257 would, among other things, make the 
Tribal HUD-VASH program permanent. S. 257 would also improve 
case management services and provide housing for eligible 
Native American veterans who are homeless or at risk of 
homelessness. This is accomplished by ensuring that Federal 
agencies work in a cooperative manner and that these programs 
are accountable to those they serve, Congress and the 
taxpayers.
    On June 27th, 2019, the Senate passed S. 257 by voice vote 
and the bill is currently awaiting action in the House. We hope 
that today's hearing will help to further raise awareness of 
Native American veterans' issues.
    Before I turn to our witnesses from the second panel, I 
will ask Senator Udall for his opening comments.
    Senator Udall. Thank you so much, Chairman Hoeven, for 
calling today's hearing. American Indians, Alaska Natives, and 
Native Hawaiians have shown a profound dedication to protecting 
our freedom and national security through their military 
service. After working with many tribal leaders in New Mexico 
who are veterans, I know firsthand when duty calls, Indian 
Country always answers.
    Native veterans have earned nearly every service award and 
decoration our Nation offers. They count among their ranks 
recipients of the Purple Heart, Service Cross medals and the 
Medal of Honor. Without question, they deserve our gratitude, 
our Country's recognition and full access to the programs and 
resources we promise veterans.
    That is why I have worked hard on behalf of Native veterans 
for the last 20 years I have been in the Congress. One of my 
first projects here in Washington was working with Senator 
Bingaman to recognize the Navajo Code Talkers with 
Congressional Gold Medals. From there, I made sure the 
Department of Defense corrected its over-taxation of Native 
veterans in the Service Member Civil Relief Act of 2003, and 
introduced legislation to give tribes resources to establish 
veterans cemeteries on trust lands.
    As Vice Chairman of this Committee, I am continuing those 
efforts, working across the aisle and across Senate committees 
to put forward Native veterans legislation. Senator Tester is 
both the current ranking member of the Veterans Affairs 
Committee and former chairman of this Committee and has been a 
true partner in helping me elevate this work in the Senate. 
Together, we have introduced four Native veteran-focused bills, 
including the Veterans Benefits and Transition Act, which 
became public law last year, and S. 524, the VA Tribal Advisory 
Committee Act.
    We have also worked with Chairman Hoeven and the Veterans 
Affairs Committee Chairman Isakson on S. 247, the Tribal HUD-
VASH Act. Most recently, we have worked with Senator Moran on 
one of the bills up for consideration today, S. 2365, the 
Health Care Access for Urban Native Veterans Act.
    We developed each of these bills in concert with Native 
veterans, tribes and organizations, including the National 
Congress of American Indians, National Indian Health Board, 
National Council of Urban Indian Health, to make sure these 
bills address the needs of all Native veterans over 150,000 
strong, whether they are living on the reservation or off the 
reservation or in a city.
    My thanks go out to everyone who has guided our work to 
ensure it is grounded in the principle of tribal consultation 
and lives up to Congress' trust and treaty responsibilities. I 
also want to take a moment to thank and to recognize our two 
tribal witnesses for their service in the Marine Corps and the 
Army. Like many Native veterans, Chairman Fox's and Councilman 
Dupree's service did not end when they retired from the 
military. They returned home and continued to dedicate 
themselves to their communities. Thank you to both. It is an 
honor to have you both here today.
    I am also glad that we have had Secretary Wilkie here 
today. He made some really strong commitments to me and to the 
Committee and to other members that questioned him.
    So with that, Mr. Chairman, thank you again for this 
hearing. I yield back.
    The Chairman. Thank you, Vice Chairman Udall.
    I want to welcome our witnesses, and I will introduce them 
and turn to Senator Tester then for purposes of an introduction 
as well. Thank you, Dr. Kameron Matthews, for being here, 
Deputy Undersecretary for Community Care, U.S. Department of 
Veterans Affairs here in Washington, D.C. Also Rear Admiral 
Chris Buchanan, Deputy Director, Indian Health Service, U.S. 
Department of Health and Human Services, Rockville, Maryland.
    The Honorable Mark Fox, Chairman, Mandan, Hidatsa, and 
Arikara Nation, New Town, North Dakota, Marine Corp veteran, 
someone I have known for many years. I have known his family 
for many years. And he has done an amazing job of leading the 
reservation, which is now absolutely, if not the leading energy 
producing reservation, it has to be the leading energy 
producing reservation in the Nation. If it were a State, it 
would be in the top ten energy producing States all by itself. 
Just his reservation. So he has brought amazing leadership to 
the Three Affiliated Tribes, and we appreciate you very much 
being here. And we appreciate your service as a Marine Corps 
veteran.
    Then I will turn to Senator Tester for an introduction of 
the Honorable Jestin Dupree, Councilman from Fort Peck.
    Senator Tester. Thank you, Mr. Chairman. You will have to 
correct me, Jestin, if I say anything that is wrong. Jestin is 
a 68-and-a-half-year veteran of the Army. He serves on the 
Tribal Council in Fort Peck. He serves on the school board. He 
has every important job there is to do at the local level, and 
I might say very difficult ones, too.
    He is a consumer of VA health care, and he is on the 
council of one of the largest frontier land-based tribal 
reservations out there. He will give us a perspective on the 
Chair. really want to thank him for making the trek out from 
Poplar and say it is good to see you here. Hopefully we will 
see you here many more times in the future. Thank you.
    Again, I want to thank and acknowledge Harriett Good Iron 
for being here, Goldstar Mother. Really a bright, bright light 
in her son Nathan, who is one of our heroes, and will always be 
with us. He will never be forgotten. Thank you for being here. 
We appreciate it.
    With that, we will turn to Dr. Kameron Matthews.
    Dr. Matthews. Sir, I would actually defer my opening 
statement. Mr. Wilkie definitely spoke on VA's behalf, so I 
would definitely be open to questions.
    The Chairman. That would be fine.
    Rear Admiral Buchanan.

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

    Mr. Buchanan. Good afternoon, Chairman Hoeven, Ranking 
Member Udall, and members of the Committee. I am Chris 
Buchanan, the Deputy Director of the Indian Health Service.
    Thank you for the opportunity to discuss S. 2365, the 
Health Care Access for Urban Native Veterans Act of 2019, and 
S. 1001, Tribal Veterans Health Care Enhancement Act. In the 
late 1980s, the IHS and the Department of Veterans Affairs 
began to explore the feasibility of entering into an 
arrangement for sharing of medical facilities and services as 
required by the Indian Health Care Improvement Act. The Patient 
Protection and Affordable Care Act of 2010 permanently 
reauthorized the Indian Health Care Improvement Act, 
authorizing IHS to enter into arrangements for the sharing of 
medical facilities and services between IHS, Indian tribes, and 
tribal organizations and the Department of Veterans Affairs and 
the Department of Defense.
    The law also directs the VA or the DOD to reimburse the 
IHS, Indian tribes or tribal organizations for the services 
provided to eligible beneficiaries of either department in the 
respective facility. While the law clearly extends this 
authority to IHS and the Indian tribes and tribal 
organizations, it does not mention urban Indian organizations.
    Since implementing the reimbursement agreements to date, VA 
has reimbursed IHS and tribal health programs over $94 million 
for direct care services covering over 10,000 eligible American 
Indians and Alaska Native veterans. Approximately 71 percent of 
American Indians and Alaska Native populations now live in 
urban areas. The IHS funded urban Indian organizations 
expressed the need for developing sharing arrangements for 
sharing of health care services with other departments, such as 
the VA and DOD, for American Indian and Alaska Native 
populations in urban settings.
    S. 2365, if passed by Congress, would authorize 
reimbursement to urban Indian organizations by the VA or DOD 
for services provided to eligible American Indian and Alaska 
Native beneficiaries under an arrangement between the urban 
Indian organizations and VA and DOD.
    S. 1001 proposes to amend the Indian Health Care 
Improvement Act by adding a new provision regarding the 
liability for payment to allow IHS to cover the cost of 
copayments assessed by the VA to eligible Indian veterans for 
covered medical care under the PRC program. In addition, S. 
1001 would amend Title IV of the Indian Health Care Improvement 
Act to require IHS, VA, and impacted tribal health programs to 
enter into a memorandum of understanding on a national or 
regional basis for the IHS or tribal health programs to pay 
copayments owed to the VA by eligible Indian veterans for 
covered medical care.
    Currently, the Indian Health Care Improvement Act prohibits 
a tribal veteran from being charged a copayment when they seek 
treatment at an IHS facility. When seeking treatment at a VA 
medical center, tribal veterans currently are charged a 
copayment that the individual pays. Current law does not permit 
a provider, including VA, to impose financial liability on a 
patient pursuant to an authorized IHS PRC referral. As a payor 
of last resort, IHS would only pay for cost sharing when there 
are no alternative resources and all of the other PRC 
requirements have been met.
    Currently, cost sharing is waived for PRC referrals and 
Medicaid, as well as referrals when a patient is covered by 
insurance obtained through the individual marketplace. IHS has 
the lowest per capita spending for Federal health programs. The 
proposed legislation would redirect funds away from direct 
services and may reduce services at IHS. It would change the 
way certain services are funded and result in disparate 
treatment for IHS beneficiaries.
    These changes could impose serious challenges to IHS's 
ability to provide quality care to its beneficiaries. This is 
not only problematic for IHS, but also concerning, given the 
Federal Government's legal responsibility to provide health 
care for American Indians and Alaska Natives.
    IHS is prepared to provide the Committee technical 
assistance on the legislation. We will remain formally 
committed to improving the quality, safety, and access to 
health care for American Indians and Alaska Natives. In 
collaboration with our sister Federal agencies, we appreciate 
all your efforts in helping us provide the best health care 
services to people we serve.
    Thank you, and 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 Service
    Good afternoon, Chairman Hoeven, Ranking Member Udall, and Members 
of the Committee. I am RADM Chris Buchanan, Deputy Director of the 
Indian Health Service (IHS). Thank you for the opportunity to discuss 
S. 2365, Health Care Access for Urban Native Veterans Act of 2019 and 
S.1001, Tribal Veterans Health Care Enhancement Act.
    The IHS mission is to raise the physical, mental, social, and 
spiritual health of American Indians and Alaska Natives to the highest 
level. As an agency within the Department of Health and Human Services 
(Department), the IHS provides federal health services to approximately 
2.6 million American Indians and Alaska Natives from 573 federally 
recognized tribes in 37 states, through a network of over 605 health 
care facilities, including hospitals, clinics, health stations, and 
other facility types. The IHS also enters into agreements with 41 Urban 
Indian Organizations (UIOs). These 41 UIOs are 501(c)(3) non-profit 
organizations that provide culturally appropriate and quality health 
care and referral services for Urban Indians throughout the United 
States in 22 states.
S. 2365
    In the late 1980s, the IHS and the Department of Veterans Affairs 
began to explore the feasibility of entering into an arrangement for 
sharing of medical facilities and services, as required by the Indian 
Health Care Improvement Act (IHCIA). \1\ The Patient Protection and 
Affordable Care Act of 2010 permanently reauthorized the IHCIA, 
authorizing IHS to enter into (or expand) arrangements for the sharing 
of medical facilities and services between IHS, Indian Tribes, and 
Tribal Organizations and the Department of Veterans Affairs (VA) and 
the Department of Defense (DOD). \2\ The law also directs the VA or the 
DOD (as the case may be) to reimburse the IHS, Indian Tribe, or Tribal 
Organization for the services provided to eligible beneficiaries of 
either Department in the respective facility. While the law clearly 
extends this authority to IHS, Indian Tribes and Tribal Organizations, 
it does not mention UIOs. In March 2012, as Federal agencies worked to 
implement this new authority, IHS and VA jointly engaged in Tribal 
consultation on a draft national agreement for VA to reimburse IHS for 
direct healthcare services provided to eligible American Indian and 
Alaska Native Veterans at IHS federally-operated facilities.
---------------------------------------------------------------------------
    \1\ 25 U.S.C.  1680f, Indian Health Service and Department of 
Veterans Affairs health facilities and services sharing.
    \2\ 25 U.S.C.  1645, Sharing arrangements with Federal agencies.
---------------------------------------------------------------------------
    On December 5, 2012, VA's Veterans Health Administration (VHA) and 
IHS executed an agreement for reimbursement for direct health care 
services under which VA reimburses IHS for covered healthcare services 
provided to eligible American Indian and Alaska Native Veterans that 
receive services at IHS facilities. The IHS and VHA have amended the 
VHA-IHS reimbursement agreement three times--to extend the period of 
agreement and to clarify the extent to which pharmaceuticals are 
reimbursable under the agreement. The most recent amendment extends the 
terms of the agreement through June 30, 2022.
    VA also has individual reimbursement agreements with Tribal health 
programs (THP) under which VA reimburses THP for direct healthcare 
services provided by THP to eligible American Indian and Alaska Native 
Veterans. Since implementing the reimbursement agreements, to date, VA 
has reimbursed IHS and THPs over $94 million for direct care services 
covering over 10,100 eligible American Indian and Alaska Native 
Veterans.
    Aside from the statutory exception that designates and treats two 
UIOs as federal service units, \3\ the law does not authorize the VA to 
enter into individual reimbursement agreements with UIOs and reimburse 
UIOs for providing direct health care services to eligible American 
Indian and Alaska Native VHA beneficiaries. This requires a change to 
law.
---------------------------------------------------------------------------
    \3\ Treatment of certain demonstration projects--Tulsa Clinic and 
Oklahoma City Clinic (25 U.S.C.  1660b).
---------------------------------------------------------------------------
    S. 2365 proposes to amend the IHCIA provision for Sharing 
Arrangements with Federal Agencies (25 U.S.C.  1645), which authorizes 
the HHS Secretary to enter into arrangements with VA or DOD, to 
reference the UIOs along with IHS, Indian tribes, and tribal 
organizations. Approximately 71 percent of the American Indian and 
Alaska Native population now live in urban areas. The IHS-funded UIOs 
expressed the need for developing sharing arrangements for the sharing 
of health care services with other Departments, here VA and DOD, for 
the American Indian and Alaska Native population in urban settings. S. 
2365, if passed by Congress, would authorize reimbursement to a UIO by 
the VA or DOD for services provided to eligible American Indian and 
Alaska Native beneficiaries under an arrangement between the UIO and VA 
or DOD, as the case may be.
S. 1001
    S. 1001 proposes to amend the IHCIA by adding a new provision 
regarding the liability for payment (25 U.S.C.  1621u), to allow IHS 
to cover the cost of a copayment assessed by the VA to eligible Indian 
veterans for covered medical care under Contract Health Services, now 
known as Purchased/Referred Care (PRC). In addition, S.1001 would amend 
Title IV of the IHCIA (25 U.S.C.  1641 et seq.) to require the IHS, 
VA, and impacted THP to enter into a memorandum of understanding on a 
national or regional basis for IHS or tribal health programs to pay 
copayments owed to the VA by eligible Indian veterans for covered 
medical care.
    Currently, the IHCIA prohibits a tribal veteran from being charged 
a copayment when they seek treatment at an IHS facility. When seeking 
treatment at a VA medical center, tribal veterans currently are charged 
a copayment that the individual pays. Current law (25 U.S.C.  1621u) 
does not permit a provider, including VA, to impose financial liability 
on a patient pursuant to an authorized IHS PRC referral. As a payer of 
last resort, IHS would only pay for cost-sharing when there are no 
alternative resources and all of the other PRC requirements have been 
met. Under IHS's current payment structure and policy, cost-sharing is 
the responsibility of the patient when a Tribal Veteran elects to seek 
treatment without a PRC referral. Currently, cost sharing is waived for 
PRC referrals in Medicaid, as well as referrals when a patient is 
covered by insurance obtained through the individual market place.
    IHS has the lowest per capita spending of Federal health programs. 
\4\ The proposed legislation would redirect funds away from direct 
services and may reduce services at IHS, would change the way certain 
services are funded, and result in disparate treatment for IHS 
beneficiaries. These changes could impose serious challenges to IHS's 
ability to provide quality care to its beneficiaries. This is not only 
problematic for IHS, but also concerning given the Federal Government's 
legal responsibility to provide health care for American Indians and 
Alaska Natives.
---------------------------------------------------------------------------
    \4\ See U.S. Government Accountability Office, Indian Health 
Service: Spending Levels and Characteristics of IHS and Three Other 
Federal Health Care Programs (GAO-19-74R), available at https://
www.gao.gov/assets/700/695871.pdf.
---------------------------------------------------------------------------
    The IHS offers the following comments on S. 1001 and is prepared to 
provide the Committee technical assistance on the legislation.
    The IHCIA defines the ``Service'' as the ``Indian Health Service'' 
(See 25 U.S.C.  1603(18)). S. 1001 predominately refers to the 
``Service,'' which would not include tribal health programs. It is 
unclear whether Congress is intending certain changes to apply to 
anyone other than IHS.
    S. 1001 envisions that such copayments would be facilitated by the 
development of new national or regional Memoranda of Understanding 
(MOU) between the Department, VA, and ``any tribal health program, if 
applicable.'' It is unclear whether each tribal health program would be 
expected to sign the national MOU or appropriate regional MOU. The 
development of either a national or regional MOU would be extremely 
difficult, if the required parties are more than the Department and VA. 
However, if the tribal health program(s) would be bound by the MOU 
terms without signing it, this would be contrary to self-determination 
and self-governance. Moreover, IHS understands that there are multiple 
MOUs currently in place between the VA and individual tribes. A 
requirement for a national or regional MOU could be disruptive to 
current services and relationships in place. To the extent the referral 
process becomes more complicated, access to services could become 
burdensome and confusing for Native American Veterans who choose to use 
IHS and tribal health care facilities for their primary health care.
    We remain firmly committed to improving quality, safety, and access 
to health care for American Indians and Alaska Natives, in 
collaboration with our sister Federal agencies. 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.
    Chairman Fox.

  STATEMENT OF HON. MARK FOX, CHAIRMAN, MANDAN, HIDATSA, AND 
                         ARIKARA NATION

    Mr. Fox. Thank you, Chairman Hoeven. I appreciate this 
opportunity today as well as the other honorable members of the 
Committee. It is a pleasure and an honor for me to be able to 
share with you today. I thank you for this privilege.
    I introduced myself as Mark Fox, I am the Chairman of the 
Mandan, Hidatsa, and Arikara Nation. My name in Hidatsa is 
[phrase in Native tongue], in Arikara it is pronounced [phrase 
in Native tongue], which means Sage Man.
    I proudly represent my nation, Fort Berthold Indian 
Reservation, the Mandan, Hidatsa, and Arikara Nation. I have 
with me, as you have introduced, and thankfully so, Chairman, 
and in recognizing Harriett Good Iron, who has accompanied me 
this day, as well as other staff.
    MHA Nation has a proud and prestigious history of military 
service. I always proudly proclaim and will until the day I 
die, whether chairman or not, that nowhere else in the world 
does a people recognize and honor its veterans more so than we 
do at Fort Berthold. Everything there we do surrounds itself 
around the reverence for Native Americans that serve in our 
military. That is whether it is at funerals, at our ceremonies, 
at our pow wow celebrations, everything, at the lead is our 
respect and honor of our veterans who bring in the flags and 
the colors, in everything that we do.
    This was never more so stark and noticeable than, for 
example, during the Vietnam War. In the Vietnam War, when many 
of the service men returned home to people spitting on them and 
hitting them with signs and things of that nature, at Fort 
Berthold, we welcomed them back with open arms. We celebrated 
their courage; we celebrated every single one of them. We have 
never turned out back in that way, never have, never will. And 
that has been a tradition, we will remain that way.
    We can go back, our traditions, actually, the first time 
that the United States Government declared war against a tribe 
west of the Mississippi, it was the Arikara War of 1823. That 
resulted in, in 1825, a peace treaty. Since that time, since 
1825, and subsequent treaties at Laramie, our three nations, 
all three tribes that came together have always honored that 
bond, have always honored that alliance. We have served the 
military of the United States ever since that time.
    So we have this proud tradition that we are very proud of, 
myself, my own family, my grandfather. One of my grandfathers 
served in World War I, and yet he was not yet a U.S. citizen. 
My father, World War II veteran, along with his two brothers, 
all three brothers served in World War II, became veterans. My 
brother served in the Vietnam era, and myself, a United States 
Marine, I served as well.
    So I come before you to really talk about when we are 
sitting as Native American veterans, when we come home, and we 
can talk day in and day out about all the good things.
    But what I want to focus now on, in the last few minutes 
here, is to really talk about what happens when veterans come 
home. When veterans come home, we have a great difficulty, 
especially those that are on the reservation. When they come 
home, PTSD, as well as other attributable ailments that come 
from the military, are very prevalent. This often leads to 
self-medication, drug abuse, things of that nature. And so we 
built ourselves a facility. The United States Government needs 
to help us step up and build more facilities for treatment.
    It is just a matter of helping our people through, 
especially our veterans. We treat a large number of veterans at 
our facilities today. So we need help with that. Our own tribe 
has built a drug treatment facility in Bismarck, North Dakota. 
We also have provided other services and members of the 
Committee, as well as Chairman Hoeven, of course, I have a 
letter here, I would like to invite you on December 19th, we 
will have a grand opening of our brand-new veterans center at 
Fort Berthold. We spent a lot of money, but we think it is 
worth the time to do that.
    So we invite you all, if you have a chance, to come up and 
celebrate with us. Because again, our reverence for Native 
veterans that we have to maintain is very important to us as 
well.
    So that all being stated, the other things that occur, as 
our veterans come home, is our health care services. In North 
Dakota alone, if you want to get some type of minimal services, 
you have to travel for a couple of hours. If you want to get 
the full breadth of services, you have to, both ways, round 
trip, travel about six hours.
    So it puts great difficulty on many of our veterans. We 
have a phrase called toughing it out. Our veterans often tough 
it out, instead of seeking medical attention and things that 
they need. They often, as veterans, sit back and say, ah, that 
is okay, I am all right, and they don't take the precautionary 
services they need and things of that that nature.
    So those are some of the things. In regard to the bill 
itself, the two bills that are before us, S. 1001 and S. 2365, 
our basic position is this. Anything we can do to help our 
service men in any area, be it copays or expanding services, is 
very important and we should do that. But I would also remind 
that if we are going to do that, make sure that we don't 
diminish current services, make sure that we have enough 
resources, so that everybody gets the services that they need. 
We can't simply provide more services and slice up that pie 
even thinner.
    So I would encourage that as well, on both fronts. Thank 
you.
    [The prepared statement of Mr. Fox follows:]

  Prepared Statement of Hon. Mark Fox, Chairman, Mandan, Hidatsa, and 
                             Arikara Nation
Introduction
    Chairman Hoeven, Vice Chairman Udall and Honorable Members of the 
Senate Committee on Indian Affairs, the Mandan, Hidatsa and Arikara 
(MHA) Nation appreciates the opportunity to provide this testimony for 
the Committee's Oversight Hearing on ``Recognizing the Sacrifice: 
Honoring A Nation's Promise to Native Veterans.'' My name is Mark Fox 
and I am the Chairman of our Tribal Business Council. The homeland of 
the MHA Nation, also known as the Three Affiliated Tribes, is located 
along the Missouri River in the west-central part of North Dakota on 
the Fort Berthold Indian Reservation. We have over 16,000 members with 
about 7,000 living on our Reservation. With me today is Harriet Good 
Iron. Ms. Good Iron is the mother of Army Corporal Nathan Good Iron, 
who gallantly sacrificed his life defending our country on November 23, 
2006, in Afghanistan. Ms. Good Iron was the 2018 North Dakota Gold Star 
Mother of the Year.
I. Tribal Military Service and Recognition
    I want to provide you with a short overview of the MHA Nation's 
history and military service. Before we were federally designated as 
the Three Affiliated Tribes, each of our tribal nations signed 
individual peace treaties in 1825 with the United States. Since that 
time, the Tribes have gone beyond the treaties call to act as an ally 
of the United States. By enlistment and special detail, the MHA Nation 
historically has served in support of the United States military. The 
MHA Nation's commitment to service would continue from the 19th into 
the 20th century including World Wars I and II, Korea, Vietnam, Desert 
Storm, and other major conflicts. A renowned military commander once 
stated that he ``found tribal soldiers to be of great courage, 
initiative, and intelligence.and they were always volunteers for the 
most dangerous missions; brave to the point of recklessness; and prove 
themselves to be soldiers of the highest type.''
    During the Second World War the MHA Nation sent over half of our 
adult male population to Europe, North Africa, and the Pacific. Tribes 
as a whole served in record numbers between 1941 and 1945. In that time 
span over 44,000 Native Americans would serve. At the time there were 
less than 350,000 Native Americans in the United States. A portion of 
our membership served as Code Talkers. Though not as well recognized as 
our Hopi, Navajo, and Lakota brethren the ``Ree Talkers'' saved 
countless lives through the use of our language to communicate orders, 
strategies, and commands.
    The exceptionally high service rates of Native Americans in the 
United States military continues to this day. According to the 
Department of Veterans Affairs in 2012 there were over 30,000 tribal 
members in the US military and it is a fact that tribal members serve 
at a higher rate than any other race or ethnicity.
    The MHA Nation takes exceptional pride in recognizing and revering 
our veterans. Our tribal nation has specific military cemeteries that 
provide burial grounds and educate on the heroic deeds of our veterans. 
Reverence for veterans is not only reserved for those who have passed 
or those who returned home from combat, but for those whose service 
remains recognized throughout their lives. For example, as many 
communities throughout the United States shamed, attacked, or ignored 
military members returning from the Vietnam War, but the MHA Nation 
welcomed home its members with appreciation and honor. That same 
recognition and reverence continues to this day with military members 
and veterans being honored at tribal meetings, community events, and 
traditional ceremonies and celebrations.
    Tribal recognition and support of veterans goes beyond just words 
and honorariums. To date, the MHA Nation has spent over seven million 
dollars for the construction of a Veteran's Affairs Building. The Tribe 
has also expended more than five million of its own dollars since 2006 
on programs specifically for veterans.
II. Difficulties of Veterans Returning Home
    Veterans returning home from military service continue to struggle 
daily. Many suffer from alcohol and drug abuse, inadequate health care, 
a lack of education, and limited job opportunities. Though the Tribe 
has expended significant funds and manpower in assisting its veterans 
we desperately need additional federal assistance. Providing cost 
effective, modernized, and accessible healthcare to our veterans is one 
of the most important issues facing the MHA Nation today. The bills 
before this Committee represent a small, but important, step in 
assisting the MHA Nation in supporting and assisting our veterans.
    Native American Veterans face unique challenges after exiting 
military service. Upon returning home Native veterans face high 
unemployment and severely limited economic opportunities. A 2010 U.S. 
Census Bureau report found that Native American veterans held the 
lowest median income of all veterans. That median income at just over 
$27,000 is almost half of the highest median income. The lower poor 
median income is a reflection of the extreme socio-economic poverty in 
Indian Country. The unemployment rate on reservations is more than 
twice the national average of 4.9 percent. Some reservations face 
unemployment that is greater than 60 percent.
    The lack of jobs and economic security does more than just effect 
the financial welfare of native veterans. It is well accepted that 
economic insecurity and economic stressors have a direct effect on 
alcohol and drug use rates. Combined with Post-Traumatic Stress 
Disorder (PTSD) and other military conditions our native veterans 
suffer extreme rates of alcohol and drug disease. These all combine to 
cause Native Americans to have less access to affordable and quality 
treatment options.
    The lack of economic opportunities is compounded by the difficulty 
that MHA Nation veterans face in securing even basic health services 
from a Veterans Administration (VA) facility. While the Tribe has a 
small veterans assistance program on the Reservation it is drastically 
understaffed and underfunded. This program can only provide minimal 
essential services. To reach a more robust VA facility requires a 4-
hour drive. Harsh winter weather conditions make even the shortest 
drives treacherous from November to April in North Dakota.
    The impact of unemployment, underemployment, and travel distances 
for health care services on Native veterans cannot be understated. 
Veterans are often forced to choose between dangerous and expensive 
travel for health services and paying for basic necessities. As a 
result, many tribal veterans choose to ``tough it out.'' This choice to 
simply forego treatment due to either distance, time, or cost only 
compounds the mental and physical ailments of our veterans.
III. Specific Bill Testimony
    The bills before this Committee are good steps in assisting native 
veterans. However, they are simply first steps and additional proposed 
legislation is necessary. The MHA Nation faces significant underfunding 
for our Veterans programs. We can only fund two employees and our Tribe 
requires a significant increase in funding for an expansion of services 
available to veterans from other health providers including the Indian 
Health Services.
    To that end Senate Bill 1001, the Tribal Veteran Heal Care 
Enhancement Act, is a positive step toward assisting tribes in its 
pursuit of better outcomes for veterans. The ability to cover certain 
copays is important as it will relieve some economic stress on our 
veterans. However, I would urge you to greatly expand this bill. The 
MHA Nation needs additional clinical and administrative staff on our 
Reservation. Saving veterans time and money on travel by providing 
services on the Reservation is paramount. These men and women served 
our Country. We must be able to give them the services they deserve.
    I also stand in support of Senate Bill 2365. The bill will help our 
members who are located in urban centers who we cannot reach or assist. 
However, that will amount to an additional cost that the VA cannot 
fully fund as of today. It is vitally important that you increase the 
total funding available to Tribes.
Conclusion
    In conclusion, I encourage this Committee to honor the commitments 
of the MHA Nation veterans. The Tribe has honored its commitment to 
peace and to act as an ally of the United States. Recommending the 
passage of the two bills before this Committee is necessary. However, 
the appropriate step for this Committee to recommend is a significant 
expansion of the VA programs and VA funding available to Tribes. The 
geographical and economic limitations of the Tribes require unique and 
forward-thinking solutions. Providing additional funding to Tribes to 
oversee on-Reservation programs is an important part of honoring Native 
veteran's service and the trust responsibility of the United States.
    I would like to thank you for your time and look forward to working 
with the Committee to finding the appropriate solutions to the problems 
facing our military members and veterans.

    The Chairman. Thank you, Chairman Fox. We appreciate it.
    Councilman Dupree.

    STATEMENT OF HON. JESTIN DUPREE, COUNCILMAN, FORT PECK 
                  ASSINIBOINE AND SIOUX TRIBES

    Mr. Dupree. Mr. Chairman, members of the Committee, good 
afternoon. My name is Jestin Dupree. I am a council member for 
the Fort Peck Tribes, which is located in northeastern Montana. 
I am also a veteran of the U.S. Army, where I served as a 
senior non-commissioned officer. I was deployed five times 
overseas, once to Bosnia, once to Afghanistan, and three times 
to Iraq. Starting in 2001 to 2010, I was deployed every other 
year as an infantryman.
    There are more than 600 veterans residing on the Fort Peck 
reservation that have served in various conflicts. 
Unfortunately, we are not honoring their service. Native 
American veterans earn less than half of the income of others 
in Montana, and their life span is 20 years less.
    I know firsthand what it is like to get out of the military 
and want to move home to better my community. But 
unfortunately, I was met with barrier after barrier. 
Thankfully, I was able to overcome those barriers. But one of 
the issues that lies out there is, for a lot of our veterans, 
that doesn't happen.
    It is hard to prioritize what is more important, a place to 
live, adequate health care or do I want to get a job. What I 
found out is in order to have one, you must have the others. 
Unfortunately, when a veteran seeks help, they are often met 
with the terms stop, no, and don't. I believe these are 
unacceptable responses. I believe the answer, when a veteran 
asks for help, should be, please, come in, and how can I help 
you.
    Before I talk about these barriers to honoring our 
veterans, I want to talk about what the military could do to 
address some of these changes that our Native veterans are 
facing. The military offers a place to learn discipline and 
leadership. For many of us, this is also a place where we find 
structure, because we were lacking that in our personal lives.
    The structure and discipline that was learned allows many 
people to suppress the trauma from their own lives, and realize 
they were meant for a higher purpose. When a veteran's service 
is up, they are often left alone to seek help. The military 
does not adequately prepare a person for reentry into the 
civilian world. The military owes it to service members that 
when their contract is up, they then go back into a normal life 
with as much as their mind, body, and spirit as possible. 
Currently, this is not happening.
    At Fort Peck, the biggest barrier to our veterans receiving 
health care is how far the VA facilities are from our 
reservation. Currently, I personally used to go to the Mile 
City VA Hospital, which is a two-and-a-half-hour trip, 325 
miles round trip. But then without any notice, I was told that 
I could only be paid to go to the nearest VA facility, which is 
in Glasgow, Montana, which is one hour to Glasgow and one hour 
back. It is 145 miles round trip.
    If a veteran was receiving care and built trust with a 
provider, it is a letdown to start off at a new facility due to 
some guidance from the VA. Personally, this is frustrating and 
a lot of our veterans will result to alcohol and drug use.
    A veteran who may not have a job and was forced to live 
with family members struggles. What little money they have will 
be used to assure their family, if they have children, have the 
basic necessities.
    I think the VA should consider a mobile health unit that 
would come to our reservations, like Fort Peck, on a regular 
basis, and be part of the community to built trust with our 
veterans. This mobile unit should be equipped to treat physical 
and mental health concerns.
    Moving on from health care, finding secure and affordable 
housing is extremely challenging. Like many reservations, we 
have a long waiting list for housing. This is challenging, 
because prior to this Bakken oil boom, which took place over in 
the Williston, North Dakota, area, this had a cause and effect 
issue of our reservation, because of rent. It went extremely 
high. What happens is a veteran will move in with their family 
members, oftentimes in crowded situations. There is simply not 
enough housing.
    I recognize that there is a VA loan program for veterans, 
but I am not sure if this is working at Fort Peck, as only one 
individual has used this program. I do not know the historical 
data from this, but I know and suspect that numbers are low.
    Finally, a foundational challenge facing our veterans is 
employment. The biggest barrier for many of our veterans is 
chemical dependency. One of our first priorities to a veteran 
should be to assure that they are physically and mentally 
capable of doing their job.
    I think one of our greatest resources that we have is our 
tribal community colleges. Congress should create a program to 
utilize our tribal colleges to retrain our veterans for jobs 
that are needed in our areas.
    In addition, the BIA and IHS must do a better job hiring 
veterans. Tribal veterans should not have to resort to being 
homeless or begging and living on the streets. We truly need to 
honor their sacrifice by removing the barriers to health care, 
housing, and employment.
    Again, my name is Jestin Dupree. Thank you for your 
attention and your efforts to address these important issues. 
Have a nice day.
    [The prepared statement of Mr. Dupree follows:]

    Prepared Statement of Hon. Jestin Dupree, Councilman, Fort Peck 
                      Assiniboine and Sioux Tribes
    I would like to thank the Committee, Senator Tester and Senator 
Daines for inviting me to testify before the Committee today. I am 
Jestin Dupree and I am a Tribal Executive Board member for the 
Assiniboine and Sioux Tribes of the Fort Peck Reservation.
    I am a veteran of the United States Army where I honorably served 
as a Senior Non-Commissioned Officer and was deployed overseas on five 
tours of duty as an Infantryman. From 2001 to 2010, I was deployed 
every other year and my tours of duty lasted from ten to fifteen 
months. While deployed I served our country in Bosnia, Afghanistan, and 
Iraq three times.
    I am honored to provide this testimony on behalf of our native 
veterans and provide some insight on the issues tribal Veterans face in 
accessing housing, employment and health care when they return home 
from service. There are more than six hundred veterans residing on the 
Fort Peck Reservation. The majority of our veterans are veterans of the 
Gulf Wars, the Vietnam War and the ongoing wars in Afghanistan and 
Iraq. We are blessed to still have seven Korean War Veterans, including 
our former Chairman Rusty Stafne, and two World War II Veterans. The 
Fort Peck Tribal Members who served during World War II were part of 
the widely heralded Sioux Code Talkers. Thus, Fort Peck tribal members 
have a long and decorated history of serving this country and I am 
proud be included with these great men and women. Unfortunately, we as 
a Nation are not honoring these great men and women. According to my 
Tribe's Health Director, Native American Veterans have less than half 
the income of others in the state of Montana and their lifespan is 
twenty years less than non-tribal members in the state.
    Now my duty of service has taken on another form. I am for better 
or worse a politician, who has been selected by my people to serve 
their needs. I think that my service in the military laid a strong 
foundation to enable me to weather the storms of politics to serve my 
Tribe. As a member of Tribal government, it is my is responsibility to 
work for all tribal members, but I hold a special responsibility toward 
Veterans.
    I know firsthand what it is like to get out of active duty and to 
want to return home with all of the knowledge and experience that I was 
taught and gained in the military and to use this knowledge and 
experience to better my community. But I was met with barrier after 
barrier. Thankfully, with a little luck and resiliency I was able to 
overcome these barriers, but for many Veterans returning home to Fort 
Peck this is not the case.
    It is hard to prioritize which is more important: does a Veteran 
need a place to live, an informed healthcare provider, or a job the 
most? What I have found, is that in order to have one you often times 
must have the other. You cannot obtain housing without employment. You 
can't obtain employment because you are struggling with mental, 
behavioral or physical health challenges. You cannot obtain health care 
because you have no vehicle or a support system to ensure you can get 
to a VA health care facility. Unfortunately, many times when a Veteran 
seeks help, he or she is told no; wait in line; or stop asking for 
help. I believe these are unacceptable responses. I believe the answer 
when a Veteran asks for help should be yes, come through this door and 
let me answer your questions and help you.
    Before I talk about these barriers to honoring our Veterans, I want 
to talk about what the Department of Defense could do to help address 
what may be at the root of some of the challenges in serving native 
veterans. The military offers a place to learn discipline, to learn 
leadership, and to learn a skill. For many of us, it is also a place 
where we were able find a structure that was lacking in our personal 
homes and families. The structure and the discipline that the military 
offered also allows many people to compartmentalize the trauma from 
their home life and know that their life was meant for a higher 
purpose. However, when a person is separated from the military, in many 
cases the trauma that was suppressed by the military structure will 
return to the surface and often times this trauma is compounded by a 
person's experiences in the military. Unfortunately, the military does 
not prepare a person for reentry into the civilian world. The 
Department of Defense owes all service members to ensure that when they 
end their service, they are going into the civilian world with as much 
of their mind, body and spirit intact as possible. Right now, I believe 
the DOD is failing at this, and the VA is left to account for this 
failure.
    Again, Veterans returning home from service face significant 
barriers upon reentry. As I said, it is difficult to prioritize which 
barrier is the most significant, but I will begin with health care, 
because in my discussions with the many Fort Peck Tribal departments 
tasked with serving Veterans it was the one constant that is lacking--
ensuring that our Veterans are able to contribute to our Reservation in 
a positive and constructive way.
    At Fort Peck, the biggest barrier to our Veterans receiving care is 
how far the VA facilities are from the Reservation. This distance is 
compounded by the VA's changing rules and bureaucracy. For example, 
while the VA reported that a Veteran could report to any VA health care 
facility, they changed the rules and the VA will now only pay costs for 
travel to the closest VA facility. For Fort Peck that would be the 
Glasgow health care facility. However, the majority of our Veterans 
receive care at the Miles City VA hospital. This change in travel 
policy was imposed on our Veterans without notice or consultation.
    Thus, a tribal Veteran who has no resources to travel to the VA in 
Miles City, must now switch from a provider he had a relationship with 
to another one in Glasgow. I have to tell you this is not likely to 
happen. For a Veteran to ask for money to go to Miles City so that he 
can seek help from a behavioral specialist, and then to build a 
relationship of trust that allows for the provider to treat him is 
probably one of the hardest things that this Veteran has ever done. For 
the VA to tell this Veteran that it will no longer support his travel 
to the provider in Miles City and that he has to step into a new 
facility in Glasgow and rebuild trust with a new provider. the VA might 
as well send this Veteran back to Iraq.
    I know some of you might say that the Veteran should not have to 
depend on the VA for the gas money to get to Miles City. Again, this is 
a man who may not have a job, whose family may be living with other 
family members and what little money he does have he may be using to 
ensure his children have food, heat and clothes on their back. He is 
not going to use the $40 in gas money that it takes to get back and 
forth to Miles City for himself. He is going to use it for his family. 
Because the VA will not pay $40 for this Veteran to receive care with 
the provider that he has built a relationship with, he will be left 
untreated, or worse, he will self-medicate with drugs or alcohol.
    I do appreciate that Fort Peck Veterans can access health care in 
Glasgow, which is anywhere from 30 to 100 miles to travel to depending 
on which tribal community the Veteran lives in or in Miles City, which 
again is at least 160 miles from our Reservation. If a Veteran needs 
more sophisticated care, like an MRI, that Veteran will have to travel 
to Sheridan, WY or Helena, MT. Both are about a nine-hour drive in good 
weather. With our lovely Montana winters this trip can be ten hours or 
more. I know a great deal of focus has been given to VA wait times, I 
can tell you that at the facilities in Montana, at least in N.E. 
Montana, this is still a problem reported by our Veterans.
    There are some legislative bills on today's agenda. I want to 
testify on S.1001, which would require the Indian Health Service to use 
limited IHS Purchased and Referred Care dollars to pay the VA for a 
native veteran's copays that are charged for treatment at the VA. This 
is inconsistent with the federal government's trust responsibility to 
provide Indian people with health care, and also the VA's 
responsibility to provide care to Veterans. As I see it, I have already 
paid twice, my ancestors paid when they signed the treaty, and I paid 
when I served five tours of duty. I do not think my elder who needs 
gallbladder surgery that would be denied because PRC money was paid to 
the VA should have to pay too. This bill should instead waive all 
copays for Indian Veterans. It is absurd that an Indian Veteran getting 
treatment at a federal facility is charged a copay for that health 
care.
    Again, I cannot over emphasize the need to secure health care that 
is targeted towards Veterans, especially mental health and behavioral 
health care. Over and over again, in my discussions with the Tribes' 
Program Directors they identified chemical dependency as the primary 
impediment to a Veteran obtaining a job, obtaining housing and 
improving the quality of their overall physical health.
    I think the VA should consider a mobile health unit that would 
travel to rural places like Fort Peck on a regular basis and be a part 
of the community to build trust and confidence with the Veterans. This 
mobile unit should be equipped to treat physical and mental health 
issues. I know from my many conversations, the hardest thing for a 
Veteran to do is to ask for help from anyone, but from a stranger it is 
almost impossible. But if this mobile unit became a regular part of our 
community and our Veterans could become familiar with the services and 
providers, that would remove a substantial impediment to access to 
care.
    Moving from health care, securing affordable housing on the Fort 
Peck Reservation is actually more challenging than accessing quality 
health care. At Fort Peck, like many Reservations, we have a long 
waiting list for Tribal housing. Accordingly, a Veteran returning home 
must put his name on that list and wait. At Fort Peck, a Veteran 
seeking an apartment is faced with high rental rates due to the Bakken 
Oil Boom. As a result, many Veterans and their families are forced to 
live with other family members, many times in overcrowded situations. 
There is simply not enough housing support for Veterans. It is tragic 
that HUD has not been able to fully implement the Tribal Veteran 
Affairs Supportive Housing Program, supporting housing for Indian 
Veterans. Congress must authorize this program and continue to fund it 
and ensure that HUD eliminates the bureaucracy that is impeding its 
implementation.
    I recognize that there is the VA Native American Veteran Direct 
loan program. I am not certain this Program is working as well as it 
could work. The Fort Peck Tribes have a Memorandum of Agreement with 
the VA for this program, but only one person on the Reservation is now 
receiving a loan from this program and is having a home built. I do not 
know the historical numbers of people who have participated in this 
program at Fort Peck, but I suspect they are very low.
    One of the barriers to applying to this program is that it is 
handled out of Denver and not locally. The VA should send a loan 
officer to the Reservation on a regular basis to explain the program 
and provide direct face to face service to Veterans. This should be 
part of the Memorandum of Agreement with the Tribes.
    Another problem with this program, is that the application process 
itself is too cumbersome, with the VA again having no one locally to 
provide assistance to potential applicants. In this regard, the VA 
should do a better job at outreach and, in some cases, waiving some of 
the requirements that may be prohibiting tribal veterans from 
participating. For example, if a person is in school or in a training 
program, the VA could waive the requirement for two paystubs.
    Finally, a foundational challenge facing Veterans returning home is 
employment. As I said the biggest barrier for many of our Veterans to 
gaining employment is chemical dependency. Chemical dependency can make 
it virtually impossible for a Veteran to hold a job successfully. The 
negative pattern of not being able to keep a job can lead to a lifetime 
of bouncing around from job to job. Thus, priority one is treating the 
Veteran's physical and mental health so that he or she can hold a job 
in the civilian world.
    However, even if a person is not battling physical and mental 
health challenges, we are not readily equipped to translate the skills 
and knowledge that a Veteran obtained from the military into a civilian 
job. A Veteran knows how to show up to work on time, he or she knows 
how to follow orders, he or she knows how to solve problems, and he or 
she knows how to operate under pressure. All of these skills are basic 
to any job and there is no reason they cannot be translated to many 
jobs such as law enforcement, health care, or teaching.
    I think one of the greatest resources we have in Indian country are 
our tribal colleges. I think that Congress should create a program at 
tribal colleges that is focused on retraining Veterans for needed 
civilian jobs in our communities. In addition, the Bureau of Indian 
Affairs and Indian Health Service must do better at hiring Veterans and 
providing education or training for them to do jobs in the area of law 
enforcement, education or health care. I served in Iraq, Bosnia and 
Afghanistan, and I simply do not believe the Bureau of Indian Affairs 
or the Indian Health Service cannot find qualified people to be police 
officers, social workers, nurses, physician assistants, or teachers 
because of the remote and isolated nature of many of the tribal 
communities. The BIA and the IHS simply must do a better job creating 
and supporting training opportunities for Veterans.
    Tribal Veterans should not have to resort to being homeless, living 
on the streets, or begging for change. We need to truly honor their 
sacrifice by removing barriers to health care, housing and employment.
    Thank you for your time.

    The Chairman. Thank you, Councilman.
    We will now turn to five-minute rounds of questioning.
    Dr. Matthews, Senate Bill 1001 was introduced by Senators 
Thune and Rounds. The purpose of the bill is to amend the 
Indian Health Care Improvement Act to authorize the Indian 
Health Service to cover the cost of copayments for American 
Indian or Alaska Native veterans receiving medical care or 
services from Department of Veterans Affairs upon authorized 
referral from IHS.
    What recommendations do you have in regard to that 
legislation?
    Dr. Matthews. Senator, thank you for the question. I think 
VA is very interested in working with the Committee, as well as 
IHS, to figure out how best to address the actual purpose of 
the bill, which is to remove the copayment.
    The way it is currently structured, it does place some 
administrative as well as financial burden on IHS. We would 
like to consider perhaps additional ways to address those 
issues with our sister agency. But overall, we do support the 
intent behind the legislation.
    The Chairman. Admiral Buchanan.
    Mr. Buchanan. Yes, we definitely want to work with VA and 
Congress to address the challenges. The way the bill is 
written, there are several technical issues that we definitely 
need to work out. We have some Indian health care authority 
activities as it relates to our PRC program that, it basically 
says that anybody that is referred by a PRC program shouldn't 
be billed, whether it is copays or any of those activities.
    So that is the challenge that we are facing. We have 
veterans that may access VA and that doesn't come through the 
IHS system. They are being charged copays. So there is that 
disparate treatment between IHS PRC referrals in how a veteran 
access the VA system.
    The Chairman. I would ask you both to work with Senator 
Thune to see if you can't come up with some ideas to address 
it.
    Dr. Matthews. Definitely.
    Mr. Buchanan. Yes, sir.
    The Chairman. Thank you.
    For Chairman Fox, I have introduced the HUD-VASH Act, along 
with Senator Udall, Senator Isakson, and Senator Tester. We 
have passed that through the Senate. Now it is in the House.
    As you know, essentially it would make permanent a program 
whereby Native American veterans would get vouchers for 
housing. We think this is just an incredibly important program 
that we get passed. We are very hopeful, and we are pushing to 
get it through the House and hope to get it through the House 
and passed into law.
    I guess the question is, are programs like Tribal HUD-VASH, 
where Congress empowers veterans to make their own decisions in 
choosing what works best for their housing and their health 
care needs, is that a good way to address some of the 
challenges you have for both housing and health care for 
veterans on the reservation?
    Mr. Fox. Absolutely. I definitely stressed the importance 
of that housing, very critical, housing and jobs, very 
critical. Anything that you can do to promote opportunities for 
veterans when they return home, or enlisted men, when they 
return home. So definitely, we need those areas.
    When you reference health care, of course, the physical 
ailments that we tend to suffer are very important. But what we 
are coming to find more so, and I heard reference to that 
earlier in previous discussions, is the mental health portion, 
addictions, the abuses that occur of alcohol and drugs or meth 
or what have you. We have been forced to build a drug treatment 
facility simply because of that.
    We truly believe that even including our veterans, in 
particular, we can help them find their way back, so to speak, 
that we can get them into good homes. If we can give them an 
opportunity to work, that is all they really want.
    But when they return home, those don't exist. It is very 
difficult for a service man who gets up at 5:00 a.m. and 
commits years and years of service at a work level, and then 
returns home and does not have that before them, an opportunity 
to do that, you are just begging for them to turn the wrong 
way. There is too much direction that they learn and acquire, 
and they no longer have that.
    So when we create these opportunities to work for that, 
then you are going to see the benefit of doing that, no doubt.
    The Chairman. Councilman Dupree, the same question, the 
value of the HUD-VASH program, both housing vouchers as well as 
health care services from VA, making that permanently 
authorized for Native American vets on the reservation.
    Mr. Dupree. Mr. Chairman, thank you for that question. As I 
stated earlier, I want to echo what Chairman Fox said, that 
there is a huge request for help for mental health in our 
remote areas. There is a big difference from the urban areas, 
in terms of reservation, compared to our rural area. We are 
very rural. In terms of rural, I always tell this story, but we 
actually have to go 85 miles into North Dakota to go to Wal-
Mart, and then drive that 85 miles back.
    We do have a huge demand. Again, I appreciate your efforts 
with the veterans issues. But we do have some tough issues, and 
these are tough questions to sit here and think about these. 
Anything that can help with funding, and issues to housing, 
employment, and health care, would be greatly appreciated. I 
know I could sit here and speak for Fort Peck all day and 
probably sound selfish. But you guys have to make these 
decisions to help everybody out. Again, I thank you for 
allowing us some time to come up here and address these very 
serious issues. Thank you.
    The Chairman. Thank you, Councilman. We will turn to Vice 
Chairman Udall.
    Senator Udall. Thank you, Mr. Chairman.
    Rear Admiral Buchanan and Dr. Matthews, I have spoken to 
IHS a number of times regarding my concerns with the IT 
coordination issues faced by the VA, the Indian Health Service, 
tribes, and urban Indian health programs. I am deeply concerned 
about the impacts these IT shortfalls can have on care 
coordination for native veterans.
    The National Indian Health Board just testified about this 
very issue in the House of Representatives last month. They 
said, and I agree, ``It is shameful that Native veterans are 
put in a position where they have to find their own solutions 
to these ITS problems.'' I have been told that sometimes that 
means they are having to hand carry their health records from 
the Indian Health Service over to the VHA provider.
    Dr. Matthews and Admiral Buchanan, how are your two 
agencies working together to address this inter-operability 
issue?
    Mr. Buchanan. Thank you for the question. IHS has initiated 
the Health Information Exchange, a utility referred to as the 
direct secure messaging part of the 2014 certification. Both VA 
and IHS are participants in the sharing of medical information 
through this secure exchange of information.
    There are still some challenges that need to be worked out, 
for sure. We are basically only able to transfer a limited 
amount of information at this time. Currently, we are working 
on the HIT, or Health Information Technology modernization 
project, which will actually look at some of these activities 
and hopefully enhance that capability going forward.
    Senator Udall. When should that be up and running?
    Mr. Buchanan. Currently, it is in the design phase. We just 
recently completed the HIT modernization project. We are 
currently, as of today, talking to tribes and tribal 
organizations and urban organizations to talk about the next 
steps. So I don't have a date for you on that for sure.
    Senator Udall. Dr. Matthews?
    Dr. Matthews. Sir, it is such an important question. Care 
coordination is critical. I am a family medicine doctor. I 
completely understand and agree that this is something that we 
need to work through. The Health Information Exchange that the 
Admiral raised, of course, is a critical piece. But as we were 
talking about in the first panel, broadband access, things of 
that nature, obviously affect the ability for that 
communication to be successful. So we do need to address all of 
the above when we are talking about electronic coordination.
    The other piece that we have definitely committed to in VA 
is moving forward with an advisory board on consultation about 
how better to bring about care coordination between not only 
IHS facilities and VA but also the tribal health programs that 
Dr. Stone mentioned, that we have reimbursement agreements as 
well, that that care coordination should go beyond the 
electronic means. But how best to do that, and how to keep it 
as veteran centric as possible, we are fully committed to that.
    It is also worth acknowledging that VA is moving into a new 
realm in the next 10 years, with our electronic health record 
modernization. We are definitely open, my leadership is 
committed to opening up discussions about how that can best 
serve our needs from an interoperability standpoint, working 
together to make sure IHS is a partner with us.
    Senator Udall. Thank you very much.
    The National Council of Urban Indian Health recently 
testified in the House of Representatives, ``The Health Care 
Access for Urban Native Veterans Act is a necessary and 
critical piece of legislation, one that will make a real, 
meaningful difference.'' Councilman Dupree, Montana has the 
second highest number of urban Indian Health programs in the 
Country. So while we don't have an Urban Indian Health Program 
director with us for today's hearing, I trust you can speak to 
the important work urban Indian clinics do for Native veterans 
in your home State.
    Do you agree that the VA and the IHS should do more to 
support urban Indian health programs that provide culturally 
competent care for Native veterans living in our urban areas?
    Mr. Dupree. Mr. Chairman, Senator Udall, that question is 
kind of the discussion we had about urban and rural. But it 
doesn't matter if you are a veteran or tribal veteran or non-
tribal veteran, you should be able to receive adequate health 
care. You should not have to live in an urban area and come all 
the way back to a reservation to receive adequate care. I think 
that this needs to be addressed. I hope I answered your 
question. Thank you.
    Senator Udall. Yes, you have. Thank you very much.
    I yield back, Mr. Chair.
    The Chairman. Senator Tester.
    Senator Tester. Thank you, Mr. Chairman. I want to thank 
you all for being here today.
    This first question is for you, Dr. Matthews. In Councilman 
Dupree's opening remarks, he talked about mobile health centers 
and how they could work very well in tribes that are remotely 
located. Many in the west are. There are a couple of mobile 
units in Montana, and I am sure we are not the only State to 
have some.
    Are they fully staffed up; do you know?
    Dr. Matthews. I apologize, sir, I will have to take that 
for the record. I am not sure.
    Senator Tester. That would be great. And do you know if 
they put priority, and I am not talking just Native American 
tribe, but to go out to the more frontier areas, which would, 
by the way, include every tribe in Montana, but it also 
includes some other areas, too. Do you guys prioritize that?
    Dr. Matthews. I would need to look at what the actual 
prioritization ranking would be. I know that we also use it for 
emergency management. They have been deployed to hurricane 
zones and the like.
    But I can definitely get you that information.
    Senator Tester. I think that information would be very, 
very helpful. I think he makes a very good point. In lieu of 
having a facility right there, that is good.
    I do want to add on to the point that he talked about, 
wanting to go to Mile City and the VA only going to offer him 
mileage reimbursement for Glasgow. What really complicates this 
is Glasgow didn't have a doc or a nurse practitioner for five 
or six years. Now they have a nurse practitioner. He has a 
relationship with a doc in Miles City. And now we are saying, 
we are not going to pay if you go to Miles City anymore. You 
have to change your home doctor and go to--we have to make some 
allowances for that.
    If you could take that down, if there are things that we 
need to do in the Senate to do that. Because I think home 
health is really important. If you have a doctor you like, we 
had this debate during the ACA. We had this debate in the VA. 
If you have a doctor you like in IHS, you should be able to 
keep them.
    So I want to go over to both Councilman Dupree and Board 
Member Fox. Do you feel like there is an avenue in Indian 
Country to give information back to the VA, not IHS, but VA, if 
they are not meeting the needs of your veterans in your 
specific reservations? Is there an avenue to give input back?
    Mr. Fox. Thank you. I appreciate it very much. I believe 
there are avenues, but I don't think at this point in time they 
are effectively workable avenues as we sit today. It is obvious 
by the lack of services that still remain out there in Indian 
Country.
    But I do I think it is going to improve? I truly do. Based 
upon what I have heard just yesterday and today, whether it is 
the meeting at the White House that we had, and now of course, 
today, that there is deliberate effort to expand those services 
and get them out there. That is really what we need. But we are 
missing too many people right now.
    Senator Tester. How about you, Councilman Dupree? What is 
your perspective?
    Mr. Dupree. Mr. Chairman, Senator Tester, thank you. In 
terms of communication, effective communication with the VA, we 
have your office in Montana that we do effectively communicate 
quite often with. But in terms of the VA, I am not tracking any 
person that really comes out and says, hey, what can we fix, 
how can we fix it. From the VA headquarters office, we are 
about eight and a half, nine hours away in good driving 
weather.
    Senator Tester. So that is good enough. So I bring this 
back to the question that I asked Secretary Wilkie and Dr. 
Stone, and that is, if there is not an avenue to give 
information back to the VA, it is pretty hard to think that 
there is an avenue to reach that 60 percent that never go to VA 
facilities.
    My guess is, it is probably not much different in Indian 
Country than it is anywhere else in this Country, that there 
are 60 percent of the people that either aren't aware of the 
services that are out there for them that have served, or they 
just have a different opinion of the VA than what really exists 
today. So if you could take some of that back, Doctor, and pass 
it along. It would really be helpful.
    I want to talk about HUD and VA just for a second. I sit on 
the Banking Committee. We deal with HUD on the Banking 
Committee. Do you guys know what the homeless, how many 
homeless vets you have on your reservation? Any idea? Is it a 
hundred? Is it 500? Is it a thousand?
    Mr. Fox. I wouldn't know the specific numbers on our 
particular reservation. I see homeless individuals that we have 
out there, and of course, you are from Montana. When we address 
homelessness at home in Fort Berthold, there are two ways to 
look at it. There is winter and non-wintertime. We are 
occupying our time trying to provide shelter, trying to make 
sure that they are safe and that they don't freeze to death 
when they are homeless. In the winter, it below minus 20.
    But at the same time, I know we are working hard to try to 
record data on how many of them are actually veterans and how 
many are not.
    Senator Tester. How about you, Councilman?
    Mr. Dupree. Senator Tester, thank you for that question. 
This is really a hard number to track down, because you have 
some veterans that, if they move home, there is no adequate 
housing, they are going to move in with their family members. A 
lot of the numbers are extremely unreported.
    So to knock on a door and ask hey, how many people are 
living in your home, you are not going to get an accurate 
number.
    Senator Tester. That is exactly the point. You have people 
who are homeless, then you have people who are living 
generations in the same house. If there wasn't that culture to 
bring people in, they would be homeless, too.
    I would just say that I know it is not in the purview of 
this Committee, but the HUD-VASH vouchers are really, really 
important. I bet you if we double them from what you get now, 
you would probably utilize every damned one of them and then a 
bunch more.
    I want to thank you all for being here. I didn't get a 
chance to talk to you and IHS, but we will, don't worry about 
that. I want to thank you very much for what you guys do every 
day, and I look forward to working with you to improve the 
situation. Thank you.
    The Chairman. All right, if there are no more questions for 
our panel, I would like to thank all of you for being here, 
particularly for our tribal chairman. Again, thank you, 
Harriett, thank you for being here. God bless you. And 
Councilman Dupree, thank you as well. We truly appreciate your 
joining us, as well as, of course, Dr. Matthews and Admiral 
Buchanan.
    The hearing record will be open for two weeks. I want to 
again thank you. With that, we are adjourned.
    [Whereupon, at 4:42 p.m., the hearing was adjourned.]

                            A P P E N D I X

Prepared Statement of Sonya Tetnowski, Vice-President, National Council 
                         of Urban Indian Health
    My name is Sonya Tetnowski, I am a member of the Makah tribe, a 
U.S. Army Paratrooper Veteran, and the Chief Executive Officer of the 
Indian Health Center of Santa Clara Valley in California. I'm also the 
Vice President of the National Council of Urban Indian Health (NCUIH), 
which represents 41 Title V Urban Indian Health Organizations (UIOs) 
across the nation, as well as the President of the California 
Consortium for Urban Indian Health (CCUIH). UIOs provide high-quality, 
culturally competent care to urban Indian populations, which constitute 
more than 78 percent of all American Indians and Alaska Natives 
(AIANs). I would like to thank Chairman Hoeven, Vice-Chairman Udall, 
and other distinguished members of the committee for holding this 
important hearing. The testimony submitted will concentrate on S. 2365, 
the Health Care Access for Urban Native Veterans Act.
    S. 2365 is a necessary and critical piece of legislation, one that 
will make a real meaningful difference in the funding for health care 
services provided by UIOs across the United States. Over the last few 
months the National Council of Urban Indian Health were invited to 
provide in person testimony on this very issue before the House 
Indigenous Peoples of the United States Subcommittee Legislative 
Hearing held on September 25, 2019 and House Committee on Veterans' 
Affairs, Subcommittee on Health, Oversight Hearing held on October 30, 
2019 to voice our support on H.R. 4153 introduced this past August by 
Representative Khanna. H.R. 4153 is an identical and companion bill to 
S. 2365.
    I cannot express more urgently, that the single most important 
thing the Department of Veterans Affairs (VA) can do to improve 
healthcare to AI/AN Veterans, is to fully implement the VA and Indian 
Health Services' Memorandum of Understanding (VA-IHS MOU) and 
Reimbursement Agreement for Direct Health Care Services. This would 
allow UIOs to be reimbursed for providing culturally competent care to 
AI/AN Veterans residing in urban areas. Despite an embattled history 
between tribal people and the United States government, and as an 
inherited responsibility to safeguard the lands of their ancestors, AI/
ANs serve this country at a higher rate than any other group in the 
nation. A significant number of these Veterans live in urban areas and 
seek out the high-quality, culturally competent care at their local 
UIO.
    UIOs were formally recognized by Congress following the end of the 
Termination Era in 1976 under the Indian Health Care Improvement Act to 
fulfill the federal government's health care-related trust 
responsibility to Indians who live off the reservations. Each UIO is 
led by a Board of Directors that must be majority Indian. They are 
collectively represented by the National Council of Urban Indian Health 
(NCUIH), which is a 501(c)(3), member-based organization devoted to the 
development of quality, accessible, and culturally sensitive healthcare 
programs for AIANs living in urban communities. UIOs are a critical 
part of the Indian Health Service (IHS), which uses a three-prong 
approach to provide health care: Indian Health Services, Tribal 
Programs, and Urban Indian Organizations commonly referred to as the I/
T/U.
VA-IHS MOU Historical Background
    In February 2003, the VA and IHS signed a Memorandum of 
Understanding (MOU) and updated this MOU in October 2010. The very 
first paragraph of the MOU states:

         ``the intent of this MOU (is) to facilitate collaboration 
        between IHS and VA, and not limit initiatives, projects, or 
        interactions between the agencies in any way. The MOU 
        recognizes the importance of a coordinated and cohesive effort 
        on a national scope, while also acknowledging that the 
        implementation of such efforts requires local adaptation to 
        meet the needs of individual tribes, villages, islands, and 
        communities, as well as local VA, IHS, Tribal, and Urban Indian 
        health programs.''

    In December 2012, the two agencies signed a reimbursement agreement 
allowing the VA to financially compensate IHS for health care provided 
to AIANs that are part of the VA's system of patient enrollment. While 
this MOU has been implemented for IHS and Tribal providers, it has not 
been implemented for UIOs, despite the fact that UIOs are explicitly 
mentioned in the original language of the 2010 MOU, and provide 
healthcare within IHS's own I/T/U system. Leaving out UIOs is a 
violation of the MOU since the agencies agreed to ``not limit 
initiatives, projects, or interactions between the agencies in any 
way.'' Not reimbursing UIOs for services provided to Native Veterans is 
limiting this vulnerable, underserved population from the healthcare 
they need and deserve. NCUIH and UIO leaders have been testifying 
before Congress for years that the MOU is not being recognized for 
UIOs. Members have said this is an ``easy fix,'' and ``an oversight,'' 
so we are happy to see that there is now a bill to address this issue 
once and for all. We maintain that as part of the I/T/U, the VA already 
has the authority to reimburse title V UIOs, but we are happy Congress 
is taking the next step to address this important issue. Between 2012 
and 2015, the VA reimbursed over $16.1 million for direct services 
provided by IHS and Tribal Health Programs covering 5,000 eligible 
Veterans under the IHS-VA MOU. In spite of the federal trust 
responsibility to AIANs, the VA had decided to deem UIOs ineligible to 
enter into the reimbursement agreement under the IHS-VA MOU. For 
context, UIOs are already extremely underfunded and receive less than 
$400 per patient from IHS, versus national health expenditure rates of 
almost $10,000 per patient. In 2018, UIOs received a total of $51.3 
million to support 41 programs, and that is before IHS's administrative 
costs are removed. UIOs only receive one line-item appropriation in the 
IHS budget- the urban Indian health line item. UIOs don't receive 
purchase and referred care dollars, Federal Tort Claims Act coverage, 
100 percent FMAP, or facilities funding. In fact, a few UIOs temporary 
closed during the shutdown due to the lack of parity within the IHS 
system. VA reimbursement, even half of the $16.1 million, would 
drastically help our facilities. It is time to fix this issue for good.
    The VA's position is that UIOs are not identified in 25 U.S.C.  
1645(c) as one of the organizations it may reimburse. However, it is 
important to note that two UIOs are covered under the IHS-VA MOU 
because VA officials report that those programs function as a service 
unit as defined in 25 U.S.C.  1603(20).
    There have been several Government Accountability Office (GAO) 
reports conducted on the VA-IHS MOU--two reports on VA and IHS 
implementation and oversight of the MOU were released in 2013 and 2014. 
In March 2019, the GAO released a study entitled ``VA AND INDIAN HEALTH 
SERVICE Actions Needed to Strengthen Oversight and Coordination of 
Health Care for American Indian and Alaska Native Veterans''. The GAO 
was asked to provide updated information related to the agencies' MOU 
oversight. This report examines (1) VA and IHS oversight of MOU 
implementation since 2014, (2) the use of reimbursement agreements to 
pay for AI/AN veterans' care since 2014, and (3) key issues identified 
by selected VA, IHS, and tribal health program facilities related to 
coordinating AI/AN veterans' care. In this report the GAO report makes 
the recommendation to both the VA Secretary and IHS Director to ensure 
measureable targets to track and measure performance, and has jump 
started efforts by VA to conduct consultation and confer. The VA is 
currently working with IHS to revise the MOU, stating their goals for 
this revision: increase access and quality of care for AI/AN veterans, 
improve health promotion and disease prevention, encourage patient 
centered collaboration and communication, consult with Tribes at the 
regional and local levels, ensure appropriate resources for services 
for AI/AN Veterans. Furthermore, the VA in a 2018 report to Congress 
stated themselves that UIOs under IHCIA are ``eligible, capable, and 
are entitled to receive reimbursement for healthcare services they 
provide to AI/AN veterans from any payer'' as part of the IHS I/T/U 
system. They also acknowledge that they have no current legal authority 
to allow for expanding existing reimbursement agreements to include 
UIOs. If the goal is to increase access to care for AI/AN veterans, 
then now is the time for the VA to finally recognize that UIOs are a 
critical part of the Indian Health Service (IHS), acknowledge the needs 
of the significant amounts of AI/AN veterans who live in urban areas 
and expand the reimbursement agreement to include UIOs.
    Both the legislative and executive branches strongly support 
efforts to increase timely access of healthcare for Veterans. 
Recognition of the MOU for UIOs and urban Indian Veterans would be 
highly consistent with those efforts. NCUIH has worked closely with the 
National Congress of American Indians who recently passed a resolution 
in support of our efforts to ensure parity for UIOs. This resolution is 
being submitted as a part of my testimony today.
In Conclusion
    We strongly recommend that the VA reimburses UIOs for services 
rendered to Native Veterans. These reimbursements must be companied by 
outreach and advocacy resources to ensure that Native Vets are aware of 
all the health care options available to them in their communities. The 
VA is known for its challenging wait times, yet we all agree access to 
care for Veterans is a priority. UIOs can provide excellent, culturally 
competent primary care, dental, and behavioral health services to 
Veterans, while reducing the burden on the VA and allowing it to focus 
on the specialty services it provides best.
    Our national interest of serving Veterans will be best carried out 
when we extend the collaborative arrangements already agreed to by the 
VA and IHS to include the bulk of our nation's Native American 
Veterans--who either are or could be served by a UIO.
    NCUIH strongly recommends, pursuant to Section 405(c) of the Indian 
Health Care Improvement Act, that the VA-IHS MOU be expanded to include 
reimbursement for care provided by the UIOs. Thank you for holding this 
hearing today and for the Committee's support of urban Indian 
healthcare issues. We strongly support S. 2365 and look forward to 
working with Congress to serve as an expert resource regarding this 
legislation and other good work regarding urban Indian health care and 
the overall health of Indian Country.
                                 ______
                                 
     Prepared Statement of the National Indian Health Board (NIHB)
    Chairman Hoeven, Vice Chairman Udall, and Members of the Committee, 
thank you for holding this important hearing on health care access for 
Native Veterans. On behalf of the National Indian Health Board (NIHB) 
and the 573 federally-recognized sovereign Tribal Nations we serve, I 
submit this testimony for the record. The federal government's trust 
responsibility to provide quality and comprehensive health services for 
all American Indian and Alaska Native (AI/AN) Peoples extends to every 
federal agency and department, including the Department of Veterans 
Affairs (VA).
    By current estimates from the VA, there are roughly 146,000 AI/AN 
Veterans, with Native Servicemembers enlisting at higher rates than any 
other ethnicity nationwide. Indeed, the Department of Defense continues 
to acknowledge the indispensable role of AI/AN Servicemembers 
throughout American history. Native Veterans are highly respected 
throughout Indian Country, in recognition of what they have sacrificed 
to protect Tribal communities and the United States. Yet despite the 
bravery, sacrifice, and steadfast commitment to protecting the 
sovereignty of Tribal Nations and the entire United States, Native 
Veterans continue to experience among the worst health outcomes, and 
among the greatest challenges in receiving quality health services.
    Over the course of a century, sovereign Tribal Nations and the 
United States signed over 300 Treaties requiring the federal government 
to assume specific, enduring, and legally enforceable fiduciary 
obligations to the Tribes. The terms codified in those Treaties--
including for provisions of quality and comprehensive health resources 
and services--have been reaffirmed by the United States Constitution, 
Supreme Court decisions, federal legislation and regulations, and even 
presidential executive orders. These federal promises have no 
expiration date, and collectively form the basis for what we now refer 
to as the federal trust responsibility. Moreover, the United States has 
a dual responsibility to Native Veterans--one obligation specific to 
their political status as members of federally-recognized Tribes, and 
one obligation specific to their service in the Armed Services of the 
United States.
    In 1955, Congress established the Indian Health Service (IHS) in 
partial fulfillment of its constitutional obligations for health 
services to all AI/ANs. The IHS is charged with a similar mission as 
the VHA as it relates to administering quality health services, with 
the exception of the following differences: (1) the federal government 
has Treaty and Trust obligations to provide health care for all 
American Indians and Alaska Natives; (2) IHS is severely and 
chronically underfunded in comparison to the VHA, with per capita 
medical expenditures within IHS at $4,078 in Fiscal Year (FY) 2017 
compared to $10,692 in VHA per capita medical spending that same year 
\1\; and (3) unlike IHS, the VHA has been protected from government 
shutdowns and continuing resolutions (CRs) because Congress enacted 
advance appropriations for the VHA a decade ago. \2\
---------------------------------------------------------------------------
    \1\ The full IHS Tribal Budget Formulation Workgroup 
Recommendations are available at https://www.nihb.org/docs/04242019/
307871_NIHB%20IHS%20Budget%20Book_WEB.PDF
    \2\ See 38 U.S.C. 117; P.L. 111-81.
---------------------------------------------------------------------------
Health Outcomes among Native Veterans and AI/ANs Overall
    Destructive federal Indian policies and unresponsive human service 
systems have left Native Veterans and their communities with unresolved 
historical and intergenerational trauma. From 2001 to 2015, suicide 
rates among Native Veterans increased by 62 percent (50 in 2001 to 128 
in 2015). \3\ In FY 2014, the Office of Health Equity within VHA 
reported significantly higher rates of mental health disorders among 
Native Veterans compared to non-Hispanic White Veterans, including in 
rates of PTSD (20.5 percent vs. 11.6 percent), depression symptoms 
(18.7 percent vs. 15.2 percent), and major depressive disorder (7.9 
percent vs. 5.8 percent). \4\
---------------------------------------------------------------------------
    \3\ VA, Veteran Suicide by Race/Ethnicity: Assessments Among All 
Veterans and Veterans Receiving VHA Health Services, 2001-2014 (Aug. 
2017) (citing CDC statistics).
    \4\ Lauren Korshak, MS, RCEP, Office of Health Equity and Donna L. 
Washington, MD, MPH, Health Equity-QUERI National Partnered Evaluation 
Center, and Stephanie Birdwell, M.S.W., Office of Tribal Government 
Relations.
---------------------------------------------------------------------------
    Native Veterans are 1.9 times more likely to be uninsured than non-
Hispanic White Veterans, and are significantly more likely to delay 
accessing care due to lack of timely appointments and transportation 
issues. \5\ Among all Veterans, Native Veterans are more likely to have 
a disability, service-connected or otherwise. \6\ Native Veterans are 
exponentially more likely to be homeless, with some studies showing 
that 26 percent of low-income Native Veterans experienced homelessness 
at some point compared to 13 percent of all low-income Veterans. \7\ 
There exists a paucity of Native Veteran specific health, housing, and 
economic resources and programs that are accessible and culturally 
appropriate. It is essential that the VHA work with IHS and Tribes to 
create more resources specifically for Native Veterans.
---------------------------------------------------------------------------
    \5\ Johnson, P. J., Carlson, K. F., & Hearst, M. O. (2010). 
Healthcare disparities for American Indian veterans in the United 
States: a population-based study. Medical care, 48(6), 563-569. 
doi:10.1097/MLR.0b013e3181d5f9e1.
    \6\ U.S. Department of Veterans Affairs. (2015a). American Indian 
and Alaska Native Veterans: 2013 American Community Survey. Retrieved 
from https://www.va.gov/vetdata/docs/SpecialReports/AIANReport2015.pdf
    \7\ U.S. Department of Housing and Urban Development, U.S. 
Department of Veterans Affairs, National Center on Homelessness Among 
Veterans. Veteran Homelessness: A Supplemental Report to the 2010 
Annual Homeless Assessment Report to Congress. Washington, D.C.2011:56.
---------------------------------------------------------------------------
    According to IHS, AI/ANs born today have a life expectancy that is 
on average 5.5 years less than the national average. \8\ In states like 
South Dakota, however, life expectancy for AI/ANs is as much as two 
decades lower than for Whites. Health outcomes among AI/ANs have either 
remained stagnant or become as AI/AN communities continue to encounter 
higher rates of poverty, lower rates of healthcare coverage, and less 
socioeconomic mobility than the general population. According to the 
Centers for Disease Control and Prevention, in 2016, AI/ANs had the 
second highest age-adjusted mortality rate of any demographic 
nationwide at 800.3 deaths per 100,000 people.
---------------------------------------------------------------------------
    \8\ Indian Health Service. 2018. Indian Health Disparities. 
Retrieved from https://www.ihs.gov/newsroom/includes/themes/
responsive2017/display_objects/documents/factsheets/Disparities.pdf
---------------------------------------------------------------------------
    In addition, AI/ANs have the highest uninsured rates (25.4 
percent); higher rates of infant mortality (1.6 times the rate for 
Whites); higher rates of diabetes (7.3 times the rate for Whites); and 
significantly higher rates of suicide deaths (50 percent higher). AI/
ANs also have the highest Hepatitis C mortality rates nationwide (10.8 
per 100,000); and higher rates of chronic liver disease and cirrhosis 
deaths (2.3 times that of Whites). Further, while overall cancer rates 
for Whites declined from 1990 to 2009, they rose significantly for AI/
ANs. For instance, from 1999 to 2015 AI/ANs encountered a 519 percent 
increase in drug overdose deaths--the highest rate increase of any 
demographic nationwide. \9\ All of these health determinants of health 
and poor health status could be dramatically improved with adequate 
investment into the health, public health and health delivery systems 
operating in Indian Country.
---------------------------------------------------------------------------
    \9\ Mack KA, Jones CM, Ballesteros MF. Illicit Drug Use, Illicit 
Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and 
Nonmetropolitan Areas--United States. MMWR Surveill Summ 2017;66(No. 
SS-19):1-12. DOI: http://dx.doi.org/10.15585/mmwr.ss6619a1
---------------------------------------------------------------------------
    The VA's Veteran Outreach Toolkit lists AI/ANs as an ``at-risk'' 
population, citing this troubling suicide rate. Additionally, AI/ANs 
grapple with complex behavioral health issues at higher rates than any 
other population-for children of AI/AN veterans, this is compounded by 
the return of a parent who may suffer from post-traumatic stress 
disorder (PTSD). Outreach events for AI/AN communities should be a VA 
priority to increase wellness, decrease stigma, and prevent suicide. It 
is essential that the VHA continue to engage with Tribal leaders, 
through consultation, to assist in carrying out these activities.
Funding Levels for IHS versus VHA: The Need for Advance Appropriations
1. Tribes and NIHB strongly urge Congress to pass bipartisan 
        legislation that would enact advance appropriations for Indian 
        programs
    By the most recent estimates, federally-operated IHS facilities, 
Tribally-operated health facilities and programs, and urban Indian 
health programs collectively serve roughly 2.6 million AI/ANs 
nationwide. In comparison, the VHA serves roughly 6.9 million Veterans 
through 18 regional networks. In FY 2019 discretionary appropriations 
for IHS equaled roughly $5.8 billion; in comparison, spending within 
the VHA totaled over $76 billion. In effect, this means that while the 
VHA service population is roughly only three times the size of the 
Indian health system, its discretionary appropriations are 
approximately thirteen times higher than for IHS.
    According to the IHS Tribal Budget Formulation Workgroup, IHS 
appropriations must reach nearly $38 billion--phased in over twelve 
years--in order to fully meet current health needs. In other words, 
even if today IHS were fully funded at the level of need identified by 
sovereign Tribal Nations, it would only equal half the total FY 2019 
discretionary appropriation for the VHA. Indeed, the federal 
government's continued abrogation of its trust responsibility for 
health services for AI/ANs is clearly exemplified by the gravity of the 
divide in health funding for the VHA versus IHS.
    Although the IHS budget has nominally increased by 2-3 percent each 
year, these increases are barely sufficient to keep up with rising 
medical and non-medical inflation, population growth, facility 
maintenance costs, and other expenses. According to a 2018 report by 
the Government Accountability Office (GAO-19-74R), from 2013 to 2017, 
IHS annual spending increased by roughly 18 percent and per capita 
spending increased by roughly 12 percent; in comparison, annual 
spending under the VHA increased by 32 percent and per capita spending 
increased by 25 percent during the same time period. \10\ The widening 
gap in funding levels between IHS and the VHA only serves to perpetuate 
the disproportionately higher levels of health disparities experienced 
by Native Veterans and AI/ANs overall.
---------------------------------------------------------------------------
    \10\ Government Accountability Office. 2018. Indian Health Service: 
Spending Levels and Characteristics of IHS and Three Other Federal 
Health Care Programs. Retrieved from https://www.gao.gov/assets/700/
695871.pdf
---------------------------------------------------------------------------
    Unequivocally, the U.S. federal government has a moral and ethical 
obligation to ensure all U.S. Veterans can access quality health 
services--and it must continue to honor this responsibility. But the 
U.S. also has a Trust obligation to ensure all AI/ANs, including Native 
Veterans, can receive quality health services, that it continuously 
fails to honor. It is long past due for the federal government to make 
good on its constitutional obligation to Native Veterans an all AI/AN 
Peoples.
    The discrepancies do not end with chronic underfunding of IHS. Of 
the four major federal healthcare entities, IHS is the only one subject 
to the devastating impacts of government shutdowns and continuing 
resolutions (CRs). This is because Medicare and Medicaid receive 
mandatory appropriations, and the VHA was authorized by Congress to 
receive advance appropriations nearly a decade ago. As a result, the 
VHA has been insulated from every government shutdown, CR, and 
discretionary sequestration over the past decade. While it is true that 
no sector of government is fully spared by the repercussions of endless 
shutdowns and CRs, those repercussions are neither equal nor 
generalizable across all entities. In fact, the worst consequences are 
levied on Indian Country.
    For instance, during the 2013 federal budget sequester, the IHS 
budget was slashed by 5.1%--or $221 million--levied on top of the 
damage elicited by that year's government shutdown. In fact, IHS was 
the only federally funded healthcare entity that was subject to full 
sequestration because Congress had already exempted the VHA when it 
authorized it to receive advance appropriations. Once again, during the 
most recent 35-day government shutdown--the nation's longest and most 
economically disastrous--IHS was the only federal healthcare entity to 
be shut down. While direct care services remained non-exempt, providers 
were not receiving pay. Administrative and technical support staff--
responsible for scheduling patient visits, conducting referrals, and 
processing health records--were furloughed. Contracts with private 
entities for sanitation services and facilities upgrades went weeks 
without payments, prompting many Tribes to exhaust alternative 
resources to stay current on bills.
    Several Tribes shared that they lost physicians to hospitals and 
clinics not impacted by the shutdown. Some Tribal leaders even shared 
how administrative staff volunteered to go unpaid so that the Tribe had 
resources to keep physicians on the payroll. These are just a few 
examples of the everyday sacrifices and ongoing struggles that widen 
the chasm between the health services afforded to AI/ANs and those 
afforded to the nation at large. While it is impossible to measure the 
full scope of adversity brought on by the 35-day government shutdown, 
one reality remains clear--Indian Country was both unequivocally and 
disproportionately impacted.
    In 2018, GAO released a report examining the benefits of 
authorizing advance appropriations for the IHS and thus establishing 
parity between IHS and the VHA (GAO-18-652). The report outlined how 
Congress has been forced to use short-term or full-year CRs in all but 
four of the last 40 years. In fact, only once in the past two decades--
in FY 2006--has Congress successfully passed the Interior, Environment, 
and Related Agencies appropriations package (which funds IHS) before 
the end of the fiscal year. As a result, year after year, the Indian 
health system is curtailed from making meaningful improvements towards 
the availability and quality of health services and programs, further 
restraining efforts to advance quality of life and health outcomes for 
AI/ANs.
    While a CR is always preferable to a government shutdown, they are 
not devoid of obstacles that directly impact patient care. Because of 
budget authority constraints under a CR, IHS is prohibited from 
initiating any new activities or projects that were not expressly 
authorized or appropriated in the previous fiscal year. In addition, 
under a CR, IHS must exercise significant precaution over expenditures, 
and is generally limited to simply maintain operations as opposed to 
improve them. When you compound the impact of chronic underfunding and 
endless use of CRs, the inevitable result are the chronic and pervasive 
health disparities seen across Indian Country. As such, Tribal Nations 
and NIHB strongly urge the Senate to pass S.229--Indian Programs 
Advance Appropriations Act and S. 2541--Indian Health Service Advance 
Appropriations Act of 2019 that would authorize advance appropriations 
for Indian programs.
Lack of IHS and VHA Care Coordination and Reimbursement Agreements
1. Congress should pass legislation exempting Native Veterans from 
        copays and deductibles
    Section 222 of IHCIA prohibits cost sharing of AI/ANs in cases 
where an AI/AN receives a referral from IHS or a Tribal Health Program 
(THP) under the Purchased/Referred Care (PRC) program. Like IHS and the 
Marketplace, the VHA is another means by which the federal government 
must uphold its trust responsibility to AI/ANs. As such, it is 
imperative that Congress enact legislation that requires the VHA to 
similarly exempt AI/AN Veterans from copays and deductibles in the VA 
system in recognition of the federal trust responsibility.
    Tribal Nations and NIHB appreciate the intent of S. 1001--Tribal 
Veterans Health Care Enhancement Act and its goal of holding all Native 
Veterans harmless from copays and deductibles. However, Tribes and NIHB 
strongly believe that copay costs should not be shifted to IHS or 
Tribal governments. The VHA must absorb these costs on behalf of AI/AN 
Veterans in recognition of their Trust and Treaty obligations to AI/AN 
Peoples. Shifting costs to IHS would also be in violation of Section 
405 of IHCIA which established IHS as the payer of last resort. As 
such, Tribes and NIHB strongly urge that S. 1001 be amended to require 
the VHA to cover the full cost of copays for AI/AN Veterans, and ensure 
that IHS, Tribes, and Native Veterans are held harmless of these costs.
2. Congress should clarify statutory language under section 405(c) of 
        the Indian Health Care Improvement Act and make explicit the 
        VHA's requirement to reimburse IHS and Tribes for services 
        under Purchased/Referred Care (PRC)
    By law, an AI/AN Veteran is eligible for services under both the 
VHA and IHS. A 2011 report showed that approximately one-quarter of 
IHS-enrolled Veterans use the VHA for health care, commonly receiving 
treatment for diabetes mellitus, hypertension or cardiovascular disease 
from both federal entities. \11\ According to the VA, more than 2,800 
AI/AN Veterans are served at IHS facilities. \12\ In instances where an 
AI/AN veteran is eligible for a particular health care service from 
both the VA and IHS, the VA is the primary payer. Under section 2901(b) 
of the Patient Protection and Affordable Care Act (ACA), health 
programs operated by the IHS, Tribes and Tribal organizations, and 
urban Indian organizations (collectively referred to as the ``I/T/U'' 
system) are payers of last resort regardless of whether or not a 
specific agreement for reimbursement is in place.
---------------------------------------------------------------------------
    \11\ Kramer, BJ, Wang M, Jouldjian S, Lee ML, Finke B, Saliba D. 
Healthcare for American Indian and Alaska native veterans: The roles of 
the veterans health administration and the Indian Health Service. 
Medical Care.
    \12\ VA/IHS listening session held on May 15, 2019
---------------------------------------------------------------------------
    Section 407(a)(2) of the Indian Health Care Improvement Act (IHCIA) 
reaffirms the goals of the 2003 Memorandum of Understanding (MOU) 
between the VHA and IHS established to improve care coordination for 
Native Veterans. In addition, during permanent reauthorization of 
IHCIA, section 405(c) was amended to require the VHA to reimburse IHS 
and Tribes for health services provided under the PRC program. In 2010, 
the VHA and IHS modernized their 2003 MOU to further improve care 
coordination for Native Veterans by bolstering health facility and 
provider resource sharing; strengthening interoperability of electronic 
health records (EHRs); engaging in joint credentialing and staff 
training to help Native Veterans better navigate IHS and VHA 
eligibility requirements; simplifying referral processes; and 
increasing coordination of specialty services such as for mental and 
behavioral health.
    According to a 2019 GAO report (GAO-19-291), since implementation 
of the 2010 MOU, the VHA has reported entering into 114 signed 
agreements with Tribal Health Programs (THPs), along with 77 
implementation agreements to strengthen care coordination. While a 
single national reimbursement agreement exists between federally-
operated IHS facilities and the VHA, THPs continue to exercise their 
sovereignty by entering into individual agreements with the VHA. From 
2014 to 2018, those reimbursement agreements with THPs alone increased 
by 113 percent.
    VA reimbursements to IHS and THPs overall during that same time 
period increased by 75 percent, reaching $84.3 million in total. Yet 
these increased reimbursements still represent just a fraction of one 
percent of the VA's annual budget. While recent increases in the 
quantity of agreements and reimbursements demonstrates a positive 
trend, there continue to be significant challenges in care coordination 
between the VHA and IHS. The 2019 GAO report highlighted three 
overarching challenges related to care coordination: ongoing issues in 
patient referrals between I/T/U facilities and the VHA; significant 
problems in EHR interoperability; and high staff turnover within both 
VHA and IHS. These complications continue to stifle Native Veterans' 
access to health care, erodes patient trust in both IHS and VHA health 
systems, and obstructs efforts to improve health outcomes.
    These issues are exacerbated by VHA claims that no statutory 
obligation exists for reimbursement of specialty and referral services 
provided through IHS or THPs. To clarify, the VHA currently reimburses 
IHS and THPs for care that they provide directly under the MOU. Despite 
repeated requests from Tribes, the VA has not provided reimbursement 
for PRC specialty and referral care provided through IHS/THPs. This is 
highly problematic, as AI/AN Veterans should have the freedom to obtain 
care from either the VA or an Indian health program. If a Veteran 
chooses an Indian health program, that program should be reimbursed 
even if the service could have been provided by a VA facility or 
program in the same community.
    But because that doesn't happen, it creates greater care 
coordination issues and burdensome requirements for Native Veterans. 
For example, if a Native veteran goes to an IHS or THP for service and 
needs a referral, the same patient must be seen within the VA system 
before a referral can be secured. This means the VHA is paying for the 
same services twice, first for those primary care services provided to 
the Veteran in the IHS or THP facility, and then again when the patient 
goes back to the VHA for the same primary care service to then receive 
a VHA referral. This is neither a good use of federal funding, nor is 
it navigable for veterans. In order to provide the care that Native 
Veterans need, many THPs are treating Veterans or referring them out 
for specialty care and paying for it themselves so that they can be 
treated in a timely and competent manner. For those Veterans that do go 
back to the VHA for referrals, there is often delayed treatment and a 
significantly different standard of care provided.
    As a step toward mitigating the confusion surrounding reimbursement 
for care provided by the VHA, NIHB recommends the VHA include PRC in 
future IHS/THP reimbursement agreements, so that there is no further 
rationing of health care provided by IHS and THPs to Native Veterans 
and other eligible AI/ANs. Ultimately, however, NIHB recommends that 
Congress clarify the statutory language under section 405(c) of IHCIA 
and make explicit VHA's requirement to reimburse under PRC.
3. NIHB strongly supports the GAO recommendation that the VHA work with 
        IHS to create written policy or guidelines to clarify how 
        referrals from IHS and THP facilities to VHA facilities for 
        specialty care should be managed, and to establish specific 
        targets for measuring action on MOU performance measures
    The GAO report cited how, for example, facilities reported 
conflicting information about the processes for referring Native 
Veterans from IHS or Tribal facilities to VHA, and VA headquarters 
officials confirmed that there is no national policy or guide on this 
topic. One of the leading collaboration practices identified by GAO is 
to have written guidance and agreements to document how agencies will 
collaborate. Without written policy or guidance documents on how 
referrals should be managed, neither agency can ensure that VHA, IHS, 
and Tribal facilities have consistent understanding of the options 
available for referral of Native Veterans for specialty care.
    As is currently the case, the result is duplicative care for AI/AN 
Veteran and duplicative costs for the federal government. NIHB has 
heard that some AI/AN Veterans prefer to simply hand carry their EHR 
records from their IHS provider to their VHA provider to avoid having 
to receive the same care twice. In short, lack of written policy 
perpetuates this burdensome, pointless, and complicated process that 
only serves to frustrate patients, worsen administrative red tape, and 
increase expenditures.
    For numerous Tribes, and especially for the Veterans themselves, it 
is an undue barrier to constantly have to refer patients back and forth 
to the VA that ultimately wastes time and delays access to care. The 
GAO identified that IHS and VA lack sufficient measures for 
quantifiable assessments of progress towards MOU goals and objectives. 
Although the VHA and IHS have created fifteen performance measures, no 
specific targets or indicators have been established that allow Tribes 
to measure progress towards achieving the goals and objectives of the 
MOU.
4. Tribes and NIHB have strongly recommended that the VHA consult with 
        Tribes and work through their MOU with IHS to create and 
        publish a living list of available Veterans Liaisons/Tribal 
        Veterans Representatives across all IHS and VHA regions
    The VHA must do more outreach and education with Native Veterans to 
improve care coordination. Tribes and NIHB have consistently stressed 
the need for VHA to create toolkits and guides to assist Native 
Veterans in navigating care access. The paucity of currently available 
newsletters, outreach workers and liaisons such as Tribal Veteran 
Service Officers (TVSOs), and online resources specifically for AI/AN 
Veterans also sends the message that care for AI/AN Veterans is not a 
priority. But despite repeated Tribal demands, the agency has yet to 
implement this request.
    A closely related issue is the fact that Native Veterans are still 
charged copays and deductibles when receiving services under the VHA. 
The federal government's trust responsibility for health services 
extends to all Native Veterans. In recognition of this, AI/ANs do not 
have copays or deductibles for services received at an I/T/U facility. 
Additionally, the ACA further affirmed the trust responsibility when it 
included language at Section 1402 to exempt all AI/ANs under 300 
percent of the federal poverty level from co-pays and deductibles on 
plans purchased on the health insurance Marketplace.
5. Congress should pass the bipartisan S. 524--Department of Veterans 
        Affairs Tribal Advisory Committee Act of 2019
    Tribal Nations and NIHB have also strongly advocated for the 
seating of a Tribal Advisory Committee (TAC) within the Office of the 
Secretary at the VA. Establishing a Veteran TAC is essential for 
strengthening the government-to-government relationship, and improving 
VA accountability to AI/AN Veteran health needs. Through the seating of 
a TAC, top VA officials would have the ability to hear directly from 
Tribal leaders about the unique health priorities and challenges that 
impact Native Veterans. In addition, it would help prevent the 
development of new rules or policies that would adversely affect care 
for AI/AN Veterans. As such, Tribes and NIHB strongly support the 
bipartisan S. 524, introduced by Senator Tester, and urges the Senate 
VA Committee to pass this significant legislation.
EHR Interoperability and Health Information Technology (IT) 
        Modernization
1. Congress must ensure parity between the VA and IHS in appropriations 
        and technical assistance for health IT modernization
    The Resource and Patient Management System (RPMS)--which is the 
primary health IT system used across the Indian health system--was 
developed in close partnership with the VHA and has become partially 
dependent on the VHA health IT system, known as the Veterans 
Information Systems and Technology Architecture (VistA). The RPMS is an 
early adoption of VistA for outpatient use, and the legacy system was 
designed with the decision to keep the same underlying code 
infrastructure as VistA. IHS began developing different clinical 
applications for their outpatient services, and the VHA adopted code 
from RPMS to provide this functionality for VistA.
    RPMS eventually began to use additional VistA code as the need for 
inpatient functionality increased. This type of enhancement and support 
for both the IHS and VHA was made possible because VistA's software 
components were designed as an Open Source solution. The RPMS suite is 
able to run on mid-range personal computer hardware platforms, while 
applications can operate individually or as an integrated suite with 
some availability to interface with commercial-off-the-shelf (COTS) 
software products.
    Currently, the RPMS manages clinical, financial, and administrative 
information throughout the I/T/U, although, it is deployed at various 
levels across the service delivery types. However, in recent years, 
many Tribes and even several Urban Indian Health Programs (UIHPs) have 
elected to purchase their own COTS systems that provide a wider suite 
of services than RPMS, have stronger interoperability capabilities, and 
are significantly more navigable and modern systems to use. As a 
result, there exists a growing patchwork of EHR platforms across the 
Indian health system.
    When the VA announced its decision to replace VistA with a COTS 
system in 2017 (Cerner), concentrated efforts to re-evaluate the Indian 
Health IT system accelerated, and arose significant concerns as to how 
VHA and I/T/U EHR interoperability would continue. In 2018, IHS 
launched a Health IT Modernization Project to evaluate the current I/T/
U health IT framework, and to, through Tribal consultation, key 
informant interviews, and national surveys, develop a series of next 
steps and recommendations towards modernizing health IT in Indian 
Country.
    Difficulties in achieving IT interoperability among VA, IHS, and 
THP facilities pose significant problems for Native Veterans' care 
coordination. Unfortunately, the VHA and IHS have yet to identify a 
systemic solution towards increasing EHR interoperability between I/T/U 
and VHA hospitals, clinics, and health stations. A resulting scenario 
includes situations where a THP provider--having treated a Veteran and 
referred them to the VHA for specialty care--would not receive the 
Veteran's follow-up records as quickly as if they had streamlined 
access to each other's systems.
    Now that the VHA is transitioning to the Cerner system, it has 
worsened concerns around care coordination and sharing of EHRs between 
I/T/U and VHA systems. The fact is, Native Veterans are suffering today 
from the lack of health IT interoperability. It is shameful that Native 
Veterans are put in a position where they have to find their own 
solutions to streamline EHR sharing, most shockingly exemplified by 
anecdotes of AI/AN Veterans hand carrying their health records between 
their IHS and VHA provider.
    Congress must ensure that the Indian health system is fully 
integrated across the development and implementation of the VHA's 
transition to Cerner; however, thus far it has failed to do so. By the 
most current estimates, the transition to Cerner will take up to 10 
years to fully implement, with a current price tag of roughly $16 
billion. None of the existing estimates include calculations of how 
much it will cost to include IHS in this transition; however, through 
its Health IT Modernization Project, IHS is attempting to arrive at an 
estimated dollar figure for this cost.
    Tribes and NIHB were pleased to see that the FY 2020 President's 
Budget included a request for a new $20 million line item in the IHS 
budget to assist with health IT modernization; however, we were 
disappointed that the FY 2020 Senate Interior Appropriations package 
included only $3 million of this request. In comparison, the FY 2020 
Senate Military Construction funding bill budgeted $1.1 billion to 
assist VHA in its transition. Ensuring EHR interoperability between I/
T/U and VHA health systems will be impossible if Congress fails to 
establish parity in appropriations for VHA and IHS health IT 
modernization.
Conclusion
    The Federal Government has a dual responsibility to Native Veterans 
that continues to be ignored. As the only national Tribal organization 
dedicated exclusively to advocating for the fulfillment of the federal 
trust responsibility for health, NIHB is committed to ensuring the 
highest health status and outcomes for Native Veterans. We applaud the 
Senate Committee on Indian Affairs for holding this important hearing, 
and stand ready to work with Congress in a bipartisan manner to enact 
legislation that strengthens the government-government relationship, 
improves access to care for Native Veterans, and raises health 
outcomes.
                                 ______
                                 
 Prepared Statement of the United South and Eastern Tribes Sovereignty 
                       Protection Fund (USET SPF)
    On behalf of the United South and Eastern Tribes Sovereignty 
Protection Fund (USET SPF), we are pleased to provide the Senate 
Committee on Indian Affairs with testimony for the record for the 
oversigh hearing on ``Recognizing the Sacrifice: Honoring A Nation's 
Promise to Native Veterans'' and legislative hearing to receive 
testimony on S.1001 & S.2365. USET SPF is appreciative of the 
Committee's tcommitment to help address some of the unique barriers 
that American Indian and Alaska Native (AI/AN) veterans face when 
returning from service, particularly when seeking healthcare. Whether 
delivered through the Indian Health Service (IHS) or the Department of 
Veterans' Affairs (VA), AI/AN veterans have pre-paid for their 
healthcare, both through the cession of Tribal homelands and the 
defense of our nation. As part of the federal trust obligation, it is 
incumbent upon the Committee to improve access to quality and 
culturally competent healthcare for AI/AN veterans.
    USET SPF is a non-profit, inter-tribal organization representing 30 
federally recognized Tribal Nations from the Canadian Border to the 
Everglades and across the Gulf of Mexico. \1\ Both individually, as 
well as collectively through USET SPF, our member Tribal Nations work 
to improve health care services for American Indians. Our member Tribal 
Nations operate in the Nashville Area of the Indian Health Service, 
which contains 36 IHS and Tribal health care facilities. Our patients 
receive health care services both directly at IHS facilities, as well 
as in Tribally-operated facilities under contracts with IHS pursuant to 
the Indian Self-Determination and Education Assistance Act (ISDEAA), 
P.L. 93-638.
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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), Chickahominy Indian Tribe (VA), 
Chickahominy Indian Tribe-Eastern Division (VA), 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), Rappahannock 
Tribe (VA), Saint Regis Mohawk Tribe (NY), Seminole Tribe of Florida 
(FL), Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY), 
Tunica-Biloxi Tribe of Louisiana (LA), and the Wampanoag Tribe of Gay 
Head (Aquinnah) (MA).
---------------------------------------------------------------------------
    As the Committee is aware, AI/AN people serve in the military at 
higher rates per capita than any other group in the nation. In 
addition, the VA has found that AI/AN veterans are more likely to have 
a serviceconnected disability than non-Indian veterans yet face 
significant disparities in care when compared to other veterans. In the 
USET SPF region, AI/AN veterans are often faced with access to only 
either the limited services provided by chronically underfunded IHS and 
Tribally-operated facilities or no services at all. As the Committee 
considers measures that would expand and improve access to quality 
healthcare for AI/AN veterans, USET SPF requests the exercise of this 
body's oversight functions ensure that the actions of all agencies of 
the federal government, including the VA, reflect and uphold the trust 
obligations unique to our population. Below, we provide comments to the 
Committee regarding how the Federal Government must address these 
barriers, as well as recommendations on S. 1001 and S. 2365.
IHS-VA MOU
    USET SPF requests the Committee exercise its oversight function to 
facilitate a strengthening of the 2010 memorandum of understanding 
(MOU) between the VA and IHS. As the Committee is likely aware, in 
2010, IHS and the VA entered into an expanded MOU with the goal of 
improving coordination between both agencies for AI/AN veterans. The 
intention of the MOU was to better facilitate patient care for AI/AN 
veterans across country within both agencies. However, a report by the 
Government Accountability Office (GAO) in 2019, ``Actions Needed to 
Strengthen Oversight and Coordination of Health Care for American 
Indian and Alaska Native Veterans,'' found that more action is needed 
to strengthen oversight and coordination between IHS and the VA 
regarding implementation of the MOU.
Reimbursement Agreements for PRC in IHS-VA MOU
    Since 2010, USET SPF, as well as Tribal Nations and Tribal 
organizations across the country, has strongly advocated for the VA to 
reimburse for all services provided by or through Tribal health 
programs. IHS and Tribal health programs are not always able to 
directly provide AI/AN veterans with all necessary health care 
services. Like other AI/ANs, many of these veterans receive essential 
health services through the Purchased/Referred Care (PRC) program, 
which authorizes the purchase of services from a network of private 
providers when care is not available at IHS or Tribal facilities. PRC 
is an integral part of IHS and Tribal health care systems, as it 
facilitates access to care that the federal government has failed in 
providing the funding to deliver directly.
    However, the VA does not currently reimburse IHS or Tribal programs 
for services provided using PRC funds. Instead, the VA requires that 
veterans in need of care return to the VA for a referral instead--an 
inefficient and time consuming process. USET SPF asserts that this 
policy fails to prioritize the healthcare necessities of AI/AN veterans 
by creating additional and unnecessary burdens. The continued lack of 
coordination of care between the VA and the Indian Healthcare System 
for the full complement of health care services will only continue to 
create additional barriers in access to care for our veterans.
    This limitation is further contrary to the plain language of 
Section 405(c) of the Indian Health Care Improvement Act, which 
provides for reimbursement ``where services are provided through the 
[Indian Health] Service, an Indian Tribe, or a Tribal organization. . 
.'' (emphasis added) without limitation to direct services. It is also 
in conflict with Section 2901(b) of the Affordable Care Act, which 
specifies that health programs operated by IHS, Tribal Nations, Tribal 
organizations, and UIOs are payers of last resort. Through these 
provisions, Congress clearly intended to shield IHS and Tribal PRC 
dollars from being used to pay for services when other sources of 
funding are available, including funding from VA. Accordingly, USET SPF 
strongly recommends the Committee facilitate measures that would 
require the VA to reimburse for all services provided by or through 
Tribal health programs.
Preservation of Existing Reimbursement Agreements in IHS-VA MOU
    USET SPF underscores to the Committee that the existing 
reimbursement agreements within MOU have demonstrated success in 
facilitating patient care for AI/AN veterans, and therefore must 
continue to be upheld and preserved. Specifically, we underscore the 
importance of preserving the IHS All-Inclusive rate on reimbursements 
for outpatient services for AI/AN veterans delivered through IHS. 
Should IHS and the VA determine any revisions to the MOU, we request 
the Committee work to ensure the preservation of the All-Inclusive rate 
within the MOU. This will ensure that critical dollars remain within 
the Indian Health System to be able to continue support the services 
provided to AI/AN veterans in fulfillment of the trust obligation.
Improved VA-IHS EHR Interoperability
    As discussed during the hearing, there are challenges with regard 
to information technology interoperability which have made it difficult 
for IHS and VA healthcare providers to have access important patient 
information within one another's EHR systems. Since 2018, the VA has 
been working to replace the agency's current electronic health record 
(EHR) system, VistA, to an off-the-shelf EHR known as Cerner 
Millennium. Since then, IHS has been considering either maintaining its 
current system, the Resource and Patient Management System, or 
implementing a new EHR system altogether--previously, IHS and the VA 
participated in cost sharing for necessary periodic updates.
    While the VA and IHS committed to facilitate the interoperability 
of health information data systems between both agencies to share 
information on common patients, challenges continue as a result of the 
differences in EHR systems. USET SPF underscores that interoperability 
between EHR systems must be prioritized as healthcare providers for AI/
AN veterans must have access to real-time, life-saving data, and we 
strongly recommend the Committee consider the necessary resources to 
facilitate this interoperability.
S. 1001, Tribal Veterans Health Care Enhancement Act
    The VA is a vital access point for AI/AN veterans when seeking 
healthcare. AI/AN veterans, who may suffer from chronic conditions or 
injuries sustained as a result of their service, often require 
specialized care than what the Indian Healthcare System may be able to 
provide and are referred to a VA facilities. However, AI/AN veterans 
are currently subject to standard copays for services received within 
the VA. When healthcare is received through IHS or Tribally-operated 
facilities, AI/AN veterans are not subject to any cost-sharing. 
However, AI/AN veterans are subject to certain copayments, such as for 
urgent care services, when they are receiving care from VA facilities. 
Subjecting AI/AN veterans to any copayments as a condition of 
healthcare access is a violation of the federal trust responsibility, 
which all federal agencies share in equally. Further, AI/AN veterans 
may be discouraged from seeking critical and life-saving healthcare if 
they are subject to copays for certain VA services.
    USET SPF recognizes that S. 1001 seeks to address the harmful 
financial impacts of unpaid VA balances accrued by AI/AN Veterans who 
have been referred to the Department of Veterans Affairs (VA) health 
system by Indian health clinics. The intent of the bill is to ensure 
AI/AN veterans receive the care to which they are entitled without 
incurring copay costs. While USET SPF supports the intent of S.1001, we 
cannot support this legislation, as it would shift the cost of care for 
AI/AN veterans from the VA to the severely underfunded IHS and 
Tribally-operated health clinics, as well as violate current law naming 
IHS as the payer of last resort. USET SPF contends that the Indian 
Health System and AI/AN veterans are best served through a waiver of 
cost-sharing entirely.
    Congress has previously recognized the inconsistencies between the 
federal trust responsibility to provide health care to AI/AN and the 
assessment of premiums and cost-sharing via federal health programs. In 
2009, Congress passed the American Recovery and Reinvestment Act, which 
eliminated premiums and cost-sharing for AI/AN patients when accessing 
services via Medicaid and the Children's Health Insurance Program. This 
provision avoids the assessment of payments to individual AI/AN without 
impacting already insufficient IHS funds. And it upholds the federal 
trust obligation by ensuring that care provided to AI/AN continues to 
be delivered at no cost. With this in mind, we call for this policy to 
be extended to all federal health care programs and facilities, 
including the VA.
S. 2365, Health Care Access for Urban Native Veterans Act
    Currently, approximately 78 percent of AI/ANs do not live on Tribal 
reservations. However, Urban Indian Organizations (UIOs) are not 
currently considered eligible to for inclusion in the VA reimbursement 
agreements, even though UIOs provide critical healthcare services to 
AI/AN veterans residing in urban areas. Instead, the VA made a 
discretionary decision to deem UIOs ineligible for inclusion in 
reimbursement agreements within the IHS-VA MOU.
    S. 2365, the Health Care Access for Urban Native Veterans Act, 
introduced by Senator Tom Udall (D-NM), would rightly include UIOs in 
existing statute that requires the VA to reimburse IHS and Tribal 
health facilities for services they provide to AI/AN veterans. USET SPF 
supports S.2365, which would address the oversight in legislation that 
made UIOs the only part of the IHS/Tribal/Urban (I/T/U) system to not 
receive reimbursement under the VA-IHS MOU reimbursement agreement.
    USET SPF reminds the Committee that the federal trust 
responsibility to provide healthcare to AI/ANs in perpetuity is not 
limited to where an AI/AN veteran resides. We further remind the 
Committee that Congress created the UIO system to honor a federal trust 
obligation and assert that UIOs are wellpositioned to play a vital role 
in closing the gap in service to AI/AN veterans. The passage of S.2365 
would increase access to care and provide parity to UIOs by ensuring 
that all three branches of the I/T/U system receive reimbursement for 
health care services delivered to AI/AN veterans. We request support 
from the Committee and Congress on this crucial legislation.
Conclusion
    It is shameful that AI/AN veterans continue to face ongoing 
challenges when it comes to accessing the quality healthcare to which 
they are entitled. The federal trust obligation to provide 
comprehensive healthcare to Tribal Nations and AI/AN veterans exists in 
perpetuity and is shared by all federal entities including IHS, the VA, 
as well as Congress. It is incumbent upon the whole of the federal 
government to remove barriers in accessing healthcare for AI/AN 
veterans, and we encourage the Committee to work to address these 
problems, in consultation with Tribal Nations, as well as strengthen 
existing partnerships between the VA and the Indian Healthcare System.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Catherine Cortez Masto 
                        to Hon. Robert L. Wilkie
    Question 1. As you know, navigating the VA claims process can be 
challenging, and I'm thankful we have dedicated Veteran Service 
Officers (VSOs) across the country ready to help Veterans understand 
their benefits. However, often due to the financial burdens and 
bureaucratic red tape associated with the VA requirements for Tribes to 
create specific organizations for Veterans, Tribes are often unable to 
receive formal VA recognition necessary to become accredited VSOs. How 
can the VA reduce this burden?
    Answer. The purpose of VA's Accreditation and Discipline Program is 
to ensure that claimants for Department of Veterans Affairs (VA) 
benefits have responsible, qualified representation in the preparation, 
presentation, and prosecution of the claims for Veterans' benefits. 38 
Code of Federal Regulations (CFR)  14.626. VA accredits three 
categories of claims practitioners: (1) representatives of recognized 
Veterans Service Organizations (VSO); (2) attorneys; and (3) claims 
agents. See 38 United States Code (U.S.C.)   5902, 5904; 38 CFR  
14.629. The mechanisms for ensuring the competence, qualifications, and 
character of the representatives varies for each category. For 
attorneys, VA generally relies upon the state bar licensure process to 
ensure the attorney's qualifications. 38 CFR  14.629(b)(1)(ii). For 
claims agents, VA conducts a character and fitness investigation and 
administers a written examination. 38 CFR  14.629(b)(1)(i). For VSO 
representatives, VA generally relies upon the recognized VSO to verify 
the representative's qualifications and to provide training and 
oversight. 38 CFR  14.629(a).
    For an organization to be recognized as a VSO, it must meet 
requirements set forth in 38 CFR  14.628(d), which include a showing 
that the organization's primary purpose is to serve Veterans, that the 
organization demonstrates a ``substantial service commitment to 
Veterans'' (i.e., has a sizeable organizational membership or provides 
services to a sizeable number of Veterans), that it commits a 
significant portion of its assets to Veterans programs, that it 
maintain a policy and capability of providing complete claims service 
to Veterans, and that it take affirmative action, including training 
and monitoring of representatives, to ensure proper handling of claims. 
VA views these longstanding requirements as essential to ensure that 
VSOs provide competent and qualified service through their 
representatives.
    Prior to 2017, VA regulations provided for recognition of 
``national'' VSOs, ``state'' VSOs, and ``regional or local'' VSOs. In 
2017, VA revised its regulations to clarify that tribal organizations 
may be recognized as VSOs in a manner similar to state organizations. 
82 Fed. Reg. 6265 (Jan. 19, 2017). That rulemaking did not change the 
longstanding requirements for recognition as a VSO, as described above.
    In the course of that rulemaking, we received comments indicating 
that some tribal organizations may have difficulty satisfying the 
requirements for recognition as a VSO, including the requirements 
relating to primary purpose, size, funding, and training. In response, 
VA explained that its goal is to ensure that VA-accredited 
organizations provide long-term, competent representation to Veterans, 
and that the requirements in section 14.628(d), which apply equally to 
all organizations seeking VA recognition, are protective of that 
mission. 82 Fed. Reg. at 6270. We noted also that the rule provided for 
recognition of tribal organizations sponsored by ``one or more tribal 
governments,'' offering a potential means for tribal governments to 
collaborate to meet the requirements for recognition as a VSO. We 
further explained that, in providing for recognition of tribal 
organizations as VSOs, we did not intend to limit other existing 
mechanisms for obtaining VA accreditation. We noted that ``there are 
several ways that individuals, including tribal members, tribal 
government employees, and others who work within and serve tribal or 
Native American communities, may be accredited by VA to represent 
claimants.'' 82 Fed. Reg. at 6271. We explained that an individual may 
apply for accreditation as a representative through an existing VA-
accredited organization or may apply for accreditation in an individual 
capacity as an attorney or claims agent. The 2017 rule also included 
provisions clarifying that a Tribal Veterans Service Officer could be, 
but is not required to be, accredited through a recognized state VSO in 
the same manner as county VSOs may be accredited through state 
organizations. 38 CFR  14.629(a)(2).
    As VA hopes the foregoing clarifies, the standards VA uniformly 
applies to organizations seeking accreditation as VSOs serve a critical 
purpose in ensuring that VSOs provide long-term, competent, and 
accountable representation to Veterans. At the same time, VA provides 
several methods by which an individual may become accredited to 
represent Veterans, either through organizations or in an individual 
capacity. We do not believe our processes impose unnecessary or 
excessive requirements upon any individuals who wish to become 
accredited to represent Veterans.
    In order to improve VA's communication to tribal governments 
regarding the requirements for VA recognition and accreditation, VA's 
Office of Tribal Government Relations (OTGR) has been informing tribal 
Veterans offices about the change in VA regulations and offering to 
assist those that are interested in requesting VA recognition with 
fully developing their request before submitting it to the Office of 
General Counsel for review.

    Question 1a. Is there a way for the VA to provide grants to help 
Tribes gain access to VSOs, and is this something the VA is exploring?
    Answer. At this time VA does not have legislative authority to 
provide grants to tribal governments to help them finance the 
establishment or development of their tribal Veterans offices for the 
purpose of assisting Veterans with their VA benefits claims. If given 
such authority, VA would need to issue regulations for implementation 
and publish a Notice of Funding Availability in the Federal Register. 
As VA noted in the response above, there are currently several 
different pathways for individuals, including tribal members, tribal 
government employees, and other individuals who serve tribal 
communities to be accredited by VA to represent Veterans on their VA 
benefits claims.

    Question 2. The transition process presents challenges for every 
Veteran and finding gainful employment after separating is critical for 
adjusting back to civilian life. Over half of Native Veterans are 
unemployed or not in the labor force, and I think the VA could do more 
to help these Veterans join the workforce. How is the VA helping Native 
Veterans find employment?
    Answer. VA's Vocational Rehabilitation and Employment (VR&E) 
Program assists Servicemembers and Veterans with service-connected 
disabilities prepare for, obtain, and maintain suitable employment. 
VR&E participants are provided all services and assistance necessary to 
achieve an employment outcome including, but not limited to:

   Educational, vocational, employment, and personal and work 
        adjustment counseling;

   Vocational and other training services and assistance;

   Payment of tuition, fees, books, and supplies, if training 
        is needed;

   Subsistence allowance, if training is needed;

   Job placement and post-placement services;

   Assistance with starting a business;

   Special services to address necessary accommodations to 
        ensure successful training and job placement;

   Coordination of health care services within Veterans Health 
        Administration (VHA); and

   Other incidental goods necessary to achieve employment.

   VA case managers work with local resources and the 
        appropriate VA employment programs to assist Native Veterans to 
        access employment when appropriate for the Veteran.

    VR&E accomplishes this mission by meeting the Veteran population 
where they are located by the placement of more than 1,000 highly 
trained Vocational Rehabilitation Counselors (VRC) across the nation at 
more than 350 locations, including VA regional offices and out-based 
locations such as college campuses, military installations, other VA 
facilities, and leased office space. In addition, the use of tele-
counseling services increases VR&E's ability to reach individuals who 
may prefer and benefit from virtual participation. Furthermore, VBA 
hosts Economic Investment Initiatives, in which VA partners with 
Federal, state, local, and tribal governments, as well as businesses 
and nonprofit organizations, to support the total economic wellbeing of 
Veterans in areas designated as Qualified Opportunity Zones
    VA's Office of Transition and Economic Development recently 
partnered with the U.S. Chamber of Commerce and Hiring Our Heroes to 
incorporate Hiring Fairs and Career Summit into VA's Economic 
Investment Initiatives. Additionally, VA hosts Economic Investment 
Initiatives, in which VA partners with Federal, state, local, and 
Tribal governments, local businesses and nonprofit organizations, to 
support the total economic well-being of Transitioning Servicemembers, 
Veterans, family members and caregivers with the following events:

   Hiring Fairs

   Benefits Fairs (i.e. VR&E, Education, Personalized Career 
        Planning and Guidance (PCPG))

   Workshops (Resume Writing, Direct Hiring Authorities)

    In addition, VA's PCPG (historically known as Chapter 36, Education 
& Career Guidance) is a great opportunity for Servicemembers, Veterans 
and dependents to receive personalized counseling and support to help 
guide their career paths, which ensures the most effective use of their 
VA benefits, and achieve their academic and career goals. PCPG is 
available free of charge if applicants meet one of the following 
conditions:

   Veteran or dependent, eligible for educational benefits 
        under a program that VA administers;

   Discharged or released from active duty under honorable 
        conditions, not more than one year ago; or

   Active duty Servicemember with six months or less remaining 
        before scheduled release or discharge from service.

    Question 2a. How is the VA ensuring that every Native Veteran is 
aware of the help VA can provide, and is able to access it, even in 
areas without broadband or a local representative?
    Answer. VA accomplishes this through comprehensive engagement, 
which includes conducting training and holding outreach events in 
tribal communities. VA also works with the Indian Health Service (IHS) 
and Tribal Health Programs within tribal communities to enroll eligible 
Veterans in VHA health care. VBA hosts Economic Investment Initiatives, 
in which VA partners with Federal, state, local, and tribal 
governments, as well as businesses and nonprofit organizations, to 
support the total economic wellbeing of Veterans in areas designated as 
Qualified Opportunity Zones. While these initiatives are new, VA 
recently held one in the South Puget Sound Region of Washington State 
in conjunction with the Washington State Department of Veterans Affairs 
and representatives from regional tribal governments to ensure that 
their membership was included in benefits and outreach efforts specific 
to their needs.
    VA continues to conduct outreach events and claims clinics, and 
Fiscal Year (FY) 2020 will be the third consecutive year in which VA 
and OTGR partner to conduct more than 30 claims clinics across the 
Indian Nations. VA facilitates Stakeholder roundtables with local 
government dignitaries and VSOs to discuss collaboration and 
partnership to gain access to tribes and remote communities.
    Veterans Benefits Administration (VBA) Minority Veteran Program 
Coordinators at 56 regional offices provide outreach services to the 
Native American communities. Additionally, VBA provides annual benefits 
training to Tribal Veterans Representatives (TVR), so they can educate 
their Veteran communities about the services and benefits VA provides. 
In FY19, VBA trained 93 TVRs at five training events. VBA participates 
and organizes events such as observation of Native American Heritage 
Month, tribal Pow Wows and partners with the Mobile Vets Center to 
visit tribal communities and provides information on VA benefits.
    Also, VA's Loan Guaranty Service, through a network of Regional 
Loan Centers (RLC), makes annual contact with every tribe or native 
community named in the Federal Register as a federally acknowledged 
tribe. Designated staff from each RLC conduct outreach events, often by 
invitation or in conjunction with other VA business lines or federal 
agencies, such as the Departments of Housing and Urban Development and 
Agriculture (Rural Development). VA Loan Guaranty Service central 
office staff also attend national conferences such as the National 
American Indian Housing Council (NAIHC) Annual Convention, NAIHC Legal 
Symposiums, and the annual convention of the Alaska Federation of 
Natives; while RLC staff attend regional, state, and local Native 
American affiliated events. VA Loan Guaranty Service central office and 
RLC staff collaborate with Regional Relationship Specialists from the 
VA OTGR to participate in outreach efforts such as Pow Wows, Veteran 
``Stand-downs,'' and Veterans benefits fairs. During outreach events, 
Loan Guaranty Service staff distribute Native American Direct Loan 
(NADL) literature (pamphlets/post cards) to interested parties and 
points of contact that can be more broadly disseminated to 
stakeholders.

    Question 3. One of the things I hear from Tribes in Nevada is the 
need for better coordination. Does VA meet with and take in suggestions 
from the National Congress of American Indian Veterans Committee?
    Answer. Yes, VA leadership and representatives meet with the NCAI 
Veterans Committee and take recommendations and have done so 
consistently for the past 8 years.

    Question 3a. How are the VA and IHS improving consultation with 
Tribes at the local level, including in Nevada, to enhance 
communication and establish effective agreements?
    Answer. When it comes to VA/IHS local consultation, local 
leadership, staff and subject matter experts frequently meet with 
tribal officials and conduct local training and outreach events in 
order to foster ongoing communication and relationship building. VA 
Sierra Nevada Healthcare System supports Rural Native Veterans by 
multiple methods which include: Providing Volunteer Transportation to 
and from rural areas and our clinical locations. We have Community 
Based Outpatient Clinics throughout Northern Nevada in Winnemucca, 
Fallon and Gardnerville. We have Tribal Health Agreements with local 
tribes and conduct ongoing Tribal Outreach throughout the region. In 
addition, we offer Telehealth to the home (VA Video Connect) for rural 
patients when clinically appropriate.

    Question 4. Just a few weeks ago, the VA Inspector General found 
that the Office of Accountability and Whistleblower Protection, an 
office created to protect whistleblowers in the VA, has in fact done 
the opposite, creating a culture alienating those it was mean to 
protect and without providing the safeguards and unbiased 
investigations whistleblowers deserve. What specific actions has the VA 
already taken to address the IG's report, and what further actions are 
planned?
    Answer. The Office of Accountability and Whistleblower Protection 
(OAWP) is working collaboratively with OIG to implement its 
recommendations. As the OIG report highlighted, a lack of oversight, 
communication, and training for staff were the root causes of the 
deficiencies. These deficiencies contributed to a lack of trust in 
OAWP. A new OAWP leadership team, under the direction of Assistant 
Secretary Bonzanto, has instituted operational changes to address these 
deficiencies. These operational changes include:

   The Assistant Secretary or her designee reviewing all OAWP 
        investigator recommendations;

   Realignment of OAWP staff to prevent duplication of efforts 
        and increase investigatory resources, with the number of 
        investigators increasing from 30 to 40;

   Requiring that investigators communicate with whistleblowers 
        about the status of their matters on a regular basis to the 
        extent permissible by law;

   implementing an information system, with an audit trail, to 
        track investigations and maintain records in compliance with 
        the law;

   Issuance of VA Directive 0500 to govern how OAWP receives 
        whistleblower disclosures; allegations of senior leader 
        misconduct, poor performance, and whistleblower retaliation; 
        and allegations of whistleblower retaliation against 
        supervisors; and

   Issuance of standard operating procedures for OAWP's Intake, 
        Investigations, Quality, and Compliance teams.

    The recent hiring of supervisory investigators with substantial 
experience overseeing administrative and whistleblower retaliation 
investigations, and the establishment of smaller investigative teams, 
has improved the oversight of investigations in OAWP. OAWP 
investigators also received comprehensive customized training designed 
by OAWP supervisors in January 2020. They will receive ongoing training 
to further develop investigative skills. Recognizing that quality 
control of OAWP investigations is essential, OAWP has established an 
independent quality review team to ensure investigative reports are 
thorough and accurate.

    Question 4a. And what is the timeline for ensuring that 
whistleblowers in the VA have proper protection and support?
    Answer. VA has taken a number of actions to ensure that employees 
are educated and trained on whistleblower rights and protections. OAWP 
developed whistleblower rights and protection training required under 
38 U.S.C.  733 with input provided by OIG and the U.S. Office of 
Special Counsel. This training provides employees with, among other 
things, an explanation on the ways in which they can make a 
whistleblower disclosure, the right of employees to petition Congress, 
and information on who to contact if whistleblower retaliation occurs. 
The training also includes an additional supervisory employee module 
that outlines ways to foster an environment where employees feel 
comfortable disclosing wrongdoing and the consequences of retaliating 
against whistleblowers. The training is mandated by the Secretary for 
all VA employees. VA also mandated whistleblower protection as a 
critical element for VA senior executive performance plans, in 
accordance with 38 U.S.C.  732.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Catherine Cortez Masto 
                        to Dr. Kameron Matthews
    Question 1. In his testimony, Mr. Fox said the impact of travel 
distances for health care services on Native Veterans ``cannot be 
understated.'' Nevada's tribal communities are spread out throughout 
the state, including in rural areas far from Nevada's two VA medical 
centers in Reno and Las Vegas. Could you describe what efforts VA is 
undertaking to bring care closer to Native Veterans, especially those 
in rural areas? And what specifically is the VA doing to mitigate 
travel distances for Native Veterans in the state of Nevada?
    Answer. VA collaborates with the Indian Health Service and Tribal 
Health Programs (THP) to ensure the health care needs of Native 
Veterans are met throughout Nevada, and particularly in rural areas 
where access may be more challenging. For example, in Southern Nevada, 
VA is actively engaged in coordinating with the Indian Health Service 
to serve the needs of 71 Native American Veterans who seek out health 
care within the local area. In 2016, VA hosted a meeting which brought 
together tribal and health care leadership from the Parker Indian 
Hospital, Irene Benn Medical Center, Las Vegas Paiute Tribe (Urban), 
the Moapa Band of Paiutes Tribe (Rural), IHS, and VA to discuss joint 
opportunities. Since that meeting, we have continued to engage in and 
implement efforts to improve health care availability whether through 
VA, IHS, or a THP. For example, if Veterans require care not available 
through IHS or a THP, they are advised of services and benefits that 
may be available through VA.
    Additionally, assistance with transportation to health care may be 
available for eligible Veterans. VA's Beneficiary Travel program 
provides eligible Veterans and other beneficiaries mileage 
reimbursement, the actual cost for use of a common carrier (airplane, 
train, bus, taxi, etc.), or when medically required, ``special mode'' 
(ambulance, wheelchair van) transport for travel to and from a VA 
facility or VA-authorized health care facility for examination, 
treatment, or care for which the Veteran is eligible (subject to 
applicable requirements).

    Question 2. Mr. Dupree wrote in his testimony that you are not 
certain the VA Native American Veteran Direct loan program is working 
as well as it could work, in part due to the lack of VA outreach. How 
are you helping to spread awareness of the program for our Veterans? 
How are you making the application process as accessible as possible to 
allow more Native Veterans to participate?
    Answer. Loan Guaranty Service has a NADL Program Manager who 
manages the program at the national level and works to ensure annual 
outreach with all tribal/Native American groups. Outside of attending 
national Native American housing conferences and outreach events, the 
VA Home Loan Web site offers detailed information regarding the NADL 
program and provides contact information to speak directly with a VA 
representative. Each RLC has a NADL coordinator that serves as a 
subject matter expert for the program as well as the loan originator, 
processor, and closer for NADL Home Loans. They achieve this by 
providing service to Native American Veterans in person and virtually. 
Awareness of the NADL program is also achieved through the distribution 
of pamphlets and other materials that highlight key information about 
the program. VA's Loan Guaranty Service welcomes the opportunity to 
share information about the NADL program. If a tribe is interested in 
Loan Guaranty Service's participation at an outreach event, they may 
contact the RLC that serves the jurisdiction for coordination.
    In order for a Native American Veteran to obtain a loan through 
VA's NADL program, the tribal organization having jurisdiction over the 
Veteran must have entered into a Memorandum of Understanding (MOU) with 
VA. 38 U.S.C.  3762. The NADL Program Manager works closely with the 
tribal organizations to ensure the MOU development process not only 
meets the needs and goals of the organization, but also meets the 
statutory requirements of VA's NADL program. These efforts are designed 
to ensure the highest level of participation in the NADL program by 
Native American Veterans.

    Question 3. One of the things I hear from Tribes in Nevada is the 
need for better coordination. Does the VA meet with and take in 
suggestions from the National Congress of American Indians' Veterans 
Committee?
    Answer. Please see the response to Question 3.

    Question 3a. How are the VA and IHS improving consultation with 
Tribes at the local level, including in Nevada, to enhance 
communication and establish effective agreements?
    Answer. Please see the response to Question 3.

    Question 4. As you know, navigating the VA claims process can be 
challenging, and I'm thankful we have dedicated VSOs across the country 
ready to help Veterans understand their benefits. However, due to 
bureaucratic red tape and financial restrictions, Tribes are often 
unable to receive the VA training to become accredited VSOs or find 
that the requirement to have a separate funded entity to be financially 
burdensome. How can VA help reduce these burdens so that Tribes gain 
access to VSOs?
    Answer. Please see the response to Question 1.

    Question 4a. Is there a way for the VA to provide grants to cover 
the financial burden, and is this something the VA is exploring?
    Answer. Please see the response to Question 1.

    Question 5. I appreciate the Administration's willingness to give a 
deeper breakdown of the data requests made during the hearing, and ask 
for data to support the following:

    What is the delta between eligible service members and those who 
are actually using their VA coverage? Do you have a state by state or 
regional (as defined by the Bureau of Indian Affairs) breakdown of 
those numbers?
    Answer. Of the estimated 13.9 million Veterans who are eligible to 
enroll in VA for health care in FY 2018, 8.8M are enrolled (end-of-year 
count). The table sets forth the total number of total, eligible, and 
enrolled Veterans by state.

  Fiscal Year 2018 End of Year (EOY) Veterans Summary by State--Source: 2019 VA Enrollee Health Care Projection
                                                      Model
----------------------------------------------------------------------------------------------------------------
                                                                          EOY Estimated          EOY Enrolled
                     State                        EOY Total Veterans    Eligible Veterans       Veterans 2018
                                                    2018 Estimate            Estimate               Actual
----------------------------------------------------------------------------------------------------------------
National                                                  19,602,300             13,894,800            8,810,400
Alabama                                                      365,900                258,200              169,100
Alaska                                                        68,800                 48,500               33,800
Arizona                                                      500,100                340,500              231,100
Arkansas                                                     219,300                165,200              109,800
California                                                 1,629,200              1,154,200              734,900
Colorado                                                     398,800                273,200              169,100
Connecticut                                                  177,200                122,700               70,900
Delaware                                                      70,800                 48,000               26,600
District of Columbia                                          27,400                 19,400               12,800
Florida                                                    1,491,000              1,065,100              711,800
Georgia                                                      694,200                478,900              312,700
Hawaii                                                       111,500                 84,300               46,500
Idaho                                                        120,900                 85,900               60,600
Illinois                                                     609,900                421,600              260,900
Indiana                                                      401,100                282,000              178,700
Iowa                                                         201,300                147,600               93,200
Kansas                                                       191,400                138,200               84,000
Kentucky                                                     291,700                212,100              136,800
Louisiana                                                    280,500                203,000              128,700
Maine                                                        111,300                 82,600               54,500
Maryland                                                     380,300                248,900              149,500
Massachusetts                                                310,600                224,400              127,800
Michigan                                                     570,700                386,000              223,100
Minnesota                                                    318,100                239,800              158,200
Mississippi                                                  189,100                142,300               93,700
Missouri                                                     434,400                312,700              192,100
Montana                                                       90,200                 67,900               48,200
Nebraska                                                     127,300                 95,000               66,300
Nevada                                                       214,600                155,800              110,200
New Hampshire                                                102,700                 71,700               43,500
New Jersey                                                   340,600                235,700              130,800
New Mexico                                                   156,600                109,400               74,800
New York                                                     747,100                559,900              355,100
North Carolina                                               728,200                518,500              333,700
North Dakota                                                  51,300                 39,800               26,300
Ohio                                                         753,800                522,200              329,100
Oklahoma                                                     300,100                216,700              135,900
Oregon                                                       297,000                209,700              139,300
Pennsylvania                                                 793,300                573,400              327,600
Rhode Island                                                  61,100                 44,600               26,300
South Carolina                                               400,700                285,100              188,900
South Dakota                                                  64,700                 50,800               38,000
Tennessee                                                    465,700                329,200              212,300
Texas                                                      1,574,000              1,114,100              741,600
Utah                                                         132,600                 93,600               58,000
Vermont                                                       42,100                 31,000               19,500
Virginia                                                     719,900                465,400              272,800
Washington                                                   552,300                368,100              219,300
West Virginia                                                140,000                109,200               74,600
Wisconsin                                                    354,300                256,500              163,000
Wyoming                                                       46,900                 36,800               25,400
Puerto Rico                                                   76,400                 71,100               63,000
Other U.S. Islands                                            12,200                 10,800                7,100
All Other Overseas*                                           58,600                 40,300                    0
Philippines                                                   28,300                 23,000                6,600
U.S. Virgin Islands                                            4,300                  4,200                2,500
----------------------------------------------------------------------------------------------------------------

        *Residence data for enrollees living overseas are not available 
        so there are no enrollment projections for this region.

    VA does not have an estimate of users by Bureau of Indian Affairs 
region. The Enrollment System (ES) does not provide enough data points 
to accommodate this request.
    Additionally, we note that the system does not provide a means to 
identify the total number of Veterans with Native American heritage. 
Also, since the race demographic is a ``self-report'' item on VA's 
Application for Health Benefits (VA Form 10-10EZ), that data point 
listed in ES would not be an accurate representation of the total 
number of Veterans who identify as American Indian or Alaska Native.

    Question 5a. What specific actions is the VA taking to close that 
delta?
    Answer. Although the specific data are unavailable, VA routinely 
engages in enterprise-wide outreach efforts to tribal communities 
through tribal consultation, Webinars, onsite training sessions, and 
in-person briefings with individual tribes, tribal Veterans Service 
Officers, regional inter-tribal organizations, and advocacy 
organizations. The following are examples of results of the ongoing 
outreach and relationship building the agency engages in with tribal 
governments and tribal communities:

   Tribal Consultation: VA has conducted tribal consultation 
        annually since the agency policy was established in 2011. As an 
        example, in 2016, the agency conducted tribal consultation with 
        567 federally recognized tribes to identify the top 5 
        Priorities for Veterans living in Indian Country. Tribal 
        leaders, national and regional tribal organizations, Veterans, 
        and other designated representatives offered their input 
        regarding access to medical care; addressing housing and 
        homelessness; treatment for Post-Traumatic Stress Disorder and 
        mental health; understanding benefits, including benefits for 
        families; and transportation. This information is used by the 
        agency to focus and prioritize partnerships and initiatives 
        within tribal communities.

   Urban Indian Health Programs: VA engages with Urban Indian 
        Programs as an outreach requirement to strengthen access to 
        care for American Indian and Alaska Native (AI/AN) Veterans 
        living in urban areas. VA holds quarterly calls with the IHS 
        Office of Urban Indian Health and works to facilitate 
        introductions to and collaborative relationships between IHS-
        funded Urban Indian Health Program personnel and the closest VA 
        facility leadership and staff.

   VA Claims Clinics: FY 2019, VA collaborated with 25 tribal 
        governments to facilitate 30 claims clinic events in 13 states. 
        An estimated 965 Veterans were served and submitted a total of 
        472 claims for VA benefits.

   VA Leadership and Tribal Engagement: VA works to ensure 
        senior VA leadership, including the Secretary and leaders from 
        all three administrations, have frequent contact and 
        communication with AI/AN Veterans.

    Question 5b. Of those Veterans who have some other form of coverage 
outside of the VA, what type of coverage do they have, and what portion 
of tribal Veterans have each type?
    Answer. The following table below is from the 2018 VA Survey of 
Enrollees. The survey data represent estimates and estimates of 
insurance coverage tend not to vary from year to year.
    In 2018, 51.3 percent of Veterans had Medicare (51 percent in 2017, 
52 percent in 2016). Six percent of Veterans reported having Medicaid 
in 2018 (6.6 percent in 2017 and 6.4 percent in 2016). In addition, 
21.2 percent of Veterans reported having Tricare in 2018 (19.8 percent 
in 2017, 19.5 percent in 2016) and 27.6 percent (28 percent in 2017 and 
28.3 percent in 2016) respondents reported having private insurance 
(outside of VA). The survey does not allow respondents to select which 
other private insurance that they may have (Blue Cross Blue Shield, 
Cigna, Kaiser, etc.). In 2018, 19.2 percent (20.2 percent in 2017 and 
20.1 percent in 2016) self-identified as having no insurance.
    The estimated number of enrollees who self-identified as American 
Indian/Native Alaskan in the same survey was 217,580. (We note that 
respondents could select multiple racial and ethnic categories.) 
Twenty-seven percent of these enrollees are estimated to have no health 
care coverage outside VA. Estimated percentages of this population with 
other types of coverage break out as follows:

   Medicare 42 percent
   Medicaid 11 percent
   Tricare 24 percent
   Private Insurance 25 percent

    For Veterans who selected private insurance, options were not 
selected for what specific type of insurance, so we are unable provide 
this information.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                          Dr. Kameron Matthews
    Question 1. The VA provides many diverse services to our Nation's 
Veterans--from health care to education and training to home financing 
assistance. Depending on a Veteran's age, service needs often differ. 
For example, younger, post 9/11 Veterans many need more assistance with 
childcare and job training. How is the VA making sure it is working 
with Tribes to serve the diverse needs of Native American Veterans--
whether they just completed their military service or whether they've 
been retired for decades?
    Answer. Through the Transition Assistance Program, the Department 
of Veterans Affairs (VA) connects and educates all transitioning 
Servicemembers on resources, benefits, and training available to them, 
and how to utilize those benefits before they separate. VA also 
sponsors Economic Investment Initiatives (EII), which bring together 
partners and stakeholders to address concerns of Veteran populations 
located in Qualified Opportunity Zones around the country as well as 
providing education, training, and direct services to Veterans, 
Servicemembers, and their families. On February 13, 2020, VA sponsored 
a follow-up Stakeholder Roundtable event to specifically address 
challenges faced by Native American Veterans.
    VA's Vocational Rehabilitation and Employment Service also meets 
claimants' diverse needs by developing individualized rehabilitation 
plans designed to address each claimant's abilities, aptitudes, and 
interests, to include honoring and incorporating cultural perspectives, 
to ensure that each claimant reaches his or her rehabilitation goals.

    Question 2. A 2015 report by VA's Office of Rural Health 
recommended that the VA find ways to partner with Tribal Colleges and 
Universities (TCUs) to better serve Native Veterans--especially those 
young Native Veterans returning from recent conflicts. However, the 
same 2015 report also indicated that information on the VA's 
collaboration with TCUs is extremely limited. Since publishing that 
report, how has the VA worked to partner with TCUs?
    Answer. VA's Office of Rural Health (ORH) created a project in 2015 
to work with Tribal Colleges and Universities to reach transitioning 
Native American Veterans. The project ran from 2015 through 2017, 
however, due to the multiple barriers, including administrative changes 
at the local Tribal College level, we were not able to progress beyond 
that.
    However, under the VA-Indian Health Services (IHS) Memorandum of 
Understanding, signed in 2010, ORH continues to work to increase 
outreach to Native Veterans. Capitalizing on past experience, ORH is 
partnering with IHS to create a Rural Native Veteran Health Care 
Navigator Program to assist Native American Veterans with issues in 
transitioning to Veterans Health Administration (VHA) health care. This 
project is in its initial stages with a plan to roll out a small-scale 
pilot towards the end of Fiscal Year (FY) 2020 and expansion to more 
sites in 2021. If the pilots are successful, ORH will create an 
enterprise wide initiative to disseminate the program across the 
country.

    Question 3. The VA's Homeless Programs Office testified last 
Congress about the successes of the Tribal HUD-VASH demonstration 
program. Please share an update about how the program is doing.
    Answer. Tribal Department of Housing and Urban Development (HUD)-VA 
Supportive Housing (HUD-VASH) is a partnership between VHA, HUD's 
Office of Native American Programs (ONAP), and tribes, which provides 
permanent supportive housing in Indian areas to homeless and at risk of 
homelessness Native Veterans. The program currently serves 26 tribes 
with expansion expected in the next 6 months. VA provides case 
management and supportive services to promote tenancy in housing 
supported by HUD grant funding for rental assistance. VA case managers 
work with local resources and the appropriate VA employment programs to 
assist Native Veterans to access employment when appropriate for the 
Veteran.

    Program Highlights Through November 18, 2019:

   There were 350 Veterans housed in Tribal HUD-VASH. Estimates 
        of 500 units of rental assistance were provided by HUD's ONAP.

   20 of the 350 are graduates, meaning they no longer require 
        case management but continue to utilize the rental assistance 
        provided by Tribal HUD-VASH.

   26 more Veterans were approved by the Tribally Designated 
        Housing Entity (TDHE) waiting for or looking for housing.

   6 additional Veterans were referred to TDHEs for the TDHE to 
        determine if the Veteran met their eligibility requirements.

   1 further Veteran was admitted into Tribal HUD-VASH and was 
        in the initial case management to prepare for the TDHE 
        referral.

   363 Veterans were enrolled in case management in Tribal HUD-
        VASH.

    Staffing:

   26 total case managers are funded for Tribal HUD-VASH.

   25 are full-time-equivalent employee; 1 is through a 
        contract with the tribe's housing authority.

   22 case managers are on board.

   4 case managers are in the process of being hired with all 4 
        in the On-Boarding/Credentialing stage.

   All tribes where there are vacancies in the permanent staff 
        have temporary/interim case management.

    Question 4. Many Tribes participating in the HUD-VASH program are 
interested in building Veterans-specific housing. To support this goal, 
the National American Indian Housing Council (NCUIH) suggested the VA, 
HUD, and USDA could assist Tribal HUD-VASH grantees to take on these 
building projects by offering additional supports--e.g. leveraging the 
VA's direct loan and loan guarantee authorities. Has the VA met with 
HUD or USDA to discuss ways to support Tribal development of Veteran 
specific housing on reservations?
    Answer. VA works closely with HUD in the implementation and 
expansion of the Tribal HUD-VASH program. However, VA does not provide 
any funds or development loans or grants for the HUD-VASH program. 
Tribal HUD-VASH grantees are encouraged to consider project-basing 
their awards to renovate or construct housing opportunities to meet the 
needs of Tribal HUD-VASH. The HUD-VASH National Program Office is 
available to assist any HUD-VASH program with the process of project-
basing, which has to be done in partnership with the Public Housing 
Agency or in the case of Tribal HUD-VASH, TDHE, or Tribe. VA's Loan 
Guaranty Service has met with HUD and USDA on outreach efforts and to 
discuss best practices related to tribal Veteran homeownership. VA 
actively participates in tribal consultations to solicit feedback from 
Native American leaders on how to improve delivery of the Native 
American Direct Loan (NADL) benefit. In order to leverage VA's 
authority to develop Veteran specific housing on trust lands, tribal 
affiliates would need to work within the legislative confines of the 
NADL program. By statute, the VA NADL program was created to allow 
Native American Veteran borrowers to utilize their home loan benefit on 
Federal Trust land. See 38 United States Code (U.S.C.)   3761-3765. 
The program is designed to allow Native American Veterans the same 
opportunity that a Veteran who is purchasing on non-tribal lands would 
possess. Banks and mortgage companies often do not lend on Federal 
Trust land due to the inability to foreclose and sell the property in 
the case of default. Consequently, the NADL program was created to make 
loans to individual Native American Veterans who chose to purchase or 
build on tribal lands.

    Question 4a. Can Tribes use any of VA's direct loan or loan 
guarantee programs? Or, are these programs limited to use by individual 
Veterans only?
    Answer. Individual Veterans who are recognized by tribes may use 
either program dependent upon where they wish to live. A VA-guaranteed 
loan is made by lenders in the private market. The NADL program 
provides individual Native Americans Veterans direct loans to purchase 
or build a home on Federal Trust land. A Native American Veteran who 
desires to purchase a home on non-Federal Trust land may obtain a VA-
guaranteed loan. VA is not prohibited from guaranteeing loans for 
individual Native American Veterans who live on Federal Trust land. 
Most private lenders do not lend on Federal Trust land due to the 
complicated nature of foreclosing on properties if the loan goes into 
default. Investors have been historically hesitant to acquire these 
loans due to issues in obtaining clear title to the property. As a 
result, VA is unable to guaranty loans that lenders do not originate.

    Question 5. RADM Chris Buchanan testimony stated: ``When seeking 
treatment at a VA medical center, tribal Veterans currently are charged 
a copayment that the individual pays. Current law (25 USC 1621u) does 
not permit a provider, including VA, to impose financial liability on a 
patient pursuant to an authorized IHS PRC referral.'' Is the VA in 
compliance with the 25 USC 1621u when it assesses copayments on IHS 
patients referred to VA through IHS's PRC system? And, if not, under 
what statute does VA use to authorize its assessment of copayments on 
IHS patients referred to the VA through IHS's PRC system?
    Answer. If IHS refers an eligible Veteran to VA for hospital care 
or medical services, the care VA provides to the Veteran is authorized 
by title 38, U.S.C., and for some eligible Veterans, a copayment may 
apply. VA is required by law to charge copayments to certain Veterans 
who receive VA health care. See 38 U.S.C.   1710, 1710B, and 1722A. 
VA cannot exempt categories of Veterans from copayment requirements 
without authorizing legislation. Note that VA's regulations set forth 
the health care services that are not subject to copayment requirements 
and the categories of Veterans exempt from VA copayment requirements, 
to include Veterans with a service-connected disability rated 50 
percent or more and Veterans whose annual income is below the 
applicable threshold. See 38 C.F.R.   17.108(d)-(f), 17.110(c), 
17.111(f). VA and IHS are committed to working with the Office of 
Management and Budget to reconcile any conflict between the Indian 
Health Care Improvement Act and VA's Title 38 authority regarding the 
application of VA copayments.

    Question 6. GAO report 18-137 details how issues with VA's human 
resource data system contribute to an alarming lack of accountability 
for VA management. GAO is working on a similar review--at the request 
of this Committee--to look at the Indian Health Service's (IHS) 
management practices and procedures for addressing employee misconduct. 
Does the VA have a standard system for documenting and tracking reports 
of misconduct like patient endangerment or abuse?
    Answer. In October 2019, VA began using a new employee relations 
platform to track and manage all employee misconduct cases. This system 
will be mandated for use across the VA. The new system is a Commercial-
off-the-Shelf cloud-based solution that will allow the VA to track, 
manage, and report on employee relations cases that may lead to 
disciplinary action including removal of a VA employee. Some incidents 
involving alleged patient endangerment or abuse could fall in the 
category of employee misconduct and will be tracked by the new system.

    Question 6a. Has the VA's Chief Information Officer of human 
resources department ever met with their IHS counterparts to discuss 
the need for human resources IT modernization?
    Answer. VA's HR technology leadership has met with several agencies 
regarding the need for human resources IT modernization, including the 
Department of Health and Human Services (HHS); however, we have not met 
with an IHS counterpart. VA has met with the human resources IT 
leadership from HHS to discuss human resources IT and understand that 
HHS and IHS use the same human resources shared service provider. VA's 
communications with HHS, including IHS, are ongoing.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                          RADM Chris Buchanan
    Question 1. In your testimony, you stated: ``When seeking treatment 
at a VA medical center, tribal veterans currently are charged a 
copayment that the individual pays. Current law (25 U.S.C. 1621u) does 
not permit a provider, including VA, to impose financial liability on a 
patient pursuant to an authorized IHS PRC referral.'' Does IHS believe 
VA has the authority to assess copayments on IHS patients referred to 
VA through IHS's PRC system?
    Answer. The Indian Health Service (IHS) believes that 25 U.S.C.   
1621u prohibits a provider, including the Department of Veterans 
Affairs (VA), from assessing copayments on IHS patients referred to VA 
through the IHS Purchased/Referred Care (PRC) program. IHS and VA are 
committed to working with the Office of Management and Budget to 
reconcile the conflict between the Indian Health Care Improvement Act 
and VA's Title 38 authority.

    Question 2. The provision of law you cited (i.e., section 222 of 
the Indian Health Care Improvement Act) states that it is the 
responsibility of the Secretary of Health and Human Services to inform 
providers of this prohibition. If IHS believes VA does not have 
authority to access copayments on IHS patients with PRC referrals, has 
the Department communicated with the VA about the conflict between 
their practices and the Indian Health Care Improvement Act?
    Answer. Yes, IHS sent a letter dated October 15, 2013, to the VA 
Under Secretary for Health and have informally met with the VA about 
this conflict between the VA practices and the Indian Health Care 
Improvement Act. IHS and VA are committed to working with the Office of 
Management and Budget to reconcile the conflict between the Indian 
Health Care Improvement Act and VA's Title 38 authority.

    Question 3. GAO report 18-137 details how issues with VA's human 
resource data system contribute to an alarming lack of accountability 
for VA management. GAO is working on a similar review--at the request 
of this Committee--to look at the IHS's procedures for addressing 
employee misconduct. Does IHS have a standard system for documenting 
and tracking reports of misconduct like patient endangerment or abuse?
    Answer. In 2019, IHS released new professional standards and 
stronger requirements for IHS employees to report suspected sexual 
abuse and exploitation of children by health care providers (Indian 
Health Manual Part 3, Chapter 20), and as part of that new policy 
issued mandatory training for all IHS employees, contractors, and 
volunteers.
    IHS is implementing a new credentialing and privileging software 
(ASM Credentialing System) and new adverse events reporting software 
(Datix). The ASM Credentialing System and Datix replace existing 
systems that had limitations in their ability to efficiently operate in 
the current Indian health system. The IHS Office of Quality is leading 
the implementation and monitoring of these transitions.
    Credentialing and privileging of health care practitioners for 
medical staff membership is one of the most critical tasks of the 
Agency and is directly related to the quality of healthcare provided at 
IHS facilities. A strong credentialing and privileging policy and 
process decreases the potential for patient harm by verifying the 
training, competence, character, and ongoing successful clinical 
performance of its medical staff. The ASM Credentialing System allows 
us to better credential and privilege providers through use of industry 
leading software, auto and continuous verification, automated 
checklists, and digital documentation. The credentialing and 
privileging software provides information on a provider's malpractice 
history, prior adverse events, and physical and mental health.
    Availability of an adverse events reporting system is consistent 
with the Joint Commission (TJC), and Centers for Medicare and Medicaid 
Services (CMS) mandates that facilities have a mechanism to track 
adverse events. CMS rules require some provider types to assure that 
any incidents of abuse are reported and analyzed and appropriate 
corrective, remedial or disciplinary action occurs, in accordance with 
applicable law. The reporting of all adverse events, including sexual 
abuse, will be required to be entered into the Datix software.
    IHS is developing an employee relations tracking module using the 
ServiceNow technology that will increase the reporting and case 
management tracking of misconduct and performance issues across all IHS 
areas. This information will allow IHS the ability to identify 
training, resources, and other services that may be necessary to 
address critical needs. The go-live of this new module is scheduled for 
late spring/early summer 2020.

    Question 3a. Has IHS's Chief Information Officer or human resources 
department ever met with their VA counterparts to discuss the need for 
human resources IT modernization?
    Answer. The IHS Chief Information Officer (CIO) supports all 
business owners of software systems by ensuring the appropriate 
technical and IT security requirements are met to host the selected 
software on the IHS network. The IHS CIO is currently engaged with the 
VA with a specific focus on clinical and health IT modernization 
efforts.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Catherine Cortez Masto 
                         to RADM Chris Buchanan
    Question 1. What is the delta between eligible service members and 
those who are actually using their VA coverage? Do you have a state by 
state or regional (as defined by the Bureau of Indian Affairs) 
breakdown of those numbers? What specific actions is the VA taking to 
close that delta?
    Answer. Veterans identified in the IHS health record are self-
identified and the reporting is not mandatory and does not imply VA or 
Tricare eligibility. Some Veterans may not realize that they can self-
identify, and some may self-identify who might not qualify for 
veterans' benefits. While the IHS continues to collaborate with the VA 
on related issues, this question is more appropriate for VA to respond.

    Question 2. Of those veterans who have some other form of coverage 
outside of the VA, what type of coverage do they have, and what portion 
of tribal veterans have each type?
    Answer. According to IHS data regarding insurance coverage among 
individuals self-reporting as being veterans in the IHS user 
population, in 2018, 17.7 percent reported only having health care 
coverage from the VA, 24.2 percent had Medicaid coverage, 40.2 percent 
had Medicare Part A coverage, 31.8 percent had Medicare Part B 
coverage, and 49.8 percent had private insurance coverage. The sum of 
these percentages is more than 100 percent because a person may have 
more than one type of coverage. These numbers reflect coverage status 
for at least part of the year and may not be for the full year. These 
percentages based on IHS users' self-reported information may be 
inaccurate because beneficiaries self-identify as veterans, they may 
not be eligible for health services from VA, and many may not identify 
as veterans who are eligible for VA services. While the IHS continues 
to collaborate with the VA on related issues, this question is more 
appropriate for VA to respond.
                                 ______
                                 

    *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. Jestin Dupree
Addressing Old vs. Young Veteran Needs
    Question 1. The VA provides many diverse services to our nation's 
veterans--from healthcare to education and training to home financing 
assistance. Depending on a veteran's age, service needs often differ. 
For example, younger, post-9/11 veterans may need more assistance with 
child care and job training. Do you believe the VA sufficiently working 
with Tribes to serve the diverse needs of Native American veterans--
whether they just completed their military service or whether they've 
been retired for decades?
Partnering with Tribal Colleges
    Question 2. A 2015 report by VA's Office of Rural Health 
recommended that the VA find ways to partner with Tribal Colleges and 
Universities (TCUs) to better serve Native veterans--especially those 
young Native veterans returning from recent conflicts. However, the 
same 2015 report also indicated that information on the VA's 
collaboration with TCUs is extremely limited.

        a. Are you aware of any collaboration efforts between the VA 
        and Fort Peck Community College?

        b. Do you believe the VA should do more to partner with TCUs?