[Senate Hearing 116-269]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 116-269
                        NATIVE COMMUNITIES AND S. 3650



                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE


                             SECOND SESSION


                              JULY 1, 2020


         Printed for the use of the Committee on Indian Affairs


41-422 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
     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

Hearing held on July 1, 2020.....................................     1
Statement of Senator Barrasso....................................     4
Statement of Senator Cantwell....................................    25
Statement of Senator Cortez Masto................................    32
Statement of Senator Daines......................................    30
Statement of Senator Hoeven......................................     1
Statement of Senator Lankford....................................    34
Statement of Senator McSally.....................................    27
Statement of Senator Moran.......................................     9
Statement of Senator Murkowski...................................     5
Statement of Senator Schatz......................................     6
    Prepared statement...........................................     7
Statement of Senator Smith.......................................     8
Statement of Senator Tester......................................     5
Statement of Senator Udall.......................................     3


Davis, Scott J., Executive Director, North Dakota Indian Affairs 
  Commission, Office of The Governor, State of North Dakota......    41
    Prepared statement...........................................    42
Elgin, Lisa, Secretary, National Indian Health Board.............    43
    Prepared statement...........................................    44
Fenton, Jr., Robert J., Regional Administrator, Region 9, Federal 
  Emergency Management Agency, U.S. Department of Homeland 
  Security.......................................................    14
    Prepared statement...........................................    16
Weahkee, Hon. Rear Admiral Michael D., Director, Indian Health 
  Service, U.S. Department of Health and Human Services..........    10
    Prepared statement...........................................    12


Allis, Kevin J., CEO, National Congress of American Indians, 
  prepared statement.............................................    68
Brown, Hon. Coly, Chairman, Winnebago Tribe of Nebraska, prepared 
  statement......................................................    62
Cawston, Hon. Rodney, Chairman, Confederated Tribes of the 
  Colville Reservation, prepared statement.......................    74
Friend, Hon. Billy, Chief, Wyandotte Nation, prepared statement..    73
Letters, submitted for the record 

Lucero, Esther, CEO, Seattle Indian Health Board, prepared 
  statement......................................................    69
Papa Ola Lokahi (POL), prepared statement........................    65
Response to written questions submitted to Robert J. Fenton, Jr. 
    Hon. Lisa Murkowski..........................................    83
    Hon. Tom Udall...............................................    81
Response to written questions submitted to Hon. Rear Admiral 
  Michael D. Weahkee by:
    Hon. Martha McSally..........................................    95
    Hon Lisa Murkowski...........................................    92
    Hon. Jon Tester..............................................    94
    Hon. Tom Udall...............................................    84
Robert Wood Johnson Foundation (RWJF), prepared statement........    76
Rupnick, Sr., Hon. Joseph, Prairie Band Potawatomi Nation, 
  prepared statement.............................................    63
Sunday-Allen, Robyn, Vice President, National Council of Urban 
  Indian Health (NCUIH), prepared statement......................    61

                      EVALUATING THE RESPONSE AND 


                        WEDNESDAY, JULY 1, 2020

                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:36 p.m. in room 
562, Dirksen Senate Office Building, Hon. John Hoeven, 
Chairman of the Committee, presiding.


    The Chairman. Good afternoon. We will call this oversight 
and legislative hearing to order.
    Before we begin, I want to remind those members who are 
connecting with us remotely to please mute your microphone. 
This will cut down on the static feedback in the hearing room.
    The Committee will receive testimony today from two 
Administration and two tribal witnesses on evaluating the 
response and mitigation to the COVID-19 pandemic in Native 
communities. The Indian Health Service witness will also 
provide testimony on S. 3650, the Coverage for the Urban Indian 
Public Health Providers Act. This bill will get us to a total 
of eight bills in two weeks that we have taken testimony on in 
Committee . I certainly look forward to marking up these bills 
and moving them to the Floor in the coming weeks.
    Today, tribal communities are experiencing some of the 
highest rates of infection for COVID-19 in the Country. The 
Indian Health Service recently reported more than 19,000 
positive cases in the 12 service areas. Data also shows that at 
least five Indian tribes such as the White Mountain Apache, the 
Pueblo of Zia, the Pueblo of San Felipe, the Navajo Nation, and 
the Kewa Pueblo, have had higher cases per capita, outpacing 
States like New York, New Jersey, Massachusetts and some 
    Additionally, the Centers for Disease Control and 
Prevention states that American Indians and Alaska Native are 
in a racial and ethnic minority group at an increased risk of 
contracting COVID-19 or experiencing severe illness, regardless 
of age. American Indian and Native American persons have a 
hospitalization rate five times that of non-Hispanic White 
    Because of these higher rates, Native communities have 
taken needed measures to limit exposure and protect their 
people, instating curfews, or shelter in place orders. Opening 
drive-through testing locations, closing non-essential 
businesses, ceasing tourism and other revenue-generating 
activities and switching schools to virtual platforms to 
provide necessary education to students are examples of how 
tribes are taking action and limiting the spread of infection 
from reaching more into their communities.
    In my home State of North Dakota, the first reported case 
of COVID-19 was on March 11th, 2020. I can say that all the 
communities across the State have taken measures to protect 
their residents against the coronavirus. One of the larger 
reservations in my home State is the Mandan Hidatsa and Arikara 
Nation. They have provided a live community impact dashboard 
that updates COVID-19 cases found on their lands.
    This community ahs experienced 42 confirmed cases, causing 
the tribe to take protective measures, such as devising a 
policy that penalizes members for violating quarantine orders. 
We should take a moment to acknowledge those law enforcement, 
first responders, and medical personnel risking their health to 
protect and care for those affected by the pandemic. Thank you 
all for your tireless work that is helping so many.
    As the Country knows, there is no vaccine to protect a 
person against this respiratory illness. But work will continue 
toward finding one. Congress will continue to fulfill the trust 
and treaty obligations to Indians. Through various funding 
authorized by Congress so far the Indian Health Service has 
allocated approximately $2.4 billion to address COVID-19 needs.
    Today's hearing will provide the Committee with an 
understanding of what both the Indian Health Service and 
Federal Emergency Management Agency is doing to mitigate and 
prevent more cases of COVID-19 appearing in Native communities. 
Specifically, I am interested to learn what is working well and 
where improvements can be made by reaching more rural 
communities, especially the tribal communities, who have less 
access to resources than may be available in urban areas.
    We are also interested in what lessons have been learned 
from both IHS and FEMA during this pandemic. The Committee is 
committed to understanding how the interactions between the IHS 
and FEMA are being coordinated during the COVID-19 pandemic 
    I am also pleased to see Mr. Scott Davis, Executive 
Director of the North Dakota Commission on Indian Affairs here 
today, testifying on panel two. Scott works tirelessly for the 
five Indian tribes in North Dakota, and is a former All-
American marathon runner at Haskell Indian School. He was also 
a great basketball player. I have watched him play basketball. 
He was very good at that. Good athlete. And he is an 
outstanding Commissioner for Indian Affairs in North Dakota.
    Moving on to the legislative agenda of today's hearing, on 
May 7th, 2020, Senators Tina Smith and James Lankford 
introduced S. 3650, the Coverage for the Urban Indian Health 
Providers Act. Senators Udall, McSally, Harris, Feinstein, 
Sinema, Moran, Tester, and Warren also have joined as co-
sponsors. This bipartisan bill amends the Indian Health Care 
Improvement Act to provide parity to the Indian Health System, 
which is made up of the Indian Health Service, tribal health 
programs, and urban Indian organizations.
    S. 3650 expands the Federal Torts Claim Act coverage to 
Urban Indian Organizations. More than 70 percent of American 
Indians and Alaska Natives live in urban areas throughout the 
Country. Urban Indian Organizations are able to provide 
culturally competent care to Natives living in these urban 
    Currently, Urban Indian Organizations are not offered 
protections that are already provided to the IHS and tribal 
health program employees. UIOs spend critical dollars on 
malpractice liability insurance for employees and volunteers, 
rather than putting these resources toward health care.
    Before we move to our witnesses, I want to turn to Vice 
Chairman Udall for his opening statement.

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

    Senator Udall. Thank you, Chairman Hoeven, for calling 
today's hearing.
    Over the last several months, our Nation has faced a 
convergence of major and seemingly unprecedented challenges; a 
global pandemic and economic crisis and flagrant systemic 
injustice. In examining the Federal response to these crises, 
it is clear that the Administration ignored the warning 
    But for Indian Country and other communities of color, the 
lack of Federal public health preparedness and the resulting 
economic freefall were not unprecedented. In fact, they were 
predictable and they were avoidable. We know that Native 
populations in the U.S. experience morbidity and mortality 
rates four times greater than non-Native populations in 
previous pandemics.
    Tribal economies are particularly vulnerable to economic 
shocks and downturns in that in matters of housing, health 
care, education, and justice, American Indians, Alaska Natives 
and Native Hawaiians were too often left behind. We know this 
because for years, tribal leaders, Native organizations and 
witnesses have testified before this Committee that Federal 
policies and failures have exacerbated health disparities, 
economic barriers, and institutional inequities.
    I understand that this is an uncomfortable truth for us to 
grapple with. But we in Congress should not be surprised by 
reports that the Indian Health Service, tribe and urban Indian 
clinics have faced challenges securing personal protective 
equipment and testing supplies when we knew that they did not 
have access to the Strategic National Stockpile, and that they 
were excluded from most Federal public health emergency 
preparedness planning.
    We should not be surprised by testimony that Indian Country 
has struggled to navigate the bureaucratic maze of COVID-19 
programs when we knew that many agencies had little to no 
meaningful engagement with tribes prior to this pandemic. And 
we should not be surprised that tribes' ability to access 
Federal assistance and resources depends largely on how good 
their relationship is with their State government, which 
Federal official they are working with, or which agency region 
they are located in, not when we knew that Federal practices 
lack consistency and policies favor State pass-through models.
    I have been fighting alongside tribes to address these very 
same issues since I first arrived in Congress. Many of you on 
this Committee have been fighting right alongside with me. But 
as we have been so humbly reminded by this pandemic, there is 
much yet to be done. That is why today's hearing is so 
important. Congress and the Administration must take a good, 
hard look in the mirror and see where we are still falling 
short. That includes the Treasury Department, which has barely 
got critical tribal CARES Act funding out the door, 50 days 
beyond the statutory deadline. That is twice as long as 
Congress intended, causing what a court determined to be 
irreparable harm to tribal governments in their fight against 
coronavirus. Whether it is the IHS or Treasury, the 
Administration must do better.
    Admiral Weahkee and Administrator Fenton, I hope you will 
commit to taking the feedback you receive back to your 
departments and work with your leadership to act on it. And I 
hope that this Committee can work together to address these 
statutory barriers and resource gaps for Native communities 
without further delay.
    Senator Smith's bill, which we are considering today, is an 
excellent example of the type of practical, bipartisan solution 
we should all be pushing. This bill not only creates parity 
with the IHS system, but also helps urban Indian health 
programs reduce operating costs due to COVID-19 related budget 
shortfalls. I am proud to be co-sponsor of her work on this 
    I will close by saying that despite the challenges that 
remain before us, I am dedicated to standing with all American 
Indians, Alaska Natives and Native Hawaiians. I am hopeful that 
the Senate will be able to work together and replicate the 
historic wins we have achieved for Native communities in the 
first set of coronavirus relief packages.
    Thank you again, Mr. Chairman, for this hearing. Thank you 
to our witness for joining us for this very important 
    The Chairman. Thank you, Vice Chairman Udall. We do have 
some opening statements. We will begin with Senator Barrasso.

                   U.S. SENATOR FROM WYOMING

    Senator Barrasso. Thank you very much, Mr. Chairman, for 
holding this important hearing today.
    As you know, when I was chair of this Committee , I 
frequently spoke about my friends in Wyoming, the Wind River 
Reservation, the Northern Arapahoe, and the Eastern Shoshone 
Tribes. Yesterday I had a chance to visit at length with the 
leadership of the Northern Arapahoe Tribe. As Senator Udall 
said, there was a delay in getting some of the money out. There 
was an initial 60 percent went out, but it took a long time to 
get that second amount. The Northern Arapahoe have gotten that 
$27 million to which they say they are grateful for what we 
have done as part of the CARES Act.
    As both of you have said, the impacts of this disease on 
our tribes is disproportionately high. In Wyoming, we have had 
20 deaths, half of them from the Northern Arapahoe Tribe. So 
when you take a look at those numbers and this disproportionate 
price that they have paid, I think it is very important for us 
to have this hearing today and to hear from our experts and 
continue to ask probing questions and see what more we can do.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Barrasso.
    Senator Tester will give an opening statement remotely.

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

    Senator Tester. Thanks for having this hearing, Chairman 
Hoeven. Look, Indian Country, it has already been said today, 
has been disproportionately impacted by COVID. They face unique 
challenges in this pandemic in their communities. That is why 
it is so very critical that the Federal Government uphold their 
trust and treaty responsibilities and provide Native 
communities the resources they need to address this crisis.
    As a result, quite frankly, of underfunding and lower 
reimbursement levels, many Indian health facilities across 
Indian Country have limited their services for caring, and even 
individuals impacted by COVID. So being able to refer patients 
to another facility during this pandemic has been critical for 
Indian health care providers, to be able to provide adequate 
care to Native folks.
    Having increased revenues as a result of things like 
Medicaid expansion has been critical for Indian health care and 
the facilities that serve them. Yet quite frankly, the Trump 
Administration is moving full steam ahead to dismantle the 
Affordable Care Act.
    The bottom line is this: there is a big problem in Indian 
Country. In Montana, they are seeing COVID infection at about 
twice the rate they should, and quite honestly, we need to step 
up to make sure that the money we have appropriated is getting 
to them, and making sure they have what they need to be able to 
come back from this horrible virus.
    With that, I look forward to the testimony. I look forward 
to the questions thereon.
    The Chairman. Thank you, Senator Tester.
    We will turn to Senator Murkowski.

                    U.S. SENATOR FROM ALASKA

    Senator Murkowski. Thank you, Mr. Chairman, and to our Vice 
Chairman, thank you for a very important hearing. I think we 
look to the impacts of COVID-19 on different sectors. We have 
certainly had many hearings in the Energy Committee on how this 
pandemic has impacted different parts of our economy and the 
people. There is probably nothing more important that we can be 
doing here in this Committee than looking to the impacts to our 
American Indians, Alaska Native and Native Hawaiians, on 
vulnerable populations, and as the statistics have been shared, 
they are troubling in terms of how we see the health 
disparities reflected when you have something like a COVID 
virus impacting.
    In Alaska, we have been, I won't say lucky, because luck 
has nothing to do with the fact that we have been able to keep 
our number of cases very low. What we have done in many of the 
communities, primarily our Alaska Native remote communities, is 
they have voluntarily shut themselves off from the rest of the 
world. They have said, we do not want travelers in here, we do 
not want the mail plane to come in here, we don't want the 
plane that is going to be delivering fresh goods for the 
grocery store, because we are so concerned about how this virus 
may repeat history, do a repeat from the 1918 flu, the Spanish 
flu, that wiped out many Alaska Native villages. Natives around 
the state today remain fearful of just that impact.
    So the efforts that have been made to keep the virus out 
have been considerable. They have been aggressive, and they 
have been expensive. So the funding for the CARES Act to help 
offset this is very, very important.
    I do think it is also important to recognize that we all 
want to see these funds dispersed to the villages, to our 
tribes, and do so in a manner that is consistent with what we 
outlined in CARES, but also quickly. It was unfortunate that we 
saw litigation delay the initial distributions of these funds, 
and are still delaying some portions of the CARES Act funding, 
all over a dispute that we felt we had made very, very clear 
when we enacted CARES, that those who would be eligible for 
this CARES Act funding would be our tribes, and the tribes 
would include, in Alaska's case, our Alaska Native 
    With the recognition of the complexity of the laws and 
impacts with how Alaska Natives are addressed and treated under 
ANSCA, and our Federal laws, we do not have reservations in 
Alaska. Our statuses are different when it comes to Alaska 
Native peoples. And it is an overlay of organizations, tribal 
health organizations, our tribes, our Native villages, our 
Native corporations. It is complex. And I think it is important 
to understand how all of these entities together, working 
together, are pulling the weight to respond to this impact of 
    I didn't intend, Mr. Chairman, to make more than a minute 
statement, but I felt it was important to outline to colleagues 
that yes, we all share the same goal here. We want to get this 
much-needed funding out to our tribes across the Country. We 
will do so. But we have to ensure that they are done in a fair 
way so that those costs that have been associated with this 
pandemic are reimbursed and reimbursed fairly and fully.
    With that, I am looking forward to the testimony this 
afternoon, and to direct some questions, primarily about where 
we are with water and wastewater when it comes to Admiral 
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Murkowski. Now we will 
turn to Senator Schatz.

                    U.S. SENATOR FROM HAWAII

    Senator Schatz. Thank you, Mr. Chairman, and Vice Chairman, 
for scheduling this hearing. I want to follow up on what 
Senator Murkowski said. It is important for us all to take a 
breath and to remember the tradition of the Committee on which 
we all serve. It has a tremendous, decades-long tradition of 
bipartisanship. But not only about bipartisanship, but a sense 
that all Native peoples hang together, that Alaska Natives, 
American Indians, and Native Hawaiians hang together.
    With the unfortunate situation of the deployment of the 
funds to Alaska being delayed as a result of litigation and a 
misinterpretation of the statute, we also need to remember that 
in the final throes of the negotiation over the CARES Act, that 
the dollars we are actually talking about were characterized as 
a sort of Democratic ask, something that had to be negotiated 
for, on behalf of Democrats. I don't think that is the 
tradition of this Committee. I don't think that is the way we 
want to move forward.
    So as we look at July and we look at another traunch of 
Federal funding for keeping people alive and keeping some 
semblance of an economy going, including Native people 
everywhere across the United States, we should remember that we 
all must hang together, Democrat and Republican, Native 
Hawaiian, Alaska Native, and American Indian. I am very, very 
hopeful that with the Chairman's leadership, we are going to be 
able to do just that.
    Thank you very much.
    [The prepared statement of Senator Schatz follows:]

   Prepared Statement of Hon. Brian Schatz, U.S. Senator From Hawaii
    Thank you Chairman Hoeven and Vice Chairman Udall for scheduling 
this hearing. Bipartisan and bicameral efforts to support native 
communities are more important than ever. The COVID-19 outbreak 
continues to rage and it's disproportionately impacting the lives of 
American Indians, Alaska Natives, and Native Hawaiians.
    Today we will receive testimony from the administration, a national 
native health organization, and a state commission on Indian affairs. 
We are seeking to understand two things:
    First, whether the authorizations and supplemental funding provided 
to tribes and native communities in previous coronavirus response bills 
were effective.
    And second, what additional legislative actions are needed to 
improve implementation, address urgent needs, and speed recovery.
    Chairman Hoeven, I request that the remainder of my opening 
statement be entered into the record so that we can move forward to the 
witness panels more quickly.
    The disproportionate health, economic and social burdens faced by 
native communities are not new. But the COVID-19 pandemic is shining a 
light on funding deficits and glaring shortcomings in access to health 
care, clean water, sanitation facilities, safe housing, and other basic 
    Native Hawaiians are at risk:

   They have the shortest life expectancy of the major ethnic 
        groups in Hawaii;

   They are more likely to have an underlying medical 
        condition, such as coronary disease, diabetes, asthma or COPD, 
        making COVID-19 a greater health threat; and

   Native Hawaiians also make up half of the homeless 
        population on the island of Oahu alone. They are also more 
        likely to live in overcrowded housing conditions, making 
        compliance with social distancing guidelines difficult.

    I have attached several documents produced by the Office of 
Hawaiian Affairs and Papa Ola Lokahi as an addenda to my remarks to 
provide additional data on the status of Native Hawaiians. *
    * The information referred to is in the hearing appendix.
    As one of the United States' indigenous peoples, who formed a 
government prior to our own and exercised sovereignty over lands that 
are now part of the state of Hawaii, we accord Native Hawaiians a 
unique legal and political status. The U.S. has a trust responsibility 
to Native Hawaiians and more than 200 laws have been enacted in 
furtherance of the special trust relationship.
    I fully support S. 3650, a bill introduced by Senator Smith and 
other SCIA colleagues to extend Federal Tort Claims Act (FTCA) coverage 
for urban Indian health providers, and I also support parity in 
treatment for Native Hawaiian Health Care Systems (NHHCS) providers.
    Just as the Congress passed the Indian Health Care Improvement Act 
to authorize funding and programs for the Indian Health Service, 
tribes, and to extend health care services for Native Americans living 
in urban areas, the Native Hawaiian Health Care Improvement Act was 
enacted to authorize funding and programs for Native Hawaiians. 
Extending FTCA coverage to the Native Hawaiian Health Care Systems 
would ensure that these health care centers can focus all of their 
scarce resources on providing patient care.
    According to the American Community Survey of 2017, the Native 
Hawaiian population in Hawaii was approximately 300,000, and the 
American Indian and Alaska Native population was approximately 36,274. 
Given a prospective service population this large, the Native Hawaiian 
Health Care Systems need relief from paying expensive insurance 
premiums so that they can grow their capacity to serve the health care 
needs of more Native Hawaiian families.

    The Chairman. Thank you, Senator Schatz. And we will turn 
to Senator Smith.

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

    Senator Smith. Thank you, Mr. Chair and Ranking Member. I 
am really glad to have this hearing today.
    It is a good time for us to take a look at what has 
happened with COVID-19 in Indian Country. I very much 
appreciate Senator Schatz's comments as we think about how we 
work in a bipartisan way to make sure that our treaty and trust 
responsibilities as the Federal Government are upheld 
    Mr. Chair, I have to say that I note, based on the 
witnesses that we have today that we won't have an opportunity 
to speak with anybody at Treasury today about Treasury's 
implementation and disbursement of the funds. I know that this 
is an issue that I can tell has been a concern for both my 
Republican and my Democratic colleagues. So I hope that we will 
have an opportunity to talk with somebody at Treasury and 
understand better what happened and how we can make sure that 
it doesn't happen in the future, as our American Indians and 
Alaska Natives and Native Hawaiians had to wait so long for 
these funds that they needed so desperately.
    I want to lift up one issue which is very important to 
Minnesota tribes, which is as grateful as they are to have this 
CARES Act funding, as I know everybody on this Committee 
understands, these dollars cannot be used to displace the lost 
revenue that tribes have experienced because of their voluntary 
decision to shut down tribal enterprises. This has resulted not 
only in dramatic increase in unemployment on tribal nations, 
but also dramatic decreases in government revenue, as a result.
    So I hope this is something that we can all work on 
together in this Committee , Republicans and Democrats 
together. Because this issue would haunt tribal nations and 
people everywhere in this Country unless we are able to address 
    Thank you, Mr. Chair.
    The Chairman. Thank you, Senator Smith.
    Now we will turn to our witnesses, beginning with the----
    Senator Moran. Mr. Chairman?
    The Chairman. Yes?
    Senator Moran. It is Senator Moran.
    The Chairman. Oh, Senator Moran. Would you like to make an 
opening statement? Go ahead.

                    U.S. SENATOR FROM KANSAS

    Senator Moran. I would, thank you. Chairman Hoeven and Vice 
Chairman Udall, thank you for conducting this important 
hearing. You were kind enough to allow me to make opening 
remarks, because I chair the Senate Veterans Affairs which will 
begin when I get there, I guess, but begin at 3:00. I did not 
want to miss the opportunity to express my view of how 
important this hearing is, and how important the topic is to 
make certain that we are doing what we should be doing in 
regard to tribes and Native Americans.
    I also would commend Senator Tina Smith and our colleague 
Senator Lankford for the bill that is being discussed today. I 
am a co-sponsor of that bill, and I look forward to seeing it 
pass the Senate and become law.
    I mentioned that I am on my way to chair a Veterans Affairs 
committee, and I wanted to highlight the role the Department of 
Veterans Affairs plays in regard to Native American health 
care, both because many Native Americans are veterans 
themselves, but also the fourth mission of the Department of 
Veterans Affairs is to assist the rest of the Country, non-
veterans, in times of health care crisis. Senator Tester, the 
ranking member of the Committee that I chair, and I have had 
weekly telephone conferences with Dr. Stone, the Director of 
Health Care at the VA, and the Secretary of the Department, 
Secretary Wilkie. In almost every weekly phone call, the 
conversation has involved the role that the Department of 
Veterans Affairs is playing in caring for the health care and 
well-being of Native Americans.
    The tribes in Kansas certainly have not been without their 
challenges related to COVID-19. But I am greatly concerned by 
what is happening in places outside my State as well. I have 
advocated to ensure that our tribes are remembered in the 
relief packages that are passed by Congress, and I intend to be 
active and engaged in the efforts as we look at what a Phase 
four package might entail as well.
    Mr. Chairman, I will not be here to ask the necessary 
questions, but I will pay attention to the results of this 
hearing, because it will inform what direction we should 
proceed in that regard. If I was present, I would highlight the 
importance of broadband and internet for delivering services on 
tribal lands and to Native Americans, but to all Americans, as 
we have seen COVID-19 demonstrate the importance of tele-health 
and tele-education.
    I also am remiss in not being able to hear the testimony of 
the North Dakota Executive Director of the Indian Affairs 
Commission. You highlighted that he is a Haskell graduate. 
Haskell of course is in Lawrence, Kansas. Every time I meet or 
hear of a Haskell grad, I take great pride in their success and 
the time that they spent in my home State.
    Mr. Chairman, thank you for the opportunity to join you for 
this brief moment. I look forward to hearing the results of 
your hearing, so that we can act appropriately on behalf of 
tribes and Native Americans.
    Thank you.
    The Chairman. Thank you, Senator Moran. I will pause for 
just a moment, if there is anyone else who is attending 
remotely who wants to give an opening statement.
    Hearing none, then we will go forward with our witnesses. 
First, we have the Honorable Rear Admiral Michael D. Weahkee. 
He is the Director of the Indian Health Service, U.S. 
Department of Health and Human Services. After he testifies, he 
will be followed by Mr. Robert Fenton, Jr., Regional 
Administrator, Region 9, Federal Emergency Management Agency, 
U.S. Department of Homeland Security, Washington, D.C.
    With that, Rear Admiral Weahkee, please proceed.


    Mr. Weahkee. Good afternoon, Mr. Chairman, Vice Chair 
Udall, and members of the Committee . Thank you for the 
opportunity to testify on the Indian Health Service's efforts 
to respond to and mitigate the coronavirus pandemic, as well as 
on S. 3650, Coverage for the Urban Indian Health Providers Act.
    Let me start with a few comments on S. 3650. I am pleased 
to mention that the IHS endorses the policy to extend Federal 
Tort Claims Act coverage to UIOs, which is consistent with our 
fiscal year 2021 budget request. However, IHS does prefer 
formulating the coverage extension as part of the statutory 
section of the Public Health Service Act, where the other 
various similar extensions are located. This is noted in my 
written statement.
    Now I will transition to our COVID-19 response. Over the 
past several months, the IHS has worked closely with our tribal 
and urban Indian organization partners, with State and local 
public health officials, and with our fellow Federal agencies 
to coordinate a comprehensive, all of government, public health 
response to this pandemic.
    Throughout our efforts, our number one priority has been 
the health and safety of our IHS patients and our staff. While 
the Indian health system is large and complex, we realize that 
preventing, detecting, treating, and recovering from COVID-19 
requires collaboration and local expertise. We continue to 
participate in regular conference calls with our tribal and 
Urban Indian Organization leaders from across the Country to 
provide updates, answer their questions, and to hear their 
concerns and engage in rapid tribal consultation in Urban 
Confer sessions, so that we can inform our COVID-19 funding 
distributions and meet the needs of Indian Country.
    I am grateful to Congress for supporting our efforts 
through several supplemental appropriations that have enabled 
the Indian Health Service to allocate $2 billion to our IHS, 
tribal, and urban Indian health program partners to prepare for 
and respond to the Coronavirus. We are detecting COVID-19 
through screening and state of the art lab testing.
    Through White House-led testing initiatives, we have 
distributed, or are in the process of distributing, a total of 
470 Abbot ID NOW test analyzers, and hundreds of thousands of 
testing supplies for various testing platforms. Our IHS 
National Supply Service Center has distributed over 60 million 
units of personal protective equipment and other Coronavirus 
related supplies, including 1.7 million testing swabs and 
transport media.
    In my written testimony, I provided data on our resting 
statistics as of June 7th, in which we had performed 157,980 
tests, which equaled 9.5 percent of our user population, 
exceeding the U.S. all races testing rate. But we do have up to 
date information that we can provide to the Committee as these 
numbers do change on a daily basis.
    We are treating each and every patient with culturally 
competent, patient-centered, relationship-based care as we look 
to recover from COVID-19. The IHS is supporting the emotional 
well-being and mental health of our workforce and the 
communities we serve, providing services that draw from a long 
history of cultural resilience among our American Indian and 
Alaska Native communities.
    In June, the IHS announced a new critical care response 
team of expert physicians, nurses, and other health care 
professionals. This mobile team is providing urgent, life-
saving medical care for COVID-19 patients and conducting hands-
on clinical education.
    HHS has also provided the Indian Health Service with access 
to 20,000 doses of remdesivir, that is being supplied to 
patients in both our Federal and tribal hospitals across the 
Country. Remdesivir is an investigational anti-viral medicine 
that has shown progress in shortening the recovery time in some 
    In April, the IHS expanded use of an agency-wide video 
conferencing platform that allows for tele-health on almost any 
device and in any setting, including in our patients' homes. 
Since this expansion, the IHS has experienced a greater than 
11-fold increase in the use of tele-health from roughly 75 
visits to week to now an average of over 907 visits per week. 
Our health care professionals are also providing a great deal 
of care over the telephone.
    We look forward to continuing our work with tribal and 
Federal partners as the Country moves forward toward phased 
reopening and recovery. We strongly encourage everyone to 
continue to follow CDC guidelines and instructions from their 
local, State, and tribal governments, to prevent the spread of 
COVID-19 and protect the health and safety of our communities.
    Before I close, I just wanted to highlight a few recent 
trips that I have made to the Navajo, Bemidji, and Phoenix 
areas, where I observed powerful and uplifting examples of 
collaboration during my visits to several area health 
facilities. I met with Navajo Nation President Jonathan Nez, 
and Oneida Nation Tribal Chairman Tehassi Hill, to hear 
directly about their challenges combating COVID-19. I am 
grateful for the strong leadership displayed by our tribal 
partners in working alongside Federal and State partners to 
ensure the safety and well-being of American Indian and Alaska 
Native communities.
    In closing, I want to acknowledge and thank our entire 
Indian Health Service team, including those on the front lines 
treating our patients, and others in supportive roles that have 
demonstrated profound commitment in raising the physical, 
mental, social, and spiritual health of American Indians and 
Alaska Natives to the highest level during this unprecedented 
time. I am extremely proud of their hard work to combat COVID-
19. I consider myself fortunate to work alongside such a truly 
committed and dedicated workforce.
    Thank you again for the opportunity to speak with you here 
today. I appreciate your continued partnership and engagement 
while we work together to combat the Coronavirus epidemic.
    Thank you.
    [The prepared statement of Rear Admiral Weahkee follows:]

 Prepared Statement of Hon. Rear Admiral Michael D. Weahkee, Director, 
  Indian Health Service, U.S. Department of Health and Human Services
    Good afternoon Chairman Hoeven, Vice Chairman Udall, and Members of 
the Committee. Thank you for the opportunity to testify on the Indian 
Health Service's (IHS) efforts to respond to and mitigate the 
Coronavirus pandemic, as well as on S. 3650, Coverage for the Urban 
Indian Health Providers Act.
Responding to and Mitigating the Coronavirus Pandemic
    Over the past several months, the IHS has worked closely with our 
tribal and Urban Indian Organization (UIO) partners, state and local 
public health officials, and our fellow Federal agencies to coordinate 
a comprehensive public health response to the pandemic. Throughout our 
efforts, our number one priority has been the safety of our IHS 
patients and staff.
    While the Indian health system is large and complex, we realize 
that preventing, detecting, treating, and recovering from COVID-19 
requires local expertise. We continue to participate in regular 
conference calls with tribal and UIO leaders from across the country to 
provide updates, answer questions, and hear their concerns. In 
addition, IHS engages in rapid Tribal Consultation and Urban Confer 
sessions in advance of distributing COVID-19 resources to ensure that 
funds meet the needs of Indian Country.
    I am grateful to Congress for supporting our efforts through the 
passage of the Coronavirus Preparedness and Response Supplemental 
Appropriations Act, 2020; the Families First Coronavirus Response Act; 
the Coronavirus Aid, Relief, and Economic Security (CARES) Act; and the 
Paycheck Protection Program and Health Care Enhancement Act. These laws 
have provided additional resources, authorities, and flexibilities that 
have permitted the IHS to administer nearly $2 billion to IHS, tribal, 
and urban Indian health programs to prepare for and respond to 
Coronavirus. These resources have helped us expand available testing, 
public health surveillance, and health care services. Moreover, they 
support the distribution of critical medical supplies and personal 
protective equipment in response to the pandemic. In addition, the $500 
million distributed by the Department of Health and Human Services 
(HHS) from the Provider Relief Fund to IHS, tribal, and urban Indian 
health programs will help providers in American Indian and Alaska 
Native communities recover lost revenue, and provide Coronavirus-
related health care services. All of these resources make a real 
difference in helping to fulfill our IHS mission as we continue to work 
with tribal and UIO partners to deliver crucial services during the 
    The IHS continues to play a central role as part of an all-of-
nation approach to prevent, detect, treat, and recover from the COVID-
19 pandemic. We are partnering with other Federal agencies, states, 
tribes, tribal organizations, universities, and others to deliver on 
that mission. We protect our workforce through education, training, and 
distribution of clinical guidance and personal protective equipment. We 
also protect our tribal communities through supporting tribal leaders 
in making their decisions about community mitigation strategies that 
are responsive to local conditions, and to protect the health and 
safety of tribal citizens as those communities make plans to safely 
return to work.
    We are detecting COVID-19 through screening and state-of-the-art 
lab testing. Through White House-led testing initiatives, we have 
distributed, or are in the process of distributing, a total of 350 
Abbot ID NOW rapid point-of-care analyzers, as well as hundreds of 
thousands of testing supplies for various testing platforms. The IHS 
National Supply Service Center has also distributed over 60 million 
units of personal protective equipment and other Coronavirus response 
related products, including 1.7 million testing swabs and transport 
media. As of June 7, we have performed 157,980 tests in our American 
Indian and Alaska Native communities, which equates to 9.5 percent of 
our user population, exceeding the U.S. all-races testing rate, and the 
testing rate of most states and foreign nations. Of those tests, 13,165 
(9.3 percent) have been positive, with large geographic variation from 
as much as 23.3 percent in the hard-hit Navajo Area, to less than 0.3 
percent in the Alaska Area.
    We are treating each and every patient with culturally competent, 
patient-centered, relationship-based care. As we look to recovery from 
COVID-19, the IHS is supporting the emotional well-being and mental 
health of its workforce and the communities we serve, providing 
training, education, and access to treatment that draws from our faith 
and traditions and a long history of cultural resilience among American 
Indians and Alaska Natives.
    Earlier this month, the IHS announced a new Critical Care Response 
Team of expert physicians, registered nurses, and other health care 
professionals that will be available on an as needed basis.
    This team will provide urgent lifesaving medical care to COVID-19 
patients admitted to IHS or tribal hospitals. These expert medical 
professionals will conduct hands-on clinical education while treating 
patients and expanding capacity. They will also train the frontline 
health care professionals on the most current information available for 
the management of COVID-19 patients, and other critically ill patients. 
The critical care response team can be mobilized and at the bedside of 
the patient within 24-48 hours' notice.
    Earlier in May, we began distributing remdesivir to IHS federal and 
tribal hospitals based on requests and current burden of patients with 
COVID-19 who are hospitalized or in an ICU. Remdesivir is an 
investigational antiviral medicine that has been used under an 
emergency use authorization to treat certain people in the hospital 
with COVID-19. Remdesivir was shown in a clinical trial to shorten the 
time to recovery in some people, although the data was not sufficient 
to determine if the drug was associated with lower mortality. HHS has 
provided the IHS with access to 8,000 vials of remdesivir, and it is 
being supplied to patients at 15 of our IHS and tribal hospitals across 
the country.
    In April, the IHS expanded use of an Agency-wide videoconferencing 
platform that allows for telehealth on almost any device and in any 
setting, including in our patients' homes. Since April's telehealth 
expansion, the IHS has experienced a greater than eleven-fold increase 
of telehealth visits, from roughly 75 telehealth visits per week on 
average to now 907 videoconferencing telehealth visits per week on 
average. This number does not include other telehealth modalities such 
as care provided over the telephone, which is common in the bandwidth-
constrained environments of Indian country.
    We look forward to continuing our work with tribal and federal 
partners. As we work towards recovery, we are committed to working 
closely with our stakeholders and understand the importance of working 
with partners during this difficult time. For instance, we are 
currently working with other federal partners to provide assistance to 
the National Indian Gaming Commission as they work to provide guidance 
to tribally owned casino facilities that want to ensure they are doing 
all they can to keep employees and customers safe. We strongly 
encourage everyone to continue to follow CDC guidelines and 
instructions from their local, state, and tribal governments to prevent 
the spread of COVID-19 and protect the health and safety of our 
    I want to share an update on a trip that I made to the Navajo Area 
IHS at the end of May. During my trip, I visited the Navajo Area Office 
and Emergency Command Center in Window Rock, Arizona. I met with Navajo 
Nation President Jonathan Nez and joined him in the Navajo Nation's 
virtual town hall meeting on COVID-19. I am grateful for the strong 
leadership displayed by our tribal partners in working alongside 
federal and state partners to ensure the safety and well-being of 
American Indian and Alaska Native communities. I observed powerful and 
uplifting examples of collaboration during my visits to the Gallup 
Indian Medical Center, the Shiprock-Northern Navajo Medical Center, and 
the Crownpoint Health Care Facility. I would like to thank our entire 
Navajo Area IHS team for their continued dedication to our patients. I 
also want to acknowledge the rest of our IHS team, including those on 
the front lines, and others in supportive roles that have demonstrated 
profound commitment to raising the physical, mental, social, and 
spiritual health of American Indians and Alaska Natives to the highest 
level during this unprecedented time. I am extremely proud of their 
hard work to combat COVID-19, and I consider myself fortunate to work 
alongside a truly talented and dedicated team.
S. 3650, Coverage for the Urban Indian Health Providers Act
    This bill would amend the Indian Health Care Improvement Act 
(IHCIA) to extend Federal Tort Claims Act (FTCA) coverage to UIOs as 
coverage is currently authorized for Indian Self-Determination and 
Education Assistance Act (ISDEAA) contractors.
    Congress must specifically authorize, in statute, the extension of 
federal tort coverage to certain groups or individuals. Currently, 
Federal law extends FTCA coverage to ISDEAA contractors' employees and 
personal services contractors [25 U.S.C. 5321(d)]. Federal law does 
not provide tort liability coverage for injuries to Urban American 
Indian and Alaska Native patients that result from the negligent acts 
of employees at UIOs providing health and medical services pursuant to 
a contract with or a grant from the IHS.
    The IHS enters into limited, competing contracts and grants with 41 
501(c)(3) non-profit organizations to provide health care and referral 
services for Urban Indians throughout the United States. In calendar 
year 2017, 35 UIOs provided 653,614 health care visits for 75,194 
American Indians and Alaska Natives, who do not have access to the 
resources offered through IHS or tribally operated health care 
facilities because they do not live on or near a reservation.
    UIOs are purchasing liability insurance with resources that could 
be better utilized to expand services available to Urban American 
Indian and Alaska Native patients. The rising cost of liability 
insurance and the general cost of providing health care services 
adversely impact the ability of UIOs to provide needed services. As a 
result, certain kinds of staff and health services, such as dental 
services, have been substantially reduced or eliminated. UIOs are an 
integral part of the IHS health care system. They provide high quality, 
culturally relevant health care services and are often the only health 
care providers readily accessible to Urban American Indian and Alaska 
Native patients.
    IHS endorses the policy to extend FTCA coverage to UIOs, which is 
consistent with the FY 2021 Budget request. However, IHS prefers 
formulating the coverage extension as part of the statutory section in 
the Public Health Service Act where the other various similar 
extensions are located.
    Thank you again for the opportunity to speak with you today.

    The Chairman. Thank you, Admiral Weahkee.
    Now we will turn to Administrator Fenton.

                      OF HOMELAND SECURITY

    Mr. Fenton. Good afternoon, Chairman Hoeven, Vice Chairman 
Udall, and distinguished members of the Committee . My name is 
Robert Fenton. I am the FEMA Region 9 Regional Administrator.
    I want to thank you for this opportunity to discuss the 
actions taken by FEMA to support Native American communities 
during the COVID-19 pandemic. But before I begin my remarks, I 
would like to provide my condolences to the families and 
relatives of the 126,000 Americans who have lost their lives 
from COVID-19. Given the scope of this hearing and the 
disproportionate impact of the pandemic on Native American 
communities, I would like to express my particular condolences 
to the families and relatives of Native American victims of 
COVID-19. My thoughts and those of FEMA's employees are with 
    For the first time in FEMA's history, there are 57 
concurrent major disaster declarations, encompassing every inch 
of our Country and impacting all 574 federally-recognized 
tribal nations. This is truly a Whole-of-America response.
    The scale of this historic event has required FEMA to adapt 
its response practices in order to both respond to COVID-19 and 
simultaneously to maintain mission readiness for other 
disasters, such as wildfires or hurricanes. As you are aware, 
the challenges facing tribal nations are as diverse as the 
United States itself. Regardless of the unique obstacles, all 
tribal nations face widespread challenges in mitigating the 
impacts of this pandemic.
    To address these challenges, FEMA headquarters, FEMA's 
regional offices, and their tribal liaisons are available to 
provide dedicated support to tribes. As previously stated, I am 
the Regional Administrator of FEMA's Region 9, which 
encompasses 400,000 square miles and includes some of the most 
culturally and economically diverse communities in the United 
States. Our region includes 157 federally recognized tribes 
within California, Arizona, and Nevada.
    In Region 9, as well as in other regions, we have dedicated 
tribal liaisons and deploy staff to tribes when additional 
coordination is needed. An example of one tribe that FEMA 
Region 9 has worked with closely during the pandemic is the 
Navajo Nation. The Navajo Nation faces particular unique 
challenges as it borders three States with higher mobility in 
and outside of its borders.
    Many Americans are not aware the Navajo Nation experienced 
the fastest rate of spread in the Country. I would like to 
highlight some of FEMA's experiences in supporting the Navajo 
government as well as other Federal agencies.
    To address the historic challenges facing the Navajo 
Nation, a unified command group was formed by President 
Jonathan Nez. It included FEMA and multiple HHS components, 
including IHS, to ensure that the right Federal assets are 
mobilized at the right time to save lives. Following emergency 
declarations, I sent our Type 1 National Team members to the 
Navajo Nation to establish a unified command and an incident 
action plan to provide interagency coordination at all levels. 
This structure remains in place today and it continues the 
    Just yesterday, I visited the Navajo Nation, where I 
participated in the Nation's uniformed command meeting and 
joined President Nez in a virtual town hall in support of the 
messaging on the importance of adhering to mitigation. 
President Nez has taken great steps to limit mobility, highly 
encouraged the use of masks, enacted curfews, and stay-at-home 
orders, and continues to champion ways to leverage CARES Act 
funding in a manner that best serves the Navajo Nation.
    While the Navajo Nation has faced some unique challenges in 
their fight to lessen the impact of COVID-19, they have also 
experienced challenges common to all tribal governments. One 
area of focus has been intricacies with FEMA's Public 
Assistance grant program. There are three paths in which tribal 
governments may become recipients of the PA program, as a 
direct recipient, as a subgrantee on other States' 
declarations, or they may request their own major declaration 
from the President.
    The Public Assistance program reimburses emergency 
protective measures taken by a tribe. FEMA has developed a 
process to advance 50 percent of a project's funding to 
applicants before the project is completed.
    Our office has performed outreach to tribal nations to 
explain this process, and continues to work with tribal 
governments interested in seeking the expedited reimbursement. 
In some cases, we have dedicated FEMA staff who assist tribal 
nations in the application process.
    I want to highlight some strong partnerships with some of 
our State partners that we have worked with to support the 
tribes. For example, California sat up a tribal affairs desk in 
the State Operations Center to assist tribes and coordinate a 
routine weekly conference call with Federal, State and local 
agencies as well as any health clinics and has provided 
deployment personnel, equipment and commodities to meet 
emergency needs of tribal communities.
    The State of Arizona has also participated closely with 
tribes, including providing a significant number of personal 
protective equipment, and delivered specific aid to specific 
IHS and 638 facilities, including the use of rotary aircraft to 
help expedite PPE, medical training, and other components such 
as Strategic National Stockpile clean ventilators.
    These are just a few of the efforts FEMA is participating 
in with the tribes to respond to COVID-19. I and the entire 
FEMA team are committed to ensuring we address the critical 
needs of the tribal governments during this challenging time. 
The historic response and our preparations for the future will 
continue to require a Whole-of-America effort. FEMA looks 
forward to coordinating closely with Congress as we work 
together to protect the lives of Native Americans.
    I would like to thank the Committee for providing FEMA with 
the resources to meet these complex mission requirements. I 
look forward to answering your questions today.
    Thank you.
    [The prepared statement of Mr. Fenton follows:]

 Prepared Statement of Robert J. Fenton, Jr., Regional Administrator, 
   Region 9, Federal Emergency Management Agency, U.S. Department of 
                           Homeland Security
    Good afternoon, Chairman Hoeven, Vice Chairman Udall, and 
distinguished Members of the Committee. My name is Robert Fenton, and I 
am the Region Nine Administrator of the Federal Emergency Management 
Agency (FEMA). Thank you for the opportunity to discuss FEMA's response 
and the actions underway to protect tribal nations during the 
coronavirus (COVID-19) pandemic.
    I would like to begin today by acknowledging and providing my 
condolences to the families and relatives of the 126,000 Americans who 
have lost their lives to COVID-19. My thoughts, and those of the men 
and women of FEMA, are with you.
    For the first time in the United States' history, there are 57 
concurrent Major Disaster Declarations encompassing every inch of our 
country and impacting all 574 federally recognized Indian tribes: from 
the native villages of Alaska, to the pueblos of the Southwest and the 
tribal communities of the Northern Plains, Mississippi Valley and 
Eastern Seaboard. The scale of this historic event has required FEMA to 
adapt its response practices and workforce posture in order to both 
respond to COVID-19 and simultaneously maintain mission readiness for 
more common disasters such as hurricanes, earthquakes, floods, or 
    Regardless of the challenges that FEMA continues to confront, the 
bedrock of our mission remains constant: helping people before, during, 
and after disasters. Although--and indeed because--COVID-19 has changed 
our daily lives and the scope of its impact is unprecedented, the 
Nation is counting on us to accomplish our mission and we will do so in 
accordance with our core values of compassion, fairness, integrity, and 
respect. FEMA will continue to leverage the Whole-of-Government 
response to serve all of America.
    Engaging with sovereign tribal nations is a key component of this 
Whole-of-America response, and overcoming the unique challenges 
confronting tribes has been a strategic prioritization for FEMA from 
the beginning of the response to the pandemic. Many tribes are in 
locations with limited transportation, medical, and communications 
infrastructure which can complicate response efforts during any 
disaster. Within the context of COVID-19, social determinants of health 
and disproportionate percentages of chronic illnesses combined with 
these infrastructural limitations to create particular challenges for 
potentially at-risk tribes.
    In direct reflection of the magnitude of this historic event, 
FEMA's unprecedented support for tribal governments is measured beyond 
financial support or the distribution of personal protective equipment 
(PPE). FEMA's response has served to stabilize lives in the most 
fundamental ways. For example, when the shelves of grocery stores 
became barren and members of two tribes in New York were unable to 
purchase scarce supplies, FEMA's emergency food distribution services 
were able to fill that critical void. This is one simple example of 
FEMA's understanding that emergency management is about putting people 
first--both the disaster survivors we serve and those who serve them.
    FEMA Headquarters and FEMA Regional Offices have provided expanded 
services in support of tribal governments across the country in 
response to the pandemic since the National Emergency Declaration was 
declared on March 13, 2020. Each of the ten FEMA regional offices have 
dedicated Tribal Liaisons within their workforces to coordinate with 
tribes located in that respective region. Regional Tribal Liaisons and 
Regional Administrators serve as the primary point of contact regarding 
FEMA assistance, and serve as the conduit to connect tribes with FEMA 
leadership and program subject matter experts, as needed, for 
information sharing, technical assistance and resource coordination. As 
part of these efforts, FEMA Regions, with the support of our federal 
partners, have hosted weekly meetings and conference calls with tribal 
leaders and tribal emergency managers to answer any of their questions 
during this pandemic response. In Washington, D.C., FEMA has a 
dedicated, permanent National Tribal Advisor Desk that further supports 
coordinated federal response efforts to support tribes during any major 
disaster or emergency activation within FEMA's National Response 
Coordination Center (the NRCC)--which is located in FEMA Headquarters. 
The NRCC has served as the fulcrum for coordinating the federal 
interagency response to the COVID-19 pandemic. The NRCC Tribal Desk, as 
is commonly referred to, was activated on March 15th and has been 
staffed every day to support response and recovery efforts.
    Today's testimony will offer an overview of FEMA's response efforts 
and strategies for COVID-19, the types of assistance we have provided, 
and the ways in which FEMA has augmented the leading efforts of our 
federal partners at Health and Human Services (HHS), including the 
Indian Health Service (IHS), to protect the lives of tribal citizens.
Overview of FEMA's Support for Tribal Partners
Public Assistance Category B
    On March 13th, 2020, President Trump declared a nationwide 
emergency pursuant to section 501(b) of the Robert T. Stafford Disaster 
Relief and Emergency Assistance Act (Stafford Act). As a result, FEMA's 
involvement in the federal response was vastly expanded. As part of 
this unprecedented nationwide declaration, all state, local, tribal, 
and territorial (SLTT) partners became immediately eligible for FEMA 
Public Assistance (PA) Category B, emergency protective measures as 
authorized by section 403 of the Stafford Act and funded by the 
Disaster Relief Fund. Such assistance includes, but is not limited to, 
funding for tribal medical centers, Alternate Care Facilities, non-
congregate sheltering, community-based testing sites, disaster medical 
assistance teams, mobile hospitals, emergency medical care, and the 
transportation and distribution of necessary supplies such as food, 
medicine, and personal protective equipment (PPE).
    Subsequent to the President's emergency declaration, all 50 states, 
five territories, the District of Columbia, and the Seminole Tribe of 
Florida have been approved for Major Disaster Declarations. As a direct 
result of every single state receiving a Major Disaster Declaration, 
every single tribal government in the country became covered by a Major 
Disaster Declaration.
    To provide flexibility, tribal governments have parallel paths 
through which they can seek assistance from FEMA. They can either 
request to be direct recipients under the nationwide emergency 
declaration, or they can seek assistance as a direct recipient or 
subrecipient under a State's Major Disaster Declaration. Tribal 
governments also have the option to request a specific Major Disaster 
Declaration directly to the President through FEMA. Regardless of the 
way in which tribal governments pursue FEMA assistance, FEMA Regional 
Offices and their Tribal Liaisons are available to provide technical 
    In total, FEMA is working directly with 85 tribes under this 
framework including partners such as the Hidatsa and Arikara Nations of 
North Dakota, the Choctaw Nation of Oklahoma, and the Mashpee Wampanoag 
Tribe of Massachusetts. In keeping with the Stafford Act, FEMA 
allocates funding to cover 75 percent of costs, and tribal governments 
are responsible for the remaining 25 percent.
Cost Share Adjustments for Public Assistance Category B
    Many state and tribal governments have requested adjustments to the 
75:25 cost-share ratio due to the economic hardship and loss of tax 
revenue associated with the COVID-19 pandemic. As of June 25th, 42 
states and 28 tribes have requested a cost share waiver. The Stafford 
Act authorizes the President of the United States to make cost share if 
    Tribal government recipients may request cost share adjustments 
from the President through their FEMA Regional Administrator.
    FEMA will then make a recommendation to the President regarding the 
request and the President has the authority to make final cost share 
adjustment determinations.
    When federal obligations meet or exceed $149 per tribal member FEMA 
will recommend the President increase the federal cost share from 75 
percent to not more than 90 percent. As part of this calculation, FEMA 
will use a tribal government's population on or near tribal lands, as 
reported by a tribal government, to determine per capita obligations 
for each tribal government that makes a request. FEMA also considers 
qualitative factors such as the historical context of recent disasters 
within the specified area.
CARES Act Funding for Cost-Share Considerations
    To help tribal governments affected by COVID-19, the Department of 
Treasury recently announced that Coronavirus Relief Fund dollars, 
provided under the Coronavirus Aid, Relief, and Economic Security 
(CARES) Act, may be used to pay for FEMA's cost share requirements 
under the Stafford Act. This is yet another example of increased 
flexibilities offered to tribal governments to nimbly respond to and 
recover from COVID-19.
Managing Critical Shortages: FEMA Resource Distributions to Tribal 
    On March 19th, FEMA's role in the pandemic response changed. Under 
the direction of the White House Coronavirus Task Force, FEMA moved 
from playing a supporting role in assisting the U.S Department of 
Health and Human Services (HHS), which was designated as the initial 
lead federal agency for the COVID-19 pandemic response, to leading the 
Whole-of-Government response to the COVID-19 pandemic.
    From the outset, a key element of FEMA's response has been managing 
shortages of medical supplies needed to combat the pandemic, such as 
PPE, ventilators, swabs, and the chemical reagents required for 
testing. This effort alone has presented a historic challenge for FEMA 
and its federal partners such as IHS and HHS. COVID-19 has been a 
global crisis-leaders across over 150 countries have simultaneously 
been competing for the exact same medical supplies. We have been 
further challenged as most of the manufacturing for PPE occurs in Asia, 
where the virus significantly slowed down private sector production 
    Concurrently, American medical professionals on the front lines of 
the pandemic have required an exponentially greater volume of PPE and 
other medical supplies. On average, the United States began consuming a 
year's worth of PPE in a matter of weeks. FEMA worked closely with HHS 
to ensure that locations in danger of running out of supplies within 72 
hours received lifesaving equipment from the Federal government's 
reserve within the Strategic National Stockpile (SNS), as administered 
by HHS.
    Many of the earliest shipments to tribal governments and IHS 
originated from HHS's SNS. From the beginning, FEMA and HHS understood 
and acknowledged that the SNS alone could not fulfill all our Nation's 
requirements. The SNS was never designed or intended to fully supply 
every state, territory, tribe and locality in the United States 
concurrently, and cannot be relied upon as the single solution for 
pandemic preparedness. It was principally designed as a short-term 
stopgap buffer to supplement state and local supplies during an 
    Expedited international shipments within Project Airbridge 
facilitated by FEMA's Supply Chain Stabilization Task Force helped to 
supplement IHS and tribal nations' PPE or medical needs until global 
supply chains could begin to stabilize. Once flown in via the Air 
Bridge, 50 percent of the supplies on each plane were sent by 
distributors to customers in areas of greatest need, such as hotspots 
within the Navajo Nation.
    Although FEMA was never intended to be the primary source of 
supplies for any entity, our Agency was able to augment the vast 
donations and supplies distributed through our partners at HHS and IHS. 
In addition to our federal partner donations, FEMA facilitated the 
distribution to tribal governments of 19,400 boot covers. 13,755 
coveralls. 65,204 face shields. 1,276,800 gloves. 32,000 goggles. 
15,000 KN90 masks. 139,670 KN95 Respirators. 397,030 N95 Respirators. 
107,911 gowns. 1,825 Powered Air Purifying Respirators. 1,506 surgical 
gowns. 120,450 surgical masks and 1,200 Tevek headcovers.
    In addition, FEMA distributed more than 26,880 meals and 17,136 
bottles of water to tribal communities and constructed five Alternate 
Care Facilities, in partnership with the U.S. Army Corps of Engineers, 
to assist the San Carlos Apache Tribe, Hualapai Tribe, and Navajo 

    An Example: FEMA Support for the Navajo Nation

    I do not need to remind the Members of this Committee that the 
breadth of challenges facing Indian tribes and Alaska Native Villages 
are as diverse as the United States itself. For example, certain tribes 
within the Yukon territory of Alaska must deal with the difficulties of 
being entirely inaccessible by roads and overcome the consequential 
challenges of receiving medical aid by small boats or aircraft. 
Conversely, other tribes in the continental United States must adapt to 
the difficulties of being directly accessible by major highways, and 
the exponentially increased risk of exposure to COVID-19 brought by 
international travel. To best exemplify the ways in which FEMA has been 
able to assist tribal governments and their wide variety of needs, I 
would like to share our experiences in supporting one of most impacted 
tribal nations within my jurisdiction: the Navajo Nation.
    Similar to the challenges faced by other tribal nations across the 
country, limited medical infrastructure and high rates of chronic 
illnesses combined to create a vulnerable demographic amongst the 
Navajo Nation. To further complicate matters, the Navajo Nation is 
spread out across Arizona, New Mexico, and Utah. Consistent with other 
aspects of the COVID-19 response, a key component of FEMA's efforts to 
protect the lives of the Navajo Nation was close coordination with our 
federal and state partners as part of the Whole-of-Government response.
    To address the immediate shortages of PPE needed to support medical 
workers on the front line in the Navajo Nation, FEMA and HHS worked 
together to deliver critical PPE such as 159,000 N95 masks, 111,000 
gloves, 30,000 face shields and 18,000 Tyvek suits. As part of the 
Whole-of-America response, FEMA and HHS were able to further augment 
these shipments to the Navajo Nation by facilitating donations of 
102,967 gowns and an additional 30,500 gloves. To address ventilator 
shortages, FEMA and HHS also facilitated the delivery of 50 ventilators 
to Navajo Area IHS and 100 ventilators to the State of Arizona, to be 
available to tribal nations, as needed.
    Experience has demonstrated that emergency management is most 
effective when federally supported, state or tribe managed, and locally 
executed. As such, FEMA and Arizona State Health mission sent a 
Disaster Medical Task Force to Tuba City Regional Health Care, which 
provided subject matter expertise and other assistance. Furthermore, 
FEMA has deployed an incident management assistance team to support the 
Navajo Nation led response through joint planning, operations and 
logistics at the Navajo Nation Health Command Operations Center.
    Testing is also an important aspect of the strategy to combat 
COVID-19 within the Navajo Nation. In keeping with lessons learned 
elsewhere in the country, FEMA supported HHS efforts to prioritize 
rapid testing for at-risk populations within the Navajo Nation. 
Prioritizing the limited number of rapid tests for populations with 
underlying health considerations was key to facilitating a rapid 
response and the strategic distribution of scarce supplies. COVID-19 
diagnostic platforms with longer turnaround times were found to be more 
appropriate in situations with lower risk of rapid spread and 
escalation. Rapid testing, as supported by HHS, IHS, and FEMA, has 
allowed for increased diagnostic screenings above the national average.
    In addition to FEMA's traditional role, we worked in nontraditional 
ways as well. Through our relationship with the Department of Homeland 
Security HQ, we deployed a ``Tactical Technical Assistance Strike 
Team'' into the Navajo Nation during the peak of the crisis there. This 
team not only helped with the traditional response, but also vectored 
nontraditional NGO partners like The World Central Kitchen and 
Community Organized Relief Effort into the Navajo Nation.
    Lastly, understanding that emergency management practices must put 
people first, FEMA deployed a six-person Incident Support Base (ISB) 
team to support staged commodities, if needed or requested by the 
Navajo Nation. FEMA staged four 52-foot trailers with cots, blankets, 
water, and meals.
    I commend our partners at HHS and IHS for working with the Navajo 
Nation and using this experience to prepare for future emergencies. For 
example, IHS is working with the Centers for Disease Control and 
Prevention, also within HHS, and the Navajo Nation to recommend 
solutions, identify resources and begin implementing plans to expand 
water access on the Navajo Nation. These actions will potentially 
assist in reducing the spread of the illness and lessen the burden on 
the Navajo Nation's health care delivery infrastructure.
    As the Regional Administrator of an area that serves 157 tribal 
governments, including the Navajo Nation, I am acutely aware of how 
critical FEMA's work is to the lives of Indian tribes, and I, and the 
entire FEMA team, am committed to ensuring we address the critical 
needs of tribal members during this challenging time.
    Finally, I would also like to recognize the men and women of FEMA, 
as well as our partner departments and agencies for their adaptability, 
hard work, and endurance during this unprecedented response and express 
our appreciation to Congress and the President for providing FEMA with 
the necessary resources to meet very complex mission requirements and 
    This historic and unprecedented response will continue to require a 
Whole-of-America effort, and FEMA looks forward to closely coordinating 
with Congress as we work, together, to protect the health and safety of 
the American people during the COVID-19 pandemic.
    Thank you for this opportunity to testify. I look forward to 
answering any questions that you may have.

    The Chairman. Thank you, Administrator Fenton.
    And we will proceed to five-minute rounds of questions. I 
am going to begin with Admiral Weahkee. I know that you have 
been using the tele-health services, following CDC guidelines. 
I guess my first question for you, Admiral, at IHS, is when do 
you see returning to normal operations, and then when you do, 
will you still have that tele-health service available?
    Mr. Weahkee. Thank you, Chairman Hoeven. I appreciate the 
question. We are very excited to have the flexibilities that 
have been provided by CMS, both in terms of licensure and the 
increased reimbursement for those services. We are very hopeful 
that many of those will continue, even beyond the pandemic. I 
think that we tested the possibility of that occurring and by 
far, our providers have taken to it, our patients have taken to 
it. So I really think it is going to be a sea change for the 
way that patient care is delivered from this point forward.
    That being said, we have a lot of challenges in Indian 
Country with broadband access. Not all of our communities have 
the ability to obtain services through that mechanism. We have 
turned to hand-held telephones. Most Americans have a telephone 
available to them. So we are trying to use that platform as a 
    In terms of when we will return to normal, I think that is 
going to be different for different parts of the Country. We 
have operations in 37 different States, 605 different 
facilities across that system of care. Some of the locations 
will be ready to return back to normal much sooner than others, 
just depending on local situations, hospital capacity, local 
infection rates.
    But we do have a very defined, phased plan to return back 
to some semblance of normalcy.
    The Chairman. Also, you have lost a lot of third-party 
reimbursements. What do you see as far as recouping some of 
those third-party reimbursements for procedures that have been 
put off because of COVID?
    Mr. Weahkee. Thank you, Chairman.
    We have assessed within our Federal family and with tribal 
entities who are willing to share their information, and our 
urban partners, what the third-party losses have been. We have 
heard everything from 30 percent to 80 percent. We have good 
insight into our Federal operations and what those numbers are. 
But depending on the size and type of facility, if you are only 
providing residential treatment, alcohol and substance abuse, 
those services are for the most part taking a major hit. Dental 
services is another line that has taken a significant hit.
    But hospital size, part of the Country that you are in, 
there is some broad variation. We have been very fortunate 
beneficiaries of the Provider Relief Fund. So we thank Congress 
for that. But the funding that we have received is not reaching 
the entire need out there.
    I visited the Phoenix Indian Medical Center this week. They 
are projecting a $14 million deficit by the end of this fiscal 
year if current situations continue.
    The Chairman. IHS has been allocated $2.4 billion from the 
CARES Act. How much of that is allocated, and do you anticipate 
being able to allocate all of it? Are you going to have some 
returned? If so, why?
    Mr. Weahkee. Thank you, Chairman. The vast majority of 
those funds have been allocated. In fact, all the funding is 
out at the area offices. The first three supplements of funding 
are in the front lines already in the coffers and being used to 
purchase testing equipment, and to continue to pay those 
salaries from that lost third-party revenue.
    One set of funds that is taking a little bit longer to get 
out is the Paycheck Protection Program and Healthcare 
Enhancement Act funds. That is $750 million worth of the 
funding. We are undergoing bilateral modifications to the 
annual funding agreements to ensure that we have testing plans 
developed in partnership with the tribes and we have a good 
understanding of their needs, estimated testing supply needs, 
in the future.
    The Chairman. You indicated testing, more than 150,000 
tests, 9.5 percent of the IHS user population. That is a rate 
that exceeds most States, a lot of them, and most foreign 
countries, too. What is your target? That is good. What is your 
target for testing?
    Mr. Weahkee. Well, Senator, our target, and I will probably 
lean back on Dr. Toedt here, the target is to assess at least 
10 percent of your population.
    Dr. Toedt. [Remark off microphone] testing the positivity 
    Mr. Weahkee. The positivity rate. So our current number is 
now 272,935 tests that have been completed. That represents 
16.4 percent of our user population. So in less than three 
weeks' time now, we have seen substantial increases in our 
testing rates. We have a high, in Navajo and Phoenix, right at 
about 20 percent of their population is being tested. I think 
positivity rates for places like Alaska where we have been able 
to test 46,772 patients, they have a positive rate of only a 
0.3 percent, which is very good.
    But we feel like we are doing a great job in terms of 
testing capacity and meeting the needs of testing in Indian 
Country. That being said, supplies deplete and hot spots 
persist in large metropolitan areas and it will be difficult to 
get those testing supplies.
    The Chairman. For those hot spots, for example, in the 
Southwest, including tribes in White Mountain, the White 
Mountain Apache, also the Navajo Nation, what are you doing in 
terms of coordinating with other agencies to try to make sure 
you are meeting their service needs?
    Mr. Weahkee. Yes, sir, and that goes to the heart of the 
all-of-government approach. It is vitally important that we are 
working with the States where our tribes exist. The State of 
New Mexico has been a fabulous partner. Governor Lujan Grisham 
has done a lot of great work in ensuring that we have testing 
capacity. She has contracted isolation sites. But it is 
important that we utilize all the resources available to us.
    We talked about government support a lot. We have also had 
a lot of support coming from non-governmental organizations and 
from universities. Johns Hopkins is engaged in both of those 
locations, White Mountain and Navajo.
    So we are taking advantage of all the resources available 
to us in this all-of-nation approach.
    The Chairman. Thank you, Admiral Weahkee. We will turn to 
Senator Udall.
    Senator Udall. Thank you, Mr. Chairman.
    Admiral Weahkee, you should know better than anyone that 
COVID-19 is hitting Indian Country particularly hard, 
especially in the Navajo service area in Arizona and New 
Mexico, and you should agree that as doctors and medical 
professionals across the Country work on the front lines to 
battle this deadly virus, the least we can do is ensure that 
they have the right personal protective equipment. That is a 
bare minimum.
    So you can understand why I am deeply troubled by recent 
reports about hundreds of thousands of substandard KN95 
respirator masks supplied to IHS hospitals serving the Navajo 
Nation on New Mexico and Arizona. I mentioned this concern in a 
brief phone call with you in May. I followed up with a May 27th 
letter asking for a full report, and posing very targeted 
questions to you about what happened there on the circumstances 
of the IHS' $3 million Federal procurement contract with Zach 
Fuentes LLC.
    First, let me state the obvious. It is outrageous that 
substandard masks were sent anywhere, let alone to a COVID-19 
hotspot. In its haste, IHS contracted for faulty PPE and failed 
its responsibility to its patients and caregivers, period.
    I understand that the IHS did not use the faulty masks, and 
by a stroke of luck, none were actually distributed for use in 
IHS facilities. That does not take away from the fact that IHS 
potentially put patients and medical personnel in harm's way by 
failing to do its due diligence.
    To make matters worse, yet another report has surfaced 
indicating that the contractor has refused to terminate the 
contract, and has demanded his $3 million payment.
    Admiral, you are in a world of hurt. How about we start 
with your explaining how this happened, for the record?
    Mr. Weahkee. Thank you, Vice Chairman. I just want to state 
for the record that this situation is procurement sensitive. We 
are still working with contract acquisition professionals and 
attorneys to go back and forth with this particular vendor on 
this purchase.
    It wasn't a stroke of luck that kept those supplies from 
getting to our front line staff, it was the systems and 
controls in place at our area offices and in our receiving, to 
ensure that those materials were not distributed to our health 
care professionals.
    So I am happy that we have been able to identify the 
situation and now, because of non-conformance of this 
particular vendor in meeting the needs of our PPE, we have the 
ability to send those supplies back. There are options 
available to him. He can make it good by providing us with 
masks that meet the FDA standards and certifications. Or he can 
try to come up with a different way of fulfilling his end of 
the contract.
    He has not been paid. Those masks are all sitting in a 
warehouse in Mexico. They are clearly identified that they are 
not to go to any of our locations.
    In terms of how this occurred, we used Federal acquisition 
regulation requirements and the flexibilities that have been 
provided to us by the CARES Act. We identified and looked at 
seven different vendors for that particular procurement. He had 
the best pricing and the delivery options available at the 
time. But since you have identified the needs that persist, and 
they do, we do need masks, not only in Navajo but throughout 
the Country, we are looking at other vendors to help meet that 
    Our National Supply Service Center immediately shipped 
100,000 N95s, not KN95s, but actual N95s, to that location as 
this is being resolved.
    Senator Udall. I expect a full response to my May 27th 
letter with written answers to all my questions. And a staff 
briefing is not enough. Your response letter last night I 
received at 11:36 p.m. It didn't answer any of the questions.
    So I want to ask one of those, or two of those questions 
today. What protocols are in place to guard against IHS 
procuring substandard PPE?
    Mr. Weahkee. Thank you, Senator. The protocols that are in 
place are controls and systems for any procurement. So we do 
have a receiving that is conducted by procurement 
professionals. They review, according to the order, to ensure 
that we have received what it was that we ordered. We also have 
quality assurance reviewers that sometimes include infection 
control nurses. So those items that a materials management 
person may not have as much familiarity with as a front line 
health care service worker, there would be multiple points to 
be able to check and ensure that we are using what it is that 
we need to be using in each setting.
    So there are multiple checks and balances built into our 
system to ensure that the PPE being used meets the quality 
control standards in place.
    Senator Udall. Will you commit to me to answer my questions 
in my May 27th letter to you?
    Mr. Weahkee. We will, sir.
    Senator Udall. Thank you. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Udall.
    Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.
    Admiral Weahkee, you heard me mention in my short opening 
the impact that we have seen in Alaska as a result of the 
pandemic, the tribal providers being forced to shut down 
elective procedures in the clinics. The negative financial 
consequences I don't think can be overstated.
    It is estimated that third-party collections have dropped 
by 80 percent in some States. We recognize that the need is 
considerable, and you certainly know that.
    One of the things that really has helped shine a spotlight 
during this time of COVID-19 is when you are telling people to 
follow certain safety protocols, like washing your hands 
frequently, and you are from a village where you don't have 
safe drinking water, you don't have running water in your home, 
you don't have the means, really, to keep yourself and your 
family clean. This is very, very, very hard. It just highlights 
again how essential adequate sanitation is for our communities.
    We are seeing not only this play out in our communities, 
but we know that other forms of disease also come with lack of 
safe drinking water, lack of the ability to clean and 
disinfect. Of the 190 Alaska Native communities, 32 are still 
not served with in-home water and sewer. Typically, these 
communities have a washeteria where you can go and you can wash 
your clothes, take a shower, get clean. But in many, many of 
these communities, and you know because you have seen them, it 
is simply inadequate.
    I was out in Wales this past year. Wales has been working 
for years now to get their washeteria back. Beyond just one 
shower, there is no washing machines that work. It is a Federal 
effort to get a washeteria in place.
    Not only a Federal effort, it then becomes a media event 
when that story is not only played in the Anchorage daily news 
but in news publications around the Country. So it speaks to 
the issue that so many rural communities lack access to 
adequate water. This comes when you have extraordinarily high 
construction costs in those communities. IHS has established 
cost caps per home that when approached, both decrease the 
priority of the project in the scoring system, and limit the 
amount of funding available.
    So my question to you, Admiral, is whether or not IHS would 
be willing to eliminate or at least to raise the cost caps for 
projects that provide piped water and sewer into these unserved 
communities. We have to be figuring out how we can do more to 
be more responsive, to get water and sanitation out there.
    Mr. Weahkee. Thank you, Senator Murkowski. I join you in 
having seen Wales and Shishmaref myself, and the dire need for 
these services. That has been in my conversation with President 
Nez on the Navajo Nation, they have a lot of very similar 
issues with a lack of available water systems.
    Even before the pandemic, we had identified a need of $2.7 
billion across our system of care for sanitation and facilities 
construction needs. But these problems are now exacerbated as a 
result of the pandemic and the inability to wash hands, as you 
say, which is one of the public health measures we need to put 
in place.
    With regard to the caps, we do have three different tiers 
in the State of Alaska. As we all know, it costs much more to 
construct. We have to barge equipment in and supplies and 
condense your construction time frame. All of those add to the 
    We are currently collecting actual data to identify whether 
or not the caps that are currently in place are meeting 
reality. We know that we now have some additional flexibilities 
that have been provided to us. President Trump also put in 
place an executive order that has enabled us to waive certain 
regulations and policies that may be impeding our construction 
projects or other infrastructure projects.
    So I am definitely open to looking at what flexibilities we 
may have available to us to make changes and get these built 
once and for all.
    Senator Murkowski. I think it is important, you mentioned 
the flexibility there and the opportunity to perhaps waive. We 
have also seen the need for community public health measures in 
terms of how we deal with community contributions in Indian 
communities for sanitation projects.
    So looking, having the IHS again look to waive the non-
Indian contribution requirements in the Indian communities is, 
I think, something that could be helpful. So I would urge you 
as you are looking to those authorities that you have, what has 
recently been laid out in this executive order.
    But I think we have known that we have had this problem for 
far too long. When we had Dr. Eastman up to the State just 
about six weeks ago or so, his eyes were opened. Even though 
this was not something that was in his bailiwick or 
jurisdiction, he was starting to think outside the box, how can 
we work with FEMA to perhaps use emergency funds. Because this 
is an emergency. It has been an emergency for a long, long 
time. That has been part of the problem and what has stalled us 
    So know that we are going to keep working aggressively with 
you. While it might not be something that we can direct funding 
to now, I think there are flexibilities that we can look to. I 
think also when you see the disparities in so many of our 
Native villages, our Native communities, following from this 
pandemic, there needs to be a greater sense of urgency as to 
our purpose and how we address it together.
    So I look forward to doing that with both the agencies 
here. Thank you, Mr. Chairman.
    I do have questions that I will be submitting for the 
record if I may.
    The Chairman. Very good. Thank you, Senator Murkowski.
    Senator Cantwell.

                  U.S. SENATOR FROM WASHINGTON

    Senator Cantwell. Thank you, Mr. Chairman, and thank you, 
Vice Chairman Udall, for holding this important hearing.
    The Urban Indian Healthcare facilities in Seattle and the 
Indian Health Board and the Native Project provide critical 
service for Native Americans and Alaska Natives throughout the 
Pacific Northwest. The Seattle Indian Health Board serves 
around 6,000 patients annually, and at least two-thirds of 
those being Native Americans or Alaska Natives. The Native 
Project in Spokane also provides a wide array of services to 
more than 300 tribes.
    However, chronic underfunding of our trust and treaty 
obligations across the Indian Healthcare system, in addition to 
the deadly COVID pandemic, is threatening Indian health and 
wellness of Native Americans and Alaska Native communities. So 
this is especially the case in a large percentage of American 
Indians and Native Alaskans who live in urban areas. Currently, 
Urban Indian health programs typically receive less than 1 
percent of the IHS budget, even though approximately 70 percent 
of American Indians and Alaska Natives live in urban areas. So 
the inequity of Urban Indian health care just has to stop.
    The situation is not helped by the fact that the Urban 
Indian health programs receive a lower Federal Medical 
Assistance Percentage, or FMAP, as other Indian health care 
facilities. To me, this inequity does not even make sense. 
These providers must have parity, particularly as they have 
needed to close their doors, reduce services, stop medicine 
delivery due to the lack of resources and capacity of COVID-19.
    So Rear Admiral, what are the benefits of extending 100 
percent FMAP parity to Indian health programs, and how can we 
get that done? How would it impact the IHS budget?
    Mr. Weahkee. Thank you, Senator Cantwell. I agree that we 
do have many of our American Indian and Alaska Native brothers 
and sisters living in metropolitan areas now. You quote 70 
percent living there. Active user counts, individuals using our 
Urban Indian programs, is about 71,000 per year, last check. So 
that contributes partially. Many of our funding formulas are 
based on the active users of the programs. That being said, we 
know that there are many urban centers across the Country who 
really want to participate in that program.
    The 100 percent FMAP would benefit those locations, because 
then 100 percent of the funding going to those locations is 
coming out of the Federal coffers, as opposed to the match 
required by the States. So there is a funding amount that 
States would need to come up with in that current system that 
would all be paid by the Federal Government if 100 percent FMAP 
were provided to the Urbans in the same way it is for our IHS 
tribal and community health centers.
    Senator Cantwell. I am glad you mentioned that part. So now 
we are talking about an Indian Health Service facility 
somewhere, let's pick Montana, or what have you, they get 100 
percent, right?
    Mr. Weahkee. Yes, ma'am.
    Senator Cantwell. Okay. So if you actually had a physical 
hospital facility in downtown Seattle that was on a tribal 
land, you would also get 100 percent?
    Mr. Weahkee. Depending on the structure of that facility, 
if it was true tribal, tribal 638, through a tribe directly 
running it or tribal resolutions. I think Phoenix Area Medical 
Center is a good example of that, where there are six service 
unit tribe and they so get 100 percent FMAP.
    Senator Cantwell. So we are only just talking about the 
structure of the building, not the obligation to meet Indian 
health. So my point is, this is an inequity, we have to fix it. 
There is no reason--do you know of a reason for the inequity?
    Mr. Weahkee. Other than historical structure, and the 
manner that the programs came about.
    Senator Cantwell. Right. So I am saying, with so much of 
the population in Urban Indian Health, and the fact that it is 
in dire pandemic and needing resources, to me, obviously States 
are coming to us too and saying, let's have full FMAP, because 
of their underwater nature in health care. Now seems the 
perfect time to fix this and to move forward.
    I don't think that there is any difference, other than the 
structure and the building, as you say, in the code. But in 
reality, we are talking about serving Indian health. That is 
all we are talking about. So to me, we should meet this 
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Cantwell.
    At this point we will turn to Senator McSally remotely.

                   U.S. SENATOR FROM ARIZONA

    Senator McSally. Thank you, Mr. Chairman, I appreciate it.
    It is good to see you gentlemen today. Arizona is home to 
22 federally recognized tribes and more than 300,000 Native 
American constituents. When the Coronavirus hit, I have been a 
tireless advocate for our Native Americans in Arizona, fighting 
for the tribal stabilization fund, that $8 billion, also for 
tribal parity and engaging with the Administration to ensure 
the execution of many parts of the CARES Act was within 
Congress' intent in order to help our Native American 
    This pandemic has devastated Native American communities 
and economies. But I do want to recognize the incredible 
response by our tribal leaders, of the health care heroes, of 
the first responders. Tribal members and their families have 
shown incredible resilience and strength and innovation and 
just service to others in this incredibly challenging time. 
They are doing an incredible job and we are here to make sure 
that they have the resources that they need to fight and defeat 
this virus. We will defeat this virus together.
    Mr. Fenton, it is good to see you remotely. The Navajo 
Nation has garnered national attention and international 
attention as one of the hardest hit communities in the world. 
While FEMA aid has been flowing since early days, the 25 
percent cost share requirement has proven to be burdensome and 
seems to unwisely divert funds away from where they are really 
needed locally.
    On April 2nd, the Navajo Nation formally requested a waiver 
for the 25 percent tribal cost share requirement. FEMA 
acknowledged receipt of the letter and reported the request was 
under review at FEMA Region 9 headquarters. Since nearly three 
months have passed since the Navajo Nation submitted the 
request, when can President Nez expect a response?
    Mr. Fenton. Yes, Senator. There are a couple of different 
ways that cost share can be changed. As you know, one is by the 
President. So that letter is in process.
    In the interim, what has happened is the Administration has 
made CARES Act funding available to be used as a cost share 
match. So that 25 percent, along with our 75 percent to cover 
the whole 100 percent. Then we can also look at a change if 
they reach the 90-10 per capita number, which is $149 per 
    So no State, tribal nation or territory has received a cost 
share change, primarily because of all the funding that is out 
there now and trying to leverage that together to provide the 
need. I talked to President Nez yesterday, and he understands 
that there hasn't been a response yet. That doesn't mean that 
there won't be one. And of course, Congress can do that through 
a change, too.
    Senator McSally. Got it. So just to be clear, they have got 
no response yet, but where is it in the process of working its 
way up the Administration? So the answer is not no. I know 
there are different ways to address this, and one could be in 
additional legislation. But through the Administration's 
process, where are they in the process and when will they get 
an answer?
    Mr. Fenton. It is within FEMA, and typically we don't 
address cost share waivers until there it goes over $149 per 
capita, which we are far short of right now. So that is what 
triggers the 90-10 change.
    So we have that, we are tracking their cost share right 
now, and their spend and need. The majority of the assistance 
we have given to the Navajo Nation has been in direct Federal 
assistance. So until we build them, there is no cost share for 
that. We have reimbursed them less than a million dollars at 
this point. So the cost share would be small amounts that they 
have been impacted which they can use CARES Act funding, or 
non-profit in lieu of that, too.
    So there hasn't been a significant impact to them yet from 
that cost share. We continue to monitor it and work closely 
with them.
    Senator McSally. So just to be clear, when you say CARES 
Act coming as a second mechanism, are you talking about using 
some portion of the Tribal Stabilization Fund, the $8 million?
    Mr. Fenton. Of the Treasury money, I think it was $600 
million provided to Navajo.
    Senator McSally. To them, that was their portion of the $8 
billion, is what you are getting at. Okay, thanks.
    So I want to talk about just the tribal initiative. Early 
on, many tribes in Arizona expressed frustration about indirect 
accessibility structure between FEMA, States, and tribes. This 
was in the early days. So how has FEMA worked to improve the 
working relationships with the tribes in a way that respects 
tribal sovereignty and also improves efficiency?
    Mr. Fenton. There are many different mechanisms that 
coordinate with the tribes. One is each region has tribal 
liaisons that work with the tribes. I have two in California, 
for northern and southern California, and one in Arizona and 
one in Nevada. In addition to that, during this event, I have 
deployed personnel to specific tribes that are heavily 
impacted, so I have a team up in the Navajo Nation, I have sent 
people over to the White Mountain Apaches. And then I have 
individuals within each State that are also coordinating that, 
along with the States that are communicating.
    There's a number of mechanisms to ensure the communication. 
In addition to that, I have dedicated people to help them with 
the public assistance reimbursement.
    Senator McSally. Okay, great. I can't totally read the 
clock; I think I might be over my time. Admiral Weahkee, I am 
going to submit some questions for the record specifically 
about testing. I am concerned the White Mountain Apache Tribe 
now has the highest infection rate per capita in Arizona and 
are in need of mobile testing sites. So please look for those 
questions for the record on testing.
    Mr. Weahkee. Thank you, Senator.
    Senator McSally. Thanks.
    The Chairman. Thank you, Senator McSally.
    We will turn to Senator Schatz.
    Senator Schatz. Thank you, Mr. Chairman, Ranking Member 
    My first question is for Director Weahkee. I wanted to 
follow up on Chairman Hoeven's question regarding tele-health. 
Some of the loosening of restrictions that just happened in the 
CARES Act are actually temporary and only apply for the period 
of the pandemic. I would like you to speak to the utility of 
these changes, the additional flexibility you have now, and 
increasingly I hear from patients, from tribal governments, 
from Native Hawaiian health care organizations, from providers, 
that not only is tele-health working, but it is sort of hard to 
imagine going back to the old way. What Congress hasn't quite 
realized is that a lot of the changes that we have made 
statutorily only apply during this pandemic.
    So could you speak to the need to making some of these 
changes permanent?
    Mr. Weahkee. Yes, and thank you, Senator Schatz, for this 
opportunity to speak to tele-health. Definitely, it is a mode 
of care that we have turned to in Indian Country for quite some 
time. We have seen rapid growth, rapid expansion, an 11-fold 
increase in only a short three or four months. We know that 
that pales in comparison to many other health systems who have 
increased their tele-health hundred-folds.
    We have had conversations within HHS. I have heard both 
Administrator Verma from CMS and Secretary Azar as the 
Secretary speak to the desire to maintain these tele-health 
flexibilities long-term. So I am hopeful that we will see that 
come to fruition. Again, the challenges in Indian Country are 
really around broadband access and our rurality. We have many 
of the broadband services that go right around our 
reservations. So individuals who may be able to access tele-
health in a neighboring rural city or county can still not 
access it on the reservation proper.
    So having partnership opportunities with the FCC and the 
vendors who provide tele-health services are going to be 
vitally important as we move forward. Of course, the necessary 
resources to build the cabling and other lines of support.
    Senator Schatz. So a couple of other questions. First of 
all, I want to make a specific point about tele-health. People 
think of as similar to this WebEx where you need a really high-
speed connection. That is certainly true, and it is certainly 
the case that we all need to do better about broadband 
connectivity in Native communities. But I think it is important 
to remember that some of tele-health is storing forward 
technology, it is remote patient monitoring technology, which 
does not require super-fast bandwidth. Those are the kinds of 
things that do not depend on our ability to deploy 
infrastructure, but rather depend on our willingness to extend 
the flexibility that exists in the CARES Act into the future.
    Second question that I have, Director, is, have you seen 
any quality of care problems now that some of these services 
are being delivered by tele-health rather than in person?
    Mr. Weahkee. Thank you, Senator. I have personally not seen 
any quality of care items. Let me turn to my chief medical 
officer, Dr. Toedt. Anything you have seen or heard?
    Dr. Toedt. [Remarks off microphone.]
    Mr. Weahkee. Thank you. We have not.
    Senator Schatz. And a final question, there was a fair 
amount of good conversation in the opening remarks around the 
need to help health care providers in order to deliver direct 
patient care and not spend too much money on costly malpractice 
insurance. I think that is true for Alaska Natives, for 
American Indians, and Native Hawaiians. I am wondering if you 
could just let us know how important you think it is from a 
standpoint of your providers.
    Mr. Weahkee. Thank you, Senator Schatz. I think that any 
time that you can have the backing of the Federal Government in 
an ever-increasing litigious society that it would be 
beneficial to our providers. It would buy them a sense of 
    Any time that you have to take away from precious few 
resources to pay malpractice insurance, you are making 
decisions, those funds could better be spent additional 
providers or nursing support, or other pieces of the health 
care system, if you didn't have to pay those high insurance 
    Senator Schatz. Thank you very much.
    The Chairman. Thank you, Senator Schatz. We will turn to 
Senator Daines.

                   U.S. SENATOR FROM MONTANA

    Senator Daines. Thank you, Chairman Hoeven, and Ranking 
Member Udall.
    Admiral Weahkee, welcome. As we look at what is happening 
in Montana and across our Nation, disasters always seem to hit 
harder in Indian Country. This one is no different, with the 
current Coronavirus pandemic. That is why I fought alongside 
Senator McSally to secure $8 billion, we worked together on 
that, to be set aside for tribal governments to respond to this 
    Additionally, we were able to secure tribal eligibility for 
an additional $803 billion in grants and loans. This has 
provided tribes in Montana with some important tools and funds 
needed to help combat this global pandemic.
    We have also worked hard to facilitate getting more PPE out 
to Montana's tribes, working with the vendors, making sure they 
have the resources to purchase the amount necessary.
    A question, Admiral, is that not enough seems to be the 
most common phrase I hear in regard to PPE in the health care 
system. What steps has IHS specifically taken to ensure that 
tribes in Montana have enough PPE and testing kits to 
accurately and safely track the Coronavirus?
    Mr. Weahkee. Thank you, Senator Daines. I appreciate your 
question. Specific to both PPE and testing supplies there are 
similar processes used to fulfill the needs for both. Early on 
in the pandemic, we, just like every other health care system 
across the Country, were really scrambling to meet the needs. 
Everybody needed the same materials at the same time, and 
manufacturing supply was just not where it needed to be to meet 
those needs.
    We worked closely with FEMA and the Assistant Secretary for 
Preparedness and Response in HHS in the early days to fulfill 
any supply needs that we couldn't meet through our regular 
channels, through the Strategic National Stockpile. We all know 
that at some point that Strategic National Stockpile was 
depleted and probably, according to many, earlier than it 
should have been.
    So we have a lot of work to do to prepare for the next 
pandemic and the potential second wave coming to ensure that we 
are ramping up the par levels and the supplies that we have, 
not only in the Strategic National Supply, but within our 
agency stockpiles as well. We have within the Indian Health 
Service a National Supply Service Center. It is located in 
Oklahoma City. It is a warehouse full of supplies as well as 
three regional supply centers, one in Anchorage, Alaska, 
Gallup, New Mexico, and Nashville, Tennessee. We have had 
internal discussions in the same way that they have at the 
national about increasing our S and S, about increasing our 
stockpiles and potentially even the need to increase by some 
additional regional centers, perhaps in the Great Lakes and the 
Pacific Northwest.
    Senator Daines. In Mille Lac, if I can interject for a 
moment, we are seeing an increase in the number of COVID-19 
positive test results in Montana, significant spikes and some 
of the hot spots have been right there in Indian Country in 
Montana. So I think we all need to make sure we don't rest on 
our laurels and assume that the storm has passed. It seems like 
it is regaining some strength. We just have to keep our eyes on 
this very, very dynamic situation going forward.
    So I want to thank you for that response. We look forward 
to continuing to work together on this to make sure that our 
Montana Tribes have enough resources to effectively respond to 
this pandemic. Because we are not out of the woods yet. We have 
a ways to go.
    Mr. Weahkee. Thank you, Senator.
    Senator Daines. I want to shift gears, before my time runs 
out, Admiral Weahkee. That is, when asked a question about 
permanent infrastructure, in Indian Country there seems to be a 
lack of that in many of our reservations. Tribes lack emergency 
shelters and quarantine facilities to provide shelter and care 
for those displaced by the pandemic. Many tribal members live 
in multigenerational housing, where social distancing and 
isolation are virtually impossible.
    My question is, could you elaborate on the effects the lack 
of permanent facilities are having on your agency's ability to 
effectively respond to this pandemic?
    Mr. Weahkee. Thank you, Senator Daines. I would probably 
start the response in terms of social determinants of health, 
and adequate, stable housing being an item that we have lacked 
within Indian Country for many, many years. Many locations 
across the Country have the luxury of turning to vacated hotels 
as an isolation site. We typically don't have many hotels on 
our Indian reservations to be able to use in that way.
    So as you note, we have been turning to vacated Bureau of 
Indian Education or tribal schools for those isolation sites. 
But the kids will need to go to school at some point.
    Senator Daines. In terms of doing better, what can IHS and 
FEMA be doing to better protect our tribes, and what more can 
Congress be doing to support you in these efforts?
    Mr. Weahkee. Yes, sir. I feel strongly that in addition to 
the housing, we have a queue of health care facility 
construction sites, $2 billion on the current grandfathered 
list, and $14 billion overall. But if we could open up the 
opportunity to enable tribal programs to request other facility 
types, outside of hospitals and health centers, they really 
want to build residential treatment centers, they want to build 
long-term care facilities for their elders. Those are 
authorized currently in the Indian Health Care Improvement Act, 
but there has not been any funding identified to be able to 
pursue those opportunities.
    Senator Daines. Admiral Weahkee, I have already run out of 
time. Thanks for your responses.
    Mr. Weahkee. Thank you, sir.
    The Chairman. Thank you, Senator Daines. We will turn to 
Senator Cortez Masto.

                    U.S. SENATOR FROM NEVADA

    Senator Cortez Masto. Thank you, Mr. Chairman. Thank you, 
gentlemen, for coming today to talk about this important issue.
    Let me just start off with Rear Admiral Weahkee. Back in 
April, I had sent you a request on behalf of the Duck Water 
Shoshone in Nevada. They were seeking an ambulance. I just have 
to say thank you because you fulfilled their request very 
quickly. You were attentive, and it made a difference for the 
tribe. So we really appreciate your response to our tribes in 
    Let me follow up on the line of questioning from Senator 
Daines, that this is really focused on the aging health 
infrastructure at IHS. I know, you talked about how you had 
allocated the CARES Act money already, about $2.4 billion. My 
question is, are you using some of those dollars in the CARES 
Act for the infrastructure investment to ensure that tribal 
members are well served, with respect to the concerns that I 
see, on IHS's aging health infrastructure?
    Mr. Weahkee. Thank you, Senator Cortez Masto. As part of 
the four waves of funding that we received, we did specifically 
target some of the CARES Act funding for infrastructure related 
purposes, both sanitation facility construction and some of the 
needs within our facilities. So we have been able to put aside 
some of the Coronavirus supplements for this purpose 
specifically. But we of course have many more needs out there 
that can be met with these resources.
    On the BEMAR, our Backlog of Essential Maintenance and 
Repair, we currently have about $767 million of need in that 
one particular line item. Of course, equipment is a big piece 
of that as well. We need to continuously update our equipment, 
so our providers have the latest and greatest tools to be able 
to care for and treat our patients.
    Senator Cortez Masto. I would appreciate your sharing al of 
that with the Committee . I think particularly we are looking 
to go to into another stimulus package to assist our tribes as 
we address the health care crisis of COVID-19. We want to make 
sure that you have all the resources and you have the 
infrastructure that is set up to provide the support that is 
necessary through this health care crisis.
    I also want to jump back to the traunch of funding that you 
did receive. You talked about you still had $750 million from 
the CARES Act to allocate to PPE and health care enhancement. 
What is your time frame for getting that money allocated?
    Mr. Weahkee. Thank you, Senator. The $750 million of the 
Paycheck Protection Program and Health Care Enhancement Act has 
been 100 percent allocated, we have just not had the 
opportunity to obligate all those funds yet. About 40 percent 
of that fund is currently obligated. We are working directly 
with tribes to pursue these bilateral modifications to the 
annual funding agreements, which is taking the time. Tribes are 
putting together their tribal-specific testing plans and 
identifying the resources that they need, because the detailed 
budget was a requirement. We are actually managing this pot of 
funding on behalf of HHS. The funds were appropriated to them, 
yet we are managing them.
    So we weren't able to, in the same way we did supplement 
one and put it out through a unilateral modification, and the 
process is just taking us a little bit longer.
    We do anticipate, just as quickly as we can get signatures 
on both sides of the paperwork, having those funds obligated. 
It is underway across the Country as we speak.
    Senator Cortez Masto. Thank you. I appreciate that.
    Mr. Fenton, welcome, and thank you so much for your good 
work in Region 9, which is a region that is very important to 
the State of Nevada. I have heard from the FEMA's Crisis 
Counseling Program, which provides emotional support, crisis 
counseling, and connection to community support systems, as 
being hugely helpful through this pandemic. Do those counselors 
that serve greater Nevada also serve the tribes? The question I 
have along with that is, or does FEMA have a process for 
providing more culturally competent services to Indian Country?
    Mr. Felton. I couldn't hear the second part of your 
question, the last sentence, ma'am, if you could repeat it.
    Senator Cortez Masto. Sure. Do you serve the tribes, and if 
you do, do you provide culturally competent services for our 
    Mr. Fenton. With regard to our crisis counseling programs, 
there are currently right now, within Region 9, we don't have 
any tribes that have their own declaration. So those crisis 
counseling programs are run through the State. Definitely they 
could go ahead and provide assistance to tribal governments 
through that mechanism and their resources.
    Navajo Nation is in the process of requesting their own 
declaration, and if they want to use their resources through 
their own declaration and submit a crisis counseling grant, 
they could go ahead and do that.
    Then as far as, I think the second part of your question, 
do we have competent----
    Senator Cortez Masto. Culturally competent. Culturally 
competence sensitive to our tribes and their needs.
    Mr. Fenton. So one of the things that we is we provide not 
only training to our staff to work with tribal governments, but 
also our territorial partners on the cultural needs, and have a 
specific cadre within FEMA that works with our tribes, so that 
we build relationships and have leveraged people from the 
tribal community that participate within that cadre to help 
with communications and better understand the cultural needs.
    Senator Cortez Masto. Thank you. I know I have gone over my 
time. Thank you very much, Mr. Chairman. Thank you, gentlemen.
    The Chairman. Thank you, Senator Cortez Masto.
    We will turn to Senator Lankford.

                   U.S. SENATOR FROM OKLAHOMA

    Senator Lankford. Mr. Chairman, thank you very much. To 
both our witnesses, I really appreciate your engagement for 
being here today and for all the work that you continue to do. 
You have had very, very busy schedules here of late, with a lot 
that is going on. I very much appreciate that.
    Admiral Weahkee, I also wanted to be able to thank you for 
some of your technical assistance and your help as we have gone 
through this process. Senator Smith and I have a bill, The 
Urban Indian Health Providers Act, that helps provide some 
quality on tort reform, and trying to deal with the basics to 
make sure that all our of our tribal health facilities are 
treated the same.
    As you know full well, some Urban Indian Health care 
providers have a different level of malpractice coverage than 
others. Senator Smith and I are trying to be able to fix that, 
to make sure everybody has quality in this coverage. We have 
several Senators that are on board on this Committee , and 
others that are welcome to be able to join. We are grateful for 
the help and the insight that you have. We look forward to 
trying to get that passed and get that implemented in the days 
ahead. I just wanted to be able to say thank you specifically 
to you, Admiral, for your help through this process as we go 
    Can I ask a question? We have been through a lot at this 
point. And there is a lot that is happening. For every single 
one of us, this is on the job training, because none of us has 
been through a pandemic before. Are you collecting a kind of a 
lessons learned as you are going through this process to make 
sure if we have weakness, if we had strength in this area, this 
is something that needs to be fixed in the future, so while the 
heat of the battle is going on right now, we are able to serve 
as many places as you can, is there an ongoing list that you 
have in your office of things to fix long-term, or lessons to 
be learned for next time?
    Mr. Weahkee. Thank you, Senator Lankford. I appreciate your 
leadership in Congress. We have stood up a structure, an 
incident command structure, within the agency. We have a 
headquarters team. Dr. Michael Toedt, who is behind me, is the 
Operations Section Chief. But we also have a planning section 
chief, which is headed by our Quality Director, Jonathan 
Merrell. We are compiling all the lessons learned as we 
progress. We have a revised concept of operations, which is 
updated on a regular basis.
    Most recently, as a result of some of my visits to Navajo 
and Phoenix and Bemidji, we have identified the need for health 
care team support. Many of our caregivers are very much 
fatigued. They are facing death on a daily basis, not only at 
work, but also at home in their communities with friends and 
family members impacted.
    So looking to resources through the UNM TeleECHO program to 
provide caregiver fatigue training, and other mental health and 
behavioral health services, is just one example of, as we learn 
these lessons, implementing them into our response. We will be 
sure that our pandemic response documents are updated in the 
hot wash when we get to that point.
    Senator Lankford. That would be very helpful.
    Quickly, I want to be able to mention this to you as well. 
There is sometimes inequity among tribes as well. Some tribes 
are very well organized and have good connections, are able to 
read the documents and know where to be able to get help. Some 
smaller tribes do not have the same structure to be able to 
know where to get help. That help is available to them, they 
just don't know to be able to ask for it and where that is.
    What is your office doing at this point to make sure we are 
reaching out to smaller tribes to make sure they are very aware 
of the help that is available to them?
    Mr. Weahkee. Thank you, Senator. One of the things that we 
are doing is focus on communications. We do have a weekly call 
with tribal and Urban Indian Organization leaders. We have 
actually decreased that tempo to once every two weeks. But that 
is a call in which we have been bringing together our partners 
from across the Federal agency. White House Intergovernmental 
Affairs is brokering and facilitating along with HHS 
Intergovernmental Affairs.
    We brought in the BIA, we have brought in FEMA, we brought 
in various other partners from VA to really speak to the 
Coronavirus-specific resources they have available to them. Our 
partners at the Department of Interior in the Bureau of Indian 
Affairs does have the capacity to help tribes develop tribal-
specific emergency response plans. So that is something that we 
have connected many tribes to. We are happy to continue to do 
that work.
    Senator Lankford. Thank you. I just wanted to make sure no 
one is overlooked in this process, that we have opportunities 
for help, and they just don't know who to call or where to dial 
in and get that.
    Mr. Fenton, let me ask a quick question as well. Is there 
any administrative flexibility or form that you see at this 
point just to streamline tribes' interaction with FEMA? 
Specifically I am thinking about things like the Public 
Assistance Administrative Claim requirements, other areas that 
as we go through this you see, we need some reforms, we need 
some streamlining?
    Mr. Fenton. I appreciate the question, Senator. One of our 
goals in our strategic plan is to lessen the complexity at 
FEMA. One of those areas that we have been working on is the 
Public Assistance program.
    One of the things we have done in this event has been able 
to, up front, 50 percent of the cost for projected costs, and 
being able to expedite that. Usually we are turning those 
around in two to three weeks. So we continue to get better. We 
have the after action process that focuses on these events. We 
have already had calls with not only our tribes, State and 
territories to talk about SNS 2.0, and get ready for the fall, 
and other events, whether it be hurricanes or the fires that 
will come as we get later into the summer and into this fall.
    Senator Lankford. Okay. Well, if there are ways that we 
need to help in that process, this Committee stands ready to be 
able to help in that. Obviously, Homeland Security, if we can 
do more, it would be great to be able to great to help. I am 
also on that committee, and so if there are ways that we need 
to help in streamlining we are glad to be able to do that to 
make it more effective and less paperwork in the process.
    Thank you both very much.
    The Chairman. Thank you, Senator Lankford. We will turn to 
Senator Smith.
    Senator Smith. Thank you, Chair Hoeven and Vice Chair 
Udall. Thanks to our folks here today testifying before us.
    I want to start where Senator Lankford started, which is to 
just talk a little bit about the FTCA coverage for urban health 
clinics. It is great to have so many of our colleagues on the 
Committee supporting this proposal. I am glad to have the 
endorsement that you have provided, Admiral Weahkee.
    I am wondering, this is just such an inequity between 
organizations serving Urban Indian populations versus IHS 
facilities and tribal health programs that we are trying to 
correct here. It can make a big difference in terms of the 
amount of money that Urban Indian Organizations have to provide 
the services needed so badly.
    So Admiral Weahkee, would you just comment for me briefly 
about the role that Urban Indian Organizations are playing 
right now in the COVID pandemic, and why this is such an 
important issue to address?
    Mr. Weahkee. Yes, thank you, Senator Smith. Definitely, our 
Urban Indian Organization partners are the third leg of our 
Indian health system stool, along with our IHS federally 
operated and our tribally operated programs. We have 41 urban 
programs located across the Country. Many of those providing 
vital ambulatory health care services.
    One of the earliest hit locations was San Jose, California, 
our Santa Clara Health System. As noted earlier, our Seattle 
Indian Health Corps program, they were early in the response to 
COVID-19, as the Country's first cases really emerged there on 
the West Coast.
    So we have had the opportunity to learn from their response 
efforts, not only the treatment protocols and the supplies that 
were going to be needed, but as things progressed and they were 
further along in their journey in combatting Coronavirus, 
having the regular calls so that those best practices can be 
shared to tribal leaders and other urban programs was vitally 
    We have been able to see and hear how they have patched 
together funding, not only from Indian Health Service but from 
other Federal agencies and States, to be able to meet the needs 
of their communities. So I really can't over-stress the value 
and importance, as we have many of our American Indian and 
Alaska Natives living in metropolitan areas, my own family 
included, down in the Phoenix area, where we have family 
members obtaining services from an organization called Native 
    So definitely valuable partners in our approach to 
providing care and treatment.
    Senator Smith. Thank you for that. I have seen the same 
thing. In the early days of the pandemic I convened a 
conversation with the urban indigenous community in Minneapolis 
and heard a lot about the struggle that they are having to 
provide health care to elders, particularly in the community. 
We talk a lot about broadband and access to technology being an 
issue in rural tribal communities. But it is also an issue in 
urban tribal communities, where there is so much poverty and 
lack of ability to pay for broadband, or even to have the 
technology. The phone that you held up earlier, even lacking 
that technology. If you can't go to the local library or cafe 
to get your tele-health, then you are in a world of hurt when 
you are trying to get access to care. So I think these issues 
apply to urban Indian populations as well.
    I want to, before I run out of time, I want to just follow 
up on this testing question that several of my colleagues have 
asked about. In Minnesota, my staff and I are part of a weekly 
conversation with Minnesota's tribal nations. Every week they 
ask, where are those testing dollars? They are so concerned 
about this. They are quite concerned about managing outbreaks 
on tribal lands.
    Of course, being able to do the occupational and 
surveillance testing that is so important to be controlling the 
spread of the virus as they reopen tribal enterprises is 
extremely important right now. So what should I tell my tribal 
leaders in Minnesota about when they can expect to see those 
testing dollars, so they can move forward with what they know 
they need to do?
    Mr. Weahkee. Thank you, Senator Smith. I think that the 
best response would be to take a look at the Paycheck 
Protection Program and Healthcare Enhancement Act. That traunch 
of funds was specifically meant to increase testing capacity, 
contact tracing, and surveillance. So as they receive the 
request to negotiate that bilateral modification, that those 
funds are specifically meant to meet that need that you just 
    Senator Smith. What they are telling me is that it is 
extremely hard to figure out how to get access to the kids to 
get connected. So can I just ask if we can follow up separately 
to try to resolve this problem for them? It is one of the 
biggest issues that they have right now.
    Mr. Weahkee. Yes, ma'am, happy to do so.
    Senator Smith. Thank you.
    The Chairman. Thank you, Senator Smith. And I do have a few 
more questions for Administrator Fenton. The Vice Chair may 
have some questions as well.
    Senator Udall. I have more.
    The Chairman. So, Administrator Fenton, FEMA spent a 
considerable amount of time updating its tribal consultation 
policy, which was published in July, 2019. The policy 
acknowledges the special government-to-government relationship 
between the Federal agency and the tribes.
    So understanding that that process can be complex for 
tribes as well as States and territories, what training and 
technical assistance or resources are available to tribes 
applying for public assistance relief directly from FEMA?
    Mr. Fenton. Throughout the year, we provide training to our 
tribes, even before disasters, and have a number of workshops 
that we schedule before disasters. With regard to this event 
specifically, we had discussions with all the tribes across the 
United States. For example, myself and Region 9 held a call 
with our State partners in each State to let them know about 
the options they have as far as being a subgrantee underneath 
the State and what that meant administratively and effort wise, 
being a direct recipient of FEMA, or requesting their own 
    Then we gave time for the tribes to make that selection. 
Then what do is reach out to them to officially apply to the 
Public Assistance program. As part of that process, we have a 
kind of discussion with them of the application process, which 
to use as far as documentation, what is eligible. Then we 
assign them someone to help them with the grant process.
    So we are working through that with all the tribes. We do 
have people dedicated to each State that are working with our 
different tribes to reimburse them costs from this event, as 
far as coordinating other types of assistance outside the PA 
program that may come from the different Federal agencies. So 
we are coordinating that, things like hoteling for isolation 
purposes. We have given out tents to some tribes that want to 
isolate people at home, food, PPE, water, other supplies that 
are needed as a result of combating COVID.
    So we are doing that across the Country, and then there is 
also coordination calls at the national level, both with the 
White House and our headquarters, to different tribal members 
so that we can make sure we are helping and addressing their 
    The Chairman. All right. As we have discussed, two of the 
hardest hit tribes fall within Arizona, the White Mountain 
Apache and also the Navajo Nation. In your time in Arizona, 
what preparedness and response has FEMA undertaken to try and 
control the spread of COVID-19 in these hot spots? And what are 
your experiences in terms of coordinating with other Federal 
agencies and also IHS to that?
    Mr. Fenton. This event, as I said in my opening comments, 
is really an all-of-nation or all-of-America event. So it 
really takes coordination to happen at multiple levels. Not 
only are we out at those locations and with our State partners 
coordinating the Federal interagency and all the different 
departments and agencies that are bringing resources, whether 
it be IHS and their mission, CDC, ASPR from HHS and others, to 
include the Corps of Engineers that provided alternate care 
sites, or VA that is providing nurses out at White Mountain 
Apache and Navajo Nation.
    So our job is to coordinate that overall Federal relief. 
That includes not only at the Federal level, but to States, 
local governments, private sector, and non-profits. So by 
bringing that in to coordinate with tribal entities to address 
their issues is kind of what has been our focus.
    As far as issues, I think that any time you have an event 
that is a new event like this, that brings complexities and 
maybe entities that are not used to working together and don't 
understand each other's authority. So there is a period that we 
have gone through to understand not only authorities but 
resources and capabilities to make sure that we are able to 
address in a timely manner the needs of Native American tribes.
    The Chairman. Admiral Weahkee, same question.
    Mr. Weahkee. Thank you, Senator. I think that the key is 
that cross-entity relationship. The VA nurses are a great 
example. We were able to work with them to bring in critical 
care nurses, not only to meet the surge capacity but also our 
nurses that have been seeing patients non-stop working very 
long hours for the past four months. They need a spell and they 
need some support.
    We now have our contractors asking for hazard pay on top of 
their contract amounts, so they are asking to increase our 
rates. But that coordination has been key. And we have, in the 
same way that have updated our con ops, or concept of 
operations, we have also updated our guidance for tribes on how 
to use the FEMA route. So we have asked tribes to go to our 
area emergency management points of contact. We look within the 
agency if we can meet that need. If we can't, then we will 
elevate it to FEMA and the Strategic National Stockpile. We put 
that into a protocol, it is in writing. It has been shared 
broadly. It will be there and available to us next time around 
when we need it, so we don't have to recreate this wheel.
    The Chairman. Thank you. Vice Chairman Udall.
    Senator Udall. Thank you, Mr. Chairman.
    Administrator Fenton, I would like to ask you about 
interagency coordination when it comes to tribes and Urban 
Indian health programs and accessing Federal channels for 
testing supplies and PPE. FEMA has led much of the procurement 
and distribution through the National Response Coordination 
Center, acquiring testing and PPE supplies for the NRCC from 
sources like the DOD stockpile, the HHS Strategic National 
Stockpile, and by other means.
    But after several months of calls, briefings, and letters, 
both from Congress and the tribes, the process for requesting 
emergency medical supplies remains confusing at best. At one 
point, I believe the NRCC promised to produce some flow charts 
on the topic. But I don't believe we have seen anything on that 
front yet.
    This confusion is leading to delays in delivery of these 
supplies and creates uncertainty related to cost shares for 
other Federal agencies, for tribes, and for Urban Indian health 
programs. We need to know that supplies are reaching the ground 
expeditiously. And we need to know whether any costs will be 
coming out of IHS, tribal or Urban Indian health program 
    Under what circumstances would IHS, a tribe, or an Urban 
Indian health program have to reimburse FEMA, in full or in 
part, for supplies it receives during the COVID-19 crisis?
    Mr. Fenton. Senator PPE and testing supplies have been a 
challenge on this event. Any time you have a demand that is 400 
percent over what is available through manufacturing, it causes 
a strain on the whole system. FEMA has done a number of things 
to improve that process, to expediting movements of resources 
from private sector medical suppliers, to establishing and 
working with private sector to established new manufacturing to 
making sure that there is not price gouging or hoarding of 
    Senator Udall. Mr. Fenton, the question is about 
reimbursement, will they have to reimburse FEMA in full or in 
part for this.
    Mr. Fenton. With regard to reimbursement, there is a number 
of ways that a tribe could get supplies. They are getting them 
directly from either the Strategic National Stockpile, which is 
not cost shared, that HHS is providing full reimbursement 
through that. And we have an interagency agreement between us 
and them to do that. IHS is providing resources to them for 
their hospitals.
    In addition to that, some States are providing resources, 
for example, California, I know has provided 7 million N95 
masks, over which they are not charging them a cost share for 
that, or any type of EMAC agreement.
    When a tribe does not have a resource, it specifically 
comes to FEMA and puts a request in. That is the only time that 
something is cost shared. Or if a tribe goes out and procures 
it on their own, then it would be cost shared, and then they 
could also use the 75-25, as I said earlier, they could use the 
CARES Act funding that they received to go ahead and offset 
that 25 percent cost share.
    Senator Udall. Are there any circumstances where the IHS, 
tribes or Urban Indian programs are asked to pay a 
reimbursement when other government or health systems are not?
    Mr. Fenton. I am not aware of us charging IHS for masks.
    Senator Udall. Will the NRCC publish any flow charts or 
guidance on the methods for accessing Federal emergency 
supplies as promised?
    Mr. Fenton. I will circle back with them and make sure that 
we submit something after this.
    Senator Udall. Thank you very much.
    This question is to both Administrator Fenton and Admiral 
Weahkee. Will you both commit to working together to simplify 
and clarify how tribes can access medical supplies during 
disasters and public health emergencies?
    Mr. Fenton. Yes, sir.
    Mr. Weahkee. Yes, sir, absolutely.
    Senator Udall. Thank you. Thank you both. Thank you, Mr. 
    The Chairman. Thank you, Vice Chairman Udall. I would like 
to thank both of our witnesses for being here, and also for the 
very important work that you are doing.
    If there are no more questions for this first panel, 
members may also submit follow-up questions. We know there are 
going to be some follow-up questions already, as Senator 
Murkowski indicated. So other members may submit follow-up 
questions for the record as well.
    So with that, again, thank you to our first panel. We 
appreciate very much both of you being here. Thank you.
    With that, we move right away to our second panel. Today 
our second panel includes two tribal witnesses. As mentioned 
earlier, Mr. Scott Davis is a member of the Standing Rock Sioux 
Tribe and a descendant of the Turtle Mountain Band of Chippewa. 
He has many years of experience working with tribes and tribal 
organizations and was appointed to be the Executive Director of 
the North Dakota Indian Affairs Commission in April of 2009.
    In his capacity as Executive Director, Mr. Davis 
coordinates the State to tribal government relationship, 
together with addressing issues affecting Native communities in 
North Dakota. Today's hearing provides a great opportunity to 
discuss how States and tribes are reducing and preventing 
Coronavirus at the local level.
    Our second witness, Ms. Lisa Elgin, is Secretary of the 
National Indian Health Board. She will be joining us virtually. 
Again, we appreciate both of you joining us. With that, I would 
turn to Mr. Davis and welcome your opening comments.

                          NORTH DAKOTA

    Mr. Davis. Thank you, Chairman Hoeven and respective Vice 
Chair Udall, thank you.
    [Greeting in Native tongue], greetings again on behalf of 
myself, Scott Davis, a proud member of the Standing Rock Sioux 
Tribe, and also a descendant of the Turtle Mountain Band of 
Chippewa. My Lakota name is Oksate' Tawa'. I would definitely 
bring a good warm handshake if I could. I come here with a good 
heart. Thank you for the invitation today.
    Today I was given permission by both of our tribes, in 
partnership with our Governor Burgum to provide testimony today 
regarding the working relationship between the five tribal 
nations in North Dakota and the State of North Dakota, and also 
our full partners regarding COVID-19 pandemic. Since the start 
of the COVID-19 pandemic, I immediately reached out to our five 
tribal leaders and asked them how they were going to respond to 
the pandemic in declaring a state of emergency.
    As you know, tribes do have the authority to declare on 
their own through the Sanford Act or to declare with the 
governor. In this case, the tribes chose to declare with 
Governor Burgum and by doing so, it opened up a lot of 
resources to the tribes.
    Since then, we have committed to weekly calls from Governor 
Burgum, my office, and to the five tribal chairs, tribal 
councils, tribal clinics, and also to the Indian Health 
Service. The majority of these calls entail discussion about 
Protective Personal Equipment, PPE, testing kits and supplies, 
and also discussions that entail guidance on opening 
businesses, schools, and tribal colleges.
    But most importantly, we have partnered with the five 
tribal nations in conducting mass testing events. Two weeks ago 
we finished our first round in testing all five tribes. Today, 
we are continuing those partnered testing events and making 
sure that all North Dakota tribal communities and members get 
tested on a regular basis, as requested from tribal leadership. 
These events at times are led by our National Guard in 
partnership with the tribal incident command staff, tribal 
health staff, Indian Health Service, and local county public 
health offices.
    As a result, we have strong working relationships in 
testing thousands of tribal members. By doing this, we are 
seeing very low positive testing results from COVID-19 in each 
of our tribal nations. We attribute this to the resources 
available that we have developed with the tribes. Examples are 
the PPE, the testing kits, surge plans, data sharing and 
consistent communications.
    This partnership is a direct result of the commitment 
Governor Burgum and my office has made with the five tribal 
nations in North Dakota since he took office. Tribal engagement 
is one of the five initiatives under the Burgum administration. 
Prior to the pandemic, Governor Burgum's office and my office 
have had countless meetings with the tribes, and have held 
three large conferences entitled Strengthening Tribal, State, 
and Federal Relations. Each conference has had over 300 
attendees from the tribes, States and Federal leaders and their 
    Mr. Chairman, this concludes my testimony. I will stand for 
any questions.
    Wopila, Che'Migwetch. Thank you.
    [The prepared statement of Mr. Davis follows:]

Prepared Statement of Scott J. Davis, Executive Director, North Dakota 
   Indian Affairs Commission, Office of The Governor, State of North 
    Greetings Chairman Hoeven and members of the U.S. Committee on 
Indian Affairs. My name is Scott J. Davis, a proud member of the 
Standing Rock Sioux Tribe and descendent of the Turtle Mt. Band of 
Chippewa. My Lakota name is Oksate' Tawa'--His Celebration. I greet you 
all today with a warm handshake and good heart.
    I was given to permission from our North Dakota (ND) Tribal Nations 
to provide testimony today regarding the working relations between our 
5 ND Tribal Nations, ND State-Governor's Office and Federal Partners 
regarding the COVID 19 pandemic.
    Since the start of the Covid19 Pandemic, I immediately reached out 
to the 5 ND Tribal Leaders in asking them how they are going to respond 
to the pandemic in declaring a State of Emergency. As you now, Tribes 
have the authority to Declare on their own, through the Sanford Act, or 
to Declare with the Governor. In this case, the Tribes chose to Declare 
with Governor Doug Burgum. By doing so, it opened a lot of resources to 
the Tribes.
    Since then, we have committed to weekly calls from Governor Burgum 
to the 5 Tribal Chairs, Tribal Councils, Tribal Clinics and the Indian 
Health Service. Majority of the calls entail discussion about 
Protective Personal Equipment (PPE) and Testing Kits/Supplies. 
Discussions also entail guidance on opening businesses, schools and 
Tribal Colleges.
    Most importantly, we have partnered with the 5 ND Tribal Nations in 
conducting Testing Events. Two weeks ago, we finished our first round 
in testing all 5 ND Tribes. Today, we are continuing those partnered 
Testing Events in making sure that all ND Tribal communities and 
members get tested on a regular basis as requested from Tribal 
leadership. The events, at times, are led by the ND National Guard in 
partnership with the Tribal Incident Command Staff, Tribal Health 
Staff, Indian Health Service and local County Public Health offices.
    As a result of strong working relations and testing thousands of 
Tribal members, we have seen low positive COVID 19 cases on each of the 
5 ND Tribal Nations. We attribute this to resources available and 
delivered to the Tribes, e.g. PPE, Testing Kits, surge plans, data 
sharing and consistent communications.
    This partnership is a result of the commitment Governor Burgum has 
made with the 5 ND Tribal Nations since he took office. Tribal 
Engagement is one of five initiatives under the Burgum administration. 
Prior to the pandemic, Governor Burgum's office and my office have held 
countless meetings with the Tribes and have held 3 conferences 
entitled, Strengthening Tribal, State and Federal Relations. Each 
conference has had over 300 attendees from Tribal, State and Federal 
leaders and agencies.
    This concludes my testimony; I will stand for any questions.
    Wopila, Che'Migwetch--Thank you.

    The Chairman. Thank you, Mr. Davis. We will turn to Ms. 


    Ms. Elgin. Good afternoon, Chairman Hoeven, Vice Chairman 
Udall and members of the Committee . Thank you for inviting me 
to testify at today's oversight hearing.
    My name is Lisa Elgin, and I am the Secretary and 
California area rep to the National Indian Health Board, or 
NIHB. I am also tribal administrator for my tribe, which is the 
Manchester-Point Arena Band of Pomo Indians, and I chair the 
California Rural Indian Health Board.
    I would like to start by thanking the Committee for the 
work it has done so far to address COVID-19 in Indian Country. 
This includes over $1 billion for IHS under the CARES Act, and 
the $750 million tribal set-aside for testing under the 
Paycheck Protection and Healthcare Enhancement Act. These were 
necessary investments but not sufficient to stem the tide of 
the pandemic in tribal communities.
    As sovereign governments, many tribal nations have set 
their own timelines for reopening, which may or may not align 
with their State. For instance, of the 109 tribal nations in 
California, 70 percent continue to have tribal emergency and 
shelter in place orders still in effect, even though the State 
of California continues to reopen.
    What I would first like to focus on in my remarks is how 
this crisis has devastated Indian Country, the factors that 
made us more vulnerable, what needs to be done to mitigate the 
impacts on our people. Just like every public health crisis 
before it, COVID-19 has disproportionately impacted our people. 
Here are a few data points I will share to demonstrate this.
    According to CDC, our people have the highest COVID-19 
hospitalization rate nationwide. Our people are experiencing 
the second highest COVID-19 death rate nationwide. In New 
Mexico, our people account for 8 percent of the population, but 
over 53 percent of all COVID cases. In Montana, our people 
equal about 6 percent of the population, but over 13 percent of 
all cases.
    None of this is by accident, but the direct result of the 
United States' ongoing failure to fully honor its treaty 
obligations for healthcare. Here are a few stats that highlight 
this truth. Our people suffer more than any population from 
nearly all the underlying health conditions that CDC noted 
increase risks of COVID-19, including diabetes, respiratory 
illness, kidney disease and obesity.
    In 2018, per capita health spending was the lowest at IHS 
$3,779 compared to over $8,000 under Medicaid, over $9,500 
under the BIA, and over $13,000 under Medicare. The average age 
of an IHS hospital is four times the average age of mainstream 
hospitals. In fact, an IHS hospital built today could not be 
replaced for 400 years under current spending figures.
    Yet in California, we don't have a single tribal or IHS 
hospital. I repeat, not one hospital. We had an average of 25 
percent provider vacancy rate before the pandemic hit, 
including four physicians, nurses, pharmacists, and nurse 
practitioners. Nearly 6 percent of our people live in 
households without running water, compared to less than 1 
percent in the Nation.
    Roughly 22 percent of our people are uninsured, the highest 
percentage of any population in the Country. And to clarify, 
access to IHS is not the same thing as health insurance. In 
fact, by law, having access only to IHS means you are still 
    Across the 24 federally operated IHS hospitals, there are 
only a total of 33 ICU beds. Less than half of all IHS and 
tribal hospitals have operating rooms and only there is only 
one hospital, a level 3 trauma center in Alaska, that has 
capacity for more than 40 inpatients per day.
    On top of this, our third-party collections from payers 
like Medicaid and private insurance has plummeted by as much as 
$5 million per tribe per month. Admiral Weahkee testified 
before the House earlier this month that, he reported the IHS 
has seen third-party collections drop 30 to 80 percent below 
this time last year, that it would take years to recoup those 
    In short, the challenge are astronomical. Here is what 
Congress must do moving forward to address COVID-19. We invite 
you to review our written testimony for additional insight and 
recommendations on what needs to be done.
    We urge you to maintain all tribal provisions in the House-
passed Heroes Act. These are tribally vetted and bipartisan 
measures that are need to alleviate the worst impact of the 
crisis on our communities.
    Ensure timely passage of fiscal year 2021 appropriations 
for IHS. We cannot afford another continuing resolution or a 
shutdown during this pandemic.
    Pass the bipartisan S. 3937 STIP Reauthorization Act of 
2020. We thank Senator McSally and Senator Murkowski on that 
committee for championing this critical bill that would provide 
five years of guaranteed funding at an increase of $200 million 
overall. We are also very pleased that this bill includes 
language authorizing tribes to receive these funds as 638 
contracting and compacting agreements.
    Provide at least $1 billion for water and sanitation 
infrastructure. Thousands of our people from Alaska and Navajo 
Nation lack running water. Handwashing continues to be the 
number one way to protect against COVID. To speak plainly, we 
need running water to do that.
    In closing, I would like to leave you with a final thought. 
During both the 1918 Spanish flu pandemic and the 2009 H1N1 
pandemic, our people died at four times the rate of all other 
races combined. Our treaties were not fully honored back then; 
the same inexcusable reality is true today.
    Once again, I thank you for holding this important hearing, 
and inviting NIHB to testify. I look forward to your questions.
    [Phrase in Native tongue.] Thank you.
    [The prepared statement of Ms. Elgin follows:]

  Prepared Statement of Lisa Elgin, Secretary, National Indian Health 
    Chairman Hoeven, Vice Chairman Udall, and Members of the Committee, 
thank you for holding this critical oversight hearing to ``Evaluate the 
Response and Mitigation to the COVID-19 Pandemic in Native 
Communities.'' On behalf of the National Indian Health Board and the 
574 federally-recognized sovereign American Indian and Alaska Native 
(AI/AN) Tribal Nations we serve, I submit this testimony for the 
    Our nation is gripped by the most unprecedented public health 
crisis in generations. As of June 28, 2020 there are over 2.5 million 
COVID-19 cases nationwide and over 125,000 COVID-19 deaths, according 
to the Centers for Disease Control and Prevention (CDC). Public health 
data continues to demonstrate that not only are new cases not 
subsiding, they are dangerously increasing in countless jurisdictions 
nationwide. According to the CDC, on Thursday June 25, the United 
States recorded 40,588 cases--the highest number of cases reported in a 
single-day since April 6. In a data analysis from Kaiser Family 
Foundation, from June 11 to June 25 a total of 26 states reported 
increased COVID-19 cases including many with large AI/AN populations 
including Arizona, Oklahoma, Michigan, Nevada, Wisconsin, Washington, 
Wyoming, Montana, California, and Oregon. \1\
    \1\ Kaiser Family Foundation. 2020. States with Upward of 14-Day 
Trends in COVID-19 Cases and Positivity Rates. https://www.kff.org/
    But similar to every prior public health crisis, there are 
disparate and disproportionate impacts on underserved and marginalized 
communities, and Indian Country is at the epicenter. According to CDC, 
people with chronic obstructive pulmonary disease (COPD), type 2 
diabetes, and chronic kidney disease are at higher risk for a more 
serious COVID illness. AI/AN populations are disproportionately 
impacted by all three of these underlying health conditions. In 2017, 
CDC reported that age-adjusted percentages of COPD were highest among 
AI/ANs (11.9 percent vs 6.2 percent across all populations). \2\ While 
rates of End Stage Renal Disease have dropped by 54 percent among AI/
ANs as a result of the Special Diabetes Program for Indians (SDPI), AI/
ANs continue to experience a significant burden of kidney disease. 
Similarly, in 2017 it was reported that AI/ANs experienced the highest 
diabetes prevalence at 15.1 percent, at more than double the percentage 
for non-Hispanic Whites. \3\
    \2\ Wheaton AG, Liu Y, Croft JB, et al. Chronic Obstructive 
Pulmonary Disease and Smoking Status--United States, 2017. MMWR Morb 
Mortal Wkly Rep 2019;68:533-538. DOI: http://dx.doi.org/10.15585/
    \3\ Department of Health & Human Services, Centers for Medicare & 
Medicaid Services. 2018. LTSS Research: Diabetes in Indian Country 
Annotated Literature Review.https://www.cms.gov/Outreach-and-Education/
    Despite alarming gaps nationwide in population-specific COVID-19 
health disparities data, available information clearly demonstrates 
that Tribal communities are facing the brunt of this public health 
crisis. The federal government has treaty and trust obligations to 
fully fund healthcare in perpetuity for all Tribal Nations and AI/AN 
Peoples, and it is imperative that this obligation be met in the face 
of the COVID-19 pandemic.
    To that end, we are pleased that each previous COVID-19 relief 
package has included important Tribal health provisions, such as the 
$64 million in funding for Indian Health Service (IHS) under the 
Families First Coronavirus Response Act; $1.032 billion in funding for 
IHS under the CARES Act; and the baseline $750 million Tribal set-aside 
in testing under the Paycheck Protection and Healthcare Enhancement 
Act. But despite these meaningful investments, it is clear that they 
have been insufficient to address the grave impacts of COVID-19 in 
Indian Country.
    On June 2, 2020 NIHB submitted a letter to Senate Majority Leader 
McConnell and Minority Leader Schumer urging that as the Senate began 
negotiations on the next relief package, that all of the Tribally-
specific funding and legislative provisions outlined in the House-
passed HEROES Act be maintained and built upon by addressing critical 
areas of unmet need. To that end, NIHB has outlined several top 
priorities--some of which fall squarely under the Committee's 
jurisdiction, and others that we urge Committee members to work on in 
lockstep with colleagues serving on Interior Appropriations, Finance, 
and Health, Education, Labor and Pensions. NIHB also strongly supports 
the bipartisan S. 3650 and urges the full Committee to pass this 
important bill.
1.Ensure timely passage and meaningful increases to the overall Indian 
        Health Service (IHS) budget for Fiscal Year 2021 in line with 
        the Tribal Budget Formulation Workgroup Recommendations

   Without an enacted FY 2021 IHS budget that is passed on-
        time, the Indian health system will be left significantly 
        unprepared to tackle a potentially stronger wave of infections 
        in the fall and winter months ahead.

            --Therefore, it is imperative that IHS not be subject to 
        another continuing resolution or face the threat of another 
        government shutdown.

   While we appreciate the $1.032 billion appropriated to IHS 
        under the CARES Act, and the additional $2.1 billion proposed 
        under the House-passed HEROES Act, these investments do not 
        replace the need for strong and meaningful investments in the 
        annual appropriated IHS budget.

            --The IHS Tribal Budget Formulation Workgroup (TBFWG) has 
        outlined the need for $9.1 billion for IHS in FY 2021 to be 
        able to effectively address healthcare needs.

   AI/ANs continue to face significant health disparities, 
        especially for conditions like diabetes and respiratory 
        illnesses, which increase the risk of a COVID-19 infection. 
        Without a bold and substantive FY 2021 IHS budget to equip the 
        Indian health system with the tools to address these 
        disparities, they will continue to go unaddressed, leaving 
        Indian Country more vulnerable to COVID-19 outbreaks.

2. Pass the bipartisan S. 3937--Special Diabetes Program for Indians 
        Reauthorization Act of 2019--with slight changes to the new 
        ``Delivery of Funds'' language to ensure Tribes and Tribal 
        organizations are able to receive awards through P.L. 93-638 
        self-determination and self-governance contracts and compacts

   According to the CDC, diabetes is one of the strongest risk 
        factors for a more serious COVID-19 infection. AI/AN 
        communities are diagnosed with diabetes at more than double the 
        rate for Whites, and higher than any other population 

   The Special Diabetes Program for Indians (SDPI) is the only 
        program that has effectively reduced incidence and prevalence 
        of diabetes, and is responsible for a 54 percent reduction in 
        rates of End Stage Renal Disease and a 50 percent reduction in 
        diabetic eye disease. In a 2019 federal report, SDPI was found 
        to be largely responsible for $52 million in savings in 
        Medicare expenditures per year.

            --Despite its documented success, since September 30, 2019, 
        SDPI has gone through four short-term extensions, with the most 
        recent extension occurring under the CARES Act. SDPI is 
        currently set to expire on November 30, 2020.

   The bipartisan S. 3937, introduced by Senator McSally, and 
        supported by Senator Murkowki and Senator Sinema, would provide 
        5-years of guaranteed funding for SDPI at an increase to $200 
        million per year overall. This represents the first increase to 
        SDPI in over sixteen years, and the longest reauthorization in 
        over a decade.

   Significantly, S. 3937 would also authorize Tribes and 
        Tribal organizations to receive SDPI awards through P.L. 93-638 
        self-determination and self-governance contracting and 
        compacting agreements, thus allowing for greater local Tribal 
        control over the life-saving program.

            --However, Tribes and NIHB are requesting slight technical 
        tweaks to the new language in S.3937 to further clarify the 
        authority and prevent any potential administrative delays in 
        implementation. We urge the Committee to pass S.3937 with the 
        requested changes below.

             ``(2) DELIVERY OF FUNDS.- On request from an Indian tribe 
        or tribal organization, the Secretary shall award diabetes 
        program funds made available to the requesting tribe or tribal 
        organization under this section as amounts provided under 
        Subsections 106(a)(1) and Subsection 508(c) of the Indian Self-
        Determination Act, 25 U.S.C.  5325(a)(1) and  
        5388(c), as appropriate.''

3. Provide minimum $1 billion for water and sanitation development 
        across IHS and Tribal facilities

   In order to stem the tide of the COVID-19 pandemic in Indian 
        Country, it is essential that Congress make meaningful 
        investments in water and sanitation development across IHS and 
        Tribal facilities.

   The HEROES Act only outlined $30 million overall for water 
        and sanitation development in Indian Country ($10 million 
        within IHS, and $20 million within Bureau of Indian Affairs). 
        This is severely below the level of need to protect and 
        preserve health in AI/AN communities.

            --According to the 2018 IHS Sanitation Facilities 
        Infrastructure Report, roughly $2.67 billion is needed to bring 
        all IHS and Tribal sanitation facilities to a Deficiency Level 
        1 designation.

4. Provide meaningful increases to the IHS budget for telehealth, 
        electronic health records and health information technology 
        (IT) infrastructure development

   Limitations in the availability of AI/AN specific COVID-19 
        data are contributing to the invisibility of the adverse 
        impacts of the pandemic in Indian Country within the general 
        public. Senior IHS officials, including Chief Medical Officer 
        Dr. Michael Toedt, have stated publicly that existing 
        deficiencies with the IHS health IT system are inhibiting the 
        agency's ability to adequately conduct COVID-19 disease 
        surveillance and reporting efforts.

            --Lack of health IT infrastructure has also seriously 
        hampered the ability of IHS and Tribal sites to transition to a 
        telehealth-based care delivery system. While mainstream 
        hospitals have been able to take advantage of new flexibilities 
        under Medicare for use of telehealth during the COVID-19 
        pandemic, IHS and Tribal facilities have not because of 
        insufficient broadband deployment and health IT capabilities.

   The TBFWG has previously outlined the need for a roughly $3 
        billion investment to fully equip the Indian health system with 
        an interoperable and modern health IT system. It is critical 
        that Congress provide meaningful investments in health IT 
        technologies for the Indian health system to ensure accurate 
        assessment of AI/AN COVID-19 health disparities and equip 
        Indian Health Care Providers with the tools to seamlessly 
        provide telehealth-based health services.

5. Eliminate the sunset provisions under Section 30106 of HEROES so 
        that removal of the ``four walls'' Medicaid billing restriction 
        and extension of 100 percent FMAP to urban Indian organizations 
        are made permanent; Clarify the four walls language to ensure 
        that the fix to the billing restriction is made both for 
        services provided by an Indian Health Care Provider outside the 
        four walls, and those services on the basis of a referral

   Currently, IHS and Tribal providers are largely restricted 
        from billing for medical services outside the four walls of a 
        clinic. This means that home visits, telehealth, and other 
        necessary outpatient COVID response services can't be 
        reimbursed, leading to serious gaps in accessibility of care.

   In March 2020, in an effort to improve access to services 
        during the COVID-19 pandemic, the Centers for Medicare and 
        Medicaid Services (CMS) announced that it would not review 
        claims for compliance with the four walls restriction before 
        January 30, 2021.

            --This means that if Section 30106 of HEROES were to be 
        enacted as is, the fix to the four walls restriction would only 
        be in effect for five months. In addition, the four walls 
        language under Section 30106 only fixes the four walls billing 
        restriction for services on the basis of a referral, not those 
        services provided by Indian Health Care Providers (IHCPs) 
        outside the four walls--such as in patient's homes, schools, 
        jails, or other locations. Not only is it critical that the 
        four walls fix be made permanent, it is equally critical that 
        the fix to the four walls billing restriction be made for both 
        services provided by IHCPs outside the four walls, and those 
        services on the basis of a referral.

   Delaying the four walls issue does not solve it. In 
        addition, there is very little incentive for states to work 
        with Tribes to amend their Medicaid programs for only a five 
        month fix to the four walls issue, especially given the 
        resources that go into that process.

            --However, Tribes and NIHB are vehemently opposed to 
        extending 100 percent FMAP to non-Indian Health Care Providers 
        as part of the legislative fix to the four walls restriction.

6. Authorize Indian Health Care Providers (IHCPs) to receive Medicaid 
        reimbursement for all medical services authorized under the 
        Indian Health Care Improvement Act (IHCIA)--called ``Qualified 
        Indian Provider Services''--when delivered to Medicaid-eligible 
        American Indians and Alaska Natives

   Currently, IHCPs only receive reimbursement for health 
        services authorized for all providers in a state. Therefore, 
        although IHCIA authorizes medical services such as long-term 
        care and mental/behavioral services that are crucial for Tribal 
        communities to respond to COVID-19, an IHCP will not be 
        reimbursed for these services if they are not covered by the 
        state Medicaid program.

   Because of chronic underfunding of IHS, many Tribes utilize 
        third party collections from payers like Medicaid to constitute 
        up to 60 percent of their healthcare operating budgets. But 
        without the authority to bill for services already authorized 
        under federal law, it is further straining Tribal COVID 
        response efforts.

            --This provision reinforces the direct relationship between 
        Tribes and the federal government by ensuring that IHCPs are 
        reimbursed at 100 percent FMAP for all services authorized 
        under IHCIA, at no cost to the states.

7. Enact Certain Sections of the Bipartisan CONNECT to Health Act

   The bipartisan Creating Opportunities Now for Necessary and 
        Effective Care Technologies (CONNECT) for Health Act of 2019 
        (S. 2741) was introduced in October 2019 and has the broad 
        support of over 100 health organizations.

            --Section 3 of the CONNECT to Health Act would provide the 
        U.S. Department of Health and Human Services (HHS) with the 
        ability to waive certain telehealth restrictions outside of the 
        national emergency context. These waivable restrictions include 
        limitations on provider types, technology, geographic area, and 
        services. These are critical authorities to ensure flexibility 
        in delivery of mental and behavioral care.

            --Section 8 of the CONNECT to Health Act would eliminate 
        originating site requirements with respect to facilities 
        operated by IHS, a Tribe or Tribal organization which make it 
        very difficult to deliver mental and behavioral health care.

   Originating site requirements currently mandate that a 
        patient be in a particular location such as a physician's 
        office, hospital, or other specified clinical setting. These 
        requirements prevent patients from being able to receive mental 
        and behavioral health services from their homes, community 
        centers, or other non-clinical locations.

            --In addition, Sections 4, 5, 7, and 14 of the CONNECT Act 
        affect use of telehealth for mental health services, emergency 
        care, rural health clinics, and Federally Qualified Health 
        Centers (FQHCs); and also expands the list of health 
        professionals who may provide services through telehealth--all 
        of which have immediate and long-term benefits to the Indian 
        health system.

8. Include Pharmacists, Licensed Marriage and Family Therapists 
        (LMFTs), Licensed Professional Counselors, and other providers 
        as eligible provider types under Medicare for Reimbursement to 
        Indian Health Care Providers

   There is a severe, longstanding, and well-documented 
        shortage of healthcare professionals in Indian Country. Because 
        of this shortage, Indian healthcare programs rely extensively 
        and increasingly on the services of other types of licensed and 
        certified non-physician practitioners, including Licensed 
        Marriage and Family Therapists (LMFTs), Licensed Professional 
        Counselors (LPCs), Certified Community Health Aides and 
        Practitioners (CHAPs), Behavioral Health Aides and 
        Practitioners (BHAPs), and Pharmacists

            --LMFTs, LPCs, and higher-level BHAPs are qualified to 
        furnish many of the same services that psychiatrists, CSWs, and 
        psychologists do. Among other services, pharmacists in Indian 
        programs deliver clinic-based, protocol-driven care on behalf 
        of physicians, including tobacco cessation, and medication-
        assisted treatment (MAT) for substance use disorders.

   All these providers furnish essential, effective, and high-
        quality care that is covered by many Medicaid programs, yet 
        Medicare does not cover them, nor do the many non-governmental 
        healthcare plans and health insurers that follow Medicare's 

   This deprives Indian Health programs of critically needed 
        federal reimbursement for vital healthcare services to AI/ANs, 
        which is critical to an effective COVID-19 response.

9. Permanently Extend Waivers under Medicare for Use of Telehealth

   COVID-19 has dramatically increased the need to connect 
        patients to their providers through telehealth for medical and 
        behavioral health services. In response, CMS has temporarily 
        waived Medicare restrictions on use of telemedicine.

   Yet for many Tribes that lack broadband and/or telehealth 
        capacity and infrastructure, it is not financially feasible to 
        purchase expensive telehealth equipment for a short-term 

            --Making permanent the telehealth waivers for both video 
        and audio-based telehealth services would ensure that the 
        telehealth delivery system remains a viable option for delivery 
        of essential medical, mental and behavioral health services in 
        Indian Country, and helps close the gap in access to care.

The Numbers: COVID-19 in Indian Country
    As of June 24, IHS has reported 18,240 positive cases, with roughly 
67 percent of positive cases being reported out of the Phoenix and 
Navajo IHS Areas alone. However, IHS numbers are highly likely to be 
underrepresented because case reporting by Tribal health programs, 
which constitute roughly two-thirds of the Indian health system, are 
voluntary. According to data analysis by APM Research Lab, AI/Ns are 
experiencing the second highest aggregated COVID-19 death rate at 36 
deaths per 100,000. \4\ The CDC reported that from March through June 
13, 2020 age-adjusted COVID-19 hospitalization rates among AI/ANs were 
higher than any other ethnicity, at 221.2 per 100,000. \5\ Reporting by 
state health departments has further highlighted disparities among AI/

    \4\ APM Research Lab. The Color of Coronavirus: COVID-19 Deaths by 
Race and Ethnicity in the U.S. https://www.apmresearchlab.org/covid/
    \5\ Centers for Disease Control and Prevention. COVID-19 Data 
Visualization. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-

   In New Mexico, AI/ANs represent roughly 8 percent of the 
        population, yet account for over 53 percent percent of all 
        COVID-19 cases. \6\
    \6\ New Mexico Department of Health. COVID-19 in New Mexico. 

   As of this writing, the Oyate Health Center in South Dakota 
        has conducted 544 COVID-19 tests, with 114 confirmed positive 
        case results (20.9 percent). Of those 114 cases, 13 were 
        reported between June 10 and June 16. \7\
    \7\ Great Plains Tribal Chairman's Health Board. CEO Update: Oyate 
Health Center To Host Mass Testing, New Website Launches. https://

   In Wyoming, AI/ANs account for over 27 percent of all COVID-
        19 cases statewide despite representing only 2.9 percent of the 
        state population. \8\
    \8\ Wyoming Department of Health. COVID-19 Map and Statistics. 

   Similarly in Montana, where AI/ANs constitute about 6.6 
        percent of the state population, over 13 percent of confirmed 
        COVID-19 cases are among AI/ANs. \9\
    \9\ Montana Department of Public Health and Human Services. https:/

   In Arizona where AI/ANs account for roughly 5 percent of the 
        state population, as of June 28, 2020 they represented 15 
        percent of those hospitalized for COVID and roughly 9 percent 
        of all COVID cases statewide. \10\
    \10\ Arizona Department of Health Services. COVID Data Dashboard. 

    Most poignantly, in a data visualization of COVID-19 case rates per 
100,000 by Tribal Nation created by the American Indian Studies Center 
at the University of California Los Angeles, it was found that if 
Tribes were states, the top five infection rates nationwide would all 
be Tribal Nations. \11\
    \11\ University of California Los Angeles. American Indian Studies 
Center. Coronavirus in Indian Country: Latest Case Counts. Retrieved 
from https://www.aisc.ucla.edu/progression_charts.aspx
    The COVID-19 pandemic has further exposed the vast deficiencies in 
health care access, quality, and availability that exists across the 
Indian health system. Prior to COVID-19, the Indian health system was 
beset by an average 25 percent clinician vacancy rate, \12\ and a 
hospital system that remains over four times older than the national 
hospital system. \13\ Limited intensive care unit (ICU) capacity to 
address a surge of COVID cases across many IHS and Tribal facilities 
has strained limited Purchased/Referred Care (PRC) dollars, creating 
further challenges that are contributing to rationing of critical 
health care services. Overall, per capita spending within IHS ($3,779) 
is at only 40 percent of national health spending ($9,409), making IHS 
the most chronically underfunded federal health care entity nationwide 
and thus severely ill-equipped to respond to COVID-19.
    \12\ Government Accountability Office (GAO-18-580). https://
    \13\ Indian Health Service. 2016. IHS and Tribal Health Care 
Facilities' Needs Assessment Report to Congress. https://www.ihs.gov/
    For example, while CDC has noted that hand-washing is the number 
one way of protecting against a COVID-19 infection, water and 
sanitation infrastructure in Indian Country is significantly 
underdeveloped. Approximately 6 percent of AI/AN households lack access 
to running water, compared to less than half of one percent of White 
households nationwide. \14\ In Alaska, the Department of Environmental 
Conservation reports that over 3,300 rural Alaskan homes across 30 
predominately Alaskan Native Villages lack running water, forcing use 
of ``honey buckets'' that are disposed in environmentally hazardous 
sewage lagoons.
    \14\ US Water Alliance. 2019. Closing the Water Access Gap in the 
United States. Retrieved from http://uswateralliance.org/sites/
    Because of the sordid history of mineral mining on Navajo lands, 
groundwater on or near the Navajo reservation has been shown to have 
dangerously high levels of arsenic and uranium. As a result, roughly 30 
percent of Navajo homes lack access to a municipal water supply, making 
the cost of water for Navajo households roughly 71 times higher than 
the cost of water in urban areas with municipal water access. \15\ In 
fact, in a new peer-reviewed study of 287 Tribal reservations and 
homelands, COVID-19 cases were found to be 10.83 times more likely in 
homes without indoor plumbing. \16\
    \15\ Ingram, J. C., Jones, L., Credo, J., & Rock, T. (2020). 
Uranium and arsenic unregulated water issues on Navajo lands. Journal 
of vacuum science & technology. A, Vacuum, surfaces, and films : an 
official journal of the American Vacuum Society, 38(3), 031003.https://
    \16\ Rodriguez-Lonebear, Desi PhD; Barcel cents, Nicol s E. MD; 
Akee, Randall PhD; Carroll, Stephanie Russo DrPH, MPH American Indian 
Reservations and COVID-19, Journal of Public Health Management and 
Practice: July/August 2020--Volume 26--Issue 4--p 371-377 doi: 10.1097/
Gaps in COVID-19 AI/AN Public Health Data
    These existing capacity and resource shortages meant that the 
Indian health system was woefully unprepared to prepare, prevent, and 
respond to the COVID-19 pandemic. Available data on AI/AN COVID-19 
health disparities reaffirms this central point. Unfortunately, because 
of high rates of misclassification and undersampling of AI/AN 
populations in federal, state, and local public health disease 
surveillance systems, available data likely significantly 
underrepresents the scope of the impact in Indian Country. To be clear, 
misclassification of AI/ANs on disease surveillance systems is not 
unique to COVID-19.
    Previous studies have found significantly higher rates of 
misclassification outside of IHS Contract Health Service Delivery Areas 
(CHSDA); \17\ for all-cause mortality rates in states like Oklahoma; 
\18\ for HIV infections among AI/ANs across five states; \19\ and on 
death certificates reported to CDC. \20\ However, the issue has taken a 
new level of urgency given the unprecedented devastation of this 
pandemic on underserved communities.
    \17\ Jim, M. A., Arias, E., Seneca, D. S., Hoopes, M. J., Jim, C. 
C., Johnson, N. J., & Wiggins, C. L. (2014). Racial misclassification 
of American Indians and Alaska Natives by Indian Health Service 
Contract Health Service Delivery Area. American journal of public 
health, 104 Suppl 3(Suppl 3), S295-S302. https://doi.org/10.2105/
    \18\ Dougherty, Tyler M. MPH, CPH; Janitz, Amanda E. PhD, BSN, RN; 
Williams, Mary B. PhD; Martinez, Sydney A. PhD; Peercy, Michael T. MPH, 
MT(ASCP)H; Wharton, David F. MPH, RN; Erb-Alvarez, Julie MPH, CPH; 
Campbell, Janis E. PhD, GISP Racial Misclassification in Mortality 
Records Among American Indians/Alaska Natives in Oklahoma From 1991 to 
2015, Journal of Public Health Management and Practice: September/
October 2019--Volume 25--Issue--p S36-S43 doi: 10.1097/
    \19\ Bertolli, J., Lee, L. M., Sullivan, P. S., & AI/AN Race/
Ethnicity Data Validation Workgroup (2007). Racial misidentification of 
American Indians/Alaska Natives in the HIV/AIDS Reporting Systems of 
five states and one urban health jurisdiction, U.S., 1984-2002. Public 
health reports (Washington, D.C. : 1974), 122(3), 382-392. https://
    \20\ Centers for Disease Control and Prevention. 2016. The Validity 
of Race and Hispanic-Origin Reporting on Death Certificates in the 
United States: An Update. https://www.cdc.gov/nchs/data/series/sr_02/
    Multiple states with large AI/AN populations including but not 
limited to Minnesota, Michigan, New York and California are reporting 
thousands of COVID cases without any information on patient ethnicity, 
or categorizing cases as ``other'' on demographic forms. In California 
for instance, the state has noted that race/ethnicity data is missing 
for nearly 30 percent of reported cases. Multiple studies have 
demonstrated that AI/ANs are more likely to be misclassified as 
``other'' or are omitted from surveillance systems entirely.
    Thus, these structural challenges in data reporting only serve to 
render invisible the disparate impact of COVID-19 in Indian Country. 
Relatedly, Tribal Epidemiology Centers (TEC) continue to face 
significant barriers in exercising their statutory public health 
authorities by facing major hurdles in accessing federal and state 
public health surveillance systems, including for COVID-19 data. \21\ 
These issues continue to have a direct negative effect on health 
outcomes for AI/AN Peoples, and are exacerbating the impact of COVID-19 
in Indian Country.
    \21\ Centers for Disease Control and Prevention. Issue Brief on 
Tribal Epidemiology Center Legal Authorities. https://www.cdc.gov/phlp/
    Unfortunately, the adverse impacts of COVID-19 in Indian Country 
extend far beyond these sobering public health statistics. Tribal 
economies have been shuttered by social distancing guidelines that have 
also severely strained Tribal healthcare budgets. Because of the 
chronic underfunding of IHS, \22\ Tribal governments have innovatively 
found ways of maximizing third party reimbursements from payers like 
Medicare, Medicaid, and private insurance. For many self-governance 
Tribes, third party collections can constitute up to 60 percent of 
their healthcare operating budgets. However, because of cancellations 
of non-emergent care procedures in response to COVID-19, many Tribes 
have experienced third party reimbursement shortfalls ranging from 
$800,000 to $5 million per Tribe, per month. In a hearing before House 
Interior Appropriations on June 11, 2020, IHS Director Rear Admiral 
(RADM) Weahkee stated that third party collections have plummeted 30-80 
percent below last year's collections levels, and that it would likely 
take years to recoup these losses.
    \22\ Per capita spending at IHS in FY 2018 equaled $3,779 compared 
to $9,409 in national health spending per capita; $9,574 in Veterans 
Health Administration spending per capita; and $13,257 per capita 
spending under Medicare.
    These funding shortfalls have forced Tribes across the lower 48 and 
Alaska to furlough hundreds of workers, curtail available healthcare 
services, or close down clinics entirely. For example, Tribes in the 
Bemidji Area reported that nearly 20 percent of their healthcare system 
and 35 percent of their government services staff were forced to be 
furloughed due to revenue shortfalls. Meanwhile, Tribal business 
closures have compounded the devastation of the COVID pandemic in 
Indian Country. According to the Harvard Project on American Indian 
Economic Development (HPAIED), before COVID-19 hit, Tribal governments 
and businesses employed 1.1 million people and supported over $49.5 
billion in wages, with Tribal gaming enterprises alone responsible for 
injecting $12.5 billion annually into Tribal programs. During the six 
week period (through May 4, 2020) whereby all 500 Tribal casinos were 
closed in response to COVID-19 guidelines, Tribal communities lost $4.4 
billion in economic activity, with 296,000 individuals out of work and 
nearly $1 billion in lost wages. \23\
    \23\ Meister Economic Consulting. Coronavirus Impact on Tribal 
Gaming. Retrieved from http://www.meistereconomics.com/coronavirus-
    Extrapolated across the entire U.S. economy, collectively $13.1 
billion in economic activity was lost during the same time period, in 
addition to $1.9 billion in lost tax revenue across federal, state and 
local governments. In a new visualization created by NIHB, over 193,000 
AI/ANs have become uninsured as a result of COVID-19 job losses, with 
the vast majority of these individuals (72 percent) lacking access to 
IHS as well. \24\
    \24\ National Indian Health Board. Estimating Covid-19 caused 
increases in Uninsured AIANs due to job loss. https://
    Such astronomical losses in Tribal healthcare and business revenue 
are exacerbating the already disproportionate impact of COVID-19 
infections in Indian Country, and are further reducing available 
resources for Tribes to stabilize their health systems and provide 
critical COVID-19 and related health services to their communities. As 
such, we urge the Committee to work on the recommendations outlined at 
the top of this letter, and stand ready to work with you in a 
bipartisan manner to secure their passage.
    Thank you for your consideration of the recommendations outlined in 
this letter. We look forward to working with you to ensure that Indian 
Country's health care concerns and priorities are comprehensively 
addressed, as we respond to the COVID-19 pandemic.

    The Chairman. Thank you, Ms. Elgin.
    At this point, we will turn to questions. I am going to 
start with Mr. Davis. I know Governor Burgum has an excellent 
working relationship with the tribes in North Dakota, and that 
you are a very important part of that.
    Can you tell the Committee how testing within the five 
tribal communities in the state is going? What are lessons 
learned? Any recommendations you have that could be useful 
    Mr. Davis. Good question, Senator Hoeven, thank you.
    That is correct; Governor Burgum has a very good 
relationship with the tribes. It is not by chance, it has been 
from hard work, I will just say that. It has been a lot of work 
go into those relations. I think in times like this, you kind 
of see the, I hate to use the word, the fruits of it, but in 
times of this pandemic, in this case, it has shown its fruits, 
because our tribal members are tested daily, weekly.
    We just wrapped up a large testing event up in Turtle 
Mountain yesterday, the largest tribe in North Dakota. We 
tested about 250 yesterday in partnership with our county 
partners, who tested another part of the tribe, and also IHS 
tested the businesses.
    So you will see a unified, partnered strategy here, 
Senator, and members of the Committee . When I think about this 
virus, it obviously does not see jurisdiction. So what affects 
my tribe will affect the county, will certainly affect the 
State and vice versa. So we are being very, very dedicated to 
the testing events upon request from the tribes, and exercising 
the National Guard in partnership with IHS and the health 
departments and the counties.
    So these testing events are very large. I have been to 
every one of them. I think I missed one. But they are very 
long, there is a lot of planning involved. But it goes back to 
the partnerships, the communications we have had. I go back to 
the weekly calls, Chairman, and the weekly calls that we have 
with our partners, the feds, obviously the IHS, a part of that, 
the tribal college presidents, the tribal councils, obviously, 
and the tribal chairs of where we are.
    Also, now we are looking at data. We do have data sharing 
agreements with the tribes that are a legal document. But now 
we are trying to home in on the results of these tests, of 
streamlining where they are by region, also by address. Age and 
gender is obviously included in that, as well.
    So these are the shared data agreements that tribes may 
have, a data dashboard, if you will. But we do have that, as 
you know, Governor Burgum is a pretty techie guy, so this data 
stuff is really important to him.
    These are the good things, the tools that we have that we 
are sharing with the tribe. The PPE stuff, just had two 
shipments delivered to the tribes today. Those are upon 
request, whether masks, gloves, you name it, we deliver that, 
and also testing kits.
    So right now, where I am from in Standing Rock, we are 
trying to work with the State of South Dakota and doing another 
unified, joint testing event, hopefully down in the South 
Dakota side this time, and making sure that my tribal members 
from Standing Rock are all tested as well.
    The Chairman. Recently, there has been an outbreak, I 
think, on the MHA Nation Reservation. To address community 
spread, what are you doing in your position with contact 
tracing and that kind of thing, in order to try to curtail 
that? Whether in this case it is MHA, or one of the other 
    Mr. Davis. Chairman Hoeven, another good question there. 
Yes, that is another big part of the portfolio, if you will, 
for COVID. Contact tracing is a big piece of this. Again, I go 
back to jurisdiction.
    So we deploy our contact tracing teams, whether it is 
through the Department of Health or the university systems, or 
even sometimes our private hospitals. We make sure that we work 
in unison with the tribes, in this case, MHA, making sure that 
that information is shared, but also when the calls are made to 
the people who are under-investigated, and that is a good word, 
I guess, in this case, of who that person has been around with 
a positive test, making sure those folks are tested immediately 
within one or two days. Then we go from there.
    Also, Chairman, at least the homeless shelters. Because as 
we all know in this room, housing and placing people who have 
limited water, that was talked about earlier, we are going 
through one right now back home at Cannonball, we have a family 
that tested positive there that doesn't have running water. So 
we deployed our resources, State resources with the tribe, to 
make sure that there was a hotel room that was available for 
that family who tested positive.
    But that time is running out. We are looking at a deadline 
of July 11th where that facility will be backing out of that 
and resuming business. But my call again this morning with FEMA 
ensures us that that funding will be available for those 
homeless shelters. It is up to us to find that facility or a 
private motel of some sort to make sure that tribal members are 
safe during the quarantine process.
    So one thing that I did want to share, Chairman, some of 
the Federal facilities that the tribes are requesting, I am on 
these calls with Interior, is that it takes a little bit longer 
time to get the okay from Interior to get that facility or that 
building switched over to a homeless shelter or a quarantine 
area. So you probably see or hear inquiries from tribes, not 
just from the Great Plains, but I am assuming across Indian 
Country, on possibly streamlining some of those Federal 
properties regarding, in this case, Interior, that could be 
opened for homeless shelters and also the quarantine process.
    The Chairman. Thank you. Vice Chairman Udall.
    Senator Udall. Thank you, Mr. Chairman.
    In the House hearing last month, IHS Director Weahkee 
indicated that IHS facilities have lost 30 to 80 percent of 
their normal revenue from third-party billing collections due 
to the COVID-19 pandemic. He also acknowledged that the 
payments to IHS facilities from the Provider Relief Fund have 
not fully offset these losses.
    Ms. Elgin, is it fair to say that a number of IHS 
facilities are still feeling the consequences of the revenue 
shortfalls caused by COVID-19?
    Ms. Elgin. Absolutely. Just two weeks ago, Admiral Weahkee 
told the House Interior Appropriations Subcommittee that the 
agency is experiencing third-party revenue shortfalls at 30 to 
80 percent, like you said, below collections this time last 
year, and that it will take years to recoup those losses. The 
House-passed Heroes Act allocated $1 billion to address revenue 
    But this was back in mid-May. Since then, COVID cases in 
Indian Country have only continued to increase, and the need is 
more likely higher than $1 billion. We urge the Senate to 
increase the funding for the tribes as you work on your next 
COVID relief package.
    Senator Udall. Thank you very much. We are doing that. I am 
working with a number of colleagues to address these 
operational funding shortfalls in the next COVID-19 relief 
package. It is clear that IHS facilities need direct access to 
supplemental funding. But I believe that there are also policy 
corrections Congress can enact to further address this issue.
    The bill on today's legislative hearing agenda, S. 3650, 
the Coverage for Urban Indian Health Providers Act, is one such 
example. It would address a longstanding imbalance within the 
IHS for Urban Indian health programs, and help reduce their 
operating costs at a time when many programs would otherwise 
face furloughs and belt-tightening.
    Ms. Elgin, what further policy corrections could Congress 
enact to alleviate operation funding shortfalls for IHS 
    Ms. Elgin. At the very least, we urge the Senate to 
maintain the $1 billion outline for revenue shortfalls within 
IHS tribal and Urban Indian facilities in the House-passed 
Heroes Act as the adverse impacts of this pandemic carry on, or 
likely even more relief funding to replenish third-party 
revenue shortfalls will be needed.
    Senator Udall. Ms. Elgin, I have heard concerns from tribal 
leaders and Urban Indian health programs about decisions other 
HHS agencies have made regarding administration of Indian 
Country's specific COVID-19 health resources, particularly 
related to administration of funding and grants. Can you 
provide some examples of grant or resource administration 
practices within HHS or FEMA that have hamstrung tribal and 
Urban Indian response and mitigation efforts during the 
Coronavirus pandemic?
    Ms. Elgin. Yes, there have been significant challenges. 
Number one, Federal treaty obligations cannot be fulfilled 
through competitive grants. Even though COVID, like many tribe 
didn't have dedicated grant writers. When they do, those grant 
writers are more likely to be wearing multiple hats.
    Tribes had limited capacity before COVID. And with the 
furloughs and reduced hours, capacity is even lower now. Many 
of HRSA's and CDC's grant application reporting requirements 
are very onerous, some requiring 20 pages per application and 
hours upon reporting.
    Unfortunately, this has led some tribes to forego applying 
for some grants to begin with, because they don't have the time 
to write these long grants. That is a very difficult decision 
to make, because the tribes absolutely need the money. No tribe 
should be put in this position. CDC needs to make sure that it 
is funding every tribe for public health, not just some of 
    To be fair, we are very appreciative of the fact that CDC 
added an additional $40 million on top of the $40 million 
Congress set aside for the tribes. And in the Corona 
Preparedness and Response Act, they also were receptive to the 
feedback to make the grants non-competitive, which they did 
with the additional $40 million they allocated to the tribes.
    But much more needs to be done and the issues continue. For 
instance, we still do not know what CDC is doing with the $125 
million in tribal funding allocated under the CARES Act. We 
have demanded answers, but have yet to receive them. Tribes 
need that money to be released as quickly as possible and it 
must cover every single tribe. If the Federal government can't 
get away with funding on State and not another, it should not 
get away with only funding some tribes.
    A major issue is lack of technical assistance given tribes 
on how to spend the COVID money, the timelines for spending it, 
the restrictions on spending it and eligibility. We need grant 
administration TA. NIHB is filling in this gap and trying to 
provide TA to the tribes, but Congress needs to provide HHS 
with dedicated funding to assist tribes with grant management.
    With FEMA, tribes have consistently urged the 
Administration to waive cost-sharing requirements. We just need 
a statutory fix to this problem.
    Senator Udall. We really appreciate that.
    Mr. Chairman, I have one more question, with your 
    The Chairman. Certainly.
    Senator Udall. In 2010, Congress designated tribal 
epidemiology centers as public health authorities and granted 
them access to CDC's disease surveillance data bases. But a 
decade later, when the Coronavirus pandemic struck, the CDC 
still hadn't worked with Indian Country to implement these 
important pieces of tribal public health infrastructure. This 
is a longstanding issue for Indian Country. Access to real-time 
accurate health data is critical to a successful COVID-19 
    Ms. Elgin, in NIHB's opinion, can IHS, tribes, and Urban 
Indian health programs accurately monitor COVID-19 activity 
using their existing public health surveillance and health IT 
    Ms. Elgin. We are trying our best, but there are 
significant barriers. Chief Medical Officer Michael Toedt has 
publicly stated that the IHS antiquated health IT system is 
seriously limiting their ability to engage in COVID 
surveillance. Many of the tribes have purchased their own 
commercial, off the shelf, EHR systems. In California, for 
instance, tribes use NextGen, but one big problem is lack of 
interoperability, our systems aren't talking to each other as 
well as they need to be. And that is negatively impacting our 
patients' health. Through the IHS tribal budget formulation 
workgroup, the tribes have recommended $3 billion to ensure the 
full Indian Health system has a well-functioning health IT 
system. To this end, we absolutely need parity with the VA.
    To give one example, under the CARES Act, Congress gave the 
VA $3.1 billion just for health IT. In comparison, IHS only got 
$65 million. With IHS relying on the VA system, we need parity 
in investment. Otherwise, Indian Country will be left behind.
    Just a related issue that has received media attention is 
the fact that the tribes and tribal epicenters have faced 
serious challenges in accessing public health data from the CDC 
and from the States. Tribes and tribal epicenters are public 
health authorities under law.
    Yet CDC continues to deny tribes access to CDC's 
surveillance systems, despite readily giving this to the 
States. Many States incorrectly cite HIPAA concerns, or flat-
out refuse to share data with the tribes. We are sovereign 
governments and we have the same authority as States to access 
public health data.
    While tribes have tried working with their States in good 
faith to access data that rightfully belongs to us, we continue 
to encounter many barriers. We urge Congress to ensure 
meaningful funding for health IT for the tribes. One way we can 
address the problem with access to State data is by having 
Congress require States to share public health data with tribes 
and tribal epicenters as a condition of receiving the CDC 
surveillance funding.
    We remain committed to working with all of you in these 
    Senator Udall. Thank you very much, Ms. Elgin. Mr. 
Chairman, just let me say, I think this has been a very 
important hearing. We have had two panels. We have looked at 
oversight in a serious way, and I think it has given us a lot 
of issues we should be working on.
    Congress must do everything in its power to keep every IHS 
facility up and running during this pandemic. I hope we can 
work in a bipartisan fashion to expeditiously enact provisions 
to close some of these policy loopholes and secure more direct 
funding for the Indian Health Service.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Vice Chairman Udall.
    We do have Senator Smith who has some questions for the 
witnesses. Senator Smith?
    Senator Smith. I know it has been a long afternoon and Ms. 
Elgin has waited to speak with us. So I am grateful just to ask 
two things I was really anxious to hear your perspective on, 
Ms. Elgin.
    The first has to do with mental health issues and the 
special mental health issues with tribal youth. This is 
something I am so concerned about, about all of our youth not 
being in school, not having access to the nutrition that they 
are used to, the structure that they are used to, potentially 
not having a safe place to be during the day, the schools not 
being open.
    I also know that the Bureau of Indian Education, as I 
understand it, didn't get CARES Act funds out to schools before 
the end of the year. Many schools in Minnesota haven't received 
those dollars yet.
    My question is, could you give us some advice about how we 
should think about meeting the mental and behavioral health 
needs of Native students in the midst of this pandemic?
    Ms. Elgin. Thank you. Yes, I will try. It is a good 
question highlighting one of the key detriments that have 
happened around mental health. We heard that from the 
Administration, that drug overdoses have increased this year, 
likely as a result of the greater social isolation. Our people 
and Native youth are definitely being impacted. We have the 
second highest opioid overdose deaths and experienced the 
highest increase in drug ODs between 1999 and 2015. Because of 
that, the tragedy of suicide does continue.
    It goes back, many tribal communities struggle with food 
insecurity. According to USDA, roughly 28 percent of our Native 
households with children are food insecure. In some areas, 
rates of food insecurity are higher than 40 percent. Only 25 
percent of our people living on the reservation are within one 
mile of the supermarket compared with 60 percent of the general 
    We are all looking at ways to fix this. I just want to say, 
too, we didn't talk too much about homelessness. But I think 
this comes into play as well. We know that can happen, even on 
the reservation, the gentleman talked about homes being 
overcrowded sometimes, and you have to move away from your 
family. With that comes this mental anguish and stress, again, 
that is not just faced by tribal or Native youth, but elders 
and the whole family in general.
    I think tribes are working their best, trying to get 
measures in place to secure an emergency housing situation that 
they may need. Speaking for my own tribe, we put things and 
measures in place that if we have to move a family away, it is 
going to be somewhere near, and not going to really put them in 
danger of going to a bigger city. I am two hours away from the 
biggest town near me, and just trying to get the food 
stockpiles there, and all the supplies you need, everything, it 
all comes with this stress and anguish going on now.
    So I along with our neighboring tribes here are working 
together just to come together and a plan that will help and 
work with the mental health issues surrounding this COVID.
    Senator Smith. I think COVID happens in the context of 
historic trauma, this is layered on that historic trauma, 
especially the trauma around an illness and sickness and 
disease that is brought to Indian Country. I really think this 
is an area where we have a shortage of mental health services 
and substance abuse services generally. It is exacerbated in 
Urban Indian communities and also on tribal land. It is very 
important for us to think of this now.
    I want to just say as I close, Mr. Chair, that the comments 
you were making, Ms. Elgin, about the challenges that tribes 
faced dealing with grant-based programs all the time really 
resonate with me, because that is often our solution. And then 
it not only puts additional pressure and stress on tribal 
governments and their leadership and those Urban Indian 
Organizations, but it also puts tribes in a position of having 
to compete against one another when that is not at all the 
spirit of our trust and treaty obligations, when it comes to 
our relationships with tribal governments.
    In exchange for the land, we had promised health care. As a 
promise, it should not be broken.
    I thank you very much, Mr. Chair. I will close, and thank 
you for the opportunity to be a part of this hearing today.
    The Chairman. Thank you, Senator Smith.
    Just a couple of quick questions I have in wrapping up. 
First, for Mr. Davis, as we work on this, and I know you are 
involved, you said both from the State side, I think from the 
Federal side, also from the tribes, as we continue to work on 
this, what costs do you see as the most in need for 
reimbursement? As we move forward, what costs are most in need 
for reimbursement?
    Mr. Davis. That is a good question, Senator Hoeven.
    I know the tribes are counting their costs as we speak, as 
well as the State. It is very costly. Hopefully, that will be 
all 100 percent reimbursable from the feds.
    As far as the high costs, I think it is the personnel, the 
time. When I look at the doctors and health care providers and 
law enforcement, even just leadership, there are a lot of 
people that I see that I work directly with that are just 
working day in, day out.
    So I think the overtime cost, Admiral Weahkee talked about 
the hazard pay. I have been in those discussions as well. The 
testing kits, the PPE, the infrastructure, those are things 
that I see as well. As we all know, infrastructure is very 
costly. Some of my tribes back home don't have the 
infrastructure to handle the cases, so they have to be referred 
out to Bismarck and Fargo and so forth. So those are the costs 
I see, Senator, that are coming down the pipeline.
    I would also mention, too, with businesses I know, this 
body has worked diligently on a bipartisan bill for 
reimbursements for businesses, casinos, all those things. I am 
so appreciative of that, with Treasury, I have been on those 
calls as well. But as we all know, it is at times not enough.
    I want to go back to what Senator Smith said, when she 
talked about mental health. For me personally, I have been in 
recovery for 16 years. What I see back home, we could use 
treatment centers, every tribe needs one, needs two of them. I 
think a conduit of that is the workforce in regard to 
licensing. That is one thing that I see as really, barrier, I 
kind of hate to say it, the regulation. Maybe it is regulation.
    I would rather see innovation in regard to mental health on 
tribal lands. Because we all know that we have a number of 
cultural providers, if you will, that can provide services for 
our members, for our youth, for whoever, who are going through 
this pandemic, who are going through historical trauma. That 
could and should be reimbursable through Federal dollars.
    So I see that as a barrier, Chairman, as far as mental 
health services go, those reimbursement costs to those. Most 
times, when you are working back home in the treatment centers, 
for mental health, you have to have a license of some sort. I 
understand that, I agree with that. But also, I think there has 
to be a way to be innovative of that. Sometimes I look at those 
licenses as red tape, quite honestly. That red tape leads to 
poor services, because you are shown to teach mental health a 
certain way, and when you are trying to teach it culturally to 
my people, it is different. And it kind of doesn't work.
    So I would urge you and your staff, Chairman Hoeven, to 
look into that, how it can be innovative with similar licensing 
when it comes to mental health on tribal lands.
    The Chairman. Thank you, Mr. Davis.
    Ms. Elgin, does the National Indian Health Board have 
educational outreach or training that they think has been 
particularly effective in helping Native communities battle 
    Ms. Elgin. Yes. There have been significant challenges, of 
course, but we have been doing this, they provide the TA that 
they can. Many of the grant application reporting requirements 
are always a concern when we try to outreach to tribes that we 
need to.
    Since March, NIHB has had a public health team that has 
conducted 12 national webinars for tribes to provide education 
on COVID that connect with tribes regarding resources and 
unanswered technical questions. They have created 35 one-
pagers, fact sheets and infographics on everything from how to 
conduct a sweat lodge during COVID to how to do home-based 
COVID testing, the vaccines, how to stay safe in 
multigenerational housing and addressing the mental and 
behavioral health challenges resulting from this distancing and 
sheltering in place orders. They are doing everything they can 
to make sure that tribes have all this information and the 
resources needed during this pandemic.
    The Chairman. Thank you.
    I would like to thank both Mr. Davis and Ms. Elgin for 
testifying on our second panel. There may be additional 
questions submitted for the record. We would ask that if there 
are, you would respond.
    With that, again, we want to thank both of you for being 
here and for the work you are doing.
    With that, our hearing is adjourned.
    [Whereupon, at 5:11 p.m., the hearing was adjourned.]

                            A P P E N D I X

  Prepared Statement of Robyn Sunday-Allen, Vice President, National 
                 Council of Urban Indian Health (NCUIH)
    My name is Robyn Sunday-Allen and I am the Vice President of the 
National Council of Urban Indian Health (NCUIH), which represents the 
41 Urban Indian Organizations (UIOs) across the nation who provide 
high-quality, culturally-competent care to Urban Indians, constituting 
over 70 percent of all American Indians/Alaska Natives (AI/AN). I also 
serve as the Chief Executive Officer of the Oklahoma City Indian 
Clinic, a permanent program within the IHS direct care program and a 
UIO, which provides culturally sensitive health and wellness services 
including comprehensive medical care, dental, optometry, behavioral 
health, fitness, nutrition, and family programs to our patients. I 
would like to thank both Chairman Hoeven and Vice Chairman Udall for 
holding this legislative and oversight hearing during this 
unprecedented pandemic, which has especially impacted Indian Country. 
My testimony is regarding S. 3650, Coverage for the Urban Indian Health 
Providers Act, and how it would improve health care outcomes for 
Oklahoma City's Urban Indian community.
    S. 3650, Coverage for the Urban Indian Health Providers Act, was 
introduced by four Senators of this Committee--Lankford, McSally, 
Udall, and Smith, who have recognized the essential nature of this 
technical fix and that it is not a partisan issue. S. 3650 will close a 
major disparate gap in the Indian Health Service (IHS) system by 
extending Federal Tort Claims Act (FTCA) coverage to UIOs. FTCA for 
UIOs was also included in President Trump's FY 2021 budget and the 
Tribal Budget Formulation Workgroup's FY 2021 and FY 2022 budget 
recommendations. Both in this esteemed Chamber and in the House of 
Representatives, the Coverage for Urban Indian Health Providers Act has 
enjoyed broad support, both geographically and across political 
parties. This extensive support shows that one thing is clear across 
the board: FTCA coverage must be extended to UIOs, especially at a time 
when it is needed most.
    At the Oklahoma City Indian Clinic, we spend approximately $200,000 
annually on malpractice insurance, money which we would rather invest 
in our services. If UIOs were covered under the FTCA, we would put 
every one of these dollars back into services to include preventative 
care, such as: mammograms, pap smears, immunizations (adult and 
children), and dental sealants, among other services.
    We are not alone in needing these funds even more during the COVID-
19 pandemic. Many UIOs fear for our staff and have been forced to 
institute hiring freezes as we stretch every dollar as far as it will 
go. In fact, 83 percent of UIOs initially reported they had been forced 
to reduce their services, and 9 UIOs have reported hiring freezes.
    Extending FTCA coverage to UIOs is a simple legislative fix, but 
the benefits would be significant. A single UIO may pay as much as 
$250,000 annually in medical malpractice insurance, funds which could 
instead be used to invest in better health outcomes for their 
communities or to prepare for public health emergencies like the one we 
are currently facing. By freeing up federal funding for UIOs, they 
would be better able to serve their communities with high-quality 
health care. For instance, some UIOs have reported to NCUIH that they 
are hesitant to hire additional providers or provide additional 
services as they cannot cover the costs of additional medical 
malpractice insurance, even as they are prepared to cover the new 
salaries and related costs. This directly and substantially limits the 
services UIOs can provide to their patients as the cost of adding 
providers or new services to malpractice insurance policies can be the 
sole prohibition to service expansion.
    The federal government maintains a trust obligation to tribes and 
AI/ANs, which originates in treaties wherein the U.S. promised certain 
duties to Native populations in exchange for the lands which make up 
this great Nation; included among these duties is the provision of 
health care services. The Indian Health Care Improvement Act recognized 
that the federal trust responsibility to provide health care to AI/AN 
people does not end at the borders of a reservation and that it extends 
to AI/ANs who reside in urban areas. It was also under this Act that 
Congress formally recognized UIOs as the entities to further the 
fulfillment of the federal government's responsibilities to Urban 
Indians. UIOs are an integral component of the IHS system, which 
facilitates the provision of essential health care services through its 
three components: Indian Health Service facilities, Tribal Health 
Programs, and UIOs, commonly referred to as the ``I/T/U'' system. Each 
component of the I/T/U system has a significant role to play in 
providing AI/ANs with high-quality, culturally-competent care. UIOs not 
only offer a wide range of critical services, which include clinical 
and behavioral health services, but they are also often the only places 
in urban settings where Urban Indians can receive traditional care 
services and function as centers for cultural activities in inter-
tribal settings.
    Although UIOs are an integral component of the IHS system, UIOs 
still have to fight to receive parity with the other two components of 
the I/T/U system. If UIOs are not explicitly included in Indian health 
care legislation, they are most often implicitly excluded, with the 
ultimate result that UIOs do not receive the resources they need to 
provide care to their communities. This is a failure of the trust 
    As it stands, all employees and eligible contractors at IHS and 
tribal facilities are treated as federal employees for the purpose of 
medical malpractice liability. This is true for Community Health Center 
employees and volunteers as well. Unlike these similarly-situated 
health centers, UIOs must use their limited federal funding to purchase 
expensive medical malpractice insurance out-of-pocket.
    Even absent the current Public Health Emergency, UIOs face 
disproportionate hardship as they attempt to stretch every dollar to 
care for a population with higher risks of chronic disease. AI/ANs face 
significant health disparities, including diabetes, cancer, and heart 
disease. \1\ Many of these disparities place AI/ANs at a higher risk 
for serious COVID-19 complications. With over 70 percent of AI/ANs 
living in urban areas, and with the highest rates of COVID-19 taking 
place in areas of high population density, many UIOs are the central 
care delivery sites for communities with compounded risks. UIOs receive 
direct funding from only one line item--and are not eligible for other 
critical IHS funding, including Health Care Facilities, Sanitation, 
Purchased/Referred Care, and Equipment, to name a few. Facing a 
pandemic with decades of underfunding made it clear in the earliest 
stages of the pandemic that UIOs would need a substantial amount of 
emergency resources in order to meet the needs of Urban Indians. 
Congress acted swiftly to support UIOs and the entire IHS system 
through emergency supplemental appropriations. We are grateful for the 
support, and cannot emphasize enough how essential these resources have 
been to positive health outcomes for Urban Indians.
    \1\ National Center for Health Statistics. Health, United States, 
2015: With Special Feature on Racial and Ethnic Health Disparities. 
Hyattsville, MD. 2016.
    In order to both maximize the value of the money Congress has 
appropriated to UIOs, and to ensure other critical needs are met, it is 
imperative that UIOs have access to critical cost-saving measures like 
FTCA coverage. UIOs have reported that they would use their medical 
malpractice savings for additional Personal Protective Equipment, 
infrastructure improvements to ensure proper distancing between 
patients and staff, hiring additional providers, and expanding 
available services. All of these are imperative to help UIOs prevent 
and treat COVID-19 among their patients and communities, while 
preparing for future Public Health Emergencies.
    We thank Congress for your support of UIOs during this Public 
Health Emergency and we urge you to keep FTCA coverage for UIOs front 
of mind as your work diligently on the next COVID-19 package. We are 
grateful for the Committee's continued support of Urban Indians and 
dedication to improving the health outcomes of Indian Country.
  Prepared Statement of Hon. Coly Brown, Chairman, Winnebago Tribe of 
    Chairman Hoeven, Vice Chairman Udall, and Members of the Committee, 
thank you for the opportunity to offer the Winnebago Tribe of 
Nebraska's perspectives on the COVID-19 pandemic. I am writing to 
discuss my tribe's experience with the Coronavirus Aid, Relief and 
Economic Security Act (``CARES Act'').
    My tribe makes our home on an Indian reservation along the banks of 
the Missouri River in Northeastern Nebraska and Northwestern Iowa. We 
have over 5000 tribal members and numerous tribal enterprises that 
employ thousands of employees in a five-county area, Nebraska, Iowa and 
around the world. The Tribe formed Ho-Chunk, Inc., the economic 
development corporation of the Tribe, in 1994. Ho-Chunk, Inc. is now 
the largest minority-owned company in Nebraska and has received 
numerous awards for its innovative approaches to tribal economic 
development. The Tribe also operates two small gaming operations in 
Nebraska and one relatively modest sized gaming operation in Iowa which 
provide approximately 40 percent of the Tribal government revenues that 
are integral to support tribal government operations and programs.
    To protect our people, we declared a public health emergency on 
March 24, 2020. That same day we created the Winnebago Pandemic Task 
Force to ensure the health, safety and welfare of Tribal members during 
the public health emergency. The Tribe provides critical health 
resources and operates social services, law enforcement, education and 
numerous other important services to our Tribal citizens. Further, we 
are responsible for protecting our invaluable workforce who provide 
these services and protections through our Tribal government and Tribal 
enterprises. We made the difficult decision to close our government and 
gaming operations on March 17, 2020. We also implemented a curfew on 
April 15, 2020 and a mandatory face mask policy on April 27, 2020. We 
have experienced 68 positive cases of COVID-19 of which there have been 
three tragic losses of life and 63 people have recovered. Currently we 
have five active cases.
    On March 27, 2020, Congress passed the CARES Act which established 
the Coronavirus Relief Fund (CRF) for state, local and tribal 
governments to respond to the public health emergency with respect to 
the Coronavirus Disease 2019. The CARES Act required that amounts to 
tribal governments ($8 billion) be distributed not later than 30 days 
of enactment (April 26, 2020). Relief funds are to be used for 
expenditures incurred March 1--December 30, 2020.
    To date, the $8 billion fund has not been fully distributed to 
Tribal governments. These critical relief funds remain the subject of 
litigation. Instead of what should have been one payment in full by 
April 26, my tribe received three partial payments of varying amounts 
in early May and mid-June. Depending on the outcome(s) of multiple 
lawsuit(s), there is potential for the remainder of the fund to be paid 
to tribal governments in yet another payment. We had no insight into 
the formula that the U.S. Department of the Treasury used despite 
several tribal leader calls with Treasury on the issue. Even when 
Treasury made what became the first, second and third payments and 
described the different formulas used, tribes were unable to determine 
how such amounts were calculated by Treasury.
    As a result, our tribe had no ability to properly plan for an 
unknown amount of CRF funds that our tribe would receive and therefore, 
no ability to plan for how to allocate CRF funds among the numerous 
priorities we have in response to the COVID-19 public health emergency. 
In addition, since the payment of CRF tribal relief funds was 
significantly delayed by almost two full months, all tribes, including 
my own, lost critical time to implement preparedness and response 
efforts. By the time we received the most recent payment on June 18, 
positive COVID cases on our reservation totaled 66 and all three of the 
COVID related deaths we have experienced in our community thus far, had 
already occurred.
    As we continue to respond to the pandemic, there is no end in 
sight. The Tribe asks Congress to extend the use of CRF funds for 
necessary expenditures to respond to the public health COVID-19 
emergency to September 30, 2021. We further ask that Congress allow 
Tribes to use relief funds to replace lost revenue and for governmental 
operations during the pandemic. Unlike state and local governments, 
Tribes do not have a tax base to draw upon during these trying times to 
support our governmental functions. Thank you very much for your 
Prepared Statement of Hon. Joseph Rupnick, Sr., Prairie Band Potawatomi 
    Chairman Hoeven, Vice Chairman Udall, and Members of the Committee 
on Indian Affairs:
    The following statement is submitted on behalf of the Prairie Band 
Potawatomi Nation (``Prairie Band'') to be included in the record of 
the Committee's hearing.
    Like all Federally-recognized tribal nations, the Prairie Band has 
been affected by the COVID-19 pandemic and our Tribal government has 
declared a disaster, imposed stay-at-home orders on our people, closed 
our enterprises, and provided direct services and support for our 
people under quarantine during the last four months. This has resulted 
in tremendous hardship to our people, our families, and the people we 
employ in our region in Kansas.
    As you know, the CARES Act provided for an $8 billion Coronavirus 
Relief Fund for Tribal governments (``Tribal CRF''). Payments from the 
Tribal CRF were to be paid within 30 days of enactment (March 27, 2020) 
and that such funds could only be used to cover costs that:

   Were necessary expenditures incurred due to the public 
        health emergency with respect to the Coronavirus Disease 2019 

   were not accounted for in the budget most recently approved 
        as of March 27, 2020 for the affected government; and

   were incurred during the period that begins on March 1, 
        2020, and ends on December 30, 2020.

    The Treasury Department, which was given responsibility for 
distributing the Tribal CRF monies, has diverged wildly from this 
Congressional mandate. The Prairie Band and over 200 Tribes were not 
treated fairly by the Treasury Department in the distribution of Tribal 
CRF monies.
    Background. To implement the CARES Act, the Treasury and Interior 
Departments held two consultation sessions with Tribal leaders to 
solicit input on how to distribute the CRF monies. In early April, the 
Treasury Department (which has the obligation to disburse the funds) 
requested information from Tribal governments for purposes of 
developing a distribution formula to allocate 60 percent of the Tribal 
CRF, or $4.8 billion (``Round 1''). This data request included a 
request for our Tribal enrollment population, as well as our land base, 
number of employees, and total expenditures.
    Inexplicably, the Treasury Department then proceeded to ignore all 
of the requested data--including tribal enrollment figures--and instead 
adopted a formula used to distribute Indian Housing Block Grants 
(``IHBG''). This was despite its acknowledgment that ``Tribal 
population is expected to correlate reasonably well with the amount of 
increased expenditures of Tribal governments related directly to the 
public health emergency.'' See U.S. Department of Treasury, Coronavirus 
Relief Fund Allocations to Tribal Governments, May 5, 2020 (see 
attached). * And also despite the fact that not one Tribal leader 
during the consultation process asked for the IHBG formula to be 
applied. The offered explanation by Treasury officials was that the 
IHBG ``formula area corresponds broadly with the area of a Tribal 
government's jurisdiction and other areas to which the Tribal 
government's provision of services and economic influence extend.'' Id.
    Based on Treasury's Round 1 formula, the Prairie Band received 
$2,456,891.27. Our first impression was that this was a low figure, 
given our tribal population of 4,561 members. However, our suspicions 
were affirmed when a report analyzing the distributions was issued by 
the Harvard Project on American Indian Economic Development. See R. 
Akee, E. Henson, M. Jorgensen, & J. Kalt, Dissecting the US Treasury 
Department's Round 1 Allocations of CARES Act COVID-19 Relief Funding 
for Tribal Governments, May 18, 2020 (``Harvard Report'') (see 
attached). *
    * The information referred to has been retained in the Committee 
    Gross Error by the Treasury Department Revealed. The Harvard Report 
revealed that, if the Treasury Department had utilized the Tribal 
enrollment data as originally requested, the Prairie Band would have 
received $10,327,948, or $7,631,673 more than we actually received! Id. 
at 10. Indeed, the Harvard Report indicated that the Prairie Band was 
in the ``top 25'' tribes that were ``under-represented'' by the 
Treasury's use of the IHBG formula. We don't consider what Treasury did 
as ``under-representing'' the Prairie Band; we consider it as once 
again an action by the U.S. government to arbitrarily and unfairly 
treat us as Indian people by disregarding the one verified measure used 
to identify us to the federal government--our Tribal enrollment 
    The Harvard Report also revealed even harsher results for many 
other Tribes, with Treasury recording ``zero'' Tribal population for 
some, thus allocating only the minimum $100,000.00 to those Tribes to 
assist their people.
    Why the reason for such unfairness? The Harvard Report explains 
that the IHBG formula used by Treasury is based on self-identified 
racial data derived from the U.S. Census. This racebased data includes 
both individuals who self-identify as American Indian/Alaska Native as 
``single race'' and those who identify as ``mixed race''. Based on 
known distributions, it appears that Treasury utilized the ``mixed 
race'' data in distributing the CRF monies. Because the foundation of 
the IHBG formula is race based, HUD rarely incorporates Tribal 
enrollment data and so its formula generates wildly divergent 
allocations of housing dollars despite the growth in a particular 
Tribe's population or its lack of HUD-funded housing. Id. at 12-13.
    The Prairie Band falls into the latter category. Because of our 
economic success and our community philosophy regarding housing--we do 
not rely heavily on federal HUD monies to provide housing to our 
people. The Prairie Band has only 17 HUD-funded housing units! And 
because of this fact, the Treasury Department underfunded us by 75 
percent of the amount of money we would have otherwise received to help 
our people address the COVID-19 pandemic.
    It flies in the face of fundamental principles of federal Indian 
law and policy that the U.S. Treasury would disregard Tribal enrollment 
data as a barometer of a Tribal government's service obligation to its 
people in favor of wildly inaccurate race-based housing data. But that 
is what happened. And it was arbitrary, capricious, and wrong.
    Judicial Relief Not Available. Because of our frustration and anger 
at Treasury's actions, the Prairie Band filed a lawsuit in Federal 
District Court to remedy the consequence of Treasury's misconduct and 
to prevent further arbitrary distributions of remaining Tribal CRF 
monies. (See U.S. D. Ct. D.C. Civil No. 20-cv1491, Jun. 11, 2020). 
Ultimately, the District Court denied our request for a temporary 
restraining order. However, the Treasury Department conceded that there 
was sufficient litigation risk associated with its position and 
notified the Court it intended to withhold $679 million for the Prairie 
Band and the 260 other Tribes that were shorted by Treasury's use of 
the IHBG data.
    Following the litigation, Treasury has since distributed the 
remaining 40 percent of the Tribal CRF monies and relied upon a formula 
utilizing employment and expenditure data (see attached). The Prairie 
Band received an additional $7,355,949 associated with this Round 2 
    Request for Relief. Despite the lack of judicial remedy, I bring to 
your attention the Prairie Band's experience because Congress should be 
aware of how poorly the Treasury Department administered the Tribal CRF 
monies. Hundreds of Tribes received far less than they would have 
received had Treasury utilized Tribal enrollment data. And that means 
that hundreds of Tribes received far less support to help their people 
than Congress intended when it enacted the CARES Act and appropriated 
the Tribal CRF monies.
    We ask for the Committee's assistance in (i) examining why Treasury 
utilized a funding formula that ignored Tribal enrollment data and 
seriously underfunded 261 Tribes and (ii) appropriating additional 
funds to provide restitution to the Tribes adversely affected by 
Treasury's action to allow us to fully respond to the COVID-19 
    We are willing to assist you in any way that you may find necessary 
to address our concerns. Thank you for your consideration.
              Prepared Statement of Papa Ola Lokahi (POL)
    Dear Chairman Hoeven, Vice Chairman Udall, Senator Schatz, Senator 
Smith, and the Members of the U.S. Senate Committee on Indian Affairs:
    Mahalo (thank you) for your leadership during the Novel Coronavirus 
Disease (COVID-19) pandemic in ensuring that Americans from all walks 
of life survive these challenging times. Papa Ola Lokahi (POL) is a 
community-based non-governmental entity that serves as the body with 
whom federal agencies consult on Native Hawaiian health policy and 
health care and that coordinates services between the Native Hawaiian 
Health Care Systems (NHHCS or the Systems). The five Systems provide 
invaluable direct health care services to the Native Hawaiian 
community. The Office of Hawaiian Affairs (OHA) is a semi-autonomous 
state agency tasked with the mission to serve and advance the well-
being of Native Hawaiians. On behalf of our organizations and the 
community we serve, we request parity for POL and the NHHCS with the 
urban Indian organizations (UIOs) by including POL, the Systems, and 
their employees as part of the Public Health Service in the expansion 
of the Federal Tort Claims Act in S. 3650, the Coverage for Urban 
Indian Health Providers Act, which was introduced by Senator Tina Smith 
    The federal government, through actions of the U.S. Congress, must 
honor its trust responsibility to all Native Americans, including 
American Indians, Alaska Natives, and Native Hawaiians. This trust 
responsibility extends beyond the trust lands and includes ensuring our 
native people receive health care and related services wherever they 
live. Over the past century, the U.S. Congress has repeatedly 
recognized this responsibility to the Native Hawaiian people in 
hundreds of legislative actions, including statutes addressing the 
health challenges faced by the Native Hawaiian community.
Native Hawaiian Health Disparities
    Like our native relatives on the continental United States, Native 
Hawaiians face disproportionate threats to our physical and mental 
health, including poverty, \1\ suicide and depression, \2\ infant 
mortality, \3\ alcohol abuse, \4\ homelessness, \5\ and prejudices 
against natives. Native Hawaiian infants are twice as likely to die 
(infant mortality rate of 7.9 per 1,000 live births) than their White 
peers (infant mortality rate of 3.5 per 1,000 live births) in the State 
of Hawai`i. \6\ Native Hawaiians are more likely to suffer from 
coronary heart disease, diabetes, and asthma than non-Native Hawaiians 
in the State. \7\ Nearly 16,000 Native Hawaiians suffer from diabetes 
and more than 36,000 suffer from asthma. \8\ These diseases are the 
result of many factors such as social determinants like housing. 
Indeed, many Native Hawaiians face homelessness-making up nearly half 
of the homeless population on the Island of O`ahu, \9\ which houses 
approximately two thirds of the State's total population.
    \1\ Anita Hofschneider, Poverty Persists Among Hawaiians Despite 
Low Unemployment, HONOLULU CIVIL BEAT (Sept. 19, 2018), https://
AFFAIRS (Feb. 2018), http://www.ohadatabook.com/HTH_Suicide.pdf.
    \3\ Ashley H. Hirai et al., Excess Infant Mortality Among Native 
Hawaiians: Identifying Determinants for Preventive Action, AM. J. OF 
PUB. HEALTH (Nov. 2013), https://www.ncbi.nlm.nih.gov/pmc/articles/
(July 2019), http://www.ohadatabook.com/NHHS.html.
    \6\ Hirai, supra note 3.
    \8\ Id. at 1-2.
    \9\ Id. at 2.
    Mental health is also a serious concern for the Native Hawaiian 
community. More than twenty percent of Native Hawaiian adults reported 
that they frequently feel their mental health is ``not good.'' \10\ 
Although Native Hawaiians make up only 27 percent of all youth in the 
State between the ages of ten and fourteen, they constitute 50 percent 
of the completed suicides. \11\ These factors contribute to the fact 
that Native Hawaiians, despite being the indigenous peoples of the 
Hawaiian Islands, have the shortest life expectancy of any major 
population in the State. \12\
AFFAIRS (Feb. 2018), http://www.ohadatabook.com/HTH_Suicide.pdf.
    \11\ David M.K.I. Liu & Christian K. Alameda, Social Determinants 
of Health for Native Hawaiian Children and Adolescents, HAW. MED. J. 
(Nov. 2011), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3254224/pdf/
The History of the Native Hawaiian Health Care Improvement Act
    To respond to the health care needs of the Native Hawaiian people, 
the U.S. Congress created a Commission and ordered a Needs Study to 
assist in understanding the status of Native Hawaiian health. The 
Native Hawaiian Health Care Improvement Act, as it is known today, 
passed into law in 1988 and created a permanent program to address the 
health disparities faced by the Native Hawaiian community. As a result 
of this legislation, POL contracts with the Health Resources and 
Services Administration at the U.S. Department of Health and Human 
Services to create, update, and implement a comprehensive health care 
master plan that promotes health and prevents disease in the Native 
Hawaiian community.
Papa Ola Lokahi and the Native Hawaiian Health Care Systems
    POL coordinates and assists health care programs and service 
delivery within the NHHCS. The NHHCS is comprised of five separate 
Systems with unique service areas. They are Ke Ola Mamo on O`ahu; 
Ho`ola Lahui Hawai`i on Kaua`i; Hui Malama Ola Na `Oiwi on Hawai`i 
Island; Hui No Ke Ola Pono on Maui; and Na Pu`uwai on Moloka`i, which 
also serves clients on Lana`i. The Systems play a critical role in the 
delivery of health care services to the Native Hawaiian community. More 
than 300,000 Native Hawaiians residing in the State, and approximately 
615,000 Native Hawaiians across the entire country, are eligible to 
receive health care services through the Systems. Additionally, as the 
sole Indian Health Service (IHS)-contracted health care provider in the 
State, Ke Ola Mamo in partnership with the Systems and other 
facilities, also provide health care for the 37,751 American Indians 
and Alaska Natives who reside in the State and the many thousands more 
Native American visitors who come to our islands each year.
    Each of the five Systems offer unique services to their patients. 
The Systems as a whole provide primary health care, behavioral health, 
and dental services as well as health education to manage disease and 
transportation to attend appointments. The Systems provide preventative 
care to improve diabetes management and cardiac health, as well as 
screenings for diseases such as breast and cervical cancer. Further, 
the Systems provide traditional Native Hawaiian healing through 
practices such as Lomilomi massage therapy to improve circulation and 
range of motion and Ho`oponopono, a traditional healing art to promote 
physical, mental, and emotional health and wellness for individuals, 
families, and communities. For Native Hawaiians seeking to overcome 
substance abuse challenges, the Systems offer smoking cessation 
programs and substance abuse counseling. The Systems also provide their 
clients with culturally enriching wellness and fitness programs, such 
as Hula for Health and nutrition classes.
    The Systems are working to address the health and well-being of 
Native Hawaiians at all stages of life. To that end, the Systems 
provide prenatal support to expectant mothers and offer newborn care. 
For our older keiki (children), the Systems provide immunizations and 
school physicals to students and athletes. The Systems also provide 
health services and nutritional support to teenagers. Finally, Native 
Hawaiian Kupuna (Elders) are eligible to receive support through adult 
day care, aging in place programs, and in-home care services.
    The Systems ensure access to health care for Native Hawaiians, as 
well as American Indians and Alaska Natives living in or visiting 
Hawai?i. They directly serve more than 23,000 clients annually. \13\ 
Each year, the Systems provide more than 4,700 clients with Native 
Hawaiian traditional healing services; provide more than 8,500 dental 
services; teach over 2,000 hours of disease and complication prevention 
classes; transport more than 1,000 clients to health care appointments; 
and instruct more than 20,000 participants in physical fitness classes. 
\14\ The critical role the Systems play in the Native Hawaiian 
community is undeniable. Since the COVID-19 pandemic began, the Systems 
have provided urgent care, telehealth, and telemedicine services that 
have proven critical during the Stay in Place and quarantine orders in 
the State. Additionally, POL and some of the Systems performed COVID-19 
testing, delivered meals to seniors, and collected information on 
critical Native Hawaiian community health needs. The Systems have 
turned to innovation to continue to offer their valuable services 
during this time.
    \13\ Native Hawaiian Health, Papa Ola Lokahi (2020).
    \14\ Id.
The Need for Parity for the NHHCS and UIOs in FTCA Coverage
    While POL and the Systems are successful in their missions to 
provide health care services to the Native Hawaiian community, the 
Systems are forced to spend a significant portion of their budget on 
malpractice insurance rather than spending those funds on the provision 
of health care and related services to patients. Including the POL and 
the Native Hawaiian Health Care Systems' employees under the expansion 
of the Federal Tort Claims Act (FTCA) found in S. 3650, Coverage for 
Urban Indian Health Providers Act, will provide parity for the Systems 
alongside the UIOs, which play a parallel role in the urban Indian 
communities. FTCA coverage will free an estimated $220,000 annually to 
provide quality health care services in response to the effects of the 
COVID-19 pandemic, not only for those infected by the disease but also 
for individuals who no longer receive employer-based insurance due to 
loss of employment or reduced hours. This would help the Systems to 
continue providing services to patients who are most at risk of 
contracting COVID-19 and who may not have any other means to receive 
health care in the aftermath of this pandemic.
    The high costs of malpractice insurance during the pandemic imposes 
limitations on the types of services the Systems can provide and 
creates barriers to retention and recruitment. Further straining the 
Systems, the provision of health care to American Indians and Alaska 
Natives in Hawai?i adds roughly twice as much in health costs compared 
to the level of funding the Systems receive from IHS to provide these 
services, including serving as the payor of last resort for patients in 
need, each year. With FTCA coverage, the Systems would be able to 
provide an estimated 25,000 additional encounters for up to 2,000 more 
patients and to provide expanded services, including primary care and 
behavioral health services, additional transportation to appointments, 
and increased traditional healing practices to cope with the stress 
placed on families facing increased hardships during the pandemic, 
among other things.
    Significantly, this expansion of coverage would also mean that the 
NHHCS can more effectively recruit and retain high-caliber medical 
professionals with specializations. For example, although some of the 
Systems already provide pediatric care, an expansion would allow the 
remaining Systems who do not offer such services to recruit a 
pediatrician to provide our keiki health services at the same place 
that their parent receives care. Additionally, the Systems could 
increase their collaboration between Systems by recruiting different 
types of specialists to provide care across the Systems and decrease 
patient travel. The Systems also project the ability to offer 25 
percent more events addressing the social determinants of health while 
integrating relevant traditional practices and culture.
    The COVID-19 pandemic has exacerbated and will widen the health 
disparities Native Hawaiians face. Unemployment in Hawai`i has 
skyrocketed, with many organizations reporting Hawai`i as the second 
worst state in terms of unemployment levels. \15\ We do not expect 
unemployment to lower significantly in the foreseeable future because 
one of our biggest industries, tourism, is almost completely shut down 
and many small business have permanently closed as a result. Our 
economy will likely not begin to see growth again until the last stages 
of the COVID-19 pandemic recovery. Native Hawaiians will continue to be 
disproportionately affected by this fact because nearly one in four 
Native Hawaiians are employed in the service industry closely tied to 
tourism in Hawai'i. \16\ This pandemic threatens the continued success 
and survival of the NHHCS. The inclusion of the NHHCS in the extension 
of the FTCA protections will address some of the most urgent needs 
facing the NHHCS and help provide parity in carrying out the federal 
government's trust responsibility to Native Hawaiians.
    \15\ Dave Segal, Hawaii's Unemployment Rate Remains High at 22.6 
percent, STAR ADVERTISER (June 19, 2020), https://
    Mahalo again for your leadership during this difficult time in our 
nation. We understand that the pandemic has negatively affected the 
health and economic well-being of all native communities across the 
nation, and the Native Hawaiian community is no different. During this 
public health crisis, we are confident you will support providing all 
native health care providers with equal treatment and the necessary 
protections to continue caring for the health of our people despite the 
many hardships resulting from this pandemic.
    Prepared Statement of Kevin J. Allis, CEO, National Congress of 
                            American Indians
    Dear Chairman Hoeven and Vice-Chairman Udall:
    On behalf of the National Congress of American Indians (NCAI), 
thank you for holding this hearing on ``Evaluating the Response and 
Mitigation to the COVID-19 Pandemic in Native Communities'' and on S. 
3650, Coverage for Urban Indian Health Providers Act. Founded in 1944, 
NCAI is the oldest and largest representative organization serving the 
broad interests of tribal nations and communities.
    As the infection rate and death toll of the COVID-19 pandemic 
intensifies, it is clear that American Indian and Alaska Native (AI/AN) 
communities are disproportionately impacted due to a chronic 
underfunding of the federal trust and treaty responsibilities. While we 
are grateful for Congress' support of Indian Country in the Coronavirus 
Aid, Relief, and Economic Security (CARES) Act, greater aid is needed 
in addition to addressing the numerous issues, barriers, and delays 
that tribal nations encountered in accessing congressional COVID-19 
relief. On July 14, 2020, we submitted extensive testimony to the 
United States Commission on Civil Rights on this topic and made short-
term and long-term recommendations. To aid this Committee's work, we 
enclose that testimony for your consideration and record. *
    * The information referred to has been retained in the Committee 
files and can be found at http://www.ncai.org/resources/testimony/
    Additionally, with regard to S. 3650, Urban Indian Organizations 
(UIOs) are an essential part of the Indian healthcare delivery system 
alongside the Indian Health Service (IHS) and tribal health programs 
(I/T/U). Currently, both IHS and tribal health programs receive Federal 
Tort Claims Act (FTCA) coverage but UIOs do not. As a result, UIOs are 
forced to spend their limited resources on tort claim coverage, which 
has negatively impacted the scope of services that they can provide. S. 
3650, addresses this gap by expanding FTCA coverage to UIOs. NCAI 
supports extension of FTCA parity which will enable UIOs to increase 
the delivery of services to urban AI/ANs at a time when those services 
are most needed.
 Prepared Statement of Esther Lucero, CEO, Seattle Indian Health Board
    Dear Chairman Hoeven and Vice Chairman Udall:
    The Seattle Indian Health Board (SIHB) would like to thank you and 
the Senate Committee on Indian Affairs for holding the Oversight 
Hearing on ``Evaluating the Response and Mitigation to the COVID-19 
Pandemic in Native Communities and Legislative Hearing to Receive 
Testimony on S. 3650''. We appreciate the opportunity to provide 
written comments on our experiences mitigating the COVID-19 pandemic at 
SIHB, and our research division, the Urban Indian Health Institute 
(UIHI) and express our support of S. 3650.
    SIHB is one of 41 Urban Indian Health Programs (UIHP) that assist 
the federal government in fulfilling their trust responsibility to 
provide healthcare for the American Indian and Alaska Native citizens 
living in urban areas. UIHPs are a critical component of the Indian 
Health Service (IHS) Direct/Tribal 628/UIHP (I/T/U) system of care and 
offer culturally attuned health services to the 1.5 million American 
Indians and Alaska Natives who live in 117 counties across 24 states.
    UIHI is an IHS designated Tribal Epidemiology Center (TEC) and 
public health authority which conducts data, research, and evaluation 
services for over 62 urban Indian organizations nationwide. These 
health, social, and cultural service agencies provide culturally 
attuned health services to urban Indian communities. Of the twelve 
TECs, UIHI is the only one with a national purview, the other eleven 
operate regionally, serving tribal nations.
Indigenous Resilience in Confronting COVID-19
    SIHB is one of the thousands of frontline health care organizations 
that is actively working to limit the spread of COVID-19 our 
communities. As a UIHP and Federally Qualified Health Center, we have 
remained open for business throughout the COVID-19 pandemic. We are 
adapting our service delivery models to ensure continued access to care 
for of our clients, for example:

   Within weeks, our clinic operationalized a COVID-19 testing 
        site at our main clinic and within two months were operating a 
        low-barrier community-based testing site at our satellite 
        site--Chief Seattle Club. Over the course of three months, our 
        staff reconfigured physical spaces and adjusted clinical 
        workflows to increase social distancing and implement safety 
        measures for patients, staff, community members, and vendors. 
        Notably, due to internal adjustments and supplemental funding, 
        SIHB did not experience mass furloughs or layoffs like many of 
        our healthcare partners.

   Over the course of several months, we have operationalized 
        expanded telehealth options for medical, dental, behavioral 
        health, and traditional Indian medicine. Today, the majority of 
        our appointments are telehealth visits. To orient our patients 
        to this new service delivery model, we developed the ``Call Our 
        Relatives Home'' initiative to outreach past and present 
        patients and encourage reconnecting to care.

   To offer telehealth services to our patients experiencing 
        homelessness, we were able to create ``telehealth kiosks''--
        private rooms on site that maintain social distance and are set 
        up for telehealth appointments.

   Through flexible supplemental HRSA funding, we were given 
        the ability to finance modest infrastructure changes that 
        improved telehealth, facility security, and sanitation 
        measures. For example, new features like keyless entry, 
        automatic doors, and plexiglass protections will work to limit 
        the spread of the virus.

   Through supplemental SAMHSA funding, we are in the process 
        of standing up an intensive outpatient program where we can 
        offer a higher level of care for our behavioral health 
        patients. This program will begin to address a longstanding 
        community need. These funds combined with new federal and state 
        telehealth waivers that allowed for increased flexibilities and 
        payment parity have proven to be successful policy changes.

   To meet the preventative health care needs of our pediatric 
        and prenatal patients, we created a Saturday clinic--open 
        exclusively to pediatrics and prenatal patients and staffed 
        with integrated care teams for wrap around health and social 

    Each of these efforts demonstrate the adaptive and innovate 
approaches UIHPs take to support the health and well-being of urban 
American Indian and Alaska Native people.
    As a TEC, UIHI immediately began producing newsletters, fact 
sheets, and webinars focused COVID-19 impacts for tribes, UIHPs, and 
urban Indian communities. To date, UIHI has disseminated 20 factsheets 
and resources for clinics, workplaces, and community members. Topics 
range from best practices for American Indian and Alaska Native data 
collection, to COVID-19 information tailored for urban Native 
homelessness service providers. UIHI has partnered with the National 
Council on Urban Indian Health (NCUIH) to create an urban Indian 
organizations national surveillance system. As of June 28, 2020:

   75 percent of UIHPs submitted data to the surveillance 

   19 of the participating UIHPs report screening a total of 
        37,476 patients for COVID-19;

   A total of 5,636 patients were tested for COVID-19 with 6 
        percent testing positive;

          -- Among the positive COVID-19 patients where age was 
        submitted, 87 percent are age 18-64 in comparison to 74 percent 
        in national surveillance data; \1\

    \1\ ``Cases in the U.S.'' Centers for Disease Control and 
Prevention, Centers for Disease Control and Prevention, 23 June 2020. 
Retrieved from: www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-
          -- Among the positive COVID-19 patients where race/ethnicity 
        was submitted, 49 percent are American Indian or Alaska Native;

          -- Among the positive COVID-19 patients where gender was 
        submitted, 64 percent are female, in comparison to 51 percent 
        in national surveillance data; \2\ and

    \2\ Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Disease 
2019 Case Surveillance--United States, January 22-May 30, 2020. MMWR 
Morb Mortal Wkly Rep. ePub: 15 June 2020.DOI: http://dx.doi.org/
10.15585/mmwr.mm6924e2external icon
          -- Among the positive COVID-19 patients where home status was 
        submitted, 94 percent live in multigenerational homes.

    This national UIO surveillance data is the only data that 
specifically looks at the experience of UIHPs in detail and is 
therefore critical to understanding the prevalence of COVID-19 and 
supporting data-driven decisionmaking among urban American Indian and 
Alaska Native communities.
    These are just a few examples of the work that UIHPs and TECs are 
undertaking to ensure the health and well-being of American Indian and 
Alaska Native people. Despite the remarkable successes of Indian 
healthcare providers in response to COVID-19, there continues to be 
notable challenges with monumental implications for American Indian and 
Alaska Native people. The following sections outline three areas of 
concern on the federal response to COVID-19 in urban Native 
communities. We share these continued challenges with the intent of 
working in partnership with Congress and federal agencies to overcome 
these barriers and support the health and well-being of urban American 
Indian and Alaska Native people.
Health Disparities Increase COVID-19 Risk Among American Indians and 
        Alaska Natives
    The IHS continues to be the most chronically underfunded healthcare 
system in the United States, despite federal promises to tribes dating 
back to the 1800s. As a result of this chronic underfunding of trust 
and treaty obligations, American Indian and Alaska Native communities 
around the country suffer from disproportionate rates of diabetes, 
heart disease, asthma and cancer, as compared to other racial or ethnic 
groups \3\--all of which are COVID-19 risk factors. Very recent studies 
seem to show that some of the most common comorbidities in fatal COVID-
19 cases were diabetes or heart disease.
    \3\ Urban Indian Health Institute. (2018). Urban Indian Health Data 
Dashboard. Retrieved from: https://www.uihi.org/urban-indian-health/
    In a factsheet entitled: Special Diabetes Program for Indians 
(SDPI): Mitigating COVID-19 Risk, UIHI outlines that individuals with 
diabetes are at a higher risk for severe complications of COVID-19 and 
potentially at a higher risk for fatality. Given that American Indian 
and Alaska Native people currently have the highest rates of diabetes 
compared to other racial or ethnic groups, there is an increased 
concern that American Indian and Alaska Native people are at a 
disproportionately higher risk for severe complications and possibly 
fatal outcomes related to COVID-19. Currently, SDPI is the only 
national public health intervention that has been shown to improve 
diabetes related outcomes including treatment and prevention and has 
the potential to help mitigate the high risk of COVID-19 for American 
Indian and Alaska Native people with diabetes.
Incomplete Data on COVID-19 Impacts Among American Indians and 
        Alaska Natives
    Recent CDC data show that ``. . .age-adjusted hospitalization rates 
[for COVID-19] are highest among non-Hispanic American Indian or Alaska 
Native and non-Hispanic black persons, followed by Hispanic or Latino 
persons.'' \4\ Even with the release of this data, our understanding of 
the impacts of COVID-19 on American Indian and Alaska Native people is 
limited. As we have seen throughout the COVID-19 response, incomplete 
demographic data complicates our understanding of health disparities 
and impacts in tribal and urban Indian communities.
    \4\ Centers for Disease Control and Prevention. (2020). COVID-19 in 
Racial and Ethnic Minority Groups. Retrieved from: https://www.cdc.gov/
    Data collected on tribal and urban Indian communities by local, 
state, and federal governments has historically misrepresented, 
misclassified, and omitted American Indian and Alaska Native 
populations in their analysis and reports. The incorrect and inaccurate 
data ultimately affects the overall health and well-being of the 
American Indian and Alaska Native population. Since the COVID-19 
outbreak, we are seeing that American Indian and Alaska Native data is 
often not being reported or has been included in the ``other'' data 
category by non-Indigenous entities.
    Efforts led the twelve Tribal Epidemiology Centers, have shed light 
on the data gaps for American Indian and Alaska Native people. In May 
2020, UIHI released a set of best practices for American and Alaska 
Native data collection to ensure state and local public health agencies 
work collaboratively with tribal and urban Indian communities, 
including Tribal Epidemiology Centers, who are adept and proficient 
with data collection and analysis of the American Indian and Alaska 
Native population.
Continued Administrative Barriers for Urban Indian Organizations
    The federal trust responsibility is a legal obligation and 
cornerstone of relations between the U.S. federal government and 
tribes; it was created by hundreds of treaties and centuries of court 
decisions. The IHS fulfills the federal trust responsibility to deliver 
healthcare to American Indian and Alaska Native citizens through the I/
T/U system of care. Nationwide, over 70 percent of the American Indian 
and Alaska Native population live in urban areas, yet UIHPs receive 
less than one percent of the IHS budget, and TECs have been chronically 
underfunded since their inception in 1996. On average, an IHS contract 
or grant is $281,128 for a UIHP and $338,675 for a TEC, but the need is 
much greater. As a result, many UIHPs rely on third-party 
reimbursements from Medicaid, Medicare, and private health insurance 
and grants to provide basic services, while TECs seek out additional 
public and private funding through grants and contracts.
    Recent federal investments are contributing to an increasingly 
integrated health care system. Yet, there is much to be done to address 
decades of chronic underfunding. As a result of legislative education 
and outreach and congressional champions, urban Indian organizations 
are increasingly included in federal legislation as a part of the I/T/U 
system of care. All four federal COVID-19 bills (Pub.L. 116-123, Pub.L. 
116-127, Pub.L. 116-136, and Pub.L. 116-139) included urban Indian 
organizations as defined by title V of the Indian Health Care 
Improvement Act.
    While the congressional intent was to fund urban Indian 
organizations, administrative challenges persist. The following bullet 
points summarize common barriers for urban Indian organizations:

   Exclusionary grant eligibility--Public policies and federal 
        grant eligibility requirements are often restricted to tribes 
        and tribal organizations, thereby excluding urban Indian 
        organizations. While federal legislation is increasingly 
        inclusive of urban Indian organizations as part of the I/T/U 
        system of care, there can be a disconnect when funding is 
        allocated through certain federal agencies. For example, CDC's 
        COVID-19 funding strategy included a grant opportunity open to 
        only 11 of the 12 IHS TECs because grant eligibility criteria 
        were limited to tribes and tribal organizations. This 
        effectively eliminated UIHI from epidemiology and surveillance 
        funds. This is a significant gap given that not only is UIHI 
        the sole TEC that operates on a national level, but 70 percent 
        of the American Indian and Alaska Native population live in 
        urban areas.

   Limited contracting with urban Indian organizations--Level 
        of experience and engagement working with the I/T/U system of 
        care varies across HHS. Some agencies have limited contracts or 
        grants with urban Indian organizations thereby complicated 
        expeditious funding. For example, when the CDC announced a $80 
        million investment in tribes, tribal organizations, and urban 
        Indian organizations in March 2020, dissemination of funds 
        across the I/T/U system of care was delayed. \5\ Due to CDC's 
        limited existing contracts with urban Indian organizations, 
        NCUIH was awarded funds to establish grants to UIHPs. As an 
        unintended consequence, it took three months for SIHB to access 
        $190,000. To date, this is the only CDC funding SIHB has 
        received of at least $205,000,000 set aside by CDC for the I/T/
        U system of care.
    \5\ Health and Human Services. (2020). HHS announces upcoming 
action to provide funding to tribes for COVID-19 response. Retrieved 
from: https://www.hhs.gov/about/news/2020/03/20/hhs-announces-upcoming-

   Lack of Urban Confer policies across HHS agencies--IHS is 
        the only HHS agency with an Urban Confer policy. Urban Confer 
        policies allow federal agencies and urban Indian organizations 
        to engage in an open and free exchange of information and 
        opinions that leads to mutual understanding and comprehension, 
        and emphasizes trust, respect, and shared responsibility. \6\ 
        These policies do not substitute for, nor do they invoke, the 
        rights of a tribal nation, rather they allow urban Indian 
        organizations to represent the needs of urban American Indian 
        and Alaska Native citizens as an Indian Health Care Provider. 
        Without an Urban Confer policy, HHS agencies have no formal 
        mechanism for gathering feedback from urban Indian 
        organizations and vice versa. As a result, submitting feedback 
        to HRSA, SAMHSA, and CDC was a significant barrier for urban 
        Indian organizations.
    \6\ Indian Health Service. Indian Health Manual: Ch. 26--Conferring 
with Urban Indian Organizations. Retrieved from: https://www.ihs.gov/
ihm/pc/part-5/p5c26/. Accessed (2020).

   Limited understanding of the public health authority status 
        of Tribal Epidemiology Centers--SIHB and UIHI are committed to 
        understanding the impacts of COVID-19 in urban American Indian 
        and Alaska Native communities. As a TEC and public health 
        authority, UIHI supports the epidemiological needs of 62 urban 
        Indian communities nationwide. Thanks to recent Congressional 
        oversight, TECs now have access to CDC COVID-19 Case 
        Surveillance. Yet, barriers persist for other HHS data access. 
        UIHI continues to be denied access to the National Notifiable 
        Disease Surveillance System (NNDSS) by CDC. A failure to grant 
        data access perpetuates systemic health inequities in American 
        Indian and Alaska Native communities. Timely analysis of NNDSS 
        data is critical to supporting tribal and urban Indian 
        organizations as they prevent, prepare, and respond to a second 
        surge of COVID-19. To fully operate as public health 
        authorities alongside local, state, and federal entities, the 
        roles and authorities of TECs must be upheld.

    We applaud the committee on your efforts to support the I/T/U 
system of care to address longstanding and emergent racial and ethnic 
health disparities in American Indian and Alaska Native Communities. As 
a result of your advocacy, tribal and urban Indian communities continue 
to innovate and demonstrate the resilience of Indigenous communities in 
the face of a global pandemic. As we work together to address 
historical and current disparities and promote the well-being of 
American Indian and Alaska Native communities, we ask that the 

   Continue to include tribes, tribal organizations, and urban 
        Indian organizations in legislative language when intending to 
        support the I/T/U system of care.

   Extend 100 percent Federal Medical Assistance Percentage 
        (FMAP) to urban Indian organizations to ensure payment parity 
        for Indian Health Care Providers and reduce the burden on 
        states responding to COVID-19.

   Extend the IHS Urban Confer policy to all HHS agencies to 
        encourage mutual understanding and strengthen relationships 
        between HHS agencies and urban Indian organizations.

   Support investments in Tribal Epidemiology Centers to 
        provide culturally competent support and services to tribes and 
        urban Indian communities responding to COVID-19 including 
        resources for emergency response planning, training and 
        technical support, communications, outreach and education, and 
        other public health surveillance activities.

   Leverage Congressional oversight authority to ensure HHS 
        agency compliance with data sharing requirements.

   Support a $1.7 billion Emergency Third-Party Reimbursement 
        Relief Fund for the I/T/U system of care to submit claims for 
        relief funding based on health care service needs or losses 
        related to COVID-19.

   Permanently Reauthorize the Special Diabetes Program for 
        Indians (SDPI) to ensure continued access to culturally attuned 
        and tribally-driven diabetes prevention and treatment.

   Permanently extend telehealth waivers under Medicare to 
        ensure expanded telehealth services across the I/T/U system of 

   Support S. 3650--Coverage for the Urban Indian Health 
        Providers Act to extend Federal Tort Claims Act coverage to 
        Urban Indian Health Program Employees.

    Thank you for your continued advocacy to address the health and 
wellness of our American Indian and Alaska Native communities. If we 
can provide any additional information in support of this request, 
please contact us by phone or email.
    Prepared Statement of Hon. Billy Friend, Chief, Wyandotte Nation
    Thank you Chairman Hoeven, Vice Chairman Udall, and Members of the 
Committee for the oppo1iunity to submit testimony on S. 2165, the 
Safeguard Tribal Objects of Patrimony (STOP) Act of2019. The Wyandotte 
Nation strongly supports swift passage of the STOP Act.
    My name is Billy Friend and I am the Chief of the Wyandotte Nation. 
The struggle to protect tribal cultural heritage from illegal 
trafficking is a tragically common challenge for communities across 
Indian Country. The Wyandotte Nation is no exception. International 
markets have become a safe harbor for trafficking federally protected 
tribal cultural heritage items, and they will remain this way until 
Congress enacts federal law to address this issue. We firmly believe 
the STOP Act will make tremendous strides in preventing international 
trafficking of federally protected tribal cultural heritage items and 
securing their return home to their tribal communities.
I. The Wyandotte Nation Has Fought to Protect Our Tribal Cultural 
    Items of tribal cultural heritage are as unique as the tribal 
nations to whom they belong. These items share the common 
characteristics of being of deep intangible and tangible significance 
to a tribal nation. Many people view our cultural heritage as beautiful 
works of art, as talismans of a past culture they would like to own, or 
as items to trade for profit. Whatever intrinsic beauty these items 
possess, that is not their intended purpose.
    Our items of cultural heritage have significant roles to play 
within our cultures, our traditional calendars. our families, and our 
ways of life. Our cultural heritage also helps us honor and uphold our 
values and teach those values to our community members, particularly 
our young people. So important are these items of cultural heritage 
that they belong to the community as a whole- as our shared inheritance 
and as our shared responsibility to honor and protect for present and 
future generations.
    The Wyandotte Nation has first-hand experience in fighting to 
prevent the loss of our cultural heritage due to theft, trafficking, 
and illegal sales. Many of our tribal artifacts are now in museums 
abroad or in private collections outside the jurisdiction of the United 
States, due to fact that we for many years did not have the financial 
means or the ability to track down and acquire the items that were 
historically ours.
II. Support for the STOP Act to Close Gaps in Existing Federal Law
    The Wyandotte Nation fully supports the passage of the Safeguard 
Tribal Objects of Patrimony (STOP) Act of 2019, S. 2165. Gaps in 
existing federal law have enabled dealers and collectors to operate in 
the shadows when it comes to items of tribal cultural 
heritageespecially once exported abroad. The STOP Act illuminates these 
dark corners.
    There is an already-existing international mechanism through which 
countries can request the return of cultural property from other 
countries. The Convention on the Means of Prohibiting and Preventing 
the Illicit Import, Export and Transfer of Ownership of Cultural 
Property is a 1970 international treaty that the United States signed. 
France, now a safe harbor for those seeking to sell federally protected 
tribal cultural heritage items, is also a signatory. When a signatory 
prohibits export of particular cultural patrimony items and introduces 
an accompanying export certificate, that signatory can call on other 
signatories to control imports of those items and help with 
repatriation. The United States has not explicitly prohibited export of 
tribal cultural heritage items otherwise protected under federal laws 
like the Native American Graves Protection and Repatriation Act 
(NAGPRA) and the Archaeological Resources Protection Act (ARP A). 
Instead, when we try to regain our sacred items from an auction block 
abroad, we are told these gaps in United States law prevent government 
action to facilitate return.
    The STOP Act places an emphasis on facilitating the return of 
protected cultural heritage items trafficked internationally. The STOP 
Act sets out to accomplish the two main goals of: (1) stopping the 
export and facilitating the international repatriation of tribal 
cultural heritage items already prohibited from being trafficked under 
federal law; and (2) facilitating coordination among federal agencies 
in protecting and repatriating such items and in aiding the voluntary 
return of tribal tangible cultural heritage more broadly.
    The STOP Act is designed to meet these very narrow goals. But NAGRA 
and ARPA have other serious limitations that make even their domestic 
implementation difficult, including restrictive provenance 
requirements. While the STOP Act works to prevent the export of items 
already protected under NAGPRA and ARPA and to secure their return, we 
hope to see larger changes to NAGPRA and ARP A in the future meant to 
resolve these other limitations.
    We understand the STOP Act has been developed with significant 
expert feedback, including from seasoned agency officials. We welcome 
this expert feedback to strengthen the STOP Act so that it best meets 
its goals.
    We need the STOP Act now. Without it, we will continue to see our 
tribal cultural heritage trafficked just out of our reach and in front 
of our very eyes. The Wyandotte Nation urges you to act swiftly to 
enact the STOP Act into law.
   Prepared Statement of Hon. Rodney Cawston, Chairman, Confederated 
                   Tribes of the Colville Reservation
    On behalf of the Confederated Tribes of the Colville Reservation 
(the ``Colville Tribes'' or the ``Tribes''), I thank you for this 
opportunity to provide written testimony for the record on the 
Committee's oversight hearing on the federal government's response and 
mitigation to the COVID-19 pandemic in Native communities.
    After more than three decades of trying to construct a new clinic 
in Omak, Washington, the Colville Tribes was fortunate for the Omak 
clinic to have been one of the five projects that the Indian Health 
Service (IHS) selected earlier this year for the Joint Venture (JV) 
Facility Construction Program. COVID-19, however, has affected the 
ability of the Colville Tribes and other JV awardees to build their 
facilities due to the precipitous decline in third party revenue.
    The Colville Tribes joins the National Indian Health Board, the 
National Congress of American Indians, and the Northwest Portland Area 
Indian Health Board in requesting that the Senate include funding to 
cover the construction costs of the eligible JV projects as part of any 
infrastructure bill that it may consider this year.
    By way of background, the Confederated Tribes of the Colville 
Reservation is, as the name states, a confederation of twelve 
aboriginal tribes and bands from across eastern Washington state as 
well as parts of Oregon, Idaho, and British Columbia. The Colville 
Reservation encompasses approximately 1.4 million acres and is in north 
central Washington state. The CCT has nearly 9,600 enrolled members, 
making it one of the largest Indian tribes in the Pacific Northwest. 
About half of our tribal members live on or near the Colville 
I. The Colville Tribes' Health Facility Needs and Joint Venture 
    In 2019, for the second time in the past decade, the Colville 
Tribes applied to replace its temporary modular building in Omak, 
Washington, with a new clinic through the IHS's JV program. The IHS 
solicits applications for the JV program very infrequently--every six 
or seven years--and the program is extraordinarily competitive. When 
the IHS selects a tribal project for the JV program, the tribe agrees 
to construct and, in most cases, equip the facility, and the IHS agrees 
to pay for 80 percent of the recurring staffing costs for at least 20 
    For decades, the Colville Tribes and its citizens have lacked a 
tribal health care facility in Omak, the largest population center on 
the Colville Reservation. In September 2007, the CCT, out of 
desperation, used tribal funds to modify a small modular office 
building for use as a temporary clinic in Omak and redeployed resources 
from its already understaffed operations in Nespelem, Washington, in an 
effort to provide at least some health care to Omak residents.
    The temporary Omak modular building is so cramped that it barely 
allows for wheelchair access in its main hallway. The lack of square 
footage has inhibited the Colville Tribes' ability to add and retain 
health care providers in Omak, which has resulted in long wait times 
for patients and fewer billable patient encounters. The Colville 
Service Unit has been operating under historically low staffing ratios 
since its inception in the late 1930s, so the Colville Tribes were 
already facing a critical shortage of providers in its health delivery 
system. The reduction in patient encounters caused by the lack of 
providers has had the domino effect of eroding the Colville Tribes' 
user population count and negatively impacting the Colville Service 
Unit's base funding.
    When the IHS solicited applications in 2009, the Colville Tribes 
intended to apply, but was unable to do so because of a lack of 
available tribal funds due to the downturn in the timber market 
associated with the housing market crash. At that time, the CCT heavily 
relied on income from the sale of on-reservation timber. In recent 
years, as its economy has diversified, the Colville Tribes have been 
able to utilize tribal resources to develop plans for a new Omak clinic 
and secure financing for that facility.
    The Colville Tribes applied in 2014, but its application did not 
progress beyond the pre-application phase. Since then, the Colville 
Tribes also engaged with the IHS on ways to improve its application 
when the IHS once again solicited applications. The Colville Tribes 
appreciates the cooperation and assistance that IHS officials and staff 
provided as it prepared its 2019 application.
    Early last month, the IHS finally announced the five projects it 
selected for the JV program out of the 10 nationwide finalists and 34 
total applicants, and the CCT was extremely grateful to be one of those 
selected. A bipartisan group of the northwest congressional delegation 
weighed in with the IHS with letters of support. The selection of the 
Omak clinic by the IHS represents just the second JV project ever 
awarded to an Indian tribe in the IHS's Portland Area, the geographic 
region of the IHS that includes more than 60 Indian tribes in 
Washington, Oregon, and Idaho.
II. Impact of COVID-19 on the Colville Tribes and Its JV Project
    The COVID-19 outbreak has impacted Indian country in a multitude of 
ways and the Colville Tribes is no exception. Since the outbreak, our 
health care system has struggled to obtain personal protective 
equipment, to treat tribal member patients with COVID-19 and others 
with chronic conditions, and with decreased budgets due to an abrupt 
decline in third party revenue.
    A significant portion of the Colville Tribes' business plan to 
repay the funds needed to build the Omak clinic hinges on collection of 
third-party revenue, most notably Medicaid. As of this writing, the 
Governor of Washington has instructed state agencies to incorporate 15 
percent cuts for the remainder of the current budget biennium. While 
Washington state has a comparatively generous Medicaid program, it also 
has many options to cut its Medicaid costs, including implementing 
provider cuts, freezing inflation increases, or not allowing rebasing 
of payments. Washington's Medicaid program also provides eligibility 
for individuals whose income exceeds the federal poverty level and 
could easily reduce eligibility thresholds down to just the minimum 
required levels, thereby reducing the number of Medicaid eligible 
    For the Colville Tribes' Omak JV project, any reduction in the 
number of Medicaid eligible patients or services will affect the 
Tribes' revenue forecasts and its ability to service debt for the 
construction of the clinic. This is coupled with the COVID-19 related 
decreases in third party revenue in the Indian health system generally, 
which Director Weahkee testified at the June 11, 2020, House 
Subcommittee on Interior and Related Agencies oversight hearing to be a 
30-80 percent reduction for IHS-operated facilities. We understand that 
other JV project awardees, specifically those in Alaska, are facing 
similar challenges to the viability of their construction plans.
III. Include Funding for the Eligible JV Project Finalists as Part of 
        any Infrastructure Bill the Senate may Consider
    The Colville Tribes requests that the Committee support including 
funding for the eligible JV projects in any infrastructure legislation 
that it may consider on its own or negotiate with the House. Because 
the JV program has a highly competitive and rigorous application 
process, the most recent awardees represent the best evidence of true 
health facility needs in all of Indian country.
    Also, unlike some projects on the legacy IHS Priority Construction 
list, the JV projects are truly ``shovel ready'' in that the IHS 
weighed construction planning heavily in the final selection process 
and successful applicants were required to provide comprehensive 
construction details in their applications. The Colville Tribes will be 
able to break ground as soon as the IHS approves our construction 
    Most significantly, there is no more important investment in 
infrastructure for Indian country than health care facilities when 
considering the myriad of health problems that affect Native Americans 
on a disproportionate basis. To the extent the Committee can recommend 
investments in Indian country in any infrastructure package that the 
Senate assembles or negotiates, we encourage you to include funding to 
construct the JV program awardees.
    Prepared Statement of the Robert Wood Johnson Foundation (RWJF)
    The Robert Wood Johnson Foundation (RWJF) is the nation's largest 
philanthropy dedicated to improving health and health care in the 
United States. Since 1972, we have worked with public and private-
sector partners to advance the science of disease prevention and health 
promotion; train the next generation of health leaders; and support the 
development and implementation of policies and programs to foster 
better health across the country, including high-quality health care 
coverage for all. RWJF is working alongside others to build a national 
Culture of Health that provides everyone in America a fair and just 
opportunity to live the healthiest life possible.
    On May 28, 2020, RWJF issued these Health Equity Principles for 
State and Local Leaders in Responding to, Reopening, and Recovering 
from COVID-19:
    COVID-19 has unleashed a dual threat to health equity in the United 
States: a pandemic that has sickened millions and killed tens of 
thousands and counting, and an economic downturn that has resulted in 
tens of millions of people losing jobs-the highest numbers since the 
Great Depression. The COVID pandemic underscores that:

   Our health is inextricably linked to that of our neighbors, 
        family members, child- and adult-care providers, co-workers, 
        school teachers, delivery service people, grocery store clerks, 
        factory workers, and first responders, among others;

   Our current health care, public health, and economic systems 
        do not adequately or equitably protect our well-being as a 
        nation; and

   Every community is experiencing harm, though certain groups 
        are suffering disproportionately, including people of color, 
        workers with low incomes, and people living in places that were 
        already struggling financially before the economic downturn.

    For communities and their residents to recover fully and fairly, 
state and local leaders should consider the following health equity 
principles in designing and implementing their responses. These 
principles are not a detailed public health guide for responding to the 
pandemic or reopening the economy, but rather a compass that 
continually points leaders toward an equitable and lasting recovery.

    1. Collect, analyze, and report data disaggregated by age, race, 
ethnicity, gender, disability, neighborhood, and other sociodemographic 

   Pandemics and economic recessions exacerbate disparities 
        that ultimately hurt us all. Therefore, state and local leaders 
        cannot design equitable response and recovery strategies 
        without monitoring COVID's impacts among socially and 
        economically marginalized groups.1 Data disaggregation should 
        follow best practices and extend not only to public health data 
        on COVID cases, hospitalizations, and fatalities, but also to: 
        measures of access to testing, treatment, personal protective 
        equipment (PPE), and safe places to isolate when sick; receipt 
        of social and economic supports; and the downstream 
        consequences of COVID on well-being, ranging from housing 
        instability to food insecurity. Geographic identifiers would 
        allow leaders and the public to understand the interplay 
        between place and social factors, as counties with large black 
        populations account for more than half of all COVID deaths, and 
        rural communities and post-industrial cities generally fare 
        worse in economic downturns. Legal mandates for data 
        disaggregation are proliferating, but 11 states are still not 
        reporting COVID deaths by race; 16 are not reporting by gender; 
        and 26 are not reporting based on congregate living status 
        (e.g., nursing homes, jails). Only three are reporting testing 
        data by race and ethnicity. While states and cities can do 
        more, the federal government should also support data 
        disaggregation through funding and national standards.

    2. Include in decisionmaking the people most affected by health and 
economic challenges, and benchmark progress based on their outcomes.

   Our communities are stronger, more stable, and more 
        prosperous when every person, including the most disadvantaged 
        residents, is healthy and financially secure. Throughout the 
        response and recovery, state and local leaders should ask: Are 
        we making sure that people facing the greatest risks have 
        access to PPE, testing and treatment, stable housing, and a way 
        to support their families? And, are we creating ways for 
        residents-particularly those hardest hit-to meaningfully 
        participate in and shape the government's recovery strategy?

         Accordingly, policymakers should create space for leaders from 
        these communities to be at decisionmaking tables and should 
        regularly consult with community-based organizations that can 
        identify barriers to accessing health and social services, lift 
        up grassroots solutions, and disseminate public health guidance 
        in culturally and linguistically appropriate ways.

         People of color (African-Americans, Latinos, Asian Americans, 
        American Indians, Alaska Natives, and Native Hawaiians and 
        other Pacific Islanders), women, people living in congregate 
        settings such as nursing homes and jails, people with physical 
        and intellectual disabilities, LGBTQ people, immigrants, and 
        people with limited English proficiency.

         For example, they could recommend trusted, accessible 
        locations for new testing sites and advise on how to diversify 
        the pool of contact tracers, who will be crucial to tamping 
        down the spread of infection in reopened communities. They 
        could also collaborate with government leaders to ensure that 
        all people who are infected with coronavirus (or exposed to 
        someone infected) have a safe, secure, and acceptable place to 
        isolate or quarantine for 14 days. Key partners could include 
        community health centers, small business associations, 
        community organizing groups, and workers' rights organizations, 
        among others. Ultimately, state and local leaders should 
        measure the success of their response based not only on total 
        death counts and aggregate economic impacts but also on the 
        health and social outcomes of the most marginalized.

    3. Establish and empower teams dedicated to promoting racial equity 
in response and recovery efforts.

   Race or ethnicity should not determine anyone's opportunity 
        for good health or social well-being, but, as COVID has shown, 
        we are far from this goal. People of color are more likely to 
        be front-line workers, to live in dense or overcrowded housing, 
        to lack health insurance, and to experience chronic diseases 
        linked to unhealthy environments and structural racism. 
        Therefore, state and local leaders should empower dedicated 
        teams to address COVID-related racial disparities, as several 
        leaders, Republican and Democrat, have already done. To be 
        effective, these entities should: include leaders of color from 
        community, corporate, academic, and philanthropic sectors; be 
        integrated as key members of the broader public health and 
        economic recovery efforts; and be accountable to the public. 
        These teams should foster collaboration between state, local, 
        and tribal governments to assist Native communities; anticipate 
        and mitigate negative consequences of current response 
        strategies, such as bias in enforcement of public health 
        guidelines; address racial discrimination within the health 
        care system; and ensure access to tailored mental health 
        services for people of color and immigrants who are 
        experiencing added trauma, stigma, and fear. Ultimately, 
        resources matter. State and local leaders must ensure that 
        critical health and social supports are distributed fairly, 
        proportionate to need, and free of undue restrictions to meet 
        the needs of all groups, including black, Latino, Asian, and 
        Indigenous communities.

    4. Proactively identify and address existing policy gaps while 
advocating for further federal support.

   The Congressional response to COVID has been historic in its 
        scope and speed, but significant gaps remain. Additional 
        federal resources are needed for a broad range of health and 
        social services, along with fiscal relief for states and 
        communities facing historically large budget deficits due to 
        COVID. Despite these challenges, state and local leaders must 
        still find ways to take targeted policy actions. The following 
        questions can help guide their response.

         Who is left out? Inclusion of all populations will strengthen 
        the public health response and lessen the pandemic's economic 
        fallout for all of society, but federal actions to date have 
        not included all who have been severely harmed by the pandemic. 
        As a result, many states and communities have sought to fill 
        gaps in eviction protections and paid sick and caregiving 
        leave. Others are extending support to undocumented immigrants 
        and mixed-status families through public-private partnerships, 
        faith-based charities, and community-led mutual aid systems. 
        Vital health care providers, including safety net hospitals and 
        Indian Health Service facilities, have also been disadvantaged 
        and need targeted support.

         Will protections last long enough? Many programs, such as 
        expanded Medicaid funding, are tied to the federal declaration 
        of a public health emergency, which will likely end before the 
        economic crisis does. Other policies, like enhanced 
        unemployment insurance and mortgage relief, are set to expire 
        on arbitrary dates. And still others, such as stimulus checks, 
        were one-time payments. Instead, policy extensions should be 
        tied to the extent of COVID infection in a state or community 
        (or its anticipated spread) and/or to broader economic measures 
        such as unemployment. This is particularly important as 
        communities will likely experience re-openings and closings 
        over the next six to 12 months as COVID reemerges.

         Have programs that meet urgent needs been fully and fairly 
        implemented? All existing federal resources should be used in a 
        time of great need. For example, additional states should adopt 
        provisions that would allow families with school-age children 
        to receive added Supplemental Nutrition Assistance Program 
        (SNAP) benefits, and more communities need innovative solutions 
        to provide meals to young children who relied on schools or 
        child care providers for breakfast and lunch. States should 
        also revise eligibility, enrollment, and recertification 
        processes that deter Medicaid use by children, pregnant women, 
        and lawfully residing immigrants.

    5. Invest in strengthening public health, health care, and social 
infrastructure to foster resilience.

   Health, public health, and social infrastructure are 
        critical for recovery and for our survival of the next 
        pandemic, severe weather event, or economic downturn. A 
        comprehensive public health system is the first line of defense 
        for rural, tribal, and urban communities. While a sizable 
        federal reinvestment in public health is needed, states and 
        communities must also reverse steady cuts to the public health 
        workforce and laboratory and data systems. Everyone in this 
        country should have paid sick and family leave to care for 
        themselves and loved ones; comprehensive health insurance to 
        ensure access to care when sick and to protect against medical 
        debt; and jobs and social supports that enable families to meet 
        their basic needs and invest in the future. As millions are 
        projected to lose employer-sponsored health insurance, Medicaid 
        expansion becomes increasingly vital for its proven ability to 
        boost health, reduce disparities, and provide a strong return 
        on investment. In the longer term, policies such as earned 
        income tax credits and wage increases for low-wage workers can 
        help secure economic opportunity and health for all. Finally, 
        states and communities should invest in affordable, accessible 
        high-speed Internet, which is crucial to ensuring that 
        everyone-not just the most privileged among us-is informed, 
        connected to schools and jobs, and engaged civically.

    These principles can guide our nation toward an equitable response 
and recovery and help sow the seeds of long-term, transformative 
change. States and cities have begun imagining and, in some cases, 
advancing toward this vision, putting a down payment on a fair and just 
future in which health equity is a reality. Returning to the ways 
things were is not an option.
                    National Council of Urban Indian Health
                                                      July 17, 2020
The Honorable Mitch McConnell,
Majority Leader;
The Honorable Charles Schumer,
Minority Leader,
United States Senate,
Washington, DC.

Dear Leader McConnell and Leader Schumer:

    On behalf of the National Council of Urban Indian Health (NCUIH), 
which represents 41 urban Indian organizations (UIOs) and the American 
Indian and Alaska Native (AI/AN) populations they serve, we write to 
express our gratitude for your tireless efforts in protecting our 
Nation during this pandemic. We appreciate your commitment to ensuring 
urban Indians have access to the critical health care they need by 
including UIOs in the COVID-19 emergency response packages.
    In continuation of this commitment, NCUIH is asking you to include 
necessary supplemental funding as well as critical legislative fixes 
for UIOs in the next Coronavirus legislative package to ensure UIOs can 
protect their urban Indian communities.

   IHS--Urban Indian Health--$64 million (in HEROES Act)

   Medicaid--Extension of the Full (100 percent) Federal 
        Medical Assistance Percentage (FMAP) to UIOs Permanently (H.R. 
        2316/S. 1180) (in HEROES Act)

   Health Care Access for Urban Native Veterans Act (H.R. 4153/
        S. 2365) (in HEROES Act)

   Parity in Medical Malpractice Liability for UIOs (H.R. 6535/
        S. 3650)

   IHS--Urban Facilities Line Item--$80 million and Amend 
        Facilities Renovation to Remove Unnecessary Limitations on 
        Accreditations so UIOs can make COVID-19 Renovations (25 U.S.C. 

   IHS--UIO Behavioral Health--$7.3 million for 3 years

   IHS--UIO Health Information Technology--$20 million

   Confer Policy for HHS with UIOs

   Inclusion of UIOs in Advisory Committees with Focus on 
        Indian Health

    These requests are essential to ensuring urban Indians are properly 
cared for, both during this crisis and in the critical times following. 
Thank you for your continued partnership. Communications on this matter 
may be directed to Meredith Raimondi, Director of Congressional 
Relations for NCUIH.

                      Francys Crevier, Executive Director *
    * Francys Crevier's Interior Appropriations Subcommittee Testimony 
on June 11, 2020 has been retained in the Committee files.
                                                       May 21, 2020
Hon. Charles E. Schumer,
Senate Democratic Leader,
U.S. Senate,
Washington, DC;

Hon. Frank Pallone,
House Committee on Energy & Commerce,
U.S. House of Representatives,
Washington, DC;

Hon. Tom Udall,
Vice Chairman,
Senate Committee on Indian Affairs,
Washington, DC.

      Re: Including Native Hawaiian Health Care Systems in 
         Parallel Urban Indian Health Organization Measures

Dear Leader Schumer, Chairman Udall, and Chairman Pallone:

    Mahalo (thank you) for your leadership during the Novel Coronavirus 
Disease (COVID-19) pandemic to ensure that Americans from all walks of 
life survive these challenging times. We are a group of Native Hawaiian 
organizations that provide health, educational, cultural, community 
development, and other services to the Native Hawaiian community. On 
behalf of our organizations and the community we serve, we request 
parity for Papa Ola Lokahi (POL) and the Native Hawaiian Health Care 
Systems (NHHCS) with the urban Indian health organizations in the 
upcoming COVID-19 response package(s).
    In the interest of parity, we request that you include POL and the 
NHHCS in any relief provision that benefits urban Indian health 
organizations. Specifically, we support including these five 
provisions--similarly requested by a consortium of tribal 
organizations--in the next package:

        1.  Extend full Federal Medical Assistance Percentage coverage 
        for Native Hawaiians receiving care at the NHHCS;

        2.  Classify NHHCS and its employees as part of the Public 
        Health Service under the Federal Tort Claims Act;

        3.  Provide reimbursements for primary health care services to 
        Native Hawaiians during this and any future health crisis;

        4.  Reimburse the NHHCS for health services provided to Native 
        Hawaiian veterans otherwise eligible for treatment at a 
        Veterans Health Administration facility and exempt Native 
        Hawaiian veterans from any cost sharing requirements; and

        5.  Clarify that the NHHCS could receive reimbursement for 
        services provided outside a physical clinic.

    This pandemic threatens the continued success and survival of the 
NHHCS, and these provisions will address the most urgent needs facing 
the NHHCS. The above five Native Hawaiian Health Care Improvement Act 
amendments would most efficiently address these needs and provide 
parity in carrying out the federal government's trust responsibility to 
Native Hawaiians. If parallel urban Indian health organization measures 
are not yet included in this response package, we also request your 
consideration to include those provisions as well.
    Mahalo again for your leadership during this difficult time in our 
nation. We understand that the pandemic has negatively affected the 
health and economic well-being of native communities across the nation, 
and the Native Hawaiian community is no different. We are confident 
that you will ensure the Native Hawaiian community does not face 
greater health disparities as a result of this pandemic by providing 
parity for the Native Hawaiian Health Care Systems with the urban 
Indian health organizations.
    (1) Native Hawaiian Health Care Improvement Act amendment language 
to address the five provisions mentioned above;
    (2) Senator Schatz's Native Hawaiian Health Care Improvement Act 
language summary and background information; and
    (3) April 15, 2020 Letter from American Indian and Alaska Native 
organizations. *
    * The attachments have been retained in the Committee files.
U.S Senate,

    1,070 people have signed a petition on Action Network telling you 
to Petition to Provide Adequate Support for Indian Country in Phase IV 
Stimulus Package: a Citizen-Led Initiative.
    Here is the petition they signed:

                                               May 21, 2020
Dear U.S. Senators,

    Petition to Provide Adequate Support for Indian Country in Phase IV 
Stimulus Package: a Citizen-Led Initiative The COVID-19 pandemic is 
highlighting the disparities this country has endured for centuries. 
Indian Country has always endured the greatest burden after disastrous 
events, but we always emerge stronger. As of May 18, there have been 
5,626 confirmed cases of COVID-19 in the Indian Health System and 174 
total deaths. Right now, tribal citizens from across the continent are 
disproportionately feeling the pandemic's impacts: they have lost jobs 
and health care, resources are stretched thin, youth cannot attend 
school, broadband Internet access is disproportionately lacking, and so 
many elders are in need of food and financial support.
    We will not accept being an afterthought in federal relief efforts 
made in this country-the country where Native people have been for 
    And yet, an afterthought is exactly how we have been treated 
throughout this crisis. Indian Country has been undersupported by 
federal relief efforts. Tribes and tribal entities received $8 billion 
in the Phase III stimulus package, but this support fell far short of 
the $20 billion for which the National Congress of American Indians 
initially advocated to cover the true needs of Indian Country. 
Moreover, the current administration was extremely slow getting the 
funds out the door, delaying the resources meant for Native 
communities. Now the HEROES Act recently passed by the U.S. House of 
Representatives includes $20 billion more for Tribal governments--
urgently needed forward progress. We ask the Senate to maintain this 
level of funding in any Phase IV stimulus package. These funds will be 
used to feed tribal citizens, aid health care work, and jump start our 
economic recovery plan. Tribal nations and communities contribute not 
just to their enrolled members, but to people from other tribes and to 
non-Native people, too. Our contributions should be recognized, and our 
people should be acknowledged and adequately supported!
    We must ensure Indian Country is accounted for in the Phase IV 
stimulus package. Specifically the Senate must do the following:
    Maintain the appropriations for tribal governments and entities in 
the HEROES Act of $20 billion, consistent with the needs of Indian 
Country. In addition, require that the administration get the funds out 
the door in a timely manner, so they are not held up in the same way 
that the CARES Act funding was.
    Provide tribal set-asides from the Federal Reserve, the U.S. 
Treasury, and other department lending, guarantees, and forbearance 
programs to ensure that Tribal governments and entities can access 
these programs without burdensome restrictions.
    As citizens of our respective Tribal Nations and the United States, 
we will continue to hold our representatives accountable for including 
us in the ongoing efforts to fight and survive this pandemic. The lives 
of millions of our people are on the line. We look forward to the day 
this has passed and to the new lessons that emerge from it.

     Isabel Coronado, Tribal affiliation: Muscogee (Creek) 
 Owen L. Oliver, Tribal affiliation: Quinault/Isleta Pueblo
 Christie J. Wildcat, Tribal Affiliation: Northern Arapaho/
  Jazmine B. Wildcat, Tribal Affiliation: Northern Arapaho/
Mikah Carlos, Tribal Affiliation: Salt River Pima-Maricopa 
                                           Indian Community
          Adam J. Soulor, Tribal Affiliation: Mohegan Tribe
     Sam Schimmel, Tribal Affiliation: St. Lawrence Island 
                             Siberian Yupik/Kenaitze Indian
     Response to Written Questions Submitted by Hon. Tom Udall to 
                         Robert J. Fenton, Jr.
    Question 1. You testified that FEMA's role in the pandemic response 
changed on March 19, 2020 when the agency moved from playing a 
supporting role in assisting the U.S. Department of Health and Human 
Services (HHS), which was designated as the initial lead agency for 
COVID-19 pandemic response, to leading the ``Whole-of-Government 
response'' to the COVID-19 pandemic. This new role includes managing 
shortages and distributing medical supplies across agencies like the 
Indian Health Service (IHS) and to Tribal governments directly. But 
FEMA's ``Whole-of-Government response'' has led to confusion on payment 
of cost-shares associated with the medical supplies being provided to 
other federal agencies and Tribal governments. For instance, Tribal 
governments report that it is unclear whether the 25 percent non-
federal cost-share under Robert T. Stafford Disaster Relief and 
Emergency Assistance Act (Stafford Act) emergency disaster assistance 
grants applies to medical supplies. Please answer for the record the 
following questions on FEMA's ``Whole-of-government'' response. Does 
the 25 percent non-federal cost-share under the Stafford Act apply to 
the procurement and distribution of medical supplies to Tribal 
    Answer. Eligible emergency protective measures taken at the 
direction or guidance of public health officials, and not provided or 
funded by the authorities of another federal agency, may be reimbursed 
under the Federal Emergency Management Agency (FEMA) Public Assistance 
(PA) program. Reimbursable activities for the COVID-19 pandemic fall 
under Category B of the FEMA PA program-Emergency Protective Measures.
Summary of COVID-19 Emergency Protective Measures
Medical Care

   Emergency and inpatient clinical care

   Purchase, lease and delivery of specialized medical 

   Purchase and delivery of Personal Protective Equipment 
        (PPE), durable medical equipment and consumable medical 

   Medical waste disposal

   Certain labor costs associated with medical staff

Temporary Medical Facilities

   Leasing, purchasing, constructing, mobilizing, operating, 
        and maintaining temporary and expanded medical facilities

Non-Congregate Sheltering to Isolate or Quarantine Populations Such as:

   Those who test positive for or have been exposed to COVID-19 
        and do not require hospitalization but need isolation 
        (including those exiting from hospitals)

   Healthcare workers and first responders who require 

Provision and Distribution of Food

   Purchasing, packaging, and/or preparing food

   Delivering food to distribution points and/or individuals

   Leasing distribution and storage space, vehicles, and 
        necessary equipment

Other Measures to Reduce Immediate Threats to Life, Property, and 
        Public Health and Safety

   Operating state or tribal Emergency Operations Centers 
        related to COVID-19 responses

   Disseminating public health and safety information

   Technical assistance and training to state and local 
        governments on disaster management and control

    The amount of non-federal cost share applied to Stafford Act 
assistance for COVID-19 declarations depends on the type and timing of 
the request. Tribal recipients may request reimbursement for emergency 
protective measures. Additionally, tribes that do not have the 
resources to procure their own equipment, supplies, or services may 
request Direct Federal Assistance (DFA). DFA is applicable when FEMA 
purchases goods and services directly and provides them to state, 
territories or tribes, or directs another federal agency through a 
mission assignment to directly provide these goods or services directly 
to a state, territory, or tribe. Both of these request types--
reimbursement and DFA--are subject to a 25 percent non-federal cost 
    However, for COVID-19 related declarations, FEMA and the U.S. 
Department of Health and Human Services (HHS) signed a reimbursable 
agreement for certain medical supplies. DFA requests for these supplies 
made within the April 14--June 13, 2020 time period will be paid in 
full by HHS (i.e., without a non-federal cost share) when the $1.383 
billion national cap has not been reached. Eligible requests under this 
agreement include, but are not limited to, PPE, hygiene and infection 
control products, portable mechanical ventilators and testing supplies, 
including the transport, storage and tracking of these items.
    For requests that fall outside the FEMA/HHS reimbursable agreement, 
a tribal recipient would be subject to the 25 percent non-federal cost 
share. Tribal subrecipients would be subject to the portion of the 25 
percent non-federal cost share that state recipient chooses to pass on 
to its subrecipients. Some State recipients choose to cover some or all 
of the non-federal cost share for their subrecipients.
    During COVID-19-related declarations, tribes may use federal 
funding from the U.S. Department of the Treasury's CARES Act 
Coronavirus Relief Fund or the U.S. Department of Housing and Urban 
Development's Community Disaster Block Grant and Indian Community 
Development Block Grant programs to meet the non-federal cost share 
required for Public Assistance.

    Question 2. Are there any circumstances in which a Tribal 
government must reimburse FEMA for medical supplies?
    Answer. Tribal recipients are required to reimburse FEMA for the 
non-federal cost share of DFA requests. When DFA requests meet the 
eligibility requirements as described above under the FEMA/HHS 
reimbursable agreement, tribes will not be asked to reimburse FEMA or 
    Additionally, tribes could be required to reimburse FEMA if 
benefits have been duplicated by another federal agency. Section 312 of 
the Stafford Act prohibits all federal agencies from duplicating 
benefits for disaster relief. Multiple agencies having authority to 
expend funds for the same purpose is not, by itself, a duplication of 
benefits under Section 312. However, all federal agencies are 
prohibited by Section 312 from paying state, local, tribal and 
territorial governments for the same work twice. FEMA is coordinating 
closely with other federal agencies to provide information about the 
eligible use of various COVID-19 funding resources. Recipients and 
subrecipients are ultimately responsible for ensuring that they do not 
accept payment for the same item of work twice. FEMA applicants will 
certify in the PA application process that assistance is not being 
    If a tribal government received duplicative assistance for medical 
supplies--e.g., it requested reimbursement for medical supplies it 
received from another source and/or it accepted funding from two 
sources for the same medical supplies, FEMA may deobligate funding to 
avoid a duplication of benefits.

    Question 3. How is the procurement and distribution of medical 
supplies to agencies like IHS budgeted and accounted for, e.g., are 
these expenses FEMA or IHS budget line-items?
    Answer. Procurement and Distribution of PPE to agencies like Indian 
Health Service (IHS) is through an Inter-Agency Agreement (Form 7600 
A&B). These expenses are not FEMA budget line-items.
   Response to Written Questions Submitted by Hon. Lisa Murkowski to 
                         Robert J. Fenton, Jr.
    Question 1. In Alaska, so many Native people have grown up hearing 
stories of devastation from the 1918 flu. This traumatic event looms 
over the current response efforts at a generational scale. Some 
communities have still not recovered from the 1918 epidemic. The memory 
of this almost unfathomable loss, where 82 percent of all deaths in the 
state were Alaska Natives--this motivates a lot of our tribal health 
system's response in Alaska.
    Alaska Natives face a combination of chronic health conditions, 
delayed access to care, inadequate housing, and limited water and 
sanitation services, which all contribute to the alarmingly 
disproportionate impact epidemics have on Alaska Native communities.
    FEMA's role in addressing the public health crisis is critical.
    We have heard from Tribal Health Organizations that there is a need 
for FEMA to preauthorize Category B expenditures (which include all 
COVID-19 disaster declaration expenses). Currently Tribal Health 
Organizations have to spend funds and have to wait months for a 
determination of what might be allowable to be reimbursed. Would FEMA 
support preauthorizing these expenditures?
    Answer. As with most federal grants, FEMA's PA Program already 
allows the award of subgrants, including for Category B expenditures, 
prior to the work being started. FEMA refers to these as ``Standard'' 
projects. Additionally, unlike many other federal grants, FEMA also 
allows the award of subgrants for work that was already completed prior 
to requesting assistance, as long as it is directly related to the 
response or recovery from the disaster event and would be otherwise 
eligible under the program, and refers to these as `work completed' 
projects. Once awarded, for both types, funds are generally made 
available within 1-3 days to the Recipient (typically the state, 
tribal, or territorial emergency management agency), which can then 
provide the funds to their subrecipients in accordance with their own 
procedures and the general guidelines of 2 CFR Subpart D (which does 
allow for the advancement of funds prior to the work being completed). 
As a result, FEMA already routinely approves funds prior to the work 
being completed, however it is not uncommon for the Recipient to hold 
the funds under their own procedures.
    In addition to the standard request for assistance, FEMA also 
allows recipients and subrecipients to make an expedited funding 
request, referred to as an `Expedited' project based on limited 
information. These projects are awarded at half of the expected costs 
to provide immediate funding, with the remainder of funds being made 
available during a later reconciliation. These projects can be 
processed in as little as a few days and are provided as an option 
specifically for applicants that have an immediate need for funding.

    Question 2. We heard that tribes in Region 9 were not able to get 
access to the FEMA grants portal (and that it took months) but other 
Regions took only 2-3 days to get tribes access to the grants portal--
can you tell me why this process isn't consistent across all FEMA 
    Answer. Each FEMA Region has unique geographical differences that 
can affect the timing of assistance. One such difference is the number 
of federally-recognized tribes within a Region. During this 
unprecedented public health emergency, every Region had to work with 
each tribe and with FEMA headquarters to determine the best path for 
providing tribes assistance in accordance with the options available to 
tribes under the Tribal Declarations Pilot Guidance, as well as under 
the President's March 13, 2020 nationwide emergency declaration for 
    The backdrop for these discussions was one of record setting 
disaster declaration and operations activity across every corner of the 
    Receiving access to FEMA's Grant Portal platform is just one step 
in a series of administrative and programmatic requirements that tribes 
must take to receive Public Assistance (PA). Each step in the process 
may take more or less time depending on the nature of the event, the 
capacity of the tribe, the activity in the FEMA region and across the 
Nation, and the choices the tribe makes on how to request assistance.
    Tribal governments typically have three options for FEMA's PA 
program under a major disaster or emergency declaration; as a 
subrecipient under a state, as a recipient under a state, or as a 
direct recipient. Under the President's March 13, 2020 nationwide 
emergency declaration for COVID-19, a tribal government could choose to 
receive FEMA PA under the nationwide emergency declaration without 
submitting a declaration request.
    In Region IX, all 48 tribal governments elected to be recipients 
under a state. When a tribal government requests to be a recipient 
under a state, each request must be processed manually and for new 
recipients this can take 2-3 days to process. Once the FEMA-Tribe 
Agreement has been signed, the regional office submits a request to the 
Grants Portal administrator at FEMA HQ to create a new recipient 
profile under the state's declaration number. The Grants Portal 
administrator must then create a change request with the Grants Portal 
developer to duplicate the state declaration number for the tribal 

    Question 3. We heard there was confusion on processing resource 
requests from tribal clinics and IHS facilities and that some of 
requests were delayed due to this confusion--what is IHS and FEMA doing 
to avoid this issue in the future?
    Answer. Resource requests from IHS or tribal clinics were screened 
by an IHS representative to ensure sourcing and distribution were 
aligned properly. FEMA has added IHS in its customer profiles as a 
drop-down section (instead of a manual write-in) in the Web Emergency 
Operation Center software. (screen shot has been retained in the 
Committee files).
     Response to Written Questions Submitted by Hon. Tom Udall to 
                  Hon. Rear Admiral Michael D. Weahkee
    Question 1. On May 27, 2020, I sent you a letter requesting 
additional information concerning reports that private company had 
provided IHS with substandard personal protective equipment (PPE) under 
a $3 million federal procurement contract. \1\ On June 30, 2020, you 
sent a letter in response to my May 27 letter that did not answer the 
questions I posed. \2\ You committed to answering these questions at 
the hearing. Please answer for the record, under what circumstances did 
IHS become aware of and enter into the contract referenced in my May 27 
letter? What safeguards did IHS deploy to ensure that this new 
contractor was qualified and able to meet the terms of the contract?
    \1\ Letter from Sen. Tom Udall, Vice Chairman, S. Comm. on Indian 
Affairs, to Michael Weahkee, Director, Indian Health Service, Dep't of 
Health and Human Services (May 27, 2020) (letter on file with S. Comm. 
on Indian Affairs).
    \2\ Letter from Michael Weahkee, Director, Indian Health Service, 
Dep't of Health and Human Services, to Sen. Tom Udall, Vice Chairman, 
S. Comm. on Indian Affairs (June. 30, 2020) (letter on file with S. 
Comm. on Indian Affairs).
    Answer. In early April, IHS was conducting market research into a 
variety of sources of PPE. An IHS contract physician was contacted by a 
third party regarding a possible source of N95 or KN95 masks. The 
contract physician forwarded the information to several individuals in 
IHS, who then forwarded the information to the IHS contracting team. 
This market research was conducted in accordance with Part 10 of the 
Federal Acquisition Regulation. Notwithstanding, this matter has been 
reported to the Department of Health and Human Services (HHS), Office 
of Inspector General (OIG). No payment has been made to Zach Fuentes 
LLC, and depending on the outcome of the OIG investigation, additional 
administrative actions may be warranted

    Question 1a. Did IHS verify the KN95 masks supplied by this 
contractor met all Food and Drug Administration standards?
    Answer. The question of whether the KN95 masks supplied by the 
contractor met all Food and Drug Administration standards has been 
raised and referred to the HHS, OIG for an investigation.
    The IHS supply centers utilize quality assurance coordinators to: 
work with subject matter experts to determine requirements; verify that 
products involved in procurement meet technical and/or clinical 
specifications; approve products moving forward for procurement; 
inspect products upon receipt for worthiness and effectiveness; and 
develop processes for routine evaluation and quality control. Each IHS 
supply center is responsible for ensuring quality assurance processes 
are in place as intended to ensure patient safety.
    IHS contracting personnel ensure technical reviews are conducted 
for each proposed product, as presented by the contractor, prior to 
award. After IHS technical evaluations and the contracting personnel 
documents determination of fair and reasonableness, the contract/order 
is issued. Upon IHS receiving the products, inspections occur and if a 
discrepancy or defect is found then the subject matter experts will 
conduct a quality review and present findings to the contracting 
personnel. The contracting personnel will then notify the contractor of 
discrepancy or defect and will request the contractor to correct. If 
the contractor cannot correct, then the entire order will be cancelled 
in its entirety.

    Question 1b. What measures did IHS take to ensure PPE provided 
under this contract was not faulty before distribution and use?
    Answer. The personal protective equipment (PPE) (KN95 masks) 
provided under this contract were not distributed or used.

    Question 1c. What portion of the masks sent to IHS under this 
contract has the IHS distributed to date? Has IHS recalled those masks 
or determined if any masks resulted in the potential exposure of IHS or 
Tribal medical personnel?
    Answer. None of the masks delivered under the contract have been 
distributed or used, therefore no recall was necessary.

    Question 1d. What protocols are in place to guard against IHS 
procuring substandard PPE? How does IHS generally prevent against 
substandard PPE from entering the field?
    Answer. The IHS supply centers utilize quality assurance 
coordinators to: work with subject matter experts to determine 
requirements; verify that products involved in procurement meet 
technical and/or clinical specifications; approve products moving 
forward for procurement; inspect products upon receipt for worthiness 
and effectiveness; and develop processes for routine evaluation and 
quality control. Each IHS supply center is responsible for ensuring 
quality assurance processes are in place as intended to ensure patient 
    IHS contracting personnel ensure technical reviews are conducted 
for each proposed product, as presented by the contractor, prior to 
award. After IHS technical evaluations and the contracting personnel 
documents determination of fair and reasonableness, the contract/order 
is issued. Upon IHS receiving the products, inspections occur and if a 
discrepancy or defect is found then the subject matter experts will 
conduct a quality review and present findings to the contracting 
personnel. The contracting personnel will then notify the contractor of 
discrepancy or defect and will request the contractor to correct. If 
the contractor cannot correct, then the entire order will be cancelled 
in its entirety.

    Question 1e. How will IHS ensure that the Navajo Service Area has 
sufficient PPE to replace the unsuitable masks? What is IHS 
headquarters doing more generally to meet current PPE demand with 
sufficient and quality supplies?
    Answer. The IHS is actively engaged in finalizing an Interagency 
Agreement (IAA) with the Assistant Secretary for Preparedness and 
Response (ASPR) to provide assisted acquisition support for the 
acquisition of supplies, including but not limited to, PPE, hygiene and 
infection control products, portable mechanical ventilators, testing 
supplies, nasopharyngeal Swabs/UTM and pharmaceutical drugs. IHS is 
also part of the HHS Testing At Scale Workgroup which includes 
representatives from multiple HHS agencies and programs. HHS Office of 
the Assistant Secretary for Health currently provides IHS with Abbott 
ID Now Analyzers, test kits, QC kits, nasal swabs, nasopharyngeal 
swabs, and transport media.

    Question 2. In your June 30 letter regarding the substandard PPE 
procurement issue referenced in question one, you stated, ``the 
contractor refused [to enter into a no-cost termination of the 
contract] and submitted a certified claim for payment.'' What steps 
will the Service take in response to the contractor's request for 
payment? Please specifically confirm whether or not IHS will issue 
payment to the contractor.
    Answer. Due to questions concerning the contractor's 
misrepresentation of fact in contract formation, a referral was made to 
the HHS Office of Inspector General. In the meantime, the contractor 
has not and will not be paid for items that did not meet the contract 
requirements. Depending on the outcome of the OIG investigation, 
additional administrative actions may be warranted.

    Question 3. During a briefing with my Committee staff on March 18, 
2020, IHS personnel indicated that the Service was not certain how many 
intensive care unit (ICU) beds, negative pressure rooms, or ventilators 
exist within the network of IHS federally-operated, Tribally-operated, 
and urban Indian organization operated facilities (i.e., ITU system). 
This uncertainty raises questions about IHS's preparedness to respond 
to public health emergencies, especially outbreaks of infectious 
respiratory diseases. How many ICU beds, negative pressure rooms, and 
ventilators did the ITU system have prior to the President's 
declaration of a national emergency concerning COVID-19 on March 13, 
    Answer. The IHS has the ability to report on various metrics within 
the IHS, Tribal, and UIO (I/T/U) community including the number of 
intensive care unit (ICU) beds, negative pressure rooms, and 
ventilators that exist within the network of the IHS system. IHS can 
currently only report on the sites that send data to the centralized 
data store, so data may be incomplete.
    IHS began collecting daily data from IHS direct facilities, 
manually, on March 11, 2020, prior to the President's declaration of a 
national emergency concerning COVID-19 on March 13, 2020. The table 
below reflects additional data collected from Tribal and Urban 
facilities on March 18, 2020. IHS can provide the information collected 
by I/T/U operated facilities that submit data to our centralized data 
store on the number of ICU beds, negative pressure rooms, and 
ventilators. IHS did not experience ICU/Negative pressure room capacity 
issues early on in the pandemic. As most hospitals have limited 
capabilities for severely ill patients, many were referred to outside 
facilities which could provide higher levels of care for critically ill 

                 I/T/U Hospital Data for March 18, 2020
                                                    # of
                                     Negative   Ventilators/   Hospital
         I/T/U           ICU Beds    Pressure     Available      Beds
                                       rooms     Ventilators
Federal (I)                     27         102        70/58          482
Tribal (T)                       6          15          9/9          772
Urban (U)                        0           0            0            0

    Question 3a. How many ICU beds, negative pressure rooms, 
ventilators, and temporary hospital beds did IHS facilities (federally-
operated, Tribally-operated, and urban Indian organization operated) 
have as of the date of this hearing?
    Answer. IHS is able to track and report on various metrics around 
ICU beds, negative pressure rooms, ventilators and hospital beds at I/
T/U operated facilities. IHS began collecting data, manually, on March 
11, 2020 and enabled data collection via a web based application on or 
about April 14, 2020. Although tools were developed to streamline data 
collection, the reporting, data accuracy, completeness, and integrity 
is contingent upon each I/T/U site. Although IHS, to date, has over 789 
I/T/U sites/facilities reporting, only a subset provide data on the 
aforementioned metrics and the accuracy of the data is contingent upon 
the site entering the data into the IHS web portal.

                  I/T/U Hospital Data for July 1, 2020
                                                    # of
                                     Negative   Ventilators/   Hospital
         I/T/U           ICU Beds    Pressure     Available      Beds
                                       rooms     Ventilators
Federal (I)                     27         123      123/122          603
Tribal (T)                      28          48      123/112          533
Urban (U)                        0           0            0            0

        Note: this data reflects the manual information reported 
        pending validation at the individual site level. Most of the 
        change in the tribal ICU bed data and ventilator counts 
        reported over time in this period reflects the vast improvement 
        over time in reporting from tribal sites. The change in federal 
        data between March 18 and July 1 is due to the increased number 
        of negative pressure rooms, ventilators, and hospital beds at 
        individual facilities. Individual facilities increased the 
        available hospital beds by staffing previously unstaffed beds 
        and creating temporary beds.

    Question 3b. Prior to the declaration of the COVID-19 national 
emergency on March 13, 2020, what steps did IHS take to prepare for 
potential public health emergencies, including pandemics?
    Answer. In January and February 2020, the IHS Chief Medical Officer 
sent reports and information regarding the novel Coronavirus infection 
(2019-nCoV) to IHS Areas, facilities, and providers. This information 
was provided to advise and prepare health care facilities for the 
potential impact to patients and the delivery of care in Indian 
    On March 6, 2020, RADM Weahkee activated the IHS Incident Command 
Structure (ICS). The ICS was activated to mitigate negative impacts of 
COVID-19 outbreak responses on IHS operations. The IHS senior 
leadership used resources available from the Federal Emergency 
Management Agency for development of the IHS ICS. Shortly after 
activating the ICS, the IHS finalized the COVID-19 Concept of 
Operations that guides clinical and administrative actions from 
    Prior to the COVID-19 national emergency, IHS had previously 
developed a Provider Influenza Resources webpage that included several 
documents developed for 2009 H1N1 and included a Resource Guide for 
American Indian and Alaska Native Governments. See the following 
websites: https://www.ihs.gov/flu/resources/providerinfluenza/ and 
https://www.cdc.gov/h1n1flu/statelocal/DTLL_H1N1_Guide_10-7-09.pdf. IHS 
also utilized the Office of the Assistant Secretary for Preparedness 
and Response 2017 Update to the HHS Pandemic Influenza Plan, available 
at https://www.cdc.gov/flu/pandemic-resources/pdf/pan-flu-report-
2017v2.pdf. In addition, IHS created the IHS Headquarters Continuity of 
Operations Special General Memorandum (SGM No. 16-01) for the 
implementation and sustainment of responsibilities, as well as the 
headquarters' office building Occupant Emergency Plan: Evacuation and 
Shelter-in-Place Procedures.

    Question 4. During a recent hearing before the House Subcommittee 
on the Interior, Environment, and Related Agencies, \3\ you indicated 
the ITU system has experienced an estimated third-party revenue loss of 
30 to 80 percent due to the COVID-19 pandemic. You stated:
    \3\ Indian Health Service COVID-19 Response: Hearing before the H. 
Subcomm. on the Interior, Environment, & Related Agencies, 116th Cong. 
(2019) (statement of Michael Weahkee, Director, Indian Health Service, 
Dep't of Health and Human Services).
    ``It will likely take several years to make up for the loss of 
third-party revenue collected previously . The initial allocation that 
we received [from the CARES Act Provider Relief Funds]--the $500 
million that went out from HHS to all of our federal, Tribal, and urban 
sites--did help to offset some of those costs. But, we still have many 
sites concerned about needing to furlough or even close their doors.''
    Is IHS aware of any ITU facilities that have closed, reduced 
operations, furloughed staff, reduced staff, or reduced services as a 
result of third-party revenue losses caused by the COVID-19 pandemic? 
If so please provide the number and service area location of the 
facilities that have experienced these impacts.
    Answer. IHS is aware of tribal and urban programs that have had to 
reduce operations, furlough staff, and reduce staff and services due to 
the impact of the COVID-19 pandemic. In addition to a nation-wide 
reduction in non-essential surgeries, and in inpatient and outpatient 
visits, almost all I/T/U facilities have reduced services for Dental 
and Optometry to emergency only. However, a variety of factors have 
gone into the decisions to implement short-term and long-term workforce 
and operation reductions and other cost saving strategies due to the 
economic and operational impacts of the COVID-19 emergency. For 
example, a temporary furlough may be required due to a temporary lack 
of revenue, risk reduction, an increase in costs for PPE, telehealth, 
and staff pay, or reduction in work due to reduced patient visits 
during the COVID-19 emergency.

    Question 4a. What steps has IHS taken to ensure the ITU system can 
participate equitably within the CARES Act Provider Relief Fund 
allocation structures set up by HHS?
    Answer. The IHS provided technical assistance, data, and other 
support to HHS and operating divisions such as the Health Resources and 
Services Administration in determining the allocation of $500 million 
for I/T/U programs from the Provider Relief Fund. Full details of the 
allocation are available here.

    Question 4b. How much money would Congress need to provide for IHS 
to fully address the third-party revenue shortfalls experienced by the 
ITU system as a result of the COVID-19 pandemic?
    Answer. It is difficult to say exactly how much funding would be 
needed to address shortfalls as a result of COVID-19 given Tribes and 
UIOs' third party revenue reporting requirements. I/T/U programs have 
anecdotally reported losses ranging from 30--80 percent. \4\ Like 
health care facilities across the country, revenues declined as health 
facilities restricted the provision of routine care to prevent the 
spread of Coronavirus. For example, some IHS facilities depend on 
third-party revenue for up to 60 percent of their operating budget to 
expand health services and pay staff.
    \4\ For more information specific to UIOs, see the National Council 
of Urban Indian Health's report ``Recent Trends in Third-Party Billing 
at Urban Indian Organizations'' available at https://www.ncuih.org/

    Question 5. The CARES Act provided $1.032 billion in additional IHS 
funding. Of that amount, Congress directed the Service to reserve up to 
$65 million for electronic health record stabilization and support. 
Please describe all activities related to electronic health record 
stabilization and support IHS has undertaken with these funds.
    Answer. The IHS will establish a project management office for 
Electronic Health Record (EHR) modernization, support acquisition 
planning, and stabilize the current technology environment and IHS 
electronic health record system, the Resource and Patient Management 
System (RPMS), in FY 2020. The project management office will focus on 
governance, acquisition, program planning, Health IT design, and 
organization change management. The funding is being used for some 
federal positions and tribal stakeholder and engagement. Additionally, 
the IHS is also piloting an eHealth Exchange connection to support 
interoperability with the VA, DOD, Tribes, and other certified health 
systems in the current and future Health IT infrastructure.

    Question 5a. Using its current electronic health record systems, is 
IHS able to track and report data on hospitalizations or adverse health 
outcomes for COVID-19 patients in federally-operated IHS facilities or 
within the ITU system as a whole?
    Answer. The EHR provides for applications and utilities for 
tracking of Hospital Adverse Events (Emergency Department and Hospital 
Admissions) and population health data at each site. These results are 
reported to the agency Incident Response team, aggregated and presented 
in an agency dashboard for continuous monitoring.
    The IHS is able to track and report data on hospitalizations or 
adverse health outcomes for COVID-19 patients in federally operated IHS 
facilities or within IHS, Tribal, Urban health care systems as a whole. 
IHS leverages its Business Intelligence framework, which consists of a 
centralized data store, or National Data Warehouse, that enables the 
ability to collect, integrate and posture data for data reporting and 
analytics. To date, IHS has over 789 I/T/U sites/facilities, within 198 
service units, across 12 geographical areas are participating in daily 
data collection and reporting of COVID-19 related metrics.

    Question 5b. How do the ITU system's electronic health record 
systems impact the ability to accurately monitor COVID-19 activity?
    Answer. While every effort was made to adapt the IHS EHR to provide 
adequate direct care capabilities to address COVID-19 for hospitals and 
clinics, its decentralized design is not well suited for nationwide 
surveillance and reporting to monitor COVID-19 activity. A standardized 
EHR graphical user interface template and note titles were created to 
electronically document COVID-19 patient visits. Training was provided 
to the critical care teams for this COVID-19 template and the note 
titles. Specific Document and Note Titles can be searched as part of 
the EHR Community Alerts due to this standardized approach. Each 
clinical site must make this update to their local EHR to utilize the 
COVID-19 template.

    Question 6. According to a recent Politico article, \5\ the 
Department of Health and Human Services (HHS) and the Centers for 
Disease Control and Prevention (CDC) are limiting or denying Tribal 
epidemiology centers (TECs) access to federal public health databases, 
including infectious disease surveillance databases. This limitation 
appears to be in violation of the Indian Health Care Improvement Act 
(IHCIA), which designates TECs as public health authorities under the 
Health Insurance Portability and Accountability Act Privacy Rule, and 
specifies that HHS must grant TECs access to ``data, data sets, 
monitoring systems, delivery systems, and other protected health 
information in the possession of the Secretary \6\.'' \7\
    \5\ Darius Tahir & Adam Cancryn, American Indian Tribes Thwarted in 
Efforts to Get Coronavirus Data, Politico (Jun. 11, 2020), 
    \6\ 25 U.S.C.  1621m(e)(1).
    \7\ 25 U.S.C.  1621m(e)(2).
    How is IHS working with other agencies within HHS to ensure Tribes 
and Native public health entities have equitable access to federal 
public health data resources, including disease surveillance data, to 
combat coronavirus spread within Native communities?
    Answer. The IHS has longstanding cooperative agreements used to 
fund the Tribal Epidemiology Centers (TECs). Since the beginning of the 
COVID-19 response, the IHS has actively engaged on weekly calls with 
TECs along with colleagues from the Centers for Disease Control and 
Prevention (CDC). These calls are coordinated and led by the TECs and 
include sharing best practices and group problem solving related to 
national and regional COVID-19 response.
    IHS is working with federal agencies, Tribes, and tribal programs 
to ensure that tribal public health authorities receive the information 
they need for public health planning and contact tracing. The IHS 
remains committed to advocacy for such access to data as permitted by 
    IHS has several ongoing coordinating efforts with CDC, including a 
number of weekly operational coordination calls with CDC at various 
organizational levels. The CDC is working with TECs to provide access 
to needed data. CDC participated on an All TECs conference call on June 
30, 2020 to discuss the process of transferring and receiving COVID-19 
case data for all TECs. Data were transferred to the TECs on July 15, 
2020 and will be updated every 2 weeks.
    CDC met with the Urban Indian Health Institute (UIHI) on June 18, 
2020 to discuss how to transfer and receive the COVID-19 data and 
followed up on June 23, 2020 to provide technical assistance on 
connecting via a secure server. CDC sent COVID-19 data to UIHI on June 
24, 2020. As with the other TECs, CDC will continue to send the most 
up-to-date COVID-19 data set to UIHI every two weeks.
    Additionally, CDC worked with UIHI on a recent Morbidity and 
Mortality Weekly Report (MMWR) on COVID-19 among AI/AN in selected 
states: COVID-19 Among American Indian and Alaska Native Persons--23 
States, January 31-July 3, 2020 (available at https://www.cdc.gov/mmwr/
?s_cid=mm6934e1_w). CDC invited all TECs to participate in drafting 
this MMWR. CDC is engaged with UIHI in other ways as well. For example, 
they are discussing a second MMWR about COVID-19 among urban Indians 
with UIHI.
    CDC is working to address access to other data and will continue to 
work with tribal and other involved stakeholders to do so. The IHS will 
continue to support such data access through partnership with CDC.

    Question 7. The IHS and Department of Veterans Affairs (VA) have 
informed the Committee that they are drafting an inter-agency agreement 
(IAA) to allow VA to treat non-Veteran IHS patients during public 
health emergencies. The agencies involved have committed to keeping 
Congress updated on the negotiations related to this IAA, including how 
the IAA would address repayment for VA's costs to provide care for 
uninsured non-veteran IHS patients. What is the current status of the 
    Answer. The IHS continues to work with VA to execute an interagency 
agreement for bed space, healthcare, resources, and staff.

    Question 7a. What information about this agreement has IHS provided 
to Indian Tribes and urban Indian organizations? And, has IHS sought 
feedback from Indian Tribes or urban Indian organizations regarding the 
structure of the IAA?
    Answer. The IAA is between IHS and VA as Federal agencies. The IHS 
has notified Indian Tribes and UIOs about the goals and intent of the 
IAA, but has not actively sought feedback regarding the structure. For 
example, the IHS has shared the lifesaving benefit of an IAA as 
demonstrated through the coordination that occurred, when the Gallup 
Indian Medical Center experienced a critical clinical issue. The 
facility had four critical COVID-19 patients, all requiring mechanical 
ventilation for life support. GIMC was unable to find any accepting 
transfer beds. Without hospital decompression for these critical 
patients, GIMC would not have been able to accept any subsequent 
critical patients. The VA came through in this crisis, accepting the 
patients at the Albuquerque VA Medical Center, allowing for 
decompression of GIMC, and allowing GIMC to remain available for 
additional critical patients.

    Question 7b. Will the IAA be fully compliant with federal law 
governing IHS patient balance billing prohibitions and IHS payer-of-
last resort provisions?
    Answer. Yes, the IHS and VA must comply with Federal law. The IHS 
is the payer of last resort by statute, 25 U.S.C.  1623(b). This 
authority prohibits IHS from paying for care when there are alternate 
resources. The IHS would not consider VA to be an alternate resource 
for IHS beneficiaries who are non-Veterans, unless those non-Veterans 
are eligible for care through VA. Based upon our conversations with VA, 
we understand that VA has certain authority to provide care to non-
Veterans. However, those non-Veterans would not be eligible for 
services from VA and VA would be required to charge. This includes care 
provided to non-Veteran IHS beneficiaries at the request of IHS. The 
IHS would defer to VA for a further explanation of VA's authorities and 

    Question 7c. How many patients has the ITU system sent to VA 
facilities for COVID-19 related care?
    Answer. The information below is reported by the IHS Area offices. 
Tribes and UIOs are not required to report this data to IHS, and the 
data below may not be representative of all patients transferred to the 
VA by Tribes or UIOs.

                                                               Number of
           IHS Area                       Facility             patients
Albuquerque                    Zuni Service Unit                       1
Navajo                         Gallup Service Unit                    14
Phoenix                        Colorado River Service Unit             1

    Question 7d. To the best of IHS's knowledge, has VA attempted to 
bill IHS or any uninsured COVID-19 IHS patients sent to VA facilities 
for treatment for the cost of providing this care?
    Answer. IHS has currently received three bills from the VA for 
patients referred to the VA in Albuquerque from the IHS Navajo Area.

    Question 8. Congress directed CDC, the Substance Abuse and Mental 
Health Services Administration, the Health Resources and Services 
Administration, and the Administration for Community Living to reserve 
over $200 million in COVID-19 resources for Indian Tribes, tribal 
organizations, and urban Indian health organizations in the Coronavirus 
Preparedness and Response Supplemental Appropriations Act, the Families 
First Coronavirus Response Act, and the CARES Act. However, I've heard 
concerns from Tribal leaders and urban Indian health program directors 
relating to the administration and allocation of these funds. As IHS 
Director, you are co-chair of the HHS Intradepartmental Council on 
Native American Affairs (ICNAA) and a member of the White House's 
Indian Country COVID-19 response team--roles that should allow to 
monitor and advocate for changes to Tribal-specific COVID-19 programs 
within HHS agencies. What kind of technical assistance or guidance is 
IHS providing to these other agencies about best practices when 
administering Tribal and urban Indian organization specific funding 
during the coronavirus pandemic?
    Answer. The IHS provides support to our sister agencies in 
distributing COVID-19 funds for tribes and UIOs as needed. For example, 
the IHS provided technical assistance to the CDC on the funding 
methodology for the $40 million for Component A of CDC's new non-
competitive grant for tribal nations, consortia, and organizations.

    Question 8a. How can Congress, the Administration, Tribes, and 
urban Indian organizations work together to make sure future COVID-19 
legislation addresses any administrative barriers or challenges 
uncovered through implementation of previous COVID-19 related 
    Answer. The IHS has unique funding authorities and mechanisms, 
including the Indian Self-Determination and Education Assistance Act 
(ISDEAA), which allow for streamlined distribution of funds. Our sister 
agencies, which are not authorized to transfer funds under the ISDEAA, 
often rely on grant mechanisms to award funds, which generally take 
longer to award because they require the agency to post a solicitation 
and review applications. Our sister agencies, like CDC, worked hard to 
alleviate potential administrative burdens associated with grant 
mechanisms and shorten the timeline as much as possible. However, when 
bill language appropriates the funds to these agencies, or directs 
funds to be awarded by grant or cooperative agreement, the agencies 
must abide by that requirement and their other authorities. Tribal 
leaders have long voiced opposition to the use of grant mechanisms due 
to the administrative burden that comes along with this award type.

    Question 9. The Committee has received reports from Direct Service 
Tribes (DST) that the service units in their communities are not 
coordinating appropriately with the Tribes' COVID-19 responses efforts. 
In particular, several DSTs have noted that their IHS facilities 
developed CARES Act spend plans in isolation without soliciting input 
from the Tribes' and without regard for the resource needs identified 
by each community. Please describe the policies and practices IHS has 
implemented to ensure robust COVID-19 response coordination between IHS 
service units and the Tribes they serve, including DSTs.
    Answer. It is the policy of the IHS that consultation with Tribes 
will occur to the extent practicable and permitted by law before any 
action is taken that will significantly affect Tribes. Such actions 
refer to policies that have Tribal implications and substantial direct 
effects on one or more Tribe(s) regarding the relationship between the 
Federal Government and the Tribe or Tribes, or on the distribution of 
power and responsibilities between the Federal Government and the Tribe 
or Tribes. The IHS tribal consultation policy can be found here: 

    Question 9a. Did IHS require service units to consult with DSTs 
regarding development of CARES Act spend plans? Please also describe 
how federally-operated IHS facilities developed their CARES Act funding 
spend plans.
    Answer. The IHS tribal consultation policy addresses consultation 
at the Service Unit level. All IHS Service Units have a process to 
ensure that full consultation with all Tribes within the service unit 
is coordinated, and that process may vary depending on the unique needs 
and preferences of the Tribal communities served.

    Question 10. On April 24, 2020, and again on May 11, 2020, 
Committee staff requested information from IHS regarding its use of 
volunteers in IHS facilities during the COVID-19 pandemic. Does IHS 
have a way to track the total number of volunteers working within the 
ITU system? If so, please provide an estimate of the number and service 
area location of volunteers currently working within the IHS.
    Answer. The information below is reported by the IHS Area offices. 
Tribes and UIOs are not required to report this data to IHS, and the 
data below does not include all volunteers that may be currently 
working for Tribes or UIOs.

             IHS Area                       Facility          Volunteers
Great Plains                        Pine Ridge Service Unit            9
Navajo                              Chinle Service Unit                8
Navajo                              Gallup Service Unit               12
Navajo                              Kayenta Service Unit              10
Navajo                              Shiprock Service Unit              5
Navajo                              Winslow Service Unit              11
Phoenix                             Whiteriver Indian                  1
Phoenix                             Urban Indian Center of           10*
                                     Salt Lake
Portland                            Yakama Service Unit                3

        *Volunteers per month.

    Question 10a. How does IHS ensure that all medical volunteers 
seeking to work in an IHS facility are appropriately credentialed and 
    Answer.It is the IHS policy to credential and privilege all 
providers, whether they are employees, contractors, or volunteers. 
Providers are credentialed and privileged according to the facility's 
bylaws, policies, and accreditation standards. Each facility also 
performs regular provider performance reviews and continuous credential 
verification through the IHS Centralized Credentialing System.

    Question 10b. Have provider vacancies within each IHS service area 
grown or decreased during the course of the COVID-19 pandemic?
    Answer. IHS's overall vacancy rate in February was 21 percent, and 
the vacancy rate in May was 21 percent. At this point it does not 
appear that COVID-19 has impacted vacancy rates.

    Question 11. On April 23, 2020, IHS announced its allocation plan 
for CARES Act funding--including reserving $10 million to support 
sanitation and potable water needs. \8\ Please provide the Committee 
with details of the recipients, including award amounts, of the $10 
million included in the CARES Act to support sanitation and potable 
water needs.
    \8\ Press Release, Indian Health Service, Dep't of Health & Human 
Services, IHS Statement on Allocation of Fiscal $367 million from CARES 
Act (Apr. 23, 2020), available online at https://www.ihs.gov/newsroom/
    Answer. See attachment, CARES Act Project PDS List. *
    * The information referred to has been retained in the Committee 

    Question 12. In responses to a question for the record I posed last 
year to ICNAA Co-Chair and Administration for Native American 
Commissioner Jeannie Hovland regarding ICNAA's plans to discuss the 
findings for the National Climate Assessment, she stated the Council 
would address the assessment during the Council's next meeting in late 
May 2019. \9\ Please provide an update on the status of discussions 
within HHS, IHS, or the ICNAA regarding the findings in the National 
Climate Assessment.
    \9\ 45th Anniversary of the Native American Programs Act and the 
Establishment of the Administration for Native Americans: Hearing 
Before the S. Comm. on Indian Affairs, 116th Cong. 46 (2019) (statement 
of Jeannie Hovland, Commissioner, Admin. for Native Americans, Admin. 
for Children & Families, Dep't of Health & Human Services).
    Answer. At the May 22, 2019 meeting of the Secretary's 
Intradepartmental Council on Native American Affairs (ICNAA) Director 
Patrick Breysse of the CDC National Center for Environmental Health/
Agency for Toxic Substances and Disease Registry (NCEH/ATSDR) outlined 
the wide variety of environmental issues affecting Indian Country. 
These issues include uranium mining in the Southwest, indoor air 
pollution from dirty fuel types, and the contamination of water due to 
mining. Funding to address environmental concerns was also discussed as 
the Administration for Children and Families Administration for Native 
Americans offers funding to American Indians, Alaska Natives, Native 
Hawaiians, Pacific Islanders, and Native non-profits. Environmental 
Regulatory Enhancement grants can be used to address environmental 
concerns within Native communities.
    The ICNAA also identified environmental issues as one of its 
priority areas for collaboration across HHS operating divisions. The 
ICNAA Chair and Vice Chair were able to raise this issue as a priority 
area when addressing the Secretary's Tribal Advisory Committee (STAC) 
in September of 2019. At the November 2019 ICNAA liaison meeting a 
representative of the CDC NCEH/ATSDR office provided an update on the 
upcoming Chlorinated Substances Conference that included coverage of a 
national study on water and sanitation for Native communities. A 
potential collaboration between CDC NCEH/ATSDR and the National 
Institutes of Health (NIH) National Institute of Environmental Health 
Sciences (NIEHS) on a 2020 conference was also discussed.
    The question of addressing environmental issues collaboratively was 
discussed among the ICNAA liaisons and the CDC outlined their plan to 
host regional summits with tribes. The Tribal Environmental Health 
Summit was one of these events, coordinated by the CDC National Center 
for Environmental Health, to be held in March of 2020. However, due to 
the COVID-19 outbreak, this event had to be cancelled. The CDC NCEH/
ATSDR's also had a presentation on addressing environmental health 
concerns in Indian country planned for the National Indian Health Board 
Tribal Public Health Summit in late March. This event was also 
cancelled due to the COVID-19 pandemic.
   Response to Written Questions Submitted by Hon. Lisa Murkowski to 
                  Hon. Rear Admiral Michael D. Weahkee
    Rear Admiral Weahkee, the impact that the pandemic has had on the 
Alaska tribal health system is unprecedented. With tribal providers 
forced to shut down elective procedures and clinics, the negative 
financial impact cannot be overstated. It is estimated that third party 
collections have dropped by 80 percent in some cases. More resources 
are needed to sustain the Alaska Tribal health system, which is the 
only provider in the vast majority of rural Alaska. Adequately 
resourcing and removing unnecessary regulatory barriers are essential 
for the Alaska Tribal health system to effectively limit the outbreak 
of COVID-19 in Native communities and to properly treat Native 
individuals that become infected. Water and sewer service in Alaska 
Native communities have long been lacking, but the pandemic has 
highlighted how essential adequate sanitation is for communities.
    The importance of adequate water and sewer to prevent `water wash' 
disease is very clear. CDC studies document skin and respiratory 
infections in rural Alaska communities without water service to homes 
that are 5 to 11 times higher than the national average. This is 
especially critical now, since COVID-19 is a respiratory disease whose 
spread can be prevented by hand washing, avoiding close contact with 
others, and cleaning/disinfecting surfaces. Lack of water service in 
these rural Alaska villages creates extreme challenges in practicing 
two of these three basic prevention techniques.
    Of the 190 Alaska Native communities, 32 are still not served with 
in-home water/sewer. These communities typically have a washeteria 
building (that is a combination water treatment plant, laundromat, 
toilets and showers) that the entire community uses. Most of these 
communities haul their water from the washeteria to their home in a 5-
gallon bucket, and haul their sewage from their home in a different 5-
gallon bucket.

    Question 1. Many rural communities do not have access to adequate 
water due to the high construction costs of projects in those 
communities, particularly in Alaska. The IHS has established cost caps 
per home that when approached both decrease the priority of the project 
in the scoring system and limits the amount of funding available.
    Would IHS be willing to eliminate, or at least raise, the cost caps 
for projects that provide piped water and sewer into these unserved 
    Answer. The process for developing and updating allowable unit 
costs is being reviewed with IHS Area staff. A proposal was developed 
to move the program toward the use of more local, actual cost data 
collected by IHS, Tribes, and tribal organizations. Until such time 
that we have the data necessary to adjust the methodology, the current 
approach will continue to be used.
    When a project exceeds the allowable unit costs it is flagged as 
economically infeasible. If other funding partners are willing to fund 
portions of a project that is deemed economically infeasible, the IHS 
is willing to provide funding for that project up to the allowable unit 
costs amount.
    The allowable unit costs are developed for each State, with the 
exception of Alaska, which has three regional allowable unit costs to 
account for geographical differences that impact costs of construction 
within Alaska. The three regions are separated as follows: Northern 
Region: $235,500; Southern Region: $169,000; and Central and Western 
Regions: $197,500. IHS developed the total allowable unit costs (also 
known as threshold costs) to provide a basis for developing overall 
project economic feasibility. The allowable unit cost represents the 
cost to construct all water, sewer, and solid waste facilities for a 
typical home. The methodology used to develop these costs is based on 
cost indices used by the IHS facilities program and the Department of 
Housing and Urban Development.

    Question 2. This pandemic has highlighted the need for community 
public health measures, the most basic and important being access to 
running water and sanitation. You've expressed willingness in past 
hearings to work with tribal organizations in Alaska on overcoming the 
issues of community contributions in ``Indian communities'' for 
sanitation projects. With the current emergency situation, is IHS 
willing to waive the non-Indian contribution requirement in ``Indian 
    Answer. Since the inception of the IHS Sanitation Facilities 
Construction (SFC) program nearly 61 years ago, the IHS has consulted 
with and encouraged the participation of Tribes, States, other federal 
agencies, local governments, non-profits and other potential 
stakeholders in all phases of SFC projects. Collaborative sanitation 
projects among IHS, Tribes, project participants, contributors and 
other stakeholders is the original tenet for the SFC program. All SFC 
projects are collaborative projects initiated by tribal request and 
requiring participation by, contributions from, and coordination among, 
the stakeholders. This approach helps ensure that communities are 
jointly engaged in the development of projects and that the limited 
funds appropriated for the program expressly benefit Tribal homes in 
need of sanitation improvements. Advance planning prior to the 
appropriation of federal resources is essential to ensure prorated 
contributions for all ineligible units are received/confirmed prior to 
the allocation of federal funds.
    The SFC program works with a variety of funding partners and 
assists communities with identifying potential sources of 
contributions. The contribution requirement is premised on and 
consistent with 42 U.S.C.  2004a(3). SFC CARES Act funds will be 
administered as part of the IHS Facilities Appropriation and as such 
are bound by P.L. 86-121, IHCIA, and the IHS policy/guidelines 
developed through these two pieces of legislation.

    Question 3. Testing Needs: Tribal health needs access to Cepheid 
GenXpert testing kits. The Cepheid GenXpert analyzers are available at 
regional hospitals, but the ATHS does not have adequate access to the 
testing kits needed. These kits have been supplied to commercial 
enterprises in Alaska, such as fishing. Will you work to provide equal 
access for proper testing for COVID-19 to prevent its spread to rural 
    Answer. IHS Division of Acquisition Policy (DAP) established an 
indefinite delivery, indefinite quantity (IDIQ) (ordering) contract 
with Cepheid. This contract has numerous line items for various 
molecular laboratory analyzer types, associated warranty and 
maintenance agreements as well as the needed COVID-19 testing kits. IHS 
Area Offices now have the ability to issue funded orders against this 
contract once IHS senior leadership approves the order. The delivery 
dates for orders will be dependent on availability due to global 
demand. On August 12, 2020, DAP hosted an IHS-wide call to answer 
questions about the contract and ordering process.
    On August 20, 2020, IHS met with Cepheid representatives to discuss 
COVID-19 testing kit supply allocations for IHS facilities, production 
capacity for additional molecular laboratory analyzers, and the need to 
continue a steady supply of testing kits for facilities with active 
analyzers. A follow-up meeting was held on August 25, 2020, with IHS 
Leadership and Cepheid representatives. This meeting covered IHS 
expectations and Cepheid supply chain realities in regard to supporting 
active analyzers with a steady supply of testing kits. Commitments were 
made from Cepheid regarding the ongoing support of all active I/T/U 
analyzers in the field, including those in rural Alaska through their 
direct contract with the Alaska Native Medical Center. DAP intends to 
have another IHS-wide call during the week of August 31, 2020 to 
address any remaining questions or issues. Additionally, weekly 
recurring meetings have been set up with Cepheid representatives to 
discuss testing kit supply volumes, any increased capacities, and 
outstanding logistics or administrative action items.
    IHS has been successful in receiving the Abbott ID NOW COVID-19 
point of care analyzers from HHS, which has an active contract with 
Abbott. This contract has allowed IHS to receive analyzers and an 
ongoing supply of test kits which are distributed through the IHS 
National Services Supply Center to I/T/U Indian Health programs. To 
date, the Alaska Area has received and distributed 31 Abbott ID 
analyzers and tests kits in support of those 31 analyzers. Both Cepheid 
and Abbott have confirmed they will work to increase production 
capacity so as to allow further allocations to IHS of both analyzers 
and test kits to be made available to I/T/U programs including those in 
rural Alaska.
     Response to Written Questions Submitted by Hon. Jon Tester to 
                  Hon. Rear Admiral Michael D. Weahkee
    Question 1. IHS acted swiftly to include funding for the newly 
recognized Little Shell Chippewa Tribe in the FY 2021 Budget 
Justification. However, the placeholder request of $2.6 million is 
inadequate. Based on the Tribe's projected user population and the IHS 
average per capita expenditure, the Tribe should receive an allocation 
of roughly $8-10 million. Can you commit to updating IHS's initial 
request in order to adequately reflect the true costs of providing 
services to Little Shell?
    Little Shell is also in the process of purchasing and renovation a 
facility in hopes that its IHS allocation will be used to staff the 
facility with IHS personnel. Can you ensure that the Tribe's allocation 
is placed under the appropriate IHS account?
    Answer. The IHS requested $2.6 million in the FY 2021 Budget 
Justification for New Tribes funding for the Little Shell Band of 
Chippewa Tribe. This funding level is an estimate, and the IHS has been 
working with the tribe to finalize the necessary data to update the 
amount. These funds are requested as New Tribes funding, consistent 
with the IHS policy for newly federally-recognized tribes, outlined in 
the Indian Health Manual.
    We understand that the tribe plans on opening its own health care 
facility in the near future. If that is the case, the tribe could 
ultimately seek to operate its own program under the ISDEAA, and use 
the New Tribes funding in support of that facility.

    Question 2. The Rocky Mountain Tribal Epidemiology Center provides 
support and information to Tribes in Montana and Wyoming yet they have 
experienced significant roadblocks to accessing critical COVID data 
from the IHS. How does IHS partner with TECs to make sure they can 
access the IHS public health surveillance data they need to be 
resources to Tribes?
    Answer. Rocky Mountain Tribal Epidemiology Center (RMTEC) has an 
active Epidemiology Data Mart (EDM) sharing agreement with the Indian 
Health Service. Supported by this agreement, RMTEC receives routine 
access to fresh, limited data sets several times a year. On July 30, 
2020, the IHS technical managers of the EDM hosted a conference call 
including RMTEC to review the elements of the EDM that are relevant for 
COVID response.
    Since the coronavirus pandemic began, the IHS has also worked to 
expand data access for Tribal Epidemiology Centers (TECs) to aid their 
response efforts. The IHS began sharing influenza-like illness 
syndromic surveillance reporting with TECs, and is currently working to 
develop standalone reporting to TECs for daily COVID-19 testing data 
reported nationally to IHS Headquarters. In addition, the Oklahoma City 
Area Office of IHS recently developed an agreement with the Southern 
Plains Tribal Epidemiology Center to disclose certain IHS data 
(including Protected Health Information in accordance with law) to 
carry out specific activities directly related to the novel COVID-19, 
including contact tracing efforts. On July 27, 2020, IHS Headquarters 
sent notice of the finalized agreement to the remaining IHS Area 
Offices to inform and support them in considering similar agreements 
and partnership with TECs.
   Response to Written Questions Submitted by Hon. Martha McSally to 
                  Hon. Rear Admiral Michael D. Weahkee
    Question 1. While early outbreaks were clustered in the northeast 
part of the state, unfortunately we are now seeing more and more 
hotspots in other tribes. For example, the White Mountain Apache Tribe 
now has the highest infection rate per capita in Arizona. Rural tribes 
in Arizona like White Mountain are in need of mobile test sites.
    What is IHS doing to deploy mobile testing in rural areas? Does IHS 
have enough employees and healthcare workers to conduct the necessary 
amount of testing and provide treatment to these hard hit communities? 
What steps could be taken to increase resources in these areas?
    Answer. IHS continues to work with HHS and testing analyzer/kit/
swab/media suppliers to acquire testing materials for IHS and tribal 
health programs. The IHS is not always able to immediately supply all 
testing analyzer/kit/swab/media orders requested due to the lack of 
supplies. Testing strategies vary by location and state. Several Tribes 
are working with federal and state partners to conduct mass testing 
events for their communities. From the onset of the pandemic, and 
continuing into the future, the IHS will work with federal and Tribal 
programs to support the availability of as many tests as possible. This 
work will continue as determined by epidemiological factors (e.g., 
decreased number of cases), transmission, population immunity, and/or 
through the availability of safe and effective vaccines which could 
eliminate the need for broad scale testing. As of June 29, the IHS had 
performed 272,935 tests, equating to 16 percent of the IHS User 
Population, and exceeding the U.S. all races testing rate of 10.8 
percent. As of August 29, the IHS had performed 650,223 tests, equating 
to 39.1 percent of the IHS User Population, compared to the U.S. all 
races testing rate of 25.4 percent. Also as of August 29, 36.8 percent 
of reported tests completed have been done with the Abbott ID NOW 
COVID-19 analyzer.

    Question 2. As states begin to reopen, many are providing free 
testing to any individual who requests it. This allows businesses to 
open with confidence and have employees tested on a regular basis to 
ensure safe operation. Are tribal members able to utilize IHS or 638 
contract facilities to get free testing on demand?
    Answer. Yes. Tribal members should contact their IHS or 638 
contract health care facilities for specific information pertaining to 
the testing programs available.

    Question 3. Tribal communities in Arizona are among the least 
digitally connected communities in the country. How has the lack of 
access to broadband hindered the IHS in moving forward with 
telemedicine opportunities throughout IHS facilities across the 
    Answer. IHS significantly expanded telehealth capabilities across 
the U.S. during the COVID-19 pandemic. The most successful telehealth 
programs are those that provide video conferencing services within IHS 
facilities. These types of telehealth visits are primarily physician-
to-physician or remote specialists to patients within an IHS facility. 
IHS is able to expand telehealth between our facilities despite the 
lack of broadband access to many tribal communities. Our primary 
challenge is conducting patient-to-provider telehealth visits while the 
patient is at home. The IHS has recognized the challenges with lack of 
access to patient due to broadband connectivity. Some rural patients do 
not have the necessary equipment such as a smart phone or laptop with 
adequate signal or broadband connectivity in their home or community.
    The IHS has supported telephonic telehealth visits to mitigate 
these issues. Also, IHS plans on using the $95 million CARES Act funds 
for central program management and services to provide a solid 
foundation which supports long-term sustainability of telehealth 
infrastructure and services. The literature has shown that system-level 
planning and support for telehealth, as opposed to a fragmented 
approach, improves continuity of primary care, access management, 
economies of scale, and platform standardization.

    Question 4. In my conversations with tribal leaders and healthcare 
administrators, they have expressed concern about the loss in revenue 
as ``elective procedures'' are put on hold to focus on coronavirus 
response. Are IHS facilities or Urban Indian Health Organizations being 
told to cancel elective procedures to address the pandemic? If so, has 
the effect of the loss of revenue from the procedures been accounted 
for when calculating the overall needs for IHS facilities?
    Answer. The IHS has not advised tribal or urban Indian health 
programs to cancel any procedures or patient appointments. However, 
some tribal and urban Indian health programs have done so. I/T/U 
programs have anecdotally reported third party revenue losses ranging 
from 30--80 percent. \10\
    \10\ For more information specific to UIOs, see the National 
Council of Urban Indian Health's report ``Recent Trends in Third-Party 
Billing at Urban Indian Organizations'' available at https://
    In some IHS Areas, due to the need to preserve patient bed capacity 
for COVID-19 patients and to prevent the spread of the COVID-19 virus, 
elective surgeries were place on hold or rescheduled. The effect of the 
loss of revenue from elective procedures has been accounted for when 
calculating the overall needs at IHS. For example, in one Area due to 
delaying elective surgery procedures, there has been a decline in third 
party revenues and the Provider Relief Funds have been applied to the 
hospitals' budgets to cover portions of revenue gaps in FY 2020. In 
addition, other areas of the hospitals' budgets have been adjusted to 
decrease expenses such as travel, training, equipment replacement, and 
medical supplies used for elective surgeries.

    Question 5. Among the factors that have contributed to higher 
transmission rates on the Navajo Nation is lack of access to running 
water in as many as 30 percent of homes on the Nation. This is 
unacceptable. It has been reported that the Indian Health Service 
Navajo Area has $620,000 to deploy water and sanitation facilities 
projects on the Navajo Nation. It is my understanding that a survey of 
all 110 chapters are complete and there are crews on the ground working 
on a few identified projects.
    Can you tell me how IHS is prioritizing which water projects to 
pursue? Can you provide a list of the identified water projects, their 
cost, and the status of each project?
    Answer. The SFC Program developed guidance to ensure that priority 
is given to homes without access to piped water. The priorities were 
established to identify the immediate need as it relates to COVID-19 
response activities:
    Priority 1: Intent is to increase access to temporary water points 
at no charge to homeowners with failed individual water systems, 
cistern systems, and other tribal homes without access to piped water. 
Priority 1 also provided public outreach information to increase 
community knowledge about the availability of temporary water access 
points, safe water hauling practices, and avoidance of septic tank 
    Priority 2: Intent is to provide PPE for solid waste and wastewater 
utility operators to ensure reduced work related virus exposures.
    Priority 3: Intent is to provide emergency project funding to 
address failed or non-operational individual water or sewer systems to 
ensure that all tribal homes have access and subsequently to reduce 
risk of coronavirus spread and basic needs such as hygiene. Also, 
intent is to provide emergency project funding to address failed 
treatment/distribution equipment and ensure that treatment chemicals 
are available for continued operation of water supply and waste 
disposal systems during the COVID-19 outbreak.
    Based on these three priorities, Area SFC Programs were directed to 
reach out to their tribal contacts to identify potential projects. 
Projects were submitted to HQ Division of Sanitation Facilities 
Construction for review and if they fit into these priorities the Area 
received funding for the project.
    The IHS has provided $5.15 million in CARES Act funding to the 
Navajo Nation to fund a single project. This project will install 
transitional water point in approximately 58 Chapters, support the 
water fees from all Chapter operated water points for the duration of 
the Navajo Nation COVID-19 Public Health Emergency (budgeted for two 
years), offer Chapters up to 37,000 five gallon water storage 
containers, and up to 3.5 million in water disinfection tablets for 
distribution to residents of homes with no piped water. The project 
will include development of public communication platform that will 
contain information about the location, Chapter contact information, 
operational hours, and public health messages about the benefits of 
safe water collection at the water points and in-home safe water 
storage. The map below shows the locations of the existing permeant 
water points and transitional water points and their construction 
status as of August 24, 2020. A summary of these status is also 
provided in the table below. *
    * The information referred to has been retained in the Committee 

    Question 6. It has been reported that the Tsehootsooi Medical 
Center, or TMC, in Fort Defiance, Arizona still doesn't not have enough 
testing capabilities to test everyone that requires a COVID-19 test. In 
fact, Tsehootsooi Medical Center has reported to directing people to 
Gallup Indian Medical Center for testing. This is due to TMC having a 
limited number of testing cartridges for the Abbott ID NOW COVID-19. 
Though TMC also has the Cepheid GeneXpert analyzer, which is more 
reliable than Abbott ID NOW COVID-19, TMC has a limited number of 
testing cartridges and swabs to be able to test at the rate needed for 
the community and surrounding areas. Additionally, the Abbott ID NOW 
COVID-19is notorious for providing false negatives, which results in 
providers needing to double-check the Abbott ID NOW COVID-19by either 
using the GeneXpert or sending the specimen to a commercial laboratory, 
overusing the limited supply of swabs and cartridges.
    Does IHS have a plan to improve testing capacity at the P.L. 93-638 
health care facilities? If so, please share this plan with the 
Committee. If not, when can IHS provide a plan to the Committee?
    Answer. IHS continues to work with Tribes, Tribal organizations, 
HHS, and testing analyzer/kit/swab/media suppliers to acquire testing 
materials for I/T/Us. The IHS is not always able to immediately supply 
all testing analyzer/kit/swab/media orders requested due to the lack of 
supplies. Testing strategies vary by location and state. Several Tribes 
are working with Federal and state partners to conduct mass testing 
events for their communities. From the onset of the pandemic, and 
continuing into the future, the IHS will work with Federal, Tribal, and 
UIO programs to support the availability of as many tests as possible. 
This work will continue as determined by epidemiological factors (e.g., 
decreased number of cases), transmission, population immunity, and/or 
through the availability of safe and effective vaccines which could 
eliminate the need for broad scale testing. As of June 29, the IHS had 
performed 272,935 tests, equating to 16 percent of the IHS User 
Population, and exceeding the US all races testing rate of 10.8 
percent. As of August 29, the IHS had performed 650,223 tests, equating 
to 39.1 percent of the IHS User Population, compared to the U.S. all 
races testing rate of 25.4 percent. Also as of August 29, 36.8 percent 
of reported tests completed have been done with the Abbott ID NOW 
COVID-19 analyzer.
    With regards to testing analyzers, the Gallup Indian Medical Center 
performed a correlation study comparing the accuracy of the Abbott ID 
NOW COVID-19 analyzer with that of the Cepheid GENEXPERT analyzer. The 
Abbott COVID instrument has been found by IHS to be acceptable for 
patient testing. The ABBOTT instrument tested at 98.9 percent accuracy 
to that of the Cepheid instrument. Independent correlation testing done 
by the Oklahoma City Area IHS also found the Abbott to be acceptable 
for use.
    On May 14, 2020, the Food and Drug Administration (FDA) released 
notice to the public of possible concerns with the accuracy of test 
results obtained on the Abbott ID NOW analyzers for COVID-19. Early 
data had suggested the potential inaccuracies of results, specifically 
false negatives. IHS provided awareness and guidance for interpretation 
of data per FDA recommendations on May 15, 2020. IHS also shared among 
its users, technical documents that were provided by Abbott following 
the FDA news release of validity of test results on the Abbott ID NOW 
analyzers. On June 11, 2020, Abbott released updated technical 
documents supporting these changes; IHS also shared this information 
with its Abbott users. Current product data and manufacturers updates 
can be found here: https://www.abbott.com/IDNOW.html.
    We agree that a negative test should be treated as presumptive and, 
if inconsistent with clinical signs and symptoms or necessary for 
patient management, should be tested with an alternative molecular 
assay. Negative results do not preclude SARS-CoV-2 infection and should 
not be used as the sole basis for patient management decisions. 
Negative results should be considered in the context of a patient's 
recent exposures, history, presence of clinical signs and symptoms 
consistent with COVID-19.
    However, many IHS federal and tribal sites still find the test 
highly useful, as a positive test result is returned in under 15 
minutes, and can allow for definitive management in that case. Negative 
results should be treated as presumptive and tested with an alternative 
FDA authorized molecular assay, if necessary for clinical management, 
including infection control.
    Cepheid testing supplies are in very short supply globally, and it 
is expected that the situation for the scarce availability of those 
supplies will likely persist.

    Question 7. It is my understanding that the Navajo Area IHS is 
operating isolation units at Shiprock, Chinle, and Gallup for 
individuals to safely self-isolate. How is IHS communicating to 
individuals who wish to self-isolate at the IHS controlled Isolation 
Units and what is the process for a patient to access those services? 
What is the occupancy rate of the Alternative Care Sites and Isolation 
Units in Shiprock, Chinle, and Gallup? Could you share with the 
Committee the occupancy rate of the care Sites and Isolation Units from 
the date of initial operation?
    Answer. In the Navajo Area, IHS patients can be referred to non-
congregate isolation sites by health care providers or public health 
nurses after receiving confirmation of COVID-19 positive testing. A 
Patient Mobilization Center at the Navajo Area Office refers patients 
to non-congregate isolation sites and assists with patient transfers. 
Isolation site Operational Managers have been assigned on the west and 
east sides of the Navajo Nation. The managers oversee admissions to the 
non-congregate isolation sites. In addition, a patient can also choose 
to use an isolation kit to stay on their own property to effectively 
isolate. The kits include water, food, cleaning supplies, and a tent. 
Currently, patients are not being referred to congregate alternative 
care sites (ACS).
    As of July 7, 2020, the occupancy rate at the congregate ACS sites 
and non-congregate isolation sites are as follows:

   Congregate ACS

          --  Chine, AZ: 12 patients, opened on May 14, 2020 and now 
        converted to a congregate isolation site in standby status. 
        This site will need support services (e.g., food service, waste 
        removal, security, cleaning, and laundering services) in place 
        before the site reopens for isolation services. The Navajo 
        Nation Unified Coordination Group (UCG) is presently pursuing a 
        contract for the support services.

          --  Gallup, NM: 35 patients, opened on April 25, 2020 and 
        closed on June 17, 2020.

          --  Shiprock, AZ: no patients, opened on May 15, 2020 and now 

   Non-congregate Isolation Site

          --  Aztec, NM hotel: 45 patients, received first patient on 
        May 9, 2020.

          --  Chinle, AZ hotel: 102 patients, received first patient on 
        May 20, 2020.

          --  Farmington, NM hotels: 6 patients, received first patient 
        on June 7, 2020.

          --  Gallup, NM hotels: 800 patients, received first patient 
        on March 24, 2020. These hotels were leased by the State of New 
        Mexico for COVID-19 isolation purposes. The Gallup Indian 
        Medical Center and the Navajo Area Patient Mobilization Center 
        were approved by the State of New Mexico to place isolation 
        patients in an isolation hotel room as needed.

          --  Kayenta, AZ hotel: Navajo Nation UCG is presently 
        pursuing a contract for this site.

    Question 8. The Navajo Nation views the Navajo Area Indian Health 
Service (NAIHS) as a valuable partner in the delivery of health 
services to the Navajo people. The IHS has a federal responsibility to 
support the Navajo Nation and our P.L. 93-638 health facilities and 
tribal health programs during this pandemic.
    On March 13, 2020, shortly after the first reported case on the 
Navajo Nation, the Navajo Health Command Operations Center was 
activated to coordinate and oversee the directions, instructions, and 
policies coming from the Navajo Department of Health related to COVID-
19. Nearly two (2) months after the detection of the initial positive 
COVID-19 cases on the Navajo Nation, on May 14, 2020, the Navajo Nation 
created a Unified Command Group (UCG) to coordinate COVID-19 response 
activities and efforts.
    The purpose of the UCG is to provide a unified, interactive 
approach to delivering services to individuals and families impacted by 
COVID-19. The UCG medical and public health branches are co-led by the 
Navajo Nation, NAIHS, and P.L. 93-638 representatives.
    Why did it take Navajo Area IHS two months to establish coordinated 
approaches to the Navajo Nation?
    Answer. The Navajo Area IHS stood up its Emergency Operations 
Center on February 25, 2020 in preparation for COVID-19 activities. 
Additionally, the Navajo Area IHS Leadership was in immediate contact 
with the Navajo Nation President and Vice President and joined the 
Navajo Nation's COVID-19 Task Force on February 28, 2020. The purpose 
of the Task Force was to begin interagency communication, coordination 
and planning in preparation for the possibility of COVID-19 cases on 
the Navajo Nation. The Navajo Area IHS Leadership participated in 
multiple Task Force meetings beginning in March and attended Navajo 
Nation-sponsored Logistics Section meetings three days per week 
beginning on March 27, 2020 and continues to participate in these 
coordination meetings to date.
    On April 6, 2020, at the request of the Navajo Nation, the Navajo 
Area IHS began serving as a member of the Nation's incident command 
structure. On May 7, 2020, the Navajo Nation, in coordination with FEMA 
representatives and the Navajo Area IHS representatives, established a 
Unified Coordination Group (UCG) structure to incorporate the various 
Tribal, state, federal, volunteer, and other organizations into the 
command structure. The draft UCG structure underwent reviews by several 
Tribal and federal programs and the final structure was officially 
released on May 14, 2020. Since that time, the Navajo Area IHS 
continues to support the Navajo Nation and participates as an active 
member of the UCG.

    Question 9. The Hopi Tribe is landlocked directly in the middle of 
the Navajo Reservation so when the pandemic flared at the Navajo Nation 
it completely surrounded Hopi. During those early days I heard from the 
Hopi Tribe that they could not obtain real time test and infection 
information from the IHS. This information was crucial for Hopi 
leadership to make appropriate decisions including quarantining 
individuals, closing villages, and similar actions. Even more 
disturbing is that without this information Hopi first responders were 
placed in unnecessary danger. What has the IHS done to aid in the flow 
of information from its facilities to the communities they serve, 
including the Hopi?
    The Hopi clinic continues to struggle with maintaining an adequate 
supply of PPE and testing kits. Governor Ducey has helped the Hopi 
Chairman secure supplies recently but it is an ongoing problem. How is 
IHS working with Hopi to ensure the clinic has the supplies that it 
    Answer. The IHS is the primary provider of public health services 
for the Hopi Tribe. Prior to the COVID-19 response, the Hopi Tribe did 
not have formal recognition as the Public Health Authority and 
therefore was not receiving direct data communication from IHS. Hopi 
Tribe requested formal recognition by the IHS as the Public Health 
Authority for the COVID-19 response on April 15, 2020. Since that time, 
the tribe has received the necessary information needed to serve the 
public health purpose. The IHS Phoenix Area has established a Public 
Health Authority process to streamline additional requests from Tribes 
throughout the region, thereby ensuring timely communication of 
information needed to streamline decisionmaking processes.
    The IHS has been given priority access to rapid point-of-care 
COVID-19 test systems as part of White House efforts to expand access 
to testing in rural communities. The IHS received 250 ID NOW COVID-19 
rapid point-of-care test systems which were distributed to federal and 
tribal health care facilities throughout Indian Country in 31 states. 
This test allows for medical diagnostic testing at the time and place 
of patient care, can provide COVID-19 results in under 13 minutes, and 
expands the capacity for coronavirus testing for individuals exhibiting 
symptoms, as well as for healthcare professionals and the first 
responder community. Additionally, this will save personal protective 
equipment and ensure our critical workforce is safe and able to support 
the response, as only gloves and a facemask are necessary to administer 
this rapid point-of-care test.
    IHS facilities generally have access to testing for individuals who 
may have COVID-19; however, there are nationwide shortages of supplies 
that may temporarily affect the availability of COVID-19 testing at a 
particular location. In addition to using rapid point-of-care testing 
systems, clinicians, including those at IHS, collect samples with 
standard synthetic fiber specimen collections swabs and access 
laboratory testing through public health laboratories in their 
jurisdictions. The IHS also utilizes commercial and other approved 
laboratories to test specimens as those services are available.
    Regarding the supply of resources, there are nationwide shortages 
of PPE. The Phoenix Area coordinates with the IHS NSSC center for PPE 
orders and allocations for the Hopi Health Care Center, as well as 
coordinating approvals of PPE donations from outside sources. When PPE 
is not readily available through regular direct purchase mechanisms, 
the Phoenix Area procures PPE internally through the Strategic National 
Stockpile in coordination with the ADHS/FEMA.
    The Phoenix Area works closely with facility supply chain managers 
to monitor PPE inventory and mobilize procurement strategies when burn 
rates indicate less than a 4-week PPE for gowns, face masks, gloves, 
N95 respirators, and face shields. As of July 24, 2020, the Hopi Health 
Care Center was >28 days for all monitored PPE elements.