[Senate Hearing 116-359]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 116-359

            S. 3126, S. 3264, S. 3937, S. 4079, AND S. 4556

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

                                HEARING

                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 23, 2020

                               __________

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

              
               
                U.S. GOVERNMENT PUBLISHING OFFICE
                
 42-479 PDF               WASHINGTON : 2021                



                      COMMITTEE ON INDIAN AFFAIRS

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

                              ----------                              
                                                                   Page
Hearing held on September 23, 2020...............................     1
Statement of Senator Cantwell....................................     5
Statement of Senator Cortez Masto................................    34
Statement of Senator Hoeven......................................     1
Statement of Senator McSally.....................................     4
Statement of Senator Murkowski...................................     6
Statement of Senator Smith.......................................    32
Statement of Senator Tester......................................     8
Statement of Senator Udall.......................................     3

                               Witnesses

Chavarria, Hon. Michael, Governor, Santa Clara Pueblo; Chairman, 
  All Pueblo Council of Governors................................    20
    Prepared statement...........................................    22
Nuvangyaoma, Hon. Timothy, Chairman, Hopi Nation.................    17
    Prepared statement...........................................    19
Osceola, Jr., Hon. Marcellus, Chairman, Seminole Nation..........    14
    Prepared statement...........................................    16
Weahkee, Hon. Rear Admiral Michael D., Director, Indian Health 
  Service, U.S. Department of Health and Human Services..........     9
    Prepared statement...........................................    10

                                Appendix

Bureau of Indian Affairs, U.S. Department of the Interior, 
  prepared statement.............................................    41
Lucero, Esther, (Dine), MPP, CEO, Seattle Indian Health Board, 
  prepared statement.............................................    49
National Congress of American Indians (NCAI), prepared statement.    45
National Indian Health Board, prepared statement.................    47
Office of Hawaiian Affairs and Papa Ola Lokahi, joint prepared 
  statement......................................................    43
Response to written questions submitted by Hon. Tom Udall to:
    Hon. Michael Chavarria.......................................    59
    Hon. Rear Admiral Michael D. Weahkee.........................    55
Response to written questions submitted to Bureau of Indian 
  Affairs, U.S. Department of the Interior by:
    Hon. John Hoeven.............................................    63
    Hon. Tom Udall...............................................    62
Riverside County Board of Supervisors, prepared statement........    54
United South and Eastern Tribes Sovereignty Protection Fund, 
  prepared statement.............................................    52



 
            S. 3126, S. 3264, S. 3937, S. 4079, AND S. 4556

                              ----------                              


                     WEDNESDAY, SEPTEMBER 23, 2020


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:49 p.m. in room 
628, Dirksen Senate Office Building, Hon. John Hoeven, 
Chairman of the Committee, presiding.

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

    The Chairman. I call this legislative hearing to order.
    Before we begin, I want to remind members who are 
connecting with us remotely to mute your microphone, if you 
would when you are not testifying.
    With that, thank you, and today the Committee will receive 
testimony on five bills, S. 3126, a bill to amend the Public 
Health Service Act to Authorize a Special Behavior Health 
Program for Indians; S. 3264, a Bill to Expedite and Streamline 
the Deployment of Affordable Broadband Service in Tribal Land, 
and for Other Purposes; S. 3937, a bill to amend Section 330C 
of the Public Health Service Act to Reauthorize Special 
Programs for Which Provide Services for the Prevention and 
Treatment of Diabetes, and for Other Purposes; S. 4079, a bill 
to authorize the Seminole Tribe of Florida to Lease or Transfer 
Certain Land, and for Other Purposes; and S. 4556, a bill to 
authorize the Secretary of Health and Human Services, Acting 
through the Director of the Indian Health Service, to Acquire 
Private Land to Facilitate Access to the Desert Sage Youth 
Wellness Center in Hemet, California.
    First, S. 3126. On December 19th, 2019, Senator Smith 
introduced S. 3126, the Native Behavioral Health Access 
Improvement Act of 2019. Senators Udall, Tester, Cortez Masto, 
and Warren are cosponsors. American Indians and Alaska Natives 
have the second highest overdose rates from opioids than any 
other racial or ethnic group. Substance abuse further increases 
the need for behavioral health treatment among Native people.
    With the opioid abuse epidemic and now the COVID-19 
pandemic, tribal communities continue to need access to 
services to properly address substance abuse and mental health 
disorders. S. 3126 will establish a special program designed 
for Indian tribes to access Federal grant funding of $150 
million per year for five years to address mental health needs 
and substance use disorders among Native people.
    S. 3264. On February 11, 2020, Senator Udall introduced S. 
3264, which was referred to the Committee. Senators Heinrich, 
Cantwell, Warren, Smith, and Schatz are cosponsors of the bill. 
No House companion bill has been introduced at this time.
    This bill contains a number of initiatives designed to 
ensure that the residents of tribal lands enjoy the levels of 
highspeed broadband access equivalent to those of other well 
connected communities across the Country. For instance, the 
bill establishes a tribal broadband interagency working group 
to coordinate broadband programs among key Federal agencies 
like the Federal Communications Commission, the Department of 
Agriculture, and the Department of Interior. The bill contains 
a tribal set-aside of 20 percent from the Department of Ag's 
Rural Utility Service, and 5 percent of the Federal 
Communication Commission's Universal Service Fund for Broadband 
Deployment on tribal lands.
    Access to broadband is a vital tool for economic 
development, educational and job opportunities, and public 
health and safety throughout the Nation. Tribal communities 
continue to lag behind the rest of the Country in access to 
affordable and reliable broadband service. The Committee is 
committed to taking steps necessary to identify and eliminate 
any barriers to the deployment of broadband services and 
infrastructure in Indian Country.
    S. 3937. On June 10, 2020, Senator McSally introduced S. 
3937, the Special Diabetes Programs for Indians Reauthorization 
Act of 2020. Senators Sinema and Murkowski are the cosponsors. 
In 1997, Congress established the Special Diabetes Program for 
Indians, SDPI, to decrease the growing rate of diabetes among 
American Indians and Alaska Natives. Since then, the SDPI 
program has received $150 million per year to provide grants to 
eligible entities that offer diabetes treatment and prevention 
services.
    A recent report found that diabetes has significantly 
decreased since 2013, which is attributable to the success of 
the SDPI program. S. 3937 reauthorizes the SDPI program for 
fiscal years 2021, 2022, 2025, and increases funding from $150 
million to $200 million per year. Additionally, the bill gives 
eligible grantees the option to receive funds through self-
governance contracts, cooperative agreements or compacts under 
the Indian Self-Determination and Education Assistance Act.
    S. 4079. June 25, 2020, Senators Rubio and Scott introduced 
S. 4079, a bill to authorize the Seminole Tribe of Florida to 
lease or transfer certain lands and for other purposes. This 
legislation authorizes the Seminole Tribe of Florida to convey 
or otherwise transfer interest in land. This authorization does 
not include lands held in trust.
    The bill rectifies the limitations placed on the tribe by 
the Non-Intercourse Act. Originally enacted in 1970, the Non-
Intercourse Act requires the tribe to first get Federal 
approval before conveying any land interest. S. 4079 would 
allow of the tribe to operate without this unnecessary delay 
and exercise greater control over their own affairs.
    S. 4556. On September 10, 2020, Senator Feinstein 
introduced S. 4556, a bill to authorize the Secretary of Health 
and Human Services, acting through the Director of the Indian 
Health Service, to acquire private land to facilitate access to 
the Desert Sage Youth Wellness Center in Hamet, California, and 
for other purposes. Desert Sage Youth Wellness Center is an IHS 
youth regional treatment center located in Hamet, California. 
This center provides culturally sensitive substance abuse 
treatment in a co-ed residential facility for Native youth.
    Currently, the only access to the center is on a dirt and 
gravel road. During extreme weather conditions, access to the 
center becomes dangerous and limited. In order to provide 
better access to the center, HHS must purchase land from local 
owners to construct a paved road. S. 4556 authorizes HHS to 
acquire land from willing sellers to construct and maintain a 
paved road to the Desert Sage Youth Wellness Center.
    With that, I will turn to Vice Chairman Udall for his 
opening statement.

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

    Senator Udall. Thank you, Mr. Chairman, for scheduling this 
hearing.
    Before I begin, I would like to congratulate the Chairman 
on successful passage of our Bipartisan Progress for Indian 
Tribes Act this week, along with four other bills we shepherded 
through this Committee. My Native American Business Incubators 
program, Senator Murkowski's Savanna's Act, Senator Cortez 
Masto's Not Invisible Act, and Senator Merkley's Middle Oregon 
Bill, are all now on their way to the President's desk. Once 
again, this Committee's tradition of bipartisanship and 
advancing Indian Country's priorities is something we should 
all be proud of.
    I would also like to extend a special welcome to Chairman 
Chavarria, the All Pueblo Council of Governors, who is also 
Governor of the Santa Clara Pueblo in my home State of New 
Mexico. Thank you, Governor, for testifying today.
    Turning to today's bills, we will hear testimony on a 
diversity of subjects, including creation of a special 
behavioral health program for Indians, the need for 
improvements to broadband deployment and availability in Indian 
Country, and reauthorizing the Special Diabetes Program for 
Indians, and expanding it to include self-determination 
contracting.
    In the interest of time, I will focus my remarks on three 
of these bills. My bill, the Bridging To The Tribal Digital 
Divide Act, would improve the deployment of broadband in Indian 
Country by shoring up broadband programs at the FCC and the 
USDA through funding set-asides from the FDA's Rural Utilities 
Service, and FCC's Universal Service Fund, to direct address 
tribal needs. Notably, it also establishes a pilot program for 
tribes to permit rights of way for broadband deployment on 
tribal lands, and a tribal advisory committee so that Congress 
can tailor legislation to truly meet Indian Country's broadband 
needs.
    Senator Smith's Native Behavioral Health Access Improvement 
Act, which I am proud to support as a co-sponsor, would create 
a special behavioral health program for Indians, to help tribes 
access flexible resources to address their community's mental 
health needs. The severe lack of access to comprehensive, 
culturally competent behavioral and mental health services in 
Native communities is one of the many disparities that the 
current COVID-19 pandemic has laid bare. And this bill, which 
builds on the successful SDPI model, is an important tool we 
should work to provide tribes as quickly as possible.
    Finally, a short note on the Special Diabetes Program for 
Indians Reauthorization Act. I have worked with Senator Murray 
to lead the charge on reauthorization of SDPI as far back as 
2013, when I introduced a bill that would permanently 
reauthorize this important program. The bill before us today 
puts forward a new SDPI proposal related to self-determination 
authority.
    As a long-time support of self-determination and self-
governance, I look forward to working with the bill's sponsors 
to ensure Congress achieves tribal self-government. Thank you, 
Mr. Chairman.
    The Chairman. With that, I would ask our other members for 
opening statements. My understanding is that Senator McSally, 
who is joining us virtually, has an opening statement.

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

    Senator McSally. Thanks, Chairman Hoeven and Vice Chairman 
Udall, for holding this legislation to review, including my 
bill, S. 3937, the Special Diabetes Program for Indians 
Reauthorization Act.
    I am honored to have Chairman Timothy Nuvangyaoma, from the 
Hopi Tribe in Arizona, participating remotely to offer 
testimony in support of this bill, and to provide important 
background and context to the way Hopi has utilized SDPI to 
improve the health of tribal community members. Diabetes 
affects millions of Americans, but its impact on tribal 
communities is especially severe. In fact, according to the 
CDC, American Indians and Alaska Natives have a greater chance 
of having Type II diabetes than any other population. For 
nearly two out of three Native Americans who have kidney 
failure, diabetes is a primary factor.
    This makes diabetes the fourth leading cause of death for 
Native Americans, while it is seventh in the general 
population. With 22 federally recognized tribes and more than 
300,000 Native constituents in Arizona, this makes addressing 
this disparate impact of diabetes on indigenous populations a 
priority that hits close to home for Arizonans.
    Since it was created in 1997, the Special Diabetes Program 
for Indians has shown great success in reducing the rate of 
Type II diabetes in Native populations, while improving overall 
health. SDPI currently awards $150 million in grants each year 
to more than 300 entities to expand access to diabetes 
treatment services, as well as administer innovative prevention 
and wellness programs.
    While demonstrably effective, the SDPI has suffered in 
recent years from a series of short-term reauthorizations and 
stagnant funding that has hindered the program's full 
potential. This uncertainty has constrained the long-term 
planning capabilities of the Indian Health Service and 
individual tribes and grant recipients when long-term 
strategies are key to successfully getting Type II diabetes 
rates in check.
    The bill I introduced along with Senators Sinema and 
Murkowski will provide a long-term five-year reauthorization of 
the Special Diabetes Program for Indians. It will also increase 
SDPI's authorization from $150 million per year to $200 million 
a year, and allow tribes to administer the program through 
self-governance contracts, cooperative agreements, or compacts 
under the Indian Self-Improvement and Education Assistance Act. 
The COVID-19 pandemic has underscored the critical need to 
address underlying health conditions, such as diabetes. The 
changes and updates included in my bill will provide long-term 
stability to a successful program and will allow SDPI to better 
meet today's tribal needs in a culturally competent manner.
    I want to again thank my Hopi Chairman, Chairman 
Nuvangyaoma, for his support and participation in today's 
hearing and the Committee's consideration of my bill. I yield 
back.
    The Chairman. Thank you, Senator McSally.

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

    Senator Cantwell. Thank you, Mr. Chairman, and thank you, 
Vice Chair Udall, for holding this hearing and including the 
Vice Chairman's bill, S. 3264, the Bridging the Digital Divide 
Act, which we have worked with on and sponsored with him. Far 
too long, our tribal communities have been left on the wrong 
side of the digital divide, and obviously, the COVID crisis 
shows us how important this issue really is.
    Less than half of rural households in tribal lands have 
access to fixed broadband services, according to an FCC report 
of 2019. The same report revealed that tribal lands have fallen 
behind in access to wireless broadband as well. According to a 
separate 2020 FCC report on nationwide broadband deployment, 
well over 1 million people in Indian Country lack access to 
adequate broadband and the critical health care and education 
services, jobs, and other economic opportunities that broadband 
affords.
    So we all know the FCC numbers underestimate the problem. 
The COVID pandemic has exacerbated the harms caused by the lack 
of broadband, leaving many communities without the ability to 
participate in online learning or telehealth. These tribes in 
our States are very concerned about this. Members of the Hoh 
Tribe, located in the Pacific Coast, essentially have had to 
ration their internet use. In the past, different members of 
the tribe would wait until the children went to school to even 
send things as basic as email because of the extraordinary low 
speeds.
    This has become worse with the COVID pandemic. For the 
Colville Tribe in North Central Washington, many of the 
households don't have access to the internet. This means many 
of the households don't have access to emergency service 
notifications. Connectivity is critically important during fire 
season, especially this year, as fires have forced evacuations 
from homes and businesses. It is absolutely unacceptable for 
these tribes and many others living on tribal lands throughout 
the State of Washington to not have access to basic, reliable 
broadband.
    We need to address this and the connectivity needs in 
tribes, now, which is why closing the tribal digital divide 
remains one of my top priorities, and I know for this Committee 
is also a big priority. It is why I have joined with the Vice 
Chairman, Senator Udall, and others in writing the FCC Chairman 
Ajit Pai two weeks ago to use all of the FCC's current 
authority and resources to take immediate steps to address the 
broadband shortcomings in Indian Country. It is why Senator 
Udall's bill and Senator Heinrich earlier this year introduced 
S. 3264, the Bridging the Digital Divide Act.
    As the Vice Chairman has worked on this issue, he knows 
that it improves coordination across Federal broadband 
programs, several tribal communities make it easier for tribes 
to navigate application processes and for them, the technical 
assistance that often comes with deploying broadband. 
Importantly, the bill sets aside 5 percent of the broadband 
deployment funds at the FCC and the USDA for tribes to build 
out broadband infrastructure in Indian Country.
    Additionally, the bill for the first time will place tribal 
lands on the same footing as other countries when it comes to 
the FCC's statutory mandate to provide universal service. The 
FCC has not taken the obligation seriously, so this bill will 
stress that agencies can no longer downplay the needs of tribal 
citizenry and will have to deal with this issue.
    So prior to helping the Makah build out a network which we 
worked on in my State, tribal students had to travel to another 
school, 40 minutes away, to basically do just basic internet 
broadband testing. So if they wanted to do the test, they had 
to go 40 miles just to take a test.
    We all know what Indian Country looks like in our States. 
We need to do better by them. So I thank the Chair, and thank 
you for giving me that moment.
    If I could just say a special thank you to Senator 
Murkowski for her leadership on Savanna's Act. So glad that 
Savanna's Act is on its way to the President's desk. Hopefully, 
indigenous women will be better protected in the future.
    The Chairman. Thank you, Senator Cantwell.
    Senator Murkowski, and I would like to echo Senator 
Cantwell's comments regarding your leadership on Savanna's Act, 
and of course also acknowledge former Senator Heitkamp from my 
State as well on that legislation.

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

    Senator Murkowski. Thank you, Mr. Chairman, for that, and 
Senator Cantwell. Thank you for allowing good bills to come out 
of this Committee. We have a good slate here today. But I 
appreciate the recognition and the acknowledgement of where we 
are, not only with Savanna's Act, but also the Not Invisible 
Act, which is the measure that Senator Cortez Masto and I have 
been working on that deals with not only murdered and missing 
indigenous women, but those who are trafficked as well, and 
recognizing that we need to be doing more in that area.
    So to the Chairman and to the Vice Chairman, thank you for 
helping us advance those through Committee and to so many of 
our colleagues who have really worked to shine a spotlight on 
this issue.
    I was up in Alaska just last month. We gathered to 
recognize the opening of a cold case office in Anchorage, one 
of six around the Nation that is being established to focus in 
on these very significant issues as they relate to our 
indigenous women. You recognized the work of Senator Heitkamp, 
who began this all with Savanna's Act. I had an opportunity to 
send her my congratulations the other day, very important. So 
we thank you all for that help with that.
    I mentioned that there is a good slate of bills on the 
calendar today. So many of them have impact on where we are 
with the impacts of COVID-19 on our Native peoples, and how the 
pandemic is exacerbating the disparities that we know exist. In 
Alaska, we have started to see some really concerning 
statistics, heard some difficult calls. I have heard that 
police calls have risen 150 percent in some of our villages. 
Sexual assaults probably will be as high as last year by the 
end of this summer. Homeless is still a major issue. Food 
insecurity, loss of income, lack of transportation, and the 
public health measures are taking their toll not only 
physically but also on mental health as well.
    We had a village in southwest Alaska that lost its only 
store to a fire. They couldn't get things like groceries and 
other supplies because the fear of the Coronavirus kept the 
villagers from moving from one village to another, so literally 
cut off. Another Native village off the road system, Newtok, 
made the news last week because they were three weeks without 
power. And we can get by in the summertime without lights, and 
without heat. But you need to be able to keep your subsistence 
meats and fish frozen. So they lost almost all of their 
subsistence harvest that they had gathered.
    In one region, tribes reported that their suicide rate has 
doubled. As I have raised so often in this Committee, we still 
have far too many communities for whom washing your hands and 
basic hygiene in a time of COVID or any time is simply not 
possible. You can't sing the ABCs because you just don't have 
the water in order to wash.
    We have, as you know, a very difficult history with 
pandemics prior, 1918 was pretty severe in Alaska. One Native 
village, Wales, lost three quarters of their population in a 
week. And those memories don't leave people. So when you are 
faced with the likes of what we are seeing with COVID-19, the 
efforts to be as cautious as we possibly can is an imperative. 
Native leaders in our State believe very, very strongly that 
overcrowding and lack of sanitation is still the key.
    So all of this reinforces why so many of these measures on 
the docket today are so important. The need for improving 
Native behavioral health access, for improving infrastructure, 
most notably bridging the digital divide, supporting the tribal 
health system, these are all imperatives.
    The last point that I want to make is to acknowledge the 
work of Senator McSally on her legislation that will 
reauthorize the Special Diabetes Program. We have seen the 
benefit there. We have seen how this program empowers our 
tribal leaders to make these local decisions, choose the best 
practices, adapt the programs and it is culturally appropriate. 
It has been vital to its success. As she pointed out, these 
short-term extensions have not been helpful. We need to 
reauthorize SDPI on a long-term basis, and to provide this 
predictability as well as, predictability for the funding, but 
also to allow for self-determination of this critical program.
    I know that the House Resolution that we are looking at 
offers a mere 11-day extension of the SDPI program, the fifth 
such extension in a year, shortest extension of the program on 
record. And as has been pointed out, these programs are tribal 
programs and the lack of funding does nothing to increase any 
level of certainty.
    So as we are talking about the impacts of COVID-19, I think 
it is important to recognize that diabetes is a leading risk 
factor in the severe effects of COVID-19. So the importance, 
the priority that we can place on this very, very important 
program is greatly appreciated.
    With that, I thank the Chairman for an extended period of 
time to comment. Thank you.
    The Chairman. Thank you, Senator Murkowski.
    I remember being up there with you, when you talk about the 
subsistence living in terms of food and the need to be able to 
refrigerate it. I remember being up in one of those villages 
and they had just gotten a seal. They were very excited about 
it. Such a big animal, that to try to save that through the 
summer, of course, that keeps the polar bear aided, which was 
pretty exciting. But it makes you realize, they do have to have 
power for that refrigeration. It is a remarkable place.
    We will turn to Senator Cortez Masto, virtually. Senator, 
are you there?
    All right, while we are checking on that, we will go to 
Senator Tester.

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

    Senator Tester. I am good, Mr. Chairman, I am just here to 
listen to the folks give their testimony. I have some questions 
about mental health care in Indian Country and the pandemic and 
PPE and testing supplies going forward and how that is working 
out in Indian Country right now. I think we all understand that 
Indian Country has been hit very, very hard by this pandemic. I 
just want to hear how IHS has potentially done things a little 
differently because of this pandemic.
    So I am looking forward to the testimony. Thank you, Mr. 
Chairman.
    The Chairman. Thank you, Senator Tester. Now we will check 
again with Senator Cortez Masto. All right, there are some 
issues with muting of her microphone. We will move forward with 
our witnesses and come back to Senator Cortez Masto.
    First, we are going to hear from the Honorable Rear Admiral 
Michael Weahkee, Director of the Indian Health Service. He is 
here in person. We will also hear from the Honorable Marcellus 
Osceola, Jr., who is Chairman of the Seminole Nation of 
Florida, in Hollywood, Florida. We will hear from the chairman 
virtually. Then we will hear from the Honorable Timothy 
Nuvangyaoma, who is the Chairman of the Hopi Nation, in 
Kykotsmovi, Arizona, virtually. I know I probably didn't get 
all that right, but fortunately, our Vice Chairman is going to 
nail all those names perfectly. He will make sure that is 
covered for me, including any mistakes I make on the next one; 
the Honorable Michael Chavarria, Chairman, All Pueblo Council 
of Governors, Albuquerque, New Mexico. We will also hear from 
him virtually.
    So with that, Rear Admiral Weahkee, if you would proceed.

 STATEMENT OF HON. REAR ADMIRAL MICHAEL D. WEAHKEE, DIRECTOR, 
  INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

    Mr. Weahkee. Good afternoon, Chairman Hoeven, Vice Chairman 
Udall, and members of the Committee. Thank you for this 
opportunity to testify on three bills today, S. 3937, the 
Special Diabetes Reauthorization Act of 2020; S. 3126, the 
Native Behavioral Health Access Improvement Act of 2019; S. 
4556, a bill authorizing the Department of Health and Human 
Services to acquire private land to facilitate access to the 
Desert Sage Youth Wellness Center in Hemet, California.
    I will go straight to the bills, noting the five-minute 
allowance for my oral statement. S. 3937, the Special Diabetes 
Programs for Indians Reauthorization Act of 2020, would amend 
the Public Health Service Act to reauthorize SDPI for five 
years at an increased annual funding level of $200 million, 
which would significantly bolster IHS' diabetes prevention and 
treatment efforts, and enable us to reach tribal programs that 
currently do not have access to resources.
    In addition, while S. 3937 provides for the SDPI to 
continue as a grant program overall, for the first time, this 
bill includes language stating that the grant may be awarded 
pursuant to an Indian tribe or tribal organization's Indian 
Self-Determination and Education Assistance Act, contract or 
compact.
    My written testimony states many positives of the SDPI that 
I won't mention here due to time. But I do want to mention the 
bill's new language regarding the issue of how these grant 
funds would be transferred to tribes or tribal organizations. 
Currently, under Title V of the ISDEAA, a statutorily mandated 
grant such as SDPI may be added to a Title V funding agreement 
after award. However, the ISDEAA authority is not currently 
applicable to Title I contracts. One of the major benefits of 
the SDPI program's structure is that it supports community 
driven interventions and local decision making, which aligns 
well with the ideals of the ISDEAA.
    S. 3126, the Native Behavioral Health Access Improvement 
Act of 2019, will create a special behavioral health program 
for Indians by awarding grants to prevent and treat mental 
health and substance use disorders. This bill requires the IHS 
to coordinate with the Office of the Assistant Secretary for 
Mental Health and Substance Use to support the behavioral 
health needs of American Indian and Alaska Native communities, 
establish a technical assistance center and develop specific 
metrics in consultation with tribes to monitor and evaluate 
outcomes and impact of the Special Behavioral Health Programs 
for Indians.
    IHS has managed behavioral health grant programs that 
support community-based, culturally appropriate prevention and 
treatment services and supports to tribal and urban 
communities. Behavioral health disparities experienced among 
the American Indian and Alaska Native population, both prior to 
and during the pandemic, continue to impact the overall health 
and well-being of individuals, families, and their communities. 
In response to the pandemic, and to support tribal communities 
experiencing new demands and stay-at-home orders, IHS has 
provided administrative flexibilities to our grantees to the 
greatest extent possible.
    IHS acknowledges the mental and behavioral health impact of 
the pandemic and that the associated consequences will likely 
be felt for a long time to come. The backdrop of COVID-19 and 
its impact will play a role in the future of mental health and 
how those services are delivered across the ITU system.
    Like other agencies, IHS is adapting to meet the needs of 
the new normal for providing health care and beginning to see 
an influx of new patients seeking care for grief, anxiety, and 
depression due to the effects of the pandemic. We anticipate 
this need to continue as long as the pandemic is impacting 
daily life.
    Our staff are equally impacted, as front line providers are 
working hard and stretching their limits to support the mission 
of the Indian Health Service. S. 3126 will provide additional 
tools to address mental health disorders across the ITU system, 
which are noted in my written testimony. Such a program would 
expand existing IHS efforts by increasing availability, access, 
and quality of evidence-based treatment and recovery services 
for alcohol and substance use disorders.
    In addition, the program would support tribes as they 
develop priority activities aligned with the Administration's 
national treatment plan, addressing unmet need by expanding 
access to medication for opioid use disorder and specialty 
addiction treatment programs, expanded clinical settings such 
as emergency departments and medical mobile units, and efforts 
to create a robust peer recovery training program.
    To wrap up, S. 4556 would authorize the IHS Director 
through the HHS Secretary to acquire private land that contains 
a dirt road in order to facilitate better access to the IHS 
Desert Sage Youth Wellness Center in Hemet, California. Once 
the land is acquired, the IHS Director could construct and 
maintain a paved road on that land and improve the road to 
provide safe access to the Desert Sage facility for both staff 
and emergency vehicles.
    Thank you again for this opportunity to meet with you 
today. I look forward to answering your questions.
    [The prepared statement of 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, Ranking Member Udall, and members 
of the Committee on Indian Affairs. Thank you for the opportunity to 
testify on S. 3937, Special Diabetes Reauthorization Act of 2020; S. 
3126, Native Behavioral Health Access Improvement Act of 2019; and 
legislation to authorize the Department of Health and Human Services 
(HHS) to acquire private land to facilitate access to the Desert Sage 
Youth Wellness Center in Hemet, California.
    As an agency within HHS, the Indian Health Service (IHS) mission is 
to raise the physical, mental, social, and spiritual health of American 
Indian and Alaska Native people to the highest level. This mission is 
carried out in partnership with American Indian and Alaska Native 
Tribal communities through a network of over 605 Federal and tribal 
health facilities and 41 Urban Indian
    Organizations (UIOs) that are located across 37 states and provide 
health care services to approximately 2.6 million American Indian and 
Alaska Native people annually.
S. 3937
    S. 3937, Special Diabetes Programs for Indians (SDPI) 
Reauthorization Act of 2020, would amend section 330C of the Public 
Health Service Act to reauthorize the SDPI for five (5) years at an 
increased annual funding level of $200 million, which would 
significantly bolster SDPI's diabetes prevention and treatment efforts. 
In addition, while S. 3937 provides for the SDPI to continue as a grant 
program overall, for the first time, this bill includes language 
stating that the grant may be awarded pursuant to an Indian tribe or 
tribal organization's Indian Self-Determination and Education 
Assistance Act (ISDEAA) contract or compact.
    Congress established the SDPI in the Balanced Budget Act of 1997 
(P.L. 105-33) to address the burgeoning diabetes epidemic in American 
Indian/Alaska Native (AI/AN) people. The initial annual funding amount 
of $30 million was increased to $100 million in Fiscal Year (FY) 2001 
and again in FY 2004 to its current level of $150 million. There are 
currently 301 SDPI program sites in 35 states operated by Tribes, 
Tribal Organizations, UIOs, and the IHS.
    FY 2020 is the twenty-third (23rd) year of the SDPI and recent data 
show that, since the beginning of the SDPI, tremendous improvements 
have been made in many important diabetes outcomes in AI/AN people. New 
cases of diabetes-related kidney failure decreased by 54 percent 
between 1996 and 2013 \1\ and a just published study \2\ shows that 
those decreases have been sustained. The HHS Office of the Assistant 
Secretary for Planning and Evaluation (ASPE) has estimated that this 
decrease in kidney failure will save Medicare as much as half a billion 
dollars over 10 years. \3\
---------------------------------------------------------------------------
    \1\ Bullock A, Burrows NR, Narva AS, Sheff K, et al. Vital Signs: 
Decrease in incidence of diabetes-related end-stage renal disease among 
American Indians/Alaska Natives--United States, 1996-2013. MMWR 
2017;66(1):26-32
    \2\ Burrows NR, Zhang Y, Hora I, Pavkov ME, et al. Sustained lower 
incidence of diabetes-related end-stage kidney disease among American 
Indians and Alaska Natives, Blacks, and Hispanics in the U.S., 2000-
2016. Diabetes Care 2020;43:2090-2097
    \3\ Office of the Assistant Secretary for Planning and Evaluation 
(ASPE). The Special Diabetes Program for Indians: estimates of Medicare 
savings. ASPE Issue Brief. Department of Health and Human Services, May 
10, 2019. https://aspe.hhs.gov/pdf-report/special-diabetes-program-
indians-estimates-medicare-savings
---------------------------------------------------------------------------
    Diabetic eye disease incidence has also decreased by more than half 
\4\ and hospitalizations for uncontrolled diabetes have decreased by 84 
percent. \5\ We are also happy to report that, after years of 
increasing, the prevalence of diabetes in AI/AN people decreased each 
year from 2013 to 2017, \6\ while it has plateaued in U.S. adults 
overall as well as for other racial/ethnic groups. \7\ As Congress 
envisioned, tremendous improvements are occurring in diabetes outcomes 
for AI/AN people--and the SDPI plays a key role in making them happen.
---------------------------------------------------------------------------
    \4\ Bursell SE, Fonda SJ, Lewis DG, Horton MB. Prevalence of 
diabetic retinopathy and diabetic macular edema in a primary care-based 
teleophthalmology program for American Indians and Alaska Natives. PLoS 
ONE 2018;13(6):e0198551
    \5\ Agency for Healthcare Research and Quality. Data Spotlight: 
Hospital admissions for uncontrolled diabetes improving among American 
Indians and Alaska Natives. AHRQ Publication No. 18(19)-0033-7-EF. 
December 2018.  https://www.ahrq.gov/sites/default/files/wysiwyg/
research/findings/nhqrdr/dataspotlight-aian-diabetes.pdf
    \6\ Bullock A, Sheff K, Hora I, Burrows NR, et al. Prevalence of 
diagnosed diabetes in American Indian and Alaska Native adults, 2006-
2017. BMJ Open Diab Res Care 2020;8:e001218. doi:10.1136/bmjdrc-2020-
001218
    \7\ Benoit SR, Hora I, Albright AL, et al. New directions in 
incidence and prevalence of diagnosed diabetes in the USA. BMJ Open 
Diab Res Care 2019;7:e000657.
---------------------------------------------------------------------------
    Regarding the issue of how these grant funds would be transferred 
to tribes or tribal organizations, currently, under Title V of the 
ISDEAA, a statutorily mandated grant such as SDPI may be added to a 
Title V funding agreement after award. This ISDEAA authority is not 
applicable to Title I Contracts. A statutorily mandated grant program 
added to a funding agreement is subject to the terms and conditions of 
the grant award (e.g., reporting requirements of the grant award 
program remain in place).
S. 3126
    S. 3126, the Native Behavioral Health Access Improvement Act of 
2019, would authorize the creation of a Special Behavioral Health 
Program for Indians by awarding grants to prevent and treat mental 
health and substance use disorders. This bill requires the IHS to 
coordinate with the Office of the Assistant Secretary for Mental Health 
and Substance Use to support the behavioral health needs of AI/AN 
communities, establish a technical assistance center and develop 
specific metrics, in consultation with Tribes, to monitor and evaluate 
outcomes and impact of the Special Behavioral Health Program for 
Indians.
    I appreciate the opportunity to share our efforts within IHS that 
address the behavioral health disparities impacting the AI/AN 
population. The Division of Behavioral Health manages and administers 
national behavioral health initiatives and policy development for 
mental health, alcohol and substance abuse, and family violence 
prevention programs for AI/AN people. IHS works in partnership with our 
IHS Facilities, Tribes, Tribal organizations, and Urban Indian health 
organizations (I/T/Us) to implement evidence-based, practice-based and 
culturally-based activities, to share knowledge and build capacity in 
Indian Country.
    IHS has managed behavioral health grant programs that support 
community-based, culturally appropriate prevention and treatment 
services and supports to tribal and urban communities. These programs 
include the Substance Abuse and Suicide Prevention Program, the 
Domestic Violence Prevention Program, and the Youth Regional Treatment 
Center Aftercare Pilot Projects. IHS also supports initiatives focused 
on improving behavioral health services within clinical settings, 
including the Zero Suicide Initiative and the Behavioral Health 
Integration Initiative. We anticipate publication of the funding 
announcement for a new grant program designed to combat the opioid 
crisis, the Community Opioid Intervention Pilot Projects, will occur 
before the end of September.
    The behavioral health disparities experienced among the AI/AN 
population prior to, and during, the pandemic continue to impact the 
overall health and wellbeing of individuals, families and communities. 
\8\ In response to the pandemic and to support tribal communities 
experiencing new demands and stay-at-home orders, IHS provided 
administrative flexibilities to our grantees to the greatest extent 
possible. For example, for current grants and initiatives scheduled to 
end in FY 2020, we authorized a one-year extension on the project 
period to provide additional time to implement services and complete 
objectives of the grant.
---------------------------------------------------------------------------
    \8\ MMWR--Hatcher SM, Agnew-Brune C, Anderson M, et al. COVID-19 
Among American Indian and Alaska Native Persons--23 States, January 31-
July 3, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1166-1169. DOI: http://
dx.doi.org/10.15585/mmwr.mm6934e1
---------------------------------------------------------------------------
    IHS acknowledges the mental and behavioral health impact of the 
pandemic and that the associated consequences will likely be felt for a 
long time to come. These priorities will shape our approach to 
behavioral health in ways that we could not have imagined a few years 
ago. The backdrop of COVID-19, and its impact will play a role in the 
future of mental health and how those services are delivered across the 
I/T/U system. Like other agencies, IHS is adapting to meet the needs of 
the ``new normal'' for providing healthcare, and mental health care in 
particular. We are beginning to see an influx of new patients seeking 
care for grief, anxiety, and depression due to the effects of the 
pandemic and we anticipate this need to continue as long as the 
pandemic is impacting daily life. Our staff is equally impacted as 
front-line providers working hard and stretching their limits to follow 
the mission of the IHS.
    S. 3126, the Native Behavioral Health Access Improvement Act of 
2019, would expand tools to address mental health, alcohol and 
substance abuse disparities, and increase access to treatment across 
the I/T/U system. The IHS currently provides access to outpatient 
clinical and preventive mental health services through a system of IHS, 
tribally operated and urban Indian health programs. While IHS is a 
direct service provider for behavioral health, the majority of 
behavioral health services are provided by tribes under Indian Self-
Determination Act contracts and compacts. The AI/AN population 
continues to experience persistently higher rates of serious behavioral 
health issues than the general population, and the impact on the 
overall health and wellbeing of individuals, families and communities 
demands a comprehensive approach.
    The suicide rate in AI/AN communities has previously been discussed 
before this Committee, and remains a priority IHS continues to address 
in partnership with the tribes. According to the CDC, the suicide rate 
for AI/AN adolescents and young adults ages 15-34 was 1.3 times higher 
than the national average for that age group in the general population. 
Suicide is the eighth leading cause of death among all AI/AN across all 
ages. \9\ According to the Substance Abuse and Mental Health Services 
Administration's (SAMHSA) National Survey on Drug Use and Health, AI/AN 
adolescents had a prevalence rate of 16.3 percent for major depressive 
episode with or without severe impairment, which was the highest rate 
compared to other ethnicities. In addition, the AI/AN adult prevalence 
rate of 8.0 percent for a major depressive episode with or without 
severe impairment was the highest when compared to other ethnicities, 
and their prevalence rate of 18.9 percent was the third highest for 
serious mental illness compared to other ethnicities. \10\
---------------------------------------------------------------------------
    \9\ Centers for Disease Control and Prevention (CDC). Web-based 
Injury Statistics Query and Reporting System (WISQARS) [Online]. (2013, 
2011) National Center for Injury Prevention and Control, CDC 
(producer). Available from
    \10\ U.S. Department of Health and Human Services, Substance Abuse 
and Mental Health Services Administration. National Survey on Drug Use 
and Health. Available from https://nsduhweb.rti.org/respweb/
homepage.cfm
---------------------------------------------------------------------------
    Under S. 3126, the creation of a Special Behavioral Health Program 
for Indians grant program would provide additional tools to address 
mental health disorders across the I/T/U system. The grant would 
increase the number of behavioral health providers and expand access to 
services such as: acute inpatient crisis stabilization to focus on 
first episode psychosis and suicidal ideation, mobile crisis teams, 
first episode psychosis peer support, behavioral health services within 
primary care and emergency rooms, assessment and treatment of early 
childhood mental health disorders and developmental disabilities, and 
assessment and treatment of post-traumatic stress disorder. With the 
expansion of services at local systems of care through these new 
grants, individuals would receive interventions aimed at preventing the 
development of severe and possibly life threatening symptoms.
    The Committee, as evidenced by past oversight and legislative 
hearings on the opioid crisis in Indian Country, is well aware of the 
significant impact the opioid crisis has had on the AI/AN population. 
The rate of drug overdose deaths among AI/ANs is above the national 
average. From 2015-2017, the overall rate of overdose deaths for AI/ANs 
increased by 13 percent. The IHS Alcohol and Substance Abuse Program's 
mission is to reduce the incidence and prevalence of alcohol and 
substance abuse among AI/ANs to a level at or below the general U.S. 
population. The Alcohol and Substance Abuse Program provides funding, 
policy, training, and technical assistance to local IHS, tribal, and 
urban Indian programs to ensure a variety of treatment options exist. 
IHS actively solicits feedback and works with tribes to develop and 
implement models of care that are effective and sustainable. Our 
primary focus is to support treatments that are evidence-based and 
culturally effective and that will have a significant impact on the 
prevention, treatment and recovery efforts to combating alcohol and 
substance abuse.
    Under S. 3126, a Special Behavioral Health Program for Indians 
would expand existing IHS efforts by increasing availability, access, 
and quality of evidence-based treatment and recovery services for 
alcohol and substance use disorders, particularly in rural, urban, and 
other underserved tribal communities. In addition, the program would 
support tribes as they develop priority activities aligned with the 
Administration's National Treatment Plan addressing unmet need by 
expanding access to medication for opioid use disorder in specialty 
addiction treatment programs, expanded clinical settings such as 
emergency departments and medical mobile units and efforts to create a 
robust peer recovery training program. The expansion of the IHS 
Community Health Aide Program (CHAP) could play a significant role in 
the training and development of a cadre of peer recovery specialists 
whose services are grounded in traditional and cultural-based practices 
and could be sustainable through reimbursement of treatment services. 
The ability to collect data and evaluate these interventions of this 
new program could help facilitate IHS taking a more unified approach in 
working with tribal communities to evaluate the overall impact of these 
interventions and build on lessons learned.
    Despite our best efforts, access to behavioral health care services 
has been a longstanding issue in many Native communities. Though true 
for all behavioral health needs, this is especially true for pediatric 
and other specialty care. One effective and efficient means of 
increasing access to care is telebehavioral health. To date, the IHS 
Telebehavioral Health Center of Excellence provides clinical services 
and technical assistance to 26 facilities with an established waitlist 
for an additional 31 sites. To better determine need, in December of 
2019, IHS polled the waitlisted sites. We found a significant and 
growing demand for services include a request for 268 hours of 
behavioral health services (roughly 450 to 500 patients) per week. When 
asked about the types of services needed, 93 percent wanted services 
for youth and 74 percent requested behavioral health prescribing 
services.
    While many of our IHS and tribal behavioral health clinics adapted 
swiftly to offer limited continuity of care through telebehavioral 
health services following the outbreak of the COVID-19 pandemic, we 
expect an influx of new patients seeking care for grief, anxiety and 
depression due to the effects of the pandemic. To address these 
concerns, and to provide timely support to Tribal communities, IHS has 
prioritized the expansion of telebehavioral health. Given the efficacy 
and efficiencies of telebehavioral health and the clearly documented 
need, the expansion of telebehavioral health would have a significant 
and positive impact on access to behavioral health services. S. 3126 
would greatly expand the IHS efforts to provide effective 
telebehavioral health services across the entire I/T/U system, 
especially those communities that are the most rural and remote.
    Finally, I would like to discuss the establishment of the Technical 
Assistance Center described in S. 3126. Both the Indian Health Service 
and SAMHSA currently provide technical assistance to grantees funded by 
the different behavioral health grant programs within a limited scope 
based on the grant objectives. We are also aware SAMHSA has other 
tribal technical assistance centers focused on AI/AN communities funded 
through contracts and cooperative agreements. A technical assistance 
center for the Special Behavioral Health Program for Indians could help 
support tribes as they implement behavioral health programming within 
their communities, and could help improve behavioral health services. 
For instance, our grantees have shared challenges that range from 
administrative challenges such as insufficient staffing or staff 
turnover to crisis response resources and coordination In addition, a 
technical assistance center could assist in the coordination of data 
collection between IHS and all facilities that serve the AI/AN 
population to improve evaluation efforts demonstrating lessons learned, 
progress, and outcomes.
S. 4556
    S. 4556, legislation introduced by Senator Feinstein would 
authorize HHS to acquire private land to facilitate access to the 
Desert Sage Youth Wellness Center in Hemet, California. This 
legislation authorizes the IHS Director, through the HHS Secretary, to 
acquire land that contains a dirt road known as ``Best Road'' and other 
land or interests in lands in order to facilitate access to the IHS 
Desert Sage Youth Wellness Note to Center (Desert Sage), in Hemet, 
California. Once the land is acquired, the Feinstein legislation 
provides for the IHS Director to construct and maintain a paved road on 
that land.
    The IHS Desert Sage is a co-ed residential treatment facility for 
youth (ages 12-17) with substance abuse and co-occurring disorders. 
Approximately 8,000 American Indian and Alaska Native youth per year in 
California require substance abuse treatment based on Census 2000 data. 
The facility concurrently provides care for maximum of 32 youth. 
Services offered include mental health, chemical dependency counseling, 
individual and group counseling, family therapy, traditional healing 
services, traditional arts and crafts, cultural activities, field/
recreation trips, educational opportunities, academic and life-skills 
education, fitness program, and access to medical specialties and 
dental care. Desert Sage began operations in 2017 and received The 
Joint Commission accreditation on February 11, 2019. Desert Sage's 
activities are authorized under Section 704 of amended P.L. 94-437, 
Indian Health Care Improvement Act.
    The Desert Sage facility is located on the ``Taylor Ranch'' 
property in Riverside County (County) near Hemet, California. The 
property was purchased in October 2012 for the facility. At that time, 
IHS had an agreement with the landowners to use the unpaved easement, 
Best Road, to cross two properties (Genus and Moon Valley Nurseries) to 
access the facility.
    Best Road is an unimproved road, privately owned, and approximately 
0.5 mile long located in the County that runs from Sage Road to the 
driveway entrance of the Desert Sage facility. The road conditions on 
Best Road deteriorate during storm events and become nearly impassible 
due to flooding in low-lying areas, poor surface drainage, and the lack 
of all-weather driving surface. Since October 2017, the IHS California 
Area Office continues to perform regularly scheduled maintenance every 
other month including grading and backfilling low areas with gravel. 
Emergency work is also done on an as-needed basis after major storm 
events. Currently, IHS does not have the authority to acquire and/or 
improve Best Road. The Feinstein legislation would authorize the 
Director of IHS to acquire and improve Best Road to provide safe access 
to the Desert Sage facility for staff and emergency vehicles.
    We appreciate all of your efforts in helping us provide the best 
possible care to the people we serve. Thank you again for the 
opportunity to meet with you today.

    The Chairman. Thank you, Admiral Weahkee.
    Next, we will turn to the Honorable Marcellus Osceola, 
Chairman of the Seminole Nation of Florida.

 STATEMENT OF HON. MARCELLUS OSCEOLA, JR., CHAIRMAN, SEMINOLE 
                             NATION

    Mr. Osceola. Thank you, Chairman. I appreciate the time 
today.
    Chairman Hoeven, Ranking Member Udall and members of the 
Committee, my name is Marcellus Osceola, Jr. I am Chairman of 
the Seminole Tribe of Florida, Tribal Council. I am here today 
to urge Congress to move quickly to enact legislation that will 
clear that the Seminole Tribe of Florida has the authority to 
lease or transfer fee lands without requiring prior 
Congressional approval.
    I especially want to thank Florida Senators Marco Rubio and 
Rick Scott for introducing the bill and working with us through 
this process.
    Seminoles have lived in Florida for thousands of years. In 
1830, when the United States enacted a law requiring that all 
Native people east of the Mississippi be removed west, we 
resisted and remained free and unconquered in the swamps of 
Florida. We kept our ways and our traditions, as well as our 
home, and we continue to do so to this day.
    We have grown and prospered over the time and number more 
than 4,000 tribal members today. We are a sovereign government 
with our own schools, police, and courts. We run one of the 
largest cattle operations in the United States. We own Hard 
Rock Hotel and Casinos, an international business with 
locations in 74 countries. And yet we still continue our 
traditions of sewing, patchwork, chickee building, and 
alligator wrestling. The world has changed, and we have 
adapted, while at the same time keeping our traditional ways, 
our culture, and our lives.
    A key strategy we have chosen to pursue in adapting to a 
changing world is diversification of our investments and 
revenue sources. I am here to ask for your help in addressing 
an outdated and paternalistic law that is hampering our efforts 
to diversify.
    The Seminole Tribe has established an investment fund to 
invest in commercial real estate properties in order to create 
generational wealth for the Seminole Tribe of Florida and its 
members. The tribe plans to establish a State chartered 
subsidiary to hold the title to invest property while acquiring 
and entering into financing transactions and grant to lender 
and mortgage interest in the property.
    However, we have been unable to move forward with the first 
project due to concerns raised by a lender and title insurance 
company about the Indian Non-Intercourse Act. The NIA in effect 
requires Congressional authorization before an Indian tribe can 
sell or mortgage any land that it owns. This is relevant to our 
investment fund because the lender requires that they be 
granted a mortgage on the investment property they finance, and 
that the mortgage be insured by the title insurance policy.
    Title insurance companies have interpreted the NIA to apply 
to real estate owned by the investment fund, which is a State 
chartered subsidiary of the tribe. Title companies will not 
insure the mortgage without an exception for the NIA. This 
effectively kills the ability to finance an acquisition.
    The Act dates back to the 1800s and was designed to prevent 
Indian tribes from being defrauded. Today, it is hampering 
efforts to diversify for tribes that are imminently capable of 
making their own business decisions.
    In order to address this issue, Senators Rubio and Scott 
introduced S. 4079 to make clear that the NIA does not apply to 
fee land owned by the Seminole Tribe. Florida Representative 
Darren Soto has introduced the House counterpart with six 
bipartisan members of the Florida delegation as cosponsors. 
This legislation is necessary for the investment fund to 
acquire properties, and there is a precedent for doing so. 
Congress has routinely approved similar legislation for other 
tribes.
    On behalf of the Seminole Tribe of Florida, I ask this 
Committee and the full Senate to act quickly to approve S. 4079 
in order to allow the Seminole Tribe to reach our goal of 
economic diversity and help secure the future of our tribal 
members.
    Thank you for the opportunity to appear before you today. I 
am happy to answer any questions that you may have. Sho-Na-
Bish.
    [The prepared statement of Mr. Osceola follows:]

 Prepared Statement of Hon. Marcellus Osceola, Jr., Chairman, Seminole 
                                 Nation
    Chairman Hoeven, Ranking Member Udall and Members of the Committee, 
my name is Marcellus Osceola, Jr. and I am chairman of the Tribal 
Council of the Seminole Tribe of Florida. I am here today to urge 
Congress to move quickly to enact S. 4079, legislation that will make 
clear that the Seminole Tribe of Florida has the authority to lease or 
transfer certain fee lands without requiring prior congressional 
approval. I especially want to thank Florida Senators Marco Rubio and 
Rick Scott for introducing the bill and working with us throughout this 
process.
    Seminoles have lived in Florida for thousands of years. Our 
ancestors were the first people to come to Florida. In 1830, when the 
United States enacted a law requiring that all Native People east of 
the Mississippi River be ``removed'' west, we resisted and remained 
free and unconquered in the swamps of Florida. We kept our ways and our 
traditions as well as our home, and we continue to do so to this day.
    We have grown and prospered over time and number more than four 
thousand Tribal members today. We are a sovereign government with our 
own schools, police, and courts. We run one of the largest cattle 
operations in t he United States. We own Hard Rock Hotel & Casinos, an 
international business with locations in 74 countries. We still 
continue our traditions of sewing, patchwork, chickee building, and 
alligator wrestling. The world has changed, as it always has, and we 
have adapted, as we always have; while keeping our ways, our culture, 
and our lives, to remain the Unconquered Seminole Tribe of Florida.
    A key strategy we have chosen to pursue in adapting to a changing 
world is diversification of our investments and revenue sources. I am 
here today to ask for your help in addressing an outdated and 
paternalistic law that is hampering our efforts to diversify.
    The Seminole Tribe has established an investment fund to invest in 
commercial real estate properties in order to create generational 
wealth for the Seminole Tribe. The Tribe will seek properties with a 
targeted rate of return of 4 percent per year on unlevered investments 
and 7 percent on levered investments, based upon invested equity. The 
proposed structure for the acquisition is for the Seminole Tribe to 
establish a state chartered subsidiary entity to act as a holding 
company. The holding company then creates a subsidiary entity to hold 
title to the property, enter into financing transactions and grant any 
lender a mortgage interest in the property.
    However, we have been unable to move forward with our first project 
due to concerns raised by the lender and proposed title insurance 
company about the Indian Non-Intercourse Act (NIA). The NIA states in 
part:

         ''No purchase, grant, lease, or other conveyance of lands, or 
        of any title or claim thereto, from any Indian nation or tribe 
        of Indians, shall be of any validity in law or equity, unless 
        the same be made by treaty or convention entered into pursuant 
        to the Constitution.''

    Lenders require that they be granted a mortgage on the property 
financed and that the mortgage be insured with a mortgagee title 
insurance policy. At least two title insurance companies approached for 
first transaction we considered have interpreted the NIA to apply to 
real estate owned by a state chartered subsidiary entity of the Tribe. 
While we believe this is a wrong reading of the NIA, the title 
companies approached have not changed their view and will not insure 
the mortgage without an exception for the NIA. This effectively kills 
any ability to finance an acquisition.
    The Act dates back to the 1800's and in part was designed to 
prevent Indian tribes from being defrauded. Today, it is hampering 
efforts to diversify for tribes that are imminently capable of making 
our own business decisions.
    In order to address this issue and provide certainty to lenders and 
title insurers, Senators Rubio and Scott introduced S. 4079 to make 
clear that the NIA does not apply to fee land owned by the Seminole 
Tribe. Florida Representative Darren Soto has introduced the House 
counterpart, H.R. 7565, with six bipartisan Members of the Florida 
delegation as cosponsors. This legislation is necessary for the 
investment fund to acquire properties.
    Congress has routinely approved similar legislation for other 
tribes. For example, ``The Oregon Tribal Economic Development Act'', 
Public Law 115-79, and Public Law 114-127 allowed certain tribes in 
Oregon and the Miami Tribe of Oklahoma to alienate non-trust property 
without further federal approval.
    On behalf of Seminole Tribe of Florida, I ask that this Committee 
and the full Senate act quickly to approve S. 4079 in order to allow 
the Seminole Tribe to reach our goal of economic diversity and help 
secure the future of our tribal members. In fact, I urge Congress to 
consider taking up broader legislation going forward in order to assure 
that this outdated and paternalistic NIA language will no longer hinder 
economic opportunities for any federally recognized Indian tribe.
    Thank you for the opportunity to appear before you today. I would 
be happy to answer any questions you may have. Sho-Na-Bish.

    The Chairman. Thank you, Chairman.
    Now we will turn to the Honorable Timothy Nuvangyaoma, who 
is Chairman of the Hopi Nation. Chairman?

  STATEMENT OF HON. TIMOTHY NUVANGYAOMA, CHAIRMAN, HOPI NATION

    Mr. Nuvangyaoma. Good afternoon, Chairman Hoeven, Vice 
Chairman Udall, and honorable members of the Senate Committee 
on Indian Affairs.
    My name is Timothy Nuvangyaoma, and I have the honor of 
serving as chairman of the Hopi Tribe. Located in the northeast 
corner of Arizona, the Hopi Reservation is approximately 2.5 
million square miles. Roughly half of the tribe's population 
resides on the reservation's 12 villages.
    I do want to thank you for the opportunity to testify and 
express our strong support for S. 3937, the Special Diabetes 
Program for Indians Reauthorization Act of 2020. I would like 
to begin by thanking Senator McSally for introducing this 
important legislation and Senator Sinema for being an original 
cosponsor.
    We also appreciate our representative, Tom O'Halloran, 
introducing similar legislation in the House of 
Representatives. Our Congressional delegation clearly 
understands the importance of the life-changing Special 
Diabetes Programs for Indians, the SDPI.
    The Hopi Special Diabetes Program, or HSDP, was awarded its 
first SDPI grant in 1998. The HSDP mission is to provide 
quality preventive services to the Hopi community in order to 
reduce the incidence rate of Type II diabetes. The program 
operates the Hopi Wellness Center, the HWC, and the Hopi 
Veterans Memorial Center, the HVMC. The HWC provides a free 
public use fitness center, childcare services for fitness 
center users, and diabetes prevention education. The HVMC is a 
multipurpose facility used for community and recreational 
events.
    The HSDP utilizes effective, evidence-based intervention 
strategies to provide the Hopi community with a broad, 
community-centered public health approach to diabetes 
prevention. Since the program's inception, we have implemented 
programs focused on reducing obesity, improving nutrition, 
addressing food insecurity, physical fitness, and weight 
management.
    I am particularly proud of our efforts to incorporate Hopi 
culture into our programs. In 2019, the HSDP served over 17,000 
people through these various programs.
    In spite of the ongoing health pandemic, the HSDP has been 
able to continue fulfilling its mission. In March, 2020, the 
Hopi tribe issued executive order 01-2020, declaring a public 
health state of emergency across the Hopi reservation due to 
the Coronavirus pandemic. Due to the health risks posed, we had 
to make a tough decision to close the Hopi Wellness Center and 
our Hopi Veterans Memorial Center. As a result, several HSDP 
events were canceled or postponed.
    Knowing the importance of maintaining a healthy body and 
mind during these trying times, the HSDP quickly adapted and 
began offering virtual health and wellness services. We are 
currently offering a wide array of online fitness classes from 
Monday through Friday, including Native fitness which 
incorporates traditional Hopi song and dance. In addition, HSDP 
is hosting a fitness bucks challenge, where participants earn 
fitness bucks by completing a virtual fitness class, classes 
that are held on the Hopi wellness center's Facebook page.
    HSDP also modified two programs that celebrate the Hopi's 
longstanding tradition of running. The 28th annual 100-Mile 
Club event just wrapped up, and despite it being virtual, there 
were nearly 800 participants ages 5 and up. Participants had to 
log 100 miles within 14 weeks. As we speak, 750 tribal members 
are gearing up for the 14th annual Taawaki Trail Run, which 
will take place on October 2nd and October 4th. Participants in 
this event will be completing an 8K, 10K, or half marathon in 
one session.
    The SDPI funding has been critical in allowing the HSDP to 
develop diabetes prevention and management programs. There is 
no doubt that our program has changed the course of diabetes in 
the Hopi community. Reauthorizing SDPI and providing an 
increase in its funding level is critical as we continue our 
efforts to combat the high rates of diabetes in our community.
    Therefore, the Hopi Tribe strongly supports S. 3937, the 
Special Diabetes Program for Indians Reauthorization Act of 
2020.
    Considering many of the issues we are dealing with are 
interrelated, I would like to take a brief moment to express 
the tribe's support for two other bills included in today's 
hearing: S. 3126, the Native Behavioral Health Access 
Improvement Act, and S. 3264, the Bridging the Tribal Digital 
Divide Act. Modeled after SDPI, Senator Smith's bill would 
provide tribes with critical resources to battle mental and 
behavioral health challenges in our communities. Further, 
Senator Udall's bill is needed now more than ever as we are 
relying heavily on broadband service during the ongoing 
pandemic.
    Once again, thank you for the opportunity to testify. The 
Hopi Tribe encourages the Committee to approve S. 3937, the 
Special Diabetes Program for Indians Reauthorization Act of 
2020; S. 3126, the Native Behavioral Health Access Improvement 
Act; and S. 3264, the Bridging the Tribal Digital Divide Act.
    I am happy to answer any questions that you may have. Thank 
you.
    [The prepared statement of Mr. Nuvangyaoma follows:]

 Prepared Statement of Hon. Timothy Nuvangyaoma, Chairman, Hopi Nation
    Good afternoon Chairman Hoeven, Vice Chairman Udall, and Honorable 
Members of the Senate Committee on Indian Affairs. My name is Timothy 
Nuvangyaoma and I have the honor of serving as Chairman of the Hopi 
Tribe. Located in the northeast corner of Arizona, the Hopi Reservation 
is approximately 2.5 million square miles. Roughly half of the Tribe's 
population resides on the Reservation's 12 villages.
    Thank you for the opportunity to testify and express our strong 
support for S. 3937, the Special Diabetes Program for Indians 
Reauthorization Act of 2020. I would like to begin by thanking Senator 
McSally for introducing this important legislation and Senator Sinema 
for being an original cosponsor. We also appreciate our Representative, 
Tom O'Halleran, introducing similar legislation in the House of 
Representatives. Our Congressional delegation clearly understands the 
importance of the life-changing, Special Diabetes Program for Indians 
(SDPI).
    The Hopi Special Diabetes Program (``Program or HSDP'') was awarded 
its first SDPI grant in 1998. The HSDP mission is to provide quality 
preventative services to the Hopi community in order to reduce the 
incidence rate of type 2 diabetes. The Program operates the Hopi 
Wellness Center (HWC) and the Hopi Veteran's Memorial Center (HVMC). 
The HWS provides a free, public use fitness center; childcare services 
for fitness center users; and diabetes prevention education. The HVMC 
is a multi-purpose facility used for community and recreational events.
    The HSDP utilizes effective, evidence-based intervention strategies 
to provide the Hopi community with a broad, community-centered public 
health approach to diabetes prevention. Since the Program's inception, 
we have implemented programs focused on reducing obesity, improving 
nutrition, addressing food insecurity, physical fitness, and weight 
management. I'm particularly proud of our efforts to incorporate Hopi 
culture into our programs. In 2019, the HSDP served over 17,000 people 
through these various programs.
    Despite the ongoing health pandemic, the HSDP has been able to 
continue fulfilling its mission. In March 2020, the Hopi Tribe issued 
Executive Order #01-2020, declaring a public health state of emergency 
across the Hopi Reservation due to the Coronavirus pandemic. Due to the 
health risks posed, we made the tough decision to close the Hopi 
Wellness Center and the Hopi Veteran's Memorial Center. As a result, 
several HSDP events were cancelled or postponed.
    Knowing the importance of maintaining a healthy body and mind 
during these trying times, the HSDP quickly adapted and began offering 
``virtual'' health and wellness services. We are currently offering a 
wide array of online fitness classes from Monday through Friday, 
including ``Native Fitness,'' which incorporates traditional Hopi song 
and dance. In addition, HSDP is hosting the ``Fitness Bucks 
Challenge,'' where participants earn ``fitness buck'' by completing 
virtual fitness classes that are held on the Hopi Wellness Center's 
Facebook page.
    The HSDP also modified two programs that celebrate the Hopi's 
longstanding tradition of running. The 28th annual ``100 Mile Club'' 
event just wrapped up and despite it being ``virtual'' there were 
nearly 800 participants (ages 5 and up). Participants had to log 100 
miles within 14 weeks. As we speak, 750 tribal members are gearing up 
for the 14th annual Taawaki Trail Run, which will take place on October 
2nd and October 4th. Participants in this event will be completing an 
8K, 10K, or half marathon in one session.
    The SDPI funding has been critical in allowing the HSDP to develop, 
sustain, and implement quality diabetes prevention and management 
programs. There is no doubt that our Program has changed the course of 
diabetes in the Hopi community. Reauthorizing SDPI and providing an 
increase in its funding level is critical as we continue our efforts to 
combat the high rates of diabetes in our community. Therefore, the Hopi 
Tribe strongly supports S. 3937, the Special Diabetes Program for 
Indians Reauthorization Act of 2020.
    Considering many of the issues we are dealing with are 
interrelated, I would like to take a brief moment to express the 
Tribe's support for two other bills included in today's hearing: S. 
3126, the Native Behavioral Health Access Improvement Act (Smith), and 
S. 3264, the Bridging the Tribal Digital Divide Act (Udall). Modeled 
after SDPI, Senator Smith's bill would provide tribes with critical 
resources to battle mental and behavioral health challenges in our 
communities. Further, Senator Udall's bill is needed now more than ever 
as we are relying heavily on broadband service during the ongoing 
pandemic.
    Once again, thank you for the opportunity to testify. The Hopi 
Tribe encourages the Committee to approve S. 3937, the Special Diabetes 
Program for Indians Reauthorization Act of 2020; S. 3126, the Native 
Behavioral Health Access Improvement Act; and S. 3264, the Bridging the 
Tribal Digital Divide Act. I would be happy to answer any questions.

    The Chairman. Thank you.
    Next, we will turn to the Honorable Michael Chavarria, 
Chairman of the All Pueblo Council of Governors, in 
Albuquerque, New Mexico.

  STATEMENT OF HON. MICHAEL CHAVARRIA, GOVERNOR, SANTA CLARA 
       PUEBLO; CHAIRMAN, ALL PUEBLO COUNCIL OF GOVERNORS

    Mr. Chavarria. [Greeting in Native tongue.] I send respect 
and good afternoon.
    Thank you, Chairman Hoeven, and Ranking Member Udall, and 
members of the Committee. Today I have been requested to 
provide testimony on two bills, S. 3126, and S. 3264. I 
appreciate the invitation to provide testimony this afternoon. 
My name is Michael Chavarria, I serve as Governor for Santa 
Clara Pueblo, and the Chairman of the All Pueblo Council of 
Governors here in New Mexico.
    First, I will provide oral testimony on S. 3126, the Native 
Behavioral Health Access Improvement Act of 2019. Santa Clara 
Pueblo has been plagued by substance abuse disorder for a 
number of decades. Northern New Mexico and the Espanola Valley 
where the Pueblo is located has among the highest rates of 
opioid abuse and overdose in the Nation. Unfortunately, in 
2000, the New York Times labeled Chimayo as the heroin capital 
of Rio Arriba County. This is a recognition no one wants, 
particularly when it refers to our own back yard.
    Of course, the opioid epidemic is not just a local problem, 
but a regional and national problem. Other forms of substance 
abuse, like alcohol abuse, still exist, too. For this 
testimony, however, I will focus on our experience with 
opioids.
    Since 2014, Santa Clara Pueblo has seen at least 30 cases 
involving opioids come to our tribal court system and the 
number continues to rise. Unfortunately, we have experienced 
serious crime in connection with drugs in the form of assaults, 
batteries, domestic violence, child and elder abuse, and babies 
born to addiction. Many of these cases involved individuals 
suffering from opioid addiction and a mental and behavioral 
health disorder.
    Tragically, we do not have the resources to access the 
unmet needs for services. Decades of underfunding, coupled by 
the effects of COVID-19, the pandemic, have made it very 
difficult for people to get help that they need. Critical 
medication assistance treatment and residential treatment 
programs are unreachable due to the facility closures. 
Counseling therapies are taking place on virtual platforms that 
our members cannot even access, and service assessment and 
evaluations are disrupted.
    This disparate impact has been exacerbated by longstanding 
issues of access to quality and timely health care caused by 
the chronic underfunding of the Indian Health Service. Tribal 
self-governance and tribal 638 clinics meet less than 60 
percent of that need.
    With that said, it is very important that legislation 
targeting behavioral health access and improvements take into 
account these complex factors, as well as the effects of 
historical trauma, to address the holistic health of our 
members. S. 3126 has the potential to do this, with the 
creation of a Special Behavioral Health Program for Indians. We 
believe such a program could be a vehicle for improving the 
behavioral and mental health resources available in tribal 
communities if implemented comprehensively and in consultation 
with tribes.
    It cannot be a one size fits all approach. The program must 
be designed with tribal flexibility in mind. For example, we 
would want to use a program to support the training and 
retention of home-grown health care providers and to provide 
all levels of treatment at the local level in a culturally 
relevant manner.
    In closing, Chairman, members of the Committee, I 
appreciate the time to provide testimony this afternoon, and I 
fully support S. 3126, to amend the Public Health Service Act 
to authorize a Special Behavioral Health Program for Indians. 
Our team has worked very hard to create written testimony which 
is submitted for the record.
    At this time, Mr. Chairman, out of respect, and members of 
the Committee, I ask for your authorization to continue to 
provide testimony on S. 3264, Bridging the Tribal Digital 
Divide Act of 2020. So Mr. Chairman, I am asking for your 
permission to carry on at this time.
    The Chairman. Without objection.
    Mr. Chavarria. Thank you, Chairman and members of the 
Committee. Thank you, Ranking Member Udall, and cosponsors of 
the Committee for proposing this critical piece of legislation.
    Broadband infrastructure development, maintenance and 
access is an underlying and persistent need not only in Pueblo 
Country, but all of Indian Country. During this difficult time 
of the COVID-19 pandemic, we have seen and experienced how 
severely limited and nonexistent broadband infrastructure on 
tribal lands has had a direct and harmful impact on Native 
health and welfare, leaving us vulnerable to health and safety 
risks.
    Broadband is vital for public safety. It enables 
communities to shelter in place while remaining connected to 
tribal government updates, to engage in tele-health, work, and 
education, to stay entertained, connected with family and 
friends. Quite frankly, it allows them to connect with hope. 
Yet in 2020, many of our Pueblo communities and families are 
cut off from these benefits, and live in isolation due to the 
lack of internet services. This puts our people at tremendous 
risk, as they must either venture off our lands for services, 
or go without, which is unacceptable.
    An all hands investment in addressing this situation is 
urgently needed. Federal legislation must facilitate leveraging 
opportunities and support broadband procurement, training, 
maintenance, spectrum rights and access, and the last-mile 
connectivity services. This will provide our Pueblo communities 
with the internal capacities and capabilities to deploy and 
maintain critical wireless services on all of our lands.
    While S. 3264 does not address all these matters at once, 
it comes close. It provides an avenue for tribal nations to 
help their communities connect to the essential broadband 
services through long-term infrastructure investments, tribal 
set-aside funding within key USDA and FCC telecommunication 
programs, a tribal broadband right-of-way pilot program, and 
the provision for technical assistance to underserved tribal 
nations to develop appropriately tailored plans to meet 
deployment benchmarks, including spectrum purchases and 
internal capacity building.
    The creation of a tribal broadband interagency working 
group and a tribal broadband deployment advisory committee 
would be very positive. Both of these types of bodies are key 
to active tribal inclusion in Federal decision making 
processes, in raising our Pueblo and others out of electronic 
isolation.
    The Pueblos and other tribal nations are sophisticated 
partners in helping to develop and shape Federal policies and 
procedures impacting our communities. I fully support the 
proactive measures included in S. 3264 to advance the 
sustainable deployment of affordable broadband on tribal lands.
    So in closing, Chairman, members of the Committee, I 
appreciate the time to provide testimony on both these critical 
bills, and I fully support, and our team has worked very hard 
to create written testimony which has been submitted for the 
record.
    At this time, Chairman, members of the Committee, kuunda, 
thank you very much, and now it is time for questions.
    [The prepared statement of Mr. Chavarria follows:]

  Prepared Statement of Hon. Michael Chavarria, Governor, Santa Clara 
           Pueblo; Chairman, All Pueblo Council of Governors
Introduction
    Thank you Chairman Hoeven, Ranking Member Udall, and Members of the 
Committee for inviting to testify on S. 3126, the ``Native Behavioral 
Health Access Improvement Act of 2019'' and S. 3264, the ``Bridging the 
Tribal Digital Divide Act of 2020.'' Behavioral health and broadband 
access represent two areas of increasingly dire need in Pueblo Country. 
S. 3126 and S. 3264 would make critical strides in addressing these two 
areas of unmet need.
    My name is J. Michael Chavarria and I am the Governor of Santa 
Clara Pueblo, also serving in the capacity of the Chairman of the All 
Pueblo Council of Governors (APCG), which is comprised of the leaders 
of the nineteen Pueblos of New Mexico and Ysleta del Sur Pueblo in 
Texas. Together and individually, our communities are dedicated to 
improving the health and welfare of our Pueblo citizens. I testify 
today on behalf of the Pueblo of Santa Clara to share our experience in 
the hope that it will assist you and your staff in considering these 
vitally important bills.
Santa Clara Pueblo and the Ubiquitous Need for Behavioral Health 
        Services
    Our Pueblo has felt and continues to feel the direct impacts of 
inadequate access to behavioral health services. It affects our 
students at the Kha'p'o Community School, our adults in social support 
programs, and our teenagers and youth throughout the community. Because 
the needs in this area are so great and diverse, it would be possible 
to spend the entirety of my testimony on this topic alone. However, for 
the purposes of manageability, I will focus on the connection between 
substance abuse disorders (SUDs) and behavioral health.
    Northern New Mexico and the Espanola Valley, where Santa Clara 
Pueblo is located, have the lamentable distinction of having among the 
highest national rates opioid abuse and overdose. Our home county of 
Rio Arriba reported an annual average of 89 drug-related fatalities per 
100,000 residents between 2012 and 2016. For comparison, New Mexico as 
a whole averaged 24 drug-related fatalities annually for the same 
period. Our Pueblo has not been spared. Tribal Court cases involving 
opioid use are on the rise with at least 30 such cases coming before 
our Tribal Judge since 2014. Many of these cases involved individuals 
subject to a dual diagnosis of an opioid SUD and a mental health 
disorder that must be treated together. Unfortunately most facilities 
and programs treat addiction and mental health separately and that is 
one of the reasons for high rates of recidivism.
    In the last six years, our Tribal Court has played an essential 
role in reducing crime by over 50 percent and reducing the 
incarceration budget by 66 percent. To continue this success, there 
must be more beds and facilities for those needing integrated dual 
diagnosis treatment. In general, the most effective treatment for a 
dual diagnosis individual is treatment at a long-term or residential 
care facility followed by targeted support upon discharge.
    Tragically, we do not have the behavioral and mental health 
resources to assist our Pueblo members in breaking cycles of addiction 
and staying on the path of sobriety. The effects of decades of 
understaffing, insufficient resourcing (including funding), and 
inadequate facilities are now painfully evident. The IHS, for example, 
has only twelve behavioral health specialists to serve the entire 
Albuquerque Area, an area that covers three states and twenty-seven 
tribal nations. Our members must often wait extended periods for an 
appointment with a behavioral health specialist. In the interim, our 
people must suffer through behavioral or mental health crises without 
formal support--placing both themselves and the greater community at 
risk.
Extenuating Circumstances Caused by the COVID-19 Pandemic
    As Ranking Member Udall is well aware, the current public health 
emergency has disproportionately impacted Pueblo and tribal communities 
in New Mexico. At one point, AI/ANs accounted for nearly 60 percent of 
all COVID-19 positive cases in the State. Today, the AI/AN positivity 
rate stands at 30 percent, meaning that 1 in 3 cases in New Mexico is 
an AI/AN individual--a terrible feat given that we make up only 11 
percent of the State's overall population.
    The disparate impacts are attributable, in significant and 
substantial part, to the direct connection between a chronically 
underfunded Indian Health Service and our members' physical welfare. 
Pueblo people suffer from high rates of chronic and acute health 
conditions like diabetes and heart disease that contribute to severe 
COVID-19 cases and increased rates of patient mortality. The Special 
Diabetes Program for Indians and other federally-funded health programs 
are key to managing contributing health factors and symptoms.
    Like other tribal nations, the Pueblo of Santa Clara has closed 
tribal businesses, offices, and borders in an attempt to stem the 
incursion of COVID-19 onto our lands. Our members have been instructed 
to shelter in place and to only leave home for essential services and 
emergencies. The prolonged social isolation is a deep hardship for many 
members. Our Pueblos are communal in nature with life taking place 
through community interactions and the gatherings of our extended, 
intergenerational families. The pandemic has prevented us from 
expressing these essential aspects of our Pueblo identities--unmooring 
us from our communal, ceremonial, and traditional lifestyle. The result 
is an across-the-board increase in depression, anxiety, and loneliness, 
along with a dangerous increase in SUDs and suicide risk among our 
vulnerable members.
Broadband and Telehealth Limitations at this Time
    Pueblo members struggle to manage the many economic, social, 
familial, personal, emotional, and physical stressors being placed upon 
them with limited to no formal support. Members who struggled with SUDs 
before the pandemic also have to deal with the unfortunate additional 
stressor of being abruptly cut off from individual and group therapies, 
treatment services (including Medication Assisted Therapy or MAT), and 
immersive SUD programs like residential and long-term treatment 
centers.
    Our members have been directed to use telehealth services to meet 
their behavioral health support and case management needs during the 
pandemic. The direction, however, assumes that (a) individuals have 
access to Internet at home through a smartphone or other device; and 
(b) communities have the requisite infrastructure to support high-speed 
connections across tribal lands. Both of these assumptions are false 
when talking about Pueblo Country. Individuals and families lack 
sufficient data plans to access services via cell phone and many homes 
are not connected to any kind of wireless or broadband service. Where 
connections are possible, the bandwidth is often overstretched due to 
the high demand for services as everyone in the household is logged on 
simultaneously for work, school, grocery shopping, family calls, and 
appointments. Further, overcrowding and potential unsafe housing 
conditions may make it difficult, if not impossible, for individuals to 
access services with any privacy.
    We are establishing hot spots across Pueblo lands to facilitate 
community access to the Internet. Students, families, workers, 
behavioral health patients, and others endure scorching temperatures 
and discomfort to use these hot spots for everything from classroom 
instruction to bill payments to medical and therapy appointments. How 
can we expect community members to continue this type of behavior as 
the pandemic stretches into the winter months? Telehealth and tele-
service programs are only as effective as the systems that support 
them. We simply must find a way to provide high-speed Internet at 
reduced or no cost to our Pueblo members. Without it, it is as if our 
most vulnerable Pueblo members have been given a boat filled with holes 
and told to make it to shore with just a single plug . and no oars. Is 
it any wonder that the behavioral and mental health needs of our 
members are at an unprecedented high?
Opportunities for Positive Change Presented by S. 3126
    The Native Behavioral Health Access Improvement Act would provide 
Pueblo members with the tools they need to plug into urgently needed 
behavioral and mental services and stay afloat. The central tool for 
this effort is the creation of a Special Behavioral Health Program for 
Indians (SBHPI) modeled after the Special Diabetes Program for Indians 
(SDPI). SDPI has been broadly successful in reducing incidences of 
diabetes and diabetes-related conditions in Indian Country through the 
successful integration of cultural derived and evidence-based health 
prevention, management and treatment practices. SDPI also provides 
tribal nations with funding flexibility to tailor their programs to 
meet local needs. We think that taking the best practices learned from 
SDPI to create a targeted SBHPI could be effective in addressing unmet 
behavioral and mental health needs.
    It is vital that covered services for a SBHPI grant include 
workforce development. As mentioned earlier, there is a severe shortage 
of behavioral and mental specialists in the IHS Albuquerque Area. We 
firmly believe that a greater investment in home-grown healthcare 
providers is needed to help address this workforce deficit and connect 
our people to culturally competent care. Flexible SBHPI grants could go 
a long way in facilitating targeted workforce development and training 
programs to increase access to behavioral health and mental health 
services in Pueblo Country.
    We fully support the requirement in S. 3126 that grant reporting 
requirements for the SBHPI be developed in consultation with tribal 
nations. Our Pueblo and other tribal nations have expressed frustration 
with grant reporting requirements that are overly burdensome, rigid, 
and unresponsive to the diverse governing structures and internal 
capacities of our country's 574 federally recognized tribal 
governments. Incorporating tribal voices into the development process 
of this new program would help to preemptively address these concerns.
    It has been the general experience of Santa Clara Pueblo and Pueblo 
Country overall that where there are behavioral health programs 
available through the IHS or tribal health programs, those programs are 
severely underfunded and cannot meet the existing and growing need for 
specialized services in our communities. Additional information on how 
Congress intends to fund the $150 million annual appropriation for the 
SBHPI. We would not want to see the establishment of the new program 
come at the direct cost of a line item that is serving Indian Country 
in the IHS, Substance Abuse and Mental Health Services Administration, 
or other federal agency budget.
Opportunity to Connect Pueblo and Indian Country to Essential Broadband 
        under S. 3264
    The Bridging the Tribal Digital Divide Act contains numerous 
provisions that would help facilitate advancements in high-speed 
broadband deployment and access in tribal communities like ours. We 
appreciate the multi-faceted approach of the bill. As you well know, 
the limited access to broadband and healthcare services that we 
experience daily in Indian Country cannot be fixed in isolation. They 
require a holistic response. One that looks at the challenge of rural 
geography in running fiber optic cables; the density of adobe walls in 
impairing signal strength; the need for AI/AN workforce development in 
sustainable programming; and the reality of low-income households that 
must too often choose between groceries and car payments or Internet 
bills and SUD treatments.
    S. 3264 does not address all of these matters at once, but it 
provides avenues for tribal nations to help their communities connect 
to essential broadband services through long-term infrastructure 
investments, tribal aside funding within key USDA and FCC 
telecommunications programs, a Tribal Broadband Right-of-Way Pilot 
Program, and the provision of technical assistance to underserved 
tribal nations to develop appropriately tailored plan for meeting 
deployment benchmarks, including spectrum purchases and internal tribal 
capacity building. We support these proactive measures to advance the 
sustainable deployment of affordable broadband on tribal lands.
    We are also very pleased by how S. 3264 would create both a Tribal 
Broadband Interagency Working Group and a Tribal Broadband Deployment 
Advisory Committee. The former would improve coordination across 
federal broadband programs that are available to tribal nations by 
breaking down the communication silos that exist across the federal 
government. The latter would ensure that tribal leaders have an active 
voice in assessing telecommunications regulations and identifying 
innovative means of meeting the broadband needs of tribal communities. 
Both of these types of bodies are key to raising our Pueblo and others 
out of electronic isolation.
Conclusion
    Kuunda, thank you, for the opportunity to testify on behalf of 
these two compelling legislative proposals. We turn to Congress and our 
federal partners to ask for your sustained assistance in addressing the 
healthcare and broadband access needs of our Pueblo and of other tribal 
communities across the United States. Passage of S. 3126 and S. 3264 
would mark two critical steps in the right direction.
    Attachment
    The information below was prepared by the Direct Service Pueblo 
Governors of the Santa Fe Service Unit in New Mexico for their virtual 
roundtable discussions with Department of Health and Human Services 
Deputy Secretary Eric Hargan and Indian Health Service Director RADM 
Michael Weahkee. Governor Chavarria submits this document for the 
legislative hearing record on S. 3126 and S. 3264 as it contains 
information that he believes may be value to the Committee Members and 
their staff in considering the benefits that these two bills may bring 
in addressing healthcare disparities, technological gaps, and needs in 
Pueblo Country.
 virtual roundtable briefing document of the direct service pueblos of 
  the santa fe service unit for hhs deputy secretary hargan and radm 
                        weahkee--august 24, 2020
    Thank You and Invitation to Speak with the APCG. On behalf of the 
Direct Service Pueblo Governors, I would like to thank Deputy Secretary 
Hargan and RADM Weahkee for the opportunity to speak with you during 
the Roundtable Discussion of August 19, 2020, and for taking the time 
to personally visit the Santa Fe Service Unit (SFSU). My name is J. 
Michael Chavarria and I serve as the Governor for Santa Clara Pueblo 
and as the Chairman for the All Pueblo Council of Governors (APCG), a 
consortium of the 19 Pueblos located in New Mexico and the Pueblo of 
Ysleta Del Sur in Texas.
    The Direct Service Pueblo Governors appreciated your engagement on 
the call, as well as your clear understanding of Indian health care 
issues. While the Pueblos share commonalities, we also differ in many 
ways, and it is important to hear our diverse voices. As extended on 
the call, we warmly invite you both, along with your staff, to speak 
with the full membership of the APCG in the near future to learn more 
about Pueblo Country concerns and healthcare matters, including best 
practices. We would be glad to work with your offices on logistics.
    Overview of Briefing Document. This briefing document summarizes 
our top priorities related to the Santa Fe Service Unit at this time. 
These include: reestablishing SFSU's ambulatory and specialty care 
capabilities; remedying the PRC billing system; and addressing 
pandemic-related needs. Attached to this briefing document is an 
addendum that sets forth a series of our broader healthcare priorities, 
along with specific questions for a federal response and our 
recommendations/requests related to healthcare services in Pueblo 
Country.
    Reinstitute Full Ambulatory and Specialty Care Services at SFSU. A 
number of Pueblos receive Direct Services through SFSU and the Santa 
Clara Health Clinic. Others have pulled their Tribal Shares and now 
operate Title I or Title V facilities. It is important to stress the 
critical need to continue to provide adequate healthcare to our Pueblo 
people through all of these facilities.
    SFSU once operated as an ambulatory care facility and full-fledged 
hospital, providing specialty healthcare services such as inpatient 
services, surgical procedures, and prenatal services. However, as we 
learned on the call, SFSU will only serve as a day clinic and possible 
ambulatory care facility going forward. Consequently, if our members 
require specialty services, they must leave the area pursuant to 
referrals for services paid through the Purchase Referred Care (PRC) 
line item. We urge you to reinvest in SFSU's facility capabilities so 
that it can once again provide critically needed ambulatory and 
specialty care services in our home community.
    PRC Billing Improvements. One major challenge that our Pueblo has 
encountered relates to the shortcomings in the PRC billing system--on a 
number of occasions elderly members have called my office asking for 
assistance because they have received notice from collection agencies 
seeking payment, which is problematic. Our CHR Director has reported 
that these bills are being hand delivered to the SFSU PRC office. We 
urge you to engage in supplemental outreach to educate providers on the 
PRC billing system and to invest in internal improvements to mitigate 
instances of patient billing and avoid potentially negative impacts on 
Pueblo members.
    SFSU and the COVID-19 Response. In the beginning, it was a 
challenge for the SFSU and the Santa Clara Health Clinic to address 
this public health emergency. There were very little to no test kits 
available, and when tests were administered, they were sent off-site 
for analysis with lengthy turnaround times that placed our already 
endangered communities at further risk. There were also challenges 
related to contact tracing, investigations, and data-sharing.
    We understand that this virus has placed all of us in an 
unfortunate and difficult situation--not just the leadership of the 
Indian Health Service but also Tribal Leaders. None of us have been 
through such an all-encompassing experience before. I have been 
fortunate to talk with RADM Weahkee and Dr. Toedt on the weekly White 
House calls and have regularly expressed my concerns to them. We also 
remain engaged with Administration officials and Members of Congress to 
ensure our needs are accounted for in the various phases of relief 
legislation. I continue to push on health-related matters the best I 
can on behalf of all of our Pueblo members.
    As Governor, I know that we face substantial challenges in meeting 
COVID-19 care needs in Pueblo Country. Because of the lack of 
sufficient isolation units in our healthcare facilities, the Buffalo 
Thunder Resort and College of Santa Fe were designated as isolation 
sites in cooperation with the New Mexico Department of Health. Greater 
communication between the State, SFSU CEO, and other officials is 
needed to provide clarity on each party's respective roles and 
responsibilities in patient care at those facilities.
    We were pleased to learn during the Roundtable Discussion that AI/
ANs are being included in the NIH's internal discussions on stratifying 
priority groups for an eventual vaccine distribution. We urge you to 
continue to support the inclusion of AI/ANs as a high risk priority 
group for the early distribution of any COVID-19 vaccination. Thank you 
for your work in educating NIH on the unique healthcare factors that 
place AI/ANs at high risk for severe symptoms and mortality from the 
virus. We appreciate your personal efforts, as our trustees, in 
advocating on our behalf in discussions with NIH and other decision-
makers on vaccine distributions.
    Tribal Data Protection. We are deeply concerned by the release of 
sensitive tribal data by the New Mexico in response to an Inspection of 
Public Record Request (IPRA). We are in discussions with the State on 
Data Sharing Agreements; however, we firmly believe that the IHS should 
serve as the gate keeper of IHS patient information as our trustee. The 
State is not subject to the same trust and legal obligations. The State 
and SFSU leadership must engage in regular and transparent 
communications on data protection. We ask for your assistance in 
protecting tribal data sovereignty through the HIT Modernization 
Project and in discussions with state health agencies.
    Conclusion. Thank you for visiting our facilities and for the 
opportunity to discuss critical matters related to the Santa Fe Service 
Unit directly with you as leaders within the HHS and IHS. We appreciate 
the continuing and robust dialogue that HHS and the IHS in particular 
have engaged in with tribal leaders. Direct communication between 
federal and tribal leadership is vital to a healthy government-to-
government relationship. We reiterate our open invitation to continue 
this exchange with the full membership of the APCG on a follow-up call 
in the near future.
    We look forward to addressing the matters raised in this briefing 
document and the attached addendum with you and your staff. Kuunda; 
thank you.
    Addendum
Pueblo Healthcare Priorities and Concerns
I. Partnerships with HHS Programs
    a. Background. The pandemic has made indisputable clear the 
importance of inter- and intra-governmental cooperation in addressing 
unmet needs. Coordinating supply chain distributions and targeting 
response actions are essential to protecting community welfare. It is 
the mission of the U.S. Department of Health & Human Services (HHS) to 
enhance and protect the health and well-being of all Americans. We 
fulfill that mission by providing for effective health and human 
services and fostering advances in medicine, public health, and social 
services for Pueblo people--a mission that is based on the trust 
responsibilities flowing from the political government-to-government 
relationship between federal and tribal sovereigns.

    b. Issue. Non-IHS agencies designated as the administering entities 
for tribal funds too often lack the institutional knowledge and funding 
distribution networks for working effectively with Indian Country. This 
has contributed, among other challenges, to significant delays in 
delivering funds to tribes. This is unacceptable at a time when every 
day counts in meeting the needs of our people.

    c. Question. What internal processes are non-IHS agencies preparing 
now to ensure that future tribal relief funds provided by Congress are 
administered efficiently? It is our understanding that the White House 
Council on Native American Affairs is leading discussions on ways to 
coordinate funding opportunities across agencies.

    d. Request: The IHS is the HHS agency with the greatest familiarity 
in working with tribes and with the most efficient network for quickly 
and effectively processing tribal funds. We recommend healthcare funds 
intended for Indian Country be processed directly through the IHS or, 
in the alternative, that administering agencies be directed to work 
closely with IHS on the development of funding distribution 
methodologies and implementation.

    e. Request: We also urge the HHS to streamline, to the maximum 
extent possible, reporting requirements across funding opportunities 
targeting tribes. These funds should be provided with the greatest 
flexibility to ensure that tribes can target the use of funds to best 
meet their peoples' needs. This would alleviate burdensome and 
duplicative administrative requirements and maximize the use of federal 
dollars.

II. Planning for the Fall and Winter
    a. Background. The CDC and other federal health officials have 
repeatedly warned that this fall and winter will be a treacherous time 
for national health. With the confluence of COVID-19 and a new flu 
season, our hospitals and clinics will need a replenishment of medical 
supplies and personnel to make it through. As of today, they are still 
running at threadbare levels in both of these areas while also trying 
to meet the increasing healthcare needs of chronic care patients and 
others.

    b. Issue. The Pueblos do not have the resources to sustain a high-
level response to the virus, let alone the virus and the flu. Supply 
chain disruptions and shortages have made it almost impossible to meet 
demand, which is only expected to grow with the devastating numbers 
predicted for the fall. We have established the APCG Pueblo Relief Fund 
as a stopgap measure to purchase disinfecting supplies, PPE, and food 
services for impacted communities. We cannot rely on this Fund alone.

    c. Question. How is the HHS preparing for the fall and winter 
season? What targeted measures are being put in place to address the 
PPE and other medical supply needs of the Indian health system? How 
will resources be distributed to tribal facilities?

    d. Question. It is our understanding that some of SFSU mortuary 
equipment has started failing and it is unclear if replacements are 
being planned. Ohkay Owingeh is working with a local funeral home to 
provide storage services in the interim. What is the status of the SFSU 
mortuary equipment?

    e. Request: We seek a targeted investment in PPE and other medical 
equipment stockpiles in Pueblo Country both to address existing 
resource needs and to prepare for future waves of the virus and other 
illnesses, like the flu. We also request that our Pueblo people be 
considered as priority for vaccines--our people suffer from many health 
disparities and are considered as high risk and vulnerable to COVID-19.

    f. Request: In addition, preparing for the future will require us 
to continue to maximize the use of telehealth and telemedicine 
services. The flexibilities provided in Medicaid and Medicare 
telehealth billing and in expanding access to telehealth services 
across the Indian health system have been critical in meeting patient 
needs, particularly the elimination of the originating site 
limitations. We strongly urge the HHS Secretary to exercise his 
authority, to the extent permissible, to make these telehealth and 
telemedicine flexibilities permanent after the public health emergency.

III. Provider Relief Fund
    a. Background. The Provider Relief Fund was established under the 
CARES Act for to distribute financial support to healthcare providers 
impacted by the pandemic. The Fund included a targeted distribution of 
$500 million to the Indian health system, along with General 
Distributions to qualifying Medicaid and Medicare providers--the 
deadlines and eligibility criteria for the General Distributions was 
recently expanded in response to requests made by tribal advisory 
committees. We were pleased by and appreciate this responsive and 
positive development.

    b. Issue. HRSA, in a recent consultation call with tribal leaders, 
reported that for the purposes of the Uninsured pot of funding, IHS 
eligible beneficiaries are being treated as insured and, therefore, no 
claims can be made on their behalf. This is concern. The HHS has 
official materials stating that ``the IHS is not insurance.'' Further, 
beneficiaries are eligible for IHS services due to their affiliation 
with a federally recognized tribe. This is automatic and does not 
require an enrollment like private insurance.

    c. Question. What reasoning guided HRSA's decisionmaking process in 
regards to IHS eligible beneficiaries and the Uninsured tranche of the 
Provider Relief Fund?

    d. Request: Additional support is needed within the Indian health 
system to respond to COVID-19 and its impacts. We recommend that 
another $500 million be provided to the Indian health tranche of 
Provider Relief Funds.

IV. Third-Party Revenue Reimbursements
    a. Background. Under Section 206 of the Indian Health Care 
Improvement Act, tribal health programs receive third-party 
reimbursements for services provided to IHS eligible patients. These 
funds provide a vital source of revenue for the Indian health system--
at times comprising the majority of a tribal health facility's budget--
that support service expansion, facility improvements, and other 
healthcare purposes.

    b. Issue. With the severe contraction of patients seeking routine 
and emergency care aside from COVID-19, the Indian health system has 
seen this revenue stream all but dry up. As direct result, some 
programs have been forced to furlough staff and restrict service 
availability. Without government intervention, the accumulating impacts 
of these lost resources will devastate our healthcare system. While we 
appreciate the relief funding that has been provided to assist with 
testing, PPE, and other needs, the issue of lost third-party 
reimbursements remains pressing.

    c. Question. What actions and/or policy changes is HHS taking or 
considering to help address financial pressures on the Indian health 
system resulting from the loss of third-party reimbursements?

    d. Request: We urge HHS to support the establishment of a $1.7 
billion Emergency Reimbursement Relief Fund for the Indian health 
system as part of its technical assistance on any future COVID-19 
relief. We will continue to advocate with Congress on including third-
party reimbursement relief in the next phase of COVID-19 legislation.

V. FY 2021 Budget
    a. Background. COVID-19 has underscored how the persistent gaps in 
funding for the Indian health system have contributed to negative 
health outcomes for Native peoples and the under-resourcing of IHS, 
tribal, and urban Indian healthcare facilities. Planning for future 
fiscal years must address not only the immediate needs of the Indian 
health system, but also its long-term preparedness and financial 
sustainability.

    b. Issue. The end of the current fiscal year is rapidly approaching 
with no final appropriations legislation in sight. We are deeply 
concerned that we will enter FY 2021 with either no appropriations 
legislation in place or under a short-term continuing resolution. Such 
a situation would cause further stress to our programs and contribute 
to even greater uncertainty in the Indian health system.

    c. Question. What is the HHS doing to prepare in the event that 
Congress enacts a continuing resolution or resolutions for FY 2021? 
Specifically, what is being done to ensure that no interruptions or 
diminishment of services/personnel impact the Indian health system?

    d. Question. What is the status of discussions on advance 
appropriations for the IHS?

    The Chairman. Thank you, Chairman Chavarria. We appreciate 
it, and with that we will proceed with five-minute rounds of 
questioning for the witnesses.
    I am going to begin with Rear Admiral Weahkee. According to 
your written testimony, the Indian Self-Determination and 
Education Assistance Act authority is not applicable to Title I 
contracts. However, an Indian tribal organization that is under 
Title V of the Indian Self-Determination and Education 
Assistance Act may add their Special Diabetes Program for 
Indians grants to a funding agreement after being awarded.
    The question is, since statutorily mandated grant programs 
like the Special Diabetes Programs for Indians are subject to 
parts of Indian Self-Determination and Education Assistance 
Act, are there any negative consequences the Committee should 
be aware of by providing the full authorities found in S. 3937?
    Mr. Weahkee. Thank you, Chairman Hoeven, for the question. 
I think an initial response, I wouldn't necessarily 
characterize it as a negative, but as a concern that we see in 
really being clear about Congress' intent, which is how those 
funds should be treated. If they are to be treated as grant 
funds, there are special considerations that have to be taken 
into account. Whereas, if they are treated as program awards, 
they would be treated differently.
    So we definitely look forward to working with the Committee 
and are willing to provide any TA necessary to help to clarify 
that language for everybody. As we read it currently, we would 
identify that tribes would not be eligible for contract support 
costs, and those funds would be treated as grant funds. Also, 
there would be reporting requirements that would come into play 
with those funds as well.
    The Chairman. IHS currently provides grants that address a 
multitude of health disparities, including substance abuse, 
mental health issues, and so forth. While it is noted in the 
testimony that IHS and the Substance Abuse and Mental Health 
Services Administration provide technical services to grantees, 
I am interested to know how this bill is different than what is 
currently being provided by your agency.
    Does S. 3126 expand or create any new authorities that the 
IHS can't implement already on its own?
    Mr. Weahkee. Thank you, Chairman. I feel that the most 
important aspect to point out is what was brought up in tribal 
testimony by Governor Chavarria, which is the ability to 
utilize the funds at the community level based on community 
needs. So similar to the Special Diabetes Program for Indians, 
where funding is allocated out and tribal communities are able 
to utilize the funds as best meets their local needs. That 
local level decision making is key and very important. Most of 
the funding that we have currently through our Substance Abuse, 
Suicide Prevention, Zero Suicide Initiative, they are somewhat 
prescriptive in the use of the funds. This Behavioral Health 
Initiative would enable that local level decision making.
    It also would help us to implement some programs that have 
been authorized under the Indian Health Care Improvement Act. 
One good example is the CHAP program, the Communication Health 
Aide Program. It includes a component which is the behavioral 
health aides, and getting those community members trained up 
and able to provide behavioral health related services would be 
very beneficial across the entire agency.
    The Chairman. S. 4556 authorizes the IHS to purchase 
private land to construct and maintain a paved road to access 
the Desert Sage Youth Wellness Center in Hamet. How much land 
is the IHS going to purchase, and does the agency have the 
funds to purchase the land? And to clarify, what status will 
the land be? Is it going to be in trust, or what will be the 
status?
    Mr. Weahkee. Thank you, Chairman Hoeven. I have had the 
opportunity to see this land firsthand. It is approximately .5 
or a half mile long dirt road. I think they have measured it 
out to be approximately 200,000 square feet total. It is across 
two different parcels of land in Hamet, California.
    The road conditions are definitely treacherous. It is 
almost like a river runs through the road when rains get high. 
So it definitely is in need of repair.
    So about 200,000 square feet. The funding, we believe that 
we have. And we do not believe that there will be any 
requirement to put that land into trust.
    The Chairman. One final question for you, Admiral. Can you 
elaborate on the idea of creating a charitable foundation 
within the Indian Health Service and what kind of work you 
might be able to do with the idea that, given the pandemic, 
there has been obviously contributions and interest in further 
contributions to help? So there has been discussion of this 
idea of setting up a charitable foundation to receive that.
    Mr. Weahkee. Thank you, Chairman Hoeven. Through this 
pandemic, there have been many different philanthropic entities 
and private citizens who have come to the agency and come to 
Indian Health sites across the Country, exhibiting interest in 
providing funding to support the efforts. I signed off on the 
acceptance of a few checks, but having a separate foundation to 
be able to handle that type of business will be very 
beneficial.
    In addition, many of our tribal leaders have seen the 
direct benefit of the CDC Foundation, and how they have been 
able to obtain services and support. So there have been 
requests to look at an Indian Health Service Foundation, 
similar to what exists at the CDC and the Food and Drug 
Administration and the National Institutes of Health, to 
further expand and support the matters that would help Indian 
health care in general, that may not be easily reached through 
annual appropriations.
    The Chairman. Right. CDC has received over $87 million in 
donations in the fiscal year. Do you need legislative authority 
to do this?
    Mr. Weahkee. I do believe so, yes, sir, I think we would 
need that legislative authority.
    The Chairman. That is something we need to look at.
    Thank you, Admiral. I will turn to the Vice Chairman.
    Senator Udall. Thank you, Admiral. Director Weahkee, your 
testimony on 638 provisions in the SDPI reauthorization bill 
suggests that current bill language would only authorize the 
IHS to deliver SDPI funds through the ISDEAA contracts and 
compacts. Do I understand that correctly? Would the language as 
written allow tribes to receive contract support costs if they 
opt to use this new provision?
    Mr. Weahkee. Thank you, Vice Chairman Udall. That is 
exactly the language that we would like to work with the 
Committee to clarify what Congress' intent is. There is some 
ambiguity there whether we put a grant into a ISDEAA mechanism. 
The way that we currently read it, those grants requirements 
would still carry over. So we just want to clarify how we 
should address those funds, and whether Congress' intent is to 
provide CSE, and to streamline reporting, or if we want to keep 
the provisions in as we have done historically for Title V.
    Senator Udall. My understanding is that Senator McSally 
disagrees with what you are saying. Her intent is to do it 
differently. So we will work with you to see that the language 
reflects the intent of the Senator who introduced it.
    Let me shift over here, and I may come back to you, 
Admiral, on this broadband rights-of-way pilot program. The 
need to deploy broadband services throughout, and this is for 
our tribal witnesses here today, our tribal leaders. The need 
to deploy broadband services throughout Indian Country is 
important now more than ever. During the Coronavirus pandemic, 
access to the internet is critical for health care, education, 
public safety needs. But there are unique challenges to 
deploying broadband services on tribal lands that predate the 
pandemic. Remoteness, rough terrain, complex permitting 
processes, and a lack of necessary infrastructure make it 
difficult, even sometimes impossible, to ensure uninterrupted 
internet service.
    While we can't easily change landscapes, we can provide 
authority for tribes to control permitting rights-of-way for 
broadband deployment on their own lands. My bill establishes a 
pilot program that allows the Interior Secretary to delegate 
authority to participating tribes to approve rights-of-way for 
broadband deployment. Such authority now rests solely with the 
Secretary, creating a potential logjam for broadband 
maintenance and construction projects that are needed to, for 
example, respond to COVID-19 crises.
    Chairman Chavarria, would this pilot program benefit New 
Mexico's Pueblo communities, especially during a national 
health crisis, when access to the internet is absolutely 
necessary?
    Mr. Chavarria. Chairman, members of the Committee, Vice 
Chairman Ranking Member Udall, thank you for that question. 
Yes, I believe the proposed legislation benefit not just my 
Pueblo, but all tribal nations during the time of this 
pandemic, and after. This COVID-19 has brought a light on all 
the existing technological infrastructure disparities affecting 
Indian Country. Our families lack home broadband, students lack 
individual computers or iPads, hospitals have insufficient 
networks, and entire communities lack fiber optic cable and 
wireless capabilities.
    The Right-of-Way pilot program proposed in your bill, S. 
3264, will assist us all in addressing each of these barriers 
by helping us lay the foundation we need for community-wide 
broadband access. I also feel this critical piece of 
legislation will aid in leveraging other technological 
opportunities, such as a short-term 90 day special temporary 
authority due to FCC that allows us to use the spectrum over 
Santa Clara lands until a tribal priority window is closed, and 
final authorization is granted by November 2nd.
    Leveraging is key to closing the gaps to delivering 
services on our lands. The pilot program will help all of us 
achieve this goal. So thank you, Chairman, members of the 
Committee.
    Senator Udall. Thank you, Mr. Chairman.
    The Chairman. Next, we will turn to Senator Smith, 
virtually.

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

    Senator Smith. Thank you, Mr. Chair, and thank you, Vice 
Chair Udall, for holding this hearing today. I want to thank 
Rear Admiral Weahkee and our tribal leaders joining us today.
    I would like to just first say a word about the Native 
Behavioral Health Access Improvement Act which is being 
considered today. Thank you so much for the consideration, and 
I want to also thank Senators Udall and Tester and Cortez Masto 
on this Committee for joining me on this bill.
    This bill addresses the issues that we have meeting 
culturally appropriate, connected care for mental health and 
behavioral health services in tribal communities, and the 
importance of being able to address needs around mental health 
in ways that really work for tribes. So we know, especially 
right now in the midst of COVID, that so many people are 
struggling with this need.
    So what my goal would do is to create a special behavioral 
health program based on the model of the Special Diabetes 
Program for Indians, something that we have also discussed 
today. Programs like these see broad support in Indian Country, 
certainly in Minnesota, because they give tribes the 
flexibility to develop solutions that work in your communities, 
using traditional practices and culturally competent care.
    So thank you for this hearing today. I want to turn first 
to Rear Admiral Weahkee. I thank you for your testimony on this 
today. I just want to make sure you are there, because I don't 
see you on my screen.
    Mr. Weahkee. Yes, ma'am, I am here.
    Senator Smith. There you are, thank you.
    So for a few years now, some of my colleagues and I have 
supported these behavioral health pilot programs, so that 
tribes can start having access to these resources as soon as 
possible. Unfortunately, despite our success in funding these 
pilots programs in annual appropriations bills, there are still 
no current grant recipients who have benefited yet.
    So as you recognized in your testimony, access to mental 
and behavioral health care can save lives. It has life or death 
consequences. So let me just start by asking, can you explain 
why the Indian Health Service has not yet awarded any grants as 
part of the behavioral health pilot program?
    Mr. Weahkee. Thank you, Senator Smith. And I do think that 
the delay in the funding for that particular program is a sign 
of the times. There are several different factors that 
contributed, noting that the funds were first appropriated to 
the Indian Health Service in 2019 a $10 million per year. We 
now have $20 million available to us.
    Reminding everybody that we started last year with a 
government shutdown, which didn't enable us to move forward 
with necessary next steps, to include tribal consultation, 
review of the consultation comments. When we did eventually get 
the consultation initiated, tribal leaders asked for an 
extension in the time frame to provide their comments, which we 
granted. And then as we got close to the end of the year, we 
started to run up against end of year deadlines, and then the 
pandemic hit.
    So really, a perfect storm of a variety of different issues 
hat have come into play. We do have the Federal Register notice 
developed, and do plan to access all $20 million of those funds 
and make those available for program awards just as quickly as 
we can.
    Senator Smith. Do you have a sense of when that might be, 
what we could expect? Or could you let me know when you know? 
Because I think this is important.
    Mr. Weahkee. Yes, ma'am, we will definitely let you know. 
My understanding is that it is in the final clearance process, 
and we are hoping to have it on the street just any time now.
    Senator Smith. Okay. Thank you, and I appreciate your 
attention to getting those dollars out as quickly as possible.
    I just have a couple of seconds, but I want to turn to the 
tribal leaders who have joined us today. I am wondering if you 
could take a stab at telling us a little bit about how the 
mental and behavioral health needs in your community have 
changed during the COVID pandemic, and whether you have the 
support that you need. Anybody want to take a stab at that?
    Mr. Chavarria. Thank you, Senator Smith. This is Governor 
Chavarria from Santa Clara.
    Senator Smith. Good to see you, Governor.
    Mr. Chavarria. Good to see you again. Yes, Mr. Chairman, 
and members of the Committee, yes, the pandemic has 
significantly increased the need for mental and behavioral 
health services in our community. I have firsthand seen the 
unfortunate increases in the emotional, mental, physical, and 
social stress on many of my community members.
    Facility closures, service and shipment disruptions, and 
prolonged isolation to stress, leaders like family and 
traditional ceremonies are taking a toll across the country. In 
response to COVID-19, our public government exerted our 
sovereign right to close down our business, our offices, our 
schools in an effort to protect our most vulnerable. We also 
instituted stay-at-home orders, limited travel, restricted 
access to tribal lands, and ceased all traditional communal 
gatherings, including our feast day, which is unfortunate. This 
isolation has created hardship for many of our members. I have 
had conversations with grandparents, parents, children, that 
all have expressed the toll the virus has caused upon them. not 
knowing the end, when safety will be restored or what the 
future will hold has increased instances of depression, 
anxiety, loneliness, substance abuse, and suicide risk is on 
the rise.
    So I feel the pain of my members, I hurt for them. Because 
as governor, along with my administration, tribal council 
staff, it is our responsibility to provide comfort, provide 
guidance, provide the necessary resources our Pueblo need to 
cope with this issue. COVID-19 has stolen that ability of our 
people to see behavior and mental health specialists. Limited 
appointments are available, access to [indiscernible] check 
into residential long-term treatment programs, and to engage in 
the traditional healing process within our community.
    So it exacerbates the problem, through no technological 
capacities within Pueblo country. Not every household has a 
broadband connection, let alone a computer or a smart phone to 
access to allow services. Many of our people are caught in a 
dangerous limbo with no in person and no tele-health options 
available to them to confront the confidence, the trauma being 
experienced.
    So lastly, the Pueblos do not have the required resources 
to handle the increased demand we are experiencing for 
behavioral and mental health services. While tribal 638 
programs are often most robust for behavioral health provider 
staffing than IHS, these programs too have been impacted by 
COVID-19 closures and restrictions, and often lack updated 
tele-health equipment and technology, further decreasing 
patient access during this critical time.
    Senator, and members of the Committee, I hope this is a 
response to your question, Senator.
    Senator Smith. Thank you so much, Governor. I appreciate 
it. You have painted the picture very well, and the need. Thank 
you so much.
    The Chairman. Thank you, Senator Smith.
    Senator Cortez Masto.

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

    Senator Cortez Masto. Thank you, Mr. Chair and Ranking 
Member. And thanks to all of you for this important 
conversation.
    Let me just start off by saying thank you so much to my 
colleagues for the introduction of these important bills.
    Let me start with S. 3264, Senator Udall, thank you. This 
is an issue that I have been dealing with in the State of 
Nevada. That is why I introduced the Access Broadband Act, 
along with my colleague in the House. The House passed their 
version. We are still looking to get the Access Broadband Act 
passed.
    Your bill sets us on a course to move even further in that 
direction. Let me briefly just say, the Access Broadband Act 
actually requires the Department of Commerce to establish the 
Office of Internet Connectivity and Growth within the National 
Telecommunications and Information Administration. The focus 
there is to include and streamline all of the broadband 
processes for all of our underserved communities. That is why I 
like your bill. The tribal communities need that support and 
connectivity. There are so many others that are underserved as 
well.
    I am hopeful that we can work together, there is a way we 
can work together so that both of our bills may be compatible, 
or look at language that I might be able to work with you on. 
Because I think you are on the right track here, and I so 
appreciate your bringing it forward.
    The other bill that I am a cosponsor of and absolutely 
support is S. 3126, behavioral health services in general. 
Thank you to the Chairman for having this conversation. It is 
so needed, even before the pandemic. Now with COVID-19, as we 
have all seen, it is a highlighted area, lacking in so many of 
our tribal communities when it comes to access for services for 
behavioral health.
    For that reason, and this is an area that was important for 
me, I introduced the Virtual Peer Support Act. It is a bill 
that would create a grant program to enable eligible local 
tribal and national organizations who currently offer peer 
behavioral health services to transition from in-person 
services to online platforms to meet the increased need because 
of the COVID-19 pandemic.
    I throw that out there because, Admiral Weahkee, I would 
love to talk to you about the bill, see if there are any 
concerns or issues or thoughts that you have about it, and get 
your input and support for it as well. I am hopeful that you 
would be willing to do that.
    Mr. Weahkee. Thank you, Senator Cortez Masto. Definitely 
look forward to working with you on that. Some of the work that 
we have done under the Tribal Behavioral Center of Excellence 
in our ECHO program has been exactly in that area, of peer 
support, resiliency, and depression and crisis intervention. So 
I look forward to working with you on that.
    Senator Cortez Masto. Thank you. And thank you all for 
being here. I can't stress enough what we have heard today, I 
hear it in my State of Nevada with our tribal communities. So 
much work needs to be done. We need the connectivity of our 
services, and so many more services, particularly now during 
COVID-19.
    So thank you for the hearing today.
    The Chairman. Thank you, Senator Cortez Masto.
    We will turn to Senator Tester.
    Senator Tester. Thank you, Mr. Chairman. I will continue on 
this same vein of behavioral health. Admiral Weahkee, I 
appreciate the work that you have done. As you well know, in 
Indian Country, they are often on the wrong side of the digital 
divide. If you are on the wrong side of the digital divide, you 
also know that tele-health doesn't work so very, very good. I 
think it is essential when it comes to behavioral health 
services.
    Can you tell me what the IHS is doing to help those folk 
who don't have broadband access?
    Mr. Weahkee. Thank you, Senator Tester. I appreciate your 
questions.
    As we have noted, many of our services during the pandemic 
have turned to alternate means of service provision. One of 
those which we have accessed heavily has been tele-health. But 
as you note, there are many tribal, rural communities that 
don't have the necessary broadband access. So for many of those 
communities, they are going without services currently, if they 
are not able to access the clinic and don't have that tele-
health opportunity.
    I noted the Tele-Behavioral Health Center of Excellence, 
which the Indian Health Service has stood up and has been 
running for a few years now has provided a number of different 
opportunities for that tele-health expansion. I think the 
statistic is that they have increased their visits by 63-fold 
from the beginning of the pandemic, providing direct patient 
care and also the training for our behavioral health providers.
    We have also leveraged our academic partnerships with 
entities like the University of New Mexico, their ECHO program. 
They have provided a number of trainings and supports to the 
agency. We are working with the Casey Family on a variety of 
different supportive mental health trainings as well.
    But as you note, when it comes to circumstance like a 
global pandemic, getting services in a rural reservation 
community is very difficult when they don't have their go-tos 
like tele-health to rely upon.
    Senator Tester. Amen, brother. We just have to figure out a 
way to get these folks connected up. I know the Chairman and 
Ranking Member understand that very, very well.
    Admiral Weahkee, in Indian Country, we continue to see a 
rise in cases, at least in Montana, we are, in Northern 
Cheyenne, and in Crow, I think there has been about 20 
community members that have passed because of COVID-19, which 
is not good. Those aren't good statistics. Unfortunately, I 
continue to hear from tribes about the need for personal 
protective equipment and testing supplies. Can you tell me how 
IHS is making sure that tribes in Montana and actually across 
the Country, they are getting PPE and testing supplies that 
they need here on the 23rd of September of 2020?
    Mr. Weahkee. Thank you, Senator Tester. I appreciate this 
opportunity to update the Committee on our COVID-19 activities. 
Really, I feel strongly that the Indian Health Service and 
Indian Country in general has fared pretty well when you look 
at us in comparison to other health systems, and in comparison 
to other rural communities. With the support of Congress and 
special White House initiatives and HHS leadership, we have 
been the benefactors of direct allocations of special 
technologies like the Abbott ID Now Test Analyzers. We were the 
recipients of 470 of those machines which we allocated out 
across the Indian Health System.
    As we speak here on September 23rd, I think that we are 
looking at 787,000 tests that have been conducted throughout 
Indian Country. Our National Supply and Service Center, or 
NSSC, which is located in Oklahoma City, has done a fabulous 
job. They are basically our logistics arm. They have supplied 
more than 65 million units of PPE, more than 400,000 tests have 
flowed through that center. They have also just recently 
completed an intra-agency agreement with the Assistant 
Secretary for Preparedness and Response, which manages the 
Strategic National Stockpile, so that we can leverage their 
special purchasing power to build our core levels and to be 
able to obtain hard-to-find PPE when the rest of the Country is 
competing for a limited supply.
    Dr. Toedt is the lead for our testing. Our testing, our 
rates are higher than the U.S. general population testing 
rates. We have tested at a higher percentage. We are currently 
at a testing rate of 6.5 percent positives. Our seven-day 
positivity rates are 5.7 percent. Both of those compare 
favorably with the U.S. general population testing rate.
    As of this point, we have tested 47.3 percent of our user 
population in comparison to the U.S. all races rate of 31.9 
percent. So we are testing more, which is important, and we do, 
because as has been noted in this hearing, there is 
disproportionate impact on our American Indian communities. 
This has been identified now in several CDC studies. Higher 
hospitalization rates at 5.2 percent more than the general 
population. Our infection rate is three and a half times higher 
than the general population.
    And recent data that has come out around deaths has 
identified that we have about a 1.4 percent higher death rate, 
using the National Center for Health Statistics data, early in 
the pandemic.
    So thank you for the opportunity, Senator Tester. I do feel 
that tribal leaders for the most part across the Country have 
been very supportive of our efforts. We do hear from time to 
time issues with certain components of PPE or certain testing 
companies. One item that has been hard to find is the Cepheid 
test supplies. That is one specific test analyzer.
    And we will hear from time to time concerns about 
identifying N-95 masks or a certain size of a glove. But our 
team works very hard to shore up those needs just as quickly as 
they hear about them.
    Senator Tester. I appreciate that. I will tell you that the 
picture you paint I hope is the right one. Because I hear of 
challenges in Indian Country quite regularly. And we will 
continue to be communicating with you and the tribes back home 
to make sure that they get what they need.
    Very quickly, Mr. Chairman, I just want to say that Little 
Shell appreciates IHS acting so quickly on Little Shell. They 
are going to be recognized, as the Committee knows, in the 
fiscal year 2021 budget justification. However, I would just 
say the placeholder doesn't reflect the tribe's actual user 
population. It is much higher than IHS estimates.
    I would just say that the virus isn't going away any time 
soon, you all know that. We have to make sure Little Shell gets 
their funds. I would just ask you to commit to updating IHS' 
request to make sure that it actually reflects the need of the 
trust costs to Little Shell members. That is all. And I would 
just like a head nod from Admiral Weahkee on that one.
    Okay, thank you.
    The Chairman. Thank you, Senator Tester.
    I just have one question, and then I will turn to Vice 
Chairman Udall before we wrap up. I do want to ask Chairman 
Osceola, tribes have routinely had to come to Congress when 
their land development plans are derailed by the Non-
Intercourse Act. So how did the need for this bill come about 
and what can Congress do to ensure that other tribes aren't 
faced with some of the same obstacles?
    Mr. Osceola. Thank you, Chairman. I appreciate the 
opportunity to explain a little further. The reason for this 
bill, as I stated earlier, was a single tribe has created a 
real estate fund to diversify its money for the tribe and its 
future. We already lost one investment chance because a title 
company refused to insure the title. Their interpretation of 
the NIA requires Congressional authorization before a tribe can 
sell or mortgage fee land.
    It is likely that other tribe will face us in the future as 
well, and as I said, other exceptions have been made in the 
past. I think that it is important for us today to get this 
bill passed for the Seminole Tribe, cause of our 
diversification prior to COVID. I think that in the future, I 
encourage Congress to take up legislation that is more broad 
and hits all the points, so that all tribes can benefit from 
the Non-Intercourse Act and its hurdles, so to speak. Thank 
you.
    The Chairman. Thank you, Chairman.
    With that, I will turn to Vice Chairman Udall.
    Senator Udall. Thank you, Mr. Chairman, and thank you to 
all of the witnesses today.
    We have votes already going off, we actually have three 
votes, so that is why we are trying to wrap things up. Director 
Weahkee, after our hearing in July, I submitted some questions 
to you about how the IHS and the Department were coordinating 
with direct service tribes during the COVID-19 pandemic.
    One of our witnesses today, Chairman Chavarria, is just one 
of the tribal leaders I have heard from with concerns that the 
coordination with direct service tribes have been lacking. I 
have also heard from Picuris Pueblo about its IHS direct 
service facility's failure to coordinate on the development of 
a CARES Act spend plan, leaving the pueblo without a means to 
safely transport patients for COVID-19 related testing and 
care. Most recently, I have heard from Acoma Pueblo with 
concerns about the potential closure of their direct service 
emergency room during the pandemic.
    Chairman Chavarria, do you believe that there are still 
COVID-19 relief barriers for direct service tribes that IHS and 
HHS need to tackle? That is kind of a yes or no question, I 
think, but if you want to elaborate just a little bit.
    Mr. Chavarria. Okay, Chairman, and members of the 
Committee, Vice Chairman Udall, yes, it is. I do have a list of 
comments, I can be short as well. We did have a meeting on 
August 19th with Deputy Secretary Hargan and Admiral Weahkee, 
as they visited the service unit here at Santa FE. We discussed 
a number of challenges our communities continue to face. So I 
can submit that document for the record, with the permission of 
the Chairman and members of the Committee. Chief among this is 
lack of adequate PPE, medical supplies, needing to replenish, 
to make it through the treacherous fall and winter that CDC and 
others have repeatedly earned.
    So IHS is running at threadbare levels in terms of being 
prepared to handle the COVID-19 and the flu related illnesses. 
Supply chain disruptions have made it almost impossible to meet 
that demand. So the demand, which is only expected to grow, 
will be devastating, is our prediction for the fall.
    So we do recommend that Congress invest in a targeted PPE 
and medical equipment stockpile for Pueblo Country as well as 
dictate dedicated stockpiles to serve all of Indian Country. 
Those stockpiles must be able to meet current levels of 
resource need to include at least a three-month supply that has 
been recommended by some of the Federal health care officials. 
AND HHS Secretary and FEMA administrators need to exercise 
their delegated authority to the maximum extend permissible to 
streamline tribal access to the National Health Supply 
Reserves.
    So, Mr. Chairman, members of the Committee, I do have some 
additional statements, but due to time, I can go ahead and 
submit those for the record. Thank you.
    Senator Udall. With the permission of the Chair.
    The Chairman. Yes.
    Senator Udall. Thank you very much. We will also share 
those with Director Weahkee, or you can do that directly.
    Admiral Weahkee, can I get your commitment that the IHS 
will reach out to direct service tribes in the Albuquerque area 
and find out ways to improve coordination in New Mexico?
    Mr. Weahkee. Thank you, Senator Udall. You have my 
commitment.
    Senator Udall. And Admiral Weahkee, I also want to add on 
the issue flagged by the Acoma Pueblo that I view the closure 
of any IHS emergency service during the COVID-19 pandemic as a 
threat to the health and safety of Indian Country. For Acoma 
and the surrounding area, the ACL hospital is not only a 
lifeline, it is part of the region's COVID-19 response 
structure.
    I appreciate that you have been in contact with Governor 
Vallo, and that your team is working to minimize disruption of 
services at the ACL hospital. But I am interested in hearing 
what more IHS can do to help the emergency room doors stay open 
there.
    Has IHS looked into the use of the director's emergency 
fund as a way to prevent closures of the ACL emergency room, or 
could IHS use some of its reserve CARES Act funds for that 
purpose?
    Mr. Weahkee. Thank you, Senator Udall. And the situation at 
the Acoma-Canoncito-Laguna Hospital is definitely one that we 
are watching closely here at the national level. Dr. Leonard 
Thomas, the area director, and his team, are in active 
negotiations with the Laguna Tribe. I believe that their 
targeted contract date or negotiation completion date is the 
end of this month, September 29th. We will have a much better 
picture of the funding and operating costs that will be 
available for the rest of that facility at that time.
    In my conversations with Dr. Thomas and with Governor 
Vallo, we have committed to robust consultation and engaging 
the tribe in what that scope of service will look like at the 
facility post-Laguna contract. One of the important factors 
that we need to really focus on is the conditions of 
participation for managing and operating the emergency 
department. That is a high bar and CMS takes it very seriously.
    There are some other models available to us currently with 
a critical access hospital. There are others that have been 
pushed by the National Rural Health Association to include a 
community outpatient hospital, which enables a streamlined 
emergency department to be maintained.
    So we are watching those proposals closely. That might be 
something that would be helpful for a site like Acoma. But at 
this point, we will be looking at all available resources. The 
Director's Emergency Fund has about $3 million in it each year. 
We have had a number of tribes already request funds for 
wildfires, hurricanes, and other emergencies. But we will look 
at that as a potential resource.
    And of course, any CARES Act, if we can justify use of 
funds for pandemic purposes, and get my CFOs right off on that, 
that we won't get ourselves into any trouble, we will look at 
all available funding sources to help alleviate that and make 
it a smooth transition.
    Senator Udall. Great, thank you. And you will commit to 
continuing your work with Acoma to address their concerns?
    Mr. Weahkee. Absolutely, yes, sir.
    Senator Udall. Thank you, Mr. Chairman. Thank you very 
much, and thank you for your courtesies.
    The Chairman. Thank you, Vice Chairman Udall.
    At this point, we will conclude the hearing. The hearing 
record will be open for two more weeks. Again, I want to thank 
all the witnesses for being here. We appreciate it very much.
    With that, this legislative hearing is adjourned.
    [Whereupon, at 4:23 p.m., the hearing was adjourned.]

                            A P P E N D I X

Prepared Statement of the Bureau of Indian Affairs, U.S. Department of 
                              the Interior
    Thank you for the opportunity to provide the Department of the 
Interior's (Department's) views on S. 3264, Bridging the Tribal Digital 
Divide Act of 2020, a bill to expedite and streamline the deployment of 
affordable broadband services on tribal land.
S. 3264
Title I--Interagency Coordination Program
    Title I of S. 3264 directs the Assistant Secretary of Commerce for 
Communications and Information and the Secretary of Agriculture to 
establish an Interagency Working Group to be known as the Tribal 
Broadband Interagency Working Group (Working Group). S. 3264 identifies 
the Administrator of the Department of Agriculture's (USDA) Rural 
Utilities Service and the Assistant Secretary of Commerce for 
Communications and Information as the co-chairs of the Working Group, 
which is tasked with improving Federal coordination, including 
activities of the USDA, Department of Commerce, Department of 
Education, Department of Health and Human Services, Department of 
Housing and Urban Development, Department of Labor, Federal 
Communications Commission (FCC), Institute of Museum and Library 
Services, any other appropriate Federal agency, and the Department.
    Connecting Indian Country to broadband and energy transmission is a 
priority for the Department. In 2020, the FCC Broadband Deployment 
Report stated that 28 percent of Native Americans who live on tribal 
lands lacked access to sufficient broadband capabilities. The 
Department has been implementing broadband initiatives since 2017, 
bringing necessary utilities and communications facilities to rural 
communities. These initiatives align with all aspects of the 
Department's trust relationship with tribes and individuals.
    The Department and its bureaus, including the Bureau of Indian 
Affairs, currently participate as members of the Administration's 
American Broadband Initiative (ABI), an interagency effort co-chaired 
by the National Telecommunications and Information Administration and 
USDA to remove regulatory barriers to broadband deployment, leverage 
public resources for broadband expansion, and maximize the impact of 
federal broadband funding. Incorporating a Tribal Broadband Interagency 
Working Group is consistent with the ABI's mission to coordinate 
federal broadband activities. The Department supports the continued 
coordination of federal stakeholders and recommends that a 
representative of the Department chair a new Tribal Working Group 
within ABI.
Title V--Broadband Rights-of-Way
    Title V of S. 3264 directs the Secretary to establish a Tribal 
Broadband Right-of-Way Pilot Program (Program), which would delegate 
certain authorities to eligible tribes to grant ROWs over and across 
tribal land. Under S. 3264, no fewer than 10 tribes would be selected 
for the Program, with no fewer than 5 of those tribes from Arizona and 
New Mexico. The Secretary's authority for the Program would expire 10 
years from enactment. Except for individual allotted lands, tribes 
could obtain the delegated authority to grant a ROW over and across 
tribal land without further approval of the Secretary. The ROW must be 
granted in accordance with approved tribal regulations and for a term 
not to exceed 25 years, except that the ROW may include an option to 
renew for two additional terms, each of which may not exceed 25 years.
    The Bureau of Indian Affairs (BIA) has the authority to approve 
ROWs and leases for broadband development on Indian trust land and 
individual restricted lands. The BIA protects and maintains the 
integrity of trust lands and trust resources, as part of the overall 
bureau mission to enhance the quality of life, to promote economic 
opportunity, and to carry out the responsibility to protect and improve 
the trust assets of American Indians, Indian tribes and Alaska Natives.
    The Program would connect the selected Tribes' communities with 
broadband projects, which furthers the BIA's mission to support tribal 
self-determination and self-governance. The Department is supportive of 
efforts to streamline approvals needed to support broadband projects, 
but the Department sees no reason to limit the Program to a few 
selected tribes. The Department recommends an eligibility structure 
similar to leasing authorities available to tribes under the Helping 
Expedite and Advance Responsible Tribal Home Ownership (HEARTH) Act of 
2012, 25 U.S.C. 415(h). Under the HEARTH Act, once tribal leasing 
regulations have been approved by the Secretary, tribes are authorized 
to negotiate and enter into leases without further approvals by the 
Secretary. In support of tribal self-determination, the HEARTH Act 
requires the Secretary to approve tribal leasing regulations, if the 
regulations are consistent with the Department's leasing regulations at 
25 CFR Part 162 and they provide for an environmental review process 
that meets HEARTH Act requirements. Opening up opportunities for all 
tribes who are interested in developing their own ROW tribal codes and 
removing bureaucratic obstacles and bottlenecks would more effectively 
address the need in Indian Country for broadband development.
    Under Title V of S. 3264, participating tribes would be given an 
opportunity to compact and amend their Indian Self-Determination and 
Education Assistance Act (ISDEAA), 25 U.S.C. 5304, funding agreements 
to include technical assistance in developing their own tribal 
broadband regulations. The Department recommends that all federally 
recognized tribes have the opportunity to receive funding for technical 
assistance to develop regulations. In addition, the Department 
recommends that the bill clearly indicate that Secretarial approval of 
tribal codes is required, that the codes would be consistent with 
existing regulations under 25 CFR Part 169, and that environmental 
reviews be addressed through a tribal process similar to the HEARTH Act 
requirements.
    The Department strongly supports efforts to expand broadband 
capacity in Indian Country. If the legislation is addressed as noted 
above, it would be an important step toward allowing tribes greater 
control in developing broadband projects on their lands for their 
communities. Tribal control of the broadband ROW regulatory process 
over tribal lands would reduce the time and expense currently required 
in seeking ROW approval from BIA.
    The Department appreciates the opportunity to present its views on 
S. 3264. We welcome the opportunity to work with the Committee to 
provide technical assistance that will improve this legislation, and 
thereby expand broadband capacity in Indian Country.

    Thank you for the opportunity to provide the Department of the 
Interior's (Department) views on S. 4079, a bill to authorize the 
Seminole Tribe of Florida to lease or transfer certain land, and for 
other purposes.
S. 4079
    S. 4079 would expressly allow the Seminole Tribe of Florida (Tribe) 
to lease, sell, convey, warrant, or otherwise transfer all or part of 
the Tribe's real property that is not held in trust by the United 
States without further approval, ratification, or authorization by the 
United States. Under S. 4079, action by the United States is not 
required to validate the Tribe's land transactions for Tribally owned 
fee land. The legislation clearly states that S. 4079 does not 
authorize the Tribe to lease, sell, convey, warrant, or otherwise 
transfer lands held in trust or affect the operation of any law 
governing such transactions. The Department defers to Congress on this 
specific matter.
    Further, the Department believes that this legislation would be 
unnecessary, at least as applied to off-reservation lands, if Congress 
clarified that all Tribes had authority to lease, sell, convey, warrant 
or otherwise transfer all or part of their off-reservation fee 
property. Congress should enact more general legislation that extends 
this authority to all Tribes. Over the years, individual tribes have 
expressed that they have encountered difficulties when attempting to 
lease, sell, convey, warrant, or otherwise transfer all or any part of 
their interests in any off-reservation real property not held in trust 
by the United States unless authorized by Congress. Tribes are 
presumably referring to federal law, 25 U.S.C.  177, which prohibits 
any ``purchase, grant, lease, or other conveyance of lands, or of any 
title or claim thereto, from any Indian nation or tribe of Indians.'' 
We urge Congress to clarify the issue of whether fee land owned by a 
tribe would fall under this prohibition, and to do so by expressly 
providing that tribes may transfer off reservation fee lands that they 
own. Such a clarification will remove obstacles to economic development 
opportunities and enhance tribal sovereignty.
Conclusion
    The Department appreciates the opportunity to present its views on 
S. 4079. This bill would enable the Tribe to more effectively manage 
its fee property by clarifying its legal authority to do so. Moreover, 
the Department notes that Congress should enact more general 
legislation that extends authority to lease, sell, convey, warrant or 
otherwise transfer all or part of their off-reservation fee property to 
all Tribes.
                                 ______
                                 
Joint Prepared Statement of the Office of Hawaiian Affairs and Papa Ola 
                                 Lokahi
    Dear Chairman Hoeven, Vice Chairman Udall, Senator Schatz, and the 
Members of the U.S. Senate Committee on Indian Affairs:
    Mahalo for your leadership during the Novel Coronavirus Disease 
(COVID-19) pandemic to protect the rights and honor the trust 
responsibility owed to all Native Americans, including American 
Indians, Alaska Natives, and Native Hawaiians. Papa Ola Lokahi (POL) is 
a community-driven, non-governmental entity that serves as the body 
with whom federal agencies consult on Native Hawaiian health policy and 
health care and that oversees the activities of the five Native 
Hawaiian Health Care Systems (NHHCS or the Systems). The Systems 
provide invaluable direct health care services to the Native Hawaiian 
community in alignment with the overarching health system, with an 
added layer of focus on meeting the nuanced health needs of Native 
Hawaiians similar to how urban Indian organizations strive to meet the 
specific needs of American Indians and Alaska Natives. The Office of 
Hawaiian Affairs (OHA) is a semiautonomous 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 urge 
the Committee to include all Native American communities, including 
American Indian, Alaska Native, and Native Hawaiian communities, in 
legislative actions to uphold the federal trust responsibility owed to 
all Natives. With that in mind, we seek to inform the Committee about 
how the issues discussed in S. 3126, the Native Behavioral Health 
Access Improvement Act of 2019 and S. 3937, the Special Diabetes 
Programs for Indians Reauthorization Act of 2020 affect the Native 
Hawaiian community. Additionally, we would like to express our support 
for broadband initiatives that aim to close the digital divide.
    In tandem with our Native cousins on the continental United States 
and in Alaska, Native Hawaiians face disproportionate threats to 
physical and mental health. \1\ As a result, Native Hawaiians have the 
shortest life expectancy of any major population within the State of 
Hawai`i. \2\ Behavioral health and diabetes are contributing factors to 
these health outcomes in the Native Hawaiian community.
Behavioral Health in the Native Hawaiian Community
    Similar to American Indian and Alaska Native communities, the 
Native Hawaiian community faces a high burden of behavioral health 
challenges. Native Hawaiians face disproportionate rates of suicide and 
depression. \3\ More than twenty percent of Native Hawaiian adults 
reported that they frequently feel their mental health is ``not good.'' 
\4\ 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 completed suicides. \5\ Additionally, Native Hawaiian youth 
have among the highest rates of youth drug use in the State of Hawai`i. 
\6\ For our Native Hawaiian kupuna (elders), depressive disorder is 9.3 
percent, which is higher than that of non-Hawaiians of the same age. 
\7\ Despite the evidence of overrepresentation in mental health 
challenges, Native Hawaiians frequently underutilize existing mental 
health services or seek therapy only after illness becomes severe. \8\ 
Those who choose to seek services may not find it due to limited 
resources. \9\
    To address these mental health issues and substance use disorders, 
the Native Hawaiian Health Care Systems each offer a unique set of 
direct behavioral health services and enabling services to the Native 
Hawaiian communities that they serve. See the figure below for a 
breakdown of services provided.

------------------------------------------------------------------------
      Clinic         Islands Served            Services Provided
------------------------------------------------------------------------
Hui Malama Ola     Hawai`i Island     Offers a variety of behavioral
 Na`Oiwi                               health services through the
                                       support of a licensed clinical
                                       social worker
Hui No Ke Ola      Maui               Offers patients access to
 Pono                                  behavioral health therapists to
                                       improve sleep patterns; improve
                                       diet; cope with stressors from
                                       grief and relationships; reflect
                                       on harmful habits like alcohol,
                                       tobacco, and drug use; and
                                       practice self-care
Na Pu`uwai         Moloka`i and       Offers services in partnership
                    Lana`i             with the Native Hawaiian Health
                                       Scholarship program and others to
                                       ensure patients receive
                                       culturally sensitive behavioral
                                       services and also provides
                                       smoking cessation and drug
                                       recovery programming
Ke Ola Mamo        O`ahu              Offers individual, group, couples,
                                       and family counseling, as well as
                                       tobacco cessation, substance
                                       abuse, and stress management
                                       workshops hosted by licensed
                                       clinical social workers and other
                                       trained professionals
Ho`ola Lahui       Kaua`i             Provides substance abuse, case
 Hawai`i                               management, and other behavioral
                                       health services Beyond POL and
                                       the NHHCS, a handful of other
                                       service providers tailor
                                       behavioral health services to the
                                       Native Hawaiian community. Among
                                       the most well-known providers is
                                       I Ola Lahui, \10\ a 501(c)(3)
                                       nonprofit corporation in Hawai`i
                                       that was created to respond to
                                       the urgent behavioral health
                                       needs of Native Hawaiian and
                                       rural communities. This nonprofit
                                       provides culturally-minded
                                       psychological services for
                                       chronic diseases and traditional
                                       mental health needs. While these
                                       providers help to address the
                                       behavioral health needs of the
                                       Native Hawaiian community, more
                                       resources are necessary to fill
                                       the gaps in services facing many
                                       Native Hawaiians.
------------------------------------------------------------------------

Diabetes in the Native Hawaiian Community
    Recent studies show that one in three Native Hawaiian adults have 
or are at risk for diabetes or pre-diabetes. \11\ As a result, Native 
Hawaiians have been hospitalized at higher rates for short-term and 
long-term diabetes complications; uncontrolled diabetes; and lower 
extremity amputations than the State of Hawai`i's overall rate. \12\ 
Native Hawaiians report increased participation in diabetes self-
management activities, which may be due in part to increased diabetes 
management education through the NNHCS and other clinics. \13\
    The POL and the NHHCS offer a variety of support for those who are 
pre-diabetic or diabetic. Hui Malama Ola Na Oiwi offers diabetes 
management classes to teach participants about diabetes, nutrition, 
exercise, medication, and the tools for continued management of 
diabetes. They also host bimonthly diabetes support groups. Hui No Ke 
Ola Pono hosts a Diabetes Self-Management Program, which includes 
classes on the signs, symptoms, and treatment for hypoglycemia and 
hyperglycemia; lifestyle adjustment; and reducing complications caused 
by diabetes. Additionally, they operate a Simply Healthy Cafe which 
serves meals for the Ho`ola Pu`uwai program, an Ornish Lifestyle 
Medicine program that assists in safely managing diabetes. Na Pu`uwai 
offers screenings to prevent diabetes and programs in wellness like 
diabetes prevention and self-management, as well as promoting lifestyle 
changes like improved nutrition. Ke Ola Mamo provides education and 
screening to assist in controlling and preventing diabetes. Ho`ola 
Lahui Hawai`i provides diabetes screening and prevention, education, 
and disease management support. The reaches of these services are 
capped by limited resources to dedicate to this important health 
challenge, but they provide culturally relevant and tailored support to 
Native Hawaiians who may not have other places to turn, or who have not 
found success in other diabetes programs.
The Digital Divide
    Reliable Internet and broadband service is not available in rural 
and remote areas in the State of Hawai`i, which coincides with where 
many Native Hawaiians live. Approximately 10 percent of Native Hawaiian 
households do not own a computer, and just under 20 percent lack 
Internet access. \14\ During the pandemic, the lack of reliable 
Internet service has highlighted the effects of the digital divide on 
Native Hawaiian families, who cannot access telehealth services, online 
distance learning, and other critical services without this basic 
resource. With this in mind, we support efforts to close this divide so 
that Native communities can take advantage of the powerful technologies 
delivering innovative programming into Native homes.
    Because pervasive diseases like behavioral health challenges and 
diabetes disproportionately affect the Native Hawaiian community, 
legislation addressing these issues is critical to the long-term health 
of the Native Hawaiian people. Mahalo for the opportunity to share 
information about the status of behavioral health and diabetes in the 
Native Hawaiian community, and how our organizations move to meet the 
specific needs of our people. Again, we urge the Committee to include 
all Native Americans, including American Indians, Alaska Natives, and 
Native Hawaiians, in its efforts to meet the obligations of the federal 
trust responsibility owed to all Native communities.
    `O maua iho nei,
    Papa Ola Lokahi

    ENDNOTES

     \1\ Anita Hofschneider, Poverty Persists Among Hawaiians Despite 
Low Unemployment, HONOLULU CIVIL BEAT (Sept. 19, 2018), https://
www.civilbeat.org/2018/09/poverty-persists-among-hawaiians-despite-low-
unemployment/.
     \2\ ISSUE BRIEF: COVID-19 AND NATIVE HAWAIIAN COMMUNITIES, NATIVE 
HAWAIIANS OVER-REPRESENTED IN COVID-19 AT-RISK POPULATIONS, OFFICE OF 
HAWAIIAN AFFAIRS 2 (2020).
     \3\ NATIVE HAWAIIAN MENTAL HEALTH AND SUICIDE, OFFICE OF HAWAIIAN 
AFFAIRS (Feb. 2018), http://www.ohadatabook.com/HTH_Suicide.pdf.
     \4\ NATIVE HAWAIIAN MENTAL HEALTH AND SUICIDE, OFFICE OF HAWAIIAN 
AFFAIRS (Feb. 2018), http://www.ohadatabook.com/HTH_Suicide.pdf.
     \5\ 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/
hmj7011_suppl2_0009.pdf
     \6\ HAW. STATE EPIDEMIOLOGICAL OUTCOMES WORKGROUP, 2018 STATE 
EPIDEMIOLOGIC PROFILE: SELECTED YOUTH AND ADULT DRUG INDICATORS 7, 
(2018), https://health.hawaii.gov/substanceabuse/files/2019/06/
Drug_2018_Hawaii_State_Epidemiologic_Profile.pdf.
     \7\ Hawai'i Health Data Warehouse. (2011-2015), Hawai`i Department 
of Health Behavior Risk Factor Surveillance System (BRFSS).
     \8\ Addressing Native Hawaiian Mental Health Needs Through 
Culturally Informed Programs and Services, OFFICE OF HAWAIIAN AFFAIRS 
1, 1 (2019), https://19of32x2yl33s8o4xza0gf14-wpengine.netdna-ssl.com/
wpcontent/uploads/OHA-4-Mental-Health-Council-External-White-Paper-
Final.pdf.
     \9\ Brittany Lyte, Hawai`i's Mental Health Care Crisis, CIVIL BEAT 
(Sept. 17, 2018), https://www.civilbeat.org/2018/09/hawaiis-mental-
health-care-crisis/.
     \10\ I OLA LAHUI, http://iolalahui.org/ (last visited Sept. 21, 
2020).
     \11\ M.A. Look et al., Assessment and Priorities for Health & 
Well-Being in Native Hawaiians & Other Pacific Peoples, UNIV. OF HAW. 
JOHN A. BURNS SCHOOL OF MEDICINE 1, 12 (2013), http://www.hicore.org/
media/assets/JABSOMStudyreNHHealth_20131.pdf.
     \12\ Native Hawaiian Health Fact Sheet 2015, OFFICE OF HAWAIIAN 
AFFAIRS (2015), https://www.oha.org/wpcontent/uploads/Volume-I-Chronic-
Diseases-FINAL.pdf.
     \13\ M.A. Look et al., Assessment and Priorities for Health & 
Well-Being in Native Hawaiians & Other Pacific Peoples, UNIV. OF HAW. 
JOHN A. BURNS SCHOOL OF MEDICINE 1, 9 (2013), http://www.hicore.org/
media/assets/JABSOMStudyreNHHealth_20131.pdf.
     \14\ ISSUE BRIEF: COVID-19 AND NATIVE HAWAIIAN COMMUNITIES, NATIVE 
HAWAIIANS OVER-REPRESENTED IN COVID-19 AT-RISK POPULATIONS, OFFICE OF 
HAWAIIAN AFFAIRS 1, 4 (2020).
                                 ______
                                 
 Prepared Statement of the National Congress of American Indians (NCAI)
    On behalf of the National Congress of American Indians (NCAI), 
thank you for holding this hearing on tribal health and broadband 
legislation. Founded in 1944, NCAI is the oldest and largest 
representative organization serving the broad interests of tribal 
nations and communities. Tribal leaders created NCAI in 1944 in 
response to termination and assimilation policies that threatened the 
existence of American Indian and Alaska Native (AI/AN) tribal nations. 
Since then, NCAI has fought to preserve the treaty and sovereign rights 
of tribal nations, advance the government-to-government relationship, 
and remove historic structural impediments to tribal self-
determination.
    To facilitate the Senate Committee on Indian Affairs' (SCIA) work, 
NCAI submits this written testimony in support of the following bills.
S. 3937--Special Diabetes Programs for Indians Reauthorization Act of 
        2020
    The Special Diabetes Program for Indians (SDPI), enacted in 1997, 
provides assistance for developing local initiatives to treat and 
prevent diabetes and has served as a comprehensive funding source to 
address diabetes issues in tribal communities. Because of SDPI, rates 
of End-Stage Renal Disease and diabetic eye disease have dropped by 
more than half. \1\ A report from the U.S. Department of Health and 
Human Services (HHS), Assistant Secretary for Preparedness and 
Response, found that SDPI is responsible for saving Medicare $52 
million per year. \2\ Despite its great success, SDPI has been flat 
funded at $150 million since 2004 and has lost much of its buying power 
due to medical inflation.
---------------------------------------------------------------------------
    \1\ Bursell SE, Fonda SJ, Lewis DG, Horton MB. Prevalence of 
diabetic retinopathy and diabetic macular edema in a primary care-based 
teleophthalmology program for American Indians and Alaska Natives.
    \2\ Office of the Assistant Secretary for Planning and Evaluation 
(ASPE). The Special Diabetes Program for Indians: estimates of Medicare 
savings. ASPE Issue Brief. Department of Health and Human Services, May 
10, 2019. https://aspe.hhs.gov/pdf-report/special-diabetes-program-
indians-estimates-medicare-savings
---------------------------------------------------------------------------
    In addition, since September 2019, Congress has renewed SDPI five 
times in short increments of just several weeks or several months. 
Right now, SDPI is set to expire on December 11, 2020. These short-term 
extensions have caused significant distress for SDPI programs and have 
created undue challenges for our patients and community members. They 
have also led to the loss of providers, curtailing of health services, 
and delays in purchasing necessary medical equipment due to uncertainty 
of funding--all while tribal nations are also battling the COVID-19 
pandemic. S. 3927 provides a five-year reauthorization to SDPI with 
added flexibility for tribal nations to receive funds through contracts 
and compacts would ensure Indian Health Service (IHS), tribal health 
facilities, and urban Indian health programs (collectively known as the 
``I/T/U'' system) have the necessary funds to address diabetes and the 
increased risk it poses for a more severe COVID-19 illness. NCAI has 
long supported increased appropriations and permanent reauthorization 
for SDPI. Additionally, in 2019 our membership passed Resolution ABQ-
19-042, supporting SDPI funding through Title I and Title V Indian 
Self- Determination and Education Assistance Act contracts or compacts. 
Accordingly, NCAI strongly supports the immediate passage of S. 3927.
S. 3126--Native Behavioral Health Access Improvement Act of 2019
    AI/ANs are disproportionately impacted by mental and behavioral 
health issues, which adversely impact the well-being of individuals, 
families, and communities. These behavioral health issues are not 
isolated and have created an urgency for tribally driven solutions. 
Unfortunately, the lack of tribal resources for education, treatment, 
preventative services, and public safety in tribal communities impact 
Indian Country's ability to create lasting positive change in this 
arena. Increased funding for mental and behavioral health is critically 
needed, and in 2016 NCAI passed Resolution PHX-16-027, supporting 
increased federal resources to combat opioid abuse and addiction in 
Indian Country. S. 3126 addresses this gap by requiring the Director of 
the IHS, in coordination with the HHS Assistant Secretary for Mental 
Health and Substance Use, to create grants for the I/T/U system in the 
amount of $150 million per year for five years to address important 
mental health and substance abuse issues. Further, the bill models this 
behavioral health program after the successful SDPI program which 
allows tribal leaders to make local level decisions, choose best 
practices, and adapt programs to be culturally appropriate. This 
framework of program implementation, alongside the funding that S. 3126 
proposes is critically needed in Indian Country. Accordingly, NCAI 
supports the immediate passage of S. 3126.
S. 3264--Bridging the Tribal Digital Divide Act of 2020
    Tribal nations experience lower rates of fixed broadband service 
than their non-tribal rural counterparts, with less than half of 
households on rural tribal lands having access to fixed broadband 
service. \3\ This disparity is exacerbated as tribal nations without 
reliable Internet access struggle to respond to and mitigate the 
challenges brought forth by the COVID-19 pandemic.
---------------------------------------------------------------------------
    \3\ Report on Broadband Deployment in Indian Country, Pursuant to 
the Repack Airwaves Yielding Better Access for Users of Modern Services 
Act of 2018, Federal Communications Commission, p. 1, (2019), https://
docs.fcc.gov/public/attachments/DOC-357269A1.pdf
---------------------------------------------------------------------------
    Tribal nations face many barriers related to program procedure, 
funding, and build out when trying to access broadband networks on 
their lands. There are various federal agencies that offer programs 
that aid in the development, deployment, and maintenance of broadband 
networks. Unfortunately, none of these programs are tailored 
specifically to assist tribal nations with their needs. Each of these 
federal broadband programs has its own provisions, regulations, 
policies, and procedures that do not always consider the unique and 
varying circumstances of tribal nations. Navigating each of these 
programs and deciding between them can be a complicated process. Once a 
tribal nation chooses to pursue a program, they encounter barriers to 
deployment. These barriers include lack of investment and funding, 
restrictive definitions for service areas, and complex right-of-way 
statutes that limit tribal nations' ability to permit projects on their 
own land.
    S. 3264 addresses these barriers and attempts to remove or lessen 
their impact to increase broadband access rates on tribal lands. S. 
3264 establishes a Tribal Broadband Interagency Working Group to 
improve coordination between federal broadband programs and helps 
streamline the application and planning process for tribal nations. 
This legislation also creates set asides through the Federal 
Communications Commission (FCC) and the United States Department of 
Agriculture (USDA) to better fund tribal broadband initiatives and 
broadens restrictive definitions to increase eligible broadband service 
areas for tribal nations. Finally, S. 3264 further establishes the 
Tribal Broadband Right-of-Way Pilot Program. This program, at the 
discretion of the Secretary of the Interior, would enable select tribal 
nations to grant a broadband right-of-way across their tribal lands.
    The pandemic has shown that broadband is critical infrastructure 
for tribal communities and the digital divide must be closed to address 
the health, safety, and welfare needs of tribal peoples. S. 3264 aids 
this goal by addressing structural issues that have decreased tribal 
access to broadband deployment and, accordingly, NCAI supports its 
immediate passage.
Conclusion
    Thank you for the opportunity to provide testimony on this 
legislation. We greatly appreciate SCIA's work to address the many 
challenges and barriers faced by AI/AN communities and look forward to 
working together to support the passage of S. 3937, S. 3126, and S. 
3264 and advance other federal policies supporting our tribal 
communities.
                                 ______
                                 
         Prepared Statement of the National Indian Health Board
    Chairman Hoeven, Vice Chairman Udall, and Members of the Committee, 
thank you for holding a legislative hearing on September 23, 2020 to 
receive testimony on S. 3126, S. 3264, S. 3937, S. 4079, and S. 4556. 
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, we submit this testimony for the record.
S. 3937
    NIHB strongly supports S. 3937, the Special Diabetes Program for 
Indians (SDPI) Reauthorization Act of 2020, introduced by Senator 
McSally and supported by Senator(s) Murkowski and Sinema.
    The bipartisan S. 3937 would provide five years of guaranteed 
funding for SDPI at an increased funding authorization level of $200 
million annually. This represents the first increase to SDPI's funding 
level in sixteen years, and the longest reauthorization of the program 
in more than 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. In short, self-determination and self-governance reinforce 
inherent Tribal sovereignty, and impart greater local Tribal control 
over programming to ensure maximize effectiveness.
    As NIHB has shared with the Committee in prior testimony, Tribes 
are requesting technical changes to the introduced text in S. 3937 to 
clarify the intent of the ``Delivery of Funds'' language in order to 
ensure proper implementation of the new 638 authority. Specifically, we 
urge the Committee to pass S. 3937 with the requested changes to the 
Delivery of Funds section outlined 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.''

    During the Committee's legislative hearing in September, Rear 
Admiral (RADM) Weahkee stated that Title V self-governance Tribes 
already have the authority to add their SDPI awards to their annual 
funding agreements (AFAs) while Title I self-determination Tribes do 
not. We believe this statement requires further context and 
explanation. While Title V self-governance Tribes may currently ``add'' 
their SDPI awards to their AFAs, they are restricted from accessing the 
full scope of authorities established under Title V of the Indian Self-
Determination and Education Assistance
    Act (ISDEAA) to support their SDPI operations. For example, Title V 
Tribes who have elected to add their SDPI funds to their AFAs are not 
currently entitled to Contract Support Costs (CSCs) for their SDPI 
programs, nor are they able to streamline diabetes data reporting. 
Authority for Tribes to receive CSCs and other ISDEAA related 
provisions specifically for SDPI would require a statutory change. 
Tribes drafted the legislative language shared earlier in this section 
precisely to achieve that goal.
    Moreover, the intent of the Tribes in pushing for this structural 
638 change to SDPI's governing statute is not simply to ensure both 
Title I and Title V Tribes can simply ``add'' SDPI funds to their 
AFAs--it is to ensure Tribes who choose to receive their SDPI funds 
through the 638 mechanism are entitled the corresponding statutory 
provisions, such as CSCs and streamlined data reporting.
    Not only would S. 3937 further reinforce Tribal self-determination 
and self-governance, but it would also finally insulate the program 
from its recent string of destabilizing short-term extensions. SDPI is 
currently slated to expire on December 11, 2020. Its most recent 
extension, under H.R. 8337, Continuing Appropriations Act, 2021 and 
Other Extensions Act, lasts for only eleven days--SDPI's shortest 
extension on record and its fifth short-term extension since September 
2019 alone. In her opening remarks during the legislative hearing in 
September, Senator McSally stated that ``SDPI has suffered from a 
series of short-term reauthorizations, and stagnant funding, that's 
hindered the program's full potential.'' Similarly, Senator Murkowski 
brought attention to the mere eleven day extension of SDPI in her 
opening comments, and discussed how short-term extensions hurt the 
programs and ``do nothing to increase any level of certainty'' for 
Tribal SDPI grantees. The Senator also acknowledged that diabetes is a 
leading risk factor for a more serious COVID-19 illness according to 
the Centers for Disease Control and Prevention (CDC), as Tribes and 
NIHB have repeatedly referenced as clear evidence of the need for long-
term reauthorization of this life-saving program.
    As NIHB reported in prior testimony, a national survey of SDPI 
grantees conducted by NIHB found that nearly 1 in 5 Tribal SDPI 
grantees reported employee furloughs, including for healthcare 
providers, with 81 percent of SDPI furloughs directly linked to the 
economic impacts of COVID-19 in Tribal communities. Roughly 1 in 4 
programs have reported delaying essential purchases of medical 
equipment to treat and monitor diabetes due to funding uncertainty, and 
nearly half of all programs are experiencing or anticipating cutbacks 
in the availability of diabetes program services--all under the 
backdrop of a pandemic that continues to overwhelm the Indian health 
system.
    We appreciate this Committee's bipartisan commitment to SDPI, but 
Tribes need Congress to collectively act on long-term reauthorization 
to ensure Tribes and Tribal citizens can continue to benefit from this 
indispensable public health program.
S. 3126
    AI/AN communities experienced some of the starkest disparities in 
mental and behavioral health outcomes before this public health 
emergency began, and many of these challenges have only worsened under 
the pandemic. This is especially true for Native youth. A 2018 study 
found that AIAN youth in 8th, 10th, and 12th grades were significantly 
more likely than non-Native youth to have used alcohol or illicit drugs 
in the past 30-days. \1\ According to the Centers for Disease Control 
and Prevention, suicide rates for AIANs across 18 states were reported 
at 21.5 per 100,000--3.5 times higher than demographics with the lowest 
rates. \2\
---------------------------------------------------------------------------
    \1\ Swaim RC, Stanley LR. Substance Use Among American Indian 
Youths on Reservations Compared With a National Sample of US 
Adolescents. JAMA Netw Open. 2018;1(1):e180382. doi:10.1001/
jamanetworkopen.2018.0382
    \2\ Leavitt RA, Ertl A, Sheats K, Petrosky E, Ivey-Stephenson A, 
Fowler KA. Suicides Among American Indian/Alaska Natives--National 
Violent Death Reporting System, 18 States, 2003-2014. MMWR Morb Mortal 
Wkly Rep 2018;67:237-242. DOI: http://dx.doi.org/10.15585/mmwr.mm6708a1
---------------------------------------------------------------------------
    To that end, NIHB supports S. 3126, the Native Behavioral Health 
Access Improvement Act of 2019. The concept of a special behavioral 
health program modeled on SDPI to address chronic and pervasive 
behavioral health challenges in Indian Country was first presented by a 
cohort of NIHB's Native Youth fellows. In May 2017, the NIHB Board of 
Directors passed a resolution formally requesting funds be allocated 
toward substance abuse prevention and intervention programs for AI/AN 
Youth that promotes high self-esteem and resilience through cultural 
enrichment. We greatly appreciate Senator Smith's leadership in 
introducing S. 3126, and thank Vice Chair Udall, Senator Tester, 
Senator Cortez Masto, and Senator Warren for supporting this critical 
legislation.
S. 4556
    We support the passage of S. 4556 for the Director of IHS to 
acquire private land to facilitate access to the Desert Sage Youth 
Wellness Center in Hemet, California. Currently, IHS does not have the 
authority to acquire and/or improve Best Road. The legislation would 
authorize the Director of IHS to acquire and improve Best Road to 
provide safe access to the Desert Sage facility for staff and emergency 
vehicles. Desert Sage is the first Youth Regional Treatment Center in 
CA to provide culturally-sensitive substance use treatment for AIAN 
youth. Previously, AIAN youth attended out-of-state treatment 
facilities that inconveniently removed them from their critical support 
systems during recovery. AI/AN youth are disproportionately impacted by 
substance use, addiction, overdose, and suicide. A 2018 study found 
that AIAN youth in 8th, 10th, and 12th grades were significantly more 
likely than non-Native youth to have used alcohol or illicit drugs in 
the past 30-days. \3\ For California Native youth, access to Desert 
Sage is critical to address these disparities.
---------------------------------------------------------------------------
    \3\ Swaim RC, Stanley LR. Substance Use Among American Indian 
Youths on Reservations Compared With a National Sample of US 
Adolescents. JAMA Netw Open. 2018;1(1):e180382. doi:10.1001/
jamanetworkopen.2018.0382
---------------------------------------------------------------------------
Conclusion
    We thank the Senate Committee on Indian Affairs for holding this 
hearing on important legislation, and stand ready to work with Congress 
in a bipartisan manner to enact legislation that strengthens the 
government-government relationship, improves access to care for all AI/
ANs, and raises health outcomes.
                                 ______
                                 
 Prepared Statement of Esther Lucero, (Dine), MPP, 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 Legislative 
Hearing to receive testimony on S. 3937: Special Diabetes Programs for 
Indians Reauthorization Act of 2020 and the S. 3126: Native Behavioral 
Health Access Improvement Act of 2019 on September 23, 2020.
Background on Seattle Indian Health Board
    SIHB is one of 41 Indian Health Service (IHS)-designated Urban 
Indian Health Programs (UIHP), as defined by Section 4 of the Indian 
Health Care Improvement Act, and a HRSA 330 Federally Qualified Health 
Center, which serves nearly 5,000 American Indian and Alaska Native 
people living in Seattle-King County, WA. As a culturally attuned 
service provider, we offer direct medical, dental, traditional health, 
behavioral health services, and a variety of social support services on 
issues of gender-based violence, youth development, and homelessness.
    We also house the Urban Indian Health Institute (UIHI), an IHS-
designated Tribal Epidemiology Center and public health authority, 
which conducts data, research, and evaluation services for 62 urban 
Indian communities nationwide. We are part of the IHS continuum of 
care, which is comprised of IHS Direct, Tribal 638, UIHP (I/T/U system 
of care). We honor our responsibilities to work with our tribal 
partners and to serve all tribal people. Our role is to address the 
community and health needs of the over 70 percent of American Indian 
and Alaska Native people that live in urban areas.
A Proven Culturally Attuned Model of Care: Special Diabetes Program for 
        Indians
    Research has shed light on the health and psychological 
vulnerabilities of American Indian and Alaska Native people that have 
resulted from a legacy of historical trauma shaped by colonization and 
forced removal of American Indian and Alaska Native people from 
traditional homelands. This has resulted in diminished natural 
resources, persistent malnutrition and nutritional deficiencies, and 
eliminated access to traditional foods. \1\ \2\ \3\ As a result, type 2 
diabetes is more prevalent in American Indian and Alaska Native people 
than in any other race and is two times higher than that of non-
Hispanic Whites. \4\ Additionally, American Indian and Alaska Native 
people have higher proportions of diabetes precursors such as poor 
nutrition, high blood pressure, insufficient physical activity, heart 
disease, and obesity. \5\
    Since 1998, Special Diabetes Program for Indians (SDPI) has offered 
thousands of American Indian and Alaska Native people access to 
culturally attuned diabetes prevention and management services across 
Indian Country. SDPI has proven to be an inexpensive and highly cost-
saving measure of diabetes care and prevention by establishing 
diabetes-focused clinical teams, diabetes patient registries, 
culturally tailored diabetes education tools, nutrition services for 
children and youth, and weight management programs for adults. The SDPI 
program has saved millions of Medicaid dollars through prevention and 
management of diabetes and associated health problems such as 
hypertension, cardiovascular disease, retinopathy, neuropathy, and end-
stage renal disease. The SDPI program has increased diabetes programs 
and services resulting in several improvements in health outcomes, 
including:

   A decrease in mean A1c, decrease in mean LDL cholesterol, 
        and well-controlled blood pressure measurements which can 
        reduce the rate of diabetes complications. \6\ \7\

   The rate of increase in diabetes prevalence among American 
        Indian and Alaska Native adults has slowed from 2006 to 2012 
        and narrowed the gap between American Indian and Alaska Native 
        adults and all adults in the general United States population; 
        and the prevalence has not increased since 2011. \8\

   Obesity and diabetes rates in American Indian and Alaska 
        Native youth remained nearly constant in more than 10 years. 
        \9\

   Diabetes eye diseases rates decreased 50 percent, reducing 
        vision loss and blindness. \10\

   Kidney failure from diabetes dropped by 54 percent in 1996 
        to 2013 in American Indian and Alaska Native adults and was 
        steeper than any other racial/ethnic group and was the same as 
        the incidence in Non-Hispanic Whites. \11\

    In the past five years, SDPI services at Urban Indian Health 
Programs has demonstrated successful implementation and service 
delivery resulting in the following outcomes:

   Maintained healthy eGFR levels in patients (eGFR > 60 ml/
        min/1.7m2).

   Maintained good blood pressure control in patients with 
        diabetes (SBP and DBP below 140/90 mmHg).

   In 2018, there was a high proportion (79.8 percent) of 
        patients with diabetes and hypertension prescribed ACE 
        inhibitors or ARBs.

   In 2018, there was a high proportion (78.0 percent) of 
        patients with diabetes who use tobacco referred to cessation 
        counseling.

   Over the five period (2014 to 2018), there was a 
        statistically significant increase in the proportion of 
        patients with diabetes receiving an annual dental exam.

   Over the five period (2014 to 2018), there was a 
        statistically significant increase in the proportion of 
        patients with diabetes receiving the hepatitis B vaccine 
        series. \12\

    In addition to clinical markers of success, many SDPI services at 
Urban Indian Health Programs offer integrated models of care that 
incorporate services and activities from traditional Indian medicine, 
community gardening and traditional foods, cooking classes, and youth 
fitness programming. Integrated services create a more holistic 
wellness experience for patients and families confronting diabetes. 
Many Urban Indian Health Programs tailor integrated services 
specifically to support patients with multiple health conditions, 
social barriers, and trauma-related stressors.
    In April 2020, UIHI released a factsheet entitled: Special Diabetes 
Program for Indians (SDPI): Mitigating COVID-19 Risk. This factsheet 
highlights that American Indians and Alaska Native people have the 
highest diabetes rates compared to the general public and diabetes 
increases the chance of severe illness from COVID-19. Therefore, the 
continuation of SDPI is crucial to mitigating COVID-19 in tribal and 
urban Indian communities through sustained diabetes prevention, 
treatment, and management efforts. The SDPI program is the only 
national public health intervention program that has improved diabetes 
related outcomes for American Indian and Alaska Native people.
Unaddressed Behavioral Health Access Needs in Native Communities
    Historically, American Indian and Alaska Native people have been 
subjected to utilizing westernized systems of care for behavioral 
health. The American Indian and Alaska Native community experiences 
higher rates of behavioral health challenges due to exposure from 
violence, trauma, and historical trauma. A continuing barrier to 
accessing behavioral health services within Indian Country is the lack 
of funding to develop both an adequate and culturally appropriate 
program. As COVID-19 persists, Indian Country is experiencing a rise in 
behavioral health issues that needs to be addressed.
    Data show that American Indian and Alaska Native people are 
disproportionately represented in poor behavioral health outcomes. 
American Indian and Alaska Native people often suffer from higher rates 
of behavioral health conditions such as mental health, substance use 
disorders, or suicide. For example, analysis of SIHB's 2017 patient 
data shows that 7 percent of clientele were diagnosed with Opioid Use 
Disorder (OUD) compared with national rates of less than 1 percent. 
\13\ According to the National Institute of Mental Health, youth and 
middle-aged American Indian and Alaska Native have the highest suicide 
rate in the country. \14\ Furthermore, a 2017 report from the CDC's 
National Violent Death Reporting System shows that American Indian and 
Alaska Native people are over two times as likely to commit suicide 
than other minority groups. \15\
    Older American Indian and Alaska Native populations, who have a 
higher rate of depression than their non-Native counterparts, also have 
a low rate of seeking out mental health services. This is often 
attributed to a lack of culturally attuned healthcare systems that are 
reflective of Indigenous values. \16\ Not only is there a demonstrated 
need behavioral health services in Native communities, there is also a 
national behavioral health provider shortage documented by federal 
agencies. A 2016 HRSA report found significant shortages of 
psychiatrists, psychologists, social workers, school counselors, and 
marriage and family therapists. \17\ As of 2019, HRSA has identified 
Washington State as a Mental Health Professional Shortage Area, 
estimating that 12.23 percent of the need for mental health providers 
is being met. \18\
    As healthcare systems move towards integration of behavioral health 
and medical care, it is a critical time to make targeted investments in 
building up the behavioral health workforce and programming across the 
Indian healthcare system. Our workforce development incentives and 
programs must reflect priorities of health integration, consumer 
demand, and identified community needs.
Recommendations
    As we work together to address historical and current health 
disparities and promote the well-being of American Indian and Alaska 
Native communities, we ask the committee to support:

   The Special Diabetes Programs for Indians Reauthorization 
        Act of 2020 or S. 3937 to reauthorize SDPI for five years to 
        protect the health of American Indians and Alaska Native people 
        with diabetes during the COVID-19 pandemic and beyond; and

   The Native Behavioral Health Access Improvement Act of 2019 
        or S. 3126 to allow tribes and urban Indian organizations the 
        opportunity to develop behavioral health solutions that 
        incorporate traditional and cultural practices into evidence-
        based prevention, treatment and recovery programs.

    Thank you for your continued advocacy to support Indian healthcare 
systems during the COVID-19 pandemic. We urge you to continue working 
for the health and wellness of American Indian and Alaska Native 
communities.

    ENDNOTES

    \1\ Prucha FP. (1986). The Great Father: The United States 
Government and the American Indians. Lincoln, NE: University of 
Nebraska Press.
    \2\ Edwards K, Patchell B. (2009). State of the science: a cultural 
view of Native Americans and diabetes prevention. Journal of cultural 
diversity. 16(1):32-35.
    \3\ Bell-Sheeter A. Food Sovereignty Assessment Tool. 
Fredericksburg, VA: First Nations Development Institute; (2004).
    \4\ Centers for Disease Control and Prevention. Native Americans 
with Diabetes. Available at: https://www.cdc.gov/vitalsigns/aian-
diabetes/index.html.
    \5\ Washington State Department of Health. (2015). Chronic Disease 
Profile. Washington.
    \6\ Changing the Course of Diabetes: Turning Hope into Reality. 
Indian Health Service. (2014). Special Diabetes Program for Indians 
2014 Report to Congress. Retrieved from: https://www.ihs.gov/sites/
newsroom/themes/responsive2017/display_objects/documents/RepCong_2016/
SDPI_2014_Report_to_Congress.pdf
    \7\ Changing the Course of Diabetes. Indian Health Service. (July 
2017). Retrieved from: https://www.ihs.gov/sites/sdpi/themes/
responsive2017/display_objects/documents/factsheets/
SDPI_FactSheet_July2017.pdf
    \8\ Changing the Course of Diabetes. Indian Health Service. (July 
2017). Retrieved from: https://www.ihs.gov/sites/sdpi/themes/
responsive2017/display_objects/documents/factsheets/
SDPI_FactSheet_July2017.pdf
    \9\ Changing the Course of Diabetes. Indian Health Service. (July 
2017). Retrieved from: https://www.ihs.gov/sites/sdpi/themes/
responsive2017/display_objects/documents/factsheets/
SDPI_FactSheet_July2017.pdf
    \10\ Ibid.
    \11\ Bullock, A., Burrows, N. R., Narva, A. S., Sheff, K., Hora, 
I., Lekiachvili, A., Espey, D. (2017). Vital Signs: Decrease in 
Incidence of Diabetes-Related End-Stage Renal Disease among American 
Indians/Alaska Natives--United States, 1996-2013. MMWR. Morbidity and 
mortality weekly report, 66(1), 26-32. doi:10.15585/mmwr.mm6601e1
    \12\ Urban Indian Health Institute, Seattle Indian Health Board 
(2019). Urban Diabetes Care & Outcomes Summary Report, Audit Years 
2014-2018. Seattle, WA: Urban Indian Health Institute.
    \13\ Seattle Indian Health Board. 2017. Uniform Data System.
    \14\ Curtin, Sally C. and Margaret Warner. Suicide Rates for 
Females and Males by Race and Ethnicity: United States, 1999 and 2014. 
Retrieved from:https://www.cdc.gov/nchs/data/hestat/suicide/
rates_1999_2014.htm
    \15\ APA Fact Sheet. Mental Health Disparities: American Indians 
and Alaska Natives. (2010). Retrieved from: https://
www.davethomasfoundation.org/wp-content
/uploads/2015/05/Fact-Sheet-Native-Americans.Wil_.pdf
    \16\ Heehyul Moon, Yeon-Shim lee, Soonhee Roh, and Catherine E. 
Burnette. (2018). Factors Associated with American Indian Mental Health 
Service Use in Comparison with White Older Adults. Retrived from: 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121725/
    \17\ Health Resources and Services Administration. (2016). National 
Projections of Supply and Demand for Selected Behavioral Health 
Practitioners: 2013-2025. Retrieved from: https://bhw.hrsa.gov/sites/
default/files/bhw/health-workforce-analysis/research/projections/
behavioral-health2013-2025.pdf
    \18\ Kaiser Family Foundation. (2019). Mental Health Care Health 
Professional Shortage Areas (HPSAs): Timeframe: as of September 30, 
2019. Retrieved from: https://www.kff.org/other/state-indicator/mental-
health-care-
health-professional-shortage-areas-hpsas/?currentTimeframe=
0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
                                 ______
                                 
 Prepared Statement of the United South and Eastern Tribes Sovereignty 
                            Protection Fund
    The United South and Eastern Tribes Sovereignty Protection Fund 
(USET SPF) is pleased to provide the Senate Committee on Indian Affairs 
(SCIA) with testimony for the record of the legislative hearing to 
receive testimony on S. 3126, S. 3264, S. 3937, S. 4079, and S. 4556. 
Our testimony will address four of the bills, as we defer to those who 
are more directly affected by S. 4556 for a discussion on its merits. 
USET SPF appreciates SCIA's efforts to continue Committee business, 
given the multiple competing priorities posed by the COVID-19 pandemic 
and other current events. Though many of these bills are related to 
COVID-19 in some way, the problems they seek to remedy existed long 
before the public health emergency, caused by decades of federal under-
investment, neglect, and harmful policies. It is our expectation that 
SCIA will make every effort mark-up these bills, and other pending 
legislation, prior to the end of the 116th Congress.
    USET SPF is a non-profit, inter-Tribal organization advocating on 
behalf of thirty (30) federally recognized Tribal Nations from the 
Northeastern Woodlands to the Everglades and across the Gulf of Mexico. 
\1\ USET SPF is dedicated to promoting, protecting, and advancing the 
inherent sovereign rights and authorities of Tribal Nations, and 
assisting our membership in dealing effectively with public policy 
issues.
---------------------------------------------------------------------------
    \1\ USET SPF member Tribal Nations include: Alabama-Coushatta Tribe 
of Texas (TX), Aroostook Band of Micmac Indians (ME), Catawba Indian 
Nation (SC), Cayuga Nation (NY), Chickahominy Indian Tribe (VA), 
Chickahominy Indian Tribe-Eastern Division (VA), Chitimacha Tribe of 
Louisiana (LA), Coushatta Tribe of Louisiana (LA), Eastern Band of 
Cherokee Indians (NC), Houlton Band of Maliseet Indians (ME), Jena Band 
of Choctaw Indians (LA), Mashantucket Pequot Indian Tribe (CT), Mashpee 
Wampanoag Tribe (MA), Miccosukee Tribe of Indians of Florida (FL), 
Mississippi Band of Choctaw Indians (MS), Mohegan Tribe of Indians of 
Connecticut (CT), Narragansett Indian Tribe (RI), Oneida Indian Nation 
(NY), Pamunkey Indian Tribe (VA), Passamaquoddy Tribe at Indian 
Township (ME), Passamaquoddy Tribe at Pleasant Point (ME), Penobscot 
Indian Nation (ME), Poarch Band of Creek Indians (AL), Rappahannock 
Tribe (VA), Saint Regis Mohawk Tribe (NY), Seminole Tribe of Florida 
(FL), Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY), 
Tunica-Biloxi Tribe of Louisiana (LA), and the Wampanoag Tribe of Gay 
Head (Aquinnah) (MA).
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S. 3126, The Native Behavioral Health Access Improvement Act
    USET SPF strongly supports the intent of S. 3126, the Native 
Behavioral Health Access Improvement Act, which would provide critical 
behavioral health resources to Tribal communities by creating a Special 
Behavioral Health Program for Indians (SBHPI). The SBHPI is modeled 
after the Special Diabetes Program for Indians (SDPI), a successful 
Tribal health program that has had a significant impact on diabetes 
within Tribal communities. Like SDPI, SBHPI responds to a public health 
crisis by providing dedicated funding to Tribal Nations to address 
behavioral health and substance use disorders, including opioid abuse 
and addiction. In addition, it would support cultural competency by 
promoting the incorporation of both modern and traditional practices 
into Tribal behavioral health programs. In order to ensure that SBHPI 
funding is distributed equitably, USET SPF recommends that the bill 
clarify the program will use a formula-based distribution methodology 
developed in consultation with Tribal Nations. This will provide the 
opportunity for Tribal Nations without grant-writing infrastructure to 
benefit from these funds. USET SPF notes that this hearing also 
addressed extending self-governance authority to SDPI. Given the 
structural design of the SBHPI, as well as our principle that all 
federal funding should be contractable and compactable, we urge that 
self-governance authority be a part of the conversation as S. 3126 
continues to move through the legislative process.
S. 3264, Bridging the Tribal Digital Divide Act of 2020
    According to a 2018 Federal Communications Commission (FCC) report 
on broadband deployment in Indian Country, just 46.6 percent of housing 
units on rural Tribal lands have access to high speed broadband, a 
nearly 27-point gap when compared with non-Tribal rural households. As 
our nation becomes ever more dependent upon these tools, including to 
combat COVID-19 and to maintain our way of life amid lockdowns, the 
digital divide between Indian Country and other communities throughout 
America becomes even more stark. For example, lack of connectivity is 
impeding the COVID-19 response by acting as a barrier to public health 
announcements and other urgent communications from Tribal leadership 
and officials, as well as access to information from other reliable 
sources regarding COVID-19 prevention measures. It also creates extreme 
difficulty as Tribal Nations work to trace the contacts of those who 
have been infected.
    Connectivity issues also impact Indian Country's ability to adapt 
to the `new normal' of conducting our daily business in the virtual 
realm. In the absence of adequate broadband and 4G, many of the 
adaptive measures that other communities have taken are unavailable to 
some Tribal communities. This leaves our citizens without access to 
preventative care and check-ups, the ability to telework, and the 
opportunity to continue their studies during school closures-
compounding the disparities we already face in these areas.
    It is with this in mind that USET SPF extends its support to S. 
3264. The Bridging the Tribal Digital Divide Act would spur the 
deployment of broadband on Tribal homelands by providing for improved 
federal coordination and focusing federal dollars in Indian Country. It 
also ensures that Tribal Nations have access to technical assistance, a 
streamlined application process, and control over broadband rights-of-
way within our territories. Passage of this bill would be a significant 
step forward in bringing Tribal connectivity into the 21st century.
S. 3937, The Special Diabetes Programs for Indians Reauthorization Act 
        of 2020
    As this body well knows, the Special Diabetes Program for Indians 
(SDPI) is a lifesaving initiative for the treatment and prevention of 
type-2 diabetes in Indian Country. In order to continue to make 
progress on the devastating effects of diabetes in Tribal communities 
and provide certainty to SDPI programs, Congress must provide a multi-
year reauthorization of SDPI. With the short-term reauthorizations 
provided over the last several Congresses (including five short-term 
extensions just this year), Indian Country has been forced to focus on 
advocating for SDPI's continued funding rather than patient care and 
programmatic expansion. Tribal Nations and Congress have made 
significant investments in preventing and managing the disease. Now is 
the time to provide certainty to this critical program.
    USET SPF continues to be frustrated by short-term reauthorizations, 
as well as the persistent flat funding of the program, in spite of a 
wealth of reliable data showing both its efficacy and continued 
necessity, as well as rising medical inflation. We have joined others 
in Indian Country in consistently advocating for an increase in funding 
that will account for newly recognized Tribal Nations, IHS/Tribal/Urban 
Indian Health Programs that haven't had the opportunity to access SDPI, 
and increases in medical costs.
    Further, in accordance with our effort to modernize the nation-to-
nation relationship between the United States and Tribal Nations, USET 
SPF has consistently urged that all federal funding be eligible for 
inclusion in self-governance contracts and compacts under the Indian 
Self-Determination and Education Assistance Act (ISDEAA), rather than 
grants, in recognition of the retained sovereign authority of Tribal 
Nations and reflective of 21st century self-determination. In addition, 
SDPI's grant application and reporting requirements are burdensome, not 
reflective of our sovereign status, and undermine service delivery, as 
staff time is dedicated to these grant-related tasks.
    USET SPF strongly supports the goals of S. 3937 and extends its 
appreciation to Sen. McSally for its introduction. The bill would 
provide a long-overdue increase in funding for SDPI, as well as a 5-
year reauthorization, both of which are necessary for program 
continuity in Indian Country. Importantly, it also seeks to extend 
self-governance authority to the program for the very first time. In an 
effort to clarify the Tribal position on this provision, USET SPF 
asserts that our objective is to extend the full benefit of ISDEAA to 
SDPI, including reducing burdensome and unnecessary reporting 
requirements, while ensuring that any programs that do not operate 
under this authority remain unchanged. With our partners, including 
National Indian Health Board and Tribal Self-Governance Communication 
and Education, we are working to offer legislative language that 
reflects these aims. We refute previous technical assistance provided 
by the Indian Health Service to the U.S. House of Representatives as 
being inappropriate, incorrect, and fearmongering, and are encouraged 
that Rear Admiral Weahkee took a more constructive tone during the SCIA 
hearing. A critical part of IHS' trust obligation includes promoting 
and supporting Tribal sovereignty and self-determination. Extending 
ISDEAA authority to SDPI will serve only to strengthen Tribal programs 
and our Nation-to-Nation relationship with the United States. USET SPF 
looks forward to working with Sen. McSally, SCIA members, our partners, 
and IHS to achieve this next step forward in Tribal self-governance.
S. 4079, A Bill To Authorize the Seminole Tribe of Florida to Lease or 
        Transfer Certain Land, and for Other Purposes
    Despite the many advances made in federal Indian law over the last 
several decades, there remain numerous examples of anachronistic and 
paternalistic laws that have yet to be repealed or rescinded. These 
policies are remnants of an era and mindset that has no place in 
current Nation-to-Nation relations, as it is based on two deeply flawed 
and paternalistic assumptions: (1) that Tribal Nations are incompetent 
to handle our own affairs, and (2) that Tribal Nations would eventually 
disappear. Indian Country has proven both of these assumptions wrong 
over and over again. The time is now to revisit and remove existing 
barriers that interfere with our ability to implement our inherent 
sovereign authority to its fullest extent. S. 4079 would confirm that 
as a sovereign government, the Seminole Nation, a USET SPF member 
Tribal Nation, has the authority to lease or transfer certain fee lands 
without Congressional approval. USET SPF strongly supports this 
legislation, as it more fully recognizes the sovereignty of the 
Seminole Nation and promotes its economic development. We encourage 
SCIA and this Congress to explore opportunities to fully repeal any 
provisions of law that do not fully recognize the sovereignty of Tribal 
Nations.
                                 ______
                                 
    Prepared Statement of the Riverside County Board of Supervisors
    On behalf of the Riverside County Board of Supervisors we write to 
express our support for H.R. 4495--Access Road for Desert Sage Youth 
Wellness Center.
    It is our understanding that the Desert Sage Youth Treatment Center 
provides culturally sensitive treatment for American Indian and Alaska 
Native (AI/AN) youths between ages 12 and 17 suffering from Substance 
Use Disorders (SUD). Previously, AI/AN youth used out-of-state 
facilities which took away their support systems at this crucial time 
of recovery from SUD. Desert Sage was constructed in 2016 and can serve 
up to 32 patients at a time. It is the only IHS Youth Regional 
Treatment Center in California.
    When the facility was constructed, the Indian Health Service-IHS 
was unable to reach agreement with landowners on adjacent properties in 
order to pave and maintain an access road. Dr. Ruiz's legislation would 
give IHS the authority to purchase the land from willing sellers and 
construct a road to the facility. H.R. 4495 would permit the IHS to 
acquire the land and construct an access road. After construction the 
road would be transferred to the county for permanent operation and 
maintenance.
    For these reasons, we support S. 4556, A bill to authorize the 
Secretary of Health and Human Services, acting through the Director of 
the Indian Health Service, to acquire private land to facilitate access 
to the Desert Sage Youth Wellness Center in Hemet, California, and for 
other purposes.
                                 ______
                                 
      Response to Written Questions Submitted by Hon. Tom Udall to
                  Hon. Rear Admiral Michael D. Weahkee
    Question 1. In response to questions for the record concerning 
IHS's public health emergency preparedness that I submitted to IHS 
following the Committee's July 1st hearing, you described, among other 
actions, creating a ``continuity of operations special general 
memorandum'' and utilizing the Office of the Assistant Secretary for 
Preparedness and Response's 2017 Update to the Department of Health and 
Human Services (HHS) Pandemic Influenza Plan. How did these pre-
pandemic actions inform IHS's response to COVID-19?
    Answer. As part of preparedness, IHS participated in a Pandemic 
Influenza Exercise: Operation Crimson Contagion, between January 2019 
and August 2019, in collaboration with the HHS. Operation Crimson 
Contagion moved through a severe influenza pandemic scenario from 
activation of the disaster simulation through devolution. In addition, 
IHS Areas and Service Units participate in disaster preparedness 
exercises to test their disaster response plans based on local and 
tribal all hazard vulnerability analysis results. The IHS was able to 
leverage the planning exercises, including the pandemic influenza 
planning, to begin to address the COVID-19 pandemic. The IHS used 
lessons learned from exercises to direct continuity of operations, 
start planning for Alternative Care Sites (ACS), coordinate alternative 
screening areas, create a linkage to the Secretary's Operation Center, 
and make the early decision to follow all CDC guidelines. Communication 
lessons learned allowed for quick sharing of clinical and 
administrative guidelines and expansion of existing relationships with 
key partners such as ASPR, which strengthened our emergency operations 
capability.

    Question 1a. What difficulties did IHS encounter mobilizing its 
response in the early days of the pandemic?
    Answer. At the onset of the COVID-19 pandemic, the IHS encountered 
work environment and efficient surveillance system difficulties. In 
early March 2020, IHS senior leadership activated the Headquarters 
Incident Command Structure (ICS) to respond to COVID-19 using the IHS 
pandemic response plan and disaster plans in IHS healthcare facilities. 
Subsequently, IHS drafted the IHS COVID-19 Response Concept of 
Operations (CONOPs) aligning with the US COVID-19 Response plan. The 
IHS ICS team is comprised of incident command leadership, Facilities/
Area Coordination Group, Liaison Section, Public Information Officer, 
Systems Support Section, Operations Section, Planning Section, and 
Safety Officer. With the evolution of the COVID-19, stay at home/
shelter in place orders, and the maximum utilization of telework for 
staff at the IHS HQ 5600 Fisher Lane building in Rockville, MD, the ICS 
moved to virtual operations in late March 2020. The IHS stood up a data 
surveillance system to track the detection of new COVID-19 cases and 
assist in planning IHS response. The surveillance system collects 
facility level data on COVID-19 related outcomes, such as ventilator 
use and hospital bed capacity, along with aggregated testing data from 
all federal sites and participating tribal and UIO facilities. The 
surveillance system has helped the IHS coordinate critical data that 
assists in addressing planning and COVID-19 surveillance challenges 
initially encountered.

    Question 1b. Is IHS evaluating the effectiveness of its COVID-19 
response actions? What are the lessons learned looking forward?
    Answer. Yes, the IHS has engaged and continues to evaluate COVID-19 
response actions. The ICS has continued regular communication with 
Areas to assess local needs and response, and at 100 days into the 
formal response, the IHS conducted an assessment of activities. The 
assessment examined actions by the IHS COVID-19 Action Plan to prevent, 
detect, treat, and recover. The IHS is also compiling a review of 
lessons learned, early analysis indicates that:

  Regular communications from and across leadership, through 
        the daily (then tri-weekly) IHS COVID-19 ICS Daily Check-In, 
        proved to be one of the most important tools for ensuring that 
        I/T/U leaders and staff received consistent and standard 
        updates, and that issues and/or risks could be highlighted and 
        resolved in a timely manner.

  Essential to the success of IHS efforts was the daily 
        coordination and integration with federal agencies (e.g., 
        Centers for Disease Control and Prevention (CDC), Federal 
        Emergency Management Agency (FEMA), and Veterans Health 
        Administration (VHA)), state, Tribal, and local governments, as 
        well as health systems, hospitals, providers and other 
        stakeholders.

  Leaders focused early on important data resources, metrics 
        and measures, and informed decisions through daily analysis 
        leveraging the data surveillance system and improved National 
        Healthcare Safety Network (NHSN) reporting from all direct 
        service hospitals.

  IHS' National Supply Service Center (NSSC) provided essential 
        coordination and management support for the distribution of 
        pharmaceuticals, medical, and other health care related supply 
        items including personal protective equipment to IHS, Tribal, 
        and Urban Indian Organization health care facilities and 
        programs nationwide.

    Question 2. In response to questions for the record concerning the 
impacts of COVID-19 related lost third-party revenue on the ITU system 
that I submitted to IHS following the Committee's July 1st hearing, you 
stated, ``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.'' Given that the majority of IHS 
third-party revenue comes from increased coverage options authorized by 
the Patient Protection and Affordable Care Act--If the ACA were 
repealed before the end of the year, would IHS be able to ensure that 
all federally-operated IHS facilities, Tribally-operated IHS 
facilities, and Urban Indian health programs could remain open and 
retain sufficient staff to continue serving their communities and meet 
all accreditation standards?
    Answer. The Indian health system, as a whole, relies heavily on 
third party resources to maintain accreditation and certification, 
sustain health care services and operations, address facilities 
maintenance and operations, and procure medical equipment. The third 
party revenue stems from all Third Party Resources: Medicaid (including 
Medicaid Expansion), Medicare, Private Insurance (including Marketplace 
Coverage), Department of Veterans Affairs and Other.
    In some instances, third party collections may constitute 50 
percent or more of a facility's operating budget. Declining collections 
due to the COVID-19 pandemic caused as a result of a decrease in 
routine and non-emergency health services has led to significant 
resource challenges across the system. Any changes to Patient Third 
Party Coverage could have an impact on Tribes and Federal facilities.
    Between April and September 2020, IHS (Federal) collections were 
16-17 percent lower when compared to the same time period in the 
previous year. Continued reductions of this magnitude compound the 
challenges of operating during a pandemic. The IHS continues to monitor 
the status of collections and adjust plans for mitigating impacts of 
reduced revenue levels.

    Question 2a. How would repeal of the ACA impact IHS's current 
COVID-19 response efforts and initiatives?
    Answer. If any losses in revenue occur as a result of changes to 
third party reimbursement, priorities may have to be shifted.

    Question 2b. What contingency planning, if any, has IHS undertaken 
to determine what authorities would disappear if the entire ACA 
(including the Indian Health Care Improvement Act (IHCIA) amendments 
and reauthorization) were repealed?
    Answer. The IHS is committed to providing quality health care, 
consistent with its statutory authorities and its government-to-
government relationship with each Indian tribe. In accordance with the 
IHS Tribal Consultation policy (IHS Indian Health Manual--IHS Circular 
2006-01), a change in law would constitute a critical event that has or 
may have substantial impact on Indian Tribes or Indian communities. To 
address any such critical event, the IHS would initiate formal Tribal 
consultation to seek input on implementation of changes in IHS programs 
or policies.

    Question 2c. What current authorities or programs would be lost for 
IHS, Tribes, and Urban Indian health programs if changes made by to the 
IHCIA by the ACA were repealed?
    Answer. The IHS has a duty to carry out its statutory 
responsibilities. The IHS administers discretionary appropriations and 
operates under broad, general authorities that give IHS significant 
discretion in how to provide health care to Indian Tribes.
    The Indian Health Care Improvement Act (IHCIA), the cornerstone 
legal authority for the provision of health care to American Indians 
and Alaska Natives, was made permanent as part of the Patient 
Protection and Affordable Care Act (PPACA). If the PPACA was repealed, 
then Congress would need to reauthorize the IHCIA in order for those 
programs to continue. In 2013 and 2019, the Government Accountability 
Office (GAO) reported on effects of the PPACA on the American Indian 
and Alaska Native population, see reports GAO-13-553 and GAO-19-612.

    Question 3. Your testimony for this hearing discusses the mental 
and behavioral health impacts of the COVID-19 pandemic on Native 
communities and mentions that IHS has seen an influx of new patients 
seeking care for these types of issues. It further states that Senator 
Smith's Native Behavioral Health Access Improvement Act would provide 
additional tools to address some of the longstanding mental and 
behavioral health access barriers for Native communities. Does IHS have 
any data that indicates a level of increased demand for mental and 
behavioral health services observed since the onset of the COVID-19 
pandemic?
    Answer. Due to COVID-19, many of the referral systems of care have 
temporarily halted services, discharged patients, and limited 
onboarding of new patients. This is additionally complicated by 
increased medically managed detoxification needs for patients 
experiencing precipitated withdrawal due to changes in illicit opioid 
supply chains and changes in access to alcohol resulting from shelter 
in place orders. As a result, alcohol withdrawal patient visits 
declined from 5,802 to a projected 5,115 between FY19 and FY20. Between 
FY14 and FY19, IHS reported an increase in opioid related outpatient 
visits by 69 percent, representing an upward trend of increasing access 
to treatment prior to COVID-19. However, in FY20, the average number of 
visits to receive care per year declined for both alcohol and opioid 
related categories. Consequently, IHS estimates a decline in medication 
assisted treatment (MAT) related encounters based on FY20 Naloxone and 
Buprenorphine prescription data.
    Overall, IHS has documented an increase for all service categories 
of ambulatory, telehealth, and telephone contacts from March to June 
2020 of the COVID-19 Public Health Emergency. From March to April 2020, 
the number of such encounters increased 1,555 percent and from April to 
May 205 percent. Finally, the telehealth related behavioral health and 
alcohol/substance use encounters (based on facility type and/or 
taxonomy developed for Alcohol SA encounter identification) is expected 
to increase 93.5 percent from FY19 to FY20 based on the first 8 months 
of data.

    Question 3a. If Tribes had additional mental and behavioral health 
tools, like those proposed by Senator Smith's bill, what kind of 
impacts on Native communities' overall health and wellbeing would IHS 
expect to see?
    Answer. It appears the intention of S. 3126 is to create a 
behavioral health program modeled after the successful Special Diabetes 
Program for Indians (SDPI) program. Many of the elements of the SDPI 
and lessons learned over the years can be adapted for a Behavioral 
Health Program (BHP), such as flexibility to allow for local priorities 
and approaches to programs and activities, standardized collection of 
program data to evaluate progress and outcomes, and the creation of a 
technical assistance center to provide guidance and resources to Tribes 
receiving grant funding.

    Question 4. HHS recently held Tribal consultation and urban confer 
sessions on COVID-19 vaccination plans and indicated that Tribes will 
have the option to receive COVID-19 vaccines through either the IHS or 
the state in which they are located. How will IHS ensure that all 
Tribes and Urban Indian health facilities, including those that offer 
only outreach and referral services, receive adequate COVID-19 vaccine 
allocations?
    Answer. In preparation for vaccine allocation and distribution, IHS 
requested vaccination estimates from all Tribal and Urban Indian health 
programs that choose to receive their vaccine from IHS. These estimates 
will be included in the overall vaccine allocation estimates across the 
health care system.
    Those programs that do not have vaccine clinic services or 
capability will be advised to utilize their existing network for 
receiving vaccine services to ensure access to COVID-19 vaccine 
allocations. IHS does not anticipate allocating COVID-19 vaccine to 
facilities where clinical services to store and administer the vaccine 
do not exist.

    Question 4a. What safe guards will HHS and IHS deploy to ensure 
Tribes and Urban Indian health facilities that opt to receive vaccine 
distributions by working through relevant state agencies are treated 
equitably by states?
    Answer. On September 24, 2020, HHS, through IHS and CDC, initiated 
Tribal Consultation to seek input from Tribal Leaders on COVID-19 
vaccination planning for Indian Country. This Tribal Consultation 
complements the state planning process that began with the September 
16, 2020 publication of the CDC's COVID-19 Vaccination Program Interim 
Playbook for Jurisdiction Operations. This playbook guides Immunization 
Program Awardees (e.g., state and local jurisdictions with routine 
immunization programs) in planning and operationalizing their COVID-19 
vaccination response. HHS hosted six Tribal consultation sessions to 
seek input from Tribal leaders on COVID-19 Vaccination Planning for 
Indian Country. The Centers for Disease Control and Prevention (CDC), 
Food and Drug Administration, Indian Health Service (IHS), and National 
Institutes of Health participated in the consultation sessions. 
Additional information on the strategy for vaccine distribution can be 
found in the Operation Warp Speed Strategy for Distributing a COVID-19 
Vaccine.
    In parallel with CDC's efforts encouraging states to reach out and 
work with the tribes and urban programs, IHS continues to encourage 
programs to work through their existing vaccine infrastructure and 
distribution networks and with their respective state, county, and 
local jurisdictions. IHS continues to offer technical assistance to 
Tribal and Urban Indian health programs working with their respective 
states, and the Agency is preparing to monitor vaccine distribution and 
allocation on an ongoing basis.

    Question 4b. How will IHS ensure that Tribes and Urban Indian 
health facilities have the necessary infrastructure to safely 
transport, store, and administer an approved vaccine?
    Answer. The IHS National Supply Service Center is actively 
monitoring vaccine development, the supply chain, and working to meet 
the transport, storage, and administration requirements associated with 
any potential vaccine received by IHS. For tribal and urban sites that 
receive their vaccine through the IHS, IHS is working to ensure any 
necessary requirements will be met for all sites. The IHS Vaccine Task 
Force has teams dedicated to developing necessary infrastructure and 
training requirements to meet transportation, storage and 
administration of the COVID-19 vaccine.

    Question 4c. Will IHS's COVID-19 vaccine allocations to Tribes 
include doses for non-Tribal members who serve essential community 
roles (e.g., public safety officers)?
    Answer. Yes, IHS expects dosage estimates and allocation to include 
non-tribal members who serve essential community roles, including 
health care workers, tribal employees, public safety officers, and 
others.

    Question 4d. How does IHS plan to provide education and outreach to 
Tribal citizens, Tribal health facilities, and Urban Indian 
Organizations on a COVID-19 vaccine once developed and approved for 
use?
    Answer. The IHS vaccine task force includes a communications team 
which is developing a strategic communication plan for vaccine 
allocation and distribution, including culturally appropriate key 
messages. IHS understands that education and outreach is critical, and 
collaboration with our federal partners and tribal communities will be 
key in reaching our American Indian and Alaska Native population. 
Throughout the COVID-19 response, IHS has worked with tribal 
communities and federal partners to issue several communications 
including: issuing public service announcements, social media messages, 
and developing COVID-19 community prevention materials.

    Question 5. Last week, the National Academies of Sciences, 
Engineering, and Medicine released their final report outlining a four-
phased equitable COVID-19 vaccine distribution framework. Phase I b of 
the framework proposes covering ``approximately 10 percent of the 
population and includes people of all ages with comorbid and underlying 
conditions... that put them at significantly higher risk of severe 
COVID-19 disease or death.'' The report also suggests the Department 
make special efforts to counter the impacts of systemic racism that 
have contributed to higher comorbidities and increase risk for a more 
serious COVID-19 illness among certain populations, including American 
Indians, Alaska Natives, and Native Hawaiians. How are IHS, HHS, and 
Operation Warp Speed incorporating the findings and recommendations of 
this report into its COVID-19 vaccine allocation plan for Tribes, Urban 
Indian health facilities, and Native Hawaiian health systems?
    Answer. Beginning in March 2020, the IHS joined the White House, 
HHS, Department of Interior and several other Federal agencies in 
scheduled calls with tribal leaders to provide updates on COVID-19. 
This all-of-government approach to provide updates and hear input from 
tribal stakeholders related to the COVID-19 pandemic strengthened 
communications across HHS to expeditiously sharing information to help 
inform planning and decisions. For example, IHS has staff assigned to 
both the HHS Secretary's Operation Center and to Operation Warp Speed 
to support communications through appropriate channels, such as HHS 
Office of Intergovernmental and External Affairs or the White House 
Office of Intergovernmental Affairs. In addition, IHS is working on 
several activities related to the National Academies of Sciences, 
Engineering, and Medicine (NASEM) recommendations including, developing 
appropriate population vaccination estimates (recommendation 1), 
conducting tribal consultation and urban confer on the IHS COVID-19 
Pandemic Vaccine Draft Plan (recommendations 1-2), and developing a 
strategic communications plan to develop key messages that are 
culturally appropriate (recommendation 4). IHS will continue to review 
report recommendations on an ongoing basis and will incorporate 
recommendations as appropriate and consistent with CDC recommendations.
    The NASEM Phase I b focuses attention on two groups that are 
particularly vulnerable to severe morbidity and mortality from COVID-19 
disease. The first group includes people of all ages with comorbid and 
underlying conditions that put them at ``significantly higher risk'', 
defining this as having two or more comorbid conditions. The second 
group includes older adults living in congregate or overcrowded 
settings.
    The IHS is working to provide robust national estimates of the 
populations it serves, specifically attempting to identify the number 
of individuals in the Phase I a and I b Tiers. The IHS COVID-19 Vaccine 
Task Force is in the process of collecting estimates from each IHS, 
Tribal and Urban (I/T/U) site within the agency to identify priority 
groups. Each I/T/U is using internal reporting methods to identify the 
number of elders and those with underlying medical conditions as 
defined by the CDC/Elixhauser ICD-10 codes. All estimates will be 
shared with the CDC and Operation Warp Speed for allocation purposes to 
ensure that these entities are fully aware of the IHS needs.

    Question 5a. Would IHS, HHS, or Operation Warp Speed require 
additional resources to fully implement the National Academies' 
recommendations?
    Answer. As previously stated, IHS is already working on several 
activities related to NASEM recommendations, consistent with CDC 
recommendations, and does not anticipate additional resources will be 
required for implementation. IHS anticipates that a critical aspect of 
vaccine distribution will be adapting or adjusting electronic health 
records, including the Resource and Patient Management System, in 
anticipation of new reporting requirements. Through feedback received 
during the HHS tribal consultation process, tribes and urban programs 
asked if funding sources have been identified for vaccine 
administration, storage, reporting, infrastructure, and communications.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                         Hon. Michael Chavarria
    Question 1. Do you believe that there are still COVID-19 relief 
barriers for direct service tribes that IHS and HHS need to tackle?
    Answer. Chairman and Members of the Committee--thank you for this 
question. Yes, I do see barriers remaining for Direct Service Pueblos 
in accessing critical COVID-19 relief and supplies. These Pueblos 
receive their primary care from the IHS through the Santa Fe Service 
Unit. My Pueblo, the Pueblo of Santa Clara, is a direct service tribe.
    Last month, on August 19th, the Direct Service Pueblos met with HHS 
Deputy Secretary Hargan and RADM Weahkee. During that virtual session, 
I discussed the challenges our communities continue to face during the 
pandemic.
    Chief among these is the lack of adequate PPE and medical supplies. 
The Santa Fe Service Unit needs to replenish its supplies to make it 
through the treacherous fall and winter that the CDC and other federal 
health officials have repeatedly warned is coming--and may, in fact, 
have already started with the upward trends we are seeing across at 
least 27 states and rising.
    As of today, the IHS is still running at threadbare levels in terms 
of being prepared to handle COVID-19 cases and flu related illness--all 
while also trying to meet the increasing healthcare needs of chronic 
care patients and routine healthcare.
    Supply chain disruptions and shortages have made it almost 
impossible to meet demand, a demand which is only expected to grow with 
the devastating numbers predicted for the fall.
    Barriers to accessing the necessary PPE and medical equipment 
include limited supply available generally, regulatory and 
administrative restrictions and burdensome reporting requirements, and 
disparate levels of need across the Indian health system that make the 
equitable distribution of limited supplies difficult to achieve.
    We are starkly unprepared.
    So what can be done?
    We recommend that Congress invest in a targeted PPE and medical 
equipment stockpile for Pueblo Country, as well as other dedicated 
stockpiles to serve Indian Country. These stockpiles must be able to 
meet current levels of resource need and include at least a three 
months' supply of necessary materials for future healthcare needs. A 
three month stockpile is the minimum level of supplies recommended by 
the federal healthcare officials.
    We also recommend that Congress direct the HHS Secretary and FEMA 
Administrators to exercise their delegated authority to the maximum 
extent permissible to streamline tribal access to national supply 
reserves.
    Further, it is critical that we plan now for the post-pandemic 
world. We should take best practices learned during the crisis to help 
improve the Indian health care system in the long-term. For instance, 
Congress should invest in broadband development and deployment in 
Indian Country--as advanced under the Bridging the Tribal Digital 
Divide Act--and direct the HHS Secretary to make permanent the 
telehealth and telemedicine flexibilities adopted in the pandemic.
    Broadband and healthcare are inseparable now and should remain in 
strong partnership after the public health emergency is lifted.
    Finally, the HHS could remove a significant barrier to COVID relief 
for Direct Service and other tribes simply by streamlining reporting 
requirements across tribal funding opportunities and providing those 
dollars with maximum flexibility. All of our tribal governments and 
health programs are operating at maximum capacity with few, if any, 
personnel available for administrative tasks. Streamlining reporting 
requirements and maximizing program flexibilities would enable us to 
apply for and manage more relief funds to better serve the complex 
needs of our people.

    Question 2. Were (Pueblo) communities able to navigate the IHS and 
the federal government's COVID-19 response structure in the early days 
of the pandemic?
    Answer. In the beginning it was a challenge for the Santa Fe 
Service Unit and SCP clinic to effectively respond to the pandemic due 
to the lack of necessary supplies and inadequate numbers of healthcare 
and administrative personnel. These deficiencies made it difficult to 
monitor relief packages, complete application and reporting 
requirements, and plan for and carry out the allocation of resources 
among eligible tribal programs. The relief being provided by Congress 
was robust and greatly appreciated; we did not have the federal 
technical assistance and internal capacities to navigate this sudden, 
new, and expansive landscape.
    Navigating the early response structure was also difficult because 
we were being told to prioritize testing and first responder safety but 
we were not given the tools to do so. Test kits were hard to find, 
turnaround times for results were lengthy because they had to be sent 
offsite, and PPE rapidly disappeared. We were underfunded and under-
resourced for years before the pandemic, there was simply no way we 
could respond at the level being asked of us when it finally arrived.
    Further, the Santa Fe Service Unit is only a day clinic. It is not 
a full-fledged hospital and provides only very limited specialty care 
services. It was not and is not equipped to handle a ravaging pandemic. 
As a result, our members must seek critical and specialty care from 
public and private medical facilities outside of the community through 
the Purchased and Referred Care system.
    Additionally, the various funding opportunities available through 
the HHS, Treasury, CDC, HRSA, IHS, FEMA, and others are critical to 
addressing the wide ranging impacts of the virus. Unfortunately, each 
opportunity came with different expenditure restrictions, reporting 
obligations, deadlines, and other requirements. The moving goal posts 
associated with the Tribal Relief Fund administered by Treasury was 
also deeply frustrating.
    While efforts emerged to try and clarify these differences through 
All Tribes and Tribal Leader calls organized by the HHS and White House 
Council on Native American Affairs, it remains confusing and a barrier 
to access that continues today.
    I do understand Chairman and Members of that Committee that this 
virus has placed all of us in an unfortunate situation--however through 
the Power of Prayer and with support from Congress, our hope is to 
receive continued support for Pueblos and Tribal Nations due to federal 
treaty and trust obligations and to mitigate the health disparities 
that plague our communities and place us at high risk for severe 
effects from the COVID-19 virus.

    Question 3. Chairman Chavarria, Director Weahkee's testimony 
discusses the mental and behavioral health impacts of the COVID-19 
pandemic on Native communities. It also mentions that IHS has seen an 
influx of new patients seeking care for these types of issues.
    Have Pueblo Governors seen a similar increase in need for mental 
and behavioral health services during this pandemic? And do you think 
Pueblos currently have the resources they need to meet that increased 
demand?
    Answer. Yes, the pandemic has significantly increased the need for 
mental and behavioral health services in our communities. I have seen 
first-hand the unfortunate increases in emotional, mental, physical, 
and social stress on my community. Facility closures, service and 
treatment disruptions, and prolonged isolation from stress relievers 
like family and traditional ceremonies are taking a toll across Pueblo 
Country.
    In response to COVID-19, all Pueblo governments exerted our 
sovereign right to close our businesses, offices, and schools in an 
effort to protect our most vulnerable members. We also instituted stay 
at home orders, limited travel, restricted access to tribal lands, and 
ceased all traditional and communal gatherings, including our feast 
days.
    This isolation has created hardship for many of our members. I have 
had conversations with grandparents, parents, and children who have 
expressed the toll this virus has caused upon them.
    Not knowing how this will end, when safety will be restored, or 
what the future may hold has increased instances of depression, 
anxiety, loneliness, substance abuse, and suicide risk.
    I feel the pain of my members, I hurt for them, because as the 
Governor--along with my administration, tribal council and staff--it is 
our responsibility to provide comfort, provide guidance, and provide 
the necessary resources our people need to cope with their issues.
    COVID-19 has stolen the ability of our people to see behavioral and 
mental health specialists (when limited appointments are available), 
access MAT, check into residential and long-term treatment programs, 
and engage in traditional healing practices within the community.
    What exacerbates the problem is limited to no technological 
capabilities in Pueblo Country. Not every household has a broadband 
connection, let alone a computer or even a smartphone to access 
telehealth services. Many of our people are caught in a dangerous limbo 
with no in-person and no tele-health options available to them to 
confront in confidence the trauma being experienced.
    The Pueblos do not have the required resources to handle the 
increased demand we are experiencing for behavioral and mental health 
services. And while Tribal 638 programs are often more robust in 
behavioral health provider staffing than the IHS, these programs too 
have been impacted by COVID closures and restrictions, and often lack 
updated telehealth equipment and technology, further decreasing patient 
access during this critical time.

    Question 4. Do you believe Tribes would benefit from access to 
flexible behavioral health funding through creation of Senator Smith's 
proposal, the ``Special Behavioral Health Program for Indians''?
    Answer. Yes, I believe Tribes across Indian Country would benefit 
greatly from Senator Smith's proposed legislation.
    I think that taking the best practices learned from the Special 
Diabetes Program for Indians to create a targeted behavioral health 
program could be effective in addressing unmet behavioral and mental 
health needs. SDPI has been broadly successful in reducing incidences 
of diabetes and diabetes-related conditions in Indian Country through 
the successful integration of cultural derived and evidence-based 
health prevention, management and treatment practices. SDPI also 
provides tribal nations with funding flexibility to tailor their 
programs to meet local needs.
    Carrying this framework over into the behavioral health field would 
be positive. I would recommend that any funds allocated under this new 
program include a 638 contracting and compacting option for self-
governance tribes. The use of self-governance funding mechanisms allows 
tribes to maximize federal dollars, build internal capacities, and meet 
our peoples' needs.
    Further, I feel that tribes are better situated to determine the 
best use of such resources at the local level while still partnering 
with IHS, SAMSHA, and other federal agencies on tribal consultation, 
technical assistance, and workforce development (including TCU 
educational pipelines to support the training of additional behavioral 
health specialists of Native descendent). The Committee may also want 
to consider an amendment to create a tribal-federal task force to 
further our partnership in and commitment to addressing this public 
health crisis.
    Addressing behavioral health needs requires an all-hands-on-deck 
approach that the proposed legislation would advance for the benefit of 
tribes.
    Question 5. Would this pilot program benefit your community, 
especially during a national health crisis when access to the Internet 
is absolutely necessary?
    Answer. Yes, I believe the proposed legislation would benefit not 
just my Pueblo but all Tribal Nations both during the pandemic and 
after.
    COVID-19 has brought to glaring light all of the existing 
technological infrastructure disparities afflicting Indian Country. Our 
families lack at-home broadband, students lack individual computers or 
iPads, hospitals have insufficient networks, and entire communities 
lack fiber optic cables or wireless capabilities.
    The right-of-away pilot program proposed in S. 3264 will assist us 
in addressing each of these barriers by helping us lay the foundation 
we need for community-wide broadband access. I also feel this crucial 
piece of legislation will aid in leveraging other technological 
opportunities such as the short-term 90-day ``Special Temporary 
Authority'' through the FCC that allows us to use the spectrum over SCP 
lands until the tribal priority window is closed and final 
authorization is granted, by Nov 2nd. Leveraging is key to closing gaps 
and delivering services on our lands and the pilot program would help 
us to achieve this goal.

    Question 6. How could this Committee help your tribal communities 
address existing obstacles to reliable broadband service, especially 
during the coronavirus pandemic?
    Answer. While we have many answers for your consideration, I will 
focus on just a few priorities here.
    First, one of the key issues for the Pueblos is increasing 
flexibility in relation to the E-Rate program administered by the FCC. 
Currently, the E-Rate program can only be used for tribal libraries to 
increase their broadband connectivity or bandwidth. However, many of 
our tribal libraries are not open due to the pandemic and where they 
are open, the facility space is too small to safely accommodate the 
many community members that need to access wifi for education, work, 
and other essential activities.
    We urge the Committee to consider, as a temporary measure, 
authorizing the FCC to expand access to the E-Rate program beyond 
tribal libraries to other tribally-owned or operated facilities. This 
simple change would dramatically increase the scope of the E-Rate 
program and allow us to provide safe, socially distanced, supervised 
spaces for our students, as well as create opportunities for 
specialized connectivity hubs--such as an office space solely for elder 
members' use or a gym repurposed for community teleworkers.
    This temporary expansion could be lifted after the public health 
emergency is lifted; by which time, hopefully, the initiatives proposed 
under the Bridging the Tribal Digital Divide Act and other broadband 
measures would have helped establish the requisite infrastructure to 
keep programs running under different authorities.
    We have made a similar request to the White House through the White 
House Intergovernmental Affairs staff for an Executive Order that would 
allow for temporary flexibility on the use of broadband funded by the 
E-Rate program. However, the response we received was that such 
flexibilities would need to be granted by Chairman Pai of the FCC 
because it is an independent agency.
    I fully support not breaking the law--however during this 
unprecedented time, I feel there has to be flexibility provided to 
utilize existing authorities and infrastructure already in place to 
solve urgent educational and community needs. I emphasize again that 
this request is only temporary; we would support a reversion to the 
current E-Rate restrictions after the public health emergency is 
lifted.
    Additionally, I would be remiss if I did not request that this 
Committee support an extension of the CRF expenditure deadline set in 
the CARES Act. A one or two year extension would allow us to plan, 
develop, and implement so many more services for our people, including 
in the area of broadband development. Large scale changes require time 
to take place. We have the funds to support our plans thanks to 
Congress's swift action in the stimulus bills; now we need the time to 
properly carry them out. Please consider extending this pivotal 
deadline.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
       Bureau of Indian Affairs, U.S. Department of the Interior
    Question 1. How many Tribes, if any, have used HEARTH Act authority 
for broadband deployment? If so, has the BIA determined that such 
authority has resulted in acceleration of broadband in those Tribal 
communities?
    Answer. HEARTH Act authority is only for business leases and does 
not include rights-ofway (ROWs) or grants of easement, which is the 
primary transaction type utilized for broadband activities. However, 
there are 50 tribes with approved HEARTH Act regulations for business 
lease purposes. In November 2020, Indian Affairs approved its 60th 
HEARTH Act application.
    The BIA does not have necessary data, such as the number of homes 
served by HEAR TH Act decisions, to determine if HEARTH Act authority 
has resulted in acceleration of broadband in tribal communities.

    Question 2. Does the BIA currently gather data on barriers to 
rights-of-way approvals on Tribal lands? If so, please explain.
    Answer. No. ROW information in the Trust Asset and Accounting 
Management System (TAAMS) includes information on when ROWs were 
entered, approved, pending, cancelled, or withdrawn. Data on barriers 
to ROW approval is not collected in TAAMS.
    However, the Office of Indian Energy and Economic Development and 
the Assistant SecretaryIndian Affairs' Management Division are 
currently working on identifying barriers to broadband infrastructure 
development beyond rights-of-way approvals.

    Question 3. What protections are in place, or should be, to ensure 
that trust land and resources are protected in broadband deployment on 
Tribal lands?
    Answer. The BIA and other federal agencies have regulatory 
enforcement mechanisms to protect and ensure that trust lands and 
resources are protected when processing ROWs or leases. The BIA 
regulatory requirements for Indian landowner consent, determination of 
fair market value, surveys, and posting of a bond, among other 
requirements inherent in the ROW or lease process protect trust land 
and resources and afford the Indian landowners an opportunity to agree 
or disagree to the proposed use.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. John Hoeven to 
       Bureau of Indian Affairs, U.S. Department of the Interior
    Question 1. Can the Department of the Interior identify other 
tribes who may be similarly impacted by the Non-Intercourse Act?
    Answer. Because this is an issue affecting tribally owned lands 
that are not held in trust or restricted fee, the Department does not 
keep records of title or transfer of ownership for such lands. However, 
it is an issue of interpretation that originates from outside the 
federal government, therefore it is fair to conclude that any tribe 
lacking specific legislation regarding the Non-Intercourse Act could be 
similarly impacted.

    Question 2. The Department of the Interior's written testimony 
supports a more general fix to the Non-Intercourse Act. Can the 
Department provide examples of legislative language that would broadly 
address the issue?
    Answer. Should a standalone bill be proposed to more broadly 
address the issue, we would recommend that such proposed legislation 
include, at a minimum, language similar to the Acts referenced in the 
question above. We would also recommend that the legislation 
specifically define the Indian tribal entities to which it applies. We 
would further recommend that such legislation should only apply to 
interests in real property that is not either: (1) held in trust by the 
United States for the benefit of such Indian tribal entity, or (2) held 
in restricted fee status for the benefit of such Indian tribal entity.
                                 ______
                                 

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

            Written Questions Submitted by Hon. Tom Udall to
                        Hon. Timothy Nuvangyaoma
    Question 1. The Bridging the Tribal Digital Divide Act would 
establish a Tribal Deployment Advisory Committee for Tribal leaders to 
make recommendations to Congress on how to improve the deployment of 
broadband services. The idea behind the Advisory Committee is to 
improve how Congress learns about broadband needs in Tribal 
communities, and to act on them through legislation. Do you believe 
establishment of this advisory committee would help the Hopi Tribe 
address existing obstacles to reliable broadband service? If so, how?

    Question 2. As mentioned at the hearing, the COVID-19 pandemic has 
revealed a number of disparities facing Tribes.

    a. What barriers has lack of universal broadband access posed for 
Pueblos as they attempt to respond to the COVID-19 pandemic?

    b. Would the Bridging the Tribal Digital Divide Act help address 
any of those barriers you mentioned in response to question (2)(a)? 
And, if so, how?

    I am deeply concerned by reports that IHS may have been under-
prepared to respond to an active public health emergency caused by an 
infectious disease at the start of the COVID-19 pandemic, including 
lacking comprehensive public health emergency protocols and standard 
practices in place.

    c. Do you believe your Tribe was able to easily navigate the IHS 
and the federal government's COVID-19 response structure in the early 
days of the pandemic? Or, were Hopi's response and mitigation efforts 
negatively impacted by disorganization within and among federal 
agencies?

    d. Do you have any recommendations for other actions IHS or other 
federal agencies could take to prepare for a more efficient response to 
public health emergency in the future?

    Question 3. IHS Director Weahkee's testimony discusses the mental 
and behavioral health impacts of the COVID-19 pandemic on Native 
communities and mentions that IHS has seen an ``influx'' of new 
patients seeking care for these types of issues.

    a. Has the Hopi Tribe seen a similar increase in need for mental 
and behavioral health services during this pandemic?

    b. Do you think your Tribe currently has the resources it needs to 
meet that increased demand?

    c. Do you believe Tribes would benefit from access to flexible 
behavioral health funding proposed by S.3126, the Native Behavioral 
Health Access Improvement Act?