[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
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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
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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
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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.
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\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.
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\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
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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\
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\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
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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.
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\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
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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.
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\1\ USET SPF member Tribal Nations include: Alabama-Coushatta Tribe
of Texas (TX), Aroostook Band of Micmac Indians (ME), Catawba Indian
Nation (SC), Cayuga Nation (NY), Chickahominy Indian Tribe (VA),
Chickahominy Indian Tribe-Eastern Division (VA), Chitimacha Tribe of
Louisiana (LA), Coushatta Tribe of Louisiana (LA), Eastern Band of
Cherokee Indians (NC), Houlton Band of Maliseet Indians (ME), Jena Band
of Choctaw Indians (LA), Mashantucket Pequot Indian Tribe (CT), Mashpee
Wampanoag Tribe (MA), Miccosukee Tribe of Indians of Florida (FL),
Mississippi Band of Choctaw Indians (MS), Mohegan Tribe of Indians of
Connecticut (CT), Narragansett Indian Tribe (RI), Oneida Indian Nation
(NY), Pamunkey Indian Tribe (VA), Passamaquoddy Tribe at Indian
Township (ME), Passamaquoddy Tribe at Pleasant Point (ME), Penobscot
Indian Nation (ME), Poarch Band of Creek Indians (AL), Rappahannock
Tribe (VA), Saint Regis Mohawk Tribe (NY), Seminole Tribe of Florida
(FL), Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY),
Tunica-Biloxi Tribe of Louisiana (LA), and the Wampanoag Tribe of Gay
Head (Aquinnah) (MA).
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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?