[Senate Hearing 116-419]
[From the U.S. Government Publishing Office]




 
     DEPARTMENT OF THE INTERIOR, ENVIRONMENT AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2020

                              ----------                              


                         WEDNESDAY, MAY 1, 2019

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.

    The subcommittee met at 9:38 a.m., in room SD-124, Dirksen 
Senate Office Building, Hon. Lisa Murkowski (Chairman) 
presiding.
    Present: Senators Murkowski, Hyde-Smith, Daines, Udall, 
Tester, and Van Hollen.

                         INDIAN HEALTH SERVICE

              OPENING STATEMENT OF SENATOR LISA MURKOWSKI

    Senator Murkowski. Good morning, everyone. The subcommittee 
will come to order.
    Today we are examining the fiscal year 2020 budget request 
for the Indian Health Service. I would like to thank Rear 
Admiral Michael Weahkee, who is the Principal Deputy Director, 
for joining us here this morning. The head of IHS is a pretty 
tough job.
    Accompanying Rear Admiral Weahkee is Rear Admiral Michael 
Toedt, who is the Chief Medical Officer. Good to have you here. 
We have Ann Church, the Acting Director for the Office of 
Finance and Accounting, and Gary Hartz. Gary, you have been 
before this subcommittee for so many years running. How many 
years? A long time. Well, we appreciate that service. Gary is 
the Director of the Office of Environmental Health and 
Engineering. Thank you all for being here today.
    The IHS budget request for fiscal year 2020 is $6 billion 
for programs within this subcommittee's jurisdiction. This is 
an increase of $140 million, or a 2.4 percent increase above 
the fiscal year 2019 enacted.
    There are some bright spots in this year's budget proposal 
to take steps to address important health concerns in our 
Native American and Alaska Native communities, and a few other 
areas where we need some additional information that we hope to 
receive today.
    The IHS budget proposes $25 million to focus on hepatitis C 
and HIV, $25 million to support electronic health record 
modernization, fully funds contract support costs, and includes 
funding for the staffing packages for newly constructed 
healthcare facilities. I am going to ask about the Yakutat 
facility on that as well. There is also a slight $1.2 million 
increase for sanitation facilities construction. This is 
important for us in the State of Alaska.
    While there are important increases in this budget and the 
Agency's budget has less reductions than others that we have 
seen in this subcommittee's jurisdiction, I am concerned about 
the proposed $78 million decrease for healthcare facilities 
when we know that the need for construction across Indian 
Country is estimated at $14.5 billion. I also want to make sure 
that we are using our resources efficiently and effectively to 
address the opioid epidemic. This has been especially acute for 
American Indians and Alaska Natives, and we need to make the 
right investments to help remove the Agency from the GAO high-
risk list. I will explore these issues in more detail when we 
move to questions.
    Before we do that, there is one issue that I would like to 
raise. Unfortunately we hear from media, more notably the 
``Wall Street Journal,'' about matters that have happened 
within the Agency, and we learn about them and we raise them in 
these budget hearings. It is not a good thing when it seems 
like it is almost an annual reference point for us. The most 
recent investigative report does not involve the Great Plains, 
as we have discussed in previous hearings, but is one that 
revealed how the Agency mishandled and routinely transferred a 
now convicted pedophile, Dr. Stanley Patrick Weber. Quite 
frankly, there are just not enough words to describe the anger, 
the disappointment, and the empathy for the victims.
    I am hoping to find out today exactly what is being done by 
the Health and Human Services Office of Inspector General, the 
White House task force, and IHS to address this intolerable 
situation. I want to go on record that I am requesting any and 
all policy requirements that come out of the ongoing 
investigations. I think we recognize that our number one 
priority around here should be protecting people, especially 
our children, and this should come before anything else. So I 
want to make sure that we are taking steps to ensure that we 
never see situations like this again.
    So, Admiral Weahkee, I look forward to your testimony.
    I am now going to turn to Senator Udall, and then we will 
open it up. Senator Udall.

                     STATEMENT OF SENATOR TOM UDALL

    Senator Udall. Thank you, Madam Chairman.
    I am pleased to join Chairman Murkowski in conducting this 
hearing on the fiscal year 2020 budget for the Indian Health 
Service.
    I would like to welcome back Rear Admiral Michael Weahkee 
before the subcommittee this morning. Thank you for appearing 
before us, and thank you for sharing the Service's budget 
priorities. And I see you are joined by Rear Admiral Michael 
Toedt, the Chief Medical Officer; Rear Admiral Gary Hartz, 
Director of the Office of Environmental Health and Engineering; 
and Ms. Ann Church, Acting Chief Financial Officer. Welcome to 
all of you.
    I am proud this subcommittee has made major investments in 
Tribal healthcare over the past several years, including 
increasing the Indian Health Service budget by 25 percent since 
fiscal year 2015. And a lot of that credit is due to the 
leadership of our Chairman, Senator Murkowski, and I have been 
honored to fight for funding alongside her as Ranking Member of 
this subcommittee. I am proud of our funding accomplishments, 
but clearly there is more work to do in fiscal year 2020.
    With that in mind, I must note my concern that we are 
beginning work on fiscal year 2020 appropriations bills without 
the benefit of a budget agreement. While I am confident that 
Congress will ultimately negotiate a budget deal to prevent a 
devastating repeat of sequestration, it is imperative we put a 
budget deal in place that provides increased top line spending 
levels. Without a deal in place, we cannot move forward with 
funding essential agencies like the Indian Health Service and 
ensure that we continue to make good on our Nation's trust and 
treaty obligations to Native Americans. And that is all the 
more ironic because, while the overall Trump budget is lacking, 
the budget request for the Indian Health Service actually puts 
forward important investments that we ought to enact into law.
    And I am happy to see a better budget request this year 
than we have seen in recent years from this administration. The 
request fully funds contract support costs and staffing for 
newly constructed healthcare facilities, expands clinical care 
programs and access to substance abuse and mental health 
treatment, proposes beginning a new community health aide 
program to train healthcare paraprofessionals in the Lower 48 
States, just as the IHS currently does in Alaska, and asks for 
resources to continue integrating newly federally recognized 
Tribes into the Indian healthcare system and for the 
administration's initiative to reduce HIV and hepatitis C 
infections, two preventable and treatable diseases that 
disproportionately impact Native populations.
    The budget request also includes $25 million to initiate 
replacement of the Service's electronic health record system, a 
down payment on what is likely to be a multi-billion dollar 
investment in a long overdue project Tribes and Congress have 
been concerned about for years.
    These proposals, combined with the 2 percent overall for 
the Agency and a 4 percent increase for medical services 
programs, are certainly a step in the right direction.
    But the overall budget still falls short of meaningfully 
addressing the healthcare needs of Indian Country. And I am 
concerned by some of the tradeoffs, cuts, and false choices 
that are proposed in the budget. Funding for health education 
is eliminated completely, and the urban Indian health programs 
are cut by 5 percent.
    Line item construction is slashed by one-third, a retreat 
from important investments that this subcommittee has made over 
the last few years. I reject the notion that cutting 
construction makes any kind of sense when some of these 
projects, like the replacement of the Gallup Indian Medical 
Center in New Mexico, has been on the priority list for nearly 
3 decades. There are more than $2 billion worth of construction 
projects in total on the current priority list and billions 
more in additional facility needs once those are completed.
    I am also disappointed that the budget does not continue 
the $10 million for Tribal grants to combat opioid addiction 
that were funded by this subcommittee in fiscal year 2019.
    And although some new funding is devoted to recruitment and 
retention initiatives, like special pay authorities and housing 
subsidies, the budget request cuts funding for scholarship and 
loan repayment programs by nearly one-quarter, or $14 million, 
even though the Service's inability to recruit and retain 
healthcare professionals is a major reason why the Agency has 
been part of the GAO high-risk list for the past several years.
    Another administration proposal related to recruitment and 
retention in the budget asks to expand the use of Title 38 
authorities used by the Veterans Administration at the IHS. In 
previous years, this subcommittee has encouraged you to make 
use of incentive programs like those found in Title 38. But 
this year's legislative request proposes access to a much 
broader set of authorities. We need to fully understand what 
impact these authorities would have on the workplace rights of 
employees. God bless you, Mr. Hartz.
    The administration's request would also cut funding for the 
community health representatives program by 60 percent, in part 
to help pay for the proposal to establish the new community 
health aide program. Tribes in New Mexico and across the 
country use this program to provide frontline health education 
and wellness services and to transport patients in my State to 
doctors' appointments that can be hundreds of miles away from 
Tribal members' homes. We should not cut the community health 
representative program to fund the health aide program when 
both programs fill different but important gaps in healthcare 
service in Indian Country.
    There are other challenges that the Service faces that we 
need to address. I want to hear from the Service about what 
steps the Agency has taken to protect Indian Country from 
horrifying misconduct like that of Stanley Patrick Weber, who 
was convicted of assaulting young patients over the course of 
several decades while serving as an IHS pediatrician. And I 
join the Chairman in her statements as to how disappointed and 
discouraged she is with what happened there. As part of that, I 
expect the Service to discuss the steps it is taking to improve 
its employee screening and credentialing system and to ensure 
that any workplace incidents are properly reported and 
documented. Employees with histories of egregious misconduct 
must not slip through the cracks.
    And finally, given the recent partial government shutdown 
and potential for ongoing uncertainty during the fiscal year 
2020 budget cycle, I look forward to having the opportunity to 
discuss advanced appropriations with you, Admiral Weahkee. Even 
though a few months have passed, I want to make sure that 
Indian Country knows that we have not forgotten the hardships 
caused by the government shutdown earlier this year. I saw what 
happened in New Mexico, and I heard from Tribal members across 
the country about the terrible price of the 35-day lapse in 
funding, whether it was medical providers working without pay, 
urban organizations forced to cut services and even close their 
doors or Tribes struggling to keep ambulance services running. 
The impacts of the shutdown were far-reaching and caused 
enormous suffering. I want to make sure that Tribes never have 
to worry again whether basic healthcare services will be 
provided in the event of a shutdown.
    And that is why I was proud to introduce legislation, the 
Indian Programs Advanced Appropriations Act, that would provide 
funding certainty for the Indian Health Service and the Bureau 
of Indian Affairs by allowing their budgets to be funded a year 
in advance. I know that my colleague, Senator Murkowski, has 
sponsored similar legislation in past Congresses and has been a 
leader on this issue. I am hoping that we can work together on 
a bipartisan basis to pass legislation to authorize advance 
appropriations, and I look forward to working together on this 
critical goal.
    Admiral Weahkee, I look forward to hearing your testimony.
    Thank you very much, Madam Chairman. Sorry for going a 
little longer but we have a lot before us here today.
    Senator Murkowski. We do and I appreciate that. I also 
appreciate your leadership on some of these legislative 
initiatives that will supplement or complement so much of what 
we are trying to do here within the subcommittee.
    With that, Rear Admiral Weahkee, we welcome any comments 
that you would share before the subcommittee and that of any of 
your colleagues that are at the table with you.
STATEMENT OF REAR ADMIRAL MICHAEL D. WEAHKEE, PRINCIPAL 
            DEPUTY DIRECTOR
ACCOMPANIED BY:
        REAR ADMIRAL MICHAEL TOEDT, M.D., CHIEF MEDICAL OFFICER
        REAR ADMIRAL GARY J. HARTZ, DIRECTOR, OFFICE OF ENVIRONMENTAL 
            HEALTH AND ENGINEERING
        ANN CHURCH, ACTING DIRECTOR, OFFICE OF FINANCE AND ACCOUNTING
    Admiral Weahkee. Thank you and good morning, Chairman 
Murkowski, Ranking Member Udall, and Members of the 
subcommittee.
    I am Rear Admiral Michael Weahkee, Principal Deputy 
Director of the Indian Health Service and a member of the Zuni 
Tribe out of New Mexico and Arizona.
    I want to thank you for your support and for the 
opportunity to testify on the President's budget for fiscal 
year 2020.
    The budget advances our Indian Health Service mission to 
raise the physical, mental, social, and spiritual health of 
American Indians and Alaska Natives to the highest level.
    The President's fiscal year 2020 budget proposes $5.9 
billion for the Indian Health Service, and this includes $25 
million to eliminate hepatitis C and to end the HIV epidemic in 
Indian Country. With the resources and tools that we have 
available to us today, we have an unprecedented opportunity to 
make a real difference in reducing hepatitis and HIV 
infections.
    The budget also proposes $25 million to begin transitioning 
to a new and modernized replacement of IHS's electronic health 
record, the Resource and Patient Management System, or RPMS. 
Our current aging system exists as more than 400 separate 
instances that are maintained at individual locations 
throughout the country. Replacing this antiquated system with a 
single modern national system would enable IHS to enhance 
medical quality, maximize the time that our doctors, our 
nurses, and other healthcare professionals have to provide 
direct patient care and increase the security of our patients' 
medical records.
    We have also requested $20 million to launch a national 
expansion of our paraprofessional program, the Community Health 
Aide Program. This program of certified health, behavioral 
health, and dental health aides will enable us to fill critical 
care gaps throughout Indian Country. The program has been used 
for decades in Alaska to great success, and I believe its 
expansion into the rest of the country would be extremely 
beneficial.
    Our budget proposes an additional $8 million to recruit and 
retain medical professionals which are critical to addressing 
gaps in care.
    To complement the increase, legislative changes are also 
proposed to provide tax exemption for our Indian Health Service 
scholarship and loan repayment programs, allowing us to provide 
$7 million in additional awards and provide discretionary use 
of all Title 38 personnel authorities, which would provide 
parity with other Federal healthcare systems like the VA.
    The budget prioritizes direct clinical healthcare services 
and maintains commitments for staffing of newly constructed 
healthcare facilities, which required some difficult choices, 
including a reduction in our facilities investments, phasing 
out of the funding for our community health representatives 
program, and two proposed program discontinuations for our 
health education line and for our Tribal management grants.
    The budget will enable us to implement our new IHS 
strategic plan for fiscal years 2019 to 2023, which includes 
three overarching goals to increase access to care, improve the 
quality of the care that our system provides, and to improve 
our management and operations of the Agency. Our plan is the 
result of robust collaboration with our Tribes and with our 
urban Indian organization partners over an 18-month 
consultation and confer period, and it is the first strategic 
plan that the Agency has had in almost a decade.
    The Indian Health Service has also realized significant 
improvements to quality of care, including the establishment of 
a new Office of Quality at Indian Health Service headquarters.
    We implemented a new standardized provider credentialing 
and privileging software system agency-wide that now includes 
the files for all licensed independent practitioners working 
either directly as Federal employees or as contractors.
    And we have recently awarded a new adverse events reporting 
system that replaces an older legacy system known as WebCident.
    I am also happy to report that since October of 2018, we 
have had more than 16 of our IHS facilities undergo surveys, 
all of which were successful, and with the support of the new 
Office of Quality, we expect continued improvement and 
enhancement of quality of care for American Indians and Alaska 
Natives served across the Nation.
    Regarding the recent media reports on patient abuse by a 
former Indian Health Service employee, I recently met with the 
Tribal leaders from both of the impacted Tribal communities to 
discuss the steps that the Indian Health Service has taken to 
ensure the protection of patients at all Indian Health Service 
facilities. I expressed my personal sincere regret that 
children were victimized by those who were entrusted to care 
for them, and I made it absolutely clear that IHS will not 
tolerate sexual assault or abuse in any of our facilities. Our 
workforce understands how serious this issue is, and I am proud 
of the efforts and the commitments of our staff for the 
progress we have made and we will continue to press forward on 
this issue.
    The IHS remains firmly committed to improving quality, 
safety, and access to care for American Indians and Alaska 
Natives and we appreciate all of your efforts in helping us to 
provide the best possible healthcare to the people that we 
serve.
    With that, Chairman, I am happy to answer any questions 
that the subcommittee may have.

    [The statement follows:]
         Prepared Statement of Rear Admiral Michael D. Weahkee
    Good morning Chairman Murkowski, Ranking Member Udall and Members 
of the subcommittee. I am Rear Admiral Michael Weahkee, Principal 
Deputy Director of the Indian Health Service (IHS). Thank you for your 
support and for the opportunity to testify on the President's fiscal 
year 2020 budget. The budget advances our mission to raise the 
physical, mental, social, and spiritual health of American Indians and 
Alaska Natives (AI/ANs) to the highest level. As an agency within the 
Department of Health and Human Services, the IHS provides Federal 
health services to approximately 2.6 million AI/AN from 573 federally 
recognized Tribes in 37 States, through a network of over 605 
hospitals, clinics and health stations.
    The President's fiscal year 2020 budget proposes $5.9 billion in 
total for IHS, which is $392 million above the fiscal year 2019 
annualized continuing resolution funding level, or $140 million above 
the fiscal year 2019 Consolidated Appropriations Act. The President's 
budget grows the resources available to meet the nation's commitment to 
AI/AN in a constrained budget environment, reflecting a strong 
commitment to Indian Country. Specifically, the budget prioritizes 
direct clinical healthcare, providing a 7 percent increase and makes 
crucial investments in the fight against Hepatitis C and HIV/AIDS, 
launches a national expansion of our health paraprofessional program 
and provides resources for planning and key infrastructure improvements 
for a replacement electronic health record system (EHR). The budget 
also proposes to extend our successful Special Diabetes Program for 
Indians (SDPI) through fiscal year 2021, at $150 million per year.
    The President's budget provides $25 million to expand partnerships 
between IHS and Native communities to eliminate Hepatitis C and end the 
HIV epidemic in Indian Country. With the resources and tools we have 
available today, we have an unprecedented opportunity to make a real 
difference in reducing hepatitis and HIV transmission. I'm pleased that 
IHS is taking part in the ``Ending the HIV Epidemic: A Plan for 
America'' initiative.
    The budget also provides $25 million to begin transition to a new 
and modernized replacement of IHS's electronic health record system, 
Resource and Patient Management System (RPMS). These resources are 
critical to allow IHS to conduct planning for this transition and 
address key infrastructure gaps necessary to implement a modern EHR. 
Our current system exists as more than 400 separate local instances 
rather than a single system, hobbling our efforts to share medical 
information efficiently, improve monitoring of medical quality, and 
recover critical third party financial resources.
    A modern system would enable IHS to enhance medical quality, 
maximize the time our doctors, nurses and other health professionals 
are providing direct patient care, and increase the security of our 
patients' medical records. I believe this transition represents an 
opportunity to meaningfully impact the care received by our patients.
    We have also requested $20 million to launch a national expansion 
of our paraprofessional program, the Community Health Aide Program 
(CHAP). This program of certified health, behavioral health, and dental 
aides will enable us to fill critical care gaps. This program has been 
used for decades in Alaska to great success and I believe its expansion 
into the rest of the country will be beneficial and an important tool 
in meeting the health needs of AI/ANs, as part of a mix of services 
determined at the local level.

    In addition to these key initiatives, our fiscal year 2020 budget 
includes:

  --$147 million to expand direct clinical health services, including 
        dental, mental health, alcohol and substance abuse services;
  --$8 million to recruit and retain medical professionals, critical to 
        addressing gaps in care;
  --$2 million to bolster the Office of Quality;
  --$11 million to fund the healthcare of six newly federally 
        recognized Tribes;
  --$98 million to fully fund staffing at four newly completed or 
        expanded healthcare facilities, including 3 joint venture 
        facilities and a youth regional treatment center;
  --$69 million to support current services, including pay costs, 
        inflation, and population growth; and
  --$855 million for Contract Support Costs, which currently aligns 
        with our estimate of those costs.

    The budget prioritizes funding for key investments in support of 
direct clinical health services, and in doing so proposes some program 
adjustments. A net reduction of $66 million in Facilities ensures 
continued priority focus on maintaining existing facilities and 
addressing continuing sanitation facilities construction projects. 
Phase out of funding for the CHR program is contemplated with a funding 
level of $24 million, as part of proposed reforms to current community-
based care. The President's budget also proposes two program 
discontinuations, including the Health Education and Tribal Management 
Grants programs, which total $23 million.
    The budget will enable us to implement our newly released Indian 
Health Service Strategic Plan for fiscal year 2019-2023. The Strategic 
Plan will improve the management and administration of the IHS and sets 
the strategic direction of the agency over the next 5 years. The 
Strategic Plan includes three goals that will guide our efforts--access 
to care, quality of care, and strengthening management and operations. 
The final plan is the result of collaboration with our Tribal and urban 
Indian organization partners who offered their feedback and expertise.
    Aligning with the IHS Strategic Plan, four legislative proposals 
are included within the budget to increase access to care by: providing 
tax exemption for IHS scholarship and loan repayment programs, 
providing discretionary use of all Title 38 personnel authorities, 
meeting loan repayment and scholarship service obligations on a half-
time basis, and providing Federal Tort Claim Act coverage for IHS 
volunteers. These proposals focus on parity with authorities provided 
to other Federal agencies providing healthcare services and seek to 
strengthen agency efforts to recruit and retain healthcare 
professionals.

    The IHS has also realized significant improvements to quality care 
for AI/ANs, including:

  --Establishing the Office of Quality as an elevated national 
        oversight component within IHS Headquarters;
  --Implementing a new standardized professional provider credentialing 
        and privileging software agency-wide for all applicants; and
  --Awarding a new contract for an adverse events reporting and 
        tracking system that replaces an older legacy system.

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

    Senator Murkowski. Thank you, Admiral. And I take it then 
that the others are standing by to answer questions and do not 
have statements. Very good.

                VILLAGE BUILT CLINICS AND 105(L) LEASES

    Let me begin with an issue that I talk about every year, 
and that is village-built clinics. As you know, we see great 
benefit from that in Alaska, but there is the issue of the 
105(l) leases. Since the Maniilaq decision a couple years ago, 
we have been trying to figure out what the impact of the costs 
that are mandated for leasing when Tribal facilities are used 
to operate IHS programs.
    The fiscal year 2019 omnibus provided $36 million to 
support both the 105 leases and the VBCs. As I understand it, 
the budget that we have in front of us does not include 
separate funding for the leases. I am trying to understand how 
we are going to address the need for village-built clinics with 
this mandate under the 105(l) leases.
    Can you update me on what you anticipate the estimate for 
105(l) costs are for this year, and what funding are you 
planning on using to support these? And is this a tradeoff 
situation here between providing clinical services and meeting 
the lease funding requirements? Walk me through where we are 
with VBC versus 105(l)s.
    Admiral Weahkee. Thank you, Chairman Murkowski.
    And this is definitely an area that we have been working on 
very closely over the last 2 years. We have had funding 
provided in the past, as you noted, for village-built clinics, 
$11 million 2 years ago. Our area director in the Alaska area, 
Mr. Chris Mandregan, held formal consultation on the use of 
those funds, and it was determined that $6 million of that $11 
million would be set aside specifically for village-built 
clinics. The other $5 million would be used for this new 
requirement to fund 105(l) leases.
    Since that time, with Congress' support, we have now got 
additional funds to address 105(l) leases. We have initiated 
Tribal consultations----
    Senator Murkowski. Where have those come from? Have those 
come from the village-built clinic account? What I am trying to 
understand is how we are meeting the needs on both accounts, 
and if you are taking from the VBC account to supplement your 
requirement under 105(l), I am going to have a little bit of 
heartburn with that. How are we distributing the funding 
between the two responsibilities that we have here?
    Admiral Weahkee. Thank you.
    We are using $5 million of that $11 million that was 
identified for village-built clinics for 105(l) leases. Many of 
the village-built clinics have pursued 105(l)----
    Senator Murkowski. Right.
    Admiral Weahkee [continuing]. As their option as opposed to 
the VBC specific money. So in that sense, the $5 million that 
has been put forward towards VBCs is being used for the same 
clinics.
    In the most recent years, we have been consulting with 
Tribes on what other funding source that we have the discretion 
to use--should we use to meet the unmet need for 105(l) leases. 
Last year, the total need grew to about $25 million by the end 
of the fiscal year.
    Senator Murkowski. Right.
    Admiral Weahkee. So we were put into a situation where we 
ended up having to pull from our inflation increases to make up 
for that gap.
    And this year, we have initiated consultation with the 
Tribes to ask again what are your recommendations on both the 
short-term and the long-term fixes to meet this need.
    Senator Murkowski. As I understand it, we can anticipate 
that that number is going to increase from year to year. If it 
was $25 million last year, what do we expect it to be in the 
next fiscal year?
    Admiral Weahkee. Thank you, Senator.
    As of today, that need has grown to $54 million. In our 
initial conversations with finance and Tribal leaders, we do 
anticipate that that number could be as high as $138 million in 
fiscal year 2020.
    Senator Murkowski. Walk me through that then. If $54 
million is the need now, how are we funding to meet that need, 
and if we know that that is effectively going to more than 
double in the following year, how are we seeing that reflected 
in the budget in the breakdown?
    Admiral Weahkee. Currently it is very difficult for us to 
assess what that dollar amount is going to be because we do not 
have any single inventory of the buildings that are owned by 
Tribes throughout the country and how many leases are going to 
come forward. So we are putting together a technical work group 
to help us come up with a methodology for identifying the out-
year costs. But at this point, we are really looking to make up 
that funding source with discretionary funding that we have 
available to us without taking money away from any existing 
annual funding agreements or from direct services.
    Senator Murkowski. I want to make sure that I understand 
where we are right now. How much will you be looking to take 
out of a discretionary account to backfill to make sure that we 
are meeting the needs within this budget?
    Admiral Weahkee. I am going to turn to my CFO to give me a 
quick count.
    Ms. Church. Currently based on our need of $54 million as 
of the end of April, we anticipate that, with the generosity of 
Congress and certainly the support of this subcommittee that 
the $36 million in total, again as Admiral Weahkee mentioned--
$6 million of that already goes on a recurring basis to the 
VBCs. So the remainder of those funds, along with----
    Senator Murkowski. So you got $5 million there.
    Ms. Church. Plus the $25 million increase. So we have a 
total of $30 million in the Tribal clinic funding line. And 
what we are looking to do is, through the Tribal consultation 
and urban confer, determine what the next steps would be. Part 
of the consultation included a proposal that we may need to use 
those inflationary dollars similar to what we did in 2018, but 
that decision has not yet been made. So you can expect that we 
will certainly be in contact with the subcommittees.
    Senator Murkowski. I guess my frustration is we had the 
same conversation last year and said we do not know what it is 
going to be the next time we come before the subcommittee for 
the ask on this, but we know for a fact that it is going to be 
more and we are going to have to start to grapple with it. We 
are now grappling with it, but it does not sound like we have 
any better funding solutions, which is concerning, and you do 
not see it wrapped into the budget when you are looking to take 
it out of some vague discretionary account.
    Know that I am very worried about this because I only see 
this number growing, and until we can figure out how we are 
going to meet this obligation, it is going to be a situation 
not unlike what we faced for years with our failure to comply 
with the obligation to fully fund contract support costs. We 
have got to get our arms around what is happening with this, 
the requirements, the obligations, and how we budget accurately 
for it.
    Senator Udall.
    Senator Udall. Thank you, Madam Chair.

                       DR. STANLEY PATRICK WEBER

    Admiral Weahkee, when you came before the Senate Indian 
Affairs Committee in March, we had the opportunity to talk to 
you about the failure of the IHS management to take action 
against and stop Dr. Stanley Patrick Weber who, as you know--
and you spoke to it in your opening statement--abused his 
position working as a pediatrician in the Indian Health Service 
facilities to prey on children for 2 decades.
    Although evidence has been uncovered by the ``Wall Street 
Journal'' that shows facility and service area managers were 
aware of the reports of Weber's egregious misconduct, the 
Service is still unable to explain why more immediate action 
was not taken when these allegations were brought forward 
multiple times, why Dr. Weber was simply moved around rather 
than face disciplinary action, and whether Agency staff have 
access to the right policies, training, and culture to make 
sure that a situation like this never happens again.
    After that hearing, you assured Members of the subcommittee 
that the Agency planned to undertake a quality assurance review 
of Dr. Weber's case to determine what systems broke down and 
you also flagged several termination actions that the Agency 
had undertaken as a result of your broader efforts to root out 
misconduct similar to Dr. Weber's.
    We asked you to provide follow-up on these issues. However, 
to date, the subcommittee has not received any follow-up from 
you on either one of these matters. I would like to renew the 
request and make sure the Appropriations Committee is also 
fully briefed.
    Has the Agency issued a contract for its formal review, and 
how long will it take to receive the results?
    Admiral Weahkee. Thank you, Vice Chairman Udall.
    I want to assure you that the Agency is moving forward full 
force on all fronts to address this issue. And the testimony I 
provided in March about both the medical quality assurance 
review, in which the finalization of a contract is imminent, we 
have solicited and gone through the full formal solicitation 
process, reviewed vendor qualifications, and we are now at the 
point where a selection should be named just any day.
    I want to point to Mr. Jonathan Merrell, who is here with 
us in the audience. He is our new Office of Quality Director. 
He will have oversight responsibility for this contract and the 
follow-up work as part of the medical quality assurance review 
oversight. And he will also be the one selecting and being the 
contract officer representative on this contract.
    So it is imminent. We cannot probably name names in a 
hearing like this, but I expect that we will be able to share 
that vendor name with you very soon.
    With regard to the personnel actions, there are a number 
that have been effected and that are still underway, some of 
them leading all the way up to termination. I am happy to 
provide more specifics for the record when we have those 
personnel actions completed.
    Senator Udall. Okay.
    Finally, your written testimony notes that IHS has 
implemented new professional standards and reporting 
requirements. Can you share the details of the actions you have 
taken with us?
    Admiral Weahkee. Thank you, sir.
    I would like to point to a couple of policies that we have 
put in place for the Agency requiring that all Indian Health 
Service employees be considered mandatory reporters. In the 
past, the Agency has only really had licensed practitioners 
who, as a result of being licensed, had a requirement to be a 
mandatory reporter.
    I mentioned in my opening statement the credentialing 
software system that we put in place that helps us to track 
provider qualifications and performance history. That 
information is now portable and viewable not only at the local 
site, which it has been historically through a paper record, 
but it is now viewable at the area office and at headquarters 
level and others who need to take a look.
    I am going to ask Dr. Toedt, who has also provided some 
Indian Health Service All emails elevating the expectation of 
all of our employees about reporting and inappropriate 
relationships, to speak a little bit about his communications 
and anything else you would like to add that I may not be 
thinking of off the top of my head here.
    Admiral Toedt. Thank you, sir.
    We have been working with the American Academy of 
Pediatrics Committee on Native American and Child Health, 
CONACH Committee, specifically on guidance for providers and 
health professionals with respect to preventing sexual abuse 
from health providers. It is completely unacceptable and will 
not be tolerated in the Indian Health Service. So we have been 
working very closely with them to develop those guidelines. 
They have been published. They are available on the IHS 
website. And now we have extended that requirement not only to 
health practitioners but to any employee aware of any 
allegations of abuse, that those be reported and they be 
reported through multiple reporting lines so that we have the 
greatest sensitivity and ability to manage those complaints, to 
investigate them, and to get to the bottom of any allegations.
    Senator Udall. Thank you, Madam Chair.
    Senator Murkowski. Senator Tester.
    Senator Tester. Thank you, Madam Chair and Ranking Member 
Udall. I appreciate you having this hearing.
    I appreciate you all being here. I appreciate the job you 
do.
    As you all know better than I, we have trust responsibility 
to the folks who are in Indian Country, our Native Americans, 
and we have to have somebody who is willing to fight for them 
and their budget. And that is in your guys' job description in 
my opinion. I have been through three different 
administrations, and I do not think any of those three 
administrations--and I want you to prove me wrong on you guys--
have fought hard enough to make sure that the budget meets the 
needs of Indians in Indian Country. Let me give you an example.

                              URBAN HEALTH

    More than 70 percent of the Native population lives in 
urban areas. More than 70 percent of our Native American 
population lives in urban areas. Yet, through this budget, 1 
percent is proposed for urban health clinics, and there is a 
cut of that 1 percent of $544 million in this budget. Tell me 
how you can justify those numbers. And from a Montana 
perspective--and they are all large land-based Tribes in 
Montana. I have been to our urban Indian clinics. They do 
incredible work, and that is no understatement. That is a fact. 
But they got no money, and you cannot do it on air. So tell me 
how this budget squares with the population in Indian Country.
    Admiral Weahkee. Thank you, Senator Tester.
    Our urban Indian programs are definitely a significant part 
of our Agency. We consider it the third leg of our stool, in 
combination with our federally operated sites and our Tribal 
operated sites. There are 41 urban Indian organizations funded 
throughout the Agency. As you noted, less than 1 percent of the 
Indian Health Service budget goes to fund those programs.
    We definitely have other sources of funds that urbans are 
able to access through competitive grant processes. There are 
also several of those programs that have sought funding through 
other parts of the Department of Health and Human Services such 
as the Health Resources and Services Administration (HRSA) 330 
funding or CDC research grants.
    Senator Tester. And those grants are not in your budget. 
They are in HHS's budget.
    Admiral Weahkee. Yes.
    Senator Tester. Okay. Keep going.
    Admiral Weahkee. We do know, in working with our urban 
Indian health program, that there are many other urban sites 
throughout the country that would benefit from having an urban 
Indian program in their metropolitan area.
    Senator Tester. Yes. So I guess the point is--and I know 
that you guys do not make the final call. I think you guys 
probably put a budget up, and it ends up on Mulvaney's desk and 
he may take the axe to it a little bit. And I may be generous 
with those comments.
    But the point here is we have trust responsibility. And if 
we want to address the issues of poverty in Indian Country, 
what is the motivation of getting off the reservation if you 
lose any healthcare benefits you have because urban Indian 
healthcare is funded at such a low level?
    Admiral Weahkee. Well, the motivation is jobs and 
educational opportunities, all the social determinants.
    Senator Tester. But you see there is a push factor back. I 
mean, if I am going to lose benefits and uproot my family, 
those are big things. All I ask you to do is take another look 
at those numbers and see if they really do meet the needs of 
folks in Indian Country.

                              RECRUITMENT

    One more question really quick, and I will do this very, 
very quickly because we went round and round about this a year 
ago. But I know for a fact that you guys are short on docs. You 
are short on nurse practitioners, all of the above. It is just 
the way it is. And it is a huge problem. It is a huge problem 
particularly in rural areas, and most of the Indian Country is 
in the rural areas.
    Does this budget meet the needs for you guys to be able to 
go out and aggressively recruit more docs and nurses in Indian 
Country?
    Admiral Weahkee. Thank you, Senator Tester.
    We have included several items in the budget that will help 
us meet that goal, including legislative requests like the 
access to Title 38 authorities, taxability on our scholarships 
and loans. We have also identified the need to expand the 
incentive programs that we already have. Housing is another big 
issue. So we have asked for quarters funding. We have a housing 
subsidy that Congress has authorized for us to be able to help 
address the lack of housing in our rural sites. So we are 
moving forward on several of these fronts. Parity with the VA 
is big. Having that Title 38 authority so we can pay more, 
incentivize better is a key ask.
    Senator Tester. So I am going to have some additional 
questions, and most of those are going to be focused around 
what is being done with IHS and VA. I know there have been some 
successes, particularly in Alaska, but I think there is some 
opportunity for both agencies to be able to maximize one 
another's ability to serve the same population.
    Did I hear you--and then I am going to go. But did I hear 
you say that you do not have any inventory of buildings within 
IHS? That was a question that Senator Murkowski asked.
    Admiral Weahkee. I will clarify that the inventory that we 
are lacking is the tribally owned buildings. So we definitely 
have an inventory of our federally owned----
    Senator Tester. So you know what you have got.
    Admiral Weahkee. We know what we have. We do not know what 
the Tribes own.
    Senator Tester. Okay, all right. Thank you very much.
    Senator Murkowski. Senator Hyde-Smith.
    Senator Hyde-Smith. Thank you, Madam Chairman.

                                  SDPI

    Under the current law, Admiral, the Special Diabetes 
Program for Indians is set to expire at the end of the 2019 
fiscal year, as we are well aware. And I have very recently 
received a letter from the Chief of the Mississippi Band of 
Choctaw Indians, Phyliss J. Anderson, outlining how truly 
important that program has been for the Mississippi Choctaws 
and for Tribes throughout the entire Nation.
    But according to her letter, nearly a quarter of the Native 
Americans living in the Nashville Indian Health Service area, 
which includes Mississippi, have diabetes. And given these 
challenges, I am glad that your budget supports extending this 
very important program to this population.
    What are some of the positive outcomes that Tribes have 
experienced because of this program? We are looking for any 
bright light for any hope, and we are sure hoping there is 
improvement. Can you share some of that with me?
    Admiral Weahkee. Thank you, Senator Hyde-Smith.
    And I am definitely going to turn to our clinical expert 
pretty quickly on this to share some of the great stories.
    I think that our Special Diabetes Program for Indians is 
one that can be pointed to with great success and the 
efficient, effective, accountable use of the funds that have 
been provided to Indian Country. We do have some great success 
stories, peer-reviewed journal articles that tout that success. 
So if Dr. Toedt does not mind sharing some of that great 
success, we appreciate it.
    Admiral Toedt. Yes. Thank you so much, Senator, for the 
question.
    There has been great success with the Special Diabetes 
Program for Indians, and it is a bright spot for the Indian 
Health Service. We have seen a 54 percent reduction in renal 
failure, kidney failure, among patients with diabetes. And that 
is the only racial or ethnic group that has had a decline in 
kidney failure in diabetes. So the special diabetes program for 
Indians is definitely a bright spot and I think a model for 
other health programs.
    And we have also seen a reduction in eye disease, which 
could lead to blindness from diabetes, and we have seen a 
reduction in new cases of diabetes. So there are definitely 
bright spots.
    There is still much work to be done. We are still a 
population that is severely disproportionately affected by 
diabetes. I worked in the Nashville area. I was the chief 
medical officer in that area prior to being Chief Medical 
Officer at headquarters, and I know that with the Eastern Band 
of Cherokee, 50 percent of their elders have diabetes. And so 
it is still very prevalent and still very much a problem, but 
we are making great success with the resources that Congress 
has provided.
    Senator Hyde-Smith. Thank you.
    Senator Murkowski. Thank you, Senator, for raising that 
very important program. We certainly support that special 
diabetes program.

                                OPIOIDS

    Let me ask about opioids. This is not unique to Indian 
Country, and we are seeing the impact of opioids throughout the 
country. But unfortunately, we look to some of the highest 
death rates from drug overdoses within Indian Country as we 
compare them to other groups.
    There was a $50 million set-aside in fiscal year 2018 and 
2019, and we provided $10 million to coordinate the 
Department's Assistant Secretary for Mental Health and 
Substance Abuse to create a special behavioral health pilot 
program in the Interior bill in fiscal year 2019.
    How is IHS coordinating with other agencies within Health 
and Human Services to ensure that our Tribes and our Tribal 
organizations and our IHS facilities are able to receive 
funding to address the opioid epidemic? If you can speak 
specifically to the special behavioral health pilot program and 
how funding for that is being awarded and the level of 
coordination that we are seeing with that program and 
utilization by Tribes and Tribal organizations.
    Admiral Weahkee. Thank you, Chairman Murkowski.
    The Indian Health Service is one component of a large HHS-
wide five-point strategy that Secretary Azar has rolled out 
under the leadership of Admiral Brett Giroir, who is our 
Assistant Secretary for Health. Within the Indian Health 
Service, Admiral Toedt is our lead, and we have a Heroin, 
Opioids and Pain Efforts Committee that was developed and leads 
many of the efforts in policy development, provider training, 
medication-assisted treatments. So I will ask Dr. Toedt to 
really give some more specifics.
    But with regard to your question on cross-agency 
collaboration, much of that cross-agency collaboration is being 
done under Admiral Giroir's leadership. We have forums where we 
come together at the Department on a regular basis to ensure 
that we are covering the various points of that five-point 
strategy and not overlapping, making the best use of the 
funding that has been provided. As an example, CDC's focus is 
really on data and surveillance; NIH on research; FDA on 
identifying alternative pain management methodologies. So 
everybody has really got their niche, and we, as a service 
agency providing direct healthcare, are really focused on 
creating best practice protocols and meeting the needs of 
patients.
    So I wanted to talk about one other example with the 
Substance Abuse and Mental Health Services Administration 
(SAMHSA). You mentioned the $50 million that was provided to 
the Substance Abuse and Mental Health Services Administration 
for Tribal opioid response grants. And we worked very closely 
with SAMHSA to help them devise a formula-based distribution 
methodology. One thing that we have heard from Tribes often is 
that they do not like competitive grants and that those who 
tend to succeed in obtaining competitive grants do so because 
they have greater capacity, they can afford a grant writer 
where other Tribes may not be able to compete at the same 
level. So competition--they would rather have the money 
directly provided without having to go through that.
    So we worked with SAMHSA to devise something similar to 
what we do with our special diabetes program and getting as 
much of that funding into Indian Country and then allowing 
communities to develop prevention, treatment, and recovery 
support programming that best meets the needs of the local 
community.
    So I will stop there and ask Dr. Toedt additional aspects 
on the opioids front.
    Senator Murkowski. Dr. Toedt, if you can speak to the 
special behavioral health pilot, if you are involved with that.
    And I am going to expand the question a little bit more. We 
are talking about opioids and the response, but I think we 
recognize that it is just not addiction to the opioids. Meth 
has reared its ugly head again, and it is decimating 
communities. How we are dealing with other substances as well, 
whether it be meth or the perennial problem back in my State? 
It all begins with alcohol.
    Admiral Toedt. Thank you, Senator Murkowski.
    Certainly I will quickly talk to what activities the Indian 
Health Service is doing, and then we will address also the 
issue about what we plan to do with the funding for the special 
behavioral health pilot program.
    So the HOPE Committee, the Heroin, Opioids and Pain Efforts 
Committee, is our lead committee focusing on heroin and 
opioids, and then our alcohol and substance abuse program is 
the lead on alcohol issues and other substances abuse.
    We do have a significant number of trainings that are 
available both live and online. We work on providing prescriber 
support so that the prescribers, the physicians, the nurse 
practitioners, the physician assistants are all aware of the 
latest evidence and trained on essential training in pain and 
addiction. And we require all of our prescribers to complete 
that training.
    We have developed guidelines for chronic non-cancer pain 
management, dental acute pain management, addressing all of 
those issues.
    With respect to treatment, we are trying to expand access, 
partnering with SAMHSA, partnering with HRSA on access for 
medication-assisted treatment therapy, and that is making sure 
that individuals have the support they need and the best 
evidence for a successful recovery.
    With respect to harm reduction, certainly addressing first 
responders, making sure they have access to naloxone, law 
enforcement, Tribal law enforcement, BIA law enforcement, and 
making sure that communities have access to safe disposal 
services as well for those substances.
    We are working to reduce maternal and perinatal substance 
exposure as well. So we have been working with the American 
College of Obstetrics and Gynecology and have recently 
published guidelines specific for American Indian and Alaska 
Native women to reduce exposure and to treat those who are 
perhaps addicted to substances. We are also working with the 
American Academy of Pediatrics on similar work on the side of 
infants who are born addicted, and that continues to be a big 
problem in Indian Country.
    And then finally we are working on improving our metrics. 
We have a great challenge in getting data that is accurate and 
responsive not only for the Federal side but for Tribes and 
supporting Tribes in their work in applying for funding. They 
have got to have the data they need to address the issue. So we 
are looking at improving our metrics and our data capabilities 
as well.

                SPECIAL BEHAVIORAL HEALTH PILOT PROGRAM

    With respect to the special behavioral health pilot 
program, we are engaging in Tribal consultation, and we want to 
make sure that we are responsive to the issues. Tribes tell us 
it is not just about opioids. It is often about 
methamphetamine. We see predominantly in Montana and Wyoming 
still a large prevalence of methamphetamine. Babies born to 
moms who are addicted to methamphetamine continues to be a big 
problem as well.
    Alcohol continues to be a huge problem in Indian Country. 
Just looking at sheer numbers, that is certainly the greatest 
substance of abuse, and 3.8 times is the number that we still 
report for liver failure death rates in American Indians and 
Alaska Natives compared with all races. So there is still a 
great concern about alcohol and its effects and deadliness in 
Indian Country.
    And then in some areas, we continue to see transition of 
patients from prescription drugs to injectable drugs, heroin, 
other substances of abuse.
    So we recognize there is variation across Indian Country 
and the approaches need to be tailored for those Tribes. So 
engaging in that Tribal consultation is extremely important to 
get the feedback and direction from Tribes on how to spend that 
money.
    Senator Murkowski. Thank you for that update.
    Senator Udall, we will defer to our colleague, Senator Van 
Hollen.
    Senator Van Hollen. Madam Chairman, thank you and the 
Ranking Member for all your work on this subcommittee.
    Thank you all for being here.

                                MEDICAID

    Admiral Weahkee, you probably will not be surprised to hear 
me ask this question because I have asked it in previous 
hearings, and that relates to the issue of the importance of 
Medicaid funding to the Indian Health Service. And as you know, 
we have had debates here in Congress over the last many years 
over proposed major cuts to Medicaid. The Affordable Care Act 
proposed elimination would have severely cut Medicaid funding, 
and even if you look at the budget that has been submitted by 
the administration this time, it calls for hundreds of billions 
of dollars of cuts to Medicaid.
    If you could just remind the subcommittee what share of 
overall healthcare expenditures in Indian Country come from 
Medicaid. I believe it is close to 70 percent.
    Admiral Weahkee. Thank you, Senator Van Hollen.
    The percentage is 68 percent of our third party resources 
are coming from Medicaid programming. Approximately $1.2 
billion of third party is collected nationally by our federally 
operated sites, and 68 percent of that number is Medicaid.
    Senator Van Hollen. Got it.
    So 2 years ago, I asked if you could provide us with an 
analysis of what impact the proposed cuts to Medicaid would 
have on the Indian Health Service. And I have the transcript 
here. You assured us on the subcommittee that we would get that 
information. The Chairman of the subcommittee asked for it at 
the same time. It has now been 2 years, and my understanding is 
we still do not have that analysis.
    So I am going to ask you again. Is that almost ready? Are 
we going to get this analysis? Because we are debating this 
every year, and the Indian health system relies more on 
Medicaid than a lot of our other public health systems in the 
country. So I think it is fair to ask you for an analysis of 
what impact this would have. I am not going to read the 
transcript. For 2 years, we have been told that we are going to 
get this information. The fact that the Chairman of the 
subcommittee asked for it on an urgent basis at the time we 
were debating the repeal of the Affordable Care Act, we asked 
for it again last year. So when are we going to get it?
    Admiral Weahkee. Thank you, Senator.
    I have seen the data. I know we have the analytic 
capabilities. There are a lot of caveats that go with that 
information. Just to give you an example, when we analyzed an 
expansion State like the State of Arizona, we actually saw a 
decline in the Medicaid numbers. It was not a result of there 
being less Medicaid money. It was actually a result of Tribal 
programs contracting. I will name a couple of the big programs 
at that time. San Carlos and Sells, the Tohono O'odham Nation, 
both contracted in that year. And so when the Tribes take over 
the programs, we no longer capture those reports. And so it 
looked like a decrease in Medicaid funding when, in fact, we 
saw at most of our Federal sites a significant increase. So 
just being able to----
    Senator Van Hollen. Admiral, if I could, that is because it 
has not been cut. Right? I mean, I am not suggesting you do not 
have adequate Medicaid funding today because the Congress did 
not support the proposal to cut Medicaid by hundreds of 
billions of dollars.
    What we are asking for is your assessment of what the 
impact of those cuts would be. Again, I am reading from 2 years 
ago where your response to my question was we will undertake 
that assessment and provide you with the information. We look 
forward to partnering with you.
    Again, the Chairman has been asking for this information. 
And I had been led to believe that maybe you were on the cusp 
of actually providing the information to the subcommittee. Is 
that not the case?
    Admiral Weahkee. I am hopeful that we are able to provide 
that information to you just as quickly as possible.
    Senator Van Hollen. Are we going to get the information?
    Admiral Weahkee. From my standpoint, yes, sir.
    Senator Van Hollen. Thank you.
    Senator Murkowski. Senator, thank you for raising the issue 
yet again. I think we recognized at the time that that question 
was asked, there was great debate on where we were with the ACA 
and that impact. And you are right. I do recall saying that 
would be very, very helpful for us at that time.
    We are no longer entangled in the immediacy of the 
discussion about the ACA, but from my perspective, coming from 
the State of Alaska, I know that we as a State are looking at 
ways that working with the Federal piece to understand how we 
can do better when it comes to providing a level of services in 
Alaska. This type of information would be helpful to us to 
understand the impact of the Medicaid payments and how it flows 
through the IHS system.
    I can appreciate that there is entanglement there, but it 
really would be helpful to get a better handle on these 
numbers. I know that we were very frustrated a couple years ago 
because we could not discern it, and we figured that there has 
to be somebody who works within the hierarchy here who can 
figure that out. I think it was a reasonable request then and I 
still think it is a reasonable request. I will back Senator Van 
Hollen in his request for a greater understanding on that.
    Admiral, yes.
    Admiral Weahkee. Thank you, Chairman Murkowski and Senator 
Van Hollen.
    I was reminded by our Chief Financial Officer that we have 
recently initiated an engagement with the Government 
Accountability Office specifically looking at the issue of 
impact of Medicaid for the Indian Health Service. So that is an 
engagement that is underway. Anything you would want to add on 
the scope?
    Ms. Church. Just in terms of that, so we do have data on 
the third party collections and what we have been able to 
collect for Federal facilities. For example, we have seen a 51 
percent increase in Medicaid collections from 2010 to 2018. And 
what we hope is through our active participation in GAO's 
current engagement on looking at the effects of the Affordable 
Care Act on health coverage and funding for American Indians 
and Alaska Natives, that we will be able to help to address 
more of these questions that you have been asking.
    So in addition to the data that we can provide on the third 
party collections State by State and looking at those trends, 
of course with the qualifiers of where we do not have access to 
Tribal collections data and there may be some other 
socioeconomic factors that contribute to those differences, but 
we hope with the GAO's study in progress that that will help 
address more of these questions.
    Senator Murkowski. When would you anticipate we should get 
that GAO report?
    Ms. Church. I know they have been working on it very 
steadily. And I think the initial anticipation was during the 
summer, but we do not control their schedule. We too are 
anxious to see the results. And I know they are working very 
hard on that.
    Senator Murkowski. I would ask that you report back to the 
subcommittee, and not a year from now when we have the next 
budget hearing, but as that report becomes available and we are 
able to review that, in conjunction with the data that you have 
collected. We will be checking back in with you in, let us just 
say, 3 months or so to see where we are because I think this 
information would be helpful.
    Senator Udall.
    Senator Udall. Thank you, Madam Chair.

                                TITLE 38

    Admiral Weahkee, I noted the Service's proposal to extend 
special personnel authorities provided to the Department of 
Veterans Affairs under Title 38 of the United States Code to 
its employees, the Service's employees. The law already allows 
the Office of Personnel Management to delegate certain 
authorities regarding pay and hours of work to the Service. And 
you are seeking a legislative change to expand IHS access to 
all Title 38 authorities, including those that govern 
collective bargaining and adverse personnel. You seem to focus 
on the Title 38 authorities' pay incentives, but IHS already 
has those.
    Given the service's longtime track record of whistleblower 
retaliation and reports of nepotism going back to the 2010 
Dorgan report, Congress needs to fully understand the Service's 
intentions before it can consider this proposal.
    Can you tell us precisely which Title 38 authorities the 
Service can and cannot access currently? Why is this 
legislation necessary when you already have many of these 
authorities?
    Admiral Weahkee. Thank you, Senator Udall.
    Related to Title 38, our major focus is on pay bands and 
incentives.
    Senator Udall. But you already have those.
    Admiral Weahkee. We have the ability to access via a very 
administratively burdensome process, and we have to submit 
individual requests that take months and sometimes years to 
develop. To give you some recent examples, we created pay bands 
for our certified registered nurse anesthetists, CRNAs. And the 
packages that our HR Office has to put together gathering the 
justification information--all of that work would be 
alleviated. Those months of work would be alleviated if we 
could just access directly the Title 38 VA pay tables.
    Senator Udall. But you said the IHS needs access to Title 
38 employee discipline authorities. Can you state why you 
believe access to these specific authorities is necessary and 
how the administration believes they will directly benefit the 
Service?
    Admiral Weahkee. Thank you, Senator.
    I think one good example is the 2-year probationary period 
that comes with Title 38. We currently have 2-year probationary 
authority in the Indian Health Service for Indian preference 
employees hired under excepted service. We do not have that 
same authority for a 2-year probationary period for clinicians 
who are hired into clinical positions. If we identify an issue 
with that provider's performance early on in the first 2 years, 
we would be able to address it much more readily.
    Another authority that comes with that Title 38 
authorization is that cases for clinical competency, clinical 
concerns would not have to go to the MSPB, the Merit Systems 
Protection Board. They could be handled within the Agency with 
the expertise of a healthcare system that understands 
healthcare operations, hospital operations. So having the 
ability to assess clinical competency by a healthcare entity as 
opposed to a Merit Systems Protection Board would be another 
good example and I think one of the reasons why the VA has that 
same authority.

                      GALLUP INDIAN MEDICAL CENTER

    Senator Udall. Now, shifting over quickly here to the 
Gallup Indian Medical Center (GIMC), I know they have gotten $2 
million in planning funds for fiscal year 2019. A replacement 
of this facility, as you know, is desperately needed, as you 
saw last year when the facility's issues contributed to the 
GIMC nearly losing its accreditation.
    I understand there have been discussions with the Navajo 
Nation about finalizing a site for the project, which is 
critical, given that the project is finally ready to start 
moving. Could you please let us know what the status of those 
discussions are and what steps IHS is taking to finally break 
ground on the facility replacement?
    Admiral Weahkee. Thank you, Senator Udall. And we 
appreciate the fact that Gallup is, after all these years, now 
close to the top of our grandfathered healthcare facility 
replacement list.
    After being here last year and sharing with you some of the 
concerns that we faced with accreditation and certification at 
that location--GIMC was built in the late 1950s, opened its 
doors in the early 1960s. So it is one of our most aged 
facilities and very much due for replacement.
    Admiral Hartz can provide us with the site selection 
reviews that have been underway. I know that I met just about a 
month ago with President Nez from Navajo Nation, and he came 
with a new proposal regarding the Gallup Indian Medical Center 
site selection. And we know that there is a lot of interest 
from the City of Gallup Mayor, the New Mexico State Governor's 
Office. We have had a lot of interest in this particular 
project. So I am going to ask Admiral Hartz if he can give the 
latest update on where we are at.
    Admiral Hartz. Thank you, Senator Udall. Good to see you 
again. We had two daughters born at GIMC. So I am very familiar 
with that facility.
    As Admiral Weahkee has indicated, this facility has been on 
the list for quite some time. We did go through an initial site 
selection evaluation in 2005. We looked at 10 sites within and 
near Gallup and from that, identified the top couple sites. 
Then more recently with President Begaye, of the Navajo Nation 
offered an alternative site, which we embarked on a couple 
years ago another site evaluation based on the site that the 
Nation was proffering.
    Based on that review, we went back and looked at the top 
three sites, added the newly recommended site, and the number 
two site in the previous evaluation became the number one site.
    And then about 4 to 6 months ago, the current president 
proffered another site. We are currently looking at the 
viability of that. We have not progressed to a formal site 
evaluation. We are looking at the viability. We are anxious to 
move forward on the construction of this much-needed facility. 
This subcommittee has given us tremendous resources to move 
forward, and all of the projects that are on the grandfathered 
list now have money in them to move them off the list. And this 
is a big project. And that planning money is in a position now 
so we can actually start thinking about what it is going to be 
regardless of the site, but we need to make that decision, and 
we are looking forward to moving this project along.
    Senator Udall. Thank you.
    Senator Murkowski. Thank you, Senator Udall.
    Senator Daines. Thank you, Chairman Murkowski and Ranking 
Member Udall.
    Admiral Weahkee, good to see you again. Thanks for coming 
today.

                         STANLEY PATRICK WEBER

    I would like to start out with Stanley Patrick Weber, a 
topic of much discussion today. As you well know, Mr. Weber was 
a former IHS pediatrician, was convicted of sexually abusing 
children on the Blackfeet Reservation in Montana. Despite 
numerous reported suspicions of Weber's inappropriate behavior, 
IHS turned a blind eye and enabled Weber to continue his 
unspeakable action for years. IHS failed to protect the 
children they were entrusted to care for. Accountability must 
be demanded.
    I applaud President Trump for creating a task force on 
protecting Native American children in the IHS system with the 
aim of investigating the systemic and institutional breakdown 
that enabled Weber to sexually abuse children for decades.
    I am also aware that the Inspector General at HHS is 
conducting a review, and an outside independent contractor is 
looking into as well. It is good to see action being taken.
    Admiral Weahkee, I know Ranking Member Udall asked for an 
update on the quality assurance review. Could you provide an 
update on the findings of the presidential task force?
    Admiral Weahkee. Thank you, Senator Daines.
    The initial review--this group has met one time, and they 
have had a form and storm meeting. We are fortunate that we do 
have one of our Indian Health Service clinicians, a 
pediatrician, who has some sexual assault background, as a 
member of this task force. She comes from our Navajo area, 
Shiprock Service Unit, and so she will be involved as a 
subject-matter expert supporting this group that has very broad 
cross-representation, Department of Justice and other 
stakeholders from the White House Office of Management and 
Budget.
    So their first meeting was really meant to scope their 
project. We anticipate that they will be taking a much bigger 
picture view of not only the situation and how the Indian 
Health Service has dealt with it, but also potentially some 
jurisdictional issues, crossover from FBI and Tribal law 
enforcement and how the Agency communicates and hands 
information back and forth between law enforcement and 
healthcare. So I anticipate that the White House review is 
going to be a much more bigger picture view. We do not have a 
lot of insight into where they are going to be and when they 
are going to be there, but we do anticipate that their review 
will be complementary to that of the Office of the Inspector 
General's and to our own medical quality assurance review.
    Senator Daines. Admiral Weahkee, thank you.
    I want to thank you for responding to my letter. It was a 
letter I sent to you back in February asking what steps can 
prevent it to ensure this never happens again, what happened 
with Stanley Weber and what steps you will be taking regarding 
accountability to prevent this systemic failure from ever 
happening again. You sent me a letter back. I received it 
yesterday. So thank you for that. I appreciate it.
    I also sent a letter in March to Secretary Azar urging him 
to take whatever action necessary within his authority to 
prevent Mr. Weber from receiving his government pension. It is 
reported to be around $100,000 per year. That is outrageous.
    I understand Weber was part of the U.S. Public Health 
Service commissioned corps, which falls under the Surgeon 
General.
    With that said, could you provide an update on IHS's and 
the Department's efforts to remove Weber's pension?
    Admiral Weahkee. Thank you, Senator Daines.
    We have been working closely with the Office of the 
Assistant Secretary for Health and the Office of the Surgeon 
General who have oversight for the commissioned corps personnel 
system. I have personally submitted a letter requesting that 
Dr. Weber's retirement pay be discontinued, and we are working 
through with legal counsel whether or not we have the authority 
to do that. Dialogue continues as we evaluate whether or not we 
have current authority or if we are going to need to seek 
legislative support to make those changes.
    Senator Daines. We will be working on the legislative 
support as well. And I want to encourage you and Secretary Azar 
to continue pursuing every possible avenue to hold Mr. Weber 
accountable and to strip Mr. Weber of his pension. It is 
shocking that a government employee can still receive a pension 
after being convicted of sexually abusing children. That is 
unacceptable, which is why I am going to be taking action, 
introduce in fact that bill today to fix this very flawed 
system. It is called the Denying Pensions to Convicted Child 
Molesters Act, and it will do exactly that. Any monster who is 
guilty of the unspeakable crimes that Stanley Patrick Weber was 
convicted of in Montana will not receive a Federal Government 
pension. A convicted pedophile should not receive 1 cent of 
taxpayer money in retirement benefits.

              MISSING AND MURDERED NATIVE WOMEN AND GIRLS

    Lastly, this Sunday will be May 5. It is an important date 
because it is the birthday of Hanna Harris. Hanna was a 21-
year-old mom, a member of the Northern Cheyenne who was 
reported missing and found murdered in July of 2013. Hanna 
would have turned 27 this year. I have introduced a resolution 
that designates May 5, Hanna's birthday, as the National Day of 
Awareness for Missing and Murdered Native Women and Girls. More 
light must be shed on this crisis of missing and murdered 
indigenous women.

                            METHAMPHETAMINES

    In fact, in Montana, part of the bigger issue with violent 
crime is the dramatic increase we are seeing in meth use. 
Indian Country is especially suffering from the influx of 
highly potent, cheap meth that comes across our southern border 
from Mexican cartels. In fact, according to a 2018 CDC report, 
reported meth use among American Indians or Alaska Natives aged 
12 and older is twice that of the overall population in the 
United States.
    Admiral Weahkee, how is IHS helping Indian Country cope 
with the devastating impacts of meth in our communities, and 
how can we work together to combat this crisis?
    Admiral Weahkee. Thank you, Senator Daines.
    First, I want to applaud you for your work on murdered and 
missing indigenous women. We know that we have heard a lot 
about what we, as a healthcare system, can and should be doing 
to help support that effort, and working with law enforcement 
and identifying solutions to that problem. So I applaud you for 
your work.
    With methamphetamine use specifically, I had the 
opportunity to tour Blackfeet Nation with Chairman Tim Davis, 
the Chairman of Blackfeet, and he drove us through his 
communities and pointed out all of the houses that have been 
shut down because they were used as meth houses and were no 
longer inhabitable. It was a large number.
    And I think that one of the major strategies that we have 
used as an agency is to provide our Tribes with the discretion 
to use their substance abuse funding as flexible as possible so 
that if money comes down--and we are talking opioids--that 
Tribes also be able to use that funding for methamphetamine or 
heroin or other issues.
    I am going to ask Dr. Toedt with methamphetamine support 
specifically, do you have some specific programming you would 
like to talk about?
    Admiral Toedt. Thank you for the question, Senator Daines.
    So certainly we agree methamphetamine continues to be a 
large problem in Indian Country, and we shared earlier about 
how in different parts of Indian Country, different conditions 
prevail. And methamphetamine certainly is of great concern in 
Montana and Wyoming, but also in other parts of the country.
    We do see great success in identifying those who need 
treatment and recovery. That is on the healthcare access side. 
But we have to do more on the prevention side as well, trying 
to prevent individuals from ever starting on meth. We have to 
do work on eliminating poverty, joblessness, homelessness, and 
the social determinants of health that lead individuals to turn 
to meth or other substances. So there is much more work to be 
done, but we have had some great successes on the treatment and 
recovery side.
    Senator Daines. Well, on the education side, I think of 
education, enforcement, and treatment, those three prongs of 
this battle. When you start hearing about 10, 11-year-old kids 
who are addicted to meth, it tells us we cannot go too far 
upstream. We have to go way upstream to grade school now 
thinking about educating these kids about the dangers of 
methamphetamines.
    And lastly, I was at a community health clinic in Montana 
last week, and they told me their meth mouth--they call it 
``meth mouth''--prevalence has actually decreased 
significantly. Now, at face value, you would say, well, that is 
good news. Well, it is not, and here is what is going on.
    Once upon a time, the meth was generated in homegrown labs 
with Drano and Sudafed and so forth. So it was that corrosive 
substance in the mouth with this lower potency meth, 25 to 35 
percent potency homegrown meth, that created meth mouth.
    Why is meth mouth decreasing significantly while meth usage 
is increasing dramatically? Because it is now Mexican cartel 
meth. It is 95 to 100 percent potent. It has a different way of 
producing the meth, and it eliminates meth mouth but it is so 
much more potent and toxic that this is the crisis that we are 
seeing right now in Montana. It is out of control.
    Thank you.
    Senator Murkowski. Thank you, Senator. It is Montana. It is 
Alaska. It is all points in between, unfortunately, and it is 
lethal, as you indicate.

                               FACILITIES

    Let me go back to some of the facilities maintenance issues 
that were raised by others previously. As you know, we have a 
$2.02 billion backlog on priority facility construction 
projects at IHS, with a further estimate of $14.5 billion to 
meet all of IHS construction needs. And yet, the healthcare 
facility construction request is $77.7 million less than what 
was provided in fiscal year 2019. I think it goes back to 
Senator Tester's question about how you address this within 
this year's budget.
    With what has been proposed, and given the extraordinary 
backlog that we face on construction projects, how do we clear 
this up with this level of funding? I worry about the backlog, 
but I also worry that if we are not able to catch up on 
backlog, this will have impact on ongoing construction projects 
as well. Where we are with the backlog issue and how this 
funding level really meets the needs?
    Admiral Weahkee. Thank you, Chairman Murkowski.
    I would definitely categorize our request for healthcare 
facility construction funding this year as one of those 
difficult choices that we had to make with rules-based 
budgeting.
    I am going to ask Admiral Hartz to speak more specifically 
about what the dollar amount that we requested means to our 
timeline and being able to meet the grandfathered list, and I 
am also going to ask him to speak to, beyond the grandfathered 
list, the other facility types that we have heard many of our 
Tribal leaders tell us that they would like to begin to 
propose, things like detoxification centers and residential 
treatment centers and specialty referral centers. So if you 
could add that as well.
    Admiral Hartz. Thank you, sir, and thank you, Chairman 
Murkowski.
    As I have previously indicated, as far as our grandfathered 
list is concerned, with the continuation of the big increase we 
got in 2018 and 2019, up to $243 million, we now have resources 
into all of the projects that are on the grandfathered list. So 
at least we have touched all of them that total that $2 
billion.
    Although we are looking at a----
    Senator Murkowski. Let me ask you about that, because we 
all know that it is one thing to say, okay, we are going to 
throw a few million dollars here to get something started on 
design, but then if you do not have funding beyond that, is 
this throwing good money at something that is not going to see 
fruition? I mean, this is my worry when you have this kind of a 
backlog and now you have put some money towards it. It is an 
ongoing project, but you are significantly delaying the 
implementation of that project if you cannot adequately fund it 
going forward.
    Admiral Hartz. Actually of that $2 billion, three projects 
account for over $1.5 billion.
    Senator Murkowski. Okay. And how far along are those three?
    Admiral Hartz. One of them has $15 million in it. We are 
just getting to the top list of the inpatient facilities. We 
put a priority on ambulatory now for a number of years. That is 
how we got to a number of the major projects in the Southwest 
and in Alaska. And with ARRA money, with other resources, we 
have been able to do that.
    But Phoenix Indian Medical Center, White River, and Gallup 
Indian Medical Center are the three big ones on the list right 
now. And of those three, two of them, Phoenix and Gallup, we 
are looking at site issues. We put the $2 million in just to 
get that--update all of the planning because they have been 
sitting there for a long time. Let us get that updated. Let us 
see what we need to have, whether it is multistory, et cetera. 
I will not go into any more details on that.
    The authorities that the committees have given us to do 
phased funding is how we have tried to progress on these 
projects. So with that money that is in the White River 
project, it is adequate to do the design and get started on 
foundations. But we would rather have the resources to be able 
to roll right into construction, but we just do not expect we 
are going to get a half a billion dollars on some of these 
projects in one shot. So we will have to do it on a phased 
approach. And that is what we have done on all these others. We 
work through phases.
    As far as the projects right now that we are looking at, 
everything is on track for Bodaway-Gap, for the Albuquerque 
projects. So we got two of them that will be going there.
    And how will we keep up at that level of $243 million? We 
have been getting what we refer to as Nonrecurring Expenses 
Fund (NEF) money, non-expensed funds, from other appropriations 
within HHS. We have gotten a sizable amount of money over the 
last few years to address not only these federally owned 
projects but also for projects of Maintenance and Improvement 
(M&I) of various types. And we are optimistic, based on what we 
have been advised, that we will be able to supplement this 
appropriation request with additional NEF monies to sustain 
hopefully that same level.
    Senator Murkowski. Let me ask you about the Alaska-specific 
projects because in the 2019 omni bill, we directed you to work 
with the State of Alaska to do an assessment of the updated 
facility needs in the State and then provide recommendations 
for alternate financing options. That report was supposed to be 
submitted 180 days after enactment of that bill. Are we going 
to be getting this report? What is the status on that?
    Admiral Hartz. I would like to say yes because whether it 
is the 5-year report or a sanitation facility report, we do 
quite well at getting our reports in on time. On that 
particular one, I am going to have to defer to the Alaska 
Native Tribal Health Consortium since they have 638'ed (Public 
Law 93-638) and compacted the entire program from the Indian 
Health Service. They and the corporations are the ones that can 
best identify what those needs are. We are available to provide 
them technical assistance as they embark on gathering that 
information. As I sit here, I am not prepared to--I do not have 
an answer for that one, Senator.
    Senator Murkowski. And that is fair. But if you can check 
on that because, again, that was a directive to IHS. I 
understand the contracting role there, but it was more than 
just identifying the needs. It was working to see if we cannot 
figure out some ways to address the financing side.

                             JOINT VENTURES

    In Alaska, joint ventures have proven to be very effective. 
We have not seen Joint Venture Construction Program (JVCP) 
awards since 2016. Are you planning on moving forward with any 
new joint venture solicitations?
    Specific to Alaska, whether or not the initial estimate 
that you have on Yakutat Tlingit project--it is in the 
administration's proposal, which I appreciate. You have the 
staffing package of $3.8 million. Is that an accurate number 
for staffing? Do you anticipate that we are going to get a 
revised estimate on that? It is really helpful to try to 
understand if we are on the money when it comes to that 
staffing package.
    So where are we with JVs and where are we with Yakutat 
Tlingit?
    Admiral Hartz. Okay. Responding to your initial question as 
far as the joint venture program, we concur with your statement 
that it is a highly popular program across Indian Country and 
it helps reduce the Federal capital investment.
    We plan to do a solicitation this fall. We put out the 
small ambulatory solicitation, and those are due at the end of 
June--for the funding received in 2019, they are due June 28. 
We did not want them out concurrently. So we will be putting it 
out probably in the last quarter of this fiscal year for the 
JV.
    And then the other one was specific to Yakutat. Right?
    Senator Murkowski. Right.
    Admiral Hartz. On Yakutat, they have recently separated 
from Southeast Alaska Regional Health Corporation, and as a 
result of that, there are some PSFAs, programs, services, 
functions, and activities, that they would like to roll into 
their new facility. So they are now in the process of 
modifying, expanding a bit of what they would provide in their 
facility. And I believe we will have to, once we get that 
information, have to assess whether that is going to equate to 
more staff or not. It is a dynamic activity that we will need 
to communicate with our CFO and others to make sure that when 
that project is finished, that the staffing is in sync with it 
being available upon completion. We are speculating that 
completion could be delayed.
    Senator Murkowski. Okay. Well, let us keep in touch on that 
one. The timing is key, but so is making sure that we are 
hitting it right in terms of what will be required.

                        SMALL AMBULATORY CLINICS

    And I was going to end my questions, but you mentioned the 
small ambulatory clinic and that you are going to go out on 
that in September. As I look at the budget, it does not include 
funds for small ambulatory clinic programs in 2020. So what is 
the status? Because in 2019, there was $15 million that we 
provided for small ambulatory clinics. It has been very, very 
helpful for us. So what is your plan with small ambulatory 
clinics funding?
    Admiral Hartz. You are correct. It is a very popular 
program. Not counting the number of applicants we will get in 
in 2019, we have got 42 awards that have occurred over a number 
of years related to that program. And as Admiral Weahkee 
indicated, there were a number of places that we had to 
prioritize in healthcare delivery that we had to make difficult 
decisions, and that was one of the places that ended up getting 
tapped.
    Senator Murkowski. Well, we will keep going here. I have a 
lot more questions. I know that Senator Udall does.
    We keep coming back to these hard decisions to make from a 
budget perspective, but when you take these programs completely 
offline, it is not as if the need goes away. It just shifts it 
to somewhere else where you have more stressors on a system, 
and that trust responsibility that I think Senator Tester 
articulated very, very clearly we fail on.
    If you were to tell me we do not need that program anymore, 
and that we have really helped address some of these issues, 
that is one thing. But we all agree that these are important 
programs, and the reason they are being utilized at the rate 
and at the level that they are is because they are so 
necessary. To hear that the funding for them is being 
completely eliminated is really hard. So that is something the 
subcommittee will consider.
    Senator Udall, I am sorry that I am well over my time. I 
may have to duck out of here to take a quick question over in 
Defense Approps, but I know that you got this.
    Senator Udall. Okay. Thank you very much, Madam Chair.

                                 INMED

    Last year, the subcommittee provided $125,000 in new 
funding to expand the Indians Into Medicine Program to an 
additional location for a total of four programs. There has 
been significant interest in expanding this program for many 
years in my home State, and we are hoping that the University 
of New Mexico will become the fourth location.
    Could you please share the status of the program expansion, 
and when will IHS select the location?
    Admiral Weahkee. Thank you, Chairman Udall.
    We definitely appreciate the addition of $195,000 into the 
2019 budget.
    We expect that we will be soliciting through the 
competitive process the opportunity for the expansion of the 
Indians Into Medicine (INMED) program to a fourth site, and I 
will have to ask Ann if she knows off the top of her head when 
we expect that solicitation on the street.
    Ms. Church. That solicitation should be coming out pretty 
soon. It will announce another 5-year competitive award cycle, 
and that would start in the fall. So current awards continue 
through September of this year--excuse me--August of this year.
    Senator Udall. Thank you very much for that answer.

                              CHAP AND CHR

    Shifting over to the Community Health Aide Program (CHAP) 
versus the Community Health Representatives Program (CHR), 
Admiral Weahkee, I want to talk about the proposal in the 
budget to cut the community health representative program by 
nearly two-thirds. Over the past year, the Congress has heard 
from Tribes in New Mexico and across the country about their 
support for the CHR program. These communities rely on the CHR 
program to provide wraparound services like health education, 
case management, and transportation to medical appointments for 
elders and other members of Tribal communities. And I 
understand that the administration heard the same message. Yet, 
here we are again with a budget request that proposes a 
significant cut to the program.
    I understand that you proposed a new community health aide 
program which would train Tribal members to provide basic 
medical, dental, and behavioral health services. And this is a 
worthy goal. But it strikes me that these activities do not 
replace the need for community health representatives.
    Do you agree that the CHR program fills a needed gap in 
services in Tribal communities and that the CHAP program you 
have requested would complement rather than replace the need 
for community health representatives?
    Admiral Weahkee. Thank you, Chairman Udall.
    I have heard from many Tribal leaders in the past 2 years 
now about their heavy reliance on their community health 
representatives for not only transportation, which I think is a 
misnomer in Indian Country that CHRs only provide 
transportation, but the vital services that they provide to 
bedridden patients, delivering medications--there is just so 
much that the CHRs do.
    I think the introduction of CHAPs is meant as a way to 
elevate community health workers, paraprofessionals who are 
extenders of physicians. That CHAP program also includes 
behavioral health aides and dental health aides. Many of our 
Tribes, especially in the Pacific Northwest and in the Great 
Lakes area and now down in the Southwest in Arizona, are really 
pushing us to advance the CHAP agenda, get a program put 
together, the policy, the training, infrastructure, the 
certification processes so that they can begin to include CHAP 
programming into their annual funding agreements because they 
see the value when we cannot recruit and retain physicians in 
some of our most rural, remote locations. We can train our own 
community health workers to fill these gaps.
    And so I think the proposal is really meant to be a 
conversation starter and to provide our Tribal communities with 
options to be able to dedicate their resources to best meet the 
needs of their local communities. We do still run into the 
challenge with our community health representatives of 
justifying workload. I have said before I think that this is as 
much a data problem that can be resolved through our IT 
modernization as it is a workload issue. There is no doubt that 
the community health representatives continue to work. We are 
just not capturing their workload in our data systems.
    Senator Udall. So there is such a need out there is what 
you are saying. And the CHRs are doing very good work. This new 
introduction which, as you have said, serves as a conversation 
piece and probably is going to provide good services too. But 
it seems to me that they complement each other and that the cut 
here to the CHR program is not one that we should be pursuing.

                        ADVANCED APPROPRIATIONS

    But let me shift over here to advance appropriations. The 
Indian Programs Advance Appropriations Act, which I have 
introduced, provides budgets for the Indian Health Service and 
other Tribal programs a year in advance so that Tribes do not 
have to live through the effects of another disastrous and 
entirely preventable government shutdown. I know that Chairman 
Murkowski has also been a leader on this issue for several 
years, and I am hoping that the two of us can work together and 
with our colleagues in the House to pass legislation and 
ultimately get these advance appropriations included in a 
budget deal.
    Admiral Weahkee, I know that the administration does not 
have an official position on legislation, but I wanted to ask 
you to confirm whether you have heard the same clamor from 
Tribes to move IHS to advance appropriations and prevent the 
impacts of another shutdown.
    Admiral Weahkee. Thank you, Senator Udall.
    And I want to confirm that I have heard robust support for 
advance appropriations from both our Tribal and our urban 
constituents, very specific stories of the heartbreak that 
occurred during the 35-day shutdown, programs having to curtail 
services, having to lay off staff, all of that information very 
recent and raw. I have also heard comparisons to the Veterans 
Health Administration where they do have advance appropriations 
and where services are not interrupted when something like a 
government shutdown or a continuing resolution occurs, that 
they are saved from those types of instances impacting 
healthcare.
    Senator Udall. Well, I think from what you have said today, 
from what I have heard, from what my staff has heard, it is 
really clear that we need to move in the direction and pass the 
Indian Programs Advance Appropriations Act. This would put the 
Indian Health Service in a much better position when we get to 
another shutdown, which we hopefully do not ever get in that 
situation again.

                        ELECTRONIC HEALTH RECORD

    I wanted to ask a little bit about electronic health 
records. Your budget includes $25 million in new funding to 
begin planning for a new electronic health record system. If 
VA's estimates are any guide, implementing a system like this 
could cost billions of dollars. Does IHS have a preliminary 
estimate on how much a system like this will cost and how long 
it will take to implement?
    Admiral Weahkee. Thank you, Senator Udall.
    We appreciate and have been using a lot of the work that 
the DoD and the Veterans Administration have done on their 
electronic health record modernization efforts to inform our 
own efforts. Mr. Mitch Thornbrugh, who is our Acting Chief 
Information Officer, is working with the Department of Health 
and Human Services Chief Technology Office on a yearlong health 
IT modernization research project, which is meant to help 
inform our future budget requests and the direction that the 
Agency would like to move in.
    As part of our 2020 request, we are also asking for some 
significant changes to the structure of our budget so that we 
create an IT line item and, at the same time, that we 
centralize our IT systems. As mentioned in my opening 
statement, we currently operate as a system with 400 separate 
instances of the Resource and Patient Management System (RPMS), 
and we would like to change that structure to a centralized 
structure where an update or a change could be made once at the 
national level and replicated throughout the Agency. So it is a 
significant undertaking that we have ahead of us. And I do 
believe that the ``B'' word, the billion word, is well in 
range, and we are learning from the VA's acquisition how much 
we should anticipate.
    I also want to note that we have had that team traveling 
out to many of our Tribal communities, those who have already 
invested in new electronic health records like NextGen or Epic 
or Cerner and pulling information from them as well on what is 
working, what is not, what can be improved, what they learned 
through their transitions. So a lot of great work, and we are 
hoping to save as much money as possible for the American 
taxpayer, but we do anticipate with the number of systems that 
we will be replacing that this will be a sizable request.
    Senator Udall. Admiral, I hope you also acknowledge that 
these investments, the investments we are making, in technology 
like this must be made without compromising increased funding 
for patient care.
    Admiral Weahkee. Yes, sir, absolutely. And we look forward 
to working with Congress on how to ensure that remains the 
case.
    Senator Udall. And who will manage the acquisition and the 
implementation of such a massive investment? How will the 
Service make sure that it avoids the problems that have plagued 
VA's transition, including lack of consistent leadership and 
difficulty decommissioning legacy IT systems?
    Admiral Weahkee. I mentioned, Senator Udall, our Chief 
Information Officer, Mr. Mitch Thornbrugh, who is leading the 
efforts on behalf of the Agency. But we are definitely not 
doing it in a vacuum. We have a lot of support from the 
Department, both the Chief Information Office and the Chief 
Technology Office, as well as a sizable contract with an entity 
that includes experts, some of whom have worked within our 
system before and have great insight into our RPMS system.
    Dr. Toedt oversees our informatics and information systems. 
Anything that you would like to add in that regard?
    Admiral Toedt. I would just like to add that we will also 
be looking at and have been in communication with VA and DoD 
about best of breed governance models. We want to make sure 
that we have got the voice of our clinicians so we can decrease 
provider burden. We want to make sure that we improve the 
revenue cycle management. So we will be highly engaged with our 
Office of Resource Access and Partnerships to make sure that we 
maximize the electronic record's ability to bill and generate 
revenue that goes back into the system and provides more 
healthcare. And we will be working with our patients to make 
sure that they have a voice and access for things that really 
are standard outside now like electronic scheduling and access 
to electronic medical records, personal health records, and 
things that we need to advance for American Indian and Alaska 
Native peoples.
    Senator Udall. Thank you for that answer.
    And you mentioned a little bit about visiting with Tribes 
on this technology issue. What will Tribal consultation on this 
new system look like? How will you integrate Tribes who have 
developed their own electronic health record system and ensure 
that the systems are interoperable?
    Admiral Weahkee. Thank you, Senator Udall.
    The modernization research project team has been traveling 
out to multiple sites. We want to visit not only those who have 
already transitioned to a new system but also those who 
continue to use RPMS to hear their feedback. We are in the 
information gathering phase. As we move forward into future 
phases of the transition, we will be robustly dialoguing with 
both our Tribal stakeholders and our urban Indian organization 
partners about how to use the resources that we request and how 
to include their systems. A big focus will be on 
interoperability with all of the systems that are being used 
throughout Indian Country, as well as interoperability with our 
VA and Department of Defense and other healthcare systems that 
we work with frequently. So much more consultation and urban 
confer to come, as we move down this 7 to 10-year transition 
period.

                           IT INFRASTRUCTURE

    Senator Udall. Admiral Weahkee, the Tribal healthcare 
system serves some of the most--you know this well--remote 
locations in the United States. So the Service is going to face 
the additional challenge of implementing its health record 
system in areas where access to broadband is limited or even 
nonexistent.
    How does IHS expect to address the lack of infrastructure 
as it modernizes its electronic health record system? Will this 
be an opportunity to help Tribes improve IT infrastructure in 
other ways?
    Admiral Weahkee. Thank you, Senator Udall.
    And broadband access has definitely been one of our major 
challenges and barriers. We have not been able to move forward 
on the use of technology like telemedicine as quickly as we 
would like to because of some of the limitations that we have 
in many areas.
    We did a lot of work last year discussing with the FCC and 
others how we can leverage resources throughout government to 
create greater broadband access. I do anticipate that our IT 
modernization is going to be broad-based and far-reaching. We 
are not just focused on replacing an electronic health record 
system within the Agency. There is so much more that is going 
to be captured under this umbrella, and expanding broadband 
access, although not specifically cited recently, is probably 
one piece of that.
    Anything you would like to add on that?
    Admiral Toedt. Certainly. We know that increasing broadband 
access lifts all ships in native communities because if we can 
get broadband access, not only for the health system, but for 
the educational system, that really helps with the entire 
community. It helps with jobs. And so broadband is a big issue 
for Indian Country.
    Specific to the electronic medical record and to our health 
IT investment, we also have to think about the actual 
investment in the computer systems themselves, the servers, the 
monitors, the keyboards, and then all the biomedical equipment 
that interfaces with those systems. We want to make sure that 
they are safe and protect access, but at the same time, let us 
make technology work for us not against us.
    Senator Udall. Yes. The other thing that I hope all the 
Members here at the table will be advocates for--you know, 
yesterday they had a meeting at the White House. They talked 
about an infrastructure package of $2 trillion. And I think it 
is really important, you know, if we start moving down that 
road, which I think there is a lot of bipartisan support, that 
all of you weigh in and let them know that part of that package 
ought to have to do with Indian Country, the things we have 
been talking about, and making sure that there are the kind of 
needs that we know that are there that are fulfilled in Indian 
Country with a significant infrastructure package.

                       RECRUITMENT AND RETENTION

    Now, talking a little bit about recruitment and retention 
incentives, last year this subcommittee was able to increase 
funding for the Indian Health Professions Program by $8 million 
for a total of $57 million. How many additional providers were 
able to receive assistance because of this increase, and how 
will this increase impact your ability to recruit?
    Admiral Weahkee. Thank you, Senator Udall.
    And I am going to ask Ms. Church to provide us the specific 
numbers. I do know it was a sizable increase in the number of 
awards that we were able to make. She has probably got the 
numbers off the top of her head here.
    Ms. Church. For 2019, we greatly appreciate that increase 
of funds. We anticipate that will give an additional 170 loan 
repayment awards during this year. We have also been working on 
our scholarships in addition. So we expect some additional 
awards there.
    Senator Udall. Great. Thank you.
    And I would like to know more about how the Service plans 
to allocate the $8 million proposed in the budget for 
recruitment and retention incentives, how many providers would 
receive increased incentives as a result of these funds. What 
types of providers would you recruit most aggressively, and 
which geographic areas would you expect to see the most impact 
from these funds?
    Ms. Church. With the $8 million that is proposed in the 
2020 budget, we were envisioning a very flexible ability to 
focus on recruitment and retention efforts. So that includes 
some funds for housing subsidies, if we were to gain authority 
for the Title 38, but then also the scholarship and loan 
repayment, and then in addition to those funds, to increase 
awards there with the tax exemption that would enable us to 
save about $7 million. So with those two investments combined, 
we think we could make over 160 additional awards, likely much 
more than that if those resources were provided.
    Senator Udall. Great.
    Admiral Weahkee, go ahead.
    Admiral Weahkee. Thank you, Senator Udall.
    I just wanted to add on the second part of your question 
there where we would focus those resources. And we have heard, 
in consultation with Tribes, an interest in expanding our 
scholarships and loans to other professions, to include 
hospital administrators. CEOs up in Alaska have recommended as 
a strategy to advance alternative pain management, we have 
heard requests to include chiropractors and acupuncturists as a 
few examples of additional professions that Tribal leaders 
would like to see us expand those programs for.
    Senator Udall. Good.

                               EQUIPMENT

    Talking about equipment now, Admiral Weahkee, I was pleased 
to see your budget include a very modest increase to the 
equipment replacement program, rather than a reduction. That 
said, we all know that IHS facilities are facing increasing 
outdated medical and diagnostic equipment, and the Agency needs 
a more aggressive funding level to keep pace with actual needs 
on the ground.
    Could you please estimate what the annual equipment 
replacement needs are at IHS facilities and talk about the 
problems that facilities face in providing adequate care given 
their existing resources?
    Admiral Weahkee. Thank you, Senator Udall.
    And Dr. Toedt reminds me all the time let us talk patient 
impacts first. The impacts to our patients, when we do not have 
access to the latest and greatest medical technology, is that 
we have delayed diagnoses, we have delayed care. When new 
students are being trained using the most recent technology and 
then come to our facilities, it is a step back for them. And so 
sometimes we lose recruitments as a result of not having the 
latest and greatest.
    I will ask Dr. Toedt, anything else you want to add on the 
clinical aspects, and then Admiral Hartz has the numbers in 
terms of our equipment replacement schedules and the needs 
there.
    Senator Udall. Admiral Toedt.
    Admiral Toedt. Thank you, Senator.
    So certainly equipment like mammography units and 
ultrasound units that impact women's health and impact 
pregnancy evaluation and reduce maternal morbidity and 
mortality by having those diagnostics are extremely important, 
making sure that we have got access to modern CT scanners and 
MRIs to assist with cancer diagnoses. Cancer continues to be 
the number two killer of American Indians and Alaska Natives, 
second only to heart disease. Making sure that we have got 
nurse call systems, central monitoring systems, ER crash carts, 
you know, I could go on and on. But obviously, the impacts are 
that we are not able to diagnose things as accurately or as 
quickly. There could be delay in care and delay in providing 
those services when we do not have that equipment.
    And then as Admiral Weahkee mentioned, the recruitment and 
retention aspect. When you are recruiting a new doctor and you 
take them on a tour of the facility, they are looking around to 
see what they are going to have to work with. And while we know 
our providers are mission-focused and they are dedicated and 
they are out there doing the best they can, they tell me every 
day that they need to have better equipment to take better care 
of our patients.
    Senator Udall. Admiral Hartz.
    Admiral Hartz. Thank you, Senator.
    As they have already talked about the medical impact, there 
are even some specific examples of what a difference it makes 
to have equipment come in. Recently in the Crow Agency service 
unit in Billings, Montana, they replaced all 12 operatories 
there in the dental suite, new chairs, new delivery units, new 
lighting, et cetera. That existing equipment was 22 years old 
and well past its life expectancy to be used as operatories for 
dental care.
    You know, with the requirements in 2015, if you have old 
radiology equipment that you are going to get reimbursed at a 
lower rate if you do not have that changed--and currently it is 
a 7 percent reduction. If it is not replaced by 2023, it is 
going to drop to 10 percent on the reimbursement rates. So not 
only does it affect the actual care and our ability to give 
quality healthcare, but it reduces even, potentially, the 
resources we would get to do more.
    So we have looked at the numbers, and it is across not just 
Federal but also the Indian Country operated facilities under 
self-determination. From a surge standpoint, we are looking at 
$100 million to $150 million, and then on a recurring basis, we 
are probably in that range of $50 million to $70 million.
    But as we have talked about our aged facilities, we have 
aged equipment, and to get new technology in there, we have got 
to get the technology that is in here (Admiral Hartz holds up a 
smartphone). And that is expensive technology. It is not just 
the broadband. It is not just all of that to get going, but it 
is the basics of the guts of this. And we have to have security 
to deal with all this medical equipment. So we are talking big 
bucks and then the recurring effort that needs to sustain that.
    Senator Udall. Admiral Weahkee, did you have anything else 
to add there?
    The points you make on the $150 million and then the 
replacement costs and everything--I mean, we are reminded here 
of this responsibility to provide healthcare to Native 
Americans. And it seems to me that--and I know you cannot get 
into--we have a budget before us, but I think it is very 
important that all of you advocate up the process and make sure 
everybody knows that we do not have the kind of equipment to 
take care of the needs that are out there.
    And I am not going to ask an additional question on that. 
The Chairman is back, and so I am going to yield back to her.
    Thank you very much for your testimony today. I really 
appreciate all your hard work on behalf of Native Americans.
    Senator Murkowski. Senator Udall, thank you for asking a 
lot of the questions. I was just given a list of all the things 
that you raised: community health aide and community health 
representatives. I appreciate that one because that is one that 
I have an interest in. Advance appropriations, electronic 
health records, recruitment and retention, and medical 
equipment. You clicked off a lot on my list.
    I just have one more, really maybe two, that I would like 
to ask. Thank you for helping out with this so ably and getting 
responses that you and I both know are important for us and for 
the subcommittee.

                                  EHR

    I wanted to ask about the electronic medical records just a 
little bit. As you know, in Alaska we have had to work through 
issues with IHS, with VA, and with DoD in order to best serve 
the needs of the people that are there. And sometimes it means 
that we work outside of the bigger, broader VA or the bigger, 
broader IHS or DoD to make sure that we are all talking on the 
same systems.
    I have to admit that when I hear that we are going to 
modernize or reform or refresh the electronic medical records, 
I worry that, once again, we are going to be in a situation 
where you have a more national system that is not going to mesh 
well with what we have tried to facilitate on the ground, 
particularly in a State where we really have had to be pretty 
innovative and creative with how our systems are talking to one 
another.
    I ask that as you are looking to ensure that the new IHS 
system is interoperable with the VA's, that we are looking 
specifically at Alaska IHS, Alaska VA and making sure that it 
works within our systems there. I am not saying that we are 
special, but sometimes we have had to carve out different 
things just because of what goes on up there. So this is kind 
of a very personal ask here to spend a little more attention to 
the Alaska-specific intersect because we think we have got a 
relatively good system going on right now between IHS and the 
VA.
    And the VA is going through its own level of overhaul. I 
was in VA Approps yesterday. So they are fixing things over 
here, and you are fixing things over here. I am just a little 
afraid as to where we are going to end up. So I am putting that 
on everyone's radar screen to make sure that we are doing this 
jointly and from my perspective, through the lens and the focus 
of Alaska. Are we good with that?

                                  CHAP

    Then on the community health aides and the community health 
representatives, this program that we developed, the CHAP 
program, is something that we are really proud of and I think 
rightly so. I am curious to know how the CHAP program expansion 
impacts is going to impact the currently funded CHAP program in 
the State? Will Alaskans see any impact from what you are doing 
nationally? Does this extension that you are proposing 
encompass certification or expansion for dental health aide 
therapists, similar to what we are using in Alaska?
    Admiral Weahkee. Thank you, Chairman Murkowski. I 
appreciate both questions.
    I want to just touch very briefly on the work that we are 
doing with the VA and assure you that we do have Alaska 
representation on our team. Stewart Ferguson is a member of our 
Information Systems Advisory Committee. He comes to us from 
Alaska. So he brings the needs and interests of many of the 
programs there to those discussions.
    And I do not know whether or not the modernization research 
team has already made their trip to Alaska or not. They are 
coming up. Dr. Toedt tells me they will be traveling to Alaska 
to look specifically at some of the systems being used. And we 
do have robust discussions with the VA on a regular basis.
    Senator Murkowski. Good. Very important. Thank you.
    Admiral Weahkee. We want to learn their lessons since they 
are a little bit ahead of us in this transition.
    With community health representatives and CHAP, I 
appreciate all of the history of the CHAP program in Alaska. It 
is touted as best practice, and many of the Tribal leaders 
there in Alaska are very proud of their program.
    I think that the impact will be, if anything, positive as 
we expand into the Lower 48 and we start to realize some 
synergies with the entire Indian healthcare system using CHAPs. 
We know that Congress has made it very clear there is to be no 
negative impact to the existing CHAP program in Alaska. So we 
have been cognizant not to burden them with the limited 
training capacity that already exists. We have definitely 
borrowed some of their experts to inform our process as we move 
forward and how they set up their training and how they set up 
their certification. We want to replicate as much as possible 
that great program. So the expansion is meant to be supportive 
and, hopefully, with a larger program, we will have more 
synergy.
    I would like to ask Dr. Toedt who oversees the CHAP Tribal 
advisory group I guess not directly, but in our structure he 
has oversight as the clinical lead. Anything you want to add on 
CHR CHAP transition and the work with Alaska?
    Admiral Toedt. Yes, thank you, Senator.
    Certainly the community health aide program has been 
demonstrated to be successful, sustainable, and culturally 
appropriate in Alaska, and we want to replicate that success 
outside of Alaska. And we will make sure that the 
implementation in the Lower 48 has no negative impact and is 
not taking from any resources that are provided to the CHAP 
program in Alaska. That is paramount for us.
    The community health aide program Tribal advisory group has 
been advising us on development of policy, and that policy is 
nearing the point of us going out with consultation for Tribal 
input. And then we intend to implement the community health 
aide program, expanding it outside of Alaska, and set up those 
governing bodies and the certification boards so that those 
processes are replicated in an area-like fashion similar to how 
it is done in Alaska.
    We are heavily drawing from the successes in Alaska, 
looking at adopting much of the training, much of the training 
materials because we really see it as best practice. And we 
recognize that it will need to be tailored and adapted for use 
in other regions where there are different health needs and 
health systems in place. But having those extenders for 
physicians through the community health aide providers, 
extenders for behavioral health for the behavioral health aide 
providers, and extenders for dental care through the dental 
health aides, including dental health aide therapists, is very 
important for us.
    Senator Murkowski. Well, it is a point of pride for us in 
Alaska that we created that program out of necessity and that 
the training that went with it was truly grassroots. You 
mentioned culturally appropriate. It was because it was 
designed by so many who lived in the village that they worked 
in and knew the needs of their community and trained themselves 
and others for that. To be able to go out to a village and 
speak with a community health aide who helped develop the 
curriculum and the training that is still in place and still 
being worked on makes us pretty proud.

                           GAO HIGH RISK LIST

    Last question very quickly. In 2017, GAO put IHS on the 
list of agencies at high risk due to vulnerabilities to fraud, 
waste, abuse, and mismanagement. When are we going to get off 
the list? Because we have addressed all of the concerns that 
were raised in that report. What is your progress report on 
that?
    Admiral Weahkee. Thank you, Senator Murkowski.
    We have just recently provided testimony about our current 
status and are working closely with the GAO to close even more 
of the open recommendations. Most recently, we reported that we 
had closed seven of the open 14 recommendations. So we were at 
the halfway point. We have since asked the GAO to close an 
additional four, which would leave us with three open. All 
three of those--let me strike that. Two of those the GAO has 
identified that they want to monitor us for an extended period 
of time to ensure that the changes that we have made are 
sustainable. And the last open recommendation is a new 
recommendation related to provider workforce and recruitment 
and retention of providers. So it is a brand new recommendation 
that they added in the most recent hearing.
    So I do anticipate that we will be getting good news from 
the GAO soon on our requested closures. Most of those were 
regarding our purchased and referred care program. We have just 
updated our PRC manual, and many of those updates were a direct 
response to the GAO's open recommendations.
    Senator Murkowski. Well, it is good to hear that you are 
moving through that list. I think we were all disappointed when 
you make that blacklist. It is not a good one. To know that you 
are moving through those various issues and resolving them is 
important on a lot of different levels. So thank you for that.
    Senator Udall.
    Senator Udall. Senator Murkowski, could I just follow up?
    What are the two extended that they want to extend on the 
monitoring? I do not think you named those. Is that correct? 
What are those two areas?
    Admiral Weahkee. I will name them quickly, if I can recall 
them.
    The first is on patient wait time standards. So they want 
to monitor to ensure that the national accountability dashboard 
for quality that we put in place and that we are monitoring all 
of our hospitals and service units on, that that monitoring 
continues and that we are improving on it.
    And, Dr. Toedt, do you remember the other ongoing 
monitoring or, better yet, our quality directive?
    Admiral Toedt. Quality oversight.
    Admiral Weahkee. Incident reporting system. We have newly 
purchased this new incident reporting system to replace 
WebCident. We have not yet fully implemented, and once that 
system is fully implemented, we expect that we will be going to 
GAO to request closure.
    Senator Udall. And, Senator Murkowski, thank you for asking 
that question.
    And I think this highlights and I hope you all take this 
high-risk status as a real opportunity. And once again, I would 
urge you, you know, with your request for budget and getting 
the President's budget out, to ask for the monies you need and 
press them to put it in there to make sure that you can use 
this opportunity being on the GAO high-risk to get these things 
done. Thank you very much.
    And thank you.
    Senator Murkowski. Thank you, Senator Udall.
    And again, these hearings that we have to review the 
budget, to go over the questions that we may have really is 
just so top line. And I know that after this, our staffs spend 
a lot of time with yours to go through more of the details.
    But I know that, Senator Udall, you and I have worked 
really hard over the years as partners on this Committee to 
make sure that we do right by the IHS budget. It is one of the 
things that I am able to point to with some degree of 
satisfaction that we have really been working to bring the 
budget to a better place so that we can work to address the 
needs, because the needs are so significant in so many 
different areas. And I know that in the other budgets that we 
are working on, we are not seeing increases. These are tougher 
budget times, and I understand that. We all understand that. 
But when you listen to some of the conditions and the 
situations that we continue to face within the IHS system or 
within BIA, I think we know that we have got a long way to go 
before we are truly doing right by our Native peoples. And so 
this will remain a priority for me. But I appreciate your 
support on this and that of the other committee members.
    You probably sit in front of us and do not necessarily 
enjoy defending a budget when you know that we need to do more 
when it comes to the facilities construction and maintenance 
accounts. You know we need to do more by the ambulatory. You 
know we need to address some of the deficiencies that we see, 
and yet, you are sent here to defend a budget. So we just ask 
you to work with us as best we can to really address the very 
significant needs that must, must, must be met.
    Anything further, Senator Udall.
    Senator Udall. I think that is good.
    Senator Murkowski. All right. With that, we stand 
adjourned. Thank you all.

                          SUBCOMMITTEE RECESS

    [Whereupon, at 11:55 a.m., Wednesday, May 1, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]