[House Hearing, 117 Congress]
[From the U.S. Government Publishing Office]
THE OPIOID CRISIS IN TRIBAL COMMUNITIES
=======================================================================
OVERSIGHT HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON NATURAL RESOURCES
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTEENTH CONGRESS
SECOND SESSION
__________
Tuesday, April 5, 2022
__________
Serial No. 117-16
__________
Printed for the use of the Committee on Natural Resources
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
or
Committee address: http://naturalresources.house.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
47-278 PDF WASHINGTON : 2022
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COMMITTEE ON NATURAL RESOURCES
RAUL M. GRIJALVA, AZ, Chair
JESUS G. ``CHUY'' GARCIA, IL, Vice Chair
GREGORIO KILILI CAMACHO SABLAN, CNMI, Vice Chair, Insular Affairs
BRUCE WESTERMAN, AR, Ranking Member
Grace F. Napolitano, CA Louie Gohmert, TX
Jim Costa, CA Doug Lamborn, CO
Gregorio Kilili Camacho Sablan, Robert J. Wittman, VA
CNMI Tom McClintock, CA
Jared Huffman, CA Garret Graves, LA
Alan S. Lowenthal, CA Jody B. Hice, GA
Ruben Gallego, AZ Aumua Amata Coleman Radewagen, AS
Joe Neguse, CO Daniel Webster, FL
Mike Levin, CA Jenniffer Gonzalez-Colon, PR
Katie Porter, CA Russ Fulcher, ID
Teresa Leger Fernandez, NM Pete Stauber, MN
Melanie A. Stansbury, NM Thomas P. Tiffany, WI
Nydia M. Velazquez, NY Jerry L. Carl, AL
Diana DeGette, CO Matthew M. Rosendale, Sr., MT
Julia Brownley, CA Blake D. Moore, UT
Debbie Dingell, MI Yvette Herrell, NM
A. Donald McEachin, VA Lauren Boebert, CO
Darren Soto, FL Jay Obernolte, CA
Michael F. Q. San Nicolas, GU Cliff Bentz, OR
Jesus G. ``Chuy'' Garcia, IL Vacancy
Ed Case, HI Vacancy
Betty McCollum, MN
Steve Cohen, TN
Paul Tonko, NY
Rashida Tlaib, MI
Lori Trahan, MA
David Watkins, Staff Director
Luis Urbina, Chief Counsel
Vivian Moeglein, Republican Staff Director
http://naturalresources.house.gov
------
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
KATIE PORTER, CA, Chair
BLAKE D. MOORE, UT, Ranking Member
Nydia M. Velazquez, NY Louie Gohmert, TX
Jesus G. ``Chuy'' Garcia, IL Jody B. Hice, GA
Steve Cohen, TN Vacancy
Jared Huffman, CA Bruce Westerman, AR, ex officio
Raul M. Grijalva, AZ, ex officio
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CONTENTS
----------
Page
Hearing held on Tuesday, April 5, 2022........................... 1
Statement of Members:
Cohen, Hon. Steve, a Representative in Congress from the
State of Tennessee, prepared statement of.................. 42
Moore, Hon. Blake D., a Representative in Congress from the
State of Utah.............................................. 4
Porter, Hon. Katie, a Representative in Congress from the
State of California........................................ 2
Prepared statement of.................................... 3
Statement of Witnesses:
Cortez, Wayne, Peer Support Specialist, Riverside-San
Bernardino County Indian Health, Inc., San Jacinto,
California................................................. 21
Prepared statement of.................................... 22
Questions submitted for the record....................... 23
Del Cueto, Art, Vice President, Western Region, National
Border Patrol Council, Tucson, Arizona..................... 11
Prepared statement of.................................... 13
Hoskin, Hon. Chuck Jr., Principal Chief, Cherokee Nation,
Tahlequah, Oklahoma........................................ 6
Prepared statement of.................................... 7
Questions submitted for the record....................... 10
Rosette, Maureen, Board Member, National Council of Urban
Indian Health, Washington, DC.............................. 15
Prepared statement of.................................... 17
Questions submitted for the record....................... 20
Additional Materials Submitted for the Record:
National Indian Health Board, Statement for the Record....... 43
List of documents submitted for the record retained in the
Committee's official files................................. 45
OVERSIGHT HEARING ON ``THE OPIOID CRISIS IN TRIBAL COMMUNITIES''
----------
Tuesday, April 5, 2022
U.S. House of Representatives
Subcommittee on Oversight and Investigations
Committee on Natural Resources
Washington, DC
----------
The Subcommittee met, pursuant to notice, at 10 a.m., via
WebEx, Hon. Katie Porter [Chairwoman of the Subcommittee]
presiding.
Present: Representatives Porter, Garcia; Moore, Gohmert,
and Westerman (ex officio).
Also present: Representatives Stansbury, Rosendale, and
Gonzales.
Ms. Porter. The Subcommittee on Oversight and
Investigations will come to order. The Subcommittee is meeting
today to hear testimony on opioids in tribal communities. Under
Committee Rule 4(f), any oral opening statements at hearings
are limited to the Chair and the Ranking Minority Member or
their designees. This will allow us to hear from our witnesses
sooner and help keep Members to their schedules.
Therefore, I ask unanimous consent that all other Members'
opening statements be made part of the hearing record if they
are submitted to the Clerk by 5 p.m. today or the close of the
hearing, whichever comes first. Hearing no objection, so
ordered. Without objection, the Chair may also declare a recess
subject to the call of the Chair.
As described in the notice, statements, documents, or
motions must be submitted to the electronic repository at
[email protected]. Additionally, please note that as with
in-person hearings, Members are responsible for their own
microphones. As with our in-person meetings, Members can be
muted by staff only to avoid inadvertent background noise.
Finally, Members or witnesses experiencing technical problems
should inform Committee staff immediately.
I want to start this hearing by congratulating my
colleague, Blake Moore, on becoming the new Ranking Member of
this Subcommittee. We have been able to find common ground with
the previous Ranking Member, and I'm optimistic that we can
continue that good working relationship as we make the return
to hybrid hearings.
I would also like to take a moment to pay tribute to former
Natural Resources Chair Don Young. Representative Young was a
longtime champion on tribal issues, and his hard work
advocating for Alaskan Natives will not be forgotten.
STATEMENT OF THE HON. KATIE PORTER, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Ms. Porter. Today, we will hear from tribal leaders about
the opioid crisis in their communities. Opioids are harming
tribal communities more than any other group in our nation.
Before COVID-19, Native Americans were almost 50 percent more
likely to die of an opioid overdose than members of any other
demographic group.
During the pandemic, while American Indian and Alaskan
Natives were getting sick and dying at some of the highest
rates in our country, opioids claimed even more lives. Opioid
overdose deaths during the pandemic increased more in Native
American communities than in communities for any other racial
or ethnic group.
American Indians and Alaskan Natives have kept their
cultures and governments alive through centuries of colonial
violence, dispossession, and forced assimilation. Today,
opioids are another assault on tribal cultures, separating
families, claiming lives, and disrupting ways of life. Tribal
public services are stretched to the breaking point dealing
with the consequences of opioid addiction. First responders are
overwhelmed with drug-related calls, entire families are made
homeless by drug-related evictions, and scarce healthcare
resources are being diverted into opioid treatment and
response.
The Federal Government is legally required to deliver
health care to all tribal people. This fiduciary trust
obligation is a promise, a promise that the United States made
in hundreds of treaties with Tribal Nations in return for land
and peace. It has been codified into law, and it has been
upheld by the courts. But the U.S. Government has never
delivered on this promise.
Due to decades of underfunding, the Indian Health Service,
IHS, can spend only $3,779 per patient. This compares to the
national average of $9,409 per person. The Indian Health
Service is so underfunded, compared to other Federal healthcare
programs, that the U.S. Civil Rights Commission called it
either ``intentional discrimination or gross negligence.''
Delayed or denied health care results in American Indians
and Alaskan Natives living sicker and dying younger than other
Americans. Only one in eight American Indians who need
substance abuse treatment get it. Our failure to deliver on our
nation's promise costs lives. It costs marriages, it orphans
children, it robs communities of elders and the wisdom they
hold, and it drives families into poverty.
To address this crisis, we need to provide more resources
for tribal governments and urban Indian health organizations to
treat the opioid epidemic. The treatment and prevention
programs run by tribes are effective and cost efficient, and
they center the local needs and cultures of the tribal citizens
they serve.
Unfortunately, Federal funding for tribal health care has
been woefully insufficient. Base funding for tribal health
systems through IHS is far too restrictive. It can take years
and an Act of Congress to take simple steps such as remodeling
a facility. Grants have not been much better. Competitive
grants needlessly pit tribal governments against other tribal
governments, and the administrative costs of running grant
programs divert funds from patient care.
Congress needs to provide long-term, sustainable funding
for tribal-run treatment and prevention programs if we want to
truly combat the scourge of opioids in Native American
communities.
I am pleased that we have Mr. Wayne Cortez as a witness
testifying today. Mr. Cortez is a Peer Support Specialist at
Riverside-San Bernardino County Indian Health, and he has seen
firsthand the need for more resources to address this epidemic.
I commend his work in Southern California, and I am grateful
for his bravery in sharing his story today.
Tribal citizens across the United States are working to
heal their communities on their own terms. It is time that
Congress supported them.
[The prepared statement of Ms. Porter follows:]
Prepared Statement of the Hon. Katie Porter, a Representative in
Congress from the State of California
I would like to start by congratulating my colleague, Blake Moore,
on becoming the new Ranking Member of this Subcommittee. We have been
able to find common ground with the previous Ranking Member and I'm
optimistic we can continue that good working relationship as we make
the return to hybrid hearings.
I would also like to take a second to pay tribute to former Natural
Resources Chairman, Don Young. Representative Young was a long-time
champion of tribal issues, and his hard work advocating for Alaska
Natives will not be forgotten.
Today we will hear from tribal leaders about the opioid crisis in
their communities.
Opioids are harming tribal communities more than any other group in
our nation. Before Covid-19, Native Americans were almost 50 percent
more likely to die of an opioid overdose than members of any other
demographic group. During the pandemic, while American Indian and
Alaska Natives were getting sick and dying at some of the highest rates
in our country, opioids claimed even more lives. Opioid overdose deaths
during the pandemic increased more in Native American communities than
in communities for any other racial or ethnic group.
American Indians and Alaska Natives have kept their cultures and
governments alive through centuries of colonial violence,
dispossession, and forced assimilation. Today, opioids are another
assault on tribal cultures: separating families, claiming lives, and
disrupting ways of life. Tribal public services are stretched to the
breaking point dealing with the consequences of opioid addiction. First
responders are overwhelmed with drug-related calls, entire families are
made homeless by drug-related evictions, and scarce healthcare
resources are being diverted into opioid treatment and response.
The Federal Government is legally required to deliver healthcare to
all tribal people. This fiduciary trust obligation is a promise the
United States made in hundreds of treaties with tribal nations in
return for land and peace. It has been codified in law and upheld by
courts.
But the U.S. Government has never delivered on this promise. Due to
decades of underfunding, the Indian Health Service, IHS, can spend only
$3,779 per patient, compared to the national average of $9,409 per
person. The IHS is so underfunded compared to other Federal healthcare
programs that the U.S. Civil Rights Commission called it either
``intentional discrimination or gross negligence.''
Delayed or denied healthcare results in American Indians and Alaska
Natives ``living sicker and dying younger'' than other Americans. Only
one in eight American Indians who need substance abuse treatment get
it. Our failure to deliver on our nation's promise costs lives. It
costs marriages, orphans children, robs communities of elders and the
wisdom they hold. It drives families into poverty.
To address this crisis, we need to provide more resources for
tribal governments and urban Indian health organizations to treat the
opioid epidemic. The treatment and prevention programs run by tribes
are effective and cost-efficient, and they center the local needs and
cultures of the tribal citizens they serve.
Unfortunately, Federal funding for tribal healthcare has been
woefully insufficient. Base funding for tribal healthcare systems
through IHS is far too restrictive--it can take years and an Act of
Congress to take simple steps such as remodeling a facility. Grants
have not been much better. Competitive grants needlessly pit tribal
governments against other tribal governments, and the administrative
costs of running grant programs divert funds from patient care.
Congress needs to provide long-term, sustainable funding for tribal-run
treatment and prevention programs if we want to truly combat the
scourge of opioids in Native American communities.
I am pleased that we have Mr. Wayne Cortez as a witness testifying
today. Mr. Cortez is a Peer Support Specialist at Riverside-San
Bernardino County Indian Health. He has seen firsthand the need for
more resources to address this epidemic. I commend his work in Southern
California and I am grateful for his bravery in sharing his story
today.
Tribal citizens across the United States are working to heal their
communities on their own terms. It is time that Congress supported
them.
Before I yield to the Ranking Member, I want to apologize that I
will not be able to attend the rest of this hearing. I thank
Representative Garcia for serving as Chair in my absence.
______
Ms. Porter. Before I yield to the Ranking Member, I want to
apologize that I am not going to be able to attend the rest of
this hearing. I want to thank Representative Garcia, a champion
for just and healthy communities in every part of this country,
for serving as the Chair in my absence.
I am now prepared to yield to Ranking Member Moore for his
opening statement.
STATEMENT OF THE HON. BLAKE D. MOORE, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF UTAH
Mr. Moore. Thank you, Chair Porter. Thanks for the note of
congratulations as well, and more importantly, your comments
about the late Representative Don Young. Don Young was an
individual that cared deeply about this institution. My first
conversations with him reflected his desire for good working
order and for us to be able to find ways to solve some of
America's biggest problems. So, thank you for that note.
First, before I give my remarks, I ask unanimous consent
that Mr. Rosendale of Montana and Mr. Gonzales of Texas be
allowed to participate in today's hearing.
Ms. Porter. So ordered.
Mr. Moore. Thank you. Today's hearing on the opioid crisis
draws attention to a somber milestone for our nation.
Tragically, a record-breaking number of more than 100,000
people in the United States died of a drug overdose between
April 2020 and April 2021, in one calendar year. In other
words, approximately 274 Americans died each day from drugs
during the last 12 months.
This crisis is impacting communities across the United
States. In 2014, my home state of Utah was hit particularly
hard by the opioid pandemic. We had the fourth highest number
of overdose deaths in the nation. My state then dedicated
resources to combat the epidemic and significantly decreased
overdose deaths. I think we all can agree that treatment
options and education are important aspects of addressing the
opioid epidemic. But these steps alone are not enough.
To effectively combat this opioid crisis, we must disrupt
the supply of drugs flowing into our communities and address
the clear threats cartels pose to our neighborhoods and tribal
communities. The American Medical Association identified three
drugs--fentanyl, methamphetamine, and cocaine--as the drugs
driving the overdose epidemic. These are the very same drugs
that agents are seizing at our southern border.
In this fiscal year alone, U.S. Customs and Border
Protection reports confiscating more than 4,200 pounds of
fentanyl, more the 77,000 pounds of methamphetamine, and more
than 23,000 pounds of cocaine. These outrageous numbers should
alarm anyone who cares about this crisis.
Cartels are responsible for bringing these drugs into our
communities. The Drug Enforcement Agency's 2020 National Drug
Threat Assessment identified Mexican transnational criminal
organizations as ``the greatest drug trafficking threat to the
United States.''
Additionally, the DEA identified Mexican criminal
organizations as the primary source of illicit substance on
Indian reservations. Not only do the cartels make drugs
available on reservations, but they also exploit tribal lands
in their trafficking efforts. For example, the Tohono O'odham
Reservation, colloquially also referred to as TO Reservation,
covers about 4 percent of the southwest border. Mexican cartels
utilize the remoteness of the highways on this reservation to
traffic drugs across the border.
To combat the cartels' operations and protect American
families, we must ensure our law enforcement officers have the
support they need. In addition to the work of Border Patrol
agents, we have seen the effectiveness of targeted policing
efforts.
For example, in 2018, the Interior Department created the
Joint Opioid Task Force to address the threat opioids pose to
tribal communities. The following year, the Task Force reported
seizing more than 2,000 pounds of illegal narcotics. During one
operation, the Task Force disrupted a Mexican cartel's
smuggling efforts with the TO Nation and confiscated 30,000
fentanyl pills. Law enforcement operations for drug
interdiction, however, also necessitates increased border
security.
Mr. Art Del Cueto joins us today. He's a 19-year veteran
Border Patrol agent. From his experience patrolling the TO
Reservation, Mr. Cueto will provide the Committee with a
firsthand account of the crisis at the southern border and
associated cartel activity.
As the Department of Homeland Security prepares for yet
another surge of people attempting to cross the border, we must
call attention to all the consequences of President Biden's
decisions. One of those consequences is diverting Border Patrol
agents from their post to assist with processing of illegal
immigrants. As a result, cartels are given a prime opportunity
to evade detection and traffic illicit drugs across the border.
After exploiting our nation's open border, cartels will funnel
deadly drugs into the nation.
Until our southern border is secured and cartel activity is
curtailed, the opioid crisis will rage on. If we want to end
the crisis, we must get the people the help they need to
recover, but that is only part of it. We need to secure the
border, prevent drug smuggling, and cut off the supply killing
American communities. And with that, I yield back.
Mr. Garcia [presiding]. Thank you, Mr. Ranking Member. And
now I would like to turn to our witness panel. Before
introducing the witnesses, I will remind them that they are
encouraged to participate in the Witness Diversity Survey
created by the Congressional Office of Diversity and Inclusion.
Witnesses may refer to their hearing invitation materials for
further information.
Let me remind the witnesses that under our Committee Rules,
they must limit their oral statements to 5 minutes, but that
their entire statement will appear in the hearing record. When
you begin, the timer will start. It will turn orange when you
have 1 minute remaining and red when your time has expired.
I recommend that Members and witnesses joining remotely pin
their timer so that it remains visible. After your testimony is
complete, please remember to mute yourself to avoid any
inadvertent background noise. I will also allow the entire
panel to testify before questioning witnesses. The Chair now
recognizes the Honorable Chuck Hoskin, Jr., Principal Chief of
the Cherokee Nation.
STATEMENT OF THE HONORABLE CHUCK HOSKIN, JR., PRINCIPAL CHIEF,
CHEROKEE NATION, TAHLEQUAH, OKLAHOMA
Mr. Hoskin. Wado. Chair Porter, I know she couldn't stay,
but I appreciate her introduction. Ranking Member Moore,
Chairman Grijalva, Ranking Member Westerman, Acting Chair
Garcia, and distinguished members of this Subcommittee, we
appreciate you holding this important hearing. It is my honor
to speak with you today on behalf of the 410,000 citizens of
the great Cherokee Nation.
For two decades, the opioid epidemic has affected every
facet of our society, from our economy, to our health system,
to schools, to our families. The pharmaceutical industry
flooded the communities within our reservation with hundreds of
millions of pills. Hundreds of Cherokee citizens have died from
overdoses as a consequence. Tens of thousands more have
suffered.
In 1 year, approximately 184 million opioid pills were
distributed within the Cherokee Nation Reservation. This is
enough to supply every person living in our reservation with
153 pills each in 1 year. Cherokee Nation is less than 6
percent of Oklahoma's population, yet nearly a third of the
opioids that were distributed in the state went into our
communities, and this was no accident.
The multi-generational trauma that still lingers within our
communities made Cherokee Nation and the Cherokee people a
prime target. The pharmaceutical industry knew our history, and
it exploited it for profit. The number of opioid pills shipped
into our communities far exceeded the national average. It was
eclipsed only by the amount that was shipped into Appalachia.
Today, a Cherokee adult is more likely to die of an
overdose than to die in a car accident. Across Indian Country,
the number of overdose deaths increased by 500 percent between
1999 and 2015. Five years ago, we sued the country's largest
distributors and pharmacies for their role in targeting
Cherokee Nation and flooding our communities with prescription
opioids.
This landmark case was the first brought by a Native
American tribe. We wanted this case not only to bring justice
to our tribe, but to be a precedent for other Tribal Nations
fighting the opioid epidemic. Last year, we settled with the
main distributors--McKesson, AmerisourceBergen, and Cardinal
Health--for $75 million, to be paid over 6\1/2\ years.
Earlier this year, we settled with Johnson & Johnson for
$18 million over 2 years. Our claims against Walmart,
Walgreens, and CVS remain pending. We believe these pharmacy
chains also greatly contributed to the crisis. With these
settlements, we will increase our investments in substance use
disorder, mental health treatment, and other programs to help
our people recover.
This work is needed now more than ever as increased
isolation, health fears, and economic insecurities, brought
about by the COVID-19 pandemic, have heightened anxiety among
our people and increased the rates of self-medication.
And my administration plans to put $15 million of our
settlement dollars toward the construction of drug treatment
facilities over the next 3 years, a minimum of $15 million.
These treatment centers will help bring about transformational
change and provide some measure of justice by bringing healing
to our people, using funds from the very industry that injured
us.
But the settlement funds alone will not be enough to end
the opioid crisis. We need the Federal Government to fulfill
its trust obligation to tribes and fully fund these vital
programs to help our tribal citizens recover from addiction and
access behavioral health services.
One of the most significant gaps that we have had to face
is prevention in the workforce. Without a significant
investment in building a highly trained prevention workforce,
we will continue to just plug holes in the dam rather than
repair the issues causing the leaks. We need tribal workforce
development programs. We need non-competitive funding for
community-based prevention efforts. We need to return to our
traditional communal values so that we can address the effects
of addiction for the next generation.
We need supportive services. We need the Government of the
United States to meet its obligation. Frankly, we need the
United States to follow the lead of the Cherokee Nation as we
lead in efforts to heal our people and address this epidemic.
Wado.
[The prepared statement of Mr. Hoskin follows:]
Prepared Statement of Chuck Hoskin, Jr., Cherokee Nation Principal
Chief
Chair Porter, Ranking Member Moore, Chairman Grijalva, Ranking
Member Westerman, and distinguished members of the Subcommittee on
Oversight and Investigations:
Osiyo, and thank you for holding this important hearing. It is my
honor to speak with you today on behalf of the 410,000 citizens of
Cherokee Nation.
My predecessor, Principal Chief Bill John Baker, said in 2017,
``Tribal nations have survived disease, removal from our homelands,
termination, and other adversities, and still we prospered.
``However, I fear the opioid epidemic is emerging as the next great
challenge of our modern era.''
Chief Baker was correct. There is an epidemic of opioid abuse
sweeping through Indian Country and across the Cherokee Nation, leaving
in its wake addiction, disability, and death.
For two decades, the opioid epidemic has plagued Cherokee Nation.
It has affected every facet of our society--our economy, our health
system, our schools, and tragically, our families. Hundreds of Cherokee
Nation citizens have died from overdoses. Tens of thousands more have
suffered.
It has caused generational health issues and vast trauma. It has
put the future of our nation at risk.
The pharmaceutical industry knowingly and purposely flooded the
communities within our 7,000 square-mile reservation in northeast
Oklahoma with hundreds of millions of pills.
In one year, an estimated 845 million milligrams of opioids--
between 360-720 pills for every prescription opioid user--were
distributed within our reservation. From 2015-2016 alone, about 184
million pills were distributed--enough to supply every man, woman, and
child living on our land with 153 pills each.
Cherokee Nation makes up less than 6 percent of Oklahoma's
population, yet nearly a third of the opioids distributed in the state
went into our communities.
This was no accident. The complex, multi-generational trauma that
still lingers within our communities made Cherokee Nation, and more
broadly, Indian Country, a target for exploitation and saturation.
Traditionally, Native people have a communal sense of self. This
means decisions are made with family and community input. Through the
detrimental effects of cultural assimilation, forced removals, and
boarding schools, Native people have been stripped away from their
traditional practices. Experiencing repeated loss and trauma without a
sense of self or opportunity to grieve has left our Native people to
turn to negative ways of coping. These coping skills exist in the form
of turning to substances to help cope with feeling of depression,
anxiety, and tremendous loss.
The pharmaceutical industry knew our history, and exploited it for
profit.
The number of opioid pills shipped into communities in Oklahoma far
exceeded the national average and was eclipsed only by the amount that
was shipped into Appalachia. In 2012, the per-capita rate of
prescriptions for the nation was 81.3 prescriptions, while the per-
capita rate in Oklahoma was 127.4, and in the 14 counties of the
Cherokee Nation Reservation it was 108.78 prescriptions per capita.
The opioid oversupply has led to significant economic and social
harms to the health, safety, and welfare of the Cherokee Nation. Today,
a Cherokee Nation adult is more likely to die of an overdose than die
in a car accident. Across Indian Country the number of overdose deaths
increased by 500 percent between 1999 and 2015. According to the CDC,
Native Americans are far more likely to use--and die from--opioids than
other groups.
In 2014 we began to see the full impact of the opioid crisis. That
year we observed a spike in the number of children taken into Tribal
custody because of parental addiction. Since that time more than 1,700
Cherokee children have gone into state or Tribal custody--at least 40
percent of those cases are due to opioid use. Additionally, there has
been a staggering increase in the number of Cherokee babies born
addicted to opioids. These infants are placed in our foster system,
tearing a family apart before it even has a chance to be whole.
Five years ago, we sued the country's largest distributors and
pharmacies for their role in targeting Cherokee Nation and flooding our
communities with prescription opioids. It was a pioneering case--one of
the first opioid-related lawsuits in the United States. It was the
first case brought by a Native American tribe.
We filed our lawsuit to hold distributors and corporate pharmacies
accountable for their negligence and greed. We wanted this case to
bring justice to our tribe and to be a precedent for other communities
fighting the opioid epidemic--particularly, the hundreds of other
Native American nations that sued the opioid industry in our wake.
In 2021 we settled with McKesson, AmerisourceBergen, and Cardinal
Health for $75 million, to be paid over 6\1/2\ years. Earlier this year
we settled with Johnson & Johnson for $18 million over two years. Our
claims against Walmart, Walgreens, and CVS, however, remain pending,
and we intend to vigorously pursue those claims at trial. We believe
these pharmacy chains greatly contributed to the crisis.
With the case against the distributors resolved, we can begin the
healing process for our tribe and our citizens. With these settlements,
we will increase our investments in substance use disorder, mental
health treatment, and other programs to help our people recover. That
work is needed more than ever, as the increased isolation, health
fears, and economic insecurities brought on by the COVID-19 pandemic
have led to heightened anxiety and higher rates of self-medicating.
These funds will support our efforts to rescue Cherokees from
addiction. Deputy Chief Bryan Warner and I propose a commitment of $15
million from that settlement over the next three years to help
construct drug treatment facilities. These settlement dollars, while
important to our future, fall short of what it will take to build the
kind of comprehensive mental health and drug treatment center the
Cherokee people deserve, although it provides a solid start. It is also
a measure of justice by bringing healing to our people using funds from
the very industry that injured us. It will help bring about something
transformational--knocking down the barriers between mental health and
physical health.
But these funds alone will not nearly be enough to end the opioid
crisis.
We know how to prevent substance abuse, delinquency, teen
pregnancy, and suicide. We know what strategies need to be deployed and
we know how to use data to prioritize locations and people and we know
how to use data to measure our effectiveness both short and long term.
The bad news is that these problems are complex, multi-faceted, and
take a long time to address.
One of most significant gaps in capacity is that we do not have the
prevention workforce to address the problems facing Cherokee Nation.
Without a significant investment in building a highly trained
prevention workforce that will become embedded into our community
fabric, we will continue to plug holes in the dam rather than repair
the issues causing the leaks.
One solution would be to increase access for tribal workforce
development programs within our own tribal communities. Human capital
is our greatest asset. Building pipelines to universities to help our
own tribal citizens to become a part of the workforce will be key to
defeating the opioid and drug epidemics.
We also need our federal partners to fulfill its trust obligation
to Indian Country and fully fund programs that will allow us to
guarantee our tribal citizens access to addiction and behavioral health
services. These programs are a vital component of our efforts to heal
from this crisis, and we call on Congress to provide more in these
areas.
We need direct, non-competitive funding for community-based
prevention efforts, as this will allow us to build a community-based
prevention system that is ground in Cherokee culture. This system would
build upon the local and historical culture to identify risk factors
that contribute to substance abuse and mental health issues, while at
the same time serve as an appropriate cultural intervention that
protects and educates our youth.
Additionally, there are barriers that prevent this funding from
being as effective as it could be.
Federal funding restricts the use of grant funding for
items that would significantly improve our ability to serve
the target audiences for our programs. For example,
celebrating culture through food is a key component of
engaging youth and families. The food purchase restriction
is limiting for programs and seems almost punitive to
communities as a response for some bad actors in the past.
Restricting the ability to provide food when serving
marginalized communities who deal with trauma, poverty, and
food insecurity is counter to the values of our culture.
Program requirements often ask a tribal community to
conform to structures and systems that do not exist in
their community.
Funding periods are often too short to provide meaningful
assistance. The Tribal Opioid Response grant is large in
scope and funding amount, but the funding period is only
two years. A minimum of 5-year funding cycles would give
tribes the ability to build strong foundations for
sustainability.
Reporting requirements are complicated, frequent, and can
be duplicative. Although we understand the need for
reporting and accountability, the administrative burden
placed on grant personnel for reporting can be significant.
The reporting burden is constantly pulling the program
staff away from service delivery in order to meet all the
quarterly, biannual, and annual deadlines. Approvals for
formally submitted changes take months for approvals. A
budget revision or carryover request can take anywhere
between three and nine months to be approved, and if there
are additional questions, that cycle starts over.
Finally, expanding traditional reimbursement mechanisms to include
nontraditional services is essential to the overall success of
treatment programs. The current limited reimbursement mechanisms for
treatment of substance use disorder do not make these programs
sustainable for tribal communities. Mental illness and substance use
disorder are not short-term problems. We need long-term solutions and
financial sustainability is essential to address these problems for the
future of our people.
While more federal resources are needed, we will not wait around
for the federal government to address this crisis. Last year, we passed
legislation that will improve access our substance abuse treatment and
wellness centers. We will earmark 7 percent of the unrestricted revenue
generated by Cherokee Nation Health Services, including health
insurance claims or billings to health insurance carriers and
providers, for public health programs. This will provide an additional
$12 million in annual funding for improved access to wellness centers
and substance abuse treatment.
Our Behavioral Heath staff are already providing many free
resources for drug diversion, overdose prevention, and addiction
treatment, and are working at an exhaustive pace to serve the mental
health and addiction related needs of our people.
Our team is taking an integrated approach to address opioid use
disorder, offering both Medication Assisted Treatment and behavioral
healthcare. Additionally, our Cherokee Marshals are trained to carry
and use Narcan, a medication used to treat opioid overdose.
Native people are known for their ability to adapt and persevere in
the face of adversity. We can address challenges by enhancing and
creating services within our communities' specific to our Tribal
population. Our communities may present our people with challenges, but
they also present us with amazing strengths to build on. Having
services that are supportive and providing a healing path for those
lost in their addiction can greatly improve the lives of those
suffering and their families. We can begin our journey on the road to
recovery through introducing programs addressing trauma and recovery
through cultural enriched interventions. Returning to our traditional
way of communal values is the key to changing the effects of addiction
for our next generation of Native people.
I am very thankful that through the efforts of our Office of the
Attorney General and our Behavioral Health Department, we are not only
bringing justice for our tribe, but beginning to repair the long-term
damage caused by the flood of opioids into our communities.
Thank you for this opportunity to testify on this important topic.
Wado.
______
Questions Submitted for the Record to the Honorable Chuck Hoskin Jr.,
Principal Chief, Cherokee Nation
Questions Submitted by Representative Cohen
Question 1. What has been the rationale, if any, for the
historically low level of funding for the Indian Health Service?
Answer. Indian Health Service spending is classified as
discretionary spending, which makes it subject to the annual
appropriations process. IHS falls under the Interior appropriations
measure, and Interior, with a FY 2022 allocation of $38 billion, is one
of the smaller annual appropriations bills. Such a meager allocation
makes it difficult to achieve substantial funding increases. Moving IHS
to the mandatory side of the ledger--as the President's FY 2023 budget
request calls for--would allow for significant funding increases that
could not be achieved under the current restraints.
Question 2. Do you have a sufficient number of residential
treatment programs available for individuals who want to detox off
opioids completely, including relapse prevention medication and
culturally responsive counseling?
Answer. Cherokee Nation does not currently have a sufficient number
of residential treatment programs available. That is why we are looking
to build our own residential treatment facility that will also include
outpatient supports in the communities.
Question 3. Can you discuss how your treatment and wellness centers
have helped the community?
Answer. We are in the process of constructing these facilities. In
the meantime, we are providing other tiers of treatment for those who
are dealing with addiction, such as transitional living centers.
When completed, we expect our facilities to turn the tide by
generating hope and giving our citizens a welcome space here at home to
focus on healing. We are developing long-term plans for a comprehensive
behavioral health system that features in-patient and out-patient
services, and plan to the best facilities that can be built for
Cherokee citizens.
Question 4. How significant of an impact do you anticipate the 7
percent earmark for public health program to be? How much more of an
investment is this in public health programs than currently exists?
Answer. Last month I signed legislation to expand our existing
Public Health and Wellness Fund Act. Through this legislation we are
broadening the type of third-party revenue Cherokee Nation Health
Services sets aside for drug treatment purposes, which will increase
our investment to $15 million over the next three years. This amount,
combined with our initial opioid settlement money, will go toward drug
treatment facilities and other opioid remediation, prevention,
treatment, and harm reduction programs.
Questions Submitted by Representative Huffman
Question 1. What specific actions is the Bureau of Indian Affairs
taking to stem the flow of illicit opioids--especially fentanyl--to
tribal lands and people?
Answer. I would refer this question to BIA.
Question 2. What further actions would you like to see from the
Bureau of Indian Affairs on this matter, if any?
Answer. BIA and congressional appropriators must look to remove
some of the barriers that prevent prevention and treatment funding from
being as effective as it could be. These barriers include the
following:
Federal funding restricts the use of grant funding for
items that would significantly improve our ability to serve
the target audiences for our programs. For example,
celebrating culture through food is a key component of
engaging youth and families. The food purchase restriction
is limiting for programs and seems almost punitive to
communities as a response for some bad actors in the past.
Restricting the ability to provide food when serving
marginalized communities who deal with trauma, poverty, and
food insecurity is counter to the values of our culture.
Program requirements often ask a tribal community to
conform to structures and systems that do not exist in
their community.
Funding periods are often too short to provide meaningful
assistance. The Tribal Opioid Response grant is large in
scope and funding amount, but the funding period is only
two years. A minimum of 5-year funding cycles would give
tribes the ability to build strong foundations for
sustainability.
Reporting requirements are complicated, frequent, and can
be duplicative. Although we understand the need for
reporting and accountability, the administrative burden
placed on grant personnel for reporting can be significant.
The reporting burden is constantly pulling the program
staff away from service delivery in order to meet all the
quarterly, biannual, and annual deadlines. Approvals for
formally submitted changes take months for approvals. A
budget revision or carryover request can take anywhere
between three and nine months to be approved, and if there
are additional questions, that cycle starts over.
______
Mr. Garcia. Thank you, Chair Hoskin, for that testimony.
The Chair now recognizes Mr. Art Del Cueto, Vice President
of the Western Region of the National Border Patrol Council.
Mr. Del Cueto, you are on.
STATEMENT OF ART DEL CUETO, VICE PRESIDENT, WESTERN REGION,
NATIONAL BORDER PATROL COUNCIL, TUCSON, ARIZONA
Mr. Del Cueto. Chair Porter, Acting Chair Garcia, Ranking
Member Moore, and distinguished members of the Subcommittee, I
would like to thank you for inviting me to testify before you
today. I hope that my testimony will assist the Subcommittee in
better understanding how the executive actions taken by
President Biden and his administration have directly resulted
in an increase in illicit fentanyl coming across our southern
border with Mexico and into our communities, including
vulnerable tribal communities.
My name is Art Del Cueto. I currently serve as Vice
President of the Western Region of the National Border Patrol
Council, where I represent Border Patrol field agents and
support staff. I was born on the border, I grew up on the
border, and I have more than 18 years of experience as a Border
Patrol agent, as well as a thorough understanding of the
policies affecting border security and illicit narcotics
trafficking.
Throughout my career in Border Patrol, I have served in the
Tucson Sector and have personally engaged in narcotic
enforcement activities in and around tribal communities in
Southern Arizona. Since he took office in January of last year,
the policies enacted by President Biden and his Department of
Homeland Security have directly resulted in the least secure
border that I have observed in my 18-year career.
Due to the Biden administration's border and immigration
policies, we have seen historically high numbers of
individuals, families, and children illegally crossing the
border over the past year, which has forced the Border Patrol
to dedicate more than 50 percent of its resources to activities
other than patrolling the border, creating gaps on our border.
Criminal cartels have consistently exploited these gaps
over the past year and have been able to easily cross high-
value products, such as illegal aliens from special interest
countries, weapons, and narcotics in massive quantities. The
amount of illicit fentanyl, a synthetic opioid pouring into our
country across our southern border, is staggering and, frankly,
terrifying knowing that just 2 milligrams is considered a
lethal dose.
According to publicly available data from Customs and
Border Protection, the Border Patrol seized over 1,000 pounds
of fentanyl nationwide from February 2021, the first full month
of President Biden's Open Border policies, to February 2022.
The Tucson Sector accounted for over 40 percent of that figure,
which amounted to 427 pounds of fentanyl seized by Tucson
agents. To give some perspective to that figure, 427 pounds of
fentanyl converts to over 193 million milligrams, enough to
potentially kill over 96 million people.
With agents forced to process huge numbers of traffic, and
unable to patrol the border, and criminal cartels consistently
exploiting the situation, these circumstances have led to a
huge increase in the flow of hard narcotics making their way
into the United States and wreaking havoc on communities as
drug overdoses soar to over 100,000 annually.
In September of last year, 8 months after President Biden's
open borders policies went into effect, the DEA issued a public
safety alert warning of the sharp increase in fake prescription
pills containing fentanyl and methamphetamines.
The DEA Administrator, Anne Milgram, stated in the alert
that the United States is facing an unprecedented crisis of
overdose deaths fueled by illegally manufactured fentanyl. The
alert goes on to allude the fact that fentanyl is illegally
being trafficked across our southern border with Mexico. They
say the vast majority of counterfeit pills brought into the
United States are produced in Mexico, and China is supplying
chemicals for the manufacturing of fentanyl into Mexico.
While the alert only implies that lethal doses of fentanyl
are being illegally smuggled into the United States across the
southern border with Mexico, and uses the word brought, the
DEA's own ``Facts about Fentanyl'' web page makes the situation
very clear.
As illicit fentanyl streams into the country at a
horrifying rate, sadly, tribal communities are not immune.
Where I work in the Tucson Sector, there is a long history of
illicit narcotics trafficking on the Tohono O'odham Nation, the
land that shares the border with Mexico.
According to information shared publicly by the Tohono
O'odham Department of Public Safety in 2017, from 2002 to 2016,
the Tohono O'odham Police Department and Border Patrol worked
to seize over 313,000 pounds of drugs.
In 2019, ABC News made a public year-long investigation of
smuggling activities on the nation and called the tribal land
one of the busiest corridors in North America. Tribal leader
David Garcia is quoted on a report saying, ``We are killing our
own people. We have to do something. And if we don't do
anything, we are just as bad within the problem.''
Garcia stated that a lot of the tribal members are involved
in drug smuggling of migrants and drugs. I have worked in and
around this area. Mr. Garcia is absolutely correct, especially
on illicit narcotics like fentanyl that are constantly coming
through the Tohono O'odham Nation.
And just like communities all over the country, when
narcotics come in, the outcomes are devastating for tribal
members. As one example of fentanyl being seized by the nation,
in 2019, the Bureau of Land Affairs seized 30,000 fentanyl
pills as part of an investigation.
The Subcommittee and Congress do not need to enact new
legislation or appropriate money to address this issue.
Thankfully, we have laws on the books that we need to stop
destroying public health humanitarian and national security
crisis. And we have more than enough funding appropriate to DEA
each year to do so. We simply need a change in policy. It
starts with policy and President Biden's policies have made our
borders the least secure in our nation.
I want to thank the Subcommittee for your time through
answering any questions you may have.
[The prepared statement of Mr. Del Cueto follows:]
Prepared Statement of Art Del Cueto, On Behalf of the National Border
Patrol Council
Chair Porter, Ranking Member Moore, and distinguished Members of
the Subcommittee, I would like to thank you for inviting me to testify
before you today. I hope that my testimony will assist the Subcommittee
in better understanding how the executive actions taken by President
Biden and his Administration have directly resulted in an increase in
illicit fentanyl coming across our Southern border with Mexico and into
our communities, including vulnerable tribal communities.
My name is Art Del Cueto and I currently serve as Vice President,
Western Region, of the National Border Patrol Council (NBPC), where I
represent Border Patrol field agents and support staff. I was born on
the border, grew up on the border and have more than 18 years of
experience as a Border Patrol Agent, as well as a thorough
understanding of the policies affecting border security and illegal
narcotics trafficking. Throughout my career in the Border Patrol, I
have served in the Tucson, Arizona Sector and have personally engaged
in narcotics enforcement activities in and around tribal communities in
Southern Arizona.
Since he took office in January of last year, the policies enacted
by President Biden and his Department of Homeland Security (DHS) have
directly resulted in the least secure border I've ever observed in my
18-year career. Due to the Biden Administration's border and
immigration policies, we have seen historically high numbers of
individuals, families and children illegally crossing the border over
the past year, which has forced the Border Patrol to dedicate more than
50% of its resources to activities other than patrolling the border,
creating gaps along our border.
Criminal cartels have consistently exploited these gaps over the
past year and have been able to easily cross their high-value products
such as illegal aliens from special interest countries, weapons and
narcotics in massive quantities. The amount of illicit fentanyl, a
synthetic opioid, pouring into our country across our Southern border
is staggering and frankly terrifying knowing that just two milligrams
is considered a lethal dose.
According to publicly available data from Customs and Border
Protection (CBP), the Border Patrol seized 1,045 pounds of fentanyl
nationwide from February 2021--the first full month of President
Biden's open border policies--to February 2022.\1\ The Tucson Sector
accounted for 40.86% of that figure which amounted to 427 pounds of
fentanyl seized by Tucson Agents during that same time period.\2\ To
give some perspective to that figure, 427 pounds of fentanyl converts
to over 193 million milligrams, enough to potentially kill over 96
million people.
---------------------------------------------------------------------------
\1\ U.S. Dep't of Homeland Security, U.S. Customs and Border
Protection, Drug Seizure Statistics, (Data current as of Mar. 3, 2022),
https://www.cbp.gov/newsroom/stats/drug-seizure-statistics.
\2\ Id.
---------------------------------------------------------------------------
With our Agents forced to process huge numbers of illegal aliens
and unable to patrol the border, and criminal cartels consistently
exploiting the situation, these circumstances have led to a huge
increase in the flow of hard narcotics making their way into the U.S.
and wreaked havoc on communities as drug overdose deaths soar to over
100,000 annually.\3\
---------------------------------------------------------------------------
\3\ Press Release, Centers for Disease Control and Prevention, Drug
Overdose Deaths in the U.S. Top 100,000 Annually, (Nov. 17, 2021),
https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/
20211117.htm.
---------------------------------------------------------------------------
In September of last year, eight months after President Biden's
open borders policies went into effect, the Drug Enforcement
Administration (DEA) issued a Public Safety Alert warning of the
``Sharp Increase in Fake Prescription Pills Containing Fentanyl and
Meth.'' \4\ President Biden's DEA Administrator appointee, Anne
Milgram, stated in the Alert that, ``The United States is facing an
unprecedented crisis of overdose deaths fueled by illegally
manufactured fentanyl . . . DEA is focusing resources on taking down
the violent drug traffickers causing the greatest harm . . .'' \5\ The
Alert goes on to allude to the fact that fentanyl is being illegally
trafficked across our Southern border with Mexico, stating, ``The vast
majority of counterfeit pills brought into the United States are
produced in Mexico, and China is supplying chemicals for the
manufacturing of fentanyl in Mexico.'' \6\
---------------------------------------------------------------------------
\4\ Press Release, U.S. Dep't of Justice, Drug Enforcement
Administration, DEA Issues Public Safety Alert on Sharp Increase in
Fake Prescription Pills Containing Fentanyl and Meth, (Sept. 27, 2021),
https://www.dea.gov/press-releases/2021/09/27/dea-issues-public-safety-
alert.
\5\ Id.
\6\ Id.
---------------------------------------------------------------------------
While the Alert only implies that lethal doses of fentanyl are
being illegally smuggled into the U.S. across our Southern border with
Mexico and uses the word ``brought,'' the DEA's own ``Facts about
Fentanyl'' webpage makes the situation very clear, ``Illicit fentanyl,
primarily manufactured in foreign clandestine labs and smuggled into
the United States through Mexico, is being distributed across the
country and sold on the illegal drug market.'' \7\ (Emphasis added)
---------------------------------------------------------------------------
\7\ U.S. Dep't of Justice, Drug Enforcement Administration, Facts
about Fentanyl, https://www.dea.gov/resources/facts-about-fentanyl.
---------------------------------------------------------------------------
As illicit fentanyl streams into the country at a horrifying rate,
sadly, tribal communities are not immune to this crisis. Where I work
in the Tucson Sector, there is a long history of illicit narcotics
trafficking on the Tohono O'odham Nation lands that shares their border
with Mexico.\8\ According to information shared publicly by the Tohono
O'odham Department of Public Safety in 2017, ``From 2002 to 2016 the
Tohono O'odham Police Dept. and U.S. Border Patrol working together
have seized on average over 313,000 pounds of illegal drugs per year.''
\9\
---------------------------------------------------------------------------
\8\ Press Release, U.S. Dep't of Homeland Security, U.S.
Immigration and Customs Enforcement, Ring leader, 20 others sentenced
for drug smuggling on Tohono O'odham Nation, (August 19, 2012), https:/
/www.ice.gov/news/releases/ring-leader-20-others-sentenced-drug-
smuggling-tohono-oodham-nation; Press Release, U.S. Dep't of Homeland
Security, U.S. Immigration and Customs Enforcement, NATIVE Task Force
shuts down smuggling ring operating on Arizona tribal land, (Feb. 20,
2014), https://www.ice.gov/news/releases/native-task-force-shuts-down-
smuggling-ring-operating-arizona-tribal-land; Press Release, U.S. Dep't
of the Interior, Trump Administration Taskforce Completes Successful
Opioid Bust in Arizona, (May 31, 2018), https://www.doi.gov/
pressreleases/trump-administration-taskforce-completes-successful-
opioid-bust-arizona.
\9\ Tohono O'odham Nation, THE TOHONO O'ODHAM NATION OPPOSES A
``BORDER WALL'', (Feb. 19, 2017), https://www.youtube.com/
watch?v=QChXZVXVLKo.
---------------------------------------------------------------------------
In 2019, ABC News made public a year-long investigation on
smuggling activities on Tohono O'odham Nation lands and called the
tribe's land, ``One of the busiest smuggling corridors in North
America.'' \10\ A tribal elder, David Garcia, is quoted in the report
as saying, ``We're killing our own people . . . We have to do
something. And if we don't do anything, then we're just as much the
problem as well.'' Mr. Garcia went on to add, ``It's no secret,''
Garcia said, ``that a lot of our tribal members are involved in the
smuggling of migrants and drugs.'' \11\
---------------------------------------------------------------------------
\10\ ABC News, On tribal land along US-Mexico border, drug and
human smuggling corrupts an ancient culture, (May 16, 2019), https://
abcnews.go.com/US/tribal-land-us-mexico-border-drug-human-smuggling/
story?id=63064992.
\11\ Id.
---------------------------------------------------------------------------
I've personally worked in and around the area of responsibility
(AOR) that includes the Tohono O'odham Nation and Mr. Garcia is
absolutely correct--illicit narcotics like fentanyl are constantly
coming to and through the Tohono O'odham Nation. And just like
communities all over the country, when narcotics come in, the outcomes
are devastating for tribal members. As one example of fentanyl being
seized on Tohono O'odham Nation lands, in 2019, a Bureau of Indian
Affairs task force seized roughly 30,000 fentanyl pills as part of an
``investigation into fentanyl pills being trafficked onto tribal
lands.'' \12\
---------------------------------------------------------------------------
\12\ ABC News, 30,000 fentanyl pills seized in Arizona drug bust,
(March 15, 2019), https://abcnews.go.com/Politics/30000-fentanyl-pills-
seized-arizona-drug-bust/story?id=61714688.
---------------------------------------------------------------------------
The Subcommittee and the Congress do not need to enact new
legislation or appropriate new money to address these issues.
Thankfully, we already have the laws on the books that we need to stop
this growing public health, humanitarian and national security crisis.
And we have more than enough funding appropriated to DHS each year to
do what we need to operationally to address these issues. We simply
need a change in policy. It starts with policy, and President Biden's
policies have made our borders the least secure in our nation's
history.
I want to thank the Subcommittee for your time this morning and I
look forward to answering any questions you may have.
______
Mr. Garcia. Thank you, for your testimony, Mr. Del Cueto.
The Chair will now recognize Ms. Maureen Rosette, a Board
Member of the National Council on Urban Indian Health.
Ms. Rosette.
STATEMENT OF MAUREEN ROSETTE, BOARD MEMBER, NATIONAL COUNCIL OF
URBAN INDIAN HEALTH, WASHINGTON, DC
Ms. Rosette. Good morning. My name is Maureen Rosette. And
I am a citizen of the Chippewa Cree Nation and serve as a Board
Member for the National Council of Urban Indian Health, which
represents the 41 Urban Indian Health Care Organizations across
the nation who provide high quality, culturally competent care
to urban Indians, constituting over 70 percent of all American
Indians and Alaskan Natives. I am also Chief Operating Officer
of the NATIVE Project, an Urban Indian Organization located in
Spokane, Washington.
Let me start by saying thank you to Chairwoman Porter,
Ranking Member Moore, and members of the Subcommittee to share
how the opioid crisis is plaguing our Native communities and to
request inclusion of Urban Indian Organizations, referred to as
UIOs, in the critical opioid response funding.
The codified Declaration of National Indian Health Policy
states that it is the policy of this nation in fulfillment of
its trust responsibilities and legal obligations to Indians to
ensure the highest possible health status for Indians and urban
Indians and to provide all resources necessary to affect that
policy.
In fulfillment of this policy, the Indian Health Service
funds three health programs to provide health care to Native
people, IHS sites, tribal sites, and Urban Indian Organizations
referred to as the I/T/U System.
Unfortunately, this system has been hampered by decades of
chronic underfunding. Additionally, while the majority of the
Native population resides in urban areas, only 1 percent of the
entire Indian health budget is provided for Urban Indian
Health.
Our UIO, the NATIVE Project, provides medical, dental,
behavioral health, pharmacy, care coordination, wellness, and
prevention services. Our patients include Native people from
over 300 different tribes. This year, we have had virtual
wellness nights with activities like pow wow, dancing,
painting, regalia making, planting, and cooking where we bring
to life the meaning behind ``culture is medicine.'' Along with
the 40 other UIOs, we play a critical role in addressing the
opioid crisis impacting Native communities.
A review of one UIO's records from 2018 to 2021, showed
that over 80 percent of clients that engage with behavioral
health services had co-occurring mental health and substance
abuse disorders. Opioid disorder was the most common substance
abuse diagnosis. However, as we will illustrate today, UIOs are
cut off from critical funding resources designed to help Native
communities, negatively impacting the health outcomes for urban
Indians.
Additionally, the opioid crisis and the COVID-19 pandemic
are intersecting with each other and presenting unprecedented
challenges for Native families and communities. A study found
that 1 out of every 168 Native children experienced orphanhood
or death of caregivers due to the pandemic. Native children
were four times more likely than white children to lose a
parent or a grandparent caregiver. This has exacerbated mental
health and substance use issues among our youth.
During the last government shutdown, one UIO suffered 12
opioid overdoses, 10 of which were fatal. This represents 10
relatives who are no longer part of our community. These are
mothers, fathers, uncles, and aunties no longer present in the
lives of our families. These are tribal relatives unable to
pass along the cultural traditions that make us, as Native
people, who we are.
To address the opioid overdose epidemic in Indian Country,
Congress has provided funding for tribal opioid response
grants. We have long advocated for UIOs to be added to these
grants given the extent of the impact of the opioid epidemic on
all American Indians and Alaskan Natives, regardless of
residence.
However, the final language in the Omnibus removed UIOs as
eligible, so UIOs, like mine, working against the same column
are again left without the resources. This is a failure of
equity and the trust responsibility. Therefore, I want to
emphasize the importance of explicitly mentioning Urban Indian
Organizations and legislation to ensure funding designed to
reach Native communities actually does.
As one advocate stated, the language everywhere has to
include the word urban. They have to say it, they have to write
it, and then it will reach a critical mass eventually. Because
they don't get it, we are just invisible.
In conclusion, more needs to be done to address the opioid
crisis and ensure that all Natives have access to life-saving
health care. I urge Congress to take this obligation seriously
and provide UIOs with all the resources necessary to protect
the lives of the entirety of the Native population regardless
of where they live.
Thank you for the opportunity to speak today. I have
provided a written testimony to the Committee, and I am happy
to answer any questions. Thank you.
[The prepared statement of Ms. Rosette follows:]
Prepared Statement of Maureen Rosette (Chippewa Cree Nation), Board
Member, National Council of Urban Indian Health
My name is Maureen Rosette, I am a citizen of the Chippewa Cree
Nation and serve as a board member of the National Council of Urban
Indian Health (NCUIH) and Chief Operating Officer at NATIVE Project, an
Urban Indian Organization (UIO) in Washington state. On behalf of
NCUIH, the national advocate for health care for the over 70% of
American Indians and Alaska Natives (AI/ANs) living off-reservation and
the 41 UIOs that serve these populations, I would like to thank the
members of this committee for the opportunity to testify on the opioid
crisis in Indian Country.
First, I would like to begin by reviewing some information about
the trust responsibility and how UIOs fit into the provision of health
care for Native people. The Declaration of National Indian Health
Policy in the Indian Health Care Improvement Act states that:
``Congress declares that it is the policy of this Nation, in
fulfillment of its special trust responsibilities and legal obligations
to Indians to ensure the highest possible health status for Indians and
urban Indians and to provide all resources necessary to effect that
policy.'' In fulfillment of the National Indian Health Policy, the
Indian Health Service funds three health programs to provide health
care to AI/ANs: IHS sites, tribally operated health programs, and Urban
Indian Organizations (referred to as the I/T/U). Unfortunately, this
system has been hampered by decades of chronic underfunding.
Additionally, while the majority of the Native population resides in
urban areas, only 1% of the entire Indian health budget is provided for
urban Indian health.
Our UIO, the NATIVE Project provides medical, dental, behavioral
health, pharmacy, patient care coordination, wellness, and prevention
services. Our patients include Natives from over 300 different tribes.
Specifically, we currently offer Youth Mental Health Services and
Substance Use Assessments, Substance Use Outpatient and Inpatient
Treatment. From January through March, we held virtual wellness nights
with prevention, culture, and nutrition activities. Activities like pow
wow dancing, painting, regalia making, planting, and cooking, we bring
to life the meaning behind ``culture is medicine''. We also believe in
fostering better outcomes for our children and are hosting an Indian
Youth Leadership Camp later this month for secondary students. Along
with the 40 other UIOs, we play a critical role in addressing the
opioid crisis impacting Native communities. However, as we will
illustrate today, UIOs are cut off from critical funding resources
designed to help Native communities and this, thusly, negatively
impacts the health outcomes for urban Indians.
Opioid Epidemic in AI/AN Communities
As you are aware, the opioid crisis has plagued Native communities
long before the pandemic we're currently facing that is also causing
devastating loss. A review of one UIO's records from 2018 to 2021
showed that over 80% of clients that engaged in behavioral health
services had co-occurring mental health and substance abuse disorders.
Opioid use disorder was the most common substance abuse diagnosis with
alcohol use disorder as the second most common. Roughly 24% of these
patients died of a known or suspected opioid overdose. Between November
2018 and March 2019, the UIO in Baltimore suffered 12 opioid overdoses,
10 of which were fatal. This represents 10 relatives who are no longer
part of our community. These are mothers, fathers, uncles, and aunties
no longer present in the lives of their families. These are tribal
relatives unable to pass along the cultural traditions that make us, as
Native people, who we are.
Additionally, AI/ANs are deeply impacted by the opioid crisis and
continue to see an overwhelming increase of deaths, addiction, and
overdoses above the national average. AI/ANs had the second-highest
rate of opioid overdose out of all U.S. racial and ethnic groups in
2017, and the second and third highest overdose death rates from heroin
and synthetic opioids, respectively, according to the Centers for
Disease Control and Prevention.\1\
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\1\ https://www.cdc.gov/drugoverdose/deaths/index.html.
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Since 1974, AI/AN adolescents have consistently had the highest
substance abuse rates than any other racial or ethnic group in the
U.S.\2\ The centuries of historical trauma do not heal overnight, and
the government has failed Indian Country by not giving us the resources
needed to heal our communities. Unfortunately, the majority of the
nation's AI/ANs living on and off reservations have limited access to
substance abuse services due to transportation issues, lack of health
insurance, poverty, inadequate healthcare facilities, and a shortage of
appropriate treatment options in their communities.\3\ Some of the
disparities in treatment that occur within the AI/AN population can be
resolved through the increased availability of culturally sensitive
treatment programs. Studies have shown that cultural identity and
spirituality are important issues for AI/ANs seeking help for substance
abuse, and these individuals may experience better outcomes when
traditional healing approaches (such as drum circles and sweat lodges)
are incorporated into treatment programs.
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\2\ Swaim RC, Stanley LR. Substance Use Among American Indian
Youths on Reservations Compared With a National Sample of US
Adolescents. JAMA Netw Open. 2018;1(1):e180382.
\3\ https://ncuih.org/2022/01/14/ncuih-endorsed-comprehensive-
addiction-resources-emergency-care-act-includes-funding-for-urban-
indian-organizations/.
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Urban AI/AN populations are at a much higher risk for behavioral
health issues than the general population. For instance, 15.1% of urban
AI/AN persons report frequent mental distress compared to 9.9% of the
general public.\4\ While behavioral health problems such as substance
abuse, suicide, gang activity, teen pregnancy, neglect, and abuse
ravage urban AI/AN communities, poor health and lack of access to
adequate health care services continue to exacerbate these issues that
AI/AN populations encounter.
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\4\ Westat (2014). Understanding Urban Indians' Interactions with
ACF Programs and Services: Literature Review OPRE Report 2014-41,
Washington, DC: Office of Planning, Research and Evaluation,
Administration for Children and Families, U.S. Department of Health and
Human Services.
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Impact of COVID-19 on Behavioral Health and Substance Abuse in AI/AN
Communities
Additionally, the opioid crisis and COVID-19 pandemic are
intersecting with each other and presenting unprecedented challenges
for AI/AN families and communities. On October 7, 2021, the American
Academy of Pediatrics published a study on caregiver deaths by race and
ethnicity. According to the study, 1 of every 168 AI/AN children
experienced orphanhood or death of caregivers due to the pandemic and
AI/AN children were 4.5 times more likely than white children to lose a
parent or grandparent caregiver.\5\ Unfortunately, this has exacerbated
mental health and substance use issues among our youth. In the age
group of 15-24, AI/AN youth have a suicide rate that is 172% higher
than the general population in that age group.
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\5\ https://publications.aap.org/pediatrics/article/148/6/
e2021053760/183446/COVID-19-Associated-Orphanhood-and-Caregiver-Death.
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The pandemic has also created challenges for providers as they work
to serve our communities. We have shifted to expanding telehealth
services, changing how we provide traditional healing practices while
addressing the demand for more services. Despite these challenges, we
have taken on the tireless work of addressing the epidemic and
providing care to our communities. However, UIOs often find themselves
excluded from funding meant to address these challenges.
UIOs Left Out of State Opioid Response Grants
Specifically, UIOs have repeatedly been left out of funding
designed to help AI/AN communities address the opioid crisis. To
address the opioid overdose epidemic in Indian Country by increasing
access to culturally appropriate and evidence-based treatment, Congress
provided funding for Tribal Opioid Response grants. NCUIH has long
advocated for UIOs to be added to the Substance Abuse and Mental Health
Services Administration's (SAMHSA) State Opioid Response (SOR) grants
given the extent of the impact of the opioid epidemic on all AI/ANs
regardless of residence. Since FY 2018, Congress has enacted set asides
in opioid response grants to help Native communities address this
crisis. However, it was only available for Tribes and Tribal
organizations, so UIOs like mine working against the same problem are
left without the resources necessary to reach the highest health status
for our people as required of the federal government. This is a failure
of equity. Without the necessary funding to address health crises in
Indian Country, urban AI/AN people will again be left out of the
equation.
Last Spring, Congress introduced the State Opioid Response Grant
Authorization Act of 2021 (H.R. 2379), which included a 5 percent set-
aside of the funds made available for each fiscal year for Indian
Tribes, Tribal organizations, and UIOs to address substance abuse
disorders through public health-related activities such as implementing
prevention activities, establishing or improving prescription drug
monitoring programs, training for health care practitioners, supporting
access to health care services, recovery support services, and other
activities related to addressing substance use disorders. NCUIH worked
closely with Congressional leaders to ensure the inclusion of urban
Indians in the funding set-aside outlined in this bill, which
eventually passed the House on October 20, 2021. Despite this effort,
UIOs were removed from the SOR Grant reauthorization, which saw a $5
million increase (9 percent increase from FY 2021), included in the
recently passed FY 2022 Omnibus (H.R. 2471). The final language in the
Omnibus only listed ``Indian Tribes or Tribal organizations'' as
eligible and did not use the language from H.R. 2379. When UIOs are not
explicitly stated as eligible entities, we are excluded from critical
resources and grants, which is a violation of the trust obligation. As
one advocate stated, ``The language everywhere has to include the word
`urban'--urban Indian or urban Native. They have to say it, they have
to write it and then it'll reach a critical mass, eventually. Because
they don't get it, you know. We're just invisible.'' \6\
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\6\ https://www.usatoday.com/story/news/politics/2022/03/07/
opioids-native-americans-funding/9380063002/?gnt-cfr=1.
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We were disappointed to yet again be left out of this key resource
as our communities are plagued by the opioid crisis. Inclusion in this
program could have enabled UIOs to expand services or workforce or to
help address the catastrophic impacts of the opioid epidemic in Indian
Country. We urge you to work to ensure funding designated to help AI/AN
communities have the proper language to prevent UIOs from lacking
access to these critical funds.
The Importance of UIO Inclusion in Opioid Funding
On December 16, 2021, the NCUIH-endorsed Comprehensive Addiction
Resources Emergency (CARE) Act (S. 3418/H.R. 6311) was reintroduced and
aims to address the substance use epidemic by providing state and local
governments with $125 billion in federal funding over ten years. Of the
nearly $1 billion, the CARE Act sets aside $150 million a year in
funding to Native non-profits and clinics, including to urban Indian
organizations. NCUIH worked closely with Congressional leaders to
ensure the inclusion of urban Indians in this important legislative
response to the nation's substance use epidemic.
NCUIH has also continued advocacy around funding and preserving
behavioral health initiatives for UIOs under the Indian health care
system by working with Congress on the introduction the Native
Behavioral Health Access Improvement Act of 2021 (H.R. 4251/S. 2226),
which would require IHS to allocate $200 million for the authorization
of a special program for the behavioral health needs of AI/AN
populations. The availability of these critical resources would allow
Congress to fulfill its trust obligations to AI/AN populations.
We are grateful for urban Indian inclusion in these Acts and want
to emphasize the importance of mentioning urban Indians in legislation,
to ensure funding reached across all AI/AN communities and urban
Indians are not excluded or forced to prove their eligibility under the
intent of the laws created. NCUIH appreciates that these bills have
detailed specific language that ensures urban Indian organizations are
listed as eligible entities.
Conclusion
More needs to be done to address the opioid crisis and ensure that
all AI/ANs are cared for when it comes to substance abuse disorders,
both during this crisis and in the critical times following. It is the
obligation of the United States government to provide these resources
for AI/AN people residing in urban areas. We urge Congress to take this
obligation seriously and provide UIOs with all the resources necessary
to protect the lives of the entirety of the AI/AN population,
regardless of where they live.
______
Questions Submitted for the Record to Maureen Rosette, National Council
of Urban Indian Health
Questions Submitted by Representative Cohen
Question 1. What has been the rationale, if any, for the
historically low level of funding for the Indian Health Service?
Answer. There is no rationale for the historically low level of
funding for Indian Health Service (IHS) other than the federal
government's failure to uphold the trust and treaty obligation to
provide healthcare to all American Indians and Alaska Natives (AI/ANs).
Although funding has gradually increased over the past few years,
Tribal and IHS facilities only receive around $4,000 per patient, while
the national average for healthcare spending is around $12,000 per
person. Urban Indian Organizations (UIOs) receive just $672 per IHS
patient--that is only 6 percent of the per capita amount of the
national average. That's what our organizations must work with to
provide health care for urban Indian patients. Full funding for IHS is
a way for the federal government to finally, and faithfully, fulfil its
trust responsibility.
For Fiscal Year 2022, the House included full funding for urban
Indian health at $200.5 million, which was the amount recommended by
the Tribal Budget Formulation Workgroup. However, the final omnibus
bill reduced the urban Indian health line item to just $73.4 million,
7.7% of the full FY23 amount ($949.9 million) requested by Tribes and
UIOs to fully meet the needs for the majority of the AI/AN population.
Full funding will empower UIOs to hire more staff, pay appropriate
wages, as well as expand vital services, programs, and facilities.
Because IHS is subject to discretionary funding, critical funds for
Native healthcare can be easily cut depending on the whim of Congress.
As such, mandatory funding for IHS is necessary and long overdue to
ensure stable and predictable funding for Native healthcare that is
exempt from the political process. We strongly urge the House Committee
on Natural Resources as the relevant authorizing committee to hold a
hearing on mandatory funding, as proposed in the President's Fiscal
Year 2023 budget, as soon as possible.
Questions Submitted by Representative Huffman
Question 1. Ms. Rosette, what educational efforts are in motion to
ensure tribal people are aware of the risks of addiction and have
access to treatment?
Answer. Some Urban Indian organizations (UIOs) have undertaken
educational efforts around the risks of addiction and access to
treatment for their community. For example, several UIOs provided
training for community members to recognize the signs of an opioid
overdose and how to administer NARCAN, and collaborated with
departments of health to provide free NARCAN kits to the community.
However, funding and staffing limitations has made it difficult for
many UIOs to provide educational efforts that are needed for their
communities. This is why it is critical that UIOs be included in
important opioid grant funding to ensure that American Indians and
Alaska Natives are aware of the risks of addiction and have access to
culturally competent treatment.
Question 2. How does the Bureau of Indian Affairs and other Federal
agencies track opioid prescriptions in tribal clinics?
Answer. Several federal agencies, including the Indian Health
Service (IHS), utilize a Prescription Drug Monitoring Program (PDMP),
which is an electronic database that tracks controlled substance
prescriptions in a state. IHS requires healthcare providers working in
IHS federal-government-operated facilities, including doctors,
pharmacists, nurse practitioners and other providers who prescribe
opioids, to check state PDMP databases prior to prescribing and
dispensing opioids for pain treatment longer than seven days and
periodically throughout chronic pain treatment.
______
Mr. Garcia. Thank you, Ms. Rosette, for your testimony.
The Chair now recognizes Mr. Wayne Cortez, Peer Support
Specialist at Riverside-San Bernardino County Indian Health,
Inc.
Mr. Cortez.
STATEMENT OF WAYNE CORTEZ, PEER SUPPORT SPECIALIST, RIVERSIDE-
SAN BERNARDINO COUNTY INDIAN HEALTH, INC., SAN JACINTO,
CALIFORNIA
Mr. Cortez. Good morning to all of you. A little bit of a
time difference, but I thank the two guests that spoke before
me. My name is Wayne Cortez. I am from Torres Martinez Desert
Cahuilla Indians, here at Riverside County.
As you know, we are talking about the opioid epidemic here.
I see it on a daily basis down here. Being a peer support
specialist, yes, we do have a problem here, and opiates do not
discriminate. It is every family member that deals with that
kind of drug there. Yes. For me, I would like to see a lot of
changes and more education with this crisis here.
But for me, being in that lived experience, I lived that
life right there, of a user, a heroin addict, for over 30 some
years now. So, it really bothers me to hear a lot of stuff
about Native Americans, the problem with it there. It is not
coming from inside the reservation, it is coming from outside
the communities.
I live in an area where it is a pipeline in the Coachella
Valley area, right there next to Mexicali. But a lot of these
so-called drug dealers, cartel members, they use Native
Americans because of the revenue that we do get. They feed off
of us a lot. But for me being in that peer support, bringing
the education to them, encouraging them to do a better job in
their life, helping their kids, supporting them in school, just
being that mentor, a father, a brother, a son, uncle, even as a
grandparent. I encourage a lot of the Native people in my
community to step up and teach them that culture more to get
them involved in the communities, get them involved in the
different tribes, because we have nine different reservations
down here, and it is very important. But being here in
Riverside County, I have seen a lot of this so-called fentanyl
epidemic. I have seen how a lot of the drugs are getting more
creative nowadays, through vape pens, through pill form. They
have like 10 different names just for fentanyl alone.
So, just bringing that awareness, bringing some light to
the subject here, like I said, it is very important. I just
want to say thank you for everybody to hearing what they have
to say today. It is not going to stop until we all acknowledge
it. This is something that continues to go on and on.
I am not sitting here reading from something that I have
written. I am coming from my heart and lived experience here.
And I don't know, all I can say is that it is just something
that needs to be addressed more.
I thank the whole Committee here for giving me this
opportunity. It is early morning, and to get going, you guys
are better suited than me. But like I said, this is not going
to go away. This drug does not discriminate. It doesn't. So,
how can we be part of the change? How can we be part of the
solution? How can we make this thing a little bit more
understanding, that we can kind of slow it down?
It is not going to go away. That is all I can say. Yes.
Usually, we start off with a prayer. Today, I had to say some
prayers to help me and give me the right things to say, the
right things to do. How can we open up Congress' eyes? How can
we open up the eyes of the people we are representing to make
them listen to that? Close the doors when they try to come up
to the reservations. It is just a big struggle.
Like I said, I really appreciate you guy's time, just
hearing just a little bit from me and the rest of the Committee
here. And like I said, if you guys have any questions or
anything, feel free to ask. But we do stay in culture here,
sweat lodges, bird singing, bird dancing, all-night wakes. We
have a lot of things going on down here.
We do spend a lot of time with the kids, though. The kids
are our future. That is my passion, the kids, helping them to
understand that they have a purpose in life, to not give up on
them but to walk beside them, to teach them something is more
important than sitting there picking up a can, or picking up
that needle, or picking up that pipe right there.
So, for me, yes, I really appreciate this. But if there is
anything that I could do for my tribe, I am going to do it, or
just any people in general. That is what I am here for is just
to get that message across to people. So, I really thank you
guys. And like I said, if you have any questions or concerns,
please feel free to ask. Thank you.
[The prepared statement of Mr. Wayne Cortez follows:]
Prepared Statement of Wayne Cortez, Peer Support Specialist, Riverside-
San Bernardino Indian Health, Inc.
I would like to introduce myself, my name is Wayne Cortez. I am a
54 year old Native American in recovery; my drug of choice was heroin.
I started using heroin at the age of 13. I started getting high once or
twice a week then it turned into an everyday thing. Before I knew it I
was strung out with no hope in life. I had no knowledge of what the
drug was doing to me, so when I wanted to take a break I couldn't. I
would get sick: cold sweats, chills, and I would be vomiting. I felt
like my skin was crawling with ants. I couldn't sleep or eat, I had no
idea what was going on with me. I thought I had the flu but, I was
actually in withdrawals and the only way to make it go away was to get
high again. There I was up and running again; a 13 year old kid with a
habit that could kill a grown a man. To tell you the truth I wanted to
die. I felt it was better than living with parents that didn't care
about what was happening to their kids. My home life took a toll on me.
I have been through a lot mentally, physically, and emotionally.
A lot of people are dealing with trauma, and it starts at an early
age. We are all seeking escape from abuse. That was my life. The older
I got the worse things became. Now a lot of adults and youths are
getting creative with drugs. The one that is the biggest issue today is
Fentanyl. This drug alone has ten different names. These dealers will
do anything to make the drug look appealing.
Many people think drugs are something that they can take without
having any consequences. I don't want to sit here and talking about how
it's only affecting Indian people, because drugs do not discriminate.
Drugs destroy lives. I thank the creator that I was one of those who
survived this sickness. Everyone I grew up with has passed away from an
overdose or blood diseases related to heroin use.
The other day I saw two of my native brother that I use to get high
with still fighting with their addiction. I stopped to ask two
questions, ``aren't you tired of waking up and having to hustle for a
morning fix?'' and ``aren't you tired of abusing your body living day
by day like a zombie?'' I said these things to them because I care.
This is probably something they haven't heard in a long time, I CARE! I
let them know if they want help I will help them. I am very grateful to
be alive, and now I can make a difference.
Today I get out in the community educating as many people as I can
about the current opiate addiction affecting the tribal communities.
talk about how I got my life back, by going to Indian Health
counseling, Wellbriety Meetings, Ceremonials, Sweat Lodge, Traditional
songs, and surrounding myself with positive people. As long as the
creator gives me the strength to live another day, I will continue to
help those in need. Please forgive me if this is not the normal
testimony of a heroin addict. I believe we can get our point across
without having to go into detail about our lives and the ones who
suffered the most. My wife, my kids, and grandkids are my biggest
supporters, and I love them with all my heart.
Thank you for giving me the opportunity to express a little bit of
my life as a heroin addict in recovery.
______
Questions Submitted for the Record to Mr. Wayne Cortez, Peer Support
Specialist, Riverside-San Bernardino County Indian Health, Inc.
Questions Submitted by Representative Cohen
Question 1. What has been the rationale, if any, for the
historically low level of funding for the Indian Health Service?
Answer. The United States has a trust responsibility to the Indian
Country and through treaty obligations to improve the health care
status of American Indian and Alaska Native people. Native Americans
exchanged large portions of their ancestor's land based on agreements
and promises in the many treaties between the US Government and Indian
Tribes, to include the obligations for health care services through
funds appropriated by Congress. These federal responsibilities are
carried out, in part, by the Indian Health Services (IHS). The IHS and
Indian health care delivery system are unique among federal health-care
related agencies in this regard.
American Indian and Alaska Native people often face the most
significant behavioral health disparities among all populations in the
U.S. The rates of diabetes, suicides (youth and adult), depression,
behavioral health challenges, and deaths are higher than most other
populations. Now, with COVID, many Indian tribes suffered much higher
rates of COVID than the population in general. Yet, the Indian health
care delivery system is underfunded by nearly 50% of the necessary
levels to address all these health care disparities. This yearly
underfunding to tribes through IHS leaves the Indian health care system
vulnerable to the instability of funding in the event of a government
shutdown. Riverside-San Bernardino County Indian Health, Inc.,
(RSBCIHI) is susceptible to sequestration should a government shutdown
exist. Health care services and other operations are significantly
impacted, delays, or disrupted during periods of a government shutdown.
Question 2. Do you have a sufficient number of residential
treatment programs available for individuals who want to detox off
opioids completely, including relapse prevention medication and
culturally responsive counseling?
Answer. There are few, if at all, Indian based programs in southern
California for the purpose of treating Native Americans for chemical
dependency or alcohol abuse. The best course of treatment is often
through the local Indian health program. A support group of Native
Americans counselors who have experienced the very same chemical or
alcohol issues can better offer the mentoring and support system needed
to keep a patient on the red road to recovery. The Desert Sage Youth
Regional Treatment center took decades to fund, construct and staff and
then the criteria for placement may sometimes prevent a youth from
being accepted into the program. Often once the addiction is faced
head-on, the patient may go back into the very same environment which
placed them in this situation in the first place. Recovery is a
challenge and the first attempt may not always be successful based on
the program and its teaching toward the unique challenges Native
Americans face.
Questions Submitted by Representative Huffman
Question 1. Mr. Cortez, what commitments does the Federal
Government make to ensure tribal communities are treated equitably and
with sensitivity to their unique tribal communities as it addresses
this crisis?
Answer. The major commitment is toward funding through IHS--but the
insufficient funding limits the number of behavioral health specialists
available to our patients. Often, it seems the need for behavioral
health is as great as the need for an MD in clinics. Competitive grant
funds through SAMHSA pits one Indian Health clinic system against
another and although these grants provide tremendous opportunities for
the benefit of the patient, another tribal health program may suffer
because their data may not meet the scoring criteria for ranking within
a grant. Yet, the need and lack of funding for a smaller clinic system
may not give the patient an opportunity to receive the mental and
physical healthcare they need. The IHS has many needs to fulfill in
meeting its obligations, and with the support of Congress, small steps
can be taken to improve overall health status of the first people of
this country.
______
Mr. Garcia. Thank you, Mr. Cortez, for your testimony. And,
of course, I want to thank all of the panelists for their
testimony. I would like to remind Members that Committee Rule
3(d) imposes a 5-minute limit on questions. The Chair will now
recognize Members for any questions that they may wish to ask.
But before I begin, I request unanimous consent that the
following Members of Congress be authorized to question the
witnesses in today's hearing: New Mexico Representative
Stansbury.
Without objection, so ordered.
I now would like to recognize myself for 5 minutes of
questions.
First, Chief Hoskin and Ms. Rosette, why is tribally
administered care for opioid addiction more effective than care
that is non-tribally run?
Mr. Hoskin. Well, Representative, if I could respond, I
think it comes down to something essential in health care in
Indian Country, which is that we know the people that we serve
and we are experts about our own families. There is something
about Native Peoples delivering health care to Native Peoples
that is not only special, but I think effective.
If we are a healthcare practitioner or a policymaker, we
share with those patients the same historic trauma. We have
been through this together for generations. That sense of self
that we have is important.
There are unique aspects of health care in Indian Country
that go beyond the issues of substance abuse to other health
ailments that are unique to Indian Country or exacerbated in
Indian Country, and our healthcare practitioners know this.
Treating people from a holistic standpoint is something we aim
to do at the Cherokee Nation. And I think health care delivery
by tribes directly is important.
Of course, that means we need that stream of revenue
flowing from the Government of the United States so that we can
meet that health care obligation. But I think in no area is it
more important than dealing with substance abuse, and we have a
great deal of work to do.
Mr. Garcia. Thank you. Ms. Rosette?
Ms. Rosette. Yes. I would echo what Chief Hoskin said. We
are definitely subject matter experts of our own people. So, I
believe we would be providing culturally focused care and
traditional healing practices that no other type of healthcare
system would be able to provide, and we know our patients. So,
the best way to treat them is by knowing your patients. Thank
you.
Mr. Garcia. Thank you for that. I would like to ask Mr.
Cortez. First, thank you for your courage in coming here to
tell your story. It must be so powerful for those struggling
with opioid addiction to know someone with your lived
experience and that you have their back.
I ask you to help us understand more about the process.
When someone seeks treatment to beat their addiction to
opioids, what are their struggles and how do you help them
overcome those struggles? And would you please walk us through
that process for you and for them, if you would?
Mr. Cortez. Yes. Thank you for that. A lot of times they
just want to be heard, so just listening to them, building that
relationship, letting them know that you are going to walk
beside them whether they succeed or fail, identifying their
strengths. I let them know that I care.
A lot of times they have been through a lot all their life
through trauma. That is something that is not said enough, that
I care. So, helping them, bringing them to the lodge, helping
them to get that healing. A lot of times they are not ready to
surrender. Dealing with opiates, it is hard dealing with that.
It is not easy to take that first step. They have to want it.
Dealing with it from my lived experience, it took me over
30 some years just to overcome that. It was a lot to process.
But for me, not giving up on my people, being there for them,
educating them to what is out there, just encouraging them that
they do have a purpose in life, in a traditional way and as a
tribal member, but also as a friend. You have to build that
relationship with them. It is very important that consistency
is there, because a lot of times they were abandoned. So, not
to give up on them. Yes. Thank you.
Mr. Garcia. Thank you for that. And very briefly, I want to
ask Ms. Rosette, what services could Urban Indian Organizations
provide to fight opioid addiction if we had more funding?
Ms. Rosette. Again, we would be providing culturally
focused care and traditional healing practices that are
tailored to combat the specific health disparity of Indian
health programs. And the problem with us is the money always.
We have to be able to hire more people. We only get 1 percent
of the IHS budget so that is the problem. We don't get enough
resources ever because we are Urban Indian Organizations.
Mr. Garcia. Thank you for that. I would now like to
recognize the Ranking Member for his time to ask questions.
Representative Moore.
Mr. Moore. Thank you, Mr. Garcia. Mr. Del Cueto, thanks for
taking the time just to be here today. Thanks for sharing with
this Committee the reality of your experience, the reality of
President Biden's border policies--that simple changes were
made that increased volume in all sorts of different areas from
just the amount of traffic with respect to drugs, as well
coming across our southern border.
Your testimony describes the gaps in coverage that are
created when agents are tasked with processing migrants. Can
you share how cartels exploit these gaps to bring drugs like
fentanyl, cocaine, and methamphetamine into our country?
Mr. Del Cueto. Yes, sir. Thank you, Ranking Member Moore.
What has been happening and happens frequently lately is the
cartels have been working the southern border, and they have
been working for quite some time. They control what comes in
through the gaps. They control what comes in specifically
between the ports of entry.
So, what they have been doing is knowing that if they bring
across large groups, agents are going to have to respond. They
are going to have to remove those individuals from that area,
they are going to have to take them to a processing center. The
cartels are aware of that. And they tell the illegal migrants
that are entering the country, you don't have to worry because
you are going to get released anyway.
So, they turn themselves in in large numbers. The cartels
wait for that to happen. As they see that Border Patrol agents
are now distracted or now have to deal with processing and
transporting these individuals at the processing sites, that is
when the drug cartels take full advantage to bring products
across, which is more drugs.
And I will add that at the same time, the number of got-
aways has gone up on the southern border. And it is then when
agents have been distracted, when agents are out in the
processing centers, that they'll bring in not only drugs, but
many, many other individuals that we know nothing about who
they are or what country they are.
It is causing a lot of problems, obviously, on the
reservation, specifically on the Tohono O'odham Reservation.
But those drugs are not just staying on the reservation, they
are going throughout the rest of America.
Mr. Moore. Thank you. Chair, I have two reports here, one
from the Drug Enforcement Agency and one from the Department of
the Interior, that simply highlight that the traffickers were
responsible for most illicit drugs on Indian reservations. And
they also detail how Mexican TCOs, these criminal
organizations, took advantage of reservation land.
We would like to submit these two reports for the record.
Mr. Garcia. No objection.
Mr. Moore. Thank you. And Mr. Del Cueto, continuing on with
that, based on your work on the Tucson Sector of the southern
border, can you describe how drug smuggling activities have
impacted the TO Nation?
Mr. Del Cueto. It has impacted it in many ways. You see the
individuals on the reservation themselves that are involved in
the illicit drugs. I talk to the people down here all the time.
And as I said earlier in my statement, I grew up here. I grew
up down here on this land. I grew up right next to the Tohono
O'odham Reservation.
And you speak to them and you see them, and they will tell
you themselves that there is a problem. They don't want to be
caught in that situation. They don't want to be involved in
drugs. But, unfortunately, the government doesn't do enough to
allow Border Patrol to work those areas, to work that land.
If you look at some of the gaps that have been done, when
the wall was being built down on the southern border, that area
on the Tohono O'odham Nation, the wall wasn't built and there
are several gaps.
Now, a lot of people are going to say that the walls
wouldn't have stopped a lot of it anyway. But the reality is it
would create a funnel, and then it allows the agency to be able
to use their resources and put them in areas where it can help.
Right now, the Tohono O'odham Nation is a bonanza for the drug
cartels bringing heroin, meth, and fentanyl into our country.
Mr. Moore. Thank you for that perspective. Mr. Cortez, I
wanted to just finish. I just want to say sincerely thank you
for your candid testimony. This is affecting numerous different
tribes across various reservations--we have seen the Lummi
Nation, the Blackfeet Nation. All have quotes that this is the
worst one yet.
You are getting at the point we are trying to make. We
can't just throw money at the problem. We really have to stop
the flow. Any last, additional thoughts to share about how
stopping the flow can help improve this situation?
Mr. Cortez. That has to come within the tribe. That has to
come with a lot of the tribal members when they have their
general meetings. They have to bring awareness of what is going
on. They can't just brush it under the rug.
It comes from a lot of tribal members marrying outside
their race. That creates an avenue, they get caught up in it,
they get manipulated in it. So, that is a hard one, it really
is a hard one. We just have to really bring more of an
understanding of what is going on, because it is not going to
stop.
The way things are now, the way I look at it, it is always
going to be there. We can slow it down. They are going to find
other ways to do it. It is a moneymaker for them. But for the
Native community, we have to step up to the plate. We have to
bring more structure for our reservations. We have to police
our reservations.
And they are doing it. They are doing it the best they can.
I love my people, all nations. But the fact is that you will
get a couple of them out there that go outside the
reservations, and they will bring that in there. But it is our
job, that is all I have to say. Thank you very much.
Mr. Moore. Thank you so much. I yield back.
Mr. Garcia. Thank you, Ranking Member Moore. We are going
to go to Round 2 of the question and answer period. I would
like to begin by coming back to Chief Hoskin and to ask you,
regarding your settlement money from the opioid litigation that
you won from opioid distributors, you could have invested it in
any number of ways to help the Cherokee. Why did you choose to
use that money to build a clinic?
Mr. Hoskin. Representative, our goal is to build a
comprehensive behavioral health system in the Cherokee Nation
with a focus on addiction treatment using the latest and best
practices. Investing in capital projects is a great use of
those limited opioid industry settlement funds.
At Cherokee Nation, we do a great deal of contracting out
of our addiction treatment. In other words, we look to third
parties to provide that treatment. In many cases, it is very
good.
But as I mentioned in the response to the earlier question,
directly delivering healthcare services to the Cherokee people
by the Cherokee people is the best regardless of ailment. And
in the case of addiction treatment, there is something
particularly important about Cherokees delivering it to
Cherokees because of our shared experience in history.
We want to create a system in terms of addiction treatments
that provides not only the initial detox type response to
addiction, but a long-term commitment to healing. And that
includes residential treatment programs, that includes getting
people back into the workforce, and that includes making sure
that moms and dads can be with their children as they are going
through recovery when the setting and situation is appropriate.
So, these opioid industry dollars will go to build those
clinics because I think it is the most effective long-term
strategy--Cherokees taking care of Cherokees.
I should mention that of the opioid settlements, as I
mentioned in my testimony, $15 million I have proposed to our
council, our legislative branch, over the next 3 years to start
building some of these facilities. That won't be enough. That
is a minimum number. We will commit more of those opioid
settlement dollars to these efforts. But it is a start, and it
is a start down a path of healing.
I should also mention in that same legislation I have
proposed to our council, not using the opioid dollars but using
our own third-party revenues, we are actually starting a harm-
reduction program. We are taking an all-of-the-above approach
to addressing addiction, and I think we are leaders in that
regard in Indian Country.
We think this investment of opioid settlement dollars will
yield so much in a return on investment in the form of opening
up opportunities for our people. Because the opioid epidemic
has foreclosed so many opportunities for individuals and really
suppressed us collectively, we can change that by making these
investments.
Mr. Garcia. Thank you for that. And if I could just
piggyback one more related question on this vein. What opioid
recovery services could the Cherokee provide, if the Federal
Government's fiduciary trust obligation was fully met?
Mr. Hoskin. Well, certainly, if we had additional operating
dollars, in particular, we could start, for example, with
children. I mean that is where we find in Indian Country, and I
think all over the world, you find the greatest hope for your
people is in the children. But you also know that children can
go down a path that leads them into the same type of
challenges, including addiction, that the generation before
them are dealing with.
So, getting involved early in terms of education and
prevention is important. Peer recovery is something I would
like to see us do more in the Cherokee Nation. I visited our
brothers and sisters in the Eastern Band and saw what they were
doing in terms of providing addiction treatment. And, often, it
involved staff members or even volunteers that themselves were
recovering from addiction.
But there is something very powerful about utilizing people
who had been through that direct trauma to provide services to
their brothers and sisters. And I think we can do more of that
if we had additional operating dollars, and I am very
optimistic in that regard. So, focusing on youth and focusing
on peer counseling. There is a host of other things we can do.
These facilities that we are building will take a great deal of
staff. Recruiting, recruiting people into these professions is
also key.
Congressman, I can build all the buildings in the world,
but if I can't fill them with the best and brightest of staff
and retain them, I have really not done what we need to do. We
have not done what we need to do. So, recruiting talent and
creating that pipeline of professionals, that is key for Indian
Country. I think the Government of the United States can help
us in that regard.
Mr. Garcia. Thank you for that. Now I would like to ask the
Ranking Member if he has more questions.
Mr. Moore. Thank you again, Mr. Garcia. Yes. I do have a
few more questions I will jump into for our witness, Mr. Del
Cueto.
I mentioned Utah in my opening statement. And as I have
been in my community and going to the doctor's office--I have
young kids, so we tend to be there more often than I would
like--I see a lot of communication. I see posters about this. I
see it is more palpable, everything related to opioids and the
potential negative effects and side effects of this.
So, I am proud of that. I think that is something to
celebrate. I think that is something that we have done well in
this society over the last 6 or 7 years. But the point we are
trying to make today is that no amount of additional spending,
or no additional advertising, or physicians being more hyper-
focused on this with their individual patients can overcome the
amount of volume that we have seen at our borders over the last
year, a 1,066 percent increase.
The South Texas ports of entry reported seizing 588 pounds
of fentanyl, a 1,066 percent increase compared to FY 2020. I
mean that is astronomical, right? And that is the point that we
are trying to make. Increased education, yes. We need to be
doing better as a society. We need to be talking about this
more with our families. Absolutely. Particularly on the
reservations, we need to keep seeing the momentum that we have
seen. But that amount of increase is unsustainable to curb this
problem.
So, again, Mr. Del Cueto, in your opinion, if President
Biden does not change his policies, will these drugs remain
readily available to be sold on the illegal drug market?
Mr. Del Cueto. Ranking Member Moore, we have seen the
increase. Obviously, what we talk about is the increase in what
we have seized, the increase in the apprehensions, and they are
astronomical. But what people need to continue to concentrate
on, and some people forget, is with these huge amounts of
seizures, there are huge amounts that are getting through. The
drugs are still cheap which means there is a lot of it coming
through. And that is a direct effect because of the lack of
border security created by the current administration.
And I will go on to say, and I have said it many times
before, it has nothing to do with whether you are on the right
side of the aisle or the left side of the aisle. At the end of
the day, we all lock our doors at night. We all want security
for our families. The reservation wants security for their
tribal members. We want security for Americans.
The cartels do not care who we voted for. The cartels do
not care who is in office. The cartels just want to bring their
drugs across. And if we need security in our homes, and we care
about security of our homes, and we lock our doors at night,
there should be no difference with our borders. This is a
nation of laws, and we need to feel secure in this country.
Mr. Moore. Thank you for that. I will also highlight Mr.
Cortez' comments too, where he mentioned there is no
discrimination with the cartels, and these drugs do not
discriminate. They are an equal-opportunity aggressor on our
communities.
And I guess one last question that I will ask with my time
is, can you describe for the Committee the ways in which
cartels smuggle drugs across the border? And from your
experience, very simply, do they use vehicles or send drugs
with migrants attempting to illegally enter our country? Just
give some perspective there.
Mr. Del Cueto. The cartels, they don't care. They will use
vehicles to come across in between the ports. They will try to
smuggle drugs at the ports of entry. They will use females and
males as body carriers, where they will carry the drug inside
their bodies. They will use children. They will use anything
they can to bring drugs into this country because they simply
do not care. It is a profit for them. And they see when there
is an administration that is allowing that profit to grow by
weak border security policies.
Mr. Moore. And with respect to profits?
Mr. Del Cueto. Monetary profit.
Mr. Moore. Cartels, do you see that they are still able to
profit off of this ongoing activity? Has that been curbed in
any way or is that getting worse?
Mr. Del Cueto. It has gotten worse over the last year. And
as I said, it doesn't just show with the amount that is being
apprehended and the seizures. Obviously, there is a lot of it
getting away. The got-away numbers themselves have gone up on
the southern border. And that is a direct effect of the cartels
distracting agents from one area so they can bring their drugs
into gaps.
Mr. Moore. Thank you so much. I appreciate it. I yield
back.
Mr. Del Cueto. Thank you.
Mr. Garcia. Thank you, Ranking Member Moore. The Chair next
would recognize Representative Stansbury.
Ms. Stansbury. Thank you so much to Chair Porter,
Representative Garcia, and also to our Ranking Member for
convening this important hearing on such an important topic. I
also want to thank all of our witnesses for joining us today
and sharing your stories and your work to serve and protect the
health and well-being of our communities.
New Mexico is ground zero for the opioid epidemic. We have
one of the highest rates of drug overdose in the United States.
In some New Mexico counties, the overdose rates are more than
five times the national rate. In 2019 alone, we lost 605 New
Mexicans to drug overdoses.
That is 605 family members, brothers, sisters, parents,
children, co-workers and neighbors. And every single one of
those lives lost was a preventable tragedy. A person who was
loved, who was cared for, a part of the fabric of their
communities. Opioid addiction touches nearly every New Mexican
life. Nearly two-thirds of our population knows someone who is
addicted to opioids, including myself.
In fact, in 2019, my life was personally changed forever by
the opioid epidemic, as I lost one of my oldest friends to a
fentanyl overdose. An artist, a father, a friend, someone who
became addicted like millions of Americans after he received a
prescription from his doctor.
His story was unique, but also like that of thousands of
people across our communities and the tragedies that we have
heard about today, and that we hear about every single day
across the country and across our tribal communities.
Our tribes, our pueblos, our governments, and law
enforcement are working every day to address this crisis, to
stem the flow of drugs into our communities and the public
safety crisis that is emerged from it, to address the crisis of
addiction that is touching every member of our communities, and
to provide opportunities for healing and addiction recovery.
But the system is broken, and we need action now. And that
is why it is crucial that this body pass legislation and
meaningful budgets that will help to enable our communities to
fight this crisis at home. Already in this chamber, several
bills have been introduced that would help to support our
tribal communities. For example, Representative Maloney's Care
Act would award grants to tribes who are disproportionately
impacted by high drug overdose rates and help to distribute
opioid reversal drugs for tribal communities.
I am also proud to co-sponsor Representative Tonko's
Mainstreaming Addiction Treatment Act which would help
community health workers treat substance abuse disorders in
their own communities. And within New Mexico, our office is
working every day to try to identify how to address the public
safety and the public health crisis that has emerged around the
opioid epidemic.
But in order to address this crisis across our tribal
communities, we need an approach that is community centered,
that is culturally relevant, that empowers our communities to
make the changes on the ground that they need, whether that is
in law enforcement, in youth opportunities, in healthcare
services, and in healing opportunities for our communities.
So, with that in mind, Mr. Chairman, I would like to ask
Ms. Rosette because of the important work that you do,
especially with our Urban Indian Organizations, can you please
take just a moment to share with us some of the things that you
think that this body can do to help support your work on the
ground?
Ms. Rosette. Well, first, thank you for the question. And
as I stated in my testimony, it is to include Urban Indian
Organizations in the legislation. Funding is always an obstacle
for us. Grants like the State Opioid Response Grant would allow
us to provide culturally appropriate treatment in our
community, but we were not included. You have to specifically
say urban along with tribal. Otherwise, we are not allowed to
get the funding.
So, that is what needs to happen to be included in all
these funding grants. Include urban and tribal, and then that
would assist us with creating the services that are needed to
help with this crisis.
Ms. Stansbury. Thank you so much. And for any other members
of the panel, are there any additional items that you feel very
strongly that this body can do to help support your work on the
ground? Folks are being shy here.
So, I will just wrap up my comments here and say thank you
for your service and for the important work that you do. And I
want to thank the Chairman and Ranking Member for convening
this important hearing. It is clear that we have to do
everything possible to help empower our communities to provide
resources and to address this crisis. Thank you. With that, I
yield back.
Mr. Garcia. Thank you, Representative Stansbury. Before we
go to Round 3 of questions and answers, I just want to point
out that the steady increase in fentanyl at the border started
in 2016 and increased steadily under President Trump. So, this
is not a Biden problem. This is a fentanyl problem that we have
to grapple with.
I would like to now go to Round 3, and I have a couple of
questions. Again, back to Chief Hoskin. Can you please explain
the roles of pharmaceutical distributors and manufacturers in
the tribal opioid crisis? If doctors are prescribing the pills
and controlling their distribution, how did the situation get
out of control?
Mr. Hoskin. Thank you, Congressman. It is a fair and
natural question to ask if doctors are involved as a point of
contact in the prescribing of these drugs. How does that
interplay with the opioid industry? What we know is that
doctors don't have a particular idea of other doctors writing
the same prescriptions. We know that.
But we also know that the opioid industry, the
pharmaceutical chains and providers, in particular, had or
should have had checks in place. In fact, there are checks in
place that should have been adhered to in limiting the
distribution of these drugs. There should have been flags.
There were flags that were raised. They were ignored. They
were ignored because of profit. They were ignored because the
distributors and manufacturers knew full well the communities
they were impacting. I am talking, of course, about tribal
communities, but you could go to other marginalized communities
in this country and find a similar targeting.
I believe that Indian Country was targeted, and I believe
Cherokee Nation communities were targeted. And I think the
stats, in many ways, speak for themselves. As I mentioned in my
testimony, when you have this deluge of pills coming into the
reservation, such that you have 153 pills in 1 year for every
man, woman, and child in the Cherokee Nation Reservation, that
is indicative of an industry that is driven by profit, not
care.
So, I would submit that that is the problem. We are getting
some measure of justice through our historic litigation. And I
have to say that building drug treatment centers using the very
funds we have finally extracted from this industry gives us
some satisfaction. But more than satisfaction, it gives us a
path toward hope.
If we can couple that with increased funding streams from
the Government of the United States that allow us to do what we
can do, which is to bring healing to our people, I think we can
get on the way again to that idea of holistic healing that
Indian Country needs, Cherokee Nation, in particular, needs.
Mr. Garcia. Thank you for that. Now I would like to turn to
Ms. Rosette. When we think about the impacts of opioids, we
typically think about death and addiction. Does opioid
addiction cause disabilities among American Indian and Alaskan
Natives as well, and what are they?
Ms. Rosette. Can you repeat that, please? I am sorry.
Mr. Garcia. Yes. Usually, when we think about opioid
addiction, we think about death and addition. But my question
is with the opioid crisis, is this causing disabilities among
the American Indian or Alaskan Native population as well?
Ms. Rosette. I believe it is. I believe there would be--my
answer, I need more time to think about it really, because that
came out of nowhere. I used to deal with clients that had that.
And, oftentimes, it created some mental health conditions or
they went hand in hand. So, there is that, and they were not
able to work. So, there are disabilities, but it depends on the
length, I guess, and how hard it hit them. So, there are lots
of answers to that, I guess, and I believe there are other
disabilities.
Mr. Garcia. OK. Thank you. And one final quick question for
Chief Hoskin. In your testimony, you said that between 2015 and
2016, there were enough opioid pills to give every man, woman,
and child on your land 153 pills each. Did those pills come
illegally over the border?
Mr. Hoskin. Mr. Chairman, not to my knowledge. I mean our
focus has been on the source of the pills coming from your
neighborhood pharmacy or more often, because of their size, the
chains. I am assuming that Walgreens didn't get their pills
from across the border. I am assuming they got them from normal
distribution channels.
We have had to check that enormous amount of pills coming
into the Cherokee Reservation from businesses and corporations
that have seen fit to profit off the pain imposed by their own
actions.
Mr. Garcia. Thank you, sir. The Chair now recognizes the
Ranking Member for a third round.
Mr. Moore. Mr. Chair, may I ask that the gentleman from
Texas, Tony Gonzales, go first? Is that possible?
Mr. Garcia. Absolutely. The gentleman from Texas, Mr.
Gonzales, is recognized.
Mr. Gonzales. Thank you, Chairman. And thank you, Ranking
Member, for allowing me to be on this hearing today. I
represent 42 percent of the southern border. A large part in
this crisis is forefront in everything that I see. And one of
the things that I see regularly is the coordination between
Border Patrol agents and tribes and pueblos. I represent part
of the Tiguas out in El Paso County.
My question is for Mr. Del Cueto. Part of what worries me
is the morale of the Border Patrol Agency in general. Can you
describe the toll the policies have had on the Border Patrol
agents that you work with? What is morale like?
And I will just preface that--on Christmas day, I did a
swing through the district, visited six different stations,
three different sectors, and one of the things I heard was
Border Patrol agents, in particular, have a mandatory 6-day
overtime. And I don't care what line of work you are in, if you
are working 6 days with no end in sight, that has to cause some
damage.
But what is the morale like there in Border Patrol with
this crisis?
Mr. Del Cueto. Well, to be honest, yes, it is a 6-day of
overtime that they are working, but it is not to be out there
on the field protecting our nation's borders. It is more so to
be processing the huge number of individuals that have come
into the country. And, yes, there has been a problem with drugs
coming through the Tohono O'odham Nation, and different
nations, and the southern border for quite some time.
But now, when you look at it, everything you see on the
news, it is constantly one load after another load of either
fentanyl or heroin or cocaine. It has gone through more
astronomical numbers than it ever has before. And it is evident
because you have agents that are too busy having to do the
processing. Because the cartels, as I said, they know what they
are doing.
Listen, I have been down here my whole life. I have seen
it. I have seen it through different administrations. This is
the worst we have seen. The agents have shown it. The agents
are fed up. They are tired. We have agents that are leaving the
agency more than before.
You speak to them constantly and they say, we can't hold up
at this pace. A couple of years ago, individuals were worried
of whether they were going to call it a crisis. Should we call
it a crisis? Should we call it chaos? I don't think it matters
at this point what we are going to call it. There are too many
individuals that have been dying on both sides of the border.
There are too many individuals, Americans as a whole, that have
been dying. And something needs to be done.
And when you look at the policies that are currently going
on, of the Catch and Release, and you are seeing huge numbers
of individuals from all over the world that are coming across,
some of them they will stay on the border themselves. You will
have agents that will come to the line. They will transport
them to areas so they can process them. And the rest of the
group, they stay there. They don't even leave. They stay there.
And they say I am just waiting for the ride. The agents that
picked up the other group are coming right back to pick up the
other group.
Mr. Gonzales. Yes. I appreciate all the hard work that your
agents are doing to keep us all safe. You know my next question
is about coordination. Can you speak a little bit about what
kind of coordination that you have with tribes or pueblos? And
once again, I will go back to the Tiguas because they represent
a portion of that border area. And they are always talking
about some of the coordination that the Border Patrol has. I am
curious, how are things going on that end?
Mr. Del Cueto. So, you obviously have coordination. There
are different radio communications that could be a problem at
times.
And I will just share this story with you. Just a couple of
weeks ago, Border Patrol was trying to stop a vehicle that was
known to be smuggling individuals coming across the border. As
they were behind that vehicle, the driver of the vehicle, at 80
miles an hour on the Tohono O'odham Reservation, decided to
start throwing the individuals he was transporting out the
vehicle while he was still moving.
Agents had to stop and assist these individuals. Obviously,
they had to have medical attention. The Tohono O'odham
Reservation assisted. They later found that vehicle abandoned
in one of the villages with a weapon inside the car. I do not
know, or I do not believe that the individual that was driving
has been captured.
But that is something that we see here every day. It is not
the numbers. It is not who is coming across and who is not. We
are seeing the chaos on the border. We are seeing the chaos on
the nation. And there has never been a time more chaotic than
there has been during this administration.
Mr. Gonzales. Well, thank you Agent Del Cueto, and thank
you, Chairman, for the time and the opportunity to be at this
hearing today. And I yield back.
Mr. Garcia. Thank you, Mr. Gonzales. The Chair would next
recognize Mr. Westerman.
Mr. Westerman. Thank you, Mr. Chair. And thank you to the
witnesses. And thank you for at least having a hybrid hearing
today.
The border crisis is exacerbating our nation's opioid
crisis. And I think with all the other crises going on in the
world, it is kind of masking what is really happening at the
border. We are not only facing a surging number of migrants but
increasing amounts of illicit substances.
And as has already been stated in here, fentanyl is one of
those substances that is doing great damage in our country. And
to think that we have apprehended enough fentanyl to give a
lethal dose to every American citizen is just outrageous.
And, Mr. Del Cueto, the deadly drug, we know a lethal dose
can be just 2 milligrams. This seems to me like not just a
national security issue, but a public safety issue. Can you
describe the concerns that you have specifically about fentanyl
flowing into our country?
Mr. Del Cueto. Obviously, the deaths that we have spoken
about. But at the same time, you have agents that are out there
having to arrest these people. They are having to deal with
some of the fentanyl that they seize. There are a limited
number of NARCAN setups out there, which is pretty much the
injection that you would get if you were directly in contact
with fentanyl.
We see the problem constantly. We see it at the
checkpoints. You open up the news, and you constantly see body
carriers coming across. And, yes, there are pills. It is in
powder form. There are different ways that they are bringing it
across. And as somebody else on the panel spoke earlier, that
it is hard to tell where it is coming from.
But I can tell you by being down here, I am seeing the
number of those illicit drugs coming through our southern
border higher than they have ever been before.
Mr. Westerman. And that was going to be a question I asked
you. Do you see it improving or getting worse? And, obviously,
it is getting worse. And we talk a lot about hockey stick
charts in this Committee.
How steep is the increase, from your experience, on the
number of illicit drugs that are being seized? And what would
you say is the No. 1 driving force behind this increase?
Mr. Del Cueto. I would have to look into the numbers
specifically to give you a percentage. I don't have those
numbers so I can't give them to you--I would hate to give you a
number that was incorrect. But I can tell you that we are
seeing a huge amount compared to other years, and a lot of it
is because agents are being distracted. And I will add that,
yes, a lot of people focus on what is being detained. And they
say, hey, the numbers of what is being seized is huge, which is
correct.
But at the same time, when you are seeing the amount of
got-aways that are coming through our border, and then you
realize that a lot of these got-aways, they are waiting for
agents to be out of the area. So, the cartels are the ones that
are directly sending them across. The number that is getting
through is astronomical.
Mr. Westerman. Right.
Mr. Del Cueto. And it is like this because they are all
working with the cartels themselves.
Mr. Westerman. But do you see a correlation between the
number of illegal migrants that you are detaining, along with
the number of the quantity of illegal drugs that is being
stopped at the border?
Mr. Del Cueto. Most definitely. We hear the term so often
Catch and Release. Individuals are coming across. They realize
that if they come in big numbers, they will have to distract
the agents from the areas that they are working. Now they have
to transport them.
During that entire time, there are gaps on our southern
border. And those gaps are the ones that are utilized by the
cartels. They are exploited by the cartels, not just with
illegal drugs coming across, but the sex trafficking, the human
trafficking, the unaccompanied children.
They will distract agents with unaccompanied children. They
will drop a huge group of unaccompanied children in one area,
knowing agents are having to respond to there. Now they are
having to transport them. All the while as they leave, you see
the got-way numbers go up. And that is where some of these
other individuals are coming across and/or the drugs.
Mr. Westerman. And if the administration goes through with
their current plans on the border, what do you expect to see
happen to both the number of illegal migrants and the amount of
fentanyl coming across the border?
Mr. Del Cueto. It will become a free-for-all. And,
basically, what will be happening is we will be handing over
the key to the front door to the drug traffickers, to the human
traffickers, and the sex trafficking in this country.
Mr. Westerman. Yes. I am out of time but thank you for what
you and all your colleagues do. I have been to the border
several times, and it is just even more eye-opening every time
I go. And I think if the general public could see what we see
as Members of Congress, there would be a huge outrage about
what is happening on the southern border and our policies
there. I yield back.
Mr. Garcia. The gentleman yields back. Mr. Gohmert of Texas
is recognized.
Mr. Gohmert. Thank you, Mr. Chairman. Mr. Del Cueto, with
regard to border states, in particular Arizona, you do have
part of our international border with Mexico that runs through
tribal lands there were in Arizona. Are you familiar with that
area?
Mr. Del Cueto. I am, Congressman. That is the area I
specifically have been working for over 18 years. That is the
Tohono O'odham Nation. It is over 60 linear miles with the
Mexican border.
Mr. Gohmert. Have you seen any problems with the drug
cartels using that area for bringing in drugs?
Mr. Del Cueto. Definitely. They scout. They put scouts on
both sides of the border many times in order so they can
coordinate the drug trafficking that they are bringing into the
United States. It happens continuously. And they exploit that
area specifically because they know the barrier in that area is
less than anywhere else, specifically in the Tucson Sector.
And at the same time, there are different gaps that they
can get through. There are different villages that they utilize
on tribal land to assist them with bringing their drugs across.
Mr. Gohmert. Is there a difference in Border Patrol's
ability to patrol that area of the border that runs through
tribal lands, as opposed to those areas that are with Arizona,
New Mexico, Texas, or California?
Mr. Del Cueto. When you are working with tribal land, there
are different roles. There are different things that you must
respect. Some of it is sacred land that they are very proud of,
which is very much understandable. So, there are different ways
that you have to go about patrolling in those spots.
There is also limited coverage at times when it comes to
radio traffic because you can't just put towers wherever you
want. So, definitely it is a different way to work there. A lot
of the agents out there, they are still using the old method of
tracking. They track the drug smugglers through. Many times,
they will be tracking drug smugglers all the way to some kind
of highway where they lose track of them, and those are some of
our got-aways.
There are different methods that they use to track to be
able to recognize if some of these individuals may be carrying
backpacks of drugs or regular backpacks. There are just
different methods. I would hate to go into it because I don't
want to give any more information to the drug traffickers
themselves so they can know what we are looking for.
Mr. Gohmert. Well, do you see any solutions that should be
pursued that are not being in that area?
Mr. Del Cueto. Definitely.
Mr. Gohmert. That you care to tell us about?
Mr. Del Cueto. Obviously, more funding when it comes to
some kind of barriers that you can funnel individuals in the
correct place. That is a huge plus. More prosecutions of the
individuals when they do get detained and get arrested. And at
the same time, you have to apply other immigration policies. It
is a domino effect.
But when you are telling individuals that they can enter
this country illegally and there will be no consequences for
their actions, that is pretty much inviting people to come here
and break the law, and the cartels are aware of that.
So, obviously, the Remain in Mexico policy is something
huge. Maybe bring some more immigration judges and/or asylum
officers down there so they can see a lot of these cases for
asylum are not true asylum claims. And that way, they can have
agents actually working these areas to stop the flow of drugs
that are entering our country.
Mr. Gohmert. Do you think it would help to have immigration
judges right there on the border working in shifts so that you
could give people immediate hearings as soon as they were
obtained or taken in custody?
Mr. Del Cueto. Definitely. When you do something like that,
you send a clear message to the drug smugglers. You send a
clear message to the human smugglers that the United States is
not going to tolerate individuals just false claiming to come
into the United States.
When you do that, it will lower the flow. And I know people
get upset, but the reality is when President Trump first took
over office, he lowered those numbers just by rhetoric alone.
Right now, rhetoric is not going to do it. We need policies
that are going to affect this change. And we owe that to the
tribal people that are on this panel. We owe it to the tribal
lands. We owe it to all Americans, frankly. And, again, the
cartels don't care.
Mr. Gohmert. One last question very quickly, though. Does
that affect just the areas on the border, or does it affect the
whole country?
Mr. Del Cueto. It affects the entire country. The drug
cartels are making money off of people in the entire country.
They transport their drugs everywhere in the United States.
Mr. Gohmert. Thank you very much. I appreciate all you do
for us.
Mr. Del Cueto. Thank you.
Mr. Garcia. The gentleman yields. The Chair will now
recognize Ranking Member Moore.
Mr. Moore. Thank you again, Chair. Let me reiterate just
one more time that we are not denying that there is a role that
pharmaceutical companies can play in improving the situation.
And I think we have seen that play out over the last several
years.
What we are trying to hit, the point we are trying to
continue to make, is that the abundance of drugs coming across
our southern border will make it so we can't get out ahead of
this issue. That it will continually be compounded on itself.
And not just border states, but every state in our nation will
continually face this epidemic.
And I will read from this--President Biden's DEA
Administrator Appointee, Anne Milgram, stated in the alert that
we have here, ``The United States is facing an unprecedented
crisis of overdose deaths fueled by illegally manufactured
fentanyl. DEA is focusing resources on taking down the violent
drug traffickers causing the greatest harm.'' OK. That is
President Biden's appointee in the DEA.
And, Mr. Del Cueto, I want to continue talking about
solutions, but focus it specifically on how the DEA can best
support Border Patrol agents. Could you share with us your
thoughts on, again, how the DEA can best support Border Patrol
agents?
Mr. Del Cueto. I think a lot of it could happen if there
was more communication and more working together with this.
Obviously, it is two different entities, it is two different
departments. But we have to work hand in hand, as I have said.
It is not something that just one particular party is going to
help. And the cartels don't care what party you are at.
I know I have done several different tours out here on the
southern border. We have gone down to the Tohono O'odham Nation
many times. Congressman, some of them that have spoken here
today, they have taken that trip. They have seen the problem.
And they can see the gaps that are happening. They can see what
is coming through. And it is going to take a joint effort, not
just by Border Patrol and DEA, it is going to take a joint
effort by all individuals that actually truly want to do
something about it.
It is a hard subject because people, they get upset or they
look at one thing about the traffic from human traffic that is
coming through the border, but it goes hand in hand. It is a
domino effect.
And I have said it many times, and I will continue saying
it. We owe it to the future of Americans. Illegal is not a
race. It comes down to we all need to get together. And if we
really care about stopping the flow of drugs, we are going to
have to focus on policies that have been enacted allowing
individuals to come across the border without any consequences.
Mr. Moore. And we will see from many of my colleagues. Not
just from border states, but we have seen a direct call for two
of these policies that you mentioned. Particularly, I will
mention the Remain in Mexico policy. This should not have been
a hyper partisan issue.
This should have been something that President Biden was
willing to embrace for the exact reasons that we are talking
about today. From our witness, Mr. Del Cueto, and from the
Majority's witness, Mr. Cortez, there is no discrimination of
this drug. It will hit everybody.
Those policies did not need to be hyper politicized. They
just needed to be enforced. And Title 42 is what is currently
taking place.
Do you have any thoughts on my last 60 seconds on those
particular two policies? And anything else that you would say
that would make the biggest difference to improve Border Patrol
agents' ability to secure our borders?
Mr. Del Cueto. Those two policies alone will have
tremendous impact. Because it will send a clear message that
you cannot just come across, claim asylum, and be released in
the United States, waiting for a court date later on. So, that
is a huge deal.
When you do that, the illegal alien flow in those areas
that are distracting agents will come down. And, thus, agents
will be able to interdict the fentanyl that is coming into our
country and killing Americans in every single state of our
country, not just on the border.
Mr. Moore. Thank you, sir. I yield back.
Mr. Garcia. The Ranking Member yields back. The Chair will
recognize Mr. Rosendale.
Mr. Rosendale. Thank you, Mr. Chair. First, I would like to
thank Chairman Porter, Acting Chair Garcia, and Ranking Member
Moore for putting this hearing on today. Also, thank you to all
the witnesses for joining us and for your testimony on this
important issue.
We have heard a lot of testimony today about how Big Pharma
is responsible for the opioid crisis and rampant drug addiction
in the United States. While these pharmaceutical companies may
share some of the blame, we cannot ignore the issue of our poor
southern border and raging border crisis.
Joe Biden's failed immigration policy has empowered Mexican
cartels to smuggle fentanyl and drugs across the southern
border undeterred, killing over 100,000 Americans last year
alone. Make no mistake, the border and immigration crisis in
our nation is at the worst point that we have ever seen.
I met with my State's Attorney General for the last 2
weeks, and he said that 100 percent of the fentanyl and
methamphetamine entering Montana is coming across the southern
border. In Fiscal Year 2021, 11,000 pounds of fentanyl was
seized by CBP, enough to give a lethal dose to every American.
And this year alone, 173 pounds has been confiscated at the
border.
Unfortunately, tribal communities do often face the brunt
of this burden in the fight against opioids and addiction. Mr.
Del Cueto, thank you so much for joining us again today. It is
always good to be with you. Thank you for securing our southern
border. Do you think that this will help tribal communities and
American communities by reducing the prevalence of fentanyl and
drugs securing our southern border?
Mr. Del Cueto. It most definitely will. We have seen it
before when different policies are enacted, the cartels, they
try to get a different way to bring their product across where
agents are able to interdict it. And right now, as I stated
earlier, it is a free-for-all. And getting rid of Title 42
authority is handing over the key to the drug cartels.
Mr. Rosendale. Do you get any feedback from the Attorney
Generals around our nation on what kind of time frame it takes
from these drugs to enter our country until they are being
distributed around the entire nation?
Mr. Del Cueto. I haven't gotten that feedback from them. I
don't know. Maybe the individuals that run the agency, they may
have gotten some type of feedback. I haven't. All I can testify
to is I see the amount of drugs that are coming through. You
see the issues that are happening throughout the country. You
see it in the news. And you know the drug cartels, they are
aware of policies that are enacted in the United States. And
they use whatever they can to bring their drugs across.
Right now, it happens to be the catching and releasing of
individuals and distracting agents from one area to the other
with a huge volume of people that they bring across.
Mr. Rosendale. Unfortunately, I have spoken with the
Attorney General about this issue. And, apparently, the cartels
are operating with the efficiency of UPS. And it takes
approximately 48 hours for those drugs to cross the southern
border before they are distributed around Montana.
Are there reasonable estimations of the amount of fentanyl
that came across the southern border that was not seized?
Mr. Del Cueto. There is not. And I know that is not a good
answer. But I will tell you what often happens is the way you
track the got-aways, one, it could be used with sensor, and it
could be used with cameras. But, oftentimes, the drug cartels
are aware of where some of these things are. So, they will go
through different areas. It could be as rudimentary as just
counting footprints in the sand.
So, it is a guesstimate on the number of got-aways, and it
would be a complete guesstimate on the amount of drugs that are
coming through. However, when you see that the price of
fentanyl, the price of heroin, the price of meth is still cheap
in America, that is because there is a huge supply coming
through.
Mr. Rosendale. What are the relationships that CBP has with
the tribal law enforcement and what can be done to improve
those to try to get some kind of collaboration in the law
enforcement efforts to reduce this fentanyl problem?
Mr. Del Cueto. It comes down to, obviously, you are dealing
with Federal lands. But when agents arrest some of these
individuals that are bringing drugs into the country, if it
would fail to meet any prosecution guideline within the Federal
Government, that the local tribal land might be able to take
over the case.
Mr. Rosendale. Very good. And as the conditions continue to
deteriorate as we speak, what would you take as your main
priority message to this body?
Mr. Del Cueto. We need to enact policies or bring back
policies that were under effect before that lowers the amount
of individuals coming across because there are actually
consequences for them. And as always, if anybody wants to come
down here, I know you and several other Congressmen have taken
me up on the offer, and they have come down here, and they have
seen the reality.
When you come down here and you see the reality of what is
happening and how those gaps have been made under the current
administration, perhaps individuals will see the difference.
Mr. Rosendale. Thank you so much. And, Mr. Chair, I would
yield back.
Mr. Garcia. The gentleman yields back. A little food for
thought. Drug smugglers themselves, with respect to this topic,
tell a different story. El Chapo's cartel members testified
that they move high value drugs through ports of entry, not
across the border. The numbers back that up. Border Patrol
agents, for example, seized 332 pounds of fentanyl in 2018,
while customs officers at ports seized 1,357 pounds.
Again, this is not a border problem. This is an opioid
problem, so just to enrich the conversation.
But before we conclude with this witness panel, are there
any Members who have not had their 5 minutes who seek
recognition to ask questions now?
If not, I thank the witnesses for their valuable testimony
and the Members for their questions. The members of the
Committee may have some additional questions for the witnesses.
And we will ask you to respond to these in writing under
Committee Rule 3(o).
Members of the Committee must submit questions within 3
business days following the hearing, and the hearing record
will be held open for 10 business days for these responses.
If there is no further business, without objection, the
Committee stands adjourned.
[Whereupon, at 11:40 a.m., the Subcommittee was adjourned.]
[ADDITIONAL MATERIALS SUBMITTED FOR THE RECORD]
Prepared Statement of the Hon. Steve Cohen, a Representative in
Congress from the State of Tennessee
Thank you, Chair Porter, Ranking Member Moore, Chairman Grijalva
and Ranking Member Westerman for holding this important hearing.
The opioid crisis in our country has unfortunately affected
millions. The crisis is more profound in minority communities--black,
Hispanic, and Native American--than in white communities.
Unfortunately, the data is not much of a surprise. Those communities
have higher rates of co-morbidities and have historically received less
funding for health care. The Native American Community is a prime
example of the underfunding.
The Indian Health Service (IHS) has traditionally been underfunded,
especially when compared to other health care programs: Medicare spends
$13,257 per beneficiary, the Department of Veterans Affairs spends,
$9,574, and Medicaid spends $8,093. Yet, the IHS spending per user is a
paltry $3,779.
Under President Biden and a democratic majority in the House and
Senate, the IHS has seen an increase in funding. In Fiscal Year (FY)
2021, it was funded at $6.2 billion. In the FY22 Omnibus that we passed
and was signed into law in March, the IHS received $7.61 billion, an
increase of $1.38 billion, or 22 percent more. For FY23, President
Biden's budget request recommends $9.1 billion, a $1.5 billion increase
over the enacted level for FY22, another 20 percent increase. It would
also move the IHS from discretionary spending to mandatory spending.
Despite these increases, total IHS per beneficiary will still be at
$5,500, approximately 2/3 of what was spent per Medicaid beneficiary in
2021.
I am hopeful that Congress will find the will to continually expand
the IHS so that it is more in line with other public health programs
and can fulfill its mission to ensure the highest possible health
status for Indians and urban Indians. It's the right thing to do.
______
Statement for the Record
National Indian Health Board
Good morning, Chairman Porter, Ranking Member Moore, and Members of
the Subcommittee. On behalf of the 574 federally recognized Tribal
nations and the member organizations the National Indian Health Board
serves, thank you for the opportunity to provide written testimony on
``The Opioid Crisis in Tribal Communities''.
Background
The U.S. Constitution recognized the political and government-to-
government relationship between the U.S. and Tribal nations. As
sovereign nations, the U.S. and Tribal governments entered treaties--
which exist in perpetuity--in which the Tribes exchanged millions of
acres of land for the federal obligations and responsibilities,
including the obligation for the provision of comprehensive health care
from the federal government.
The U.S. Supreme Court decisions acknowledged this relationship
while also recognizing a trust relationship and obligation to Tribes
existed to honor these agreements, among other duties. This trust and
treaty obligation extends and applies throughout the federal
government, including all agencies. These responsibilities are carried
out, in part, by the primary agency, Indian Health Service, within the
Department of Health and Human Services (HHS). This agency provides
both direct care and resources for health care services to American
Indian and Alaska Native (AI/AN) people. Among all federal health care-
related agencies, the IHS and the Indian health care delivery system
are unique in this regard.
The IHS provides health care services either directly to AI/AN
people, or through contracts or compacts with Tribal nations which
provide the services. The IHS may also enter contracts with urban
Indian organizations to provide health care services to AI/AN people in
certain urban locations. For specialty care and other services not
available within the Indian health system, the IHS may--contingent upon
available funding--purchase or provide funding to Tribes to purchase
such care through the Purchased Referred Care program.
According to the IHS, ``[t]he IHS provides comprehensive primary
health care and disease prevention services to approximately 2.6
million American Indians and Alaska Natives through a network of over
600 hospitals, clinics, and health stations on or near Indian
reservations. Facilities are predominantly located in rural primary
care settings and are managed by IHS, Tribal, and urban Indian health
programs.'' \1\
---------------------------------------------------------------------------
\1\ Justification of Estimates for the Appropriations Committees.
Department of Health and Human Services. Fiscal Year 2022. Indian
Health Service. At CJ-1.
---------------------------------------------------------------------------
Tribal Communities in Crisis
In his December 2021 Advisory, the U.S. Surgeon General found that
Native youth were at a higher risk for mental and behavioral health
challenges during the pandemic. While the Advisory focused on youth,
these findings could also apply to our adults and other health
challenges.
Before the pandemic, Tribal communities were already in a
behavioral health crisis. According to the National Center for Health
Statistics, American Indian and Alaska Native women experienced the
highest increase in suicide rates of 139% from 1999 to 2017. The men
between the ages of 15 to 44 experience the highest rates of suicide of
all race and ethnicity groups.
The overall death rate of adults from suicide is about 20 percent
higher compared to the non-Hispanic white population.\2\ Suicides have
skyrocketed for Native veterans, from 19.1 to 47 in 100,000 persons.\3\
But most shocking, for those aged 18 to 39, it was 66 in 100,000
persons.
---------------------------------------------------------------------------
\2\ Office of Minority Health. Minority Population Profiles,
American Indian and Alaska Natives. https://minorityhealth.hhs.gov/omh/
browse.aspx?lvl=4&lvlid=39. Accessed on March 21, 2018.
\3\ High suicide rates in American Indian/Alaska Native veterans--
Wolters Kluwer.
---------------------------------------------------------------------------
These facts, combined with down-spiraling health disparities
experienced by AI/ANs, demonstrate the human consequences of
underfunding IHS. Deferral of care due to funding and workforce
shortages has pushed more and more Tribal members into health
conditions wherein prescription opioids are used to treat chronic pain
that would otherwise successfully be treated earlier with non-opioid
therapies, if they were available. Failure to address basic health
needs through routine visits and preventative care also has led to
preventable diseases becoming fatal when the diagnoses are too late to
seek treatment.
Congress Must Invest in Tribal Communities for Prevention and Treatment
Congress must tackle these issues head-on with aggressive funding
for prevention and treatment measures for Tribes. The Indian health
system is underfunded by nearly 50% of the minimum levels necessary to
begin addressing the existing health care disparities. In FY 2020, the
national health expenditure was $12,530 per capita which also accounted
for COVID-19 relief spending. In FY 2019, the national health
expenditure was $11,582 per capita. In FY 2019, based on the latest
information provided by the IHS, the IHS expenditure was only $4,078
per user population. As funding gaps grow and the IHS funding increases
cannot close those gaps, the AI/AN people suffer.
The persistent chronic underfunding of the IHS, historical trauma,
and other social and economic conditions contribute to the unacceptable
health conditions. The AI/AN people often face the most significant
health disparities among all populations in the United States--besides
behavioral health challenges--including diabetes, suicides, and COVID-
19 infections, hospitalizations, and deaths.
The pandemic devastated our communities. It highlighted the
consequences of chronic underfunding. For example, according to the
Substance Abuse and Mental Health Service Administration, 13% of the
Native population needs substance abuse treatment, but only 3.5%
receives any treatment.
Programs with treatment approaches that include traditional healing
and cultural practices have been reportedly more successful. However,
again, due to lack of funding availability and the challenges with the
grant-funded model, several culturally responsive in-patient treatment
centers have had to close their doors leaving major gaps in service
availability and more specifically availability of detox beds with the
rising number of opioid and/or other addictions. Opioid and heroin use
is high in many IHS regions, with limited treatment facilities
available.
In FY 2008, Congress appropriated $14 million to support a national
methamphetamine and suicide prevention initiative to be allocated at
the discretion of the IHS director. Today, those funds continue to be
allocated through competitive grants, despite Tribal objections. For
over a decade, Tribes have noted that IHS reliance on grant programs is
counter to the federal trust responsibility and undermine self-
determination tenets. Furthermore, because grant funding is never
guaranteed, vulnerable communities, with the greatest needs but least
capacity, often slip through the cracks. The needed increase must be
applied to IHS funding base and away from the inefficient use of grants
in order to stabilize programs and ensure the continuity of the program
and care to our struggling Tribal members and their families.
Tribes have recommended full funding of the Indian health care
system at $49.8 Billion beginning in FY 2023. The fundamental
responsibilities of IHS to deliver excellent health care and reduce
health care disparities--including opioid overdoses and use--cannot
happen without the appropriate support and resources from Congress.
However, these services must be provided in appropriate settings
and facilities. Specialty care and other health care facilities are
also necessary to make an impact on these problems. In 2010, Congress
authorized the construction of inpatient behavioral health and other
specialty facilities, such as long-term care and dialysis. While
suicides, other health problems, and costs escalate, construction of
these specialty care facilities has yet to be funded. In fact, Congress
has not funded the completion of several health care facilities still
on a nearly 30-year-old, 1993 waiting list. The IHS has indicated that
the health care and specialty care facilities construction cost alone
is now up to $22 Billion--yet Congress funded the entire Indian health
care system at only $6.6 Billion for FY 2023.
As a result, Tribal leaders and health policy experts determined
that full funding of the IHS at $49.8 Billion is required to make a
difference. This figure takes into account medical and non-medical
inflation, compliance with costly federal mandates, and other emerging
needs. It also uses a more accurate per user benchmark based on the
national health expenditure.
Congress Can Swiftly Adopt Legislative Behavioral Health-Related
Improvements
Native Behavioral Health Access Improvement Act. The bill, H.R.
4251, the Native Behavioral Health Access Improvement Act, was
introduced by Representatives Frank Pallone and Raul Ruiz on June 30,
2021. It was referred to the House Committee on Energy and Commerce,
Subcommittee on Health, and the Committee on Natural Resources.
There is a Senate companion bill as well, S. 2226, introduced by
Senators Smith and Cramer on June 24, 2021. The bill was referred to
the Senate Committee on Indian Affairs, but no further action has been
taken.
This bill would amend the Indian Health Care Improvement Act by
establishing a special behavioral health program for Indians to treat
and prevent mental health and substance use disorders. It would provide
funding through grants to the IHS, Tribes and urban Indian health
programs at $200 Million for each fiscal year from 2022 to 2026
according to a formula developed through consultation with Tribes and
urban Indian organizations. The grantees would agree, as a condition of
receiving funds, to submit data and reports consistent with the
submission requirements established through consultation.
This base funding is important to Tribal communities and would
complement the comprehensive behavioral health provisions of Title VIII
of the Indian Health Care Improvement Act. Likewise, the interplay of
the Indian Self-Determination and Education Assistance Act with the
funding approaches, data collection, and reporting requirements is a
necessary consideration to ensure this legislation is most effective
for Tribal communities in reducing the opioid and other behavioral
health crises. We urge Congress to move swiftly on finalizing this bill
in close collaboration with NIHB and Tribal nations.
Comprehensive Addiction Resources Emergency Act of 2021. On
December 16, 2021, Representative Maloney introduced the Comprehensive
Addiction Resources Emergency Act of 2021. There are 105 co-sponsors.
This Senate companion bill, S. 3418, was introduced by Senator Warren
and is currently pending before the Senate Health, Education, Labor,
and Pensions Committee.
The bill requires the Secretary of the Department of Health and
Human Services to provide grants to address substance abuse and
increase access to preventive, medical, and recovery care. It includes
direct funding to Tribal nations and includes Tribal representation on
the planning council, among other things.
The bill has been referred to four Committees including the Natural
Resources Committee. We urge this Committee to secure swift passage of
this bill and NIHB and Tribal nations stand ready to join you in this
effort.
Conclusion
Aggressive solutions are needed to make a difference. The President
challenges Congress to move the bar through his FY 2023 Budget Request
for the IHS and his mental health initiative introduced in his State of
the Union address. Indian Country challenges Congress to also make a
difference and move in the right direction. NIHB and Tribal nations
stand ready to join in this fight for the lives, health, and future of
American Indians and Alaska Native people.
______
[LIST OF DOCUMENTS SUBMITTED FOR THE RECORD RETAINED IN THE COMMITTEE'S
OFFICIAL FILES]
Submissions for the Record by Rep. Moore
-- Report titled, ``2020 Drug Enforcement Administration
National Drug Threat Assessment,'' from the U.S.
Department of Justice, Drug Enforcement
Administration, dated March 2021.
-- Report titled, ``FY 2019 Year End Report: U.S. Department
of the Interior, Bureau of Indian Affairs--Office
of Justice Services, Division of Drug
Enforcement,'' dated 2020.
[all]