[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                     
          
-----------------------------------------------------------------------------------            
         
                     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
                                 
                              -----------                                
                               
                               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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \5\ https://publications.aap.org/pediatrics/article/148/6/
e2021053760/183446/COVID-19-Associated-Orphanhood-and-Caregiver-Death.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \6\ https://www.usatoday.com/story/news/politics/2022/03/07/
opioids-native-americans-funding/9380063002/?gnt-cfr=1.
---------------------------------------------------------------------------
    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]